What some of the most common causes of stress?
Stress can arise for a variety of reasons. Stress can be brought about by a traumatic accident, death, or emergency situation. Stress can also be a side effect of a serious illness or disease. There is also stress associated with daily life, the workplace, and family responsibilities.
What are some early signs of stress?
Stress can take on many different forms, and can contribute to symptoms of illness. Common symptoms include headache, sleep disorders, difficulty concentrating, short-temper, upset stomach, job dissatisfaction, low morale, depression, and anxiety.
What is post-traumatic stress disorder (PTSD)?
Post-traumatic stress disorder (PTSD) can be an extremely debilitating condition that can occur after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. Traumatic events that can trigger PTSD include violent personal assaults such as rape or mugging, natural or human-caused disasters, accidents, or military combat.
Many people with PTSD repeatedly re-experience the ordeal in the form of flashback episodes, memories, nightmares, or frightening thoughts, especially when they are exposed to events or objects that remind them of the trauma. Anniversaries of the event can also trigger symptoms. People with PTSD also experience emotional numbness and sleep disturbances, depression, anxiety, and irritability or outbursts of anger. Feelings of intense guilt (called survivor guilt) are also common, particularly if others did not survive the traumatic event.
Most people who are exposed to a traumatic, stressful event experience some of the symptoms of PTSD in the days and weeks following exposure, but the symptoms generally disappear. However, about 8% of men and 20% of women go on to develop PTSD, and roughly 30% of these individuals develop a chronic form that persists throughout their lifetimes.
Is there any way to relieve your stress?
There are many stress management programs that can teach you about the nature and sources of stress, the effects of stress on health, and personal skills to reduce the effects of stress. Examples of stress reducing skills include time management and physical exercise.
For more serious stress related disorders, like PTSD, research has demonstrated the effectiveness of cognitive-behavioral therapy, group therapy, and exposure therapy, in which the patient repeatedly relives the frightening experience under controlled conditions to help him or her work through the trauma. Studies have also shown that medications help ease associated symptoms of depression and anxiety and help promote sleep.
Is there a relationship between cancer and stress?
The complex relationship between physical and psychological health is not well understood. Although studies have shown that stress factors (such as death of a spouse, social isolation, and medical school examinations) alter the way the immune system (the body’s defense against infection and disease, including cancer) functions, they have not provided scientific evidence of a direct cause-and-effect relationship between these immune system changes and the development of cancer. Scientists know that many types of stress activate the body's endocrine (hormone) system, which in turn can cause changes in the immune system. It has not been shown that stress-induced changes in the immune system directly cause cancer.
Several studies have indicated an increased incidence of early death, including cancer death, among people who have experienced the recent loss of a spouse or other loved one. But, most cancers have been developing for many years, and it is unlikely that cancer would be triggered by the recent death of a loved one. However, some studies of women with breast cancer have shown significantly higher rates of this disease among those women who experienced traumatic life events and losses within several years before their diagnosis.
Although the relationship between psychological stress and cancer has not been scientifically proven, stress reduction is of benefit for many other reasons.
Are hormones related to stress in women?
Scientists know that many types of stress activate the body's endocrine (hormone) system, which in turn can cause changes in the immune system, the body's defense against infection and disease (including cancer). On the positive side for women, there is some evidence that women who breast-feed their infants produce lower levels of stress response hormones, such as adrenalin, and cortisol, than do women who bottle-feed. It is also known, however, that hormone changes during pregnancy, menopause, and during the menstrual cycle can trigger symptoms of depression and stress.
For More Information . . .
You can find out more about stress by contacting the following organizations:
National Institute of Mental Health
Phone: (301) 443-4513
National Mental Health Services Knowledge Exchange Network
Phone:(800)789-2647
American Institute of Stress
Phone: (914) 963-1200
Internet Address: http://www.stress.org
National Center for Post Traumatic Stress Disorder
Phone: (802) 296-5132
Internet Address: http://www.ncptsd.org
Anxiety Disorders Association of America
American Psychiatric Association
Association for the Advancement of Behavior Therapy
305 7th Avenue
Suite 16
ANew York, NY 10001
(212) 647-1890
American Psychological Association
Freedom from Fear
308 Seaview Avenue
Staten Island, NY 10305(
718) 351-1717
National Mental Health Consumers' Self-Help Clearinghouse
1-800-553-4539
National Mental Health Association
1-800-969-6642
National Alliance for the Mentally Ill
1-800-950-6264
This information was abstracted from the National Cancer Institute fact sheet on Psychological Stress and Cancer and the National Institute of Mental Health fact sheet on Post-traumatic Stress Disorder.
Publication date: September, 2001
Sleepless in Seattle can mean toothless in Tacoma - relationship between stress and gum disease
Nutrition Health Review, Summer, 2003 by Gail Gorman
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According to the Journal of Periodontology, (1) high levels of stress and poor coping skills increase twofold the likelihood of development of periodontal disease. What is worse is that certain antidepressants as well as heart and high blood pressure medications can increase your risk further! (2) Of course, teeth clenching and grinding do not help either. If you would like to keep your teeth, get some peaceful sleep.
Stress is not the only cause of gum disease, but, more important, gum disease is virtually preventable. Still, a walloping 90 percent of Americans have some form of gum disease and tooth decay. More than 13 million of us have lost all of our teeth. Even the average two-year-old has already suffered tooth decay. (3) Remember, if you ignore your teeth, they will go away!
Let us take a look at the structure of the teeth, gums, and bone. In a healthy tooth, the collagen matrix (connective tissue) of the periodontal membrane serves as the anchor to the alveolar bone (jawbone) and allows the dissipation of the tremendous amount of pressure exerted during chewing. (4)
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Periodontal disease is an inflammatory condition in the gums, leading to distress of supporting structures. The process usually starts with gingivitis, marked by red, swollen gums or gums that bleed easily. When these symptoms are ignored, a more serious condition, periodontitis, can lead to bone and eventually tooth loss.(4)
The main cause of gum disease is plaque, the sticky, colorless film that constantly forms on the teeth. Plaque breeds bacteria that cause gums to become inflamed. (5) Left untreated, plaque is likely to spread below the gum line, worsening the condition. Over time, toxins produced by the bacteria stimulate a chronic inflammatory response that causes destruction of the bone and tissue that support the teeth. When the gums eventually separate from the teeth, an even greater chance for breeding infection exists.
Gingivitis is the mildest form of gum disease and is reversible with professional treatment and good care at home. If your gums bleed easily, see your dentist or periodontist.
Aggressive periodontitis is an advanced form of gum disease that occurs in people who are otherwise clinically healthy. Common features include rapid loss of attachment and bone destruction, resulting in lost teeth. By the way, the bacteria that cause inflammation can be passed from family member to family member through such innocent acts as a loving kiss.
Thankfully, aggressive periodontitis is not the most common form of gum disease; chronic periodontitis is the most common and hazardous form. It is prevalent in adults but can occur at any age. Usually, it comes with loss of attachment and bone and progresses slowly and relentlessly toward tooth loss. The disease is characterized by the formation of "pockets" (the spaces between the teeth and gums) and gum recession, swelling, and bleeding.
Make no mistake, there is more at risk here than just teeth. Dental disease is not only a disease of the mouth but also a disease of the body.
Any time a part of your body becomes diseased, the entire immune system is stressed. This event can be most harmful when disease is chronic or long term. Dental disease, especially gum disease, overloads the body's protective defensives 24 hours a day; this reaction can drain you of energy and can drastically lower your resistance to any other disease to which you may have been exposed. (6)
In fact, a study published by the Journal of Periodontology links periodontal disease to elevated C-reactive protein (CRP) levels. The medical profession has known for some time that the CRP level is a good indicator of heart health. (7) An elevated CRP level is a stronger predictor of heart attack than elevated cholesterol levels are. This study showed that the inflammatory effects from chronic bacterial infection in the gums can cause oral bacterial by-products to enter the bloodstream. This can cause the liver to make proteins such as CRP that inflame arteries and contribute to clotting. Clotting contributes to clogged arteries that can lead to heart attacks and stroke. Can something as prevalent as gum disease contribute to heart attacks? Some studies suggest that the answer is yes!
In light of the consequences, the question "Have you been brushing and flossing?" takes on new meaning.
So what causes periodontal disease? In addition to plaque, research implicates (in no particular order) the following factors:
* stress
* smoking
* poor nutrition, especially low dietary vitamin C
* some medications
* clenching and grinding the teeth
* diabetes
* systemic disease
* genetics.
Being female also appears to raise your risk. (8) During puberty, levels of progesterone and, possibly, estrogen overstimulate blood circulation to the gums, making them sore and swollen. Menstruation can bring on temporary gingivitis, which usually starts right before the onset and clear up once the period is over.
For pregnant women or those of childbearing age, it is important to realize that there might be a relationship between periodontal disease and pre-term low-birth-weight babies. Be sure to include teeth and gum evaluation and care into your prenatal regimen. Some women experience a greater incidence of gum disease not only during pregnancy but also if they are taking oral contraceptives
Antioxidants and Eye Health Printable Page
A recent study that found vitamin C and carotenoids to be protective against certain types of cataracts adds to the growing body of data on the relationship between nutrition and eye health. The results are published in the American Journal of Clinical Nutrition.
Source: Tufts University
Evidence from the Nurses' Health Study
Researchers in Boston studied almost 500 women from the Nurses' Health Study cohort. The women were between the ages of 53 and 73, did not have diabetes, and were without previously diagnosed cataracts.
Nutrient intake was assessed using five food-frequency questionnaires collected during the 13- to 15-year period before eye examination, with the average intake from these five surveys used to define usual nutrient intake. Vitamin supplement use was also quantified, using seven questionnaires administered during this same time period. Lens opacities were classified using the Lens Opacities Classification System III, with cortical opacities defined as grade >/= 0.5 and subcapsular opacities as grade >/= 0.3.
No significant associations between specific nutrients and odds of developing cataracts were identified in the full sample. However, associations were found between age and vitamin C, and between carotenoids and smoking status.
Vitamin C and age
In women younger than 60, a vitamin C intake of >/= 362 mg/day was associated with a 57% lower odds ratio of developing a cortical cataract than was an intake of < 140 mg/day (OR=0.43, 95% CI 0.2-0.93).
Vitamin C supplement use was also a factor, with longer duration of supplement use (>/= 10 years) associated with lower odds of developing cortical cataracts than with no supplement use (OR=0.40, 95% CI 0.18-0.87).
Carotenoids and smoking
In women who never smoked, total carotenoid intake in the highest intake quintile was associated with lower odds of developing posterior subcapsular cataracts compared with the lowest intake quintile (OR=0.19, 95% CI 0.05-0.68).
Applying the results
While the results of this study add to existing evidence that good nutrition, particularly with regard to antioxidant nutrients, may play a role in eye health, further studies are necessary to corroborate the results in larger groups of women, as well as in men.
The results of this study alone do not warrant recommendations for antioxidant supplementation to protect against cataracts, but they do suggest that eating a diet high in antioxidants, such as those found in brightly colored fruits and vegetables, may help prevent or delay age-related lens opacities
Interrelationship of Nutrition and Immunity1
G. D. Butcher, DVM, Ph.D., R. D. Miles, Ph.D.2
Poultry encounter numerous stressors during their lives. These stressors cause hormone changes, declines in feed intake, altered nutrient metabolism and suppressed immune function. The adverse effects of the stressors are additive and every attempt should be made in all poultry operations to lessen the number and intensity of these stressors. Nutrients are known to influence the responses of poultry to a disease challenge. Normally, during such a challenge nutrients are shunted away from growth. For example, body proteins are broken down and amino acids are shunted away from growth and are used by specific cells to synthesize critical proteins which allow the bird to mount a successful immune response to a particular disease challenge. Lymphoid cells increase in their numbers, and acute phase proteins and antibodies also increase through the use of amino acids. Defense mechanisms take priority in a disease challenge and these nutrients help the bird's system overcome the challenge. If specific nutrients are at or below the bird's requirement, then a limited amount of nutrients will be available to meet all of the body's needs during a time of challenge.
The immune system benefits greatly from proper nutrition of the bird. Not only does the immune system benefit directly from proper nutrition, but indirectly proper nutrition will also prepare the bird for periods of stress, reducing the adverse effects of stress and enhancing recovery from stressful periods. Therefore, in many instances, proper nutrition lessens the immune suppression associated with the stress response in the bird. The immune system of the bird can be influenced by nutrition in several ways:
Anatomical development of lymphoid tissues.
Mucus production.
Synthesis of immunologically active substances.
Cellular proliferation.
Cellular activation and movement.
Intracellular killing of pathogens.
Modulation and regulation of the immune process.
When an immune response occurs from challenge by a pathogen, a systemic acute phase or inflammatory response results that is considered to be the foundation of non-specific immunity. Antibody titers that arise as a result of the humoral response are not a direct burden on the anima'ls pool of nutrients and are therefore nutritionally inconsequential. It is therefore the systemic acute phase response that has nutritional consequences for the animal. It is this response that is associated with a shift in nutrients use away from skeletal muscle accretion and towards hepatic secretion of acute phase proteins as well as cellular and macromolecule turnover (Klasing, 1998).
There is no question that a well-nourished bird is more immunologically competent and better able to cope with disease challenges than a poorly nourished bird. A change in feed intake leads to a change in nutrient and energy intake. The development and maturation of the immune system of young poultry fed nutritionally deficient diets will be compromised. However, young poultry in today's commercial poultry industry are usually not subjected to diets which are severely limited in nutrients and energy. It is well known that immunological challenge in the bird is accompanied by a decrease in feed intake. Many nutritionists increase the energy density of the diet when feed intake declines. Using fat as the energy source of choice in such instances may not be the best decision. Carbohydrate calories may be the best choice since immunological stress is known to impair triglyceride clearance from the blood, thus decreasing fat use. Literature data clearly show that for most nutrients, dietary concentrations, which are necessary for optimal growth, are also necessary for optimal immunocompetence. However, data collected in studies with poultry and other species have shown that when a diet is deficient in protein or amino acids, the concentration of circulating antibodies to a specific challenge organism is low.
Recently, Kidd et al., (2001) reported that a dietary arginine concentration near the 1.25% of the diet recommended by the NRC (1994) should support proper immune system functions in healthy chicks. Also, these researchers reported that dietary arginine and lysine fed near the NRC (1994) requirement did not interact to affect immunity of chicks and cellular and humoral immune system functions of healthy chicks were not improved by fortified diets with aginine levels in excess of the NRC (1994) recommendation. This essential amino acid, arginine, plays a very important role as a potent immunological modulator since the cellular metabolic pathway of arginine produces nitric oxide (Collier and Vallance, 1989). Sung et al., (1991) found that nitric oxide production of macrophages is increased by a local concentration of arginine. Additional improvements in immunity, as affected by dietary arginine in animals including humans, include improved thymic weight and function, enhanced lymphocyte mitogenesis, improved immunity against tumors and enhanced wound healing (Efron and Barbul, 1998; Evoy et al., 1998).
