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Nutrition and Weight Management,

Second Edition


Basic Nutrition, Second Edition Nutrition and Disease Prevention Nutrition and Eating Disorders, Second Edition Nutrition and Food Safety Nutrition and Weight Management, Second Edition Nutrition for Sports and Exercise, Second Edition

Nutrition and Weight Management,

Second Edition
Lori A. Smolin, Ph.D., and Mary B. Grosvenor, M.S., R.D.

Nutrition and Weight Management, Second Edition Copyright 2010 by Infobase Publishing All rights reserved. No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage or retrieval systems, without permission in writing from the publisher. For information, contact: Chelsea House An imprint of Infobase Publishing 132 West 31st Street New York, NY 10001 Library of Congress Cataloging-in-Publication Data Smolin, Lori A. Nutrition and weight management / Lori A. Smolin, Mary B. Grosvenor. 2nd ed. p. cm. (Healthy eating, a guide to nutrition) Includes bibliographical references and index. ISBN 978-1-60413-803-0 (hardcover) ISBN 978-1-4381-3447-5 (e-book) 1. Nutrition. 2. Weight loss. I. Grosvenor, Mary B. II. Title. III. Series. RA784.S5979 2010 613.2dc22 2009041335 Chelsea House books are available at special discounts when purchased in bulk quantities for businesses, associations, institutions, or sales promotions. Please call our Special Sales Department in New York at (212) 967-8800 or (800) 322-8755. You can find Chelsea House on the World Wide Web at http://www.chelseahouse.com Text design by Annie ODonnell Cover design by Alicia Post Composition by Mary Susan Ryan-Flynn Cover printed by Bang Printing, Brainerd, Minn. Book printed and bound by Bang Printing, Brainerd, Minn. Date printed: August 2010 Printed in the United States of America 10 9 8 7 6 5 4 3 2 1 This book is printed on acid-free paper. All links and Web addresses were checked and verified to be correct at the time of publication. Because of the dynamic nature of the Web, some addresses and links may have changed since publication and may no longer be valid.

by Lori a. Smolin, Ph.d., and Mary B. grosvenor, M.S., r.d.

1 the obesity epidemic 2 What is a healthy Body Weight? 3 health risks of too Much or
too Little Body Fat

9 24 38 51 71 90 100 113 128

143 150 154 155

4 5 6 7

Food, Nutrition, and Body Weight how Many Calories do You Need? the Biology of Body Weight achieving and Maintaining a healthy Weight

8 diets and other Weight Fixes 9 Weight Management in

Children and adolescents appendices
A. Dietary Reference Intakes B. Healthy Body Weight C. Blood Values of Nutritional Relevance D. USDAs MyPyramid

glossary Bibliography Further resources Picture Credits index about the authors

156 165 173 175 176 184


hundred years ago, people received nutritional guidance from mothers and grandmothers: Eat your carrots because theyre good for your eyes; dont eat too many potatoes because theyll make you fat; be sure to get plenty of roughage so you can more easily move your bowels. Today, everyone seems to offer more advice: Take a vitamin supplement to optimize your health; dont eat fish with cabbage because you wont be able to digest them together; you cant stay healthy on a vegetarian diet. Nutrition is one of those topics about which all people seem to think they know something, or at least have an opinion. Whether it is the clerk in your local health food store recommending that you buy supplements or the woman behind you in line at the grocery store raving about the latest low-carbohydrate diet, everyone is ready to offer you nutritional advice. How do you know what to believe or, more importantly, what to do? The purpose of these books is to help you answer these questions. Even if you dont love learning about science, at the very least you probably enjoy certain foods and want to stay healthyor

Nutrition and Weight Management

become healthier. In response to this, these books are designed to make the science you need to understand as palatable as the foods you love. Once you understand the basics, you can apply this simple health knowledge to your everyday decisions about nutrition and health. The Healthy Eating set includes one book with all of the basic nutrition information you need to choose a healthy diet, as well as five others that cover topics of special concern to many: weight management, exercise, disease prevention, food safety, and eating disorders. Our goal is not to tell you to stop eating potato chips and candy bars, give up fast food, or always eat your vegetables. Instead, it is to provide you with the information you need to make informed choices about your diet. We hope you will recognize that potato chips and candy are not poison, but they should only be eaten as occasional treats. We hope you will decide for yourself that fast food is something you can indulge in every now and then, but is not a good choice every day. We encourage you to recognize that although you should eat your vegetables, not everyone always does, so you should do your best to try new vegetables and fruits and eat them as often as possible. These books take the science of nutrition out of the classroom and allow you to apply this information to the choices you make about foods, exercise, dietary supplements, and other lifestyle decisions that are important to your health. This knowledge should help you choose a healthy diet while allowing you to enjoy the diversity of flavors, textures, and tastes that food provides, and also encouraging you to explore the meanings food holds in our society. When you eat a healthy diet, you will feel good in the short term and enjoy health benefits in the long term. We cant personally evaluate each meal you consume, but we believe these books will give you the tools to make your own nutritious choices. Lori A. Smolin, Ph.D., and Mary B. Grosvenor, M.S., R.D.

the obesIty epIdemIC

o you weigh more than you would like? You are not alone. In the United States today, 66% of adults are either overweight or obese. This percentage has increased dramatically over the past 40 to 50 years. According to data from the Centers for Disease Control and Prevention (CDC), the prevalence of obesity has increased dramatically in the last half-century (Figure 1.1). In 1960, 13.4% of American adults were obese; by 1990, about 23% were obese; and today, 32% are obese. Obesity affects both men and women and spans every age group and culture in the nation. Sixteen percent of U.S. children and adolescents ages 2 through 19 are obese. The rise in obesity has been referred to as an obesity epidemic. Many of us think about extra pounds in terms of how we will look in a bathing suit, but being overweight is more than a matter of appearance. Too much body fat increases health risks and shortens life expectancy. It increases the risk of developing conditions such as high blood pressure, high blood cholesterol, heart disease, diabetes, gallbladder disease, arthritis, breast cancer, uterine cancer, prostate


Nutrition and Weight Management

The Obesity Epidemic

cancer, and colon cancer. The more overweight people are, and the longer they have been overweight, the greater their health risks. It is estimated that obesity causes 112,000 excess deaths per year. In addition to affecting health, obesity increases health care costs. The current estimate is that excess body weight costs Americans about $117 billion per year. In addition to this, it also limits the amount and type of work people can do, increases absenteeism, and decreases the length of time people can remain in their jobs.


What Is the Cause of the Obesity Epidemic?

The simple reason why people are getting fatter is that they are eating more and exercising less. The calories we consume in food are used by our bodies to keep us alive and moving. When we eat the same number of calories we use, we are in energy balance and our weight stays the same. When we eat more calories than we need, our bodies store the extra, mostly as fat, and we gain weight. This ability to store extra calories as fat is good when food is scarce and you do not know where your next meal is coming from. But it can be bad when food is plentiful and continuously available, as it is for most of us today.

Weight Is Determined by Genes and Lifestyle

How much people weigh is determined both by the genes that they inherit from their parents and the lifestyle choices they make about what they eat and how active they are. A gene is a unit of biological information that is passed from parent to child. The genes we

(opposite) Figure 1.1 More Americans are overweight than ever before. In 1990, the highest incidence of obesity in any state was 14%. In 2008, only Colorado had an adult obesity incidence rate less than 20%.


Nutrition and Weight Management

inherit determine our unique characteristics or traits. Genetic traits explain why your body size, shape, and composition are similar to those of your parents. If one or both of your parents are obese, your risk of becoming obese is higher than someone whose parents are not obese. However, genes do not act in isolation. What we weigh is affected by our environment and lifestyle. For example, someone with a genetic predisposition to obesity may never become obese, if he or she has a limited supply of food or performs strenuous physical labor every day. On the other hand, someone with no genetic tendency toward obesity who consumes a high-calorie diet and gets little exercise may pack on enough extra pounds to become obese. The dramatic increase in the number of overweight people in the United States over the past 50 years is not due to changes in our genes. It takes many generations for the gene frequencies in a population to change enough to affect the characteristics of that

Is Obesity Really an Epidemic?

An epidemic is a widespread outbreak of an infectious disease. Throughout human history, epidemics have devastated populations. The Black Death that first struck Europe in the fourteenth century killed about half the population before it ran its course. The influenza epidemic of 1918 infected one-fifth of the worlds population and killed between 20 and 40 million people. The virus that causes AIDS currently infects about 33 million people worldwide. Now we are faced with what has been called the obesity epidemic. Although it is technically not an epidemic (because obesity is not an infectious disease), there are now more than 1 billion overweight adults around the world. According to the World Health Organization, at least 300 million of them carry enough body fat to be classified as obese. This means that overweight and obesity now affect more people around the world than the Black Death or the influenza epidemic did in the past, and more than the AIDS epidemic does today.

The Obesity Epidemic

population. Lifestyle changes, however, can occur rapidly. Our increasing girth is likely related to changes in our environment that have promoted an increase in food intake and a decrease in activity level. Over the past 50 years, the availability and variety of food has increased, and the need for physical activity has declined. When genetically susceptible people find themselves in an environment where food is appealing and plentiful and physical activity is easily avoided, obesity is a likely outcome.


Why Are We Eating More?

Americans today eat more than they did in the past. Why has this happened? A quick comparison of the food supply today with that of the late 1970s shows that the availability of tasty, high-calorie foods, the number of food choices we have, and the portions of food we eat have all increased. Today, palatable and affordable food is readily available to the majority of the population 24 hours a day in supermarkets, fast-food restaurants, and all-night convenience stores. Having more food and more food choices can lead people to eat more. Think about what makes you buy an ice cream cone. Is it because you are hungry or because the ice cream looks good? How do you know when to stop eating? Is it when your ice cream is gone or when your stomach is full? Your appetite may be triggered or inhibited by many things:

The sight, taste, and smell of food The time of day Emotions Cultural and social conventions The appeal of the foods available

Appetite is the reason we find room for cookies when strolling the mall or dessert after a big dinner, and it may also be the connection between an environment where food is plentiful and increases in body weight. Other changes over the past few decades also affect how many calories Americans eat. There are now more single-parent house-


Nutrition and Weight Management

Minority Report
Healthy People 2010 is a set of health objectives established by the U.S. government. It includes 467 objectives and has two overarching goals: to help people of all ages increase life expectancy and improve their quality of life, and to eliminate health disparities among different segments of the population. One measure of the nations health is the incidence of overweight and obesity. One Healthy People 2010 objective is to reduce adult obesity to less than 15% of the population. Our report card in this area is not so good, and the minority report is even worse. A study that ended in 2008 found that 25.6% of blacks, whites, and Hispanics were obese. When ethnic groups were looked at individually, blacks were found to have a 51% higher prevalence of obesity, and Hispanics a 21% higher obesity prevalence, compared with whites. This pattern was consistent across most U.S. states, although state prevalence varied substantially. Not only have we failed to meet the objective to reduce obesity to 15% of the population, but disparities still exist among different segments of the population. Effective policies and strategies that promote healthy eating and physical activity are needed for all populations and geographic areas, but particularly for those populations and areas disproportionately affected by obesity.

holds and households with two working parents. This means that many families have less time to prepare meals at home. As a result, prepackaged meals and fast food have become mainstays. These foods are typically higher in fat and calories than foods prepared from scratch. Almost half of the money Americans now spend on food goes for foods prepared outside the home. We now consume about one-third of our calories from fast food and other foods prepared outside the home. Another factor that has contributed to our increased calorie intake is increased portion sizes. People tend to eat in units,

the obesity epidemic

such as one cookie, one sandwich, or one bag of chips. Increasing the size of the unit causes us to increase our intake. The portions that we consume have increased over the past 50 years, and research has shown that providing a person with a larger serving increases the amount he or she eats.


figure 1.2 Portion sizes at fast-food restaurants have increased dramatically since fast food was first introduced in the 1950s. At that time, only one size was offered.


Nutrition and Weight Management

Portions from fast-food chains are now two to five times their original size (Figure 1.2). Despite calls from health authorities to reduce portion sizes, the portions offered in fast-food chains have changed little since 1998. Increasing portion sizes is partly a marketing strategy. Consumers are unlikely to order a second hamburger if they are not full, but they are willing to choose a larger one at the start. Because the cost of the food is only a small portion of what it costs a restaurant to feed you, restaurants can increase profits by offering you more food for your money. Americans cant resist a bargain, so people usually spend the extra pennies to buy a meal that has 300 more calories. Portion sizes offered in the marketplace are often twice as large as the standard serving sizes set by government agencies, such as the U.S. Department of Agriculture (USDA) and the Food and Drug Administration (FDA).

Why Are We Moving Less?

Along with changes that make it easier to eat more, there have been cultural and technological changes that have decreased the number of calories most people burn every day. Fewer adults work in jobs that require physical labor. People drive to work in automobiles rather than walking or biking. They take elevators instead of the stairs. They mow their lawns with riding mowers, rather than push mowers. All of these simple changes reduce the amount of energy expended to perform the tasks of daily living. In addition, busy schedules, long days at work, and long commutes make people feel that they have no time for active recreation. Instead, at the end of the day, they sit in front of televisions, video games, and computersall sedentary ways to spend leisure time. The reduction in physical activity is not restricted to adults. Many schools have reduced or even eliminated their physical education programs, and children are less active after school than they used to be. In the 1960s, kids spent their after-school hours outdoors with bikes, balls, and friends. Today, many children live in unsafe neighborhoods and are forced to stay inside. Even those who

The Obesity Epidemic


More exercise needed

Any exercise is better than none, and within reason, more is better than less. U.S. government guidelines recommend that adults get two-anda-half hours of activity per week and children get 60 minutes per day. Unfortunately, more than three of every four Americans are not meeting these guidelines. Many are not exercising at all. In a survey begun in 1988 by the CDC, about 31 of every 100 American adults reported that they were not active at all during their leisure time. When the survey was repeated in 2007, there was improvement; only 24 of every 100 American adults reported being inactive. Unfortunately, if 24 of every 100 adults are sedentary, that means more than 50 million people in the United States are not exercising. This puts them at a significantly increased risk of chronic health problems.

can go out after school are more likely to spend their time indoors with the Internet, video games, and cell phones. The end result is that they burn fewer calories than they consume.

Managing the Obesity Crisis

To stop the obesity epidemic, people need to find a way to maintain their weight at a healthy level. For some people, this may mean avoiding weight gain as they age by making healthy food choices, controlling portion sizes, and staying active. For others, it may mean developing a meal and exercise plan that will allow them to reach a healthy weight and stay there. For the nation as a whole, it will require efforts from public health programs, medical professionals, food manufacturers, communities, businesses, and schools in order to change our environment and lifestyle so they are less conducive to weight gain.


Nutrition and Weight Management

U.S. Surgeon Generals Call to Action

The government addressed the rising incidence of obesity in the 2001 report U.S. Surgeon Generals Call to Action to Prevent and Decrease Overweight and Obesity. This report outlines strategies to improve food choices and increase physical activity. It points out that although successful weight management ultimately depends on an individuals choices, food manufacturers and restaurants can offer healthier foods and package or serve foods in smaller portions, and communities, businesses, and schools can provide more opportunities for physical activity.

We Need to Reduce Our Calorie Intake

Calorie intake is one of the biggest issues to address when trying to prevent weight gain and promote weight loss. For many people, reducing portion sizes can help. People are used to servings that exceed our calorie needs, so decreasing what they see as a reasonable portion size will be difficult. Education about appropriate portion sizes and food choices may help. Making food labels easier to understand and providing information about portion sizes in restaurants may also help to make people more aware of how much they are eating. Food manufacturers can be involved in reeducating the public by reducing the portions they offer. Studies show that people are more likely to eat the amount provided in one container than the amount listed on the label as one serving. So even though a small package of cookies contains two servings, people will eat both of them at once. The food industry might also develop foods that have fewer calories in the same portion. For example, it might increase the amount of vegetables included in a prepared meal while reducing the fat content. Consumers also need to recognize that the value of smaller portions to their health is greater than the value of getting more food for less money.

We Need to Get Moving

America has become a sedentary society. People drive to work and the grocery store, take the elevator to their offices, and sit

The Obesity Epidemic

in front of computers all day. In addition, long commutes have decreased our ability to be active after work. Safe and accessible community recreational facilities, such as parks and bike paths, would offer people the option to be physicaly active. Businesses could offer employees access to company fitness programs and on-site fitness equipment and recreational facilities. Schools could offer more fitness classes during the school day and more recreation programs after school.


We Need to Start Young

Children can learn about healthy eating and exercise habits at any age. The U.S. Surgeon Generals Call to Action recommends the following to help children develop healthy eating and exercise habits:

Eat meals together as a family. Dont use food as a reward or punishment. Replace soft drinks and juice with water or low-fat milk. Eat breakfast. Discourage meals and snacks in front of the television.

Changing the meals and foods available in schools also can improve food choices and help decrease the fat and calorie intake of children and adolescents. Nutrition professionals have recommended that schools reduce access to foods high in fat, calories, and added sugar. U.S. Department of Agriculture regulations prohibit serving foods of minimal nutritional value during mealtimes in school food service areas, including in vending machines, but these regulations are rarely enforced. To increase activity level in children and adolescents, the U.S. Surgeon Generals Call to Action suggests that physical education be required in all school grades. To promote activity at home, the government recommends no more than two hours per day of television and suggests planning family activities, such as walks or bike rides, that allow everyone to enjoy being active.


Nutrition and Weight Management

A Brownie a Day
Did you know that eating a brownie a day in addition to your usual meals and snacks can cause you to gain over 20 pounds (9.1 kg) in a year? One brownie doesnt sound like much, but even a small one provides about 200 calories. Two hundred calories multiplied by 365 days equals 73,000 extra calories in a year. One pound of body fat contains about 3,500 calories. If you eat a brownie every day and dont increase your activity to burn off the extra calories, you will be 20 pounds heavier after a year.

Small Changes Make a Big Difference

Population-based strategies to decrease food intake and increase activity levels are a good start, but they will take a long time to have an effect. A more feasible goal might be to stop the increase in the number of obese people that has occurred for the past few decades. Even small changes in the energy balance equation could make a big difference here. It has been estimated that if people altered their energy balance by only 100 calories a day, it could prevent weight gain and reduce obesity rates in the population. One hundred calories is the equivalent of walking for an extra 15 to 20 minutes a day (about 1 mile, 1.6 km, or 2,000 steps) or reducing an ice cream serving by half a cup. This alteration is small and does not require major lifestyle changes. However, it must be done every day, or almost every day, for it to work. We must learn to consciously manage our energy balance.

Not Just an American Problem

Obesity is not only a problem in the United States, but also in many other countries. The term globesity has been used to describe the worldwide obesity epidemic. Around the world, about 1.6 billion adults are overweight, and 400 million are obese

The Obesity Epidemic

(Figure 1.3). The World Health Organization projects that by the year 2015, approximately 2.3 billion adults will be overweight, and more than 700 million will be obese. Overweight and obesity were once considered a problem only in high-income countries, but they are now on the rise in low- and middle-income coun-


Figure 1.3 In some countries, the incidence of obesity is almost as high as it is in the United States. Even in developing countries, such as China, the incidence of obesity is growing.


Nutrition and Weight Management

tries, particularly in cities. In many countries, the incidence of underweight from consumption of too few calories exists side by side with overweight from consuming more calories than are expended.

Nutrition Transition
When economic conditions improve in a developing country, obesity and its accompanying chronic diseases start to appear. Economic growth brings increased access to food, as well as changes in diet and lifestyle to patterns similar to those in developed countries. Traditional diets in developing countries are based on a limited number of foods , which are primarily starchy roots and high-fiber grains. As incomes increase, intakes of meat, fish, milk, refined grains, fat, and sugar also increase. Some of this nutrition transition is positive. Shifts in the diet are accompanied by increases in life expectancy, decreases in the birth rate, and decreases in the incidence of infectious diseases and nutrient deficiencies. Along with dietary changes come changes in lifestyle that decrease physical activity. There is a shift toward less physically demanding occupations, an increase in the use of transportation to get to work or school, more labor-saving technology in the home, and more passive leisure time. These changes in diet and lifestyle are associated with increases in the rates of heart disease, cancer, diabetes, obesity, and childhood obesity. In countries with rapidly growing economies, the incidence of chronic diseases may be on the rise while undernutrition and infectious disease are still common problems.

International Strategies
Many countries, developing and developed, need public health strategies to prevent and reduce obesity. The problem faced by international development agencies is more complex than it is in the United States. This is because they must promote economic growth and reduce undernutrition and infectious disease while

The Obesity Epidemic

at the same time preventing the increase in the incidence of obesity that occurs as diets become higher in fat, protein, and calories. Along with obesity, these new dietary patterns increase the incidence of chronic diseases such as heart disease, diabetes, and certain types of cancer. To address these growing health concerns, public health campaigns and policies must include strategies to prevent overnutrition and promote healthy lifestyles to reduce chronic disease risk while also preventing undernutrition by ensuring the availability of a safe and adequate food supply.


The United States is in the midst of an obesity epidemicmore people than ever are overweight or obese. The rate at which obesity is increasing is particularly alarming. People are gaining weight because they are eating more and moving less. Body weight is determined by both genetic and environmental factors. The genes in a population take generations to change, so it is environmental changes that have led to the increase in food intake and decrease in activity level that are the cause of the obesity epidemic. Modern lifestyles with readily available, plentiful food and the reduced need for exercise have created a situation that promotes weight gain. The surgeon general of the United States has recommended that Americans be educated on how to reduce their caloric intake and increase their activity level. The obesity crisis is not limited to the United States; it is an emerging problem, called globesity, throughout the world.

