MODULE 5A - Nutrition Science, Assessment and Prescription
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OBJECTIVES:
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nutrition in clinical medicine
In 1957, a surgeon named Denis Burkitt first encountered a puzzling form of childhood cancer. The condition, which came to be called Burkitt's lymphoma, caused a massive swelling of the jaw and was often fatal. But Burkitt noticed something peculiar: The disease followed a geographic pattern, never appearing far from the equator and the east coast of Africa. He painstakingly identified the cause - a virus (known as Epstein-Barr) transmitted by an insect vector - and then found an effective treatment. His lifesaving work was acclaimed throughout the world of medicine.
Soon thereafter, Dr. Burkitt set his sights on larger medical epidemics whose solutions were hidden in much bigger geographical puzzle. He noticed that the great bulk of diseases occurring in the Western world - heart disease, diabetes, obesity, and many others - were surprisingly rare in rural Africa. During 20 years of surgical practice in Africa, he removed only 2 gallbladders, something he might have done on a single morning in London hospital. Many other conditions, from appendicitis to colon cancer, were rare in Africa, but common in Europe. He ruled out genetics as the main explanation, because people moving from one country to another eventually assumed the same risks as the populations in their adopted homes.
Burkitt proposed that the culprit was diet. In Europe and the Americas, diets bore no resemblance to a fiber-rich African diet. On the contrary, they were fiber-depleted and laden with fat, cholesterol, and sugar. His work, and that of other medical pioneers, launched a major rethinking of the fundamental causes of illness. Previously, nutrition had been thought to play a fairly minor role in health. There were rare deficiency states such as pellarga or scurvy, but these were little more than details on medical school examinations. The major killer diseases were thought to have more to do with genes and bad luck than diet. but this new breed of researchers held that nutrition was decisive. It was a fundamental contributor to the major diseases that filled doctors' waiting rooms throughout the Western world.
Soon thereafter, Dr. Burkitt set his sights on larger medical epidemics whose solutions were hidden in much bigger geographical puzzle. He noticed that the great bulk of diseases occurring in the Western world - heart disease, diabetes, obesity, and many others - were surprisingly rare in rural Africa. During 20 years of surgical practice in Africa, he removed only 2 gallbladders, something he might have done on a single morning in London hospital. Many other conditions, from appendicitis to colon cancer, were rare in Africa, but common in Europe. He ruled out genetics as the main explanation, because people moving from one country to another eventually assumed the same risks as the populations in their adopted homes.
Burkitt proposed that the culprit was diet. In Europe and the Americas, diets bore no resemblance to a fiber-rich African diet. On the contrary, they were fiber-depleted and laden with fat, cholesterol, and sugar. His work, and that of other medical pioneers, launched a major rethinking of the fundamental causes of illness. Previously, nutrition had been thought to play a fairly minor role in health. There were rare deficiency states such as pellarga or scurvy, but these were little more than details on medical school examinations. The major killer diseases were thought to have more to do with genes and bad luck than diet. but this new breed of researchers held that nutrition was decisive. It was a fundamental contributor to the major diseases that filled doctors' waiting rooms throughout the Western world.
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Burkitt proposed that health authorities should spend less time dealing with the results of bad diet and more time encouraging people to change the way they eat.
To continue to treat illnesses while ignoring prevention, he said, was like a plumber mopping up a kitchen floor rather than turning off the faucet in an overflowing sink. A new focus on nutrition and prevention could turn the tide in the epidemics of our time. |
evolving knowledge in nutrition*
Just as new medications often have advantages over previous ones, diet approaches evolve as well, with new dietary methods building on previous ones and research studies putting diets to the test. Heart-healthy diets are a case in point. For decades, cardiologists have encouraged heart patients to switch from red meat to white meat, trim away chicken skin, and stay physically active. These steps were modestly helpful. Following such guidance, an average patient experienced roughly a 5% drop in low density lipoprotein (LDL) cholesterol.
However, in 1990, a Harvard-trained physician named Dean Ornish published the results of a study using a much more vigorous regimen. His research participants had significant heart disease. His experimental treatment included low-fat, vegetarian diet, smoking cessation, modest exercise, and stress management. The diet was logical: Foods from plants have no cholesterol and no animal fat. For comparison study included a control group that received the usual care that doctors provide for heart patients.
The result made medical history. Not only did the program reduce cholesterol far more effectively than previous diets, it visibly changed the disease process itself. Angiograms done before and after the one-year intervention showed that participants in the control group gradually worsened. But the patients in the experimental group had a very different experience. Their coronary arteries were beginning to open up again, so much so that signs of reversal were clearly evident in 82% of participants within the first year.
In 1999, Dr. Caldwell Esselstyn, a Cleveland Clinic surgeon, published the results of remarkable 12-year study integrating nutrition with medications. In a group of patients with severe heart disease, he used a diet similar to that used by Dr. Ornish. For any patient whose total cholesterol remained above 150 mg/dl despite the diet, he added cholesterol-lowering medications. In the ensuing 12 years, the research participants had no cardiac events. The combination of the the diet and judiciously used medications made the patients practically health-attack-proof.
However, in 1990, a Harvard-trained physician named Dean Ornish published the results of a study using a much more vigorous regimen. His research participants had significant heart disease. His experimental treatment included low-fat, vegetarian diet, smoking cessation, modest exercise, and stress management. The diet was logical: Foods from plants have no cholesterol and no animal fat. For comparison study included a control group that received the usual care that doctors provide for heart patients.
The result made medical history. Not only did the program reduce cholesterol far more effectively than previous diets, it visibly changed the disease process itself. Angiograms done before and after the one-year intervention showed that participants in the control group gradually worsened. But the patients in the experimental group had a very different experience. Their coronary arteries were beginning to open up again, so much so that signs of reversal were clearly evident in 82% of participants within the first year.
In 1999, Dr. Caldwell Esselstyn, a Cleveland Clinic surgeon, published the results of remarkable 12-year study integrating nutrition with medications. In a group of patients with severe heart disease, he used a diet similar to that used by Dr. Ornish. For any patient whose total cholesterol remained above 150 mg/dl despite the diet, he added cholesterol-lowering medications. In the ensuing 12 years, the research participants had no cardiac events. The combination of the the diet and judiciously used medications made the patients practically health-attack-proof.