A reduced humoral immune response in poultry has been associated with low mineral levels in the feed. For example, sodium and chloride have been associated with the humoral immune response in broilers. Broilers fed diets deficient in sodium or chloride have lower antibody concentrations in their bodies. The balance between sodium and chloride in the diet is important because a high chloride concentration in relation to that of sodium may result in a reduced immune response.
Even though most nutrients required by the immune system are present in the diet in sufficient concentrations there is evidence that increased dietary supplementation of certain nutrients, above that needed for maximum growth and feed efficiency, is of benefit to the immune response. Vitamins A, E and C as well as the amino acids methionine and valine have been shown to benefit immune function when added to the diet of poultry at higher concentrations than are required to maximize growth and feed efficiency. However, too much of a good thing may also be detrimental to the immune system. For instance, too much dietary methionine will suppress the immune system. Usually, the immune suppression caused by excess dietary methionine is evident before changes in growth and feed consumption are detected. It is essential to ensure that poultry diets contain enough of a specific nutrient to ensure the desired growth, feed conversion and immune response, but not too much so as to impair the immune function either directly or indirectly. The omega 3 and 6 fatty acids are also of benefit to the immune system at higher than normal concentrations in the diet. Several nutrients have been shown to have a negative effect on the immunological response in the bird when they are deficient in the diet. Sodium, chloride, zinc, methionine, valine, threonine, vitamin A, riboflavin, pantothenic acid, pyridoxine and selenium will have a negative impact on the immune system if they are deficient in the diet. Thus, these are considered essential to proper immune function.
One vitamin that has received a lot of attention with respect to its importance to the immune response in poultry has been vitamin E. This vitamin appears to be an immune system "booster." Vitamin E seems to exert a complementary effect on the immune system by inhibiting the synthesis of prostaglandins. These prostaglandins are produced in the cells following the oxidation of cellular membranes and are responsible for inhibiting the inflammation and immune response. Vitamin E prevents oxidation and thus, the production of prostaglandins. It is well known that deficiencies of vitamin E and selenium will inhibit the immune response in poultry. Selenium works with vitamin E in tissues to protect biological membranes from oxidative damage. Zinc is another element that is important in assisting the bird's immune system to overcome a challenge. Zinc is especially important in wound healing, thymic function and proliferation of lymphocytes. Leshchinsky and Klasing (2001) showed that supplementing broiler diets with vitamin E at 25 to 50 IU/Kg of diet was not immunomodulatory and higher levels of vitamin E supplementation to the diet were less effective. As discussed by Gershwin et al., (1985) it is very likely that vitamin E, like other nutritional factors, affects the development and maintenance of immunocompetence through multiple factors, by acting directly on the immune cell or by indirectly altering metabolic and endocrine parameters, which in turn influence immune function. The main mechanism of the bioactivity of vitamin E is associated with its antioxidant potential in reducing free radical-induced pathology during normal metabolic stress and immune challenge. By controlling the production of free radicals, vitamin E affects free radical-mediated signal transduction events and ultimately modulates gene expression caused by free radical signaling (Packer and Suzuki, 1993). Vitamin E is also very important in preventing fatty acid peroxidation (Benedich, 1990). Fatty acids can act as immunoregulatory molecules that mediate cellular communication, membrane fluidity and second messenger elaboration (Klasing, 1997; Watkins, 1991). Another potential immunoregulatory mechanism that is associated with vitamin E is the modulation of arachidonic metabolism via cyclooxygenase and lipoxygenase pathways (Blumberg, 1994) which lead to the synthesis of prostaglandins and leukotrienes, respectively.
The effects of vitamin E on performance and immune response have been studied in our laboratory using commercial egg-type pullets fed diets supplemented with 10, 50 and 100 IU/kg of vitamin E from one day through seven weeks of age and levels of 5, 25 and 50 IU/kg from eight through nineteen weeks of age, respectively. Tracheal lesion severity scores were evaluated four days post-injection challenge with a Massachusetts Infectious Bronchitis live field virus. Tracheal lesion scores decreased in a dose-related manner as dietary vitamin E levels increased. Thus, these data demonstrated the effectiveness of vitamin E supplementation in limiting the severity of disease after a challenge.
Disease challenge is only one of the many factors that will have an effect on the nutrient requirements of poultry. Insufficient nutrient consumption will reduce the effectiveness of the bird's defense mechanisms. Nutritionists must supply enough dietary nutrients and energy to allow the bird to express the desired growth and feed efficiency. Since the possibility of disease challenge is always present in today's poultry operations, the nutritionist must realize that the bird's metabolism and immune system are constantly adjusting to the stress of environment or disease and nutrient requirements may need to be increased at certain times.
It must not be forgotten that even though immune stimulation is essential for any animal to cope with the continual challenge of antigens, it is not without a cost. For instance, in broilers, immune stimulation is of extreme importance, but continued genetic selection for growth in broilers results in birds which have inefficient immune systems. Immune stimulation is associated with a catabolic response that results in a growth depression. This fact will continually cause a conflict between geneticists and nutritionists. Geneticists are interested in breeding faster growing birds. Accelerated growth is accompanied by impaired immune systems. Nutritionists attempt to promote immune stimulation realizing that maximal growth may not be attained if birds get sick. As a result it is not surprising that today commercial meat birds express their extremely high growth potential but seem to be more vulnerable to disease. Keeping this in mind, it must be realized that the acute phase response associated with immune, neurogenic or non-specific injury will boost the innate immune response rapidly and is associated with catabolism (Berczi et al., 1998).
Keeping flocks of poultry in excellent immunological health, so that they suffer no immuno-depression from any cause, especially nutrition, should be the goal of the company's veterinarian and nutritionist. Veterinarians and nutritionists working together with the production manager of the flocks make a very strong team which will be one of any poultry company's greatest assets.
Stress: Its Effect on Nutrition and Immunity
Anyone wishing to understand the interrelation between nutrition and immunity has to also understand that the stress response in the bird has an important influence on the above interrelationship. A three-way interrelationship exists among stress, nutrition and immunity and it is because of this that this paper emphasizes all three of these important factors that influence overall poultry performance.
The word stress means different things to different people and because of this, stress has been difficult to define. Stress is brought about by stress-producing factors, called stressors. It is important to be able to distinguish between a stressor and stress. Stress is the nonspecific response that the body of an animal has to any demand made upon it. An animal is under stress when it has to make extreme functional, structural, behavioral, or immunological adjustments to cope with adverse aspects of its environment (Curtis, 1983). A natural environment is composed of various potentially hostile stressors. Animals that are able to cope with the stressors to which they are exposed are those that will perform best in stressful situations. In nature, stress is the rule not the exception--after all, complete freedom from stress is death (Selye, 1973). Survival depends on the severity, duration, and interaction of the environmental stressors and the animal's physiological and behavioral ability to respond and adapt to them (Harvey et al., 1984). Once an animal perceives a stressor, its immediate response is usually behavioral (Friend an Dellmeier, 1986). It will tend to move away from the unpleasant stimulus. Depending on the severity and nature of the stressor, the autonomic nervous system responds, followed by a neuroendocrine response. These biological responses can eliminate or reduce the potential effects of the stressor by changing either the animal's relationship to the stressor or its perception of the stressor. If these responses are not successful, a pathological state may be induced that can result in decreased performance or a disease state.
Many of the problems in the poultry industry today are a direct result of the bird having to cope with one or a combination of stressors in the environment. Poor management is one of the greatest causes of stress in all types of poultry. The exposure to disease agents, poor nutrition and exposure to immunosuppressive agents also contribute to reduced performance. Poultry must be managed correctly in order to minimize the effects of stress on their performance and health. Successful identification and correction of problems in the poultry house and in the diet will benefit the bird. This paper will review some of the nutritional factors related to stress in poultry.
Energy Need During Physiological Stress
Whenever poultry are confronted with physiological stress they have to adapt to the situation in order to survive. This process of adaptation is essential and requires energy. The energy for adaptation comes from the three energy-yielding nutrients: carbohydrates, lipids and proteins. These nutrients are only available from the feed and the nutrient reserves in the animal. During the first stages of stress, poultry will eat less initially, and then increase their feed intake. (Siegel, 1995). During stress, nutrients in the feed are not digested and absorbed efficiently, and the animal must rely on the nutrient reserves of the body. These reserves are very important and help to sustain the animal during the stress. The muscle and liver carbohydrate stores (glycogen) are immediately called upon to furnish energy. Protein is broken down to yield the glucogenic and ketogenic amino acids which, following deamination, will supply the bird with energy. This energy from carbohydrate and protein allows the bird to maintain its health and survival. During stress the vital functions of the brain, liver, heart, lungs, kidney, etc. cannot be compromised. Therefore, the less important functions such as egg production, reproduction, growth and immunity are set aside to promote the vital functions of the body in stressful situations. Immediate survival has the number one priority in all animals when they are confronted with a severe stressor. The full genetic potential of the bird for growth and egg production is not expressed during stress.
The shift in metabolism during stress favors fat deposition. This is contrary to what is happening to protein and glycogen stores in the bird, but carcass data (muscle depletion and fat accretion) confirm that muscle protein declines and fat deposition increases (Nagra and Meyer, 1963; Bartov et al., 1980; Siegel and Van Kampen, 1984). During stress the consumption of water increases as a result of the necessity to clear the additional uric acid excretion arising from protein breakdown (Siegel and Van Kampen, 1984). The increased water consumption is also probably necessary to maintain osmolality in the body fluids due to the increased sodium retention concurrent with the effects of corticosterone (Holmes and Phillips, 1976).
Adrenal Gland, Stress Hormone and Nutrient Requirements
Corticosterone is the main stress hormone that is produced and released from the cortex of the adrenal gland when an animal is confronted with stress. This hormone influences the metabolism of the energy-yielding nutrients. Corticosterone is responsible for ensuring that the nutrient stores are allowed to furnish the energy the animal must have in order to cope with the stress. This hormone is responsible for increased use of glucose and amino acids for energy. A high rate of muscle protein synthesis does not occur in the presence of this hormone since the carbon skeletons of the amino acids are used for energy.
Most of the research in Universities and Research Centers conducted to determine the nutritional requirements is done under ideal situations for each species of animal, especially poultry. However, under commercial conditions, ideal environments do not always exist. Poultry are continually exposed to various stressors that often have a negative effect on their nutritional requirements. To the nutritionist, this "negative" effect is an increase in the dietary requirement for several nutrients.
Teeter and Wiernusz (1994) discussed how new management approaches could be used to allow poultry to cope and adapt to stressful situations. In their review these authors discussed how environmental effects, such as ambient temperature, could have a negative effect on performance and how the bird needed to adapt to high temperatures in order to survive. Growth rate was sacrificed in order that survival have the top priority. These authors also discussed how the bird was able to respond in growth following a stressful encounter. Bird growth rate during the "recovery phase" can possibly be accelerated by either a more rapid return to homeostatic conditions, or via a classical compensatory gain response. The daily gain in excess of that observed for non-stressed control animals following a period of stress is commonly known as compensatory gain (Teeter and Wiernusz, 1994). It has been shown that in most stressful situations, the breast muscle of the bird, especially the broiler, is the first muscle to lose protein and the last muscle to rebuild protein to replenish breast mass. The data presented by Teeter and Wiernusz (1994) indicated that the viscera, leg and thigh muscles all have a greater potential for compensatory gain than the breast muscle when a stress-free period follows a period of stress.
Other researchers have shown that the environmental temperature has an influence on the immune response of poultry (Beard and Michell, 1987; Donker et al., 1990; Henken et al., 1982). Siegel and Latimer (1984) speculated that the increased activity of the adrenal gland due to heat stress increased the level of serum corticosteroids which resulted in the decreased performance of poultry. Also, Arjona et al., 1990 reported that high environmental temperature stress before or soon after hatching would induce resistance to extreme environmental temperature fluctuations later in adult life. This adaptation to high temperatures brought about by early exposure has also been reported by Tetter and Wiernusz (1994). Thaxton and Siegel (1970) reported that the influence of environmental temperature variations on the immune response depends on the degree of adaptation of the animal and the time of immunization.
Vitamin C
As stated previously, the stress hormone corticosterone is responsible in all physiological stress for the channeling of nutrients and body reserves away from the economically important traits of poultry production to those vital physiological functions necessary for immediate bird survival. Therefore, any measure of reduction in the release of corticosterone allows nutrients to be used for growth, egg production immune response, etc. (Bains. 1996). Supplementation of vitamin C in stressful situations has been shown to be of benefit to the animal and has helped to restore some of the performance loss.
All poultry are capable of synthesizing vitamin C in the kidney tissue, and because of this, supplementation is often considered by a few nutritionists to be unnecessary. However, the synthesis and use of vitamin C are not constant. The ability of the kidney to synthesize vitamin C in the amount needed changes with age, management, environment, disease, nutrition and stress. In order to understand why vitamin C is beneficial in helping to alleviate stress it is necessary to consider vitamin C as an "anti-stress" vitamin and not a growth promotor in these situations. Some of the highest concentrations of vitamin C in animals can be found in the testicles, ovaries, and adrenal gland. In the adrenal gland, vitamin C functions metabolically to help control the production of the adrenal hormone, corticosterone. Stressors in the environment have a direct influence on plasma and tissue levels of vitamin C. A controlled rate of corticosterone release from the adrenal cortex is preferred in coping with stress. For adrenal cortical depletion of this hormone to occur would result in death of the animal. Vitamin C plays a central role in the continued synthesis of corticosterone. The proposed mechanism for this effect is through inhibition of the 21-hydroxylase and 11 beta-hydroxylase enzymes in the steroid biosynthetic pathway in the adrenal cortex. Vitamin C supplementation to the diet and water during periods of stress causes reduced synthesis of corticosterone (Brake, 1988). For best results, the use of vitamin C in the diet or water should begin at least 24 or 48 hours before the onset of stress and should continue throughout the stressful period. The recommended amount of vitamin C to use in the diet is usually between 100 and 150 ppm. Higher levels can be used, but are often cost prohibitive.
Vitamin C is not the only vitamin that should be supplemented during periods of stress. Research has shown that all vitamins should be increased in the diet if the stress level in poultry is high. Without these supplemental vitamins, acceptable performance and carcass characteristics will not occur. Vitamins also enhance disease resistance under conditions of stress. These vitamins exert their mechanism of action during stress by protecting immune tissue via a reduction of certain hormonal effects and oxidative damage, and enhancment of cell differentiation and production.