What Is a heaLthy body WeIGht?

healthy body weight is a weight that is associated with health and longevity. It is a weight at which the risk of illness and death is lowest. What a healthy weight is for you depends not only on how much you weigh, but also on your body composition. Body composition refers to the proportion of your body that is fat versus lean tissue. It is important because the risks associated with being overweight are affected by how much body fat you have and where that fat is located. Most overweight people are carrying too much fat, and it is this extra fat that increases their health risks.

What Is youR body mass Index?

Traditionally, body weight has been assessed by evaluating weight for height. The current standard for evaluating body weight is body mass index, abbreviated BMi. BMI is determined from height and weight using a mathematical equation. Calculated values are shown in the BMI chart (Figure 2.1).


Figure 2.1 This chart can be used to determine the health risk associated with BMI by following a line from your weight to the top line and your height on the left. The number at which these lines meet is your BMI. For adults, a healthy BMI is between 18.5 and 24.9 kg/m2. A body mass index of 30 or greater indicates obesity, while BMI under 18.5 is underweight.


Nutrition and Weight Management

For adults, a healthy body weight is defined as a BMI of 18.5 to 24.9 kg/m2. Those whose body weight is in this range have the lowest health risks. Those with weights above or below this have higher risks of illness and early death. Underweight for adults is defined as a body mass index of less than 18.5 kg/m2. Overweight is defined as a BMI of 25 to 29.9 kg/m2. Obese is having a BMI of 30 kg/m2 or greater. A BMI of 40 or over is classified as extreme or morbid obesity. The average BMI of adults in the United States is 28 kg/m2. BMI also can be used to assess healthy weight for teens and children over the age of 2. However, rather than individual numbers, healthy BMI for these groups is defined using growth charts with percentiles. Growth charts consist of a series of percentile curves that illustrate the distribution of body measurements in U.S. children from birth to age 20. They were developed as a clinical tool for health professionals to determine if the growth of a child is appropriate. The percentile indicates where the childs or teens growth falls in relation to population standards. For example, if a 14-year-old boy is at the 40th percentile for BMI, 39% of boys his age have a lower BMI and 60% have a higher BMI. A healthy BMI for this age group is one that falls from the 5th to less than the 85th percentile. A child is considered overweight when his or her BMI is greater than or equal to the 85th percentile but less than the 95th percentile and obese when BMI falls at or above the 95th percentile. Underweight children have a BMI of less than the 5th percentile. The BMI-for-age growth chart for boys ages 2 to 20 provides a simple way to view BMI information (Figure 2.2). A similar chart for girls is in Appendix B.

(opposite) Figure 2.2 Body weight in children and teens is assessed by calculating BMI and plotting it on a BMI-for-age growth chart to determine the percentile. The percentile classifies their weight as underweight, healthy, overweight, or obese.

What is a healthy Body Weight?



Nutrition and Weight Management

BMI is preferred over a standard weight for height determination. This is because BMI correlates better with the amount of body fat. Despite this, BMI is not a perfect tool for evaluating the health risk associated with obesity. Someone with a BMI in the overweight range who consumes a healthy diet and exercises regularly may be more fit than someone with a BMI in the healthy range who is sedentary and eats a poor diet. It is also possible to have a high BMI but not have excess body fat. For example, a weight lifter with a large amount of muscle mass will weigh a lot, and therefore have a high BMI, but may have very little body fat (and, hence, have a low risk for the diseases associated with obesity) (Figure 2.3). In evaluating the risks associated with a given BMI, it is important to assess both the proportion and location of body fat.

How Much Body Fat Is Healthy?

Our bodies are made up of lean tissue and fat tissue. The lean tissue, or lean body mass, is the component of our weight that is

Is Your Weight in the Healthy Range?

To find out if your body weight is in the healthy range, calculate your body mass index (BMI): 1. Measure your weight in pounds and your height in inches. 2. Divide your weight by your height, and then divide the answer by your height again. 3. Multiply the answer by 703. 4. If you are 20 years old or younger, use the growth chart (Figure 2.2) to determine if your BMI is in the healthy range for someone of your age. 5. If you are older than 20 and your answer is 18.5 to 24.9, your BMI is in the healthy range.

What Is a Healthy Body Weight?


Figure 2.3 This weight lifter has a BMI that falls into the obese category. Yet, because he clearly does not carry excess body fat, his risk of disease is not increased.

muscle, bone, fluids, and internal organs. The fat tissue is the body fat that we store. A persons percentage of body fat is affected by age and gender. A newborn baby typically has about 12% body fat, and this percentage increases in the first year of life. During childhood, muscle mass increases and body fat decreases, so the percentage of body weight that is fat declines. During adolescence, body weight increases. Females gain proportionately more fat, and males gain more muscle mass. As adults, women continue to have more stored body fat than men. A healthy level of body fat for a young adult female is between 21% and 32% of total weight. For young adult males, it is between 8% and 19%. As people age, lean body mass decreases and body fat increases, even if body weight remains the same. Some of this change may be prevented by physical activity.


Nutrition and Weight Management

Lifestyle can affect what is considered a desirable amount of body fat. For athletes, such as distance runners, a lower percentage of body fat is desirable because this decreases the amount of weight they have to carry. Some male athletes may perform best when their body fat is only 5% to 10%, and female athletes when body fat is 15% to 20%. These athletes need enough fat to provide essential functions such as insulating the body, supplying energy reserves, and supporting normal hormonal activity, but not so much that it adds bulk. Other athletes, such as a professional football fullback, for instance, may need to carry extra fat to excel in their sport. Environment also can affect how much body fat is desirable. For example, people who live and work in cold climates may benefit from extra body fat to prevent heat loss.

Weight Statistics

Adults in the western region of the United States are less likely to be overweight. Married men are less likely to be in the healthy weight range than are single, divorced, or separated men. Married women are more likely to be in the healthy weight range than are single, divorced, or separated women. Women who live below the poverty level are more likely to be overweight than women in other economic groups. Men who live below the poverty level are less likely to be overweight. The youngest adults (1824 years) and the oldest adults (65 years and older) are more likely than other age groups to be underweight. Being overweight is twice as common in black and Hispanic adults than it is in Asian/Pacific Islanders.

What Is a Healthy Body Weight?


How Much Body Fat Do You Have?

Body fat can be measured in a number of ways. Some measurements can be made in a doctors office or at a health club. Others require expensive, sophisticated equipment and are most often used in research settings.

Electrical Current Flow

The human body is basically a container of salt water, so it is a good conductor of electrical current. However, body fat is a poor conductor of electricity, so it offers resistance or impedance to current flow. Impedance is the degree to which something slows or stops a current. Bioelectric impedance analysis measures percent body fat by measuring the flow of electrical current. It is performed by sending a painless low-intensity electric current through the body either by holding a small device or standing on a special scale and measuring the current flow. The more body fat there is, the more impedance and the less current passes through the body. The measure of impedance can be used to calculate the amount of body fat. Bioelectrical impedance devices are used at gyms and health clubs and can be purchased for home use. These devices are easy to use, and their measurements are relatively accurate, as long as they are taken when you are well hydrated and your stomach and bladder are empty. Measurements are not accurate if done within 24 hours of strenuous exercise that causes large sweat losses. This is because the measurement assumes that body water is in the normal range. If a person is dehydrated, the proportion of water is lower than normal. That means a person will appear to have a greater percentage of body fat than he or she actually does.

Skinfold Thickness
Another noninvasive method of estimating body fat is skinfold thickness. This measures the fat under the skin, which is called


NutritioN aNd Weight MaNageMeNt

figure 2.4 Skinfold thickness is measured by pinching the fat layer under the skin with a caliper (left). The diagram on the right shows a cross-section of a skinfold test done on an arm.

subcutaneous fat. Skinfold thickness assumes that the amount of subcutaneous fat is representative of total body fat. The measurement is done by pinching the skin and fat layer that lies over the muscles and measuring its thickness using a caliper (Figure 2.4). Skinfold thicknesses are measured at one or more locations; the most common sites for skinfold measurements are the umbilicus (near the belly button), the triceps (the area over muscles on the back of the upper arm), and the subscapular area (just below the shoulder blade). Mathematical equations are then used to estimate body fat percentage from these measurements. Skinfold thicknesses can provide accurate estimates of body fat if they are performed by a trained person. However, even then, they are difficult to perform and are less accurate for obese and elderly individuals.

What Is a Healthy Body Weight?


Water Tanks and BOD PODs

For years, the standard for assessing body composition was underwater weighing. This involves weighing a person both on land and under the water. The difference between these measurements can be used to determine body density. Body density can be used to estimate body fat, because fat is less dense than lean tissue. Someone with a lower body density has a higher percentage of body fat than someone with a higher body density. To measure a persons weight under water, the person sits on a scale, exhales the air from his or her lungs, and is lowered into a tank of water. Although this method is accurate, it is not practical for many people, such as small children or frail adults. A newer method for estimating body composition measures air displacement rather than water displacement to calculate the percentage of body fat. A person is placed in an air-filled chamber (known as the BOD POD) rather than in water. The amount of air displaced is used to calculate body volume and body density. This is accurate and more convenient than underwater weighing.

Body fat also can be assessed based on the principle of dilution. Because water is present primarily in lean tissue and not in fat, a detectable water-soluble substance can be ingested or injected into the bloodstream and allowed to mix with the water throughout the body. The concentration of this substance in a sample of body fluid, such as blood, can then be measured. The extent to which it has been diluted can be used to calculate the amount of lean tissue in the body, and body fat can then be calculated by subtracting lean weight from total body weight. Dilution techniques are expensive and invasive, usually requiring injections. They are used primarily for research purposes.

Imaging the Inside

A variety of sophisticated techniques, typically used by radiologists to diagnose illness, have been used to assess body composition. Dual-energy X-ray absorptometry (DXA) uses low-energy X-rays to


Nutrition and Weight Management

Whos the Fattest?

Did you ever flop down in a chair after a big meal, feeling like a beached whale? Whales are the largest mammals and have an enormous amount of body fat, but if you express a whales fat as a percentage of its body weight, it is much leaner than most humans. The largest animal on earth, the blue whale, weighs about 264,000 pounds (120,000 kg). Blue whales have a layer of subcutaneous fat that is about 3 inches (6 to 8 cm) thick. This represents about 530 cubic feet (15 cubic meters) of fat. Thats enough to fill your bedroom from floor to ceiling. But as a percentage of its body weight, a blue whale is only about 12% fat, the same as many male athletes. When feeling fat, perhaps you should say you feel like a ringed seal or a lab rat! At weaning, a ringed seal pup is about 50% body fat. An adult mouse, of the genetically obese Ob strain, carries about 70% fat. This is much higher than the 20% to 30% body fat found in an average human. But, when it comes to records, the humans have it. When the fattest man on record died in 1983 at age 42, he weighed 1,397 pounds (634 kg) and was estimated to be 80% fat.

assess body composition. DXA distinguishes among various body tissues by measuring differences in the way X-rays are absorbed. A single test can determine total body mass, bone mineral mass, and body fat percentage. Other radiologic methods, such as CT (computerized axial tomography) scans and MRI (magnetic resonance imaging), also can be used to get a picture of what is inside the body to estimate the amount of body fat.

Are You an Apple or a Pear?

The location of the fat in your body is important in determining the risks associated with excess body fat. Fat around the hips and thighs is generally subcutaneous fat. Subcutaneous fat carries less

What is a healthy Body Weight?

risk than fat that is deposited around the organs in the abdominal region, which is called visceral fat. An increase in visceral fat is associated with a higher incidence of heart disease, high blood pressure, stroke, diabetes, and breast cancer. People who tend to deposit fat in their hips and thighs have been described as pear shaped, whereas those who deposit it in the abdomen have been described as apple shaped (Figure 2.5).


figure 2.5 People who carry excess fat in their upper body are described as apple-shaped. They have a higher risk of obesity-related disease than people who carry their weight in their lower body, who are described as pear-shaped.


Nutrition and Weight Management

Where your body fat is deposited is determined primarily by the genes you inherited from your parents, but gender, age, and lifestyle also influence where fat is stored. Visceral fat storage is more common in men than in women. After menopause, though, visceral fat increases in women. African-American women, who have an incidence of obesity that is 50% higher than that of Caucasian women, store less visceral fat. Tobacco use, stress, and alco-

Table 2.1 BMI, Waist Circumference, and Disease Risk

Disease Risk Men, waist 40 inches (102 cm); Women, waist 35 inches (89 cm) Men, waist > 40 inches (102 cm); Women, waist > 35 inches (89 cm)

BMI (kg/m2)*
Underweight Normal weight Overweight Obesity (class I) Obesity (class II) Extreme or morbid obesity (class III) <18.5 18.5 to 24.9 25.0 to 29.9 30.0 to 34.9 35.0 to 39.9 >40

Increased High Very high Extremely high

High Very high Very high Extremely high

*BMI = body weight (kg)/ height squared (m2) Disease risk for type 2 diabetes, hypertension, and cardiovascular disease relative to individuals with a normal weight and normal waist circumference. Source: National Institutes of Health, National Heart, Lung, and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Available online at: http://www.nhlbi.nih.gov/guidelines/obesity/ ob_home.htm.

What Is a Healthy Body Weight?

hol consumption increase visceral fat deposition; exercise reduces the amount of visceral fat. Distinguishing the relative amounts of visceral and subcutaneous fat a person has requires sophisticated imaging techniques. But measuring waist circumference is an easy way to assess whether a person carries too much visceral fat. In an individual with a high BMI, a large waist circumference indicates a high amount of visceral fat. For males, a BMI of 25 to 34.9 kg/m2 and a waist circumference greater than 40 inches (102 cm) is associated with increased risk. For females in this BMI range, a waist circumference of greater than 35 inches (89 cm) increases health risks (Table 2.1).


A healthy body weight is one at which the risk of illness is the lowest. The risks associated with being overweight are really due to excess body fat. The term overweight generally refers to excess body fat. The accepted standard for assessing body weight is body mass index (BMI). A healthy BMI for adults is from 18.5 kg/m2 to 24.9 kg/m2; for children and adolescents, a healthy BMI is from the 5th to less than the 85th growth percentile for age. The proportion of body weight that is fat can be assessed by a variety of techniques, including current flow, skinfold thickness, water or air displacement, dilution, and sophisticated imaging techniques. The location of body fat can also affect the risks associated with being overweight. Subcutaneous fat, located under the skin, carries less risk than visceral (abdominal) fat, located around the internal organs.

heaLth RIsks of too muCh oR too LIttLe body fat

he guidelines for a healthy BMI, body fat percentage, and waist circumference were developed by evaluating the body weights and compositions that are associated with the lowest incidences of disease and death. As BMI and body composition rise above the healthy range, the risks of weight-related diseases increase. Psychological and social problems also increase with rising weight. People who are underweight also are at risk if they do not have enough fat to provide insulation and energy reserves for times of illness.

beInG oveRfat InCReases youR heaLth RIsks

Carrying excess body fat increases the risk of developing diseases such as high blood pressure, heart disease, diabetes, stroke, gallbladder disease, arthritis, sleep disorders, breathing problems, and cancer. It also increases the risk of developing infections and


Health Risks of Too Much or Too Little Body Fat

has been linked to poor healing and complications during and after surgery. Being overweight increases the risk of complications during pregnancy and childbirth. People who gain excess weight at a young age and remain overweight as adults have greater health risks than those who do not.


Heart Disease
Obesity increases the risks of developing cardiovascular disease, which includes diseases of the heart and circulatory system. Extra body fat increases the amount of work that the heart must perform. Each pound of fat adds miles of blood vessels through which the heart must circulate the blood. Extra body fat, particularly in the

Your Heart Works Hard Enough

Your heart is a hollow, muscular organ that is about the size of a mans fist. Despite its small size, it works very hard. Every day, your heart beats about 100,000 times. Each year, it beats about 35 million times, and during an average lifetime, the human heart will beat more than 2.5 billion times. A person has about 6 quarts (5.7 liters) of blood. The heart circulates all of this blood throughout the body three times every minute. This means that in an average lifetime, a heart pumps enough blood to fill three supertankers. But your blood doesnt go into supertankers; it is pumped through blood vessels. Placed end to end, the blood vessels in a persons body would stretch approximately 60,000 miles (96,540 km), or almost three times around the Earth. When a body gains weight, it must develop more blood vessels to supply nutrients and oxygen to the new cells. This means the heart has to work even harder, pumping blood through these added miles of blood vessels. It is estimated a person who is 25 pounds (11 kg) overweight has nearly 5,000 extra miles (8,045 km) of blood vessels through which the heart must pump blood. Isnt your heart working hard enough without having to pump the extra miles?


NutritioN aNd Weight MaNageMeNt

abdomen, also increases the risks of high blood pressure and high blood cholesterol. These contribute to the development of the heart disease atherosclerosis (Figure 3.1). In people with atherosclerosis, fatty material builds up in the walls of arteries, reducing their elasticity and eventually blocking the flow of blood. Weight loss can

figure 3.1 Excess body weight and high levels of cholesterol in the blood increase the risk of developing atherosclerosis. Atherosclerosis occurs when fatty material called plaque builds up on the artery wall and narrows the space available for blood flow.

Health Risks of Too Much or Too Little Body Fat

lower blood pressure, blood cholesterol, and the risk of developing atherosclerosis. Regular exercise decreases heart disease risk by promoting a healthy body weight and percent body fat, improving blood cholesterol levels, and lowering blood pressure.


Diabetes mellitus is a disease in which blood glucose levels remain too high. Glucose is the sugar that travels in the blood and is delivered to cells, where it serves as fuel. Glucose comes primarily from the breakdown of carbohydrates in the diet. Normally, it enters cells with the help of insulin. Insulin is a hormone that is secreted into the blood by the pancreas. Blood glucose rises after a meal. In response, insulin is released, enabling glucose to enter cells and returning blood levels to normal (Figure 3.2). People with diabetes either do not release enough insulin or do not respond normally to the insulin that is released. As a result, glucose levels are too high. Over time, this leads to kidney failure, nerve damage, blindness, and heart disease. More than 23 million Americans have diabetes, and more are diagnosed every day. Most of these people have type 2 diabetes. Type 2 diabetes occurs when body cells stop responding to insulin. This is called insulin resistance. Type 2 diabetes used to be called adult onset diabetes, because it usually develops in adults age 40 and older and is most common in people over age 60 years. However, type 2 diabetes is becoming more common in children and adolescents. One reason is that more Americans are overweight and sedentary. Type 2 diabetes is three times more likely to develop in someone who is obese than in someone of a healthy body weight. About 80% of people with type 2 diabetes are overweight or obese. Type 2 diabetes also is more common in people with more visceral fat, because cells in the abdominal region tend to be larger and more resistant to insulin than subcutaneous fat cells. Type 2 diabetes often occurs as part of metabolic syndrome, or syndrome X. This is a group of disorders that includes diabetes,


NutritioN aNd Weight MaNageMeNt

figure 3.2 These blood glucose curves show normal and diabetic blood glucose during fasting and for five hours after eating. In people with diabetes, fasting blood glucose levels are higher than normal. After a meal, their blood glucose levels increase dramatically and remain high for much longer than normal.

obesity, high blood pressure, and high levels of blood lipids. It is estimated to affect up to 25% of Americans. Treatment for type 2 diabetes involves diet, exercise, and sometimes medication to keep blood glucose in the normal range. A diet moderate in calories and carbohydrates and high in fiber should be balanced with medications and excercise.Exercise is recommended because it lowers blood glucose levels by decreasing insulin resitance and helping to keep weight in the healthy range. Weight loss is recommended for

Health Risks of Too Much or Too Little Body Fat

individuals who are overweight because it diminishes insulin resistance and improves glucose tolerance.


It is estimated that about 30% of cancers in developed countries are related to diet. One of the most important dietary factors is excess body fat. Obesity increases the risk of cancers of the breast, colon, prostate, endometrium (lining of the uterus), cervix, ovary, kidney, gallbladder, liver, pancreas, rectum, and esophagus. There are many ideas as to how excess body fat increases cancer risk, but the exact mechanisms are not known. Obesity is caused by complex interactions between genetics and lifestyle factors, so it is possible that some of the increase in cancer risk is due to the same factors that led to obesity, rather than the obesity itself. To help reduce cancer risk, experts suggest eating a varied diet including plenty of fruits, vegetables, and whole grains; maintaining a healthy body weight with the help of regular physical activity; and limiting alcohol consumption.

Gallbladder Disease
Being overweight is associated with an increase in gallstones. Gallstones are clumps of solid material that form in the gallbladder. They are typically composed mostly of cholesterol and may form as a single large stone or many small ones. These stones generally do not cause symptoms unless they become lodged in the bile ducts. These small ducts allow bile to flow from the galbladder into the small intestine to aid in fat digestion and absorption. Gallstones in the ducts can cause pain and cramping when the gallbladder constricts to release bile. They can also block the passage of bile, impairing fat absorption. The more obese a person is, the greater his or her risk of developing gallstones. Women with a BMI of 30 kg/m2 or higher have about twice the risk of developing gallstones as women with a BMI of less than 25 kg/m2. The reason that obesity increases the risk of gallstones is unclear, but researchers believe that in obese


Nutrition and Weight Management

people, the liver produces too much cholesterol, which deposits in the gallbladder and forms stones. Unfortunately, gallstones also are associated with weight loss. As fat is released from body stores, cholesterol synthesis increases, making it more likely that gallstones will form.