Then, in 2005, David Jenkins, from the University of Toronto, took things a step further. He emphasized foods with known cholesterol-lowering properties - oats, soy, and certain nuts, for example. In four weeks' time, LDL cholesterol fell nearly 30%. As research has moved forward, our idea of an effective diet has advanced as well.
The same sort of trend has occurred in the approach to cancer. For many years, lifestyle advice from cancer authorities was limited to avoiding tobacco and getting regular checkups. But it has become clear that diet plays a major role in cancer risk. We now encourage all patients to include more fruits and vegetables in their routines, to focus on foods that are rich in antioxidants, and to limit fat and boost fiber.
More recently, nutritional steps have been tested not only for cancer prevention, but for cancer survival. Studies of individuals diagnosed with breast or prostate cancer have shown that diet may make a major difference in the ensuing years.
The same sort of trend has occurred in the approach to cancer. For many years, lifestyle advice from cancer authorities was limited to avoiding tobacco and getting regular checkups. But it has become clear that diet plays a major role in cancer risk. We now encourage all patients to include more fruits and vegetables in their routines, to focus on foods that are rich in antioxidants, and to limit fat and boost fiber.
More recently, nutritional steps have been tested not only for cancer prevention, but for cancer survival. Studies of individuals diagnosed with breast or prostate cancer have shown that diet may make a major difference in the ensuing years.
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Article Review
Plant-based diet and coronary artery disease
The origin of dietary fiber hypothesis
Dietary Portfolio of cholesterol lowering food
Plant-based diet and coronary artery disease
The origin of dietary fiber hypothesis
Dietary Portfolio of cholesterol lowering food
safe and effective approach*
Dietary approaches are often remarkably effective. The cholesterol lowering power of the diets by Drs. Ornish, Esselstyn, and Jenkins rivals that of typical cholesterol-lowering medications. Their effect on blood glucose control rivals that of oral diabetes drugs. For migraines or arthritis, not everyone improves with dietary adjustments that eliminate common dietary triggers, but many do; in controlled clinical trials, sometimes simple diet changes bring dramatic improvements.
Unlike the undesirable side-effects we associate with medications, healthful diet changes desirable side-effects. people who adjust the menu in hopes of reducing their cholesterol get the bonus of losing unwanted weight. Their blood pressure drifts downward as well. If they have diabetes, it comes under better control, and they may be able to reduce their need for medication.
While many still think of medications as "conventional medicine" and dietary changes as "alternative therapies," a growing number of clinicians would turn the definitions around. For many conditions, attention to diet and lifestyle is the foundation of good clinical care. Medications, surgery, or other treatments should be used when diet and lifestyle changes do not apply or are not, by themselves, sufficient for the task at hand.
New clinicians come to find that problems they had once regarded as strictly medical, or perhaps even genetic - diabetes and coronary disease, for example - have major nutritional antecedents. As time goes on, they start to see nutritional problems everywhere. The role of nutrition is indeed greater than most clinicians and patients realize. At the same time, not all problems have nutritional connections, and even for nutrition-related conditions, medical diagnosis and treatment have as important a role now as ever.
Unlike the undesirable side-effects we associate with medications, healthful diet changes desirable side-effects. people who adjust the menu in hopes of reducing their cholesterol get the bonus of losing unwanted weight. Their blood pressure drifts downward as well. If they have diabetes, it comes under better control, and they may be able to reduce their need for medication.
While many still think of medications as "conventional medicine" and dietary changes as "alternative therapies," a growing number of clinicians would turn the definitions around. For many conditions, attention to diet and lifestyle is the foundation of good clinical care. Medications, surgery, or other treatments should be used when diet and lifestyle changes do not apply or are not, by themselves, sufficient for the task at hand.
New clinicians come to find that problems they had once regarded as strictly medical, or perhaps even genetic - diabetes and coronary disease, for example - have major nutritional antecedents. As time goes on, they start to see nutritional problems everywhere. The role of nutrition is indeed greater than most clinicians and patients realize. At the same time, not all problems have nutritional connections, and even for nutrition-related conditions, medical diagnosis and treatment have as important a role now as ever.
food patterns
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It is more important to utilize a general approach to food than specific types of food. The simple and effective advice comes from the journalist Michael Pollan.
Among the many types of nutrition guidelines, the most important is to consume whole food which is often called "food as grown." Giving emphasis on the level of food processing will clearly define the optimal source for daily food consumption. It effectively provides a clear guide as to food item choices commonly purchased by patients. It is also necessary to establish mindful eating habit, visualizing what follows after every swallows . |
levels of processing
Most foods that we consume require some processing. Everything from chopping to mixing ingredients to packaging can be considered as part of processing food. But the amount of processing varies and it is recommended that 80% of average caloric intake come from whole or slightly processed foods, and no more than 5% of average caloric intake come from ultra processed food.
PROCESSING LEVEL |
DESCRIPTION |
Level 1 - Slightly Processed |
Smahed or cut but nothing removed |
Level 2 - Moderately Processed |
Some of the original content removed, and/or mixed with other ingredients available in a typical kitchen |
Level 3 - Ultra Processed |
Created in a processing plant, is closer to a chemical mix than actual food; has ingredients not found in a typical kitchen |
ADVANCED GLYCATION END PRODUCTS
This is a family of oxidative stress by-products. Advanced Glycation End Products (AGEs) damage cells that live a long time including nerve, kidney, eye and collagen that can be increased in three ways:
ARTICLE REVIEW
Advanced glycation end products
This is a family of oxidative stress by-products. Advanced Glycation End Products (AGEs) damage cells that live a long time including nerve, kidney, eye and collagen that can be increased in three ways:
- Processed foods
- Animal products
- Foods prepared in dry heat (grilling, broiling, roasting, searing and frying)
ARTICLE REVIEW
Advanced glycation end products
mindful eating
This is a practice of maintaining an in-the-moment awareness of food and drink you put into your mouth. This requires you simply acknowledge and accept the feelings, thoughts and bodily sensations you observe and can extend to the process of buying, preparing, serving as well as consuming the food.
Most people have busy lives that usually makes rush during mealtimes and eat mindlessly shoveling food down regardless of whether they're hungry or not. A person would eat for reasons other than hunger including satisfying emotional needs, relieving stress, and coping with unpleasant emotions such as anxiety, loneliness, boredom and sadness. Mindfulness is totally the opposite of this mostly unconscious practice of "mindless" eating.