Stressed animals are less resistant to disease challenge and are at a greater risk from infection than non-stressed animals because of an impaired immune response. The glucocorticoids are known to be immnosuppressive (Golub and Gershwin, 1985). In stress, immune cell function is adversely affected by increased eicosanoid levels. Various stimuli, including stress hormones, activate phospholipase A2 which frees the 20-carbon fatty acid, arachidonic acid, from membrane phospholipids. As a by product of this breakdown of cellular membranes and the production of prostaglandins from arachidonic acid, reactive oxygen molecules (H2O2, OH and O2) are formed and the free radicals can cause damage to cell membranes. These free radicals can also result in the disruption of protein function, DNA structure, and energy production within the cell (Freeman and Crapo, 1982). This is why the antioxidant compounds (vitamin E and beta carotene) are also beneficial during stress. As stated by Nockels et al., (1986), whatever reduces immunosuppressive prostaglandin production and limits cellular membrane levels of its precursor, arachidonic acid, should affect disease resistance.
Stress also causes the animal to increase its metabolic rate, which through normal oxidative metabolic pathways produces increased free radicals. Increased mineral losses have been reported in stressful conditions, which reduce metalloenzymes necessary for free radical and peroxide removal from the body (Nockels, 1990). This is another reason that the need for antioxidants in the diet will usually increase during stress. Vitamins E and C are very important during disease stress, such as in infection. In infection, phagocytes destroy ingested particles by generating free radicals which may prove self destructive if antioxidant systems are inadequate. Phagocytic function and surrounding tissues can be protected by feeding vitamins E and C (Boxer, 1986; Anderson and Lukey, 1987). Vitamin C helps to regenerate vitamin E by reducing vitamin E radicals formed when vitamin E scavenges oxygen radicals (Niki, 1987).
Disease resistance is also a function of cell differentiation and one of the primary functions of vitamin A is to maintain proper epithelial tissue differentiation and prevent epithelial keratinization which occurs in a deficiency (Chytil et al., 1983). Vitamin A is required for maintaining cellularity of lymphoid organs, which are essential in combating disease stress. Vitamin A is also required for enhancing both cellular and humoral immunity and enhances phagocyte activity (Chew, 1987). Vitamin A has reduced mortality in chicks infected with coccidial oocysts from E. tenella and E. acervulina (Erasmus et al., 1960). Since vitamins A, E, C and carotenoids are able to protect cells from free radical oxidation, reduce the detrimental effects of certain eicosanoids, and enhance humoral and cellular immune responses in disease stress, nutritionists must continually redefine the levels of vitamins necessary to maximize health during stress and disease (Nockels, 1989).
Trace Mineral Requirements
Stress decreases the circulating levels of trace minerals in animals, causes greater endogenous loss, decreases the efficiency of trace minerals and increases the metabolic need to fight the stress. Because of this, nutritionists often without question will increase the dietary concentration of trace minerals when poultry and other animals are confronted with a stressful situation. During stress, increased serum copper and decreased serum iron, zinc and manganese have been reported (Klasing et al., 1991). One of the most serious stressors that can confront poultry is disease. Trace mineral metabolism is radically changed during disease challenge because of the demand by a family of acute phase proteins that are central to the early phases of the immune response.
Zinc concentrations in the serum are decreased as a result from the redistribution of zinc from the plasma pool to a newly synthesized metallothionein pool in the liver and other tissues. Metallothionein induction supplies zinc to be used as a cofactor for metalloproteinases and other acute phase proteins (Klasing et al., 1991).
Copper-containing ceruloplasmin serves as a protective antioxidant and is a necessary component of the acute phase response. The quantity of copper required to sustain this role is large relative to other functions of copper. A copper deficiency reduces the amount of ceruloplasmin which is released during an inflammatory stress (DeSilvestro and Marten, 1990).
One of the most interesting mechanisms of defense that animals have to fight infection is to remove the circulating iron from circulation. During infection, iron is removed from the circulation and sequestered into compartments which are nutritionally unavailable to bacteria and parasites. Weinberg (1974) names this iron sequesting process "nutritional immunity." It has been shown that if the iron lost from circulation is replenished by injections or very high dietary supplementation, increases in mortality and morbidity will occur in a variety of diseases (Beisel, 1977). The absorption of iron from the digestive tract is markedly reduced within hours after a disease challenge.
Manganese needs by the gastrointestinal tract, lungs and several other tissues in the bird are increased during an immune response. The reason for this is that manganese serves as a cofactor of superoxide dismutase and ameliorates damage induced by the immune response itself. However, there is very little change in the circulating manganese levels in the plasma during stress (Klasing, et al., 1991).
The goal of trace mineral supplementation during stress should be to provide a readily available form that can be absorbed and give replete storage pools prior to the time that stress is encountered. These storage pools of the trace minerals will buffer the low levels due to stress and facilitate the greater tissue accretion that follows an encounter with stress (Klasing, et al., 1991).
Summary
Stressors are a part of every poultry operation. Management of these stressors to minimize the stress response in the bird should be the goal of every good poultry manager. Stress will not allow the bird to express its full genetic potential for growth, feed conversion and egg production. Stress also depresses the bird's ability to mount a successful immune response. Modern poultry are continuously and simultaneously exposed to a number of stressors. The successful poultry enterprise is the one in which the nutritionist, production manager, veterinarian and other personnel have an understanding of stress and make an attempt to do everything possible to minimize the stressors in the operation. The three way interrelationship which exists among stress, nutrition and immunity must also be kept in mind. Using common sense to solve the everyday problems encountered in poultry operations will go a long way in helping poultry flocks to cope with the stressors in their environment. Stress is unavoidable, but it can be managed.
References
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Bains, B. S., 1996. The role of vitamin C in stress management. World Poultry-Misset, Vol. 12, no. 4, pp. 38-41.
Bartov, I., L. S. Jensen and J. R. Veltmann, 1980. Effect of corticosterone and prolactin on fattening in broiler chicks. Poultry Sci. 59:1328-1334.
Beard, C. W. and B. W. Michell, 1987. Influence of environmental temperatures on the serological responses of broiler chickens to inactivated and viable Newcastle disease vaccines. Avain Dis. 31:321-326.
Beisel, W. R., 1977. Magnitude of the host nutritional responses in infection. Am. J. Clin. Nutr. 30:1236-1247.
Benedich, A., ed., 1990. Antioxidant vitamins and their function in immune response. Pages 35-55 in: Advances in Experimental Medicine and Biology, Vol. 262. Plenum Press, New York, NY.
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Boxer, L. A., 1986. Regulation of phagocyte function by alpha-tocopherol. Proc. Nutr. Soc. 45:333-334.
Brake, J. T., 1988. Stress of birds, modern poultry management relationship defined. Poultry Digest, May, pp. 226-231.
Chew, B. P., 1987. Symposium: Immunofunction: Relationship of nutrition and disease control. Vitamin A and beta-carotene on host defense. J. Dairy Sci. 70:2732-2743.
Chytil, R., M. Omori, G. Liau and D. E. Ong, 1983. Function of vitamin A in C differentiation. Fed. Proc. 42:2744-2753.
Collier, J. and P. Vallance, 1989. Second messenger role for NO widens to nervous and immune systems. Trends Pharmacol. Sci. 10:427-431.
Curtis, S. E. 1983. Environmental aspects of housing for animal production. Iowa State Univ. Press, Ames, IA
DeSilvestro, R. A., J. T. Marten, 1990. Effects of inflammation and copper intake on rat liver and erythrocyte Cu-Zn superoxide dismutase activity levels. J. Nutr. 120:1223-1227.
Donker, R. A., M. G. B. Nieuwland, and A. J. Van Der Zijpp, 1990. Heat-stress influences on antibody production in chicken lines selected for high and low immune responsiveness. Poult. Sci. 69:599-607.
Efron, D. T. and A. Barbul, 1998. Modulation of inflammation and immunity by arginine supplements. Curr. Opin. Clin. Nutr. Metab. Care 1:531-538.
Erasmus, J., M. L. Scott and P. P. Levine, 1960. A relationship between coccidiosis and vitamin A nutrition in chickens. Poultry Sci. 39:565-571.
Evoy, D., M. D. Lieberman, T. J. Fahey, III, and J. M Daly, 1998. Immunonutrition: The role of arginine. Nutrition 14:611-617.
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Friend, T. H. and G. R. Dellmeier, 1986. Recent developments in stress research. Prof. Anim. Sci., pp. 1-6.
Gershwin, M., R. Beach and L. Hurley, 1985. The potent impact of nutritional factors on immune response. Pages 1-7 in: Nutrition and Immunity. Academic Press, New York, NY.
Golub, M. S. and M. E. Gershwin, 1985. Stress-induced immunomodulation: What is it, if it is? In: Animal Stress. Gary P. Moberg (ed.) Am. J. Physiol. Soc., Bethesda, MD, pp. 177-192.
Harvey, S., J. G. Phillips, A. Rees, and T. R. Hall, 1984. Stress and adrenal function. J. Exp. Zoo, 232:633-645
Henken, A., A. M. J. Groote Schaarsberg and M. G. B. Nieuwland, 1982. The effect of environmental temperature on immune response and metabolism of the young chicken. 3. Effect of environmental temperature on the humoral immune response following injection of sheep red blood cells. Poult. Sci. 62:51-58.
Holmes, W. N. and J. G. Phillips, 1976. The adrenal cortex of birds, in: I. Chester-Jones & I. W. Hnderson (Es) General, Comparative and Clinical Endocrinology of the Adrenal Cortex, Vol. 1, pp. 292-420. (New York, Academic Press).
Kidd, M. T., E. D. Peebles, S. K. Whitmarsh, J. B. Yeatman and R. F. Wideman, Jr., Growth and immunity of broiler chicks as affected by dietary arginine. Poultry Sic. 80:1535-1542.
Klasing, D. C., B. J. Johnstone, and B. N. Benson, 1991. Implications of an immune response on growth and nutrient requirements of chicks. In: Recent Advances in Animal Nutrition (Haresign, W., Cole, D. J. A., ed), Butterworth Heinemann.
Klasing, 1997. Interaction between nutrition and infectious disease. Pages 73-80 in: Diseases of Poultry, B. W. Calnek, ed. Iowa State University Press, Ames, IA.
Klasing, K. C., 1998. Avian macrophages: Regulators of local and systemic immune responses. Poultry Sci. 77:983-989.
Leshchinsky, T. V. and K. C. Klasing, 2001. Relationship between the levels of dietary vitamin E and the immune response of broiler chickens. Poultry Sci. 80:1590-1599.
Nagra, C. L. and Meyer, R. K., 1963. Influence of corticosterone in the metabolism of palmitate and glucose in cockerels. Gen. And Comp. Endo., 3:131-138.
National Research Council, 1994. Nutrient Requirement of Poultry. 9th Rev. Ed. National Academy Press, Washington, DC.
Niki, E., 1987. Interaction of ascorbate and alpha-tocopherol. N. Y. Acad. Sci. 498:186-198.
Nockels, C. F., 1986. Dietary fatty acids and vitamin E alter immune organ lipids. Fed. Proc. 45:353-360.
Nockels, C. F., 1989. Vitamin needs increase during stress, disease. Poultry Digest, May, pp. 218-226.
Nockels, C. F., 1990. Mineral alterations with changing environment. In: Proceedings 51st Annual Conference for Veterinarians. January 6-9, Colorado State University, Ft. Collins, CO, pp. 461-474.
Packer, L. and Y. Suzuki, 1993. Vitamin E and alpha-lipoate: Role in antioxidant recycling and activation of the NK-B transcription factor. Mol. Asp. Med. 14:229-239.
Selye, H., 1973. The evolution of stress concept. American Scientist, Vol. 61: Nov.-Dec., pp. 692-699.
Siegel, H. S. and M. Van Kampen, 1984. Energy relationships in growing chickens given daily injections of corticosterone. British Poult. Sci., 25:471-485.
Siegel, H. S. and J. W. Latimer, 1984. Interaction of high temperature and Salmonella pullorum antigen concentration on serum agglutinin and corticosteroid responses in white rock chickens. Poultry Sci. 63:2483-2491.
Siegel, H. S., 1995. Stress, strains and resistance. British Poult. Sci., 36:003-22.
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Footnotes
1. This document is VM139, one of a series of the Veterinary Medicine-Large Animal Clinical Sciences Department, Florida Cooperative Extension Service, Institute of Food and Agricultural Sciences, University of Florida. Original publication date June 12, 2002. Visit the EDIS Web Site at http://edis.ifas.ufl.edu.
2. Gary D. Butcher, DVM, Ph.D., Diplomate, American College of Poultry Veterinarians, University of Florida College of Veterinary Medicine, Gainesville, FL., Richard D. Miles, Ph.D., Professor, Poultry Nutritionist, Department of Dairy and Poultry Sciences.
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The Institute of Food and Agricultural Sciences (IFAS) is an Equal Opportunity Institution authorized to provide research, educational information and other services only to individuals and institutions that function with non-discrimination with respect to race, creed, color, religion, age, disability, sex, sexual orientation, marital status, national origin, political opinions or affiliations. For more information on obtaining other extension publications, contact your county Cooperative Extension service.
U.S. Department of Agriculture, Cooperative Extension Service, University of Florida, IFAS, Florida A. & M. University Cooperative Extension Program, and Boards of County Commissioners Cooperating. Larry Arrington, Dean.
Promote health and reduce chronic disease associated with diet and weight.
Overview
Issues and Trends
Nutrition is essential for growth and development, health, and well-being. Behaviors to promote health should start early in life with breastfeeding[1] and continue through life with the development of healthful eating habits. Nutritional, or dietary, factors contribute substantially to the burden of preventable illnesses and premature deaths in the United States.[2] Indeed, dietary factors are associated with 4 of the 10 leading causes of death: coronary heart disease (CHD), some types of cancer, stroke, and type 2 diabetes.[3] These health conditions are estimated to cost society over $200 billion each year in medical expenses and lost productivity.[4] Dietary factors also are associated with osteoporosis, which affects more than 25 million persons in the United States and is the major underlying cause of bone fractures in postmenopausal women and elderly persons.[5]
Many dietary components are involved in the relationship between nutrition and health. A primary concern is consuming too much saturated fat and too few vegetables, fruits, and grain products that are high in vitamins and minerals, carbohydrates (starch and dietary fiber), and other substances that are important to good health. The 2000 Dietary Guidelines for Americans recommend that, to stay healthy, persons aged 2 years and older should follow these ABCs for good health: Aim for fitness, Build a healthy base, and Choose sensibly. To aim for fitness, aim for a healthy weight and be physically active each day. To build a healthy base, let the Pyramid guide food choices; choose a variety of grains daily, especially whole grains; choose a variety of fruits and vegetables daily; and keep food safe to eat. To choose sensibly, choose a diet that is low in saturated fat and cholesterol and moderate in total fat; choose beverages and foods to moderate intake of sugars; choose and prepare foods with less salt; and if consuming alcoholic beverages, do so in moderation.[6] The Food Guide Pyramid, introduced in 1992, is an educational tool that conveys recommendations about the number of servings from different food groups each day and other principles of the Dietary Guidelines for Americans.[7] [Note: In text that follows in this chapter, Dietary Guidelines for Americans will refer to the 2000 Dietary Guidelines for Americans unless otherwise noted.]