Breathing Problems
The breathing problem most often associated with obesity is sleep apnea. Sleep apnea is serious and potentially life threatening. People with sleep apnea have brief interruptions of breathing during sleep. They are sleepy during the day because their sleep is disrupted at night. Weight loss may help to reduce sleep apnea symptoms. Asthma is also more common in obese individuals.

Excess weight and fat can increase the risk of osteoarthritis. This is a type of arthritis that occurs when the cartilage that cushions the joints breaks down and gradually becomes rougher and thinner. As the process continues, the bones in the joints rub against each other, causing pain and reducing movement. Being overweight is the most common cause of excess pressure on the joints, which causes the cartilage to wear down faster. Losing weight reduces the pressure and strain on the joints and slows wear and tear on the cartilage. Weight loss also can help reduce pain and stiffness in the affected joints, especially those in the hips, knees, back, and feet.

Reproductive Problems
Carrying excess body fat, particularly in the abdominal region, can reduce a womans ability to conceive and to have a successful pregnancy. Weight loss, even only 5% to 10% of body weight, can improve fertility and the outcome of future pregnancies. Obesity is associated with irregular and infrequent menstrual cycles and less success with fertility treatments, such as in vitro

Health Risks of Too Much or Too Little Body Fat

fertilization. The reasons for reduced ovulation and fertility are not completely understood. They may be caused by changes in the amount and breakdown of estrogen and other hormones, including insulin and leptin. Adipose tissue produces estrogen, so people with a lot of fat tissue make more estrogen. In obese women, this extra estrogen may interfere with the normal menstrual cycle. Another condition that contributes to infertility in obese women is polycystic ovary syndrome (PCOS). This disorder is associated with being overweight, diabetes, and cardiovascular disease. Women with PCOS have menstrual problems, and ovulation is either disturbed or absent. Excess body fat also can cause problems during pregnancy. Women who begin pregnancy overweight or gain too much weight during pregnancy are at a greater risk of the following:


Developing high blood pressure and diabetes during pregnancy Having a baby with birth defects or who is large for gestational age Having a miscarriage, difficult delivery, or caesarean delivery

Despite these risks, women who begin a pregnancy overweight should still gain weight during the pregnancy. Adequate weight gain during pregnancy is essential to the health of both the mother and fetus. The recommended weight gain during pregnancy is 25 to 35 pounds (11 to 15 kg) for healthy women of normal weight, but it is 15 to 25 pounds (7 to 11 kg) for women who are overweight at the start of pregnancy, and only 11 to 20 pounds (5 to 9 kg) for women who are obese. Dieting during pregnancy is not advised, even for obese women. Doctors suggest losing the excess weight before pregnancy or after the child is born and weaned. In either case, the weight loss should be gradual and accomplished by increasing activity and consuming a low-calorie, nutrient-dense diet.


Nutrition and Weight Management

Psychological and Social Impact of Being Overweight

In addition to medical issues, psychological and social problems often occur in people who are overweight. Unlike other chronic health conditions, such as diabetes and heart disease, obesity is a health problem that can be seen from the outside. Our society places a great deal of importance on physical appearance, and attractiveness is often equated with being thin. Obesity is associated with gluttony or laziness. These stereotypes are not

The Cheeseburger Bill

Are the 67 grams of fat and more than 1,500 calories in a burger, fries, and a shake the reason we are fat? It probably plays a part for many people, but some people are going so far as to sue the restaurant industry. In July 2002, a 56-year-old maintenance worker filed a lawsuit against McDonalds, Burger King, Wendys, and Kentucky Fried Chicken. The man claimed he had eaten fast food because it was convenient and cheap, but was unaware that it could harm his health. The man weighed about 272 pounds (125 kg), had survived two heart attacks, and suffered from diabetes and high blood pressure. The lawsuit argued that the companies failed to adequately inform the public of what was in their food and to provide clear warnings about the risks of a diet that includes a lot of fast food. In another lawsuit, two teenagers accused McDonalds of making them fat by serving them highly processed food that affected their health. Should consumers know that eating huge amounts of fast food is bad for their health? Many believe they should. In order to protect food manufacturers and restaurants from lawsuits and class-action suits from obese customers, a bill called the Personal Responsibility in Food Consumption Act, or the Cheeseburger Bill, was introduced to Congress. The bill was passed by the House of Representatives but never became a law because it failed to pass in the Senate.

Health Risks of Too Much or Too Little Body Fat

true but are often at the core of the prejudice and discrimination that obese people may experience in the job market, at school, and in social situations. Overweight and obese individuals of any age are more likely to experience depression, negative self-image, and feelings of inadequacy. They may also experience discrimination in college admissions, in the workplace, and even on public transportation. The physical health consequences of excess body fat may not manifest themselves as disease for years, but the psychological and social problems are experienced every day.


Being Underweight Has Health Consequences

We all need body fat stores. Stored fat provides cushioning, acts as an insulator, and serves as an energy reserve for periods of illness. Statistically, people with little stored fat have a greater risk for illness than people with body fat in the normal range. However, the health implications for someone who is naturally on the lean side are very different from the health problems seen in someone who is starving due to a food shortage or an eating disorder.

Natural Leanness
Research has suggested that being on the low side of the body weight standard may reduce the risk of diabetes, heart disease, and other chronic diseases. It may even increase longevity. Many lean people live to a healthy old age, but people with little energy reserves have a disadvantage when battling a medical condition that causes wasting and malnutrition, such as cancer. Therefore, statistically, a low body weight is associated with an increased risk of early death.

Restricted Food Intake

As opposed to being naturally lean, some people are thin because they do not eat enough to keep their weight in the healthy range. In the developing world, starvation due to food shortage is a real concern. In developed countries, socioeconomic conditions


Nutrition and Weight Management

Figure 3.3 The eating disorder anorexia nervosa is characterized by a restriction in food intake that leads to extreme weight loss and eventually starvation. Brittany Bethel, seen here at age 21 in 2007, battled anorexia nervosa and suffered a heart attack while running on a campus track. She was eventually asked to leave her college after university officials deemed her to be a danger to herself.

Health Risks of Too Much or Too Little Body Fat

may create isolated pockets of undernutrition, but severe cases of starvation usually result from either eating disorders, such as anorexia nervosa, or diseases like AIDS and cancer (Figure 3.3). Eating too little to maintain adequate fat stores causes problems at all stages of life. Low weight gains during pregnancy are associated with an increase in low-birthweight infants. These babies have a higher risk of health complications and death. In teenage girls, too little body fat can delay sexual development. In healthy but very lean female athletes, menstrual irregularities are common, causing infertility and increasing the risk of osteoporosis. Too little body fat in the elderly increases the risk of malnutrition. This is especially a problem when the low body weight is due to weight loss, rather than to a lifetime of being lean. If food intake restriction is severe enough that weight loss continues, not only are fat stores depleted, but significant amounts of body protein also are lost. Starvation in children can lead to stunted growth and impaired mental development. As starvation progresses, its victims become weak, find it difficult to concentrate, and may have difficulty sleeping. Their metabolic rate slows down to decrease energy expenditure. In females, estrogen levels drop and abnormalities in the menstrual cycle occur. Substantial reductions in body weight have been shown to decrease the ability of the immune system to fight infection, increasing the risk of disease. The final stages of starvation are characterized by inactivity, apathy, and withdrawal from life. Conditions such as electrolyte imbalances, dehydration, edema, cardiac abnormalities, and infection become life threatening.


Carrying too much or too little body fat increases health risks. The incidence of high blood pressure, atherosclerosis, and diabetes are increased in people who carry excess body fat. Weight loss can lower blood pressure, blood cholesterol, and the risk of heart disease and diabetes. The incidence of certain cancers is increased by obesity, and both obesity and weight loss increase


Nutrition and Weight Management

the formation of gallstones. Breathing problems and arthritis also are more common in those who are overweight. Excess body fat affects fertility and reproductive outcome. Obese individuals are also more likely to suffer from depression than their peers who are at a healthy weight. Being too lean also carries risk. If the leanness is natural, it may have little impact, unless energy stores are needed as a reserve during illness. However, leanness due to weight loss associated with disease or a lack of food can cause serious health problems.

food, nutRItIon, and body WeIGht

ne of the first things that comes to mind when considering body weight is food. If you eat too much, you will gain weight. If you eat too little, you will lose weight. The science of nutrition studies all of the interactions that occur between people and food. This includes how foods provide us with energy and the nutrients we need to stay alive and healthy. Nutrition also considers how much of each nutrient is too much and how many calories are needed to keep weight in the healthy range. An understanding of nutrition can help people choose the types and amounts of food that keep weight in the healthy range and also how to navigate the thousands of weight loss diets, programs, supplements, books, and foods on the market today that promise to help people lose weight.

food pRovIdes nutRIents and CaLoRIes

We dont eat individual nutrients; we eat food. Food provides the body with energy and nutrients. It also contains other substances,



Nutrition and Weight Management

such as chemicals found in plants called phytochemicals, that have not been defined as nutrients but have health-promoting properties. When we choose the right amounts and combinations of food, our diet provides all of the nutrients and other substances we need to stay healthy. If we choose a poor combination of foods, we may be missing out on some essential nutrients. Choosing a diet that provides all of the essential nutrients can be challenging because we eat for many reasons other than to obtain nutrients. We eat because we see or smell a temping food, its lunchtime, were at a party, we feel sad or happy, its Thanksgiving, as well as a multitude of other reasons. In order to meet nutrient needs, we must understand what these needs are and how to choose a diet that provides them. There are more than 40 nutrients that are essential to human life. We need to consume these essential nutrients in our diets because either they cannot be made in our bodies or they cannot be made in large enough amounts to optimize health. Foods contain different nutrients in varying amounts and combinations. For example, beef, chicken, and fish provide protein, vitamin B6, and iron. Bread, rice, and pasta provide carbohydrates, folic acid, and niacin. Fruits and vegetables provide carbohydrates, fiber, vitamin A, and vitamin C. Vegetable oils provide fat and vitamin E. In addition to the nutrients found naturally in foods, many foods have nutrients added to them through fortification to replace losses that occur during cooking and processing or to supplement the diet. Dietary supplements also are a source of nutrients. Although most people can meet their nutrient needs without them, supplements can be useful for maintaining health and preventing deficiencies.

What Nutrients Do
Nutrients provide three basic functions in the body. Some nutrients provide energy, some help form body structures, and some help to regulate the processes that keep us alive. Each nutrient

Food, Nutrition, and Body Weight

performs one or more of these functions. All nutrients together are needed for growth, to maintain and repair the body, and to allow us to reproduce.


Our bodies need energy to keep us alive: to keep our hearts pumping, our lungs respiring, our muscles working, and our body warm. This energy is provided by carbohydrates, lipids, and proteins. These are the only nutrients that provide energy to the body and therefore are referred to as the energy-yielding nutrients. The energy used by the body is measured in calories or kilocalories (abbreviated as kcalories or kcals). In some other countries, food energy is measured in joules or kilojoules (abbreviated as kjoules or kJs). Each gram of carbohydrate we eat provides the body with 4 calories. A gram of protein also provides 4 calories. A gram of fat provides 9 calories, more than twice the calories of carbohydrates or protein. For this reason, foods that are high in fat are high in calories. Alcohol can also provide energy in the diet7 calories

Is a Calorie a Kilocalorie?
There are 16 calories in a teaspoon of sugar. Yet, if in your chemistry class you measured the amount of energy in a teaspoon of sugar, the result would be about 16,000 calories, or 16 kilocalories. This is because the calories we use in nutrition to refer to the energy content of food are really kilocalories. A kilocalorie is 1,000 calories. Sometimes, as is the case on food labels, calorie is spelled with a capital C to indicate that it is referring to kilocalories. In the popular press, however, the term calorie with a lower case c is typically used to express the kilocalorie content of a food or of a diet. Therefore, when you eat a cookie that has 50 calories, keep in mind that it really has 50 kilocalories, or 50,000 calories.


Nutrition and Weight Management

per grambut alcohol is not considered a nutrient because the body does not need it to survive. The more calories you use, the more calories you need to eat in order to maintain your weight. If you increase the amount of exercise you get without increasing the amount you eat, you will lose weight. Or, if you increase the amount you eat without increasing your exercise, your body will store the extra energy, mostly as body fat, and you will gain weight. When you consume the same number of calories as you use, your body weight remains the samethis is called energy balance.

There is truth to the saying You are what you eat. All of the structures in a persons body must be formed from the nutrients that are consumed. By weight, the human body is about 60% water, 16% protein, 16% fat, and 6% minerals. For example, the minerals calcium and phosphorus make bones and teeth hard. Protein forms the structure of tendons, ligaments, and muscles, and lipids are the major component of body fat. Water has a structural role because it plumps up cells, giving them shape.

All of the bodys processesfrom the breakdown of carbohydrates and fat to provide energy, to the building of bone and muscle to form body structures, must be regulated in order to allow the body to function normally. Conditions in the body must be maintained within certain limits to support life. For instance, the processes that maintain body temperature at 98.6F (37C) must be regulated, or body temperature will rise above or fall below the healthy range. Maintaining this stable internal body environment, referred to as homeostasis, requires many different nutrients. Water helps regulate body temperature. Lipids and proteins are needed to make regulatory molecules called hormones, and certain protein molecules, vitamins, and minerals help regulate the rate of chemical reactions within the body.

Food, Nutrition, and Body Weight


Getting Nutrients to Your Cells

The food we eat must be broken down, and the nutrients it provides must be transported into the body in order to be useful. Digestion breaks down food. Absorption brings the nutrients into the blood so they can be transported to the cells that need them. The digestive system is responsible for the digestion of food and the absorption of nutrients (Figure 4.1). The main part of this

Bacteria in Your Intestine

Did you know that the large intestine is home to several hundred species of bacteria? You provide them with a nice, warm home with lots of food, and they do you some favors in returnif they are the right kind. These bacteria improve the digestion and absorption of essential nutrients. They make some vitamins, break down harmful substances, help the immune system work, and are responsible for the proper growth of cells in the large intestine. A healthy population of intestinal bacteria may also help prevent constipation, gas, and excess stomach acid. However, if the wrong bacteria take over, the result could be diarrhea, infections, and perhaps an increased risk of cancer. How can you make sure the right bacteria are in your gut? One way is to eat them. This is referred to as probiotic therapy. Live bacteria are found in foods such as yogurt and acidophilus milk and can be purchased as bottled suspensions or tablets. One problem with probiotic therapy is that the bacteria are washed out of the colon if you stop eating them. A second approach that can modify the bacteria in your gut is to consume foods or other substances that encourage the growth of particular types of bacteria. Substances that pass into the large intestine and serve as food for these bacteria are called prebiotics. Prebiotics are sold as dietary supplements, but dont run to the store just yet. For most of us, eating a healthy diet supports a healthy population of intestinal bacteria.


NutritioN aNd Weight MaNageMeNt

system is the gastrointestinal tract, also called the GI tract. This hollow tube starts at the mouth, where chewing breaks food into small pieces. From there, food passes down the esophagus into

figure 4.1 The digestive system consists of the gastrointestinal tract and the salivary glands, liver, pancreas, and gallbladder, which aid digestion. The digestive system breaks down food and nutrients into molecules that are small enough to be absorbed.

Food, Nutrition, and Body Weight

the stomach and then on to the small intestine. Rhythmic contractions of the smooth muscles that line the GI tract help mix food and move it along. Digestive enzymes secreted into or found in the gastrointestinal tract break down the food. The digestive system also secretes hormones into the blood that help regulate GI activity. Most of the digestion and absorption of nutrients occurs in the small intestine. Anything that is not absorbed passes into the large intestine. Here, some additional nutrients can be absorbed, and waste is prepared for elimination.


How Your Body Uses Nutrients

Once inside body cells, carbohydrates, lipids, and proteins are involved in chemical reactions that allow them to be used for energy or to build other substances that the human body needs. The sum of these chemical reactions that occur inside body cells is called metabolism. The chemical reactions of metabolism can synthesize the molecules needed to form body structures, such as muscles, nerves, and bones. The reactions of metabolism also break down carbohydrates, lipids, and proteins to yield energy in the form of ATP (adenosine triphosphate). Cells use ATP as an energy source so they can do work, such as pump blood, contract muscles, or make new tissue. The production and use of ATP will be discussed more in the next section.

The Six Classes of Nutrients

The nutrients we need come from six classes: carbohydrates, lipids, protein, water, vitamins, and minerals. Each class, with the exception of water, contains a variety of molecules that the body uses in different ways. Some classes of nutrients are needed in relatively large amounts. Some are needed only in tiny amounts. Carbohydrates, lipids, protein, and water often are referred to as macronutrients because the body needs them in large amounts. Vitamins and minerals are referred to as micronutrients because they are needed in small amounts (Table 4.1).


Nutrition and Weight Management

Table 4.1 Categories of Nutrients

Nutrient Category
Macronutrients Carbohydrates Protein Lipids Sugars, starches, and fiber Proteins and amino acids Triglycerides, fatty acids, phosphoglycerides (phospholipids), and sterols (including cholesterol) Water Fat-soluble vitamins: vitamins A, D, E, and K Water-soluble vitamins: vitamins C, B6, B12, thiamin, riboflavin, folate, niacin, pantothenic acid, and biotin Major minerals: sodium, potassium, chloride, calcium, phosphorus, magnesium, and sulfur Trace minerals: iron, copper, zinc, manganese, selenium, iodine, fluoride, chromium, and molybdenum

Nutrients included

Water Micronutrients Vitamins


Carbohydrates include sugars, starches, and fiber. Sugars are the simplest form of carbohydrate. They taste sweet and are found in fruit, milk, and sweeteners, such as honey and table sugar. Starches are made of many sugar units linked together. They do not taste sweet, and are found in cereals, grains, and starchy vegetables, such as potatoes. Starches and sugars are good sources of energy in the diet and provide 4 calories per gram of carbohydrate. Most fiber also is a carbohydrate. Good sources of fiber include whole grains,

Food, Nutrition, and Body Weight

legumes (peas and beans), fruits, and vegetables. Fiber provides little energy to the body because it cannot be digested or absorbed. It is, however, important for the health of the digestive tract.


Lipids are commonly called fats. Fat is a concentrated source of energy in our diet and in our bodies, providing 9 calories per gram of fat. Most of the fat in our diet and in our bodies is in the form of triglycerides. Each triglyceride contains three fatty acids. Fatty acids are basically long, short, or medium-length chains of carbon atoms. Depending on how these carbons are linked together, fats are classified as either saturated or unsaturated. Saturated fats are typically solid at room temperature. They are found mostly in animal products, such as meat, milk, and butter. Unsaturated fats are found in vegetable oils, and are usually liquid at room temperature. Small amounts of certain unsaturated fatty acids are essential in the diet. Cholesterol is another type of lipid found in animal foods. Diets high in saturated fat, trans fat, and cholesterol may increase the risk of heart disease.

Protein is needed for growth, maintenance and repair of body structures, and for the synthesis of regulatory molecules. It also can be broken down to provide energy (4 calories per gram of protein). Protein is made of folded chains of units called amino acids. The right amounts and types of amino acids must be consumed in the diet in order to meet the bodys protein needs. Animal foods, such as meat, poultry, fish, eggs, and dairy products, generally supply a combination of amino acids that meets human needs better than do plant proteins. A vegetarian diet containing only plant foods like grains, nuts, seeds, vegetables, and legumes, however, also can meet protein needs.

Water is an essential nutrient that makes up about 60% of the adult human body. It provides no energy but is needed to transport


Nutrition and Weight Management

nutrients, oxygen, waste products, and other important substances. It also is needed for many chemical reactions, for body structure and protection, and to regulate body temperature. Water is found in beverages as well as solid foods. Water is not stored in the body. People must take in enough water to balance losses through urine and sweat production, as well as evaporation.

Vitamins are small carbon-containing molecules needed to regulate metabolic processes. They are found in almost all the foods we eat, but no one food is a good source of all vitamins. Some vitamins are soluble in water, and others in fat. This affects how they are absorbed by and transported through the body (see Table 4.1). Vitamins do not provide energy, but many are needed to regulate the chemical reactions that extract energy from sugars, fatty acids, and amino acids. Some vitamins are antioxidants, which protect the body from reactive oxygen compounds like free radicals. Others have roles in tissue growth and development, bone health, and blood-clot formation.

Minerals are single elements. Some are needed in the diet in significant amounts. Some are needed only in very small amounts. Like vitamins, minerals provide no energy but perform a number of very diverse functions. Some are needed to regulate chemical reactions. Some participate in reactions that protect cells. Others have roles in bone formation and maintenance, oxygen transport, or immune function.

How Much Of Each Nutrient Do You Need?

To stay healthy, people need enough energy and enough of each of the essential nutrients. The amount of each that a person needs depends on age, size, sex, genetic makeup, lifestyle, and

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health status. The Food and Nutrition Board of the National Academy of Sciences has developed general guidelines called Dietary Reference Intakes (DRIs). The DRIs make recommendations about how much of each nutrient should be consumed in order to promote health, prevent deficiencies, and reduce the incidence of chronic disease. Still, the exact amount of any nutrient that any one person needs depends on his or her particular circumstances.