Mindful eating is not about imposing strict rules for how much calories you can only eat or which types of foods you need to include or avoid on your plate. It's not about being always eating the right thing, rather, its about focusing all your senses and being present when you select food from the shop and market, when you cook and eat. Evidence show this practice can help you avoid overeating and eventually make it easier to change dietary habits for improved mental and physical well-being that comes with a healthier diet.
Basic tips:
ARTICLE REVIEW
Mindful Eating with Diabetes
Most people have busy lives that usually makes rush during mealtimes and eat mindlessly shoveling food down regardless of whether they're hungry or not. A person would eat for reasons other than hunger including satisfying emotional needs, relieving stress, and coping with unpleasant emotions such as anxiety, loneliness, boredom and sadness. Mindfulness is totally the opposite of this mostly unconscious practice of "mindless" eating.
Mindful eating is not about imposing strict rules for how much calories you can only eat or which types of foods you need to include or avoid on your plate. It's not about being always eating the right thing, rather, its about focusing all your senses and being present when you select food from the shop and market, when you cook and eat. Evidence show this practice can help you avoid overeating and eventually make it easier to change dietary habits for improved mental and physical well-being that comes with a healthier diet.
Basic tips:
- Eat slowly
- Use small plates, bowls, and utensils
- Chew each bite at least 20 times
- Pause between bites
- Sitting down, not multi-tasking (social media, phone, etc.)
- Savor the moment
ARTICLE REVIEW
Mindful Eating with Diabetes
food consumption timing
There could be may variations of food consumption timing that would apply to different cases and situations.
- Two meals per day plus a snack. This means skipping lunch or dinner and/or turn it into a snack and making sure you eat breakfast.
- Time restricted eating. This is a practice of eating all food within the 12 hour window. Example is having breakfast at 7am and finishing dinner by 7pm. Another way is doing a 10 or 8 windows may be even better.
FASTING
Fasting can have therapeutic benefit with many different types:
Fasting can also vary in length:
ARTICLE REVIEW
Intermittent Fasting and Diabetes
Effect of Short-term fasting on Cancer treatment
Fasting can have therapeutic benefit with many different types:
- Water fast: drink only water - for detox and rests
- Juice fast: drink vegetable/fruit juices - for individuals needing a high antioxidant load
- Longevity fast: 800 calories, half from nuts/half from vegetables
Fasting can also vary in length:
- 24-36 hours: a good place to start
- 3-10 days: where days: where real therapeutic benefit begins
- >10 days: requires close medical supervision, usually done in a residential setting
ARTICLE REVIEW
Intermittent Fasting and Diabetes
Effect of Short-term fasting on Cancer treatment
plant based food
Plant based food is the typical diet with 95% of calories coming from vegetables, fruits, whole grains, legumes, nuts and seeds and up to 5% of calories may come from meat, fish, dairy and eggs. The goal is to eat varied colors of food everyday ideally consuming about 20 varieties of fruits, vegetables, grains, legumes, nuts and seeds.
Nutrition is a vital part of providing lifestyle counseling. This includes understanding which nutrients we need, what kinds of food provide them and how our body uses them. We have to keep in mind is that humans don’t need individual nutrients but food. Which is always a mixture of multiple substances, nutrients and some types of chemicals.
Our goal is to consume the right combination of foods so that our diet provides all the nutrients and other substances we need. Unfortunately, now a days, many people follow a diet that includes a poor combination of foods. Not only are they missing out on important nutrients or consuming others in excess, but they’re also putting their health in danger.
In the basic application of clinical nutrition you need to get an overview of the most important principles of diet and nutrition. That way, you will be able to set up a healthy diet for your patient that provides enough of the essential nutrients without an excess of calories. Knowing this principles is the first step to become an authority in your field and understand the science behind successful diet.
Our goal is to consume the right combination of foods so that our diet provides all the nutrients and other substances we need. Unfortunately, now a days, many people follow a diet that includes a poor combination of foods. Not only are they missing out on important nutrients or consuming others in excess, but they’re also putting their health in danger.
In the basic application of clinical nutrition you need to get an overview of the most important principles of diet and nutrition. That way, you will be able to set up a healthy diet for your patient that provides enough of the essential nutrients without an excess of calories. Knowing this principles is the first step to become an authority in your field and understand the science behind successful diet.
MEAL PLANNING
When it comes to meal planning and nutrition, your patient's goals might be to lose weight, gain weight, to lose fat, or to gain muscle, or to simply live a healthy life. Whatever your goals maybe, you have to know how to reach those goals and provide what strategies and principles are proven to work. In order to give a complete and concise introduction into nutrition we have to start with the most abstract principles and work our way to most practical advice later in the course.
It is important to understand dieting principles that govern the body composition and will determine whether or not you will reach your goals. Just like a properly functioning car, it must be based on principles of internal combustions, structural design and computer control, the diet must be based on principles too. Together they will make up what we call a meal and diet plan and you have to understand each aspect to execute your plan correctly.
All of this principles play an important role in your diet, but some are a lot more important than others. Think about it this way, the most important component of the car is the engine. Without the engine, your car won’t go anywhere, no matter what the other features. Now the frame and the wheels come and close second, and the control system right behind, but after that the details are much less important. Even the car with only a steering wheel but not seat or display could get you from point A to point B.
When it comes to meal planning and nutrition, your patient's goals might be to lose weight, gain weight, to lose fat, or to gain muscle, or to simply live a healthy life. Whatever your goals maybe, you have to know how to reach those goals and provide what strategies and principles are proven to work. In order to give a complete and concise introduction into nutrition we have to start with the most abstract principles and work our way to most practical advice later in the course.
It is important to understand dieting principles that govern the body composition and will determine whether or not you will reach your goals. Just like a properly functioning car, it must be based on principles of internal combustions, structural design and computer control, the diet must be based on principles too. Together they will make up what we call a meal and diet plan and you have to understand each aspect to execute your plan correctly.
All of this principles play an important role in your diet, but some are a lot more important than others. Think about it this way, the most important component of the car is the engine. Without the engine, your car won’t go anywhere, no matter what the other features. Now the frame and the wheels come and close second, and the control system right behind, but after that the details are much less important. Even the car with only a steering wheel but not seat or display could get you from point A to point B.
When applying this frame board to nutrition and dieting, the most important principles are:
As you can see your calorie balance is the most important principle of any diet, and has by far the largest effect in your body composition an weight. In it’s most basic form it imply that your weight gain is mostly eating more calories and weight loss is a matter of eating less calories.