The Dietary Guidelines for Americans also emphasize the need for adequate consumption of iron-rich and calcium-rich foods.6 Although some progress has been made since the 1970s in reducing the prevalence of iron deficiency among low-income children,[8] much more is needed to improve the health of children of all ages and of women who are pregnant or are of childbearing age. Since the start of this decade, consumption of calcium-rich foods, such as milk products, has generally decreased and is especially low among teenaged girls and young women.[9] Because important sources of calcium also can include other foods with calcium—occurring naturally or through fortification—as well as dietary supplements, the current emphasis is on tracking total calcium intake from all sources, as demonstrated by an objective in this focus area. In addition, in recent years there has been a concerted effort to increase the folic acid intake of females of childbearing age through fortification and other means to reduce the risk of neural tube defects.[10], [11] (See Focus Area 16. Maternal, Infant, and Child Health.)
In general, however, excesses and imbalances of some food components in the diet have replaced once commonplace nutrient deficiencies. Unfortunately, there has been an alarming increase in the number of overweight and obese persons.[12], [13] Overweight results when a person eats more calories from food (energy) than he or she expends, for example, through physical activity. This balance between energy intake and output is influenced by metabolic and genetic factors as well as behaviors affecting dietary intake and physical activity; environmental, cultural, and socioeconomic components also play a role.
When a body mass index (BMI) cut-point of 25 is used, nearly 55 percent of the U.S. adult population was defined as overweight or obese in 1988–94, compared to 46 percent in 1976–80.12, [14], [15] In particular, the proportion of adults defined as obese by a BMI of 30 or greater has increased from 14.5 percent to 22.5 percent.12 A similar increase in overweight and obesity also has been observed in children above age 6 years in both genders and in all population groups.[16]
Many diseases are associated with overweight and obesity. Persons who are overweight or obese are at increased risk for high blood pressure, type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea, respiratory problems, and some types of cancer. The health outcomes related to these diseases, however, often can be improved through weight loss or, at a minimum, no further weight gain. Total costs (medical costs and lost productivity) attributable to obesity alone amounted to an estimated $99 billion in 1995.[17]
Disparities
Disparities in health status indicators and risk factors for diet-related disease are evident in many segments of the population based on gender, age, race and ethnicity, and income. For example, overweight and obesity are observed in all population groups, but obesity is particularly common among Hispanic, African American, Native American, and Pacific Islander women. Furthermore, despite concerns about the increase in overweight and certain excesses in U.S. diets, segments of the population also suffer from undernutrition, including persons who are socially isolated and poor. Over the years, the recognition of the consequences of food insecurity (limited access to safe, nutritious food) has led to the development of national measures and surveys to evaluate food insecurity and hunger and to the ability to assess disparities among different population groups. With food security and other measures of undernutrition, such as growth retardation and iron deficiency, disparities are evident based not only on income but also on race and ethnicity.
In addition, there are concerns about the nutritional status of persons in hospitals, nursing homes, convalescent centers, and institutions; persons with disabilities, including physically, mentally, and developmentally disabled persons in community settings; children in child care facilities; persons living on reservations; persons in correctional facilities; and persons who are homeless. National data about these population groups are currently unavailable or limited. Data also are insufficient to target the fastest growing segment of the population, old and very old persons who live independently.
Opportunities
Establishing healthful dietary and physical activity behaviors needs to begin in childhood. Educating school-aged children about nutrition is important to help establish healthful eating habits early in life.[18], [19] Research suggests that parents who understand proper nutrition can help children in preschool choose healthful foods, but they have less influence on the choices of school-aged children.[20] Thus, the impact of nutrition education on health may be more effective if targeted directly at school-aged children. Unfortunately, a survey done in 1994 showed that only 69 percent of States and 80 percent of school districts required nutrition education for students in at least some grades from kindergarten through 12th grade.[21]
A well-designed curriculum that effectively addresses essential nutrition education topics can increase students’ knowledge about nutrition, help shape appropriate attitudes, and help develop the behavioral skills students need to plan, prepare, and select healthful meals and snacks.18, [22], [23] Curricula that encourage specific, healthful eating behaviors and provide students with the skills needed to adopt and maintain those behaviors have led to favorable changes in student dietary behaviors and cardiovascular disease risk factors.18, 22, 23 In order to enhance the effectiveness of these lessons, however, nutrition course work should be part of the core curriculum for the professional preparation of teachers of all grades and should be emphasized in continuing education activities for teachers.
Topics considered to be essential at the elementary, middle, junior high, and senior high school levels include using the Food Guide Pyramid; learning the benefits of healthful eating; making healthful food choices for meals and snacks; preparing healthy meals and snacks; using food labels; eating a variety of foods; eating more fruits, vegetables, and grains; eating foods low in saturated fat and total fat more often; eating more calcium-rich foods; balancing food intake and physical activity; accepting body size differences; and following food safety practices.18, [24] In addition, the following topics are considered to be essential at the middle, junior high, and senior high school levels: the Dietary Guidelines for Americans; eating disorders; healthy weight maintenance; influences on food choices such as families, culture, and media; and goals for dietary improvement.18
Nutrition education should be taught as part of a comprehensive school health education program, and essential nutrition education topics should be integrated into science and other curricula to reinforce principles and messages learned in the health units. Nutrition education is addressed within a school health education objective. (See Focus Area 7. Educational and Community-Based Programs.) In addition, students must have access to healthful food choices to enhance further the likelihood of adopting healthful dietary practices. For these reasons, monitoring students’ eating practices at school is important.
Although health promotion efforts should begin in childhood, they need to continue throughout adulthood. In particular, public education about the long-term health consequences and risks associated with overweight and how to achieve and maintain a healthy weight is necessary. While many persons attempt to lose weight, studies show that within 5 years a majority regain the weight.[25] To maintain weight loss, healthful dietary habits must be coupled with decreased sedentary behavior and increased physical activity and become permanent lifestyle changes. (See Focus Area 22. Physical Activity and Fitness.) Additionally, changes in the physical and social environment may help persons maintain the necessary long-term lifestyle changes for both diet and physical activity.
Policymakers and program planners at the national, State, and community levels can and should provide important leadership in fostering healthful diets and physical activity patterns among people in the United States. The family and others, such as health care practitioners, schools, worksites, institutional food services, and the media, can play a key role in this process. For example, registered dietitians and other qualified health care practitioners can improve health outcomes through efforts focused on nutrition screening, assessment, and primary and secondary prevention.
Food-related businesses also can help consumers achieve healthful diets by providing nutrition information for foods purchased in supermarkets, fast-food outlets, restaurants, and carryout operations. For example, the introduction of a new food label in 1993 has resulted in nutrition information on most processed packaged foods, along with credible health and nutrient content claims and standardized serving sizes.[26] While efforts were made in the 1990s to increase the availability of nutrition information, reduced-fat foods, and other healthful food choices in supermarkets, significant challenges remain on these fronts for away-from-home foods purchased at food service outlets. The importance of addressing these challenges is suggested by recent data indicating that nearly 40 percent of a family’s food budget is spent on away-from-home food, including food from restaurants and fast-food outlets.[27] One analysis found that away-from-home foods are generally higher in saturated fat, total fat, cholesterol, and sodium and lower in dietary fiber, iron, and calcium than at-home foods.27 Away-from-home sites include restaurants, fast-food outlets, school cafeterias, vending machines, and other food service outlets. This study also suggested that persons either eat larger amounts when they eat out, eat higher calorie foods, or both.
Many of the Healthy People 2010 objectives that address nutrition and overweight in the United States measure in some way the Nation’s progress toward implementing the recommendations of the Dietary Guidelines for Americans. The recommendations for food and nutrient intake are not intended to be met every day but rather on average over a span of time. Although the Healthy People 2010 dietary intake objectives address the proportion of the population that consumes a specified level of certain foods or nutrients, it is also important to track and report the average amount eaten by different population groups to help interpret progress on these objectives. Other objectives target aspects of undernutrition, including iron deficiency, growth retardation, and food security.
In summary, several actions are recognized as fundamental in achieving this focus area’s objectives:
n
Improving accessibility of nutrition information, nutrition education, nutrition counseling and related services, and healthful foods in a variety of settings and for all population groups.
n
Focusing on preventing chronic disease associated with diet and weight, beginning in youth.
n
Strengthening the link between nutrition and physical activity in health promotion.
n
Maintaining a strong national program for basic and applied nutrition research to provide a sound science base for dietary recommendations and effective interventions.
n
Maintaining a strong national nutrition monitoring program to provide accurate, reliable, timely, and comparable data to assess status and progress and to be responsive to unmet data needs and emerging issues.
n
Strengthening State and community data systems to be responsive to the data users at these levels.
n
Building and sustaining broad-based initiatives and commitment to these objectives by public and private sector partners at the national, State, and local levels.
Interim Progress Toward Year 2000 Objectives
Of the 27 nutrition objectives, targets for 5 have been met, including 2 related to the availability of reduced-fat foods and prevalence of growth retardation.[28] The majority of the objectives have shown some progress, including those related to total fruit, vegetable, and grain product intake and total fat and saturated fat intake; availability of nutrition labeling on foods; breastfeeding; nutrition education in schools; and availability of worksite nutrition and weight management programs. For certain other objectives, such as consumer actions to reduce salt intake and home-delivered meals to elderly persons, there has been little or no progress. And for others, such as intake of calcium-rich food and overweight and obesity, movement has been away from the targets. In particular, the proportion of adults and children who are overweight or obese has increased substantially, and this represents one of the biggest challenges for Healthy People 2010.
Note: Unless otherwise noted, data are from the Centers for Disease Control and Prevention, National Center for Health Statistics, Healthy People 2000 Review, 1998–99.
Healthy People 2010—Summary of Objectives
Nutrition and Overweight
Goal: Promote health and reduce chronic disease associated with diet and weight.
Number
Objective Short Title
Weight Status and Growth
19-1
Healthy weight in adults
19-2
Obesity in adults
19-3
Overweight or obesity in children and adolescents
19-4
Growth retardation in children
Food and Nutrient Consumption
19-5
Fruit intake
19-6
Vegetable intake
19-7
Grain product intake
19-8
Saturated fat intake
19-9
Total fat intake
19-10
Sodium intake
19-11
Calcium intake
Iron Deficiency and Anemia
19-12
Iron deficiency in young children and in females of
childbearing age
19-13
Anemia in low-income pregnant females
19-14
Iron deficiency in pregnant females
Schools, Worksites, and Nutrition Counseling
19-15
Meals and snacks at school
19-16
Worksite promotion of nutrition education and weight management
19-17
Nutrition counseling for medical conditions
Food Security
19-18
Food security
Healthy People 2010 Objectives
Weight Status and Growth
19-1.
Increase the proportion of adults who are at a healthy weight.
Target: 60 percent.
Baseline: 42 percent of adults aged 20 years and older were at a healthy weight (defined as a body mass index [BMI] equal to or greater than 18.5 and less than 25) in 1988–94 (age adjusted to the year 2000 standard population).
Target setting method: Better than the best.
Data source: National Health and Nutrition Examination Survey (NHANES), CDC, NCHS.
Adults Aged 20 Years and Older, 1988–94 (unless noted)
Healthy Weight
19-1.
Both
Genders
Females*
Males*
Percent
TOTAL
42
45
38
Race and ethnicity
American Indian or Alaska Native
DSU
DSU
DSU
Asian or Pacific Islander
DSU
DSU
DSU
Asian
DNC
DNC
DNC
Native Hawaiian and other
Pacific Islander
DNC
DNC
DNC
Black or African American
34
29
40
White
42
47
37
Hispanic or Latino
DSU
DSU
DSU
Mexican American
30
31
30
Not Hispanic or Latino
43
47
39
Black or African American
34
29
40
White
43
49
38
Age
20 to 39 years
51
55
48
40 to 59 years
36
40
31
60 years and older
36
37
33
Family income level†
Lower income (<130 percent of poverty threshold)
38
33
44
Higher income (>130 percent of poverty threshold)
43
48
37
Disability status
Persons with disabilities
32 (1991–94)
35 (1991–94)
30 (1991–94)
Persons without disabilities
41 (1991–94)
45 (1991–94)
36 (1991–94)
Select populations
Persons with arthritis
36 (1991–94)
37 (1991–94)
34 (1991–94)
Persons without arthritis
43 (1991–94)
47 (1991–94)
40 (1991–94)
Persons with diabetes
26
DNA
DNA
Persons without diabetes
43
DNA
DNA
Persons with high blood pressure
27
29
26
Persons without high blood
pressure
46
50
42
DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.
*Data for females and males are displayed to further characterize the issue.
†A household income below 130 percent of poverty threshold is used by the Food Stamp Program.
19-2.
Reduce the proportion of adults who are obese.
Target: 15 percent.
Baseline: 23 percent of adults aged 20 years and older were identified as obese (defined as a BMI of 30 or more) in 1988–94 (age adjusted to the year 2000 standard population).
Target setting method: Better than the best.
Data source: National Health and Nutrition Examination Survey (NHANES), CDC, NCHS.
Adults Aged 20 Years and Older, 1988–94 (unless noted)
Obesity
19-2.
Both
Genders
Females*
Males*
Percent
TOTAL
23
25
20
Race and ethnicity
American Indian or Alaska Native
DSU
DSU
DSU
Asian or Pacific Islander
DSU
DSU
DSU
Asian
DNC
DNC
DNC
Native Hawaiian and other
Pacific Islander
DNC
DNC
DNC
Black or African American
30
38
21
White
22
24
21
Hispanic or Latino
DSU
DSU
DSU
Mexican American
29
35
24
Not Hispanic or Latino
22
25
20
Black or African American
30
38
21
White
22
23
20
Age (not age adjusted)
20 to 39 years
18
21
15
40 to 59 years
28
30
25
60 years and older
24
26
21
Family income level†
Lower income (<130 percent of poverty threshold)
29
35
21
Higher income (>130 percent of poverty threshold)
22
23
20
Disability status
Persons with disabilities
30 (1991–94)
38 (1991–94)
21 (1991–94)
Persons without disabilities
23 (1991–94)
25 (1991–94)
22 (1991–94)
Select populations
Persons with arthritis
30
33
27
Persons without arthritis
21
23
19
Persons with diabetes
41
DNA
DNA
Persons without diabetes
22
DNA
DNA
Persons with high blood pressure
38
47
33
Persons without high blood
pressure
18
20
16
DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.