The Dietary Reference Intakes (DRIs)

The DRIs include recommendations for amounts of nutrients and energy (calories) for different groups of people based on age, gender, and, when appropriate, pregnancy and lactation. The recommendations for nutrient intakes include four different types of values. The Estimated Average Requirements (EARs) are the amounts of nutrients that are estimated to meet the average needs of the population. They are not used to assess individual intake but rather are intended for planning and evaluating the adequacy of the nutrient intake of population groups. The Recommended Dietary Allowances (RDAs) and Adequate Intakes (AIs) are values that are estimated to meet the needs of nearly all healthy people in each gender and life-stage group. These can be used to plan and assess diets. The fourth set of DRI values is the Tolerable Upper Intake Levels (ULs). These are the maximum levels of intake that are unlikely to pose a risk of adverse health effects. ULs can be used as a guide to limit intake and evaluate the possibility of excessive intake. When your diet provides the RDA or AI for each nutrient and does not exceed the UL for any, your risk of nutrient deficiency or toxicity is low. The recommendations for calorie intake in healthy people are expressed as Estimated Energy Requirements (EERs). They are based on age, gender, size, and activity level. Formulas for calculating EERs are included in Appendix A.


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What Happens if You Get Too Little or Too Much?

Consuming either too much or too little of one or more nutrients or energy can cause malnutrition. Typically, we think of malnutrition as a lack of energy or nutrients. This may occur if a persons diet doesnt contain the recommended amount of each nutrient, and it can occur in those eating the recommended amounts if they have higher needs because their bodies do not absorb or use nutrients normally. Energy deficiency is called starvation. It causes a loss of body fat and muscle mass so the person becomes very thin. Malnutrition due to individual nutrient deficiencies causes symptoms that reflect the functions of the nutrient in the body. For example, vitamin D is needed for strong bones. A deficiency of vitamin D in a child causes the leg bones to bow outward, because they are too weak to support the body weight (Figure 4.2). Vitamin A is needed for healthy eyes; a vitamin A deficiency can result in blindness. For many nutrient deficiencies, supplying the lacking nutrient can quickly reverse the symptoms. Overnutrition, an excess of energy or nutrients, is also a form of malnutrition. An excess of energy causes obesity. It increases the risk of developing diseases such as diabetes and heart disease. Taking in too much of a vitamin or mineral rarely occurs from

Too Much of a Good Thing Can Kill You

We usually think of vitamins as a healthy addition to our diets, but too much can be dangerous. Taking too many dietary supplements can cause problems, including ulcers, kidney stones, and liver and heart damage. In extreme cases, it can cause death. Overdosing on iron is one of the more common forms of poisoning in children under the age of five. To be safe, take supplements according to the recommended doses, and use the UL values from the DRIs to check for toxic doses.

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Figure 4.2 A child with vitamin D deficiency cannot absorb enough calcium for his or her bones to harden, and he or she may develop rickets. When the child begins to walk, his or her body weight causes the soft bones to bow. This child has what is known as windswept deformity, which is caused by rickets.


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eating food. But people can get too much through dietary supplements. Consuming too much vitamin B6 can cause nerve damage. Consuming too much iron can cause liver failure.

Tools for Choosing a Healthy Diet

Knowing which nutrients your body needs to stay healthy is the first step in choosing a healthy diet, but knowing how many milligrams of niacin, micrograms of vitamin B12, grams of fiber, or what percent of calories from carbohydrates are in a healthy diet doesnt help people decide what to eat for breakfast or pack for lunch. A variety of tools have been developed to help people make these choices. Three of themstandardized food labels, the Dietary Guidelines for Americans, and MyPyramidare discussed below.

Understanding Food Labels

Food labels were designed to help people make healthy food choices. They provide information about the nutrients in a food and show how the food fits into the recommendations for a healthy diet. Almost all packaged foods must carry a standard food label. Raw fruits, vegetables, fish, meat, and poultry are not required to have food labels. For these foods, the nutrition information is often posted in the grocery store or printed in brochures. Food labels must include both an ingredient list and a Nutrition Facts panel. The ingredient list includes all of the substances contained in the product, including food additives, colors, and flavorings. The ingredients are listed in order of their prominence by weight. A label that lists water first indicates that most of the weight of that food comes from water. The ingredient list is especially useful for people trying to avoid certain ingredients, such as animal products, or a food to which he or she has an allergy. The Nutrition Facts portion of a food label lists the serving size of the food, followed by the total calories, calories from fat, total fat, saturated fat, cholesterol, sodium, total carbohydrates, dietary fiber, sugars, and protein per serving of the food (Figure

Food, Nutrition, and Body Weight

4.3). The amounts of these nutrients are given by weight and as a percent of the daily Value (dV). DVs are standards developed for food labels. They are based on a 2,000-calorie diet. They help


figure 4.3 Standard nutrition labels, such as this one, appear on all packaged foods to help consumers make informed choices about their diets.


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Food Groups by the Numbers

Using something like MyPyramid to guide food intake is not new. The first food guide, called Food for Young Children, was published in 1916. Like MyPyramid, it divided food into five groups, but the groups were different: milk/meat, cereals, vegetables/fruits, fats/fatty foods, and sugars/sugary foods. During the Great Depression, the government developed a food guide consisting of 12 food groups. It was supposed to help families save money on groceries. In 1943, shortages brought on by World War II led to a food guide called the Basic Seven. In 1956, this complicated guide was simplified and renamed the Basic Four. The Basic Four included milk, meats, fruits and vegetables, and grain products. It was used for the next 20 years. In the late 1970s, as concerns about chronic disease began to intensify, the USDA added a fifth category to the Basic Four: fats, sweets, and alcoholic beverages, which people were advised to consume in moderation. In 1992, the Food Guide Pyramid was introduced. It used a pyramid shape to emphasize the relative contribution that six food groups should make to a healthy diet. It was replaced by MyPyramid in 2005. Food guides are not unique to the United States. Those developed in other countries use different shapes and numbers of groups. Korea and China use a pagoda shape; Mexico, Australia, and most European countries use a pie or plate shape; and Canada uses a rainbow.

people see how a food fits into their diet. For example, if a food provides 10% of the DV for fiber, then the food provides 10% of the daily recommendation for fiber intake in a 2,000-calorie diet. The amounts of vitamin A, vitamin C, iron, and calcium are also listed as a percent of the DV. In addition to the required nutrition information, food labels often highlight certain aspects of a product in which people might be interested. The food label might advertise that a food is low

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in calories or high in fiber. The Food and Drug Administration (FDA) has developed definitions for these nutrient content descriptors. For example, to be low in calories, a food must contain no more than 40 calories per serving. Food labels are also permitted to include certain health claims if they are relevant to the product. For example, the label on oatmeal may claim that it helps to lower blood cholesterol. Health claims are only permitted on labels if the FDA has found that scientific evidence supports the claim.


The Dietary Guidelines

The Dietary Guidelines for Americans are meant to help people choose diets and lifestyles that keep them as healthy as possible. The Dietary Guidelines recommend choosing a variety of nutrientdense foods. These include vegetables, fruits, whole grains, low-fat dairy products, lean meats, beans, nuts, and seeds. This type of diet is rich in fiber, micronutrients, and phytochemicals, and low in saturated fat. The key recommendations of the Dietary Guidelines,

Table 4.2 Key recommendations of the Dietary Guidelines for Americans, 2005

Consume a variety of foods within and among the various food groups. Balance calorie intake with expenditure to manage body weight. Be physically active every day. Choose more fruits and vegetables, whole grains, and low-fat dairy products. Choose fats wisely. Choose fiber-rich carbohydrates and limit added sugars. Choose and prepare foods with little salt. If you drink alcoholic beverages, do so in moderation. Prepare, handle, and store food safely.


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shown in Table 4.2, are appropriate for all healthy Americans ages two and older.

MyPyramid is a tool designed to help consumers choose foods that meet the recommendations of the Dietary Guidelines. It divides foods into five food groups based on the nutrients they provide. The groups are grains, vegetables, fruits, milk, and meat and beans. These groups, plus oils, are represented by the colored triangles that make up the pyramid. The shape of the pyramid reflects the recommendations for how much of a persons diet should come from the different groups (Figure 4.4). Foods in the wider base of each triangle contain the most nutrients per calorie. Those in the narrow tip are lower in nutrients per calorie. The person climbing the pyramid shows the importance of physical activity. People can find a MyPyramid plan that fits them by going to www.mypyramid.gov. Plans depend on age, gender, and activity level. The MyPyramid Web site also provides other interactive tools to help people figure out how many calories they need to eat every day, choose nutritious foods, plan healthy diets, analyze what they are eating, and calculate how many calories they burn in physical activity.

Food provides our bodies with energy, measured in calories, and nutrients, which are substances required in the diet for growth,

(opposite) Figure 4.4 The USDAs MyPyramid divides foods into five food groups based on the nutrients they provide. The width of the colored triangles that make up the shape of the pyramid reflects the government agencys recommendations for how much of a persons diet should come from each of the different food groups.

Food, Nutrition, and Body Weight



Nutrition and Weight Management

reproduction, and maintenance of our bodies. The right number of calories is needed to keep weight in the healthy range, and the right combination of nutrients is needed to maintain health. There are six classes of nutrients. Carbohydrates include sugars, starches, and fibers. Sugars and starches provide 4 calories per gram. Fibers provide little energy because they cannot be digested by human enzymes and therefore cannot be absorbed. Lipids are a concentrated source of calories in the diet and in the body, providing 9 calories per gram. They also are needed to synthesize molecules that provide structure and help regulate body processes. Proteins are made from amino acids. In the body, proteins can provide energy but are more important for their structural and regulatory roles. Water is the most abundant nutrient in the body. Water intake must equal output to maintain balance. Vitamins and minerals are needed in the diet in small amounts. They both have regulatory roles, and some minerals also provide structure. Consuming too much or too little energy or nutrients results in malnutrition. The Dietary Reference Intakes (DRIs) recommend amounts of energy and nutrients needed to promote health, prevent deficiencies, and reduce the incidence of chronic disease. Food labels, the Dietary Guidelines for Americans, and MyPyramid, provide information and recommendations that help people choose foods that make up a healthy diet.

hoW many CaLoRIes do you need?

ow many calories do you need to eat to maintain your weight? The answer depends mostly on your age, gender, size, and activity level. To keep your weight stable, the energy (calories) you consume in food must be equal to the amount your body uses to stay alive, to move, to digest food, and to grow. When the two are equal, your body is in energy balance and your weight remains the same (Figure 5.1). Being in energy balance, however, does not necessarily mean you are at a healthy weight. Energy intake can be in balance with energy output at any weightobese, lean, or in between. Likewise, regardless of your current weight, if you consume more calories than you burn, your weight will increase as you store the excess energy for later use, mostly as fat. If you burn more calories than you consume, your body will use some of its stored energy and you will lose weight.



NutritioN aNd Weight MaNageMeNt

figure 5.1 When someone is in energy balance, the amount of energy (calories) he or she consumes in food is equal to the amount of energy his or her body uses to stay alive and keep moving.

WheRe does youR eneRGy Come fRom?

The energy needed to fuel your body comes from the carbohydrates, fat, protein, and alcohol you consume in food and beverages. Vitamins, minerals, and water are essential to life, but they do not provide energy. Some of the energy you consume in food is used immediately, and some is stored in your body to be used as an energy source when food is not available.

How Many Calories Do You Need?


Energy in Food and Drink

The amount of energy you consume depends on the foods you choose. The amounts of carbohydrates, protein, and fat in a food determine the number of calories it provides. In the laboratory, it is possible to determine the number of calories in a food by using a bomb calorimeter. This device is based on the principle that energy can be converted from one form to another. To determine the energy in a food, a sample of the food is dried and placed in a chamber that is surrounded by a jacket of water. The food is then burned, converting the energy it contains into heat and raising the temperature of the water. The increase in water temperature is then used to calculate the number of calories in the food, based on the fact that 1 kilocalorie is the amount of heat needed to increase the temperature of 1 kilogram of water by 1C (33.8F). Although most people dont have bomb calorimeters in their kitchens, they can still determine how much energy is in a food by looking at food labels or food composition tables and databases. It also is possible to estimate the number of calories in a food or meal if you know the amounts of carbohydrates, fat, and protein that the food or meal contains. Based on bomb calorimeter measurements, we know that carbohydrates and protein provide about 4 calories per gram, and fat provides 9 calories per gram. So for example, 5 grams of sugar, which is almost pure carbohydrate, contains about 20 calories (5 g x 4 cal/g). But 5 grams of corn oil, which is almost pure fat, contains about 45 calories (5 g x 9 cal/g). Because most foods are mixtures of carbohydrates, protein, and fat, the arithmetic is a little more complicated. For example, if one-half cup of stew contains 9 grams of protein, 15 grams of carbohydrates, and 12 grams of fat, its calorie content can be calculated like this:
(4 cal/g x 9 g protein) + (4 cal/g x 15 g carbohydrates) + (9 cal/g x 12 g fat) = 204 calories


Nutrition and Weight Management

Figure 5.2 Most of the size of an adipocyte (or fat-storing cell) is due to droplets of triglycerides. When we store more energy, the amount of triglycerides in each cell increases, and the adipocytes increase in size.

Energy in Your Body

Your body stores energy as glycogen and fat. Glycogen is stored carbohydrates. It is made up of branching chains of glucose molecules. Glycogen is stored in your muscles and liver. Muscle glycogen provides fuel for the contraction of the specific muscles where the glycogen is located. Liver glycogen is broken down into glucose, which can be transported in the blood to cells throughout the body. Together the glycogen in the muscles and liver provides about 1,400 calories of stored energy. Fat is stored as triglycerides in adipose tissue. Adipose tissue is made up of fat-storing cells, called adipocytes (Figure 5.2). When people take in extra calories, triglycerides accumulate, and adipocytes increase in size. Most adipocytes are formed between infancy and adolescence. But even

How Many Calories Do You Need?

in adulthood, excessive weight gain can trigger the production of new adipocytes, allowing the storage of a virtually unlimited amount of body fat.


Using Your Stored Energy

When a person needs more energy, whether it is between meals or over the course of days, weeks, or months, body stores are used to supply it. Some tissues, including the brain and red blood cells, must use glucose as an energy source. At first, this glucose comes from the breakdown of stored glycogen. When glycogen stores begin to decrease, or when no food has been eaten for more than

Watch That Serving Size!

On a hot day, a bottle of iced tea or fruit juice may be just what you need to cool off. The label says that a serving has only 100 calories. But take a closer look. The serving size is 8 ounces (237 milliliters), and the bottle holds 20 ounces (592 mL). Therefore, your cool gulp of iced tea may be giving you 250 calories, mostly as added sugars. People tend to eat in units: one cookie, one can, one bottle. Most people do not drink half of a bottle of iced tea and save the rest for later. Food manufacturers are required to use standard serving sizes on food labels, but they are not required to package products to match these serving sizes. Even if the package is clearly meant to contain multiple servings, people do not always eat only one serving. For example, 1 cup of granola might seem like the right amount to eat for breakfast. But if the serving size is cup, 1 cup is four servingsand thats four times as many calories as listed on the label. Pasta servings are a challenge because the serving size is usually given as dry pasta. Once cooked, what does 2 ounces (57 g) of dry spaghetti look like? It is about 1 cup. So someone who eats 2 cups of pasta is eating 400 calories, rather than the 200 calories per serving listed on the label.


Nutrition and Weight Management

several hours, the body can make glucose. This process is called gluconeogenesis. Gluconeogenesis uses small molecules that come mostly from the breakdown of amino acids as the raw material for glucose production. These amino acids come from the breakdown of body proteins, primarily from muscles. Because the body does not store protein, when protein is broken down to provide raw materials to make glucose, functional body proteins are lost. Energy for tissues that dont require glucose is provided by the breakdown of body fat. Stored triglycerides are broken down to fatty acids that can be used to provide energy. The body needs a small amount of glucose to completely break down fatty acids. When glucose is limited or not available, fatty acids cannot be completely broken down. As a result, molecules called ketones are formed. Ketones can be used as an energy source by many tissues; during starvation, even the brain can adapt to use ketones to supply some of its energy needs. The use of ketones for energy reduces the amount of glucose needed and, therefore, decreases the amount of protein that is broken down to provide glucose. Ketone production is a normal adaptation, but if large amounts of ketones are produced, as occurs in starvation or uncontrolled diabetes, they build up in the blood. This results in a condition called ketosis. Ketosis makes the blood more acidic. Severe ketosis, such as that which occurs in uncontrolled diabetes, can eventually result in coma and death. In a typical day, the amount of stored energy does not change. Some glycogen and fat stores are used between meals and then replaced by nutrients consumed at the next meal. However, if the energy stores are not replenished, the amount of stored energy and hence, body weightwill decrease. It is estimated that burning about 3,500 calories, and not replacing them, results in the loss of a pound (0.45 kg) of body fat.

Adding to Your Energy Stores

The energy consumed in meals and snacks throughout the day often is more than the body needs at that moment in time. When

How Many Calories Do You Need?

this occurs, the body determines which nutrients to use immediately and which to store. This determination is based on what the body needs, which nutrients can be stored, and how efficiently they can be stored. For example, when alcohol is consumed, it is quickly broken down and used for energy. This is because it is toxic and the body cannot store it. When protein is consumed, its constituent amino acids are used to make body proteins and other nitrogen-containing molecules. Protein cannot be stored, so any leftover amino acids are broken down and used for energy. When carbohydrates are consumed, they are used to supply blood glucose and to build glycogen stores. When fat is consumed, it is used to meet immediate energy needs. Remaining fat is stored as triglycerides, primarily in adipose tissue. Most of the fat deposited in adipose tissue comes from dietary fat. This is because excess fat from the diet is readily stored, and the energy required to convert dietary fat to stored body fat is very small. Fat can be stored in the body in virtually unlimited amounts. It is not needed to build tissues as proteins are or to provide blood glucose as carbohydrates are. Dietary fat consumed in excess of needs can be transported directly to adipose tissue. There, an enzyme on the surface of cells lining the blood vessels breaks the triglycerides into fatty acids and glycerol, which can then enter the fat cells. The fatty acids and glycerol are then reassembled into triglycerides for storage. The body can convert excess carbohydrates and amino acids into fat for storage, but this takes much more energy than converting dietary fat to stored fat.


What Do We Use Energy For?

The total amount of energy used by the body each day is called total energy expenditure (TEE). TEE includes the energy needed to maintain basic body functions, fuel physical activity, and process the food we eat. During growth and pregnancy, TEE also includes the energy used to make new tissues. During lactation, it includes the energy used to produce milk. There is also


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a small amount of energy used to maintain body temperature in a cold environment.

Energy to Stay Alive

Energy used for basic body functionssuch as breathing, circulating blood, and maintaining a constant body temperatureis referred to as basal energy expenditure (BEE). BEE accounts for about 60% to 75% of the bodys total energy requirement. It is defined as the minimum amount of energy needed to keep an awake, resting body alive. BEE includes the energy necessary for all metabolic reactions and life-sustaining functions, but it does not include the energy needed for the digestion and absorption of food, or for physical activity. The rate at which energy is used to keep the body alive is called basal metabolic rate (BMR). This usually is expressed in calories per hour. BMR is not easy to determine because it has to be measured after 12 hours without food or activity. It is easier to measure something called the resting energy expenditure (REE) or resting metabolic rate (RMR) because it is measured after only five to six hours without eating or moving. RMR values are about 10% to 20% higher than BMR. Basal needs are affected by body weight, the amount of lean body tissue, gender, age, and growth rate. Needs increase with increasing body weight; BMR is higher in heavier people. The amount of lean body mass (muscle) also affects BMR. People with more lean body mass have higher energy needs. That is because muscle requires more energy than fat does. Men typically have higher energy needs than women because they have more lean body mass. Basal needs are lower in older adults, partly due to a decrease in lean body mass that occurs with age. Basal needs increase during periods of rapid growth, because energy is required to produce new body tissue. Basal energy needs can be affected by certain abnormal conditions. Increased body temperaturesuch as a feverwill increase energy needs. It is estimated that for every 1F (0.56C) above normal body temperature, there is a 7% increase in RMR. Surgery and injury can also increase energy requirements, because energy

How Many Calories Do You Need?

is needed to repair body tissues. Abnormal levels of thyroid hormones also can affect basal needs. An overproduction of thyroid hormones, called hyperthyroidism, increases energy needs. Hypothyroidism, an underproduction of thyroid hormones, decreases energy needs and can lead to weight gain. The effect of thyroid hormones on energy needs and body weight is the reason that obesity was once explained as a gland problem. It is now known that obesity due to a lack of thyroid hormone is rare. Energy needs also may be affected by consuming insufficient energy. Consuming too few calories may depress metabolic rate as the body attempts to conserve energy. This drop in BMR decreases the amount of energy needed to maintain weight. This is helpful in surviving starvation, but it makes intentional weight loss more difficult.


Energy to Keep You Moving

Physical activity, whether it involves standing and talking on the telephone or running a marathon, requires energy above that needed for basal needs. In most cases, activity accounts for 15% to 30% of a persons total energy expenditure, but this varies greatly depending on how much activity is performed and how strenuous it is. The energy used in physical activity can be divided into two categories: that which we expend in intentional exercise, such

Exercise Extremes
The number of calories a person burns in exercise varies widely. Most people burn only a few hundred calories each day through exercise, but for some athletes, the numbers are surprisingly high. The average rider in the Tour de France bicycle race expends 6,000 to 7,000 calories each day during the three-week race, in which riders average more than 100 miles (161 km) per day. Expenditure may increase to more than 10,000 calories on the days they ride through the Alps or Pyrenees.