Determining your optimal calorie intake can be more difficult than you think. But keep in mind that the calorie is the most important aspect of your diet. Macronutrients is in second place. While the calories defines how much you eat, macronutrients define what you eat. Eating the right amount of protein, carbs and fat makes an important difference in your body composition. Especially if you want to build muscle or lose fat. Nutrient timing comes in third on the list and it basically states when you eat. Food composition is on the fourth place and plays a detailed role of your dieting process. In general all food composition is important for your overall health.
- Calorie Balance
- Macronutrient amounts
- Nutrient timing
- Food composition
- Supplements
As you can see your calorie balance is the most important principle of any diet, and has by far the largest effect in your body composition an weight. In it’s most basic form it imply that your weight gain is mostly eating more calories and weight loss is a matter of eating less calories.
Determining your optimal calorie intake can be more difficult than you think. But keep in mind that the calorie is the most important aspect of your diet. Macronutrients is in second place. While the calories defines how much you eat, macronutrients define what you eat. Eating the right amount of protein, carbs and fat makes an important difference in your body composition. Especially if you want to build muscle or lose fat. Nutrient timing comes in third on the list and it basically states when you eat. Food composition is on the fourth place and plays a detailed role of your dieting process. In general all food composition is important for your overall health.
The same applies to supplements. As the name implies supplements and meant to supplement an already effective diet. No supplement in the world will magically make you overcome deficiency and your calorie balance, macros or timing. When designing a diet, it must be that you address the bigger picture first. If you focus on the important things first and come up with a functional diet plan, the right supplements can further improve your diet.
The last thing you want to do is invest all your time and energy into small details that have little to no effect on the outcome of your diet. Like so many others, your patient may quickly lose motivation and give up dieting. This is not what lifestyle medicine is all about, here we first build a solid foundation and later at the small improvements, that will make an effective diet plan.
- Calorie Balance (=How much you eat)
- Macronutrient Amounts (=What you eat – Protein, Carbs, Fats)
- Nutrient Timing (=When you eat)
- Food composition
- Supplement
The last thing you want to do is invest all your time and energy into small details that have little to no effect on the outcome of your diet. Like so many others, your patient may quickly lose motivation and give up dieting. This is not what lifestyle medicine is all about, here we first build a solid foundation and later at the small improvements, that will make an effective diet plan.
CALORIE EXPLAINED
One of the most important variable in determining diet success is calorie balance. From scientific standpoint, whether you gain weight or lose weight is determined by the first law of thermodynamics which states that energy cannot be created or destroyed, it can only be transformed from one type to another. But implied to dieting, the first law of thermodynamics states that your body weight is dependent only on the difference on the amount of calories that you consumed versus the amount of calories that you burned, which is known as your calorie balance.
A Calorie is the amount of energy needed to raise temperature of 1 liter of water by 1 degree Celsius. So that means a calorie is a form of energy measurement. When you eat your food, you consume the energy that is stored within the food. Your body then uses this energy to produce movement and keep your organism alive. Alternatively, when all energy is not used right away, it can also be stored for later use. Some energy can be stored in the muscles and liver as glycogen but store fill up pretty quickly so your body will then store any additional calories in the form of body fat.
One of the most important variable in determining diet success is calorie balance. From scientific standpoint, whether you gain weight or lose weight is determined by the first law of thermodynamics which states that energy cannot be created or destroyed, it can only be transformed from one type to another. But implied to dieting, the first law of thermodynamics states that your body weight is dependent only on the difference on the amount of calories that you consumed versus the amount of calories that you burned, which is known as your calorie balance.
A Calorie is the amount of energy needed to raise temperature of 1 liter of water by 1 degree Celsius. So that means a calorie is a form of energy measurement. When you eat your food, you consume the energy that is stored within the food. Your body then uses this energy to produce movement and keep your organism alive. Alternatively, when all energy is not used right away, it can also be stored for later use. Some energy can be stored in the muscles and liver as glycogen but store fill up pretty quickly so your body will then store any additional calories in the form of body fat.
There are 3 different states of calorie balances and you can only be at one state at a time.
- NEGATIVE CALORIE BALANCE. This occurs when someone burns more calories than he or she consumes. Here your body needs more calories to produce energy for your daily functions that it gets from your food. That means it makes up the difference by burning stored energy, meaning you will lose weight. Because the necessary energy will come from the breakdown of body tissue and negative calorie balance always results on weight loss.
- NEUTRAL CALORIE BALANCE. Here a person’s intake of calories is the same as the expenditure of activities and body processes. This means all the calories you consumed will be used for some form of body process and your weight will remain stable. Now of course calorie intakes and activities on any given day are not going to be exactly a 100% the same but over the course of weeks and months, a neutral calorie balance is quite possible. If your weight hasn’t changed in the last few months, your calorie balance is almost always neutral.
- POSITIVE CALORIE BALANCE. Here more energy is consumed through food and is being burned to produce body processes and movements. As I explained before, in this case the extra calories are stored as either glycogen in the muscle and liver or as fat.
What you need to understand is that your calorie balance will determine how much muscle you can gain or how much fat you can lose over period of time. Why? Because literally, calories are the building blocks of body tissue. If you want to build more muscle you are not only need to train, but you need to provide your body with the necessary raw materials to form muscle cells. On the other hand, if you want to burn fat, you have to make sure that not enough calories are shuttle into fat cells to keep them the same size.
FOOD SOURCES
Food sources refer to the individual foods you eat and what nutrients they have. Though fitness schools always tell you that it’s super important to eat certain foods and not others, for example you will often hear claim that there are certain weight loss foods that will accelerate the metabolism and make fat loss that much easier. When it comes to meal planning for fitness, meaning your goals are to lose weight, gain muscle or both. Our bodies are very intelligent organism that can handle variety of food sources. That said, when it comes to giving optimal diet and avoiding risk for chronic diseases, a healthy diet means consuming nutrient rich meals rather than calorie dense meals.
In the study published in many peer-reviewed journals exploring the diet and chronic disease in Chinese population groups, Dr. T. Collin Campbell and his colleagues were able to establish the many different links between various food groups and disease risks and have documented the relevance of diet and nutrition in the initiation and development of disease. The findings of the world-known study "The China Study" have highlighted the implications of consuming animal and plant-based nutrients and their differences. The study confirmed the link between fat, fiber and cholesterol to degenerative disease including heart disease, diabetes and even cancer.