*Data for females and males are displayed to further characterize the issue.
†A household income below 130 percent of poverty threshold is used by the Food Stamp Program.
19-3.
Reduce the proportion of children and adolescents who are overweight or obese.
Target and baseline:
Objective
Reduction in Overweight or Obese Children and Adolescents*
1988–94
Baseline
2010
Target
Percent
19-3a.
Children aged 6 to 11 years
11
5
19-3b.
Adolescents aged 12 to 19 years
11
5
19-3c.
Children and adolescents aged 6 to 19 years
11
5
*Defined as at or above the gender- and age-specific 95th percentile of BMI based on the revised CDC Growth Charts for the United States.
Target setting method: Better than the best.
Data source: National Health and Nutrition Examination Survey (NHANES), CDC, NCHS.
Children and Adolescents Aged 6 to 19 Years, 1988–94 (unless noted)
Overweight or Obese
19-3a.
Children Aged
6 to 11 Years
19-3b.
Adolescents Aged 12 to 19 Years
19-3c.
Children and Adolescents Aged
6 to 19 Years
Percent
TOTAL
11
11
11
Race and ethnicity
American Indian or Alaska Native
DSU
DSU
DNA
Asian or Pacific Islander
DSU
DSU
DNA
Asian
DNC
DNC
DNC
Native Hawaiian and
other Pacific Islander
DNC
DNC
DNC
Black or African American
15
13
14
White
11
11
11
Hispanic or Latino
DSU
DSU
DSU
Mexican American
17
14
15
Not Hispanic or Latino
11
10
11
Black or African American
15
13
14
White
10
10
10
Gender
Female
11
10
10
Male
12
11
12
Family income level*
Lower income (<130 percent of poverty threshold)
11
16
13
Higher income (>130 percent of poverty threshold)
11
8
10
Disability status
Persons with disabilities
DSU
(1991–94)
DSU
(1991–94)
DSU
(1991–94)
Persons without disabilities
13 (1991–94)
11 (1991–94)
12 (1991–94)
DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
*A household income below 130 percent of poverty threshold is used by the Food Stamp Program.
Maintenance of a healthy weight is a major goal in the effort to reduce the burden of illness and its consequent reduction in quality of life and life expectancy. The selection of a BMI cut-point to establish the upper limit of the healthy weight range is based on the relationship of overweight or obesity to risk factors for chronic disease or premature death. A BMI of less than 25 has been accepted by numerous groups as the upper limit of the healthy weight range, since chronic disease risk increases in most populations at or above this cut-point.14, 15, [29] The lower cut-point for the healthy weight range (BMI of 18.5) was selected to be consistent with national and international recommendations.14, 15 Problems associated with excessive thinness (BMI less than 18.5) include menstrual irregularity, infertility, and osteoporosis. There is some concern that the increased focus on overweight may result in more eating disorders, such as bulimia and anorexia nervosa. (See Focus Area 18. Mental Health and Mental Disorders.) However, no evidence currently exists that suggests the increased focus on overweight has resulted in additional cases of eating disorders.
Overweight and obesity are caused by many factors. These factors reflect the contributions of inherited, metabolic, behavioral, environmental, cultural, and socioeconomic components. As weight increases, so does the prevalence of health risks. Simple, health-oriented definitions of overweight and obesity should be based on the amount of excess body fat at which health risks to individuals begin to increase. No such definitions currently exist. Most current clinical studies assessing the health effects of overweight rely on a measurement of body weight adjusted for height. BMI is the choice for many researchers and health professionals. While the relation of BMI to body fat differs by age and gender, it provides valid comparisons across racial and ethnic groups.[30] However, BMI does not provide information concerning body fat distribution, which has been identified as an independent predictor of health risk.15, 29 Thus, until a better surrogate for body fat is developed, BMI often will be used to screen for overweight and obese individuals. Health risks also increase as waist measurement increases, and thus waist measurement also can be a useful indicator.6
Interpretations of data about overweight and obesity have differed because criteria for these terms have varied over time, from study to study, and from one part of the world to another. National and international organizations now support the use of a BMI of 30 or greater to identify obesity.14, 15 These BMI cut-points are only a guide to the identification and treatment of overweight and obese individuals and allow for the comparison across populations and over time. However, the health risks associated with overweight and obesity are part of a continuum and do not conform to rigid cut-points.
Overweight and obesity affect a large proportion of the U.S. population—55 percent of adults. Between 1976 and 1994, the number of cases of obesity alone increased more than 50 percent—from 14.5 percent of the adult population to 22.5 percent. Approximately 25 percent of U.S. adult females and 20 percent of U.S. adult males are obese.12 Because weight management is difficult for most persons, the Healthy People 2010 target of no more than 15 percent of adults aged 20 years and older having a BMI of 30 or more is ambitious. Nonetheless, the potential benefits from reduction in overweight and obesity are of considerable public health importance and deserve particular emphasis and attention. A concerted public effort will be needed to prevent further increases of overweight and obesity. Health care providers, health plans, and managed care organizations need to be alert to the development of overweight and obesity in their clients and should provide information concerning the associated risks. These groups need to provide guidance to help consumers address this health problem. To lose weight and keep it off, overweight persons will need long-term lifestyle changes in dietary and physical activity patterns that they can easily incorporate into their lives.
Patterns of healthful eating behavior need to begin in childhood and be maintained throughout adulthood. These patterns can be encouraged through nutrition education at schools and worksites that takes into account cultural and other factors influencing diet. Persons should be aware of the impact that away-from-home eating can have on weight management. In order to address physical activity needs, changes in the physical environment—such as access to walkways and bicycle paths—and the social environment—through social support and safe communities—will be needed to achieve long-term success.
There is much concern about the increasing prevalence of obesity in children and adolescents. Overweight and obesity acquired during childhood or adolescence may persist into adulthood and increase the risk for some chronic diseases later in life. Teenaged boys lose some fat accumulated before puberty during adolescence, but fat deposition continues in girls. Thus, without measures of sexual maturity, measures of body fat and body weight are difficult to interpret in children and adolescents. Therefore, the objective to reduce the prevalence of overweight and obesity among children and adolescents has a target set at no more than 5 percent and uses the gender- and age-specific 95th percentile of BMI from the revised Centers for Disease Control and Prevention (CDC) Growth Charts for the United States. Interventions need to recognize that obese children also may experience psychological stress. The reduction of BMI in children and adolescents should be achieved by emphasizing physical activity and a properly balanced diet so that healthy growth is maintained. Additional research is needed to better define the prevalence and health consequences of overweight and obesity in children and adolescents and the implications of such findings for these persons as they become the next generation of adults.
19-4.
Reduce growth retardation among low-income children under age 5 years.
Target: 5 percent.
Baseline: 8 percent of low-income children under age 5 years were growth retarded in 1997 (defined as height for age below the fifth percentile in the age-gender appropriate population using the 1977 NCHS/CDC growth charts;[31] preliminary data; not age adjusted).
Target setting method: Better than the best.
Data source: Pediatric Nutrition Surveillance System, CDC, NCCDPHP.
Low-Income Children Under Age 5 Years, 1997
Growth Retardation
19-4.
Under Age
5 Years
Under Age
1 Year*
Aged
1 Year*
Aged
2 to 4 Years*
Percent
TOTAL
8
10
9
6
Race and ethnicity
American Indian or Alaska
Native
8
9
7
9
Asian or Pacific Islander
9
9
11
8
Asian
DNC
DNC
DNC
DNC
Native Hawaiian and other Pacific Islander
DNC
DNC
DNC
DNC
Black or African American
DNC
DNC
DNC
DNC
White
DNC
DNC
DNC
DNC
Hispanic or Latino
7
7
8
5
Not Hispanic or Latino
DNC
DNC
DNC
DNC
Black or African American
9
15
10
5
White
8
10
9
6
Gender
Female
8
10
8
6
Male
8
10
10
6
Disability status
Children with disabilities
DNC
DNC
DNC
DNC
Children without disabilities
DNC
DNC
DNC
DNC
DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Preliminary data; not age adjusted.
*Data for specific age groups under 5 years are displayed to further characterize the issue.
Retardation in linear growth in preschool children serves as an indicator of overall health and development and also may reflect the adequacy of a child’s diet. Full growth potential may not be reached because of less than optimal nutrition, infectious diseases, chronic diseases, or poor health care. Inadequate maternal weight gain during pregnancy and other prenatal factors that influence birth weight also affect the prevalence of growth retardation among infants and young children.
Growth retardation is not a problem for the majority of young children in the United States. By definition, approximately 5 percent of healthy children are expected to be below the fifth percentile of height for age due to normal biologic variation. If more than 5 percent of a population group is below the fifth percentile, this suggests that full growth potential is not being reached by some children in that group. Among some age and ethnic groups of low-income children under age 5 years in the United States, up to 15 percent are below the fifth percentile. While progress has been made in reducing the prevalence of growth retardation among low-income Hispanic and Asian or Pacific Islander children, it remains especially high for African American children in the first year of life.
Interventions to improve children’s linear growth potential include better nutrition; improvements in the prevention, diagnosis, and treatment of infectious and chronic diseases; and provision and use of adequate health services. Although the response of a population to interventions for growth retardation may not be as rapid as for iron deficiency or underweight, achievement of the objective by the year 2010 in all racial and ethnic, socioeconomic, and age groups should be possible. Special attention should be given to homeless children and those with special health care needs.
Food and Nutrient Consumption
19-5.
Increase the proportion of persons aged 2 years and older who consume at least two daily servings of fruit.
Target: 75 percent.
Baseline: 28 percent of persons aged 2 years and older consumed at least two daily servings of fruit in 1994–96 (age adjusted to the year 2000 standard population).
Target setting method: Better than the best.
Data source: Continuing Survey of Food Intakes by Individuals (CSFII) (2-day average), USDA.
Persons Aged 2 Years and Older, 1994–96
Two or More Daily
Servings of Fruit
Percent
TOTAL
28
Race and ethnicity
American Indian or Alaska Native
DSU
Asian or Pacific Islander
DSU
Asian
DNC
Native Hawaiian and other Pacific Islander
DNC
Black or African American
DNA
White
DNA
Hispanic or Latino
32
Mexican American
29
Other Hispanic
30
Not Hispanic or Latino
Black or African American
24
White
27
Gender and age
Female
2 years and older
26
2 to 5 years (not age adjusted)
43
6 to 11 years (not age adjusted)
26
12 to 19 years (not age adjusted)
23
20 to 39 years (not age adjusted)
20
40 to 59 years (not age adjusted)
26
60 years and older (not age adjusted)
35
Male
2 years and older
29
2 to 5 years (not age adjusted)
46
6 to 11 years (not age adjusted)
27
12 to 19 years (not age adjusted)
22
20 to 39 years (not age adjusted)
23
40 to 59 years (not age adjusted)
28
60 years and older (not age adjusted)
39
Household income level*
Lower income (<130 percent of poverty
threshold)
23
Higher income (>130 percent of poverty
threshold)
29
Disability status
Persons with disabilities
DNC
Persons without disabilities
DNC
DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.
*A household income below 130 percent of poverty threshold is used by the Food Stamp Program.
19-6.
Increase the proportion of persons aged 2 years and older who consume at least three daily servings of vegetables, with at least one-third being dark green or orange vegetables.
Target: 50 percent.
Baseline: 3 percent of persons aged 2 years and older consumed at least three daily servings of vegetables, with at least one-third of these servings being dark green or orange vegetables in 1994–96 (age adjusted to the year 2000 standard population).
Target setting method: Better than the best.
Data source: Continuing Survey of Food Intakes by Individuals (CSFII) (2-day average), USDA.
Persons Aged 2 Years and Older, 1994–96
Servings of Vegetables
19-6.
Meet Both
Recommend-
ations
3 or More Daily
Servings*
One-Third or More Servings From Dark Green or
Orange
Vegetables*
Percent
TOTAL
3
49
8
Race and ethnicity
American Indian or Alaska Native
DSU
DSU
DSU
Asian or Pacific Islander
DSU
DSU
DSU
Asian
DNC
DNC
DNC
Native Hawaiian and other
Pacific Islander
DNC
DNC
DNC
Black or African American
DNA
DNA
DNA
White
DNA
DNA
DNA
Hispanic or Latino
2
47
6
Mexican American
2
50
5
Other Hispanic
DSU
44
6
Not Hispanic or Latino
DNA
DNA
DNA
Black or African American
DNA
43
14
White
DNA
50
8
Gender and age
Female
2 years and older
4
41
10
2 to 5 years (not age adjusted)
DSU
23
9
6 to 11 years (not age
adjusted)
DSU
24
7
12 to 19 years (not age
adjusted)
2
38
7
20 to 39 years (not age
adjusted)
4
43
10
40 to 59 years (not age
adjusted)
4
49
11
60 years and older (not age
adjusted)
6
43
13
Male
2 years and older
3
57
7
2 to 5 years (not age adjusted)
DSU
23
8
6 to 11 years (not age
adjusted)
DSU
27
6
12 to 19 years (not age
adjusted)
DSU
55
4
20 to 39 years (not age
adjusted)
3
68
4
40 to 59 years (not age
adjusted)
4
64
9
60 years and older (not
age adjusted)
6
57
11
Household income level†
Lower income (<130 percent of poverty threshold)
3
42
8
Higher income (>130 percent of poverty threshold)
4
50
8
Disability status
Persons with disabilities
DNC
DNC
DNC
Persons without disabilities
DNC
DNC
DNC
DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Aged adjusted to the year 2000 standard population.
*Data for number and type of daily servings are displayed to further characterize the issue.
†A household income below 130 percent of poverty threshold is used by the Food Stamp Program.
19-7.
Increase the proportion of persons aged 2 years and older who consume at least six daily servings of grain products, with at least three being whole grains.
Target: 50 percent.
Baseline: 7 percent of persons aged 2 years and older consumed at least six daily servings of grain products, with at least three being whole grains in 1994–96 (age adjusted to the year 2000 standard population).
Target setting method: Better than the best.
Data source: Continuing Survey of Food Intakes by Individuals (CSFII) (2-day average), USDA.
Persons Aged 2 Years and Older, 1994–96
Servings of Grains
19-7.