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Table 5.1 Calories Burned for Various Activities

Activity Body Weight (lb) Sitting
Male Female 73 63 77 66 81 69 85 72 89 76 93 79 97 82

Calories per hour 110 125 140 155 170 185 200

Male Female 121 105 128 110 135 115 142 121 148 126 155 131 162 136

Male Female 455 394 480 413 506 433 531 453 556 472 582 492 607 511

Biking (12 miles per hour)

Male Female 380 329 401 345 422 361 443 378 464 394 486 410 507 427

Walking (15 minutes per mile)

Male Female 257 222 271 233 285 244 300 255 314 266 328 277 342 288

Male Female 303 294 320 309 337 323 354 338 371 352 388 367 405 382

How Many Calories Do You Need?

Activity Body Weight (lb) Weight lifting
Male Female 340 294 359 309 378 323 397 338 415 352 434 367 453 382


Calories per hour 110 125 140 155 170 185 200

Swimming (laps)
Male Female 364 315 384 331 405 346 425 362 445 378 465 393 486 409

Male Female 364 315 384 331 405 346 425 362 445 378 465 393 486 409

Golf (walking with a bag)

Male Female 425 368 448 386 472 404 496 422 519 441 543 459 567 477

Jumping rope
Male Female 595 515 628 540 661 566 694 591 727 617 760 642 793 668

Running (10 minutes per mile)

Male Female 619 536 653 562 688 589 722 615 757 642 791 669 826 695


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as swimming, jogging, or playing tennis, and what is referred to as non-exercise activity thermogenesis (NEAT). NEAT includes all of the activities done throughout the day that burn calories, but are not planned exercise. For example, a construction worker doing physical labor uses a great deal more energy for NEAT than does an office worker who spends most of the day sitting at a desk. The energy burned through activity is affected by weight, how strenuous the activity is, and how long it is performed. For many activities, the energy burned increases as a persons body weight increases (Table 5.1). Regardless of your weight, it takes more energy to jog for 30 minutes than it does to walk for 30 minutes. However, if you walk for an hour you will expend about as much energy as you would if you jogged for 30 minutes.

Energy to Process Your Food

People need energy to digest food and to absorb, metabolize, and store the nutrients from this food. This energy use is called the thermic effect of food (TEF), or diet-induced thermogenesis. It causes body temperature to rise slightly for several hours after eating. TEF is estimated to use about 10% of the energy a person consumes, but it can vary depending on the amounts and types of nutrients consumed. TEF increases with the size of the meal, because it takes energy to store the excess nutrients. A meal that is high in fat has a lower TEF than a meal high in carbohydrates or protein, because fat is stored more efficiently. This difference in the energy cost of storing energy from fat, carbohydrates, and protein means a diet high in fat may produce more body fat than a diet high in carbohydrates.

Measuring How Much Energy Is Used

To be in energy balance, the amount of energy consumed must equal the amount of energy used by the body. Scientists have developed a number of ways to measure how much energy a person uses. Direct calorimetry is a process that assesses energy expenditure by measuring the amount of heat produced.

How Many Calories Do You Need?

Calculating a persons energy needs by direct calorimetry involves measuring the amount of heat given off by his or her body. This is done by housing an individual in an insulated chamber that can measure the rise in temperature. The heat is generated by metabolic reactions that convert food energy into ATP and use ATP for body processes and is proportional to the amount of energy needed by the individual. Direct calorimetry is accurate but expensive and impractical. For one thing, the person being assessed must remain in the chamber for up to 24 hours. A less cumbersome method of estimating energy use is indirect calorimetry. This method measures oxygen intake or carbon dioxide release by analyzing the difference between inhaled and exhaled air. The bodys energy use can be calculated from these values because the nutrient fuels burned by the body in


Figure 5.3 Using indirect calorimetry, the amount of carbon dioxide in expired air can be used to calculate energy expenditure. Here, a nutritionist tests a womans energy expenditure with a calorimeter.


Nutrition and Weight Management

cellular respiration use oxygen and produce carbon dioxide. Measuring the composition of inhaled and exhaled gases requires that the person breathe into a mouthpiece, mask, or ventilated hood (Figure 5.3). Indirect calorimetry can measure the energy used for individual components of expenditure, such as physical activity or RMR. It also can be used to estimate total energy needs, but it is not practical for measuring energy expenditure for more than a few hours because the equipment is cumbersome and uncomfortable. A method that can assess energy use over longer periods of time is the doubly labeled water method. It determines carbon dioxide production, but the person does not have to wear a mask or hood. Instead, he or she consumes or is injected with water that is labeled with isotopes of oxygen and hydrogen. The labeled oxygen and hydrogen are used by the body in metabolism. By measuring the rate at which they disappear from body fluids, the amount of carbon dioxide produced by the energy-requiring reactions in the body can be estimated. This method does not require the individual to carry any equipment and can be used to measure energy use while a person goes about their daily acitivities for periods of up to two weeks. Doubly labeled water is the preferred method for determining total daily energy expenditure. However, it cannot be used to determine the proportions of total energy expenditure that are used for basal energy expenditure, TEF, or physical activity.

Calculating Energy Needs

As discussed earlier, the current recommendations for energy intake in the United States are the estimated energy requirements (EERs) established by the DRIs. An EER is the amount of energy predicted to maintain energy balance in a healthy person. The equations to calculate EER values were determined from studies that used doubly labeled water to measure energy expenditure. They take into account age, gender, height, weight, life stage, and level of physical activity. The EER values for infants, children, and

How Many Calories Do You Need?

adolescents include the energy used to deposit tissues associated with growth. The EER for pregnancy includes the energy needed to maintain pregnancy and deposit maternal and fetal tissue. The EER for lactation includes the energy in the milk produced and the energy needed to produce the milk. Before calculating EER, a person must estimate his or her activity level. By keeping a daily log of activities, recording the amount


Table 5.2 Categorizing Intensity of Activity

Activities of Daily Living
Gardening (no lifting) Watering plants Raking leaves Mowing the lawn Household tasks, such as mopping and vacuuming Walking from the house to car Walking from the bus Loading/unloading the car

Moderate Activities
Calisthenics (light, no weights) Cycling (leisurely, 6 to 7 mph) Golf (without cart) Swimming (slow) Walking (3 mph, 20 min/mile) Walking (4 mph, 15 min/mile)

Vigorous Activities Aerobics (moderate to heavy) Climbing (hills or mountains) Cycling (greater than 10 mph) Dancing Jogging (12 min/mile or faster) Jumping rope Skating or skiing Swimming (moderate to fast) Tennis Walking (5 mph, 12 min/mile) Vigorous activities expend more than 350 kcal/hr for a 150-lb individual.

It is assumed that we spend about 2.5 hours per day in these types of activities.

Moderate activities expend about 250 to 350 kcal/hr for a 150-lb individual.


Nutrition and Weight Management

of time spent doing each, and using Table 5.2 and Table 5.3, you can estimate activity level. The EER calculations use four activity levels to estimate energy needs: sedentary, low active, active, and very active. A sedentary person does not participate in any activity beyond that required for daily independent living, such as housework, homework, yard work, or gardening. To be in the low active category, an adult weighing 154 pounds (70 kg) would

Table 5.3 Levels of Physical Activity with PA Values

Physical Activity Level Boys
Sedentary: Engages in only the activities of daily living and no moderate or vigorous activities Low active: Daily activity equivalent to at least 30 minutes of moderate activity and a minimum of 15 to 30 minutes of vigorous activity depending on the intensity of the activity. Active: Engages in at least 60 minutes of moderate activities or a minimum of 30 to 60 minutes of vigorous activity depending on the intensity of the activity. Very active: Engages in at least 2.5 hours of moderate activity or a minimum of 1 to 1.75 hours of vigorous activity depending on the intensity of the activity. 1.00

PA values 318 years Girls


19 years Men Women

1.00 1.00













How Many Calories Do You Need?


TABLE 5.4 Calculating Estimated Energy Requirements

To determine EER: Determine your weight in kilograms (kg) and your height in meters (m). Weight in kg = weight in pounds (lb)/2.2 lb per kg Height in m = height in inches (in.) x 0.0254 in. per m For example: 160 lb = 160 lb/2.2 lb/kg = 72.7 kg 5 feet 9 inches (in.) = 69 in. x 0.0254 in./m = 1.75 m Determine your PA (physical activity) value by estimating the amount of physical activity you get per day and using Table 5.3 to find the PA value. For example, if you are a 19-year-old male who performs 40 minutes of vigorous activity a day you are in the active category and have a PA of 1.25. Use the appropriate EER prediction equation below to find your EER: For example: if you are an active 19-year-old male, EER = 662 (9.53 x age in yrs) + PA ([15.91 x weight in kg] + [539.6 x height in m]) Where age = 19 yrs, weight = 72.7 kg, height = 1.75 m, Active PA = 1.25 EER = 662 (9.53 x 19) + 1.25([15.91 x 72.7] + [539.6 x 1.75]) = 3,107 cal/day

Life Stage
Boys 918 yrs Girls 918 yrs Men 19 yrs

EER Prediction Equation

EER = 88.5 (61.9 x age in yrs) + PA ([26.7 x weight in kg] + [903 x height in m]) + 25 EER = 135.3 (30.8 x age in yrs) + PA ([10.0 x weight in kg] + [934 x height in m]) + 25 EER = 662 (9.53 x age in yrs) + PA ([15.91 x weight in kg] + [539.6 x height in m])

Women 19 yrs EER = 354 (6.91 x age in yrs) + PA ([9.36 x weight in kg] + [726 x height in m])


Nutrition and Weight Management

need to expend an amount of energy equivalent to walking about 2 miles (3.2 km) at a rate of 3 to 4 miles per hour (4.8 to 6.4 km/hr), in addition to the activities of daily living. To be active, this adult would need to perform daily exercise equivalent to walking at least 4.4 miles (7.1 km) per day at a rate of 3 to 4 miles per hour (4.8 to 6.4 km/hr), and to be very active, he or she would need to perform the equivalent of walking at least 10.3 miles per day (16.6 km/day) at this rate, in addition to the activities of daily living. Each physical activity level is assigned a numerical Physical Activity (PA) value that can then be used to calculate EER (Table 5.4). The only component of the EER equations over which you have control is the amount of activity you get. The effect activity level has on EER can be seen by comparing total calorie needs at two different activity levels. For example, a 30-year-old woman who is 5 feet 5 inches (1.65 m) tall and weighs 130 pounds (59 kg) uses about 1,900 calories per day if she is sedentary. If she increases her activity to the active level, her energy needs increase to 2,370 calories per day. In order to maintain a healthy weight and reduce the risk of chronic disease, physical activity at the active level is recommended.

When body weight is stable, the number of calories you consume is equal to the number expended, and you are in energy balance. The energy used to fuel the body comes from the food you eat and energy stores in the body. Protein, carbohydrates, fat, and alcohol in your diet provide energy (calories). Energy is stored in the body as glycogen and triglycerides. When you eat food, some of the energy is used for immediate needs, and the rest is stored. These stores are then used when you have not eaten for a few hours or for longer. Fat is the nutrient that is most efficiently stored in the body; it can be stored in virtually limitless quantities in the adipocytes. The body uses energy to maintain basal functions, digest and absorb nutrients, and fuel activity.

How Many Calories Do You Need?

The amount of energy used in activity is affected by how much you move, both in intentional exercise and in the activities performed throughout the day called NEAT. The amount of energy needed by the body can be measured in a number of ways. The best method for long-term measurements is the doubly labeled water technique. Individual energy needs can be estimated by calculating EERs from standard equations.


the bIoLoGy of body WeIGht

he principle of energy balance tells us that if you eat the same number of calories you use, your weight will remain the same. But have you ever known someone who can eat whatever he or she wants without gaining an ounce? Or someone who seems to eat very little but is overweight? This can be explained by the fact that body weight and fat are regulated to remain at a particular level in each person. This level is influenced by your genes.

Genes and body WeIGht

In most adults, body fat and weight remain relatively constant, despite fluctuations in food intake and activity level. This is extraordinary, considering how variable most peoples food intake is from day to day. For example, the huge meal at Thanksgiving or the thousands of calories burned running a marathon dont actually change body weight very much in the long term. The signals


The Biology of Body Weight

that regulate body weight, body size, body shape, and the amount of body fat are carried in our genes. Our understanding of how a persons genetic background contributes to body fatness is expanding rapidly. Thus far, more than 300 genes have been linked to the regulation of body weight. They often are referred to as obesity genes because the proteins they code for are involved in sending signals or receiving signals about energy intake and levels of body fat stores. Most human obesity is likely not due to a single gene, but rather to variations in many genes that interact with one another and the environment to regulate body shape and size as well as energy intake and expenditure.


How Is Body Weight Regulated?

Body weight is regulated by matching energy intake to energy output. If intake increases, expenditure must also increase to prevent weight gain. Some of the regulating systems that modulate energy intake and expenditure are concerned with short-term weight regulation. They regulate how much you eat at a given meal and how often you eat on any given day. Others are concerned with longer-term regulation and are involved in monitoring and responding to the amount of body fat you have over long periods to keep body weight at a set level. Many of these short-term and long-term regulatory mechanisms act through the release of hormones. These hormones travel in the blood and then act in a region of the brain called the hypothalamus, where they trigger short-term and long-term changes in appetite and metabolism.

Short-term Regulation: Are You Hungry or Full?

How much you eat for breakfast and when you get hungry for dinner are, to some extent, determined by short-term regulatory systems that affect hunger and fullness. Feeling hungry or full results


Nutrition and Weight Management

from signals that come from the gastrointestinal tract, levels of circulating nutrients, or signals from the brain. Some of these signals occur before food is eaten, some are sent when food is in the gastrointestinal tract, and some are sent after the nutrients have been absorbed. The simplest type of signal about food intake comes from local nerves in the walls of the stomach and small intestine. They sense the volume or pressure of food and send a message to the brain to either start or stop eating. You experience this as a growling stomach when you are hungry, or a stuffed feeling after eating a large meal. More complex regulatory signals arise from the presence of nutrients in the gastrointestinal tract. This presence sends nerve signals to the brain and triggers the release of hormones that affect hunger and fullness. After the nutrients in a meal have been absorbed into the blood, they continue to send information to the brain to modulate food intake. For example, circulating levels of glucose, amino acids, ketones, and fatty acids are monitored by the brain and may trigger signals to eat or not to eat. Hormones released before and after eating help to regulate when to eat and how much. The hormone insulin is released by the pancreas in response to the intake of carbohydrates. Insulin allows the uptake of glucose by cells. It may affect hunger and fullness by lowering the levels of circulating nutrients. The presence of glucose, fat, and amino acids in the gastrointestinal tract also sends information directly to the brain and triggers the release of gastrointestinal hormones that affect how much people eat. For example, the hormone ghrelin, which is produced by the stomach, is believed to stimulate the desire to eat at usual mealtimes. Blood levels of ghrelin rise an hour or two before a meal and drop very low after a meal. Overproduction of ghrelin could contribute to obesity. Ghrelin levels increase in people who have lost weight. This stimulates the desire to eat and may make it harder to keep weight off. Cholecystokinin is a hormone released from the gastrointestinal tract when food enters the small intestine. It regulates food intake by causing a feeling of fullness. Peptide YY (PYY) is another hormone that stops food intake. It is released from the gastrointestinal tract after a meal. The more calories in a meal, the more PYY is produced.

The Biology of Body Weight


The Long Term: Regulating How Much Body Fat You Have
Most people overeat on occasionfor example, at a birthday party or on summer vacation. They also undereat; some days they are too busy to stop for lunch, or it is too hot to cook dinner. These highs and lows of intake rarely result in long-term weight changes because the body monitors its level of body fat and prevents long-term changes in energy balance that affect the amount of body fat. Some of the information about how much fat we store comes from hormones, such as insulin and leptin, that are secreted in proportion to the amount of body fat. Insulin is secreted from the pancreas when blood glucose levels rise. People with more body fat will secrete more insulin. Insulin has long-term effects in the brain that decrease food intake and increase energy expenditure, but at high levels, such as occur with obesity, the effect of insulin on energy balance decreases. Leptin is also a protein hormone that affects energy intake and expenditure. It is produced by the

We Evolved to Store Fat, Not to Lose It

Humans have adaptations that protect against weight loss. When fat cells shrink, less of the hormone leptin is released, causing appetite to increase and the body to conserve energy. This helps us maintain or regain body fat. When fat cells expand and leptin levels rise, there is a decrease in appetite and an increase in energy use, but the effect of the leptin does not continue to increase with increasing levels. Beyond a certain level, an increase in leptin does not change things. Obese people have high leptin levels in their blood, but these high levels dont help them lose weight. The leptin system appears to have evolved to protect humans from famine, rather than from weight gain. The ability to store and preserve body fat has allowed humans to survive the famines that have plagued them throughout history, but our evolutionary past has not prepared us to avoid obesity now that food is plentiful.


NutritioN aNd Weight MaNageMeNt

adipocytes, and the amount of leptin produced is proportional to the size of adipocytes, so more leptin is released as fat cells grow in size. High leptin levels stimulate pathways that increase energy

figure 6.1 When leptin levels increase, it causes a decrease in food intake and an increase in energy expenditure. When leptin levels decrease, food intake is stimulated and energy expenditure suppressed.

The Biology of Body Weight

expenditure and decrease food intake. Pathways that promote food intake, and therefore weight gain, are inhibited. When fat stores shrink, less leptin is released. Low leptin levels in the brain allow pathways that decrease energy expenditure and increase food intake to become active. Thus, leptin acts like a thermostat to keep body fatness from changing (Figure 6.1). As is the case with insulin, leptin regulation is less effective in obese individuals.


Searching for the Cause of Obesity

For years, researchers have looked for factors that could explain obesity. Leptin offered great hope in terms of solving the obesity

Figure 6.2 These obese mice have a defect in the gene that codes for leptin. Without leptin, they become extremely obese. In a Rockefeller University study by Dr. Jeffrey Friedman, the mouse on the right received leptin treatments for four and a half weeks and then weighed in at about 35 grams (1.2 ounces); the mouse on the left did not have any treatment and was weighed at about 67 grams (2.4 oz). (Normal mice starting the study weighed about 24 grams, or 0.8 oz.)


Nutrition and Weight Management

problem when it was first discovered by studing a genetically obese strain of mice. These mice have a defective leptin gene and are unable to produce the hormone. Without leptin they become extremely obese (Figure 6.2). Researchers hoped to use the knowledge gained from studying these mice to find the cause of, and the cure for, human obesity. Injecting leptin into the mice caused them to lose weight; however, injecting it into obese people did not. It turns out that obese people already have high leptin levels, but this doesnt decrease their energy intake or increase their energy expenditure. Scientists now believe that most human obesity is due to a combination of factors that lead to the accumulation of excess body fat. Some of these include a slow metabolic rate, an inability to burn off extra calories, and a tendency to move less.

Pima Genes and Lifestyle

The Pima Indian population in Arizona has one of the highest rates of obesity in the United States. Scientists have identified a number of genes that may be responsible for this groups tendency to store more body fat. These genes make the Pima very efficient at using energy, so they have lower-than-average calorie needs. This is a good trait when it comes to survival during times of food shortage, but it is a detriment when food is plentiful and the workload is light. The Pimas in Arizona get little exercise in their daily lives, and they have abandoned their traditional diet in favor of the typical U.S. high-fat, high-calorie diet. The combination of their genes, low activity level, and high-calorie diet has resulted in a high incidence of obesity. However, there is a group of Pima Indians living in Mexico who have a much lower rate of obesity. They have the same genes as the Pimas in Arizona, but they are farmers who eat the food they grow and have a high level of physical activity. The obesity rate among Pima men in Mexico is one-tenth the rate of Pima men in Arizona. These two Pima populations clearly show that obesity is due to both genes and lifestyle.

The Biology of Body Weight


Do Obese People Have a Thrifty Metabolism?

Many overweight people contend that they eat almost nothing and still continue to gain weight. This would imply that they burn fewer calories than normal-weight people do. Studies have shown that some people do have a more thrifty metabolism than others. That is, they use nutrients more efficiently, so that more of the energy they take in is converted into ATP or deposited as body fat. They therefore need to eat less to maintain a particular body weight. Throughout human history, people with more efficient metabolisms would have had an advantage during times of famine, so it makes sense that these individuals survived and passed on the thrifty genes. The Pima Indians of the Southwestern United States are an example of a population that has inherited a thrifty metabolism that contributes to obesity. In the United States today, food is abundant and activity levels are low, so people who have inherited thrifty genes are more likely to be obese.

Can Obese People Burn Extra Calories?

Adaptive thermogenesis refers to the adjustments in energy expenditure that the body makes in response to trauma, changes in temperature, or changes in food intake. Adaptive thermogenesis helps keep weight constant. When body weight is increased above normal by overeating, energy expenditure increases to burn extra calories and help return weight to the original level. Likewise, when weight is lost, energy expenditure decreases to prevent or slow further weight loss. These responses occur in both obese and lean people, but they seem to be less effective in obese people. When obese people eat less, the reduction in energy use is greater; their metabolisms slow more than those of normal-weight people do. When obese people eat more, their bodies dont rev up energy use as much as the bodies of normal-weight people do. These differences may partly explain why it is so hard for obese people to keep weight off.