Food sources refer to the individual foods you eat and what nutrients they have. Though fitness schools always tell you that it’s super important to eat certain foods and not others, for example you will often hear claim that there are certain weight loss foods that will accelerate the metabolism and make fat loss that much easier. When it comes to meal planning for fitness, meaning your goals are to lose weight, gain muscle or both. Our bodies are very intelligent organism that can handle variety of food sources. That said, when it comes to giving optimal diet and avoiding risk for chronic diseases, a healthy diet means consuming nutrient rich meals rather than calorie dense meals.
In the study published in many peer-reviewed journals exploring the diet and chronic disease in Chinese population groups, Dr. T. Collin Campbell and his colleagues were able to establish the many different links between various food groups and disease risks and have documented the relevance of diet and nutrition in the initiation and development of disease. The findings of the world-known study "The China Study" have highlighted the implications of consuming animal and plant-based nutrients and their differences. The study confirmed the link between fat, fiber and cholesterol to degenerative disease including heart disease, diabetes and even cancer.
THE MACRONUTRIENTS
After the calorie balance, the next important variable of your diet are the macronutrients. Your body needs each macronutrients in relatively large quantities to function properly.
*Carbohydrate, protein, and fat are essential for health maintenance, growth, reproduction, immunity, and healing. Deficits or excesses of any of these nutrients may compromise these processes, resulting in poor health outcomes, which vary depending on the macronutrient in question and the life stage of the affected person.
In decades past, research on nutrition and disease frequently focused on the problems caused by diets that provided inadequate intakes of protein, calories, or micronutrients. Concerns that such deficient diets could lead to poor growth and development or might result in weight loss in the hospitalized elderly were appropriate. Currently, however, an excess of macronutrients is a far greater threat to health and well-being in developed countries and in many developing nations as well.
After the calorie balance, the next important variable of your diet are the macronutrients. Your body needs each macronutrients in relatively large quantities to function properly.
*Carbohydrate, protein, and fat are essential for health maintenance, growth, reproduction, immunity, and healing. Deficits or excesses of any of these nutrients may compromise these processes, resulting in poor health outcomes, which vary depending on the macronutrient in question and the life stage of the affected person.
In decades past, research on nutrition and disease frequently focused on the problems caused by diets that provided inadequate intakes of protein, calories, or micronutrients. Concerns that such deficient diets could lead to poor growth and development or might result in weight loss in the hospitalized elderly were appropriate. Currently, however, an excess of macronutrients is a far greater threat to health and well-being in developed countries and in many developing nations as well.
DIETARY PROTEIN
*Protein supports the maintenance and growth of body tissues. Th amino acids that make up proteins are used for the synthesis of nucleic acids, cell membranes, hormones, neurotransmitters, and plasma proteins that serve transport functions and exert the colloid osmotic pressure needed to maintain fluid in vascular space. Protein is also the second-largest energy store, second to adipose tissue because of the large amount of muscle tissue that is a liable source of amino acids for gluconeogenesis, although carbohydrate (in the form of glycogen) is used in between meals as a primary source.
During growth and in various disease states, several other amino acids (arginine, cysteine, glutamine, glycine, proline, tyrosine) are regarded ad conditionally indispensable. The term conditionally indispensable applies when endogenous synthesis cannot meet metabolic need (eg, under special pathophysiologic circumstances, including prematurity in infants and severe catabolic stress in adults).
Although deficiency in dietary protein is clearly detrimental, many chronic conditions may be caused or exacerbated by an excess of protein, particularly animal protein. These include osteoporosis, kidney stones, chronic kidney disease, and possibly certain cancers. Food from plant sources can supply protein in the amount and quality adequate for all ages.
The major difference between diets providing animal protein and those providing plant proteins appears to be that, while plant foods contain all essential amino acids, some are limited in lysine or sulfur-containing amino acids. The amino acids provided by various plant foods, however, tend to complement each other, and it is not necessary to intentionally combine foods. The natural combinations of foods in typical vegetarian diets provide more than adequate amounts of complete protein. Soy products provide protein with a biological value as high as that of animal protein. Because plant sources are free of cholesterol and low in saturated fat and provide dietary fiber and various phytochemicals, they present advantages over animal protein sources.
For body composition purposes, protein is actually the most important dietary macronutrient. The reason for this is that muscle is literally made out of it. If muscle is the car then protein is the metal out of which the parts are built. Protein not only provides the building blocks for muscle growth it also supplies the amino acids needed to reduce muscle breakdown. So in essence, protein both builds new muscles and saves existing muscles from being lost. Both functions are very important in maximizing muscle and minimizing fat.
About 90% of the protein you eat is broken down into amino acids and becomes part of the amino acid “pool” that the body draws up on when it needs to build or repair a muscle or any other tissue. Unlike carbohydrates and fat, which the body can store for later use, amino acids have no form of storage in the body so it’s important you have some protein everyday.
*Protein supports the maintenance and growth of body tissues. Th amino acids that make up proteins are used for the synthesis of nucleic acids, cell membranes, hormones, neurotransmitters, and plasma proteins that serve transport functions and exert the colloid osmotic pressure needed to maintain fluid in vascular space. Protein is also the second-largest energy store, second to adipose tissue because of the large amount of muscle tissue that is a liable source of amino acids for gluconeogenesis, although carbohydrate (in the form of glycogen) is used in between meals as a primary source.
During growth and in various disease states, several other amino acids (arginine, cysteine, glutamine, glycine, proline, tyrosine) are regarded ad conditionally indispensable. The term conditionally indispensable applies when endogenous synthesis cannot meet metabolic need (eg, under special pathophysiologic circumstances, including prematurity in infants and severe catabolic stress in adults).
Although deficiency in dietary protein is clearly detrimental, many chronic conditions may be caused or exacerbated by an excess of protein, particularly animal protein. These include osteoporosis, kidney stones, chronic kidney disease, and possibly certain cancers. Food from plant sources can supply protein in the amount and quality adequate for all ages.
The major difference between diets providing animal protein and those providing plant proteins appears to be that, while plant foods contain all essential amino acids, some are limited in lysine or sulfur-containing amino acids. The amino acids provided by various plant foods, however, tend to complement each other, and it is not necessary to intentionally combine foods. The natural combinations of foods in typical vegetarian diets provide more than adequate amounts of complete protein. Soy products provide protein with a biological value as high as that of animal protein. Because plant sources are free of cholesterol and low in saturated fat and provide dietary fiber and various phytochemicals, they present advantages over animal protein sources.