Meet Both
Recommend-
ations
6 or More Daily
Servings*
3 or More Servings From Whole Grain*
Percent
TOTAL
7
51
7
Race and ethnicity
American Indian or Alaska Native
DSU
DSU
DSU
Asian or Pacific Islander
DSU
DSU
DSU
Asian
DNC
DNC
DNC
Native Hawaiian and other Pacific Islander
DNC
DNC
DNC
Black or African American
DNA
DNA
DNA
White
DNA
DNA
DNA
Hispanic or Latino
4
46
4
Mexican American
3
46
4
Other Hispanic
4
46
4
Not Hispanic or Latino
DNA
DNA
DNA
Black or African American
3
40
4
White
7
54
8
Gender and age
Female
2 years and older
4
39
5
2 to 5 years (not age
adjusted)
4
40
5
6 to 11 years (not age
adjusted)
2
46
2
12 to 19 years (not age
adjusted)
6
49
6
20 to 39 years (not age
adjusted)
4
40
5
40 to 59 years (not age
adjusted)
4
38
5
60 years and older (not
age adjusted)
4
28
6
Male
2 years and older
9
64
10
2 to 5 years (not age
adjusted)
5
50
6
6 to 11 years (not age
adjusted)
5
60
5
12 to 19 years (not age
adjusted)
9
77
9
20 to 39 years (not age
adjusted)
10
70
11
40 to 59 years (not age
adjusted)
10
64
11
60 years and older (not age adjusted)
11
54
12
Household income level†
Lower income (<130 percent of poverty threshold)
4
44
5
Higher income (>130 percent of poverty threshold)
7
53
8
Disability status
Persons with disabilities
DNC
DNC
DNC
Persons without disabilities
DNC
DNC
DNC
DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.
*Data for number and type of daily servings are displayed to further characterize the issue.
†A household income below 130 percent of poverty threshold is used by the Food Stamp Program.
The Dietary Guidelines for Americans recommend that Americans choose a variety of grains daily, especially whole grains, and a variety of fruits and vegetables daily.6 In the United States, persons of all ages eat fewer than the recommended number of servings of grain products, vegetables, and fruits.28 Vegetables (including legumes, such as beans and peas), fruits, and grains are good sources of vitamins and minerals, carbohydrates (starch and dietary fiber), and other substances that are important for good health. Some evidence from clinical studies suggests that water-soluble fibers from foods such as oat bran, beans, and certain fruits are associated with lower blood glucose and blood lipid levels.[32] Dietary patterns with higher intakes of vegetables (including legumes), fruits, and grains are associated with a variety of health benefits, including a decreased risk for some types of cancer.32, [33], [34], [35], [36], [37]
The Dietary Guidelines for Americans recommend three to five servings from various vegetables and vegetable juices and two to four servings from various fruits and fruit juices, depending on calorie needs. Consumers can select from a plentiful supply of fresh, frozen, dried, and canned products throughout the year to obtain five or more servings of fruits and vegetables daily. The Dietary Guidelines for Americans recommend that persons choose dark green leafy vegetables, orange vegetables and fruits, and dry beans and peas often. In 1994–96, the average daily intake of fruits and vegetables was five servings, but only about 7 to 10 percent of vegetable servings were dark green or deep yellow (orange), and only about 5 to 6 percent were legumes.[38] In contrast, fried potatoes accounted for about one-third (32 percent) of vegetable servings consumed by youth aged 2 to 19 years. Consumption of fruits and vegetables also is tracked at the State level and is discussed in Tracking Healthy People 2010.
The Dietary Guidelines for Americans recommend 6 to 11 daily servings of grain products, depending on calorie needs, with several of these from whole-grain foods. Although grain product consumption increased during the 1990s, consumption of whole-grain products remains very low. In 1994–96, for the population aged 2 years and older, the average daily intake of grain products was nearly seven servings, but only about 14 to 15 percent of grain servings were whole grain.38 The guidelines also recommend that grain products be prepared with little added saturated fat and moderate or low amounts of added sugars; however, considerable amounts of fats and sugars are contributed to U.S. diets by baked products such as cookies, cakes, and doughnuts.[39], [40] No State-level data on grain intakes are available for adults, adolescents, and children.
19-8.
Increase the proportion of persons aged 2 years and older who consume less than 10 percent of calories from saturated fat.
Target: 75 percent.
Baseline: 36 percent of persons aged 2 years and older consumed less than 10 percent of daily calories from saturated fat in 1994–96 (age adjusted to the year 2000 standard population).
Target setting method: Better than the best.
Data source: Continuing Survey of Food Intakes by Individuals (CSFII) (2-day average), USDA.
Persons Aged 2 Years and Older, 1994–96
Less than 10 Percent of Calories From Saturated Fat
Percent
TOTAL
36
Race and ethnicity
American Indian or Alaska Native
DSU
Asian or Pacific Islander
DSU
Asian
DNC
Native Hawaiian and other Pacific Islander
DNC
Black or African American
DNA
White
DNA
Hispanic or Latino
39
Mexican American
37
Other Hispanic
40
Not Hispanic or Latino
DNA
Black or African American
31
White
35
Gender and age
Female
2 years and older
39
2 to 5 years (not age adjusted)
23
6 to 11 years (not age adjusted)
23
12 to 19 years (not age adjusted)
34
20 to 39 years (not age adjusted)
41
40 to 59 years (not age adjusted)
42
60 years and older (not age adjusted)
47
Male
2 years and older
32
2 to 5 years (not age adjusted)
23
6 to 11 years (not age adjusted)
25
12 to 19 years (not age adjusted)
27
20 to 39 years (not age adjusted)
32
40 to 59 years (not age adjusted)
33
60 years and older (not age adjusted)
42
Household income level*
Lower income (<130 percent of poverty
threshold)
33
Higher income (>130 percent of poverty
threshold)
36
Disability status
Persons with disabilities
DNC
Persons without disabilities
DNC
DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.
*A household income below 130 percent of poverty threshold is used by the Food Stamp Program.
19-9.
Increase the proportion of persons aged 2 years and older who consume no more than 30 percent of calories from total fat.
Target: 75 percent.
Baseline: 33 percent of persons aged 2 years and older consumed no more than 30 percent of daily calories from total fat in 1994–96 (age adjusted to the year 2000 standard population).
Target setting method: Better than the best.
Data source: Continuing Survey of Food Intakes by Individuals (CSFII) (2-day average), USDA.
Persons Aged 2 Years and Older, 1994–96
No More Than 30 Percent of
Calories From
Total Fat
Percent
TOTAL
33
Race and ethnicity
American Indian or Alaska Native
DSU
Asian or Pacific Islander
DSU
Asian
DNC
Native Hawaiian and other Pacific Islander
DNC
Black or African American
DNA
White
DNA
Hispanic or Latino
36
Mexican American
33
Other Hispanic
38
Not Hispanic or Latino
DNA
Black or African American
26
White
33
Gender and age
Female
2 years and older
36
2 to 5 years (not age adjusted)
35
6 to 11 years (not age adjusted)
34
12 to 19 years (not age adjusted)
36
20 to 39 years (not age adjusted)
38
40 to 59 years (not age adjusted)
33
60 years and older (not age adjusted)
40
Male
2 years and older
30
2 to 5 years (not age adjusted)
33
6 to 11 years (not age adjusted)
30
12 to 19 years (not age adjusted)
30
20 to 39 years (not age adjusted)
29
40 to 59 years (not age adjusted)
28
60 years and older (not age adjusted)
34
Household income level*
Lower income (<130 percent of poverty
threshold)
30
Higher income (>130 percent of poverty
threshold)
34
Disability status
Persons with disabilities
DNC
Persons without disabilities
DNC
DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.
*A household income below 130 percent of poverty threshold is used by the Food Stamp Program.
Both the Dietary Guidelines for Americans and the National Cholesterol Education and Prevention Program recommend a diet that contains less than 10 percent of calories from saturated fat and no more than 30 percent of calories from total fat.6, 33, [41] This can be achieved by obtaining most calories from plant foods (grains, fruits, vegetables) that have little added fat. Such a healthful diet also can include low-fat and lean foods from the milk group and the meat group. The increase of overweight and obesity in the United States indicates that more attention needs to be paid to serving size and total calorie content because a low-fat content does not, automatically, signify a lower calorie content.
The role of fat in the diet is complicated because different types of fatty acids have different effects on health. Evidence to date is complicated, but certain messages appear clear: persons in the United States consume too much dietary fat in general, and too much of the fat consumed is from saturated fatty acids—the type associated with an increased risk for heart disease. (See Focus Area 12. Heart Disease and Stroke.)
Strong evidence from human and animal studies shows that diets low in saturated fatty acids and cholesterol are associated with low risks and rates of coronary heart disease. Saturated fatty acids are the major dietary factors that raise blood low-density lipoprotein (LDL) cholesterol levels, increasing the risk for heart disease. Increasing evidence suggests that trans-fatty acids also can increase LDL-cholesterol levels.[42] Monounsaturated and polyunsaturated fatty acids do not raise blood cholesterol. Omega-3 polyunsaturated fatty acids, which are found in some fish such as salmon, tuna, and mackerel, are being studied to determine whether they offer protection against heart disease.6
A 1989 National Research Council report33 indicated that diets high in total fat were associated with a higher risk of several cancers, especially cancer of the colon, prostate, and breast, but noted that findings were inconsistent. (See Focus Area 3. Cancer.) A 1996 review of the evidence showed that the relationship between the amount and type of fat and the risk of cancer continues to be uncertain.[43] To help clarify the relationship between total dietary fat and the risk of cancer, a randomized clinical trial called the Women’s Health Initiative has been started. Set to conclude in 2003, it is a multicenter trial designed to test several risk factors for chronic disease in U.S. females.[44] A major emphasis is to reduce fat to 25 percent of dietary calories to determine whether a low-fat diet has any effect on breast cancer risk.
The proportion of calories in the U.S. diet provided by total fat is about 33 percent, saturated fat is about 11 percent, and trans-fat is about 2.6 percent.[45] The primary sources of saturated fat are meats and dairy products that contain fat. Thus, nonfat and low-fat dairy products and lean meats are choices that can help reduce saturated fat intake. Trans-fatty acids are formed when vegetable oil is hydrogenated to solidify the oils and increase the shelf life and flavor stability of the fats and the foods that contain them. Margarines that have been formulated to contain no trans-fats are available in most U.S. grocery stores. Other dietary sources of trans-fat are restaurant and fast-food fats (including frying fats), baked products, and some snack foods, such as chips.
The major vegetable sources of monounsaturated fatty acids include nuts, avocados, olive oil, canola oil, and high-oleic forms of safflower and sunflower seed oil. The major sources of polyunsaturated fatty acids are vegetable oils, including soybean oil, corn oil, and high-linoleic forms of safflower and sunflower seed oil and a few nuts, such as walnuts. Substituting monounsaturated and polyunsaturated fatty acids for saturated fatty acids can help lower health risks.
The proportion of all meals and snacks from away-from-home sources increased by more than two-thirds between 1977–78 and 1995, from 16 percent of all meals and snacks in 1977–78 to 27 percent of all meals and snacks in 1995.27 Away-from-home food tends to have a higher saturated fat content, and persons tend to consume more calories when eating away from home than at home.27 In 1995, the average total fat and saturated fat content of away-from-home foods, expressed as a percentage of calories, was 38 percent and 13 percent, respectively, compared with 32 percent and 11 percent for at-home foods.27 Meals and snacks eaten by children at school had the highest saturated fat density of all food outlets. Thus, to help assess fat and saturated fat intake, as well as develop strategies to help children reduce the amount of fat they consume, additional tracking of saturated fat and total fat intake from foods eaten away from home as well as at home is important.
19-10.
Increase the proportion of persons aged 2 years and older who consume 2,400 mg or less of sodium daily.
Target: 65 percent.
Baseline: 21 percent of persons aged 2 years and older consumed 2,400 mg or less of sodium daily (from foods, dietary supplements, tap water, and salt use at the table) in 1988–94 (age adjusted to the year 2000 standard population).
Target setting method: Better than the best.
Data source: National Health and Nutrition Examination Survey (NHANES), CDC, NCHS.
Persons Aged 2 Years and Older, 1988–94 (unless noted)
Consume 2,400 mg of Sodium or Less
Percent
TOTAL
21
Race and ethnicity
American Indian or Alaska Native
DSU
Asian or Pacific Islander
DSU
Asian
DNC
Native Hawaiian and other Pacific Islander
DNC
Black or African American
25
White
20
Hispanic or Latino
DSU
Mexican American
25
Not Hispanic or Latino
21
Black or African American
25
White
20
Gender and age
Female
2 years and older
32
2 to 5 years (not age adjusted)
64
6 to 11 years (not age adjusted)
26
12 to 19 years (not age adjusted)
29
20 years and older
30
Male
2 years and older
9
2 to 5 years (not age adjusted)
50
6 to 11 years (not age adjusted)
16
12 to 19 years (not age adjusted)
4
20 years and older
6
Family income level*
Lower income (<130 percent of poverty
threshold)
25
Higher income (>130 percent of poverty
threshold)
20
Disability status (aged 20 years and older)
Persons with
disabilities
18 (1991–94)
Persons without
disabilities
16 (1991–94)
Select populations
Females with high blood pressure
32
Females without high blood pressure
29
Males with high blood pressure
7
Males without high blood pressure
5
DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.
*A household income below 130 percent of poverty threshold is used by the Food Stamp Program.
The Dietary Guidelines for Americans recommend choosing and preparing foods with less salt (salt consists of both sodium and chloride). Most studies in diverse populations have shown that salt intake is linked to increasing levels of blood pressure.6, [46], [47], [48] (See Focus Area 12. Heart Disease and Stroke.) Persons who consume less salt or sodium have a lower risk of developing high blood pressure.6 Data also show that high sodium intake may increase the amount of calcium excreted in the urine and therefore increase the body’s need for calcium.[49] Eating less salt may decrease the loss of calcium from bone.6
Most persons in the United States consume more sodium than is needed, and reduction of sodium or salt or both to no more than 2,400 mg sodium or 6 g salt per day is recommended by some authorities.33, 46 Data from the Continuing Survey of Food Intakes by Individuals show that, even without including salt added at the table, both home foods and away-from-home foods provide excessive amounts of sodium.27 Higher sodium intakes also tend to be associated with higher calorie intakes; for example, males, who consume more calories than females, also consume more sodium.27
Sodium occurs naturally in foods. However, most dietary salt or sodium is added to foods during processing or preparation, with smaller amounts added at the discretion of the consumer in the form of table salt or use of condiments such as soy sauce.[50], [51] Thus, both the sodium content of foods and estimates of the amount of salt added have been used to assess dietary sodium consumption. Other contributing sources of sodium are water, dietary supplements, and medications such as antacids.