Nutrition and Weight Management

Several biochemical mechanisms might play a role in adaptive thermogenesis. One is substrate cycling, or futile cycling. This process wastes energy by allowing a molecule to be formed and then immediately broken down. Energy is used, but the number of molecules in the body doesnt change. A second way that energy use might be increased is by separating or uncoupling the electron transport chain from the production of ATP. When this occurs, energy is lost as heat, rather than being converted to a form that can be used by the body. A type of adipose tissue called brown adipose tissue can waste energy as heat. Brown adipose tissue increases energy usage in rodents to keep them warm in a cold envirnment and to prevent weight gain when they overeat. It is present in human infants, but its presence and role in adults has been more difficult to study. Recently, brown adipose tissue was detected in young men. Its activity was lower in overweight and obese men, suggesting that it may play a role in obesity.

How Much Does Activity Affect Energy Needs?

If a person increases his or her overall level of physical activity, it is necessary to eat more to maintain weight. According to the EER equation shown below, a sedentary 16-year-old girl who is 5 feet, 4 inches (1.6 m) tall and weighs 127 pounds (58 kg) needs to eat only 1,770 calories a day to maintain her weight. If she adds an hour of moderate activity to her day, she will be in the active PA category and will need to increase her food intake to 2,420 calories per day to maintain her weight. If she joins the soccer team and gets 2 hours of vigorous exercise at practice every day, she will need to increase her intake to 2,940 calories or more per day. The formula below is for a 16-year-old female. EER = 135.3 (30.8 x age in yrs) + PA ([10.0 x weight in kg] + [934 x height in m]) + 25 PA = sedentary 1.0, active 1.31, very active 1.56

The Biology of Body Weight


Do Obese People Move Less?

The amount of energy a person uses depends on metabolic rate and activity level. Genetics determine metabolic rate. Activity level is affected by genetics and lifestyle choices. People with more body fat tend to exercise less, but energy also is used in activities other than planned exercise. This non-exercise activity thermogeneiss (NEAT; see earlier discussion) may be responsible for differences in the tendency to gain weight. NEAT includes the movements that occur during daily living activities, such as walking to class and doing housework. It also includes fidgeting and moving to maintain posture. In a research study that overfed people, some people gained more weight than expected and some gained less. Those who did not gain much weight had higher levels of involuntary exercise than those who gained more weight. Variations in planned exercise and NEAT may also explain some of the decrease in total energy usage that occurs in people who lose weight. This decrease makes it hard to continue losing weight and to maintain weight loss.

The signals that regulate body size, shape, weight, and fatness are carried in our genes. Genes that affect body weight are referred to as obesity genes. These genes make proteins that affect how much we eat, how much energy we expend, and how much body fat we store. Body weight is regulated in the short term by mechanisms that affect feelings of hunger and fullness and therefore how much and how often we eat during the day. Other regulators of body weight, such as the hormone leptin, work over the long term by sending messages about the amount of body fat. Human obesity may be due to a combination of genes that result in a lower than normal energy expenditure or an inability to increase energy usage to compensate for an increase in intake. Factors that may contribute to obesity in some people include a thrifty metabolism that allows them to eat little but maintain their weight, a reduced ability to burn off extra calories when they are consumed, and a lower amount of energy expended through NEAT.

aChIevInG and maIntaInInG a heaLthy WeIGht
anaging weight to keep it in the healthy range will reduce the risk of a variety of chronic diseases. People already at a healthy weight should balance activity and food intake to stay in the healthy range. In overweight people, the goal of weight management is to prevent further weight gain and, over time, reduce body fat to a healthy level that can be maintained for a lifetime. Reducing food intake, increasing activity, and changing behaviors that contribute to weight gain can help people achieve and maintain a healthy weight.

Who needs to Lose WeIGht?

The first step in managing weight is assessment. This is done by evaluating a persons current weight, their weight history, and existing medical conditions to determine whether weight loss is recommended. In general, a BMI above the healthy range means that weight loss would improve long-term health, but this is not


Achieving and Maintaining a Healthy Weight

always the case. Some people with high BMIs, such as football players, may have a large muscle mass but no more body fat than is recommended. Because of this BMI values are evaluated along with meaures of body composition or waist circumference. If a person has a high BMI and a body fat percentage or waist circumference above the recommended range, weight loss usually is recommended. A persons age also is important in the decision, because extra weight may be less of a health risk at certain times. For example, for a teenager who is still growing, an increase in body weight may be followed by a growth spurt that puts his or her BMI back in the healthy range. In older adults, a few extra pounds may provide a reserve in the event of a longterm illness. A key factor in whether weight loss is recommended is the presence of diseases or abnormalities that are linked with excess body fat (Table 7.1). For example, high blood pressure, high blood sugar, and high blood cholesterol levels are all common in overweight people. If someone is overweight and has two or more of the conditions listed in Table 7.1, weight loss is recommended. A family history of these conditions is also a consideration in determining whether weight loss will improve health. Based on these criteria, not everyone who is a few pounds over ideal body weight should lose the extra weight. People with no health conditions associated with excess body fat and who have a healthy lifestyle but have a BMI in the overweight range (25 to 29.9 kg/m2) may not benefit from weight loss. For example, a person with a BMI of 28 kg/m2 whose blood pressure and cholesterol are normal and who exercises regularly would not significantly reduce his or her health risks by losing weight. For such a person, weight management may mean simply preventing further weight gain. For others, this risk assessment may indicate that body weight is a health risk and a weight loss plan should be developed. For example, for a person with a BMI of 28 kg/m2 who has high blood pressure and high blood cholesterol levels, weight loss would be recommended to stay healthy.



Nutrition and Weight Management

Table 7.1 Conditions That Increase the Risk of Excess Weight

Cardiovascular Disease

Blood pressure increases as body weight increases. Total blood cholesterol increases as body weight increases. Triglycerides increase as body weight increases. LDL cholesterol increases as body weight increases. HDL cholesterol falls as body weight increases. Fasting blood sugar increases with increasing body weight. 80% of people with type 2 diabetes are obese. BMI >35 increases diabetes risk by as much as 30-fold. Sleep apnea is more common in overweight people. Being overweight increases the muscular work of breathing. Asthma is worse at increased weight.

Type 2 Diabetes

Respiratory problems

Gallbladder disease is more common in overweight people. Osteoarthritis and degenerative joint disease increase with increasing weight. Menstrual irregularities are increased in overweight women. Cancer

Obese women are at increased risk for cancers of the endometrium, breast, cervix, and ovaries. Obese men are at increased risk for colorectal and prostate cancer. Obese individuals who are inactive have higher risks of illness and death. Inactivity increases the likelihood of developing diabetes and heart disease.

Physical Inactivity

achieving and Maintaining a healthy Weight

Nearly all obese people have tried repeatedly to lose weight. Although many succeed in the short term, most gain back the weight they have lost within a year or two. Repeated cycles of weight loss and gain are referred to as weight cycling (Figure 7.1). With each regaining of weight, the proportion of body fat increases and the basal metabolic rate decreases. Th is makes further weight loss more difficult. Despite this, weight loss is still recommended in someone who has lost and regained weight in the past, if he or she is still obese or overweight and has two or more health conditions that are associated with obesity.


figure 7.1 Rapid weight loss is more likely to be gained back. This may contribute to a pattern of weight cycling.


Nutrition and Weight Management

How Much Weight Should You Lose?

The medical goal for weight loss in an overweight person is to reduce the health risks associated with being overweight. The initial goal of weight loss should be to reduce body weight by approximately 10% over a period of about 6 months. After this initial weight loss, risks can be reassessed to determine if additional weight loss would be beneficial.

How Fast Should You Lose?

A safe rate of weight loss is a to 2 pounds (0.23 to 0.9 kg) per week. This helps promote fat loss while retaining muscle mass. When weight is lost more rapidly, the additional loss will be from water, muscle and liver glycogen, and muscle protein, rather than from fat. Weight loss at a slow rate is more likely to be permanent than faster weight loss. Most people who lose large amounts of weight, or lose weight rapidly, gain it back.

Can the Internet Make Snacking Healthier?

Advergames are online computer games developed to market products. Public health officials are concerned that their influence on childrens activity and food choices may be even greater than that of television. But what happens if the game promotes healthy intake? In a recent study, 30 low-income children were assigned to play one of two different versions of a video game. One version rewarded the children with more points for having their video character eat healthy foods, such as bananas, apples, orange juice, and baby carrots. The other version rewarded them for having their character eat foods such as potato chips, soda, candy bars, and chocolate-chip cookies. The study then monitored the kinds of snacks the children chose. The results showed that children who played the healthier version of the advergame chose healthier snacks than did children who played the less healthy version.

Achieving and Maintaining a Healthy Weight


What Does It Take to Lose a Pound?

In order to decrease body fat, energy intake must be less than energy output. It is estimated that a pound (0.45 kg) of body fat provides 3,500 calories. Therefore, to lose a pound of fat, a person must decrease energy intake by this amount, increase energy output by this amount, or use a combination of decreased intake and increased output to shift energy balance by 3,500 calories. To lose a pound in a week, energy balance would need to shift by 500 calories per day (500 cal/day x 7 days in a week = 3,500 calories or 1 pound per week). This is the predicted average weight loss. The actual amount of weight lost per week may vary over time.

Weight Loss Through the Life Cycle

Usually, weight-loss diets are not recommended for children, pregnant women, or older adults. Children need a nutritionally adequate diet in order to continue to grow in height and develop physiologically. Restricting calorie intake can interfere with growth. Therefore, experts recommend that overweight young children limit their calorie intake slightly and increase their exercise to slow weight gain. The goal is for them to continue to grow in height without gaining too much weight, so they will eventually have a BMI in the healthy range. A more extensive discussion of weight management in children is included in Chapter 9. Weight loss is not recommended during pregnancy. Women who are overweight or obese at the start of pregnancy should gain at a slow, steady rate to accumulate about 15 to 25 pounds (7 to 11 kg) or 11 to 20 pounds (5 to 9 kg), repectively, over the course of pregnancy. A weight-loss program can be started after the baby is born and the mother has recovered. Slow weight loss is appropriate for nursing mothers, but rapid weight loss can decrease milk production. For older adults, the risks associated with excess body fat are lower than they are for younger adults. However, the decision to treat obesity should not be based on age alone. Weight loss can enhance day-to-day functioning and improve cardiovascular


Nutrition and Weight Management

disease risk factors at all ages. Older people tend to lose muscle and replace it with fat, so weight-training activities are an important part of a weight-loss program for the elderly.

Finding the Right Weight-Loss Plan

There are thousands of weight-loss diets and programs. Some recommend specific foods. Some provide social support. Some offer a detailed exercise plan. For many plans, you just need to buy a book and follow the diet plan. Others have weekly meetings, and some guide you over the Internet. Which one will work best depends on the person who wants to lose weight. Some people like working in groups, while others prefer to tackle challenges alone. It also depends on lifestyle. Some people travel frequently. Some are busy all day and only have time in the evening. Those people who are most successful at weight loss combine a reduced-calorie diet with an exercise plan and a program of behavior change that promotes weight management (Table 7.2). For people with a BMI greater than 30 kg/m2, drug therapy may be recommended. For those with a BMI more than 40 kg/m2, weight-loss surgery may be appropriate.

Decreasing Intake
To lose weight, a person must eat fewer calories than are burned. But to lose weight safely, a diet must be low in calories while still providing all needed nutrients. Drastic restrictions in food intake make it difficult to meet nutrient needs. Generally, experts recommend reducing intake by 250 to 500 calories per day. Even without changing exercise patterns, this should produce a weight loss of pound to 1 pound (0.23 to 0.45 kg) per week in most people. This slow rate of weight loss promotes a loss of body fat, rather than lean body mass. When reducing energy intake, choosing a nutrient-dense diet becomes very important. Foods must provide plenty of vitamins and minerals with few calories. For example, a salad with sliced chicken is a more nutrient-dense choice than a burger and fries. A nutrient-dense diet offers more food than a less nutrient-dense

Achieving and Maintaining a Healthy Weight

diet (Figure 7.2). With energy intakes of fewer than 1,200 calories per day, a multivitamin and mineral supplement is recommended to ensure that nutrient needs are met. Experts recommend a doctors supervision if intake is 800 calories per day or less.


Table 7.2 What to Look for in a WeightManagement Program

A healthy dietary pattern that can be followed for life

Does the diet plan meet all your nutrient needs? Can the diet plan meet individual health needs? For example, can it be used by someone who has diabetes or high blood cholesterol? Does the program include an educational component to teach you how to make healthy food choices? Does the program take into consideration your eating habits and preferences? Is the diet plan flexible enough to be followed in different settings and on different occasions? Does the diet require you to purchase special foods or supplements? Does the program set realistic weight-loss goals ( to 2 pounds [0.23 to 0.9 kg] per week)? Does the program stress the need for you to increase physical activity? Does the program include some type of social support? Does the program promote changes in behavior that you can maintain over the long term? Is the program based on sound scientific principles? Are health professionals monitoring the program?

Reasonable weight loss

Physical activity

Behavior change

Scientifically sound

Adapted from the American Heart Associations Web site at http://www.amhrt.org/Health/ Risk_Factors/Overweight/Fad_Diets/fadguide.html.


NutritioN aNd Weight MaNageMeNt

figure 7.2 Choosing carefully can allow you to have more food for the same calories. For instance, a cup of French fries has the same number of calories as 2 cups of broccoli.

Increasing activity
Increasing calories burned through physical activity also is important for weight management. Even if calorie intake is not reduced, increasing activity promotes weight loss. Exercise also helps build muscle and prevent the loss of muscle that often accompanies weight loss. Muscle uses more calories to maintain itself than fat does. So increasing the amount of muscle helps to prevent the drop in BMR that occurs as body weight decreases. In addition to increasing energy expenditure, exercise also improves overall fitness and relieves boredom and stress. It is easier to lose weight and to maintain weight loss when physical activity is included in a weight management program. According to U.S. Department of Health and Human Servicess 2008 Physical Activity Guidelines for Americans, adults

Achieving and Maintaining a Healthy Weight

should exercise moderately for about 150 minutes a week, or vigorously for about 75 minutes a week. The Dietary Guidelines for Americans recommends about 60 minutes of moderate to vigorous activity on most days to prevent gradual weight gain in adults. More than 60 minutes of moderate exercise per day is recommended to lose weight or maintain weight loss.


Changing Behavior
Reducing energy intake and increasing exercise requires a change in behavior. In order to manage weight at a healthy level, these behavior changes must become part of your daily life for the long term. But changing behavior is difficult. It requires identifying the old patterns that led to weight gain and replacing them with new ones to promote and maintain weight loss. This can be accomplished through a process called behavior modification, which is based on the theory that behaviors involve antecedents that lead to a behavior, the behavior itself, and the consequences of the behavior. These are referred to as the ABCs of behavior modification for Antecendent, Behavior, and Consequence. For example, a person might grab a bag of cookies every time he or she sits in front of the television. Then he or she mindlessly eats half of the bag and regrets eating too much (Figure 7.3). This

What about the Wii?

Today, children spend more time sitting in front computers than they do playing active games. Video games are unlikely to go away, so developers have introduced games that encourage movement. Will this new generation of games have a positive impact? The answer may be yes. Activity-promoting games helped children burn an extra 189 calories per hour, compared with traditional video games. Adults burned an extra 148 calories per hour. Playing video tennis may not offer all the benefits of a real game of tennis, but it gets people off the couch.


NutritioN aNd Weight MaNageMeNt

figure 7.3 Maintaining weight loss requires modifying behavior over the long term. The key to modifying the behavior is to recognize the antecedent so that the behavior and consequences can be changed.

behavior chain involves the antecedent (sitting in front of the television with a bag of cookies), the behavior (eating half the bag of cookies), and the consequence (regretting the consumption of excess calories). The key to modifying the behavior is to recognize the antecedent, so that the behavior and consequences can be changed. For example, this person could have a healthy snack waiting instead, such as some fruit salad or cut-up vegetables.

Achieving and Maintaining a Healthy Weight

After eating the healthy snack, he or she will feel satisfied and not guilty. Modifying eating behaviors improves long-term weight maintenance. Other techniques also help, such as stress management and stimulus control.


Suggestions for Weight Gain

As difficult as weight loss is for some people, weight gain can be equally difficult for underweight people. The first step toward weight gain is a visit to the doctor to rule out medical reasons for low body weight. This is particularly important when weight loss occurs unexpectedly. If low body weight is due to low energy intake or high expenditure and is not a medical problem, gradually increasing consumption of energy-dense foods is suggested. More frequent meals and high-calorie snackssuch as peanut butter sandwiches or milkshakes between mealscan help increase energy intake. It also may help to replace low-calorie fluids, such as water and diet beverages, with fruit juices and

How Much Would You Pay for a Doughnut?

Some people have proposed a junk-food tax as a way to cut down on the amounts of sugar and fat that people eat. It is not clear whether this would work. First of all, what is junk food? Is a yogurt with 7 teaspoons of added sugar a junk food or a healthy food? Many energy bars are high in sugars and fat. Are they junk food? Even if we could define junk food, would a tax limit peoples intake? When someone has a late-night snack attack and finds himself in the 24-hour food mart in front of the doughnuts and snack cakes, would the price make him choose a piece of fruit instead? Probably not, although the tax might limit purchases when doing the family shopping. But, even then, would such a tax make people eat a healthier diet with more fruits, vegetables, and whole grains?


Nutrition and Weight Management

milk. Strength-training exercise should be a component of any weight-gain program. This stimulates muscle growth and helps ensure that the weight gained will be lean tissue, rather than fat. Keep in mind, however, that extra calories are needed to fuel the muscle-building activities. These recommendations apply to people who are naturally thin and have trouble gaining weight on the recommended energy intake. This dietary approach will not result in weight gain in people who have an eating disorder.

Weight management involves developing healthy eating habits and maintaining active lives that promote the achievement and maintenance of a healthy weight. Weight management is important for everyone, even those who are currently at a healthy weight. To determine if someone should lose weight, his or her weight must be evaluated, along with his or her medical history, family history, and lifestyle. For those who would benefit from weight loss, an initial loss of 10% of current weight is recommended. More weight loss may be recommended if it is needed to further reduce health risks. Losing weight at a slow rate of about a to 2 pounds (0.23 to 0.9 kg) per week has been shown to promote the loss of fat while retaining muscle. Reducing intake and/or increasing activity by 3,500 calories will result in the loss of a pound (0.45 kg) of fat. A program that combines reduced intake with increased exercise and attention to behavioral changes to promote weight loss or maintenance has been shown to be the most effective way to manage weight. Those who need to gain weight can increase the amounts of higher-calorie foods at meals and snacks and start a weight-training program.

dIets and otheR WeIGht fIxes

re you going on a diet? To most of us, this means we are trying to reduce our intake to lose weight. But, if you go on a diet, it implies that you will go off it at some point. Even if you lose weight, when you stop dieting and resume your previous eating pattern, you will most likely gain the weight back. This on again, off again pattern may allow you to lose 5 pounds (2.3 kilograms) for the prom, but it isnt what you need for weight management. To manage your weight at a healthy level, you need to establish a pattern of food intake and exercise that allows you to enjoy the foods and activities you like without gaining weight. If you are looking for a healthy weight-loss program, find one that has a documented success rate and also meets your needs in terms of food preferences, cost, convenience, and time commitment. Although many quick fixes are temptingwhat dieter wouldnt want to lose 10 pounds (4.5 kg) in just two days? they are unlikely to promote long-term success. Even the best weight management program may not help some people lose



Nutrition and Weight Management

weight and reduce their health risks. Prescription medications that help decrease food intake may be helpful. In cases of morbid obesity, surgery is an option when conventional approaches fail.

What Is A Healthy Diet?

Whether you are trying to lose weight, gain weight, or maintain your weight, the principles of choosing a healthy diet are the same. A healthy diet provides the right number of calories for a person to lose, gain, or maintain weight so overall weight is in the desirable range. It supplies the proper balance of carbohydrates, protein, and fat. It supplies plenty of water and sufficient but not excessive amounts of vitamins and minerals. It minimizes the risk of developing chronic diseases such as obesity, heart disease, cancer, and osteoporosis. MyPyramid and the Dietary Guidelines for Americans recommend a diet that is rich in whole grains, fruits, and vegetables; high in fiber; moderate in fat and sodium; and low in saturated fat, cholesterol, trans fat, and added sugars. Choosing this dietary pattern doesnt mean giving up favorite foods. Still, people do need to watch portion sizes and eat a variety of foods. Choosing a variety of foods is important because different foods provide different nutrients. This is true even when the foods are in the same food group. For example, strawberries provide vitamin C but little vitamin A, whereas apricots provide vitamin A, but less vitamin C. If you choose only strawberries, you will get plenty of vitamin C but may be lacking in vitamin A. A balanced diet includes foods that complement one another. For example, foods low in nutrient densitynutrients per caloriesuch as baked goods, snack foods, and sodas, should be balanced with nutrientdense choices, such as vegetables, fresh fruit, and low-fat dairy products. If this type of balance is maintained, a weight-loss diet need not exclude favorite foods. An occasional snack of chips or an ice cream cone wont destroy a weight-loss diet if it is balanced with lowercalorie choices at other times. When trying to lose weight, choosing more nutrient-dense foods, such as salads and vegetables, means it is possible to eat more food before you have reached your calorie limit.

Diets and Other Weight Fixes

No single dietary component can make or break a diet. Rather, it is the overall pattern of dietary intakecombined with lifestyle factors, such as activity levelthat determines the relationship between a persons diet and his or her health.