For body composition purposes, protein is actually the most important dietary macronutrient. The reason for this is that muscle is literally made out of it. If muscle is the car then protein is the metal out of which the parts are built. Protein not only provides the building blocks for muscle growth it also supplies the amino acids needed to reduce muscle breakdown. So in essence, protein both builds new muscles and saves existing muscles from being lost. Both functions are very important in maximizing muscle and minimizing fat.
About 90% of the protein you eat is broken down into amino acids and becomes part of the amino acid “pool” that the body draws up on when it needs to build or repair a muscle or any other tissue. Unlike carbohydrates and fat, which the body can store for later use, amino acids have no form of storage in the body so it’s important you have some protein everyday.
How much protein exactly should you consume per day? This question sounds pretty straight forward, there is no one size fits all here. Because your ideal protein intake will depend on a variety of factors such as your weight, muscle mass and most importantly your fitness goals. Your average person will have completely different protein needs than a professional athlete or a 300 pound body builder. With this in mind, protein need is based on 3 specific cases:
- To simply live a healthy life
- To build muscle
- To lose fat
Protein requirements are increased in certain conditions. These include severe acute illness, burn injury, end-stage renal disease and body building. Protein needs are also influence by life stage. Protein requirements are highest in the growing years, with infants up to 12 months and children 1 to 3 years of age requiring 1.5 g/kg and 1.1 g/kg, respectively. Requirements for protein remain high relative to adult needs during the period from growth to puberty (ages 4 to 13 years), at 0.95 g/kg, and are reduced to near-adult levels (0.85 g/kg) from 14 to 18 years of age. Pregnancy and lactation also increase protein needs, to 1.1 g/kg of maternal prepregnancy weight for the former and 1.3 g/kg for the latter.
For healthy adults, the Estimated Average Requirement (EAR) is considerably lower (0.66 g/kg/day), 47 and 38 grams per day for men and women, respectively. In addition, the intake of adequate protein-sparing calories allows for maintenance of lean body mass at roughly this level of intake. More adults in Western countries consume more protein than the recommended EAR and RDA of 0.66 g/kg/day and 0.8 g/kg/day, respectively. Excessive intakes may contribute to risk for certain chronic disease.
Not what if you want to build muscle. How much protein should someone consume that is working out and looking to grow muscle mass. If you ever join a body building or fitness forum then you will notice that this question pops up a lot and it usually triggers a lot of debate. People usually post values that are way too high or way too specific.
If we look at the present literature on protein intake for anyone looking to build muscle, the ideal daily intake always lies anywhere between 0.8 grams and 1 gram of protein per pound of body weight. If you are below this range, your body will not build muscle at the optimal rate. However, if you go above this range, then you will see no increase in protein synthesis which is the rate at which new proteins are produced and therefore no tissue is built.
Now what if you want to lose fat instead of building muscle? Does this range change? The short answer is no, not really. When losing weight, your primary goal is always maximize fat loss and preserve muscle mass.
For healthy adults, the Estimated Average Requirement (EAR) is considerably lower (0.66 g/kg/day), 47 and 38 grams per day for men and women, respectively. In addition, the intake of adequate protein-sparing calories allows for maintenance of lean body mass at roughly this level of intake. More adults in Western countries consume more protein than the recommended EAR and RDA of 0.66 g/kg/day and 0.8 g/kg/day, respectively. Excessive intakes may contribute to risk for certain chronic disease.
Not what if you want to build muscle. How much protein should someone consume that is working out and looking to grow muscle mass. If you ever join a body building or fitness forum then you will notice that this question pops up a lot and it usually triggers a lot of debate. People usually post values that are way too high or way too specific.
If we look at the present literature on protein intake for anyone looking to build muscle, the ideal daily intake always lies anywhere between 0.8 grams and 1 gram of protein per pound of body weight. If you are below this range, your body will not build muscle at the optimal rate. However, if you go above this range, then you will see no increase in protein synthesis which is the rate at which new proteins are produced and therefore no tissue is built.
Now what if you want to lose fat instead of building muscle? Does this range change? The short answer is no, not really. When losing weight, your primary goal is always maximize fat loss and preserve muscle mass.
PROTEIN
Broccoli florets (0.105 grams protein/calorie are higher in per calorie protein content than hamburger beef (30 grams for 1/2 breast) in available protein.
Soybeans (29 grams protein/cup) are comparable to chicken (30 grams for 1/2 breast) in available protein.
- Should be about 15% of total calorie intake
- Protein is more important the older you get
- Rarely needs to be prescribed separately when general diet principles are followed
Broccoli florets (0.105 grams protein/calorie are higher in per calorie protein content than hamburger beef (30 grams for 1/2 breast) in available protein.
Soybeans (29 grams protein/cup) are comparable to chicken (30 grams for 1/2 breast) in available protein.
DIETARY FATS
Dietary fats are the least-require macronutrient, with only a few grams per day needed for the absorption of fat-soluble vitamins A,D, E and K, among other functions. Foods contain combinations of saturated and unsaturated fats. Substantial quantities of saturated fat are found in dairy products, eggs, meats, and tropical oils, while unsaturated fats predominate in liquid fats (eg, vegetable oils). The latter are subdivided into monounsaturated fats (predominant in olive and canola oils) and polyunsaturated fats (found in nuts, seed oils, and, to a lesser extent, in meats).
Only the polyunsaturated fatty acids (PUFA) are essential to human nutrition, since the boy does not synthesize these. PUFA have roles as structural components of cell membranes and as signaling molecules (eg, eicosanoids). The essential fatty acids )EFA) include linoleic acid (an omega-6 fatty acid) and alpha-linolenic acid (an omega-3 fatty acid). The Institute of Medicine recommends a ratio of dietary linoleic (omega-6) to alpha-linolenic (omega-3) acid intake of 10:1; however this figure is controversial, some suggest a higher intake of omega-3.
The IOM Food and Nutrition Board currently recommends a range of fat intake of 20% to 35% of total energy intake. This too is controversial, given that good health outcomes have been achieved with considerably lower levels of fat intake. most individuals can meet their EFA needs by consuming very small amounts of fat per day (14g) although many people are eating far more than this (85 g on average).