19-11.
Increase the proportion of persons aged 2 years and older who meet dietary recommendations for calcium.
Target: 75 percent.
Baseline: 46 percent of persons aged 2 years and older were at or above approximated mean calcium requirements (based on consideration of calcium from foods, dietary supplements, and antacids) in 1988–94 (age adjusted to the year 2000 standard population).
Target setting method: Better than the best.
Data source: National Health and Nutrition Examination Survey (NHANES), CDC, NCHS.
Persons Aged 2 Years and Older, 1988–94 (unless noted)
Met Calcium
Recommendations
Percent
TOTAL
46
Race and ethnicity
American Indian or Alaska Native
DSU
Asian or Pacific Islander
DSU
Asian
DNC
Native Hawaiian and other Pacific Islander
DNC
Black or African American
30
White
49
Hispanic or Latino
DSU
Mexican American
44
Not Hispanic or Latino
46
Black or African American
30
White
50
Gender and age
Female
2 years and older
36
2 to 8 years (not age adjusted)
79
9 to 19 years (not age adjusted)
19
20 to 49 years (not age adjusted)
40
50 years and older (not age adjusted)
27
Male
2 years and older
56
2 to 8 years (not age adjusted)
89
9 to 19 years (not age adjusted)
52
20 to 49 years (not age adjusted)
64
50 years and older (not age adjusted)
35
Family income level*
Lower income (<130 percent of poverty
threshold)
39
Higher income (>130 percent of poverty
threshold)
48
Disability status (aged 20 years and older)
Persons with disabilities
44 (1991–94)
Persons without disabilities
44 (1991–94)
DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.
*A household income below 130 percent of poverty threshold is used by the Food Stamp Program.
Calcium is essential for the formation and maintenance of bones and teeth.32 The recommendations for adequate daily intakes of calcium are 500 mg for children aged 1 to 3 years, 800 mg for children aged 4 to 8 years, 1,300 mg for adolescents aged 9 to 18 years, 1,000 mg for adults aged 19 to 50 years, and 1,200 mg for adults aged 51 years and older.[52] Approximated mean calcium requirements are defined as 77 percent of the recommendations by the Institute of Medicine for adequate intakes of calcium.52, [53] The bone mass achieved at full growth (peak bone mass) appears to be related to intake of calcium during childhood and adolescence.33 Opinion is divided as to the age at which peak bone mass is achieved, although most of the accumulation of bone mineral occurs in humans by about age 20 years. After persons reach their adult height, a period of consolidation of bone density continues until approximately age 30 to 35 years. A high peak bone mass is thought to be protective against fractures in later life.
Osteoporosis is a complex disorder caused by many contributing factors. (See Focus Area 2. Arthritis, Osteoporosis, and Chronic Back Conditions.) Regular exercise and a diet with enough calcium help maintain good bone health and reduce the risk of osteoporosis later in life. However, the ideal level of calcium intake for development of peak bone mass is unknown. For the most part, young children appear to meet the approximate calcium requirements. In contrast, the majority of adolescent and adult females do not meet the average requirements. This is in part because of their lower food consumption, as well as the lower consumption of milk products relative to soft drinks in U.S. diets.[54] For example, in the period 1994–96, the amount of soft drinks consumed was about twice that consumed in the late 1970s and surpassed consumption of fluid milk. Thus, an increase in consumption of various sources of calcium is recommended for nearly all groups and especially for teenaged girls and women. In postmenopausal females—the group at highest risk for osteoporosis—estrogen replacement therapy under medical supervision is the most effective means to reduce the rate of bone loss and risk of fractures.32
The relationship between dietary calcium and blood pressure is uncertain. Results from studies that have used calcium supplements show a small reduction in systolic blood pressure in hypertensive individuals, with no significant reduction in diastolic blood pressure.[55] Among persons with normal blood pressure, there is no significant difference in blood pressure with calcium supplements.[56]
Dietary sources of calcium include milk and milk products such as cheese and yogurt, canned fish with soft bones such as sardines, dark green leafy vegetables such as kale and mustard or turnip greens, tofu made with calcium, tortillas made from lime-processed corn, calcium-enriched grain products, and other calcium-fortified foods and beverages.6 In some locations, water is a source of calcium, but in amounts that cannot readily be determined. With current food selection practices, use of dairy products may constitute the difference between getting enough calcium in one’s diet or not. Nonfat and low-fat dairy products are choices that help reduce the intake of saturated fat while still providing calcium, vitamin D, and other nutrients important for bone health. For those who have lactose intolerance, a range of lactose-reduced dairy products can provide calcium. Persons who do not (or cannot) consume and absorb adequate levels of calcium from dairy food sources may consider use of calcium-fortified foods, while persons with clinical evidence of inadequate intake should receive professional advice on the proper type and dosage of calcium supplements. Calcium supplements come in different forms, including calcium-containing antacids.
Fluid milk (but not yogurt or cheese) is an excellent source of vitamin D, which is essential for calcium utilization. Vitamin D also is synthesized in the skin upon exposure to sunlight.
Iron Deficiency and Anemia
19-12.
Reduce iron deficiency among young children and females of childbearing age.
Target and Baseline:
Objective
Reduction in Iron Deficiency*
1988–94 Baseline
2010
Target
Percent
19-12a.
Children aged 1 to 2 years
9
5
19-12b.
Children aged 3 to 4 years
4
1
19-12c.
Nonpregnant females aged 12 to 49 years
11
7
*Iron deficiency is defined as having abnormal results for two or more of the following tests: serum ferritin concentration, erythrocyte protoporphyrin, or transferrin saturation. Refer to Tracking Healthy People 2010 for threshold values.
Target setting method: Better than the best.
Data source: National Health and Nutrition Examination Survey (NHANES), CDC, NCHS.
Select Populations, 1988–94 (unless noted)
Iron Deficiency
19-12a.
Aged
1 to 2 Years
19-12b.
Aged
3 to 4 Years
19-12c.
Females of Childbearing Age
Percent
TOTAL
9
4
11
Race and ethnicity
American Indian or Alaska
Native
DSU
DSU
DSU
Asian or Pacific Islander
DSU
DSU
DSU
Asian
DNC
DNC
DNC
Native Hawaiian and other Pacific Islander
DNC
DNC
DNC
Black or African American
10
2
15
White
8
3
10
Hispanic or Latino
DSU
DSU
DSU
Mexican American
17
6
19
Not Hispanic or Latino
DNA
DNA
DNA
Black or African American
10
2
15
White
6
1
8
Family income level*
Lower income (<130 percent of poverty threshold)
12
5
16
Higher income (>130 percent of poverty threshold)
7
3
9
Disability status (aged 20 to 49 years)
Persons with disabilities
DNC
DNC
4 (1991–94)
Persons without disabilities
DNC
DNC
12 (1991–94)
DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
*A household income below 130 percent of poverty threshold is used by the Food Stamp Program.
19-13.
Reduce anemia among low-income pregnant females in their third trimester.
Target: 20 percent.
Baseline: 29 percent of low-income pregnant females in their third trimester were anemic (defined as hemoglobin <11.0 g/dL) in 1996.
Target setting method: Better than the best.
Data source: Pregnancy Nutrition Surveillance System, CDC, NCCDPHP.
Low-Income Pregnant Females, Third
Trimester, 1996
Anemia
Percent
TOTAL
29
Race and ethnicity
American Indian or Alaska Native
31
Asian or Pacific Islander
26
Asian
DNC
Native Hawaiian and other Pacific Islander
DNC
Black or African American
DNC
White
DNC
Hispanic or Latino
25
Not Hispanic or Latino
DNA
Black or African American
44
White
24
Disability status
Females with disabilities
DNC
Females without disabilities
DNC
DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
19-14.
(Developmental) Reduce iron deficiency among pregnant females.
Potential data source: National Health and Nutrition Examination Survey (NHANES), CDC, NCHS.
The terms anemia, iron deficiency, and iron deficiency anemia often are used interchangeably but are not equivalent. Iron deficiency ranges from depleted iron stores without functional or health impairment to iron deficiency with anemia, which affects the functioning of several organ systems. Iron deficiency anemia is more likely than iron deficiency without anemia to cause preterm births, low birth weight, and delays in infant and child development.[57], [58], [59] Iron deficiency (with and without anemia) in adolescent females has been associated with decreased verbal learning and memory.[60] The prevalence of iron deficiency anemia among children aged 1 to 2 years and 3 to 4 years and females aged 12 to 49 years in 1988 to 1994 was 3 percent, less than 1 percent, and 4 percent, respectively.
Anemia can be caused by many factors other than iron deficiency, including other nutrient deficiencies, infection, inflammation, and hereditary anemias. Anemia is used for monitoring risk of iron deficiency at the State and local levels because of the low cost and feasibility of measuring hemoglobin or hematocrit in the clinic setting.[61] Anemia is a good predictor of iron deficiency when the prevalence of iron deficiency is high, such as during the third trimester of pregnancy. It is not a good predictor of iron deficiency when the prevalence of iron deficiency is expected to be low, such as among white, non-Hispanic children aged 3 to 4 years in the United States. In that case, the majority of anemia is due to other causes.8 However, changes in the prevalence of anemia over time at State and local levels can be used to evaluate the effectiveness of programs to decrease the prevalence of iron deficiency.
Iron deficiency and anemia among young children declined during the 1970s in association with increased iron intake.8 Although the prevalence of iron deficiency among low-income children continued to decline from 1976–80 to 1988–94, the prevalence of iron deficiency among all young children remained the same, and the prevalence of iron deficiency among females of childbearing age actually increased.9 From 1979 to 1996, the prevalence of third trimester anemia among low-income pregnant females did not change.[62], [63]
Iron deficiency is highest among toddlers and among certain racial, ethnic, and low-income children.[64] Iron deficiency can be prevented among young children by teaching families about child nutrition, including promoting breastfeeding of infants, with exclusive breastfeeding for 4 to 6 months; the use of iron-fortified formulas when formulas are used; delayed introduction of cow’s milk until age 12 months; and age-appropriate introduction of iron-rich solid foods, such as iron-fortified infant cereals and pureed meats, and foods that enhance iron absorption such as vitamin C-rich fruits, vegetables, or juices.61
Nonpregnant females of childbearing age are at increased risk for iron deficiency because of iron loss during menstruation coupled with inadequate intake of iron.61 Pregnant females are also at increased risk because of the increased iron requirements of pregnancy.61, 63 Consequently, a Healthy People 2010 objective has been established to reduce the prevalence of anemia among low-income pregnant females in their third trimester. Although groups other than low-income females are considered at risk for iron deficiency during pregnancy, no nationally representative data exist on the prevalence of iron deficiency or iron deficiency anemia among pregnant females.
National data indicate that only one-fourth of all females of childbearing age (12 to 49 years) meet the U.S. recommended dietary allowance for iron (15 mg) through their diets.[65] Iron deficiency among females of childbearing age may be prevented by periodic anemia screening and appropriate treatment and by counseling them about better eating practices, such as selecting iron-rich foods, taking iron supplements during pregnancy, increasing consumption of foods that enhance iron absorption (for example, orange juice and other citrus products), and discouraging consumption of iron inhibitors (for example, coffee and tea) with iron-rich foods.61 Some good sources of iron include ready-to-eat cereals with added iron; enriched and whole grain breads; lean meats; turkey dark meat; shellfish; spinach; and cooked dry beans, peas, and lentils.
Schools, Worksites, and Nutrition Counseling
19-15.
(Developmental) Increase the proportion of children and adolescents aged 6 to 19 years whose intake of meals and snacks at school contributes to good overall dietary quality.
Potential data sources: Continuing Survey of Food Intakes by Individuals (CSFII), USDA; National Food and Nutrition Survey, USDA and CDC; National Health and Nutrition Examination Survey (NHANES), CDC, NCHS.
Students today have increased food options at school. Although students may understand that good nutrition and good health are connected, that understanding may not be reflected in their food choices and meal patterns. The U.S. Department of Agriculture (USDA) has established standards requiring schools to plan menus that meet the 1995 Dietary Guidelines for Americans, but these standards do not apply to à la carte foods; to foods sold in snack bars, school stores, and vending machines; or to foods students bring from home. Students’ food choices are influenced by the total eating environment created by schools. This includes the types of foods available throughout the school, point-of-choice nutrition information in the cafeteria and around the school, nutrition education provided in the classroom, and nutrition promotions that reach families and affect the choices of foods brought to school.
Improving the quality of students’ dietary intake in the school setting is important because, for many children, meals and snacks consumed at school make a major contribution to their total daily consumption of food and nutrients. National food consumption data collected in 1994 and 1995 show that school foods had the highest saturated fat density of all food outlets.27 School foods also had higher than recommended levels of sodium—as did other away-from-home foods and at-home foods. Nonetheless, these analyses also showed positive aspects of foods obtained from school. School foods had the highest calcium density of all sources and the highest dietary fiber density of all away-from-home sources. The establishment of an environment that supports a good overall diet would enable school nutrition and food services, in conjunction with students, their families, and other school employees, to make an important contribution to short- and long-term disease prevention and health promotion. In addition, such an environment would foster learning readiness (for example, by encouraging students to consume substantial breakfasts).[66], [67], [68]
19-16.
Increase the proportion of worksites that offer nutrition or weight management classes or counseling.
Target: 85 percent.
Baseline: 55 percent of worksites with 50 or more employees offered nutrition or weight management classes or counseling at the worksite or through their health plans in 1998–99.
Target setting method: 55 percent improvement.
Data source: National Worksite Health Promotion Survey, Association for Worksite Health Promotion (AWHP).
Worksites, 1998–99
Offer Nutrition or Weight Management
Classes or Counseling
Worksite Size
Worksite or Health Plan
Worksite
Health Plan
Percent
Total (50 or more employees)
55
28
39
50 to 99 employees
48
21
39
100 to 249 employees
51
29
37
250 to 749 employees
59
44
42
750 or more employees
83
70
50
Worksite programs can reach large numbers of employees with information, activities, and services that encourage the adoption of healthy dietary and physical activity behaviors.[69] (See Focus Area 7. Educational and Community-Based Programs and Focus Area 22. Physical Activity and Fitness.) Employer-sponsored programs can be offered onsite or in partnership with community organizations. Examples of such programs include weight management classes, physical activity programs, lunchtime seminars, self-help programs, cooking demonstrations and classes, healthy food service and vending machine selections, point-of-purchase nutrition information, and flexible health benefits that include nutrition-related services.