Weight-Loss Plans That Reduce Calories

Weight-loss plans that are based on reducing calorie intake are the most common. Some do not restrict the types of foods. Some use exchange systems to plan calorie and nutrient intake. Others

Do the Diets of American Children Make the Grade?

A healthy diet should be based on whole grains, vegetables, and fruits, with smaller amounts of low-fat dairy products, lean meats, and beans. It should include limited amounts of solid fats and added sugar. How do the diets of American children stack up to these recommendations? This question can be answered by scoring their diets using the Healthy Eating Index. This tool evaluates diets based on how well they conform to 12 components of the recommendations of the Dietary Guidelines and MyPyramid. A diet that meets all 12 recommendations would have a score of 100. The component of childrens diets that received the lowest score, only 0.6 out of 5 possible points, was consumption of dark green and orange vegetables and legumes. Total vegetable consumption was only about half the recommended amount. Total grain consumption met recommendations and received a full score of 5 out of 5, but the amounts of whole grains were far below recommendations and received a score of 0.8 out of 5. The diets also received low scores for intake of saturated fat, sodium, and extra calories from solid fats and added sugars, which were all consumed in excess. Diet quality was poor for all age groups, and the combined score for children ages 2 to 17 years was only 55.9 out of 100. By all accounts, a failing grade.


Nutrition and Weight Management

provide low-calorie, portion-controlled packaged meals and formulas. A few try unusual approaches, such as wiring a persons jaw to limit intake to liquids through a straw. The most successful plans offer less dramatic dietary changes that can be maintained over time.

Just Eating Less

The most common type of diet recommends choosing low-calorie foods over higher-calorie choices. These programs offer flexibility and variety and can suit anyones food preferences. Food choices can be varied, but to be successful, calorie intake needs to be monitored. The Weight Watchers point system restricts intake to a specific number of points, but does not tell people which foods to eat. Weight Watchers points are based on a foods calorie, fat, and fiber content. The disadvantage is that these diets may not meet nutrient needs unless they are planned based on some type of food selection guidelines. The MyPyramid system can provide the structure necessary to plan a balanced, low-calorie diet. People can log on (www. MyPyramid.gov) and enter their age, gender, and activity level. The site will show the amounts needed from each food group to maintain a healthy weight. The site also provides the MyPyramid Tracker, which allows people to analyze what they eat and compare it to the calories they burn.

Following an Exchange Plan

Food exchanges are groups of foods that are similar in their energy and macronutrient content. Foods in the same group can be exchanged for one another. Diets that are based on exchanges recommend certain numbers of servings from specific food groups in order to provide a limited calorie intake but an adequate balance of nutrients. Some diet plans use Exchange Lists developed by the American Diabetes Association and the American Dietetic Association. This type of diet offers variety and is more likely to meet a persons nutrient needs than simply eating less food. In

Diets and Other Weight Fixes

addition, this type of diet teaches lifelong meal-planning skills that are easy to apply away from home and can be used over the long term.


Preportioned Meal Plans

Many weight reduction diets require the purchase of preportioned packaged meals that are designed to replace some or all of the dieters meals. Each meal contains a specific number of calories; meals can be combined to provide the days intake. Diets that rely on prepackaged meals are easy to follow, because they eliminate the need to plan a meal. They can be expensive, however, and are not practical in the long term. These diets do not teach the food selection skills needed to make a long-term lifestyle change.

Liquid Formula Diets

Rather than a prepackaged meal, some diet plans rely on prepared liquid meals. Some plans replace all meals with the liquid, while others replace one or two meals per day. These diets can make reducing intake easy, because they eliminate the problem of choosing low-calorie foods. Plans that use only liquid formulas are not recommended without medical supervision. Most of these diets have high dropout rates and poor long-term results. Most liquid weight-loss formulas are designed to be used in combination with food to provide a daily energy intake of about 800 calories to 1,200 calories. They can be effective if the foods eaten with them are low in calories. These formulas can be purchased in grocery stores and pharmacies. They are easy to use and not very expensive, but they do little to change a persons eating habits for life.

Special Foods or Food Combinations

Some diets focus on the magical properties of specific foods or food combinations. For example, the grapefruit diet was based on the myth that grapefruit stimulates the breakdown of body fat. Diets that focus on food combinations and timing of food intake


Nutrition and Weight Management

are based on the faulty premise that foods should be eaten only in certain combinations and at certain times. They lead consumers to believe that if the rules are followed, body fat will melt away and that if the rules are not followed, weight gain and disease will result. In reality, weight loss on such diets is due to the reduction in energy intake, not the magical properties of specific foods or combinations of foods. These types of diets may promote weight loss over the short term, but most cannot be followed safely for long periods of time because they can result in nutrient deficien-

What Can You Believe?

Lose 10 pounds in a week! Weight loss diets and products often make fabulous claims. Can you believe everything you read? How can you tell what is fact and what is fantasy? Generally, the rule is: If it sounds too good to be true, it is. The following tips offer some suggestions for evaluating nutritional claims.

Think about it. Does the information presented make sense? If not, disregard it. Consider the source. Where did the information come from? If it is based on personal opinions, be aware that one persons perception does not make something true. Ponder the purpose. Is the information helping to sell a product? Is it making a magazine cover or newspaper headline more appealing? If so, the claims may be exaggerated to help the sale. View it skeptically. If a statement claims to be based on a scientific study, think about who did the study, what their credentials are, and what relationship they have to the product. Do they benefit from the sale of the product? Finally, evaluate the risks. Be sure the expected benefit of the product is worth the risk associated with using it.

Diets and Other Weight Fixes

cies. They also do not encourage exercise or promote the behavior changes needed to affect body weight over the long term.


Severe Calorie Restriction: VeryLow-calorie Diets

Someone who wants to lose weight very fast may be tempted to try a very-low-calorie diet. These diets provide fewer than 800 calories per day. They are a variation of the protein-sparing modified fast , which is a diet that provides few calories but has a high proportion of protein. The theory behind this is that the protein in the diet will be used to meet the bodys protein needs and will prevent excessive loss of body protein. Frequently, very-low-calorie diets are offered as a liquid formula that provides between 300 and 800 calories and 50 to 100 grams of protein per day and meets all other nutrient needs. At first, people lose weight quickly with very-low-calorie diets. They can lose 3 to 5 pounds (1.4 to 2.3 kg) per week. This can provide a psychological boost and motivate people to continue losing weight. However, in most cases, about 75% of the initial weight loss is from water. Once the initial water loss ends, weight loss slows. The dieters metabolic rate decreases to conserve energy, and physical activity decreases because the dieter feels less energetic. In the long term, very-low-calorie diets are no better than other weight-loss diets. Plus, they carry more risks. At this low level of calorie intake, body protein is broken down and potassium is excreted. A potassium deficiency can cause the heart to beat irregularly, which could result in death. Other side effects include gallstones, fatigue, nausea, cold intolerance, light-headedness, nervousness, constipation, diarrhea, anemia, hair loss, dry skin, and menstrual irregularities. These diets are not recommended for those with a BMI of less than 30 kg/m2. Since 1984, the FDA has required that all very lowcalorie diet formulas carry a warning that they can cause serious illness and should be used only under medical supervision. Despite rapid initial weight loss, these diets are no more effective for long-term weight loss than less restrictive low-calorie diets.


Nutrition and Weight Management

Low-Fat Diets
Because fat is high in calories, consuming a low-fat diet typically reduces energy intake. Choosing low-fat foodssuch as grains, fruits, and vegetablescan allow you to eat more food for the same number of calories than you could with a high-fat diet. Differences in the way dietary fat and dietary carbohydrates are used by the body may also make low-fat diets more effective for weight loss. As with other weight-loss diets, low-fat diets only promote weight loss if they also are low in calories. A low-fat diet that includes large servings of rice, pasta, bread, and low-fat sweets can be high in calories. Even when a diet is low in fat, if you eat more calories than you burn, you will gain weight. The importance of total calorie consumption is illustrated by the fact that while the percent of fat calories in the typical American diet has decreased over the last few years, the number of people who are overweight continues to increase.

Low-Carbohydrate Diets
The popularity of low-carbohydrate diets, such as the Atkins diet, Sugar-Busters, and the South Beach Diet, has come and gone and returned. In addition to promising weight loss, these diets claim to improve athletic performance and promote overall health. Some low-carbohydrate diets severely restrict carbohydrate intake by prohibiting foods such as breads, grains, and fruits and limiting vegetable intake. They allow high-protein foods such as eggs, red meat, fish, and poultry in unlimited amounts. Other low-carbohydrate diets are less restrictive and limit carbohydrate intake to 40% of energy. Low-carbohydrate diets are based on the idea that high carbohydrate intake causes an increase in insulin release, which promotes fat accumulation and stimulates hunger. Restricting carbohydrate consumption is thought to reduce insulin levels, decrease hunger, and promote fat loss. Although it is true that blood insulin levels rise when carbohydrates are consumed, the regulation of body fat stores, hunger, and fullness depends on more than changes in insulin levels.

Diets and Other Weight Fixes

Despite the claims that carbohydrate-free foods can be eaten in unlimited amounts, most people tire of the limited variety allowed in these diets. They lose weight because they eat less. People consuming these diets often experience an initial rapid weight loss, most of which is water. This occurs because, when carbohydrate intake is low, glycogen stores (along with the water they hold) are lost quickly. Ketones are produced because fat is not completely broken down in the absence of carbohydrate, and excretion of these ketones causes additional water loss. Ketones in the blood suppress a persons appetite, making it easier to reduce food intake. The risks associated with severe carbohydrate restriction are dehydration, potassium depletion, and ketosis. These diets also are high in saturated fat. In the short term, low carbohydrate diets do not increase blood lipid levels, but the long-term effect of these diets on the risk of cardiovascular disease and cancer is not known.


Weight-Loss Drugs and supplements

Many overweight people dream of a pill that would cause them to slim down without having to account for every morsel that goes into their mouth. An ideal drug to treat obesity would permit people to lose weight and maintain the loss, be safe when used for long periods of time, have no side effects, and not be addictive. Unfortunately, no such drug exists, but many drugs have been developed for weight loss. Some are well studied and can be helpful; others are ineffective and even dangerous. Currently, drug treatment is recommended only for people whose health is seriously compromised by their excess body weight. This includes people with a BMI greater than 30 kg/m2 regardless of whether they have obesity-related conditions, and people with a BMI greater than or equal to 27 kg/m2 who have obesityrelated conditions. One of the major disadvantages of drug treatment is that even if it works, the weight is usually regained when the person stops taking the drug.


Nutrition and Weight Management

Prescription Medications
Millions of Americans are taking medications prescribed by doctors to help with weight management. The most commonly used drug is phentermine. The U.S. Food and Drug Administration (FDA) says this drug should be used for no longer than three months. Phentermine decreases appetite by stimulating the hypothalamus and affecting the activity of certain neurotransmitters. Sibutramine (Meridia) is another medication prescribed for weight loss that decreases food intake by affecting the activity of brain neurotransmitters. Orlistat (Xenical) is a weight loss drug that reduces energy intake by blocking fat-digesting enzymes in the intestine and hence reducing dietary fat absorption by up to 30%. These drugs have shown promise at promoting weight loss in the short term, but the weight is regained when people stop taking them. None of the drugs currently available are a cure for obesity, so researchers continue to look for new medications that promote weight loss and are safe for long-term use.

Over-the-Counter Medications
The FDA has approved a limited number of substances to be sold as nonprescription weight-loss medications. These include fibers, benzocaine, caffeine, and Alli, an over-the-counter version of the prescription drug Orlistat. Fiberssuch as methylcellulose and glucomannanare used in weight-loss products because they absorb water to create a feeling of fullness. Pills containing these fibers claim to fill the stomach with indigestible bulk so that a person feels full and eats less. The anesthetic benzocaine is included in weight-loss products because it numbs the tongue, making eating a less pleasurable experience. Caffeine is used in many weight-loss products. It is a stimulant and a diuretic. Stimulants tend to blunt the appetite, and diuretics cause the kidneys to increase fluid excretion, resulting in weight loss from water loss. These same effects can be derived from caffeine-containing beverages such as coffee, some teas, and some soft drinks. Alli prevents fat absorption by blocking fat digestion in the intestines.

Diets and Other Weight Fixes

This allows undigested fats to pass into the large intestine and be eliminated in the feces. It reduces the number of calories absorbed from a meal but can have some unpleasant side effects, such as gas, diarrhea, and frequent, hard-to-control bowel movements. As with prescription medications, most of these over-the-counter products are effective in the short term but do little to promote maintenance of weight loss over the long term.


Dietary Supplements
Dietary supplements promoted for weight loss include substances that promise to burn fat or reduce fat synthesis, or rev up metabolism. Many include herbal ingredients. Although most are safe, there is little evidence that they work. Hydroxycitric acid, chromium, and conjugated linoleic acid are ingredients commonly included in weight-loss supplements. Hydroxycitric acid is marketed to alter fat synthesis in the body. Chromium is a mineral needed for insulin action. The supplement chromium picolinate is marketed to reduce body fat, increase lean tissue, and boost basal metabolic rate. Neither hydroxycitric acid nor chromium picolinate have been shown to lead to weight loss in humans. Conjugated linoleic acid reduces the depostion of fat in animals, but there is no evidence that it helps people lose weight. Supplements that claim to increase metabolism are called fat burners. They are the most effective of all the supplements that claim to promote weight loss but have serious and potentially life-threatening side effects. One of the most controversial fat burners is ephedra. This herbal stimulant increases blood pressure and heart rate. Use of ephedra-containing products has been associated with heart palpitations, high blood pressure, abnormal heartbeat, heart attacks, stroke, and seizure. Due to safety concerns, the FDA banned ephedra in 2004. Bitter orange is an herbal central nervous system stimulant that still can be used in weightloss supplements. It may cause side effects that are similar to those caused by ephedra, such as an increase in heart rate and blood


Nutrition and Weight Management

pressure. Most fat-burner supplements also include an herbal source of caffeine, such as guarana, to further boost metabolism. Some herbal weight-loss products act by causing water loss. Dandelion is a diuretic, so it increases the amount of water lost in the urine. Other products are laxatives, which increase water loss from the gastrointestinal tract by inducing diarrhea. These are sold as teas or supplements and include senna, aloe, buckthorn, rhubarb root, cascara, and castor oil. Cascara, senna, and castor oil are approved by the FDA and regulated as drugs for use in nonprescription laxatives. Although water loss may cause a temporary weight loss, laxatives dont lead to fat loss, because they do not significantly reduce nutrient absorption. Most nutrient absorption occurs in the small intestine, and laxatives act in the colon. Overuse of herbal laxatives can cause serious side effects, including nausea, diarrhea, vomiting, stomach cramps, chronic constipation, fainting, and severe electrolyte imbalances leading to cardiac arrhythmia (irregular heartbeat) and death. Some herbal supplements are powerful drugs with dangerous side effects. But because they are sold as dietary supplements and not drugs, they are not strictly regulated. Also, their safety and effectiveness may not have been carefully tested. Do not assume that a product is safe simply because it is labeled herbal or all natural. The FDA does not regulate dietary supplements for weight loss unless they claim to be a substitute for a drug or claim to perform a drug action or therapy.

Bariatric Surgery
A more drastic method of weight management is surgery. Weight-loss surgery, called bariatric surgery, has become increasingly popular. However, this is considered major surgery, and simply having the procedure done does not solve the weight problem. Promoting and maintaining weight loss still requires significant lifelong lifestyle changes.

Diets and Other Weight Fixes


Who Is a Surgical Candidate?

Bariatric surgery is recommended when the risk of dying from obesity and its complications is great. It is appropriate only for people with a BMI of 40 kg/m2 or more (extreme obesity) and those with a BMI between 35 and 40 kg/m2 (obesity) who have other obesity-related conditions (see Table 7.1). The success of weight-loss surgery, as with other treatments, depends on a persons motivation and behavior. The appropriateness of surgery has to be evaluated on a case-by-case basis by considering the individuals potential risks and benefits.

Types of Surgery
The most common surgical approaches used to treat obesity include gastric banding and gastric bypass (Figure 8.1) Adjustable gastric banding is a surgical procedure in which a band is placed around the upper portion of the stomach to create a small stomach pouch. This limits the amount of food that the stomach can hold and slows the rate at which food leaves the stomach. As weight loss progresses, the band can be adjusted to allow greater food intake. Gastric bypass surgery permanently bypasses part of the stomach and connects the small portion of the stomach that is not bypassed to the intestines. Both of these surgeries reduce energy intake because the stomach becomes full after the person eats only a small amount of food. Gastric bypass also promotes weight loss by reducing nutrient absorption in the small intestine. Significant weight loss takes 18 to 24 months after surgery. Some weight often is regained after two to five years. Both procedures have short-term surgical risks and a longterm risk of nutrient deficiencies. More than one-third of patients develop gallstones. Many people develop dumping syndrome, which occurs when food moves too rapidly into the small intestine, causing water to be drawn in with it. This can cause nausea, sweating, and diarrhea. Nutrient deficiencies can occur even if


NutritioN aNd Weight MaNageMeNt

figure 8.1 (A) Gastric banding creates a small stomach pouch from which food empties slowly. It causes weight loss by reducing the amount of food that can be eaten. (B) Gastric bypass causes weight loss by reducing the amount of food that can be eaten and the amount that can be absorbed.

Diets and Other Weight Fixes

nutrient-dense foods are chosen. Deficiencies in vitamin B12, folate, calcium, and iron are of particular risk. Almost 30% of patients experience nutritional deficiencies such as anemia, osteoporosis, and metabolic bone disease. To prevent these deficiencies, patients must take nutritional supplements (or in the case of vitamin B12, injections) to meet nutrient needs. Because rapid weight loss and nutritional deficiencies can harm a developing fetus, a woman who has weight-loss surgery should not become pregnant until her weight is stable. Another surgical approach, liposuction, is primarily cosmetic. It will not significantly reduce overall body weight but may alter fat distribution. In liposuction, a large hollow needle is inserted under the skin into a localized fat deposit, and the fat is literally vacuumed out. It is often advertised as a way to remove cellulite, which is fat that has a lumpy appearance because of the presence of connections to the tissue layers below.


There are thousands of different weight-loss diets and programs. To reduce body weight and maintain weight loss, food intake patterns need to be changed for life. A diet that does not promote permanent changes will not maintain weight loss over the long term. When selecting a program, a person needs to choose one that will meet his or her personal preferences for food, activity, and social support. There are many ways to reduce calorie intake, including simply eating less; purchasing preportioned foods or liquid formulas that limit intake; reducing specific nutrients, such as carbohydrates or fat; and severely restricting total energy intake. When diet and exercise are not enough, there are drugs that may help reduce intake. Some are available by prescription only; others are over-the-counter medications or dietary supplements. There also are surgical methods that promote weight loss by making the stomach smaller and reducing nutrient absorption. Surgery is generally recommended only when the risks associated with remaining obese are severe.

WeIGht manaGement In ChILdRen and adoLesCents

he obesity crisis in the United States is not limited to adults. It also affects Americas youth. It is estimated that 11% of children 2 to 5 years old, 15% of children 6 to 11 years old, and almost 18% of adolescents 12 to 19 years old are overweight. The incidence of obesity among adults has doubled since 1980, but the number of overweight adolescents has more than tripled (Figure 9.1). As with the adult population, this growing trend is likely to be the result of eating too much and not exercising enough. The diagnosis and treatment of overweight and obesity in children and teens is more complex than in adults because they are still growing and developing. A weight increase might occur because the childs body is getting ready for a growth spurt, or it may be a health concern. Weight-loss planning in children can be challenging because of the importance of consuming a diet that supplies enough energy and the right amounts of essential nutrients to ensure normal growth and development.


Weight Management in Children and Adolescents

There are different standards to define overweight and different approaches to manage weight for children and teens.


What Is A Healthy Weight For Children And Teens?

In adults, overweight and obesity are assessed using BMI ranges. The BMI ranges that define weight as healthy, overweight, or obese are the same for both genders and all adult age groups. In

Figure 9.1 The number of American children who are obese has increased dramatically since the 1970s.


Nutrition and Weight Management

children and teens from ages of 2 to 20, overweight and obesity are defined based on where the BMI falls in relation to the BMIs of other children and teens of the same age and gender. A single standard cannot be applied to both genders and all age groups, because the definition of a healthy weight varies with the stage of growth and development.

Consider Growth Patterns

From birth, healthy children follow standard patterns of growth. A childs growth can therefore be monitored by comparing his or her size to these standards. Growth charts that display typical growth patterns for infants, children, and adolescents in the United States have been developed by the CDC. There are separate charts for infants from birth to 36 months of age, and for children and adolescents from 2 to 20 years of age. For infants from birth to 36 months of age, charts are available to monitor weight-forage, length-for-age (measured lying down), head-circumferencefor-age, and weight-for-length. For those age 2 and older, charts are available to monitor weight-for-age, height-for-age, weightfor-height, and BMI-for-age (see Figure 2.2 and Appendix B). By plotting a childs measurements over time on a growth chart, his or her pattern of growth can be monitored and compared with that of other children of the same age and gender. The resulting ranking, or percentile, indicates where the child falls in relation to population standards. There are variations in overall growth potential. For instance, a child whose parents are 5 feet tall may not have the genetic potential to be 6 feet tall. However, most children and adolescents follow standard patterns of growth, so a child who is at the 50th percentile for length and 25th percentile for weight probably will follow these length and weight curves as he or she gets older.