This level of excess consumption of fats is problematic because EFA derivatives are raw materials for eicosanoids (ie, prostaglandins, leukotrienes, and thromboxanes), hormone-like chemicals with short-lived but powerful effects. Eicosanoids play significant roles in immune function, inflammation, thrombosis, proliferation, reproduction, gastroprotection, and hemostasis, in addition to other functions. The omega-6 and omega-6 PUFA are metabolized to long-chain fatty acids (arachidonic and eicosapentanoic acids, respectively), which are the precursor for the eicosanoids. These long-chain derivatives are also found in some food products, with arachidonic acid being present in meat, eggs, and dairy products, and eicosapentanoic acid found in fish. these food sources are not required, however, as eicosanoids are produced in the body.
Dietary fats are the least-require macronutrient, with only a few grams per day needed for the absorption of fat-soluble vitamins A,D, E and K, among other functions. Foods contain combinations of saturated and unsaturated fats. Substantial quantities of saturated fat are found in dairy products, eggs, meats, and tropical oils, while unsaturated fats predominate in liquid fats (eg, vegetable oils). The latter are subdivided into monounsaturated fats (predominant in olive and canola oils) and polyunsaturated fats (found in nuts, seed oils, and, to a lesser extent, in meats).
Only the polyunsaturated fatty acids (PUFA) are essential to human nutrition, since the boy does not synthesize these. PUFA have roles as structural components of cell membranes and as signaling molecules (eg, eicosanoids). The essential fatty acids )EFA) include linoleic acid (an omega-6 fatty acid) and alpha-linolenic acid (an omega-3 fatty acid). The Institute of Medicine recommends a ratio of dietary linoleic (omega-6) to alpha-linolenic (omega-3) acid intake of 10:1; however this figure is controversial, some suggest a higher intake of omega-3.
The IOM Food and Nutrition Board currently recommends a range of fat intake of 20% to 35% of total energy intake. This too is controversial, given that good health outcomes have been achieved with considerably lower levels of fat intake. most individuals can meet their EFA needs by consuming very small amounts of fat per day (14g) although many people are eating far more than this (85 g on average).
This level of excess consumption of fats is problematic because EFA derivatives are raw materials for eicosanoids (ie, prostaglandins, leukotrienes, and thromboxanes), hormone-like chemicals with short-lived but powerful effects. Eicosanoids play significant roles in immune function, inflammation, thrombosis, proliferation, reproduction, gastroprotection, and hemostasis, in addition to other functions. The omega-6 and omega-6 PUFA are metabolized to long-chain fatty acids (arachidonic and eicosapentanoic acids, respectively), which are the precursor for the eicosanoids. These long-chain derivatives are also found in some food products, with arachidonic acid being present in meat, eggs, and dairy products, and eicosapentanoic acid found in fish. these food sources are not required, however, as eicosanoids are produced in the body.
In cases when weight gain is the goal in a healthy individual you may consider increasing plant-based unsaturated fat intake above 15 or 20% and that is when you’re bulking. Bulking is the term used for going into calories surplus to ensure optimal muscle growth. Skinny people to put on size often had a hard time with this. When all carbohydrate, fat and protein needs are already met but your daily calories are not yet filled for example, imagine needing 3500 calories to gain weight, but you’ve already met your macro needs at 2500 calories, you have a choice to make. You can either chose to add protein, carbs or fat or any combination of these three.
Take in together this points highly support the role of fats as a default calorie buffer. Now in some cases it can also make sense to consume additional carbs especially when exercising very intensively. However, then you need to make sure that this extra carbs come from quality sources such rice or potatoes and not from candies and junk food. Never allow consumption of too much simple carbs as they will keep the insulin levels up and can lead to prediabetes which is both harmful to muscle gains, fat losses, and general health.
Take in together this points highly support the role of fats as a default calorie buffer. Now in some cases it can also make sense to consume additional carbs especially when exercising very intensively. However, then you need to make sure that this extra carbs come from quality sources such rice or potatoes and not from candies and junk food. Never allow consumption of too much simple carbs as they will keep the insulin levels up and can lead to prediabetes which is both harmful to muscle gains, fat losses, and general health.
FAT
Source of Fat
Omega-6s - pro-inflammatory: corn oil, sunflower oil
Stearic acid: dark chocolate - neutral
Palmitic acid: palm oil, meat - harmful
Myristic acid: butter - harmful
- Should be 15-30% of total calorie intake. Ancestral and indigent intake in populations with minimal chronic disease is closer to 15%. USDA recommends 20-35%
- More commonly prescribed as a "negative" prescription - most people get too much fat.
- General guidelines around fat intake includes polyunsaturated and mounsaturated fats that are healthful. Saturated and trans fats are harmful.
Source of Fat
- Poly-unsaturated
Omega-6s - pro-inflammatory: corn oil, sunflower oil
- Mono-unsaturated
- Saturated
Stearic acid: dark chocolate - neutral
Palmitic acid: palm oil, meat - harmful
Myristic acid: butter - harmful
THE CARBOHYDRATES
Carbohydrates are the most misunderstood macronutrients. Just as with fats and proteins, there are a lot of debates around carbohydrates. Carbohydrates, in the form of starches and sugars, is the main energy source in the human diet, providing 50% or more of total calories and are found in foods including fruits, vegetables, grains, potatoes and considered the body’s preferred energy source. More specifically, carbs are sugar molecules that are the union of carbon, hydrogen and oxygen. Think of carbs as one or more sugar molecules that are bound together and broken down by the body to be used as fuel. When a person consume high carbs food, the body breaks them down into simple sugar glucose which is then transported throughout the body to provide energy, to fuel important reactions and maintain blood sugar levels. Any glucose that is not used is stored in your liver and muscles as glycogen or as fat.
During high intensity activities such as weight training your body uses glycogen and converts them back to glucose for new fuel. If glycogen levels are low, hard workouts become increasingly difficult to complete and your performance will suffer. Next to it’s importance for workouts, carbohydrates have other benefits: They include:
Carbohydrates are the most misunderstood macronutrients. Just as with fats and proteins, there are a lot of debates around carbohydrates. Carbohydrates, in the form of starches and sugars, is the main energy source in the human diet, providing 50% or more of total calories and are found in foods including fruits, vegetables, grains, potatoes and considered the body’s preferred energy source. More specifically, carbs are sugar molecules that are the union of carbon, hydrogen and oxygen. Think of carbs as one or more sugar molecules that are bound together and broken down by the body to be used as fuel. When a person consume high carbs food, the body breaks them down into simple sugar glucose which is then transported throughout the body to provide energy, to fuel important reactions and maintain blood sugar levels. Any glucose that is not used is stored in your liver and muscles as glycogen or as fat.