A recent study of worksite health promotion programs found that specific interventions at the worksite resulted in employees choosing to reduce the amount of fat calories they consumed and eating more fruits, vegetables, and dietary fiber.[70] Worksite health promotion programs may reduce health care costs, including employer costs for insurance programs, disability benefits, and medical expenses.[71], [72]
If possible, nutrition education and weight management programs at the worksite should be part of a comprehensive health promotion program. In addition, employers could reimburse health promotion activities and provide company time for employees to participate in the programs.[73]
Worksite programs should be made available to the family members of employees and company retirees as well as current employees. Also, these programs should be offered in a culturally and linguistically competent manner and any educational materials provided should be culturally and linguistically appropriate.
19-17.
Increase the proportion of physician office visits made by patients with a diagnosis of cardiovascular disease, diabetes, or hyperlipidemia that include counseling or education related to diet and nutrition.
Target: 75 percent.
Baseline: 42 percent of physician office visits made by patients with a diagnosis of cardiovascular disease, diabetes, or hyperlipidemia included ordering or providing counseling or education on diet and nutrition in 1997 (age adjusted to the year 2000 standard population).
Target setting method: Better than the best.
Data source: National Ambulatory Medical Care Survey (NAMCS), CDC, NCHS.
Persons With Specific
Conditions, 1997
Physician Office Visits That Include
Ordering or Providing Diet and Nutrition Counseling or Education
19-17.
Any of the Three
Conditions
Hyper-
lipidemia*
Cardio-
vascular
Disease*
Diabetes*
Percent
TOTAL
42
65
36
48
Race and ethnicity
American Indian or Alaska Native
DSU
DSU
DSU
DSU
Asian or Pacific Islander
DSU
DSU
DSU
DSU
Asian
DNC
DNC
DNC
DNC
Native Hawaiian and other
Pacific Islander
DNC
DNC
DNC
DNC
Black or African American
46
DSU
40
54
White
41
64
35
47
Hispanic or Latino
DSU
DSU
DSU
DSU
Not Hispanic or Latino
DSU
DSU
DSU
DSU
Black or African American
DSU
DSU
DSU
DSU
White
DSU
DSU
DSU
DSU
Gender
Female
39
55
34
46
Male
44
73
38
49
Age
20 to 44 years
45
75
37
49
45 to 64 years
41
62
36
47
65 years and older
33
44
32
45
Family income level†
Lower income (<130 percent of poverty threshold)
DNC
DNC
DNC
DNC
Higher income (>130 percent of poverty threshold)
DNC
DNC
DNC
DNC
Disability status
Persons with disabilities
DNC
DNC
DNC
DNC
Persons without disabilities
DNC
DNC
DNC
DNC
DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.
*Data for separate conditions are displayed to further characterize the issue.
†A household income below 130 percent of poverty threshold is used by the Food Stamp Program.
Primary care providers are well positioned in the health care system to provide preventive services, including nutrition screening and assessment, referral, and counseling. For example, they can screen for age-specific and diagnosis-related nutrition risk factors as a part of routine patient contact. The public views physicians—and registered dietitians in particular—as credible sources of nutrition information.[74] Dietary assessment, counseling, and followup by physicians and qualified nutrition professionals are effective in reducing patient dietary fat intake and serum cholesterol.[75], [76], [77], [78] For many physicians, referring patients to qualified nutrition professionals for nutrition assessment, education, counseling on behavioral change, diet modification, and specialized nutrition therapies represents appropriate clinical practice.
Nutrition counseling by registered dietitians and other qualified nutrition professionals has been found to be cost effective for patients with hyperlipidemia[79], [80] and type 2 diabetes mellitus.[81] Nutrition services also are a critical component of improved health outcomes for many other diseases and conditions, including obesity, gastrointestinal and hepatic disease, renal disease, cancer, HIV/AIDS, pressure ulcers, burns and trauma, eating disorders, and prenatal care. A 1997 study that evaluated the cost of covering medical nutrition therapy under Medicare part B projected savings to the program of $11 million in 2001 and $65 million in 2004.[82], [83] (See Focus Area 3. Cancer, Focus Area 4. Chronic Kidney Disease, Focus Area 13. HIV, and Focus Area 16. Maternal, Infant, and Child Health.)
Food Security
19-18.
Increase food security among U.S. households and in so doing reduce hunger.
Target: 94 percent.
Baseline: 88 percent of all U.S. households were food secure in 1995.
Target setting method: 6 percentage point improvement (50 percent decrease in food insecurity; consistent with the U.S. pledge to the 1996 World Food Summit).
Data sources: Food Security Supplement to the Current Population Survey, U.S. Department of Commerce, Bureau of the Census; National Food and Nutrition Survey (beginning in 2001), HHS and USDA.
U.S. Households, 1995
Food Secure
Percent
TOTAL
88
Race and ethnicity
American Indian or Alaska Native
78
Asian or Pacific Islander
91
Asian
DSU
Native Hawaiian and other Pacific Islander
DSU
Black or African American
76
White
90
Hispanic or Latino
75
Mexican American
73
Not Hispanic or Latino
89
Black or African American
76
White
91
Lower income level (<130 percent of poverty threshold)*
All
69
With children (under age 18 years)
59
With elderly persons (aged 65 years and over)
85
Higher income level (>130 percent of poverty threshold)*
All
94
With children (under age 18 years)
91
With elderly persons (aged 65 years and over)
98
Disability status
Persons with disabilities
DNC
Persons without disabilities
DNC
Select populations
Household characteristics
With children
83
With elderly persons
94
DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
*A household income below 130 percent poverty threshold is used by the Food Stamp Program.
Food security means that people have access at all times to enough food for an active, healthy life. It implies that people have nutritionally adequate and safe foods and sufficient household resources to ensure their ability to acquire adequate, acceptable foods in socially acceptable ways—that is, through regular marketplace sources and not through severe coping strategies like emergency food sources, scavenging, and stealing. Hunger in this context refers to the uneasy or painful sensation caused by a lack of food.
While the vast majority of persons in the United States are food secure and have not experienced resource-constrained hunger, both food insecurity and hunger have remained a painful fact of life for too many people.[84], [85] The specific concern is with food insecurity and hunger resulting from inadequate household resources. Other sources of food insecurity (such as illness, child abuse and neglect, or loss of function or mobility) are not included in this definition. Food insecurity and hunger may coexist with malnutrition, but they are not the same thing or even necessarily closely associated. Food insecurity and hunger, however, are believed to have harmful health and behavioral impacts in their own right.[86] These are of particular concern for pregnant women, children, elderly persons, and other nutritionally vulnerable groups.[87]
The United States is committed to increasing food security by working with local leaders as outlined in the U.S. Action Plan on Food Security, through USDA’s Community Food Security Initiative, and the Maternal and Child Health Bureau’s Healthy Start.[88], [89]
Related Objectives From Other Focus Areas
1.
Access to Quality Health Services
1-3.
Counseling about health behaviors
2.
Arthritis, Osteoporosis, and Chronic Back Conditions
2-9.
Cases of osteoporosis
3.
Cancer
3-1.
Overall cancer deaths
3-3.
Breast cancer deaths
3-5.
Colorectal cancer deaths
3-10.
Provider counseling about cancer prevention
4.
Chronic Kidney Disease
4-3.
Counseling for chronic kidney failure care
5.
Diabetes
5-1.
Diabetes education
5-2.
New cases of diabetes
5-6.
Diabetes-related deaths
7.
Educational and Community-Based Programs
7-2.
School health education
7-5.
Worksite health promotion programs
7-6.
Participation in employer-sponsored health promotion activities
7-10.
Community health promotion programs
7-11.
Culturally appropriate and linguistically competent community health promotion programs
10.
Food Safety
10-4.
Food allergy deaths
10-5.
Consumer food safety practices
11.
Health Communication
11-4.
Quality of Internet health information sources
12.
Heart Disease and Stroke
12-1.
Coronary heart disease (CHD) deaths
12-7.
Stroke deaths
12-9.
High blood pressure
12-11.
Action to help control blood pressure
12-13.
Mean total blood cholesterol levels
12-14.
High blood cholesterol levels
16.
Maternal, Infant, and Child Health
16-10.
Low birth weight and very low birth weight
16-12.
Weight gain during pregnancy
16-15.
Spina bifida and other neural tube defects
16-16.
Optimum folic acid levels
16-17.
Prenatal substance exposure
16-18.
Fetal alcohol syndrome
16-19.
Breastfeeding
18.
Mental Health and Mental Disorders
18-5.
Eating disorder relapses
22.
Physical Activity and Fitness
22-1.
No leisure-time physical activity
22-2.
Moderate physical activity
22-3.
Vigorous physical activity
22-6.
Moderate physical activity in adolescents
22-7.
Vigorous physical activity in adolescents
22-9.
Daily physical education in schools
22-13.
Worksite physical activity and fitness
26.
Substance Abuse
26-12.
Average annual alcohol consumption
Terminology
(A listing of abbreviations and acronyms used in this publication appears in Appendix H.)
Anemia: A condition in which the hemoglobin in red blood cells falls below normal. Anemia most often results from iron deficiency but also may result from deficiencies of folic acid, vitamin B12, or copper, or from chronic disease, certain conditions, or chronic blood loss.
Body mass index (BMI): Weight (in kilograms) divided by the square of height (in meters), or weight (in pounds) divided by the square of height (in inches) times 704.5. Because it is readily calculated, BMI is the measurement of choice as an indicator of healthy weight, overweight, and obesity.
Calorie: Unit used for measuring the energy produced by food when metabolized in the body.
Cholesterol: A waxy substance that circulates in the bloodstream. When the level of cholesterol in the blood is too high, some of the cholesterol is deposited in the walls of the blood vessels. Over time, these deposits can build up until they narrow the blood vessels, causing atherosclerosis, which reduces the blood flow. The higher the blood cholesterol level, the greater is the risk of getting heart disease. Blood cholesterol levels of less than 200 mg/dL are considered desirable. Levels of 240 mg/dL or above are considered high and require further testing and possible intervention. Levels of 200-239 mg/dL are considered borderline. Lowering blood cholesterol reduces the risk of heart disease.
HDL (high-density lipoprotein) cholesterol: The so-called good cholesterol. Cholesterol travels in the blood combined with protein in packages called lipoproteins. HDL is thought to carry cholesterol away from other parts of the body back to the liver for removal from the body. A low level of HDL increases the risk for CHD, whereas a high HDL level is protective.
LDL (low-density lipoprotein) cholesterol: The so-called bad cholesterol. LDL contains most of the cholesterol in the blood and carries it to the tissues and organs of the body, including the arteries. Cholesterol from LDL is the main source of damaging buildup and blockage in the arteries. The higher the level of LDL in the blood, the greater is the risk for CHD.
Complex carbohydrate: Starch and dietary fiber.
Coronary heart disease (CHD): The type of heart disease due to narrowing of the coronary arteries.
Dietary fiber: Plant food components, including plant cell walls, pectins, gums, and brans that cannot be digested.
Dietary Guidelines for Americans: A report published by the U.S. Department of Agriculture and U.S. Department of Health and Human Services that explains how to eat to maintain health. The guidelines form the basis of national nutrition policy and are revised every 5 years. This chapter refers mostly to the 2000 guidelines.
Fats/fatty acids: Fats and fatty acids are hydrocarbon chains ending in a carboxyl group at one end that bond to glycerol to form fat. Fatty acids are characterized as saturated, monounsaturated, or polyunsaturated depending on how many double bonds are between the carbon atoms. Fatty acids supply energy and promote absorption of fat-soluble vitamins. Some fatty acids are “essential,” because they cannot be made by the body.
Saturated fatty acids: Fatty acids with no double bonds between carbon atoms. Levels of saturated fatty acids are especially high in meat and dairy products that contain fat. Saturated fatty acids are linked to increased blood cholesterol levels and a greater risk for heart disease.
Trans-fatty acids: Alternate forms of naturally occurring unsaturated fatty acids produced in fats as a result of hydrogenation, such as when vegetable oil becomes margarine or shortening. Trans-fatty acids also occur in milk fat, beef fat, and lamb fat. These fatty acids have been associated with increased blood cholesterol levels.
Unsaturated fatty acids: Fatty acids with one or more double bonds between carbon atoms. These fatty acids do not raise blood cholesterol levels.
Polyunsaturated: Fatty acids with more than one double bond between carbon atoms.
Monounsaturated: Fatty acids with one double bond between carbon atoms.
Food Guide Pyramid: A graphic depiction of U.S. Department of Agriculture’s current food guide that includes five major food groups in its “base” (grains, vegetables, fruits, milk products, and meats, and meat substitutes) and a “tip” depicting the relatively small contribution that discretionary fat and added sugars should make in U.S. diets. The Food Guide Pyramid provides information on the choices within each group and the recommended number of servings.
Food security: Access by all people at all times to enough food for an active, healthy life. It includes at a minimum (1) the ready availability of nutritionally adequate and safe foods, and (2) an assured ability to acquire acceptable foods in socially acceptable ways.
Food insecurity: Limited or uncertain availability of nutritionally adequate and safe foods or limited and uncertain ability to acquire acceptable foods in socially acceptable ways.
HDL-cholesterol: See cholesterol.
Hunger: The uneasy or painful sensation caused by a lack of food.
Hypertension: High blood pressure.
Hypertriglyceridemia: Elevated levels of triglycerides in the blood.
Iron deficiency: Lack of adequate iron in the body to support and maintain functioning. It can lead to iron deficiency anemia, a reduction in the concentration of hemoglobin in the red blood cells due to a lack of iron supply to the bone marrow.
LDL-cholesterol: See cholesterol.
Linear growth: Increase in length or height.
Medical nutrition therapy: Use of specific nutrition counseling and interventions, based on an assessment of nutritional status, to manage a condition or treat an illness or injury.
Metabolism: The sum total of all the chemical reactions that go on in living cells.
Nutrition: The set of processes by which nutrients and other food components are taken in by the body and used.
Obesity: A condition characterized by excessive body fat.
Osteoporosis: A bone disease characterized by a reduction in bone mass and a deterioration of the bone structure leading to bone fragility.
Overweight: Excess body weight.
Physical activity: Bodily movement that substantially increases energy expenditure.
Registered dietitian: A food and nutrition expert who has met the minimum academic and professional requirements to receive the credential “RD.” Many States and Commonwealths also have licensing laws for dietitians and nutrition practitioners.
Sedentary behavior: A pattern of behavior that is relatively inactive, such as a lifestyle characterized by a lot of sitting.
Type 2 diabetes: The most common form of diabetes, which results from insulin resistance and abnormal insulin action. Type 2 diabetes was previously referred to as noninsulin-dependent diabetes mellitus (NIDDM) and adult-onset diabetes.
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