During high intensity activities such as weight training your body uses glycogen and converts them back to glucose for new fuel. If glycogen levels are low, hard workouts become increasingly difficult to complete and your performance will suffer. Next to it’s importance for workouts, carbohydrates have other benefits: They include:
- Supplying the nervous system with fuel. Well maintained blood glucose level will directly benefit the nervous system which not only means better concentration but also better muscle recruitment, more fatigue resistance and even more workout motivation. Much of the fatigue in long duration training is due to a tired nervous system and not a result of sored muscles. So providing the nervous system with an adequate source of blood glucose is important for optimizing workout intensity and duration.
- Refueling glycogen stores. In addition to glycogen’s role as provider of energy in high intensity workout, its storage in the muscle plays a role in the regulation of muscle growth. Low levels of glycogen by themselves have been shown to downregulate muscle growth. That is just having low muscle glycogen levels irrespective of physical activity level, training intensity and protein intake can affect muscle gains and increase the risk of muscle loss. This is just another reason why getting enough carbs is a very important factor when wanting to build muscle.
- Secreting insulin. The more carbs you eat the more insulin is secreted. This is important because insulin has a profound effect on muscle growth. When insulin is secreted into the blood it binds to target receptor on the muscle cell surface and increases muscle growth. Because of the powerful anabolic effect of insulin, the fact that carbs consumption increased more insulin than the other macronutrients fat and protein, carbohydrate is anabolic to muscle tissue. This means it helps grow it.
How much carbohydrates we need?
In order to optimize your meal plan once protein and fats have been addressed, you also want to look at carbohydrates. If minimal values are not met especially for extended periods, you will not grow as much muscle as you could. Now the optimal intake of carbohydrates can be based on a variety of factors. Fortunately, even without knowing your exact measurements we can still narrow in on a range using only two measures. Body weight and physical activity/training intensity.
Can you eat too many carbohydrates?
Keeping in mind the quality sources of carbohydrates, as a general rule for most active people and athletes, there does not seem to be such a thing as an excessive intake of carbohydrates, so long as minimal protein and fat intakes are met. We know from studies done in endurance runners and vegetarians that diets very high in carbohydrates can be very healthy in a long term. But this assumes though that you get your carbs from quality sources such as rice, quinoa, oats and potatoes. These are all complex carbs that do not lead to a sudden spike in insulin levels which is the case for simple carbs like candy and sugar. What this means is that when you exercise a lot and meet the extra energy and you can’t consume large amounts of carbs as long as you get them from complex carbs and you also get your minimum protein and fat needs.
Keeping in mind the quality sources of carbohydrates, as a general rule for most active people and athletes, there does not seem to be such a thing as an excessive intake of carbohydrates, so long as minimal protein and fat intakes are met. We know from studies done in endurance runners and vegetarians that diets very high in carbohydrates can be very healthy in a long term. But this assumes though that you get your carbs from quality sources such as rice, quinoa, oats and potatoes. These are all complex carbs that do not lead to a sudden spike in insulin levels which is the case for simple carbs like candy and sugar. What this means is that when you exercise a lot and meet the extra energy and you can’t consume large amounts of carbs as long as you get them from complex carbs and you also get your minimum protein and fat needs.
Do carbohydrates make you fat?
Carbohydrates themselves do not make you fat. They serve an important function in your body especially if you train in high intensity. What is true is that many processed food such as candy or fast food are high in sugar and other types of simple carbohydrates. These foods often lead to cravings and can make it easier to overeat even when you already filled up your daily calories but are still hungry. That is why many people who follow a diet that is based around these foods will see weight gain overtime. However, in order to get fat, you always need a calorie surplus which you could also reach with a high protein or high fat diet. Incorporating quality carbs in the diet is the simple solution.
Carbohydrates themselves do not make you fat. They serve an important function in your body especially if you train in high intensity. What is true is that many processed food such as candy or fast food are high in sugar and other types of simple carbohydrates. These foods often lead to cravings and can make it easier to overeat even when you already filled up your daily calories but are still hungry. That is why many people who follow a diet that is based around these foods will see weight gain overtime. However, in order to get fat, you always need a calorie surplus which you could also reach with a high protein or high fat diet. Incorporating quality carbs in the diet is the simple solution.
GLYCEMIC INDEX AND GLYCEMIC LOAD
CARBOHYDRATES
- The average person doesn't get enough
- Goal is 40-45 grams daily
- The average person gets too much
- Sugars in whole foods, however, tend to be accepted
- Increase neutral fiber
- The average person doesn't get enough
- Goal is 40-45 grams daily
- Decrease added sugars
- The average person gets too much
- Sugars in whole foods, however, tend to be accepted
- Stay steady on starch
micronutrients
Whole foods of a variety of types help to achieve micronutrient balance better than taking supplements. It is important to keep micronutrient levels balanced. The body's homeostasis mechanisms maintain micronutrient levels in relatively narrow ranges. Too much or too little is stressful to the body. Specific nutrients are not often prescribed but specific foods that contain specific micronutrients can be prescribed.
Micronutrients have many values including the presence of high antioxidants which decreases oxidation, thereby decreasing inflammation and decreased variety of disease states.
Micronutrients have many values including the presence of high antioxidants which decreases oxidation, thereby decreasing inflammation and decreased variety of disease states.
TASK - Clinical Application |
Task 1: Meal Planning A 52-year-old woman visited your clinic for a consult. She revealed she was hospitalized for a "heart problem" and it was the chest pain that prompted her to seek consult and was immediately admitted. Six months after the event, she claims that all symptoms have already resolved and she stated working on eating a plant-based diet but not sure how to go about it. She can also tolerate moderate physical activity and claimed that she could even push vigorous exercise if not for the weight she's been struggling with. She reported that she's still on medication and is strictly complying on her regimen. Her visit to your clinic is primarily to consult on how to integrate lifestyle change to resolve obesity and gain muscle mass to sustain her physical activity routine. She presented a normal laboratory panel with normal blood pressure and heart rate. The body mass index is 30 kg/m2. As a lifestyle medicine practitioner, what would be the initial meal plan you can advise the patient aiming to resolve excess weight and gain muscle mass and strength. Task 2: Reflective Journal |