Watch for Abnormal Growth Patterns

A persons maximum size is affected by genetic, environmental, and lifestyle factors. Proper nutrition is essential to achieve opti-

Weight Management in Children and Adolescents

mal growth. Slight fluctuations in growth rate are normal, but if a childs growth does not follow the normal growth curve, there is cause for concern. At first, a child who is not consuming sufficient calories will lose weight, and if the deficiency continues, growth in height will slow or stop. A BMI that falls below the 5th percentile is considered underweight. In contrast, a rapid increase in weight without an increase in height may indicate that a child is consuming more calories than he or she needs. This change in growth pattern should be evaluated to determine the causes. For children and teens, a BMI greater than or equal to the 85th percentile and less than the 95th percentile puts them in the overweight category. A BMI that is at the 95th percentile or above is defined as obese (see Figure 2.2).


What Are The Risks For Overweight Kids?

Being overweight or obese in childhood and adolescence increases the risks of chronic disease. Overweight children and teens may have high blood cholesterol, high blood pressure, and high blood glucose levels. These put them at risk for heart disease, hypertension, and diabetes. Overweight girls may have hormonal imbalances that increase the risk of certain cancers. In addition to its health impact, being overweight affects the psychosocial development of children. Finally, obese children and adolescents are more likely to become obese adults.

Blood Cholesterol and Heart Disease

The recommended level for blood cholesterol in children ages 2 to 18 is less than 170 milligrams per 100 milliliters. In the United States today, more than one-third (33.3%) of youth ages 12 to 19 have high cholesterol. The risk increases with the amount of excess body weight. It is important for children over 2 years of age to have their blood cholesterol checked if they are overweight/


Nutrition and Weight Management

obese or have a family history of high cholesterol or heart disease. High blood cholesterol levels during childhood and adolescence are associated with higher blood cholesterol and higher mortality rates from cardiovascular disease in adulthood. Abnormal blood cholesterol levels are related to the amount and type of fat we eat. Diets high in saturated fat and cholesterol (found in meat and milk), as well as trans fat (the fat used in some shortenings and margarines), can lead to high blood cholesterol levels. Diets high in fiber from whole grains, fruits, and vegetables help to keep blood cholesterol levels in the healthy range.

Hypertension, or high blood pressure, may also be a concern in children and teens (Figure 9.2). Children who have blood pressure that is at the high end of normal are more likely to develop high blood pressure as adults. Blood pressure can be affected by body fat, activity level, and sodium intake, as well as by the total pattern of dietary intake. Children with family histories of hypertension may be at particular risk.

The incidence of type 2 diabetes is increasing among children and adolescents, particularly those who are obese. A typical example of type 2 diabetes in this population is a child age 10 to mid-puberty who is overweight and has a family history of type 2 diabetes. In children at risk for type 2 diabetes, preventive measures such as weight management and increased physical activity may delay or prevent it. The goal of treatment is to keep blood glucose levels in the normal range by eating a balanced diet that is moderate in energy, increasing physical activity, and taking medications as needed. The complications of diabetes are more likely in people who have had the disease longer; therefore, developing diabetes during childhood increases the lifetime risk of advanced complications such as heart disease, blindness, and kidney failure.

Weight Management in Children and Adolescents


Figure 9.2 The American Heart Association recommends that all children three years of age and older have their blood pressure measured every year. In this image, the doctor has wrapped a sphygmomanometer around the young boys arm while using a stethoscope to listen to the blood flow.


Nutrition and Weight Management

Menstrual Problems
Excess body fat causes hormonal abnormalities. Girls with higher body weights begin menstruation at younger ages than leaner girls do. Early menarche is a risk factor for breast cancer and cancers of the reproductive tract. It also has been proposed as a risk factor for psychiatric disorders common in adolescent girls, including depression, eating disorders, and substance abuse.

Sleep Disorders
Sleep apnea is a sleep-associated breathing disorder. People with the disorder stop breathing for at least 10 seconds while they sleep, and then start again. Symptoms include loud snoring and labored breathing during sleep. Although it is less common than other complications, one study estimated that sleep apnea occurs in about 7% of obese children.

Psychological and Social Consequences

Obesity among children and teens has important social and psychological consequences. Obese children in the United States are less well accepted by their peers than normal-weight children. They are often ridiculed and teased. They may have a poor selfimage and low self-esteem. Children and adolescents who are overweight may be stereotyped as lazy, sloppy, or stupid. These social stigmas can cause low self-esteem, which, in turn, can hinder academic and social functioning, and increase the risk of developing an eating disorder. There are more overweight children and teens today than there were 50 years ago, but they are still not accepted socially. A study done in 1961 had children rank drawings of children with various handicaps, indicating which ones they liked best. The drawing of the obese child was ranked last among drawings depicting a child with crutches, a child in a wheelchair, a child missing a hand, and a child with a facial disfigurement. The study was repeated in 2001 with similar results.

Weight Management in Children and Adolescents


Increased Risk for Eating Disorders

Overweight adolescents have a greater risk of developing an eating disorder than teens of normal weight. Overweight girls are more likely than normal-weight girls to worry about their weight, be less satisfied with their appearance, and diet or fast. Obesity in childhood predisposes individuals to a type of eating disorder called bulimia nervosa. People with this disorder overeat, or binge, and then purge their bodies of food, through self-induced vomiting or other methods that are intended to rid the body of excess calories consumed. Dieting among overweight children and teens can also lead to the development of binge eating disorder. This eating disorder involves binge eating without purging.

Weight Management for Children and Teens

As with adult obesity, heredity, environment, and lifestyle all play a role in the development of childhood obesity. Obese parents are more likely to have obese children. This is not only because they pass on a genetic tendency to be overweight, but also because their children may learn poor eating and exercise habits. If sound nutrition and exercise habits are developed early and are followed throughout life, obesity can be avoided, despite a genetic predisposition. The goal of weight management in children and teens is to develop healthy eating and exercise patterns to maintain weight in the normal range. Because children are still growing, weight loss is rarely recommended. Rather, the goal is to slow weight gain, allowing the child to grow into his or her weight. For example, when the rate of weight gain is slowed but intake is sufficient to allow growth in height, a child who is at the 95th percentile for weight at age 7 and gains only a few pounds a year can be at the 90th percentile by age 9 and at the 75th percentile by age 11.


Nutrition and Weight Management

Managing weightwhether this means losing weight, maintaining weight, or slowing weight gainrequires changes in energy intake and energy use. Changes in food intake and activity patterns should be gradual and should involve the entire family. If weight control at home is not effective, professional help may be needed.

Reducing Intake
In order to promote weight loss or prevent weight gain, calorie reduction is necessary. Small reductions in calorie intake of only about 100 and 200 calories per day are recommended. This slows weight gain and when necessary allows weight loss. Small reductions in intake are more easily accepted and more likely to maintain weight changes over the long term. Drastic reductions can compromise growth. They also can promote overeating, if the child feels that he or she is being starved. Even extremely overweight children should lose weight gradually. Any weight management program for children should be monitored by a physician. A healthy weight management diet should be safe and nutritious. It needs to provide adequate protein and micronutrients to allow growth. Vitamin A, vitamin C, vitamin E, calcium, iron, and zinc are of particular concern are because they are likely to be deficient in the diets of children in the United States. A diet that follows the recommendations of MyPyramid will provide adequate vitamins and minerals. This diet is based on whole grains, fruits, and vegetables, lean meats, and reduced-fat dairy products. It limits high-calorie, highfat snacks. As with adults, the recommended amounts of food from each food group are based on age, gender, and activity level. This can be determined by going to the MyPyramid plan at the MyPyramid Web site (www.mypyramid.gov). Children with particularly erratic eating habits may benefit from a multivitamin and mineral supplement that provides no more than 100% of the Daily Values.

Weight Management in Children and Adolescents


Increasing Activity
All healthy children should be physically active. Most are naturally active; extended periods of inactivity are not normal for healthy children. When treating overweight children and adolescents, promoting an increase in physical activity may be even more important than limiting food intake. This is because young people are getting heavier, yet energy intake among American youth overall is not increasing, suggesting that a major contributor to the increase in body weight is a lack of physical activity. Some of this decrease in activity has come about because watching television, playing video games, and surfing the Internet have replaced neighborhood games of tag and soccer. Other sociocultural factors such as long days at school, living in singlefamily households, and unsafe outdoor environments also have contributed to inactive lifestyles. Overweight children and adolescents are less likely to be physically active than lean children. They often feel inadequate when participating in sports. Teasing may make them less likely to take part. They may be embarrassed by their bodies and shy away from taking part in group activities. A good way to get them moving is to encourage activities such as games,

Sweetened Drinks Add Pounds

Today we think of soda and other sweetened beverages as part of the American lifestyle. Soft-drink consumption has increased by 300% in the past 20 years, as obesity rates have climbed. More than half of schoolchildren consume at least one soft drink every day. Studies have found that the risk of obesity increases as sugar-sweetened drink consumption rises. Drinking a sweetened beverage does not reduce hunger. It may actually stimulate appetite.


Nutrition and Weight Management

walks after dinner, bike rides, hikes, swimming, and volleyball that can be enjoyed by the whole family. This sends a positive message to be more active rather than a negative message of do not eat so much. An exercise program is most effective if the activities are enjoyable. To make exercise a positive experience, increases in physical activity need to be gradual. Involvement of the whole family is key. Parents who are active, play with their children, watch their children compete or play, or take children to physical activities or sports events have more active children. Physical activity guidelines for Americans recommend that children and adolescents engage in 1 hour (60 minutes) or more of physical activity every day. Most of this time should be spent in either moderate- or vigorous-intensity aerobic activity. As part of their daily physical activity, children and adolescents should participate in vigorous-intensity activity on at least three days per week. They also should include musclestrengthening activity on at least three days per week and bone-strengthening activity on at least three days per week. For children, muscle-building activities may include climbing on playground equipment or playing tug of war. For adolescents, this may involve more structured activities such as lifting weights. Bone-strengthening activities include any weightbearing activities such as running, jumping rope, and playing hopscotch, tennis, basketball, or soccer. Because children have short attention spans, it is recommended that the 60 minutes of activity be broken up into smaller units. Periods of moderate to vigorous activity lasting 10 to 15 minutes or more each day should be interspersed with periods of rest and recovery. Children should be exposed to many different types of activities at varying levels of intensity. Children and adolescents who are already active should be encouraged to remain active, and those who are inactive should be counseled as to how they can increase their activity level. Some

Weight Management in Children and Adolescents

may enjoy organized team sports, but these are not the only way to maintain an active lifestyle. Skating, skiing, bike riding, swimming, power- or race-walking, hiking, tennis, aerobic dancing, kickboxing, rowing, racquetball, and handball are some other options. Children and adolescents should be involved in the decision-making process so they can select the activities they enjoy most. Role models are important. Parents who encourage a child or teen to exercise should set the example by exercising themselves. Learning to enjoy exercise during childhood and adolescence will set the stage for an active lifestyle and weight management in adulthood.


Reducing TV Time
Television and computer games are part of childhood in American society today. Children spend more time watching television than they do in school. As a result, it has become a lifestyle factor that influences childrens nutrition and health. Television promotes snacking. Although snacks are an important part of a growing childs diet, many children snack on sweet and salty foods that are low in nutrient density while watching television. Through advertising, television has a strong influence on the foods young children select. Almost half of the commercials shown during childrens television programming advertise candy, snack foods, beverages, and pastries that are high in fat, salt, and added sugar. These commercials introduce children to foods to which they might otherwise not be exposed. Children who view food ads choose these foods more often than children who are not exposed to the ads. Perhaps the most important nutritional influence of television is that it reduces activity. Hours spent watching television are hours when physical activity is at a minimum. One study showed that children who watch four or more hours of TV per day are 40% more likely to be overweight than those who watch an hour or less a day.


Nutrition and Weight Management

Dangerous Weight-Loss Practices

Because children need energy and nutrients to continue their growth and development, severe approaches to weight loss can be dangerous. Sometimes weight goals are set based on peer pressure. Other times, they are set in order to meet weight guidelines or optimize performance in sports. Sports with weight categories such as wrestling may require an athlete to gain or lose weight to fit into a specific weight category. Weight loss is more common because competing at the high end of a weight class is believed to give a competitor an advantage over smaller opponents. Athletes may use dehydration to reduce weight rapidly. This is accomplished through such practices as vigorous exercise, fluid restriction, wearing impermeable clothing, and using hot environments such as saunas and steam rooms. More extreme measures include self-induced vomiting and the use of diuretics and laxatives. These practices can be dangerous and even fatal. They may reduce performance and can adversely affect heart and kidney function, temperature regulation, and electrolyte balance. Athletes often think they can make weight by dehydrating for the weigh-in and then rehydrating in time for competition. However, the time between weigh-in and competition is not sufficient for fluid and electrolyte balance to return to normal in the muscles, or replenishment of muscle and liver glycogen. Three young wrestlers died in 1997 due to complications brought on by dehydration. They were exercising in rubber suits in order to sweat off water. Now, wrestling weight classes have been changed, rubber and other impermeable sweat suits are banned, weigh-ins are now one hour before competition, and there are mandatory weight-loss rules to try to reduce dangers.

The number of overweight children in the United States is increasing. It is estimated that 15% of children 6 to 11 years old and 18% and of adolescents in the United States are currently

Weight Management in Children and Adolescents

overweight. In children and adolescents, body weight is assessed by using growth charts to compare a childs BMI with that of other children of the same age and gender. Healthy weight management can be difficult for children and teens because they must consume enough calories and nutrients to fulfill their growth potential. Too little energy can cause a decrease in growth. Too much energy can result in overweight. Overweight and obesity in children and teens increases the risk of chronic diseases such as heart disease, diabetes, and high blood pressure; hormonal


Balance High-Calorie Choices with More Activity

If you choose . . .
A quarter-pounder with cheese instead of a plain hamburger Breaded chicken sandwich instead of a grilled chicken sandwich Large French fries instead of small fries Nachos with cheese sauce instead of baked tortilla chips and salsa A slice of stuffed-crust pepperoni pizza instead of a slice of thin-crust vegetarian pizza

Then add this to your day . . .

30 minutes of racquetball

A 30-minute walk

A 60-minute bike ride A 30-minute swim

A 30-minute tennis game


Nutrition and Weight Management

disturbances that can increase the risk of certain cancers; and difficulties in psychosocial development. The goal of weight management in children and teens is to develop healthy eating and exercise patterns that will allow weight to be maintained in the normal range for a lifetime. In most cases, rather than weight loss, the goal is to slow weight gain and allow the child to grow into his or her weight. If calories are limited, the restriction should be mild. Activity should be increased, and sedentary activities such as watching television and playing video games should be decreased.

appendIx a
dIetaRy RefeRenCe Intakes
aCCeptabLe maCRonutRIent dIstRIbutIon RanGes (amdR) foR heaLthy dIets as a peRCentaGe of eneRGy
age Carbohydrates added sugars total fat Linoleic acid -Linolenic acid protein

13 years old 418 years old 19 years old



















Source: Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Energy, Carbohydrates, Fiber, Fat, Protein, and Amino Acids. Washington, D.C.: National Academies Press, 2002.



Nutrition and Weight Management

Recommended Intakes of Vitamins for Various Age Groups

Life Stage Infants 06 mo 712 mo Children 13 yrs 48 yrs Males 913 yrs 1418 yrs 1930 yrs 3150 yrs 5170 yrs >70 yrs Females 913 yrs 1418 yrs 1930 yrs 3150 yrs 5170 yrs >70 yrs Pregnancy 18 yrs 1930 yrs 3150 yrs Lactation 18 yrs 1930 yrs 3150 yrs 1,200 1,300 1,300 115 120 120 5 5 5 19 19 19 75 90 90 750 770 770 80 85 85 5 5 5 15 15 15 75 90 90 600 700 700 700 700 700 45 65 75 75 75 75 5 5 5 5 10 15 11 15 15 15 15 15 60 75 90 90 90 90 600 900 900 900 900 900 45 75 90 90 90 90 5 5 5 5 10 15 11 15 15 15 15 15 60 75 120 120 120 120 300 400 15 25 5 5 6 7 30 55 400 500 40 50 5 5 4 5 2.0 2.5 Vit A (g/day) Vit C (mg/day) Vit D (g/day) Vit E (mg/day) Vit K (g/day)



Recommended Intakes of Vitamins for Various Age Groups (continued)

Life Stage Infants 06 mo 712 mo Children 13 yrs 48 yrs Males 913 yrs 1418 yrs 1930 yrs 3150 yrs 5170 yrs >70 yrs Females 913 yrs 1418 yrs 1930 yrs 3150 yrs 5170 yrs >70 yrs Pregnancy 18 yrs 1930 yrs 3150 yrs Lactation 18 yrs 1930 yrs 3150 yrs 1.4 1.4 1.4 1.6 1.6 1.6 17 17 17 2.0 2.0 2.0 500 500 500 1.4 1.4 1.4 1.4 1.4 1.4 18 18 18 1.9 1.9 1.9 600 600 600 0.9 1.0 1.1 1.1 1.1 1.1 0.9 1.0 1.1 1.1 1.1 1.1 12 14 14 14 14 14 1.0 1.2 1.3 1.3 1.5 1.5 300 400 400 400 400 400 0.9 1.2 1.2 1.2 1.2 1.2 0.9 1.3 1.3 1.3 1.3 1.3 12 16 16 16 16 16 1.0 1.3 1.3 1.3 1.7 1.7 300 400 400 400 400 400 0.5 0.6 0.5 0.6 6 8 0.5 0.6 150 200 0.2 0.3 0.3 0.4 2 4 0.1 0.3 65 80 Thiamin (mg/day) Riboflavin (mg/day) Niacin (mg/day) Vit B 6 (mg/day) Folate (g/day)



Nutrition and Weight Management

Recommended Intakes of Vitamins for Various Age Groups (continued)

Life Stage Infants 06 mo 712 mo Children 13 yrs 48 yrs Males 913 yrs 1418 yrs 1930 yrs 3150 yrs 5170 yrs >70 yrs Females 913 yrs 1418 yrs 1930 yrs 3150 yrs 5170 yrs >70 yrs Pregnancy 18 yrs 1930 yrs 3150 yrs Lactation 18 yrs 1930 yrs 3150 yrs 2.8 2.8 2.8 7 7 7 35 35 35 550 550 550 2.6 2.6 2.6 6 6 6 30 30 30 450 450 450 1.8 2.4 2.4 2.4 2.4 2.4 4 5 5 5 5 5 20 25 30 30 30 30 375 400 425 425 425 425 1.8 2.4 2.4 2.4 2.4 2.4 4 5 5 5 5 5 20 25 30 30 30 30 375 550 550 550 550 550 0.9 1.2 2 3 8 12 200 250 0.4 0.5 1.7 1.8 5 6 125 150 Vit B12 (g/day) Pantothenic Acid (mg/day) Biotin Group (g/day) Choline* (mg/day)

Note: This table presents Recommended Dietary Allowances (RDAs) in bold type and Adequate Intakes (AIs) in ordinary type. * Not yet classified as a vitamin Source: Adapted from Dietary Reference Intake Tables: The Complete Set. Institute of Medicine, National Academy of Sciences. Available online at www.nap.edu.



Recommended Intakes of Selected Minerals for Various Age Groups

Life Stage Infants 0 6 mo 712 mo Children 13 yrs 4 8 yrs Males 9 13 yrs 14 18 yrs 1930 yrs 3150 yrs 5170 yrs >70 yrs Females 913 yrs 14 18 yrs 1930 yrs 3150 yrs 5170 yrs >70 yrs Pregnancy 18 yrs 1930 yrs 3150 yrs Lactation 18 yrs 1930 yrs 3150 yrs 1,300 1,000 1,000 44 45 45 1,300 1,300 1,300 3 3 3 290 290 290 1,300 1,000 1,000 29 30 30 1,000 1,000 1,000 3 3 3 220 220 220 1,300 1,300 1,000 1,000 1,200 1,200 21 24 25 25 20 20 700 890 900 900 900 900 2 3 3 3 3 3 120 150 150 150 150 150 1,300 1,300 1,000 1,000 1,200 1,200 25 35 35 35 30 30 700 890 900 900 900 900 2 3 4 4 4 4 120 150 150 150 150 150 500 800 11 15 340 440 0.7 1 90 90 210 270 0.2 5.5 200 220 0.01 0.5 110 130 Calcium (mg/day) Chromium (g/day) Copper (g/day) Fluroide (mg/day) Iodine (g/day)



Nutrition and Weight Management

Recommended Intakes of Selected Minerals for Various Age Groups (continued)

Life Stage Infants 0 6 mo 712 mo Children 13 yrs 4 8 yrs Males 913 yrs 14 18 yrs 1930 yrs 3150 yrs 5170 yrs >70 yrs Females 913 yrs 14 18 yrs 1930 yrs 3150 yrs 5170 yrs >70 yrs Pregnancy 18 yrs 1930 yrs 3150 yrs Lactation 18 yrs 1930 yrs 3150 yrs 10 9 9 360 310 320 1,250 700 700 70 70 70 27 27 27 400 350 360 1,250 700 700 60 60 60 8 15 18 18 8 8 240 360 310 320 320 320 1,250 1,250 700 700 700 700 40 55 55 55 55 55 8 11 8 8 8 8 240 410 400 420 420 420 1,250 1,250 700 700 700 700 40 55 55 55 55 55 7 10 80 130 460 500 20 30 0.27 11 30 75 100 275 15 20 Iron (mg/day) Magnesium (mg/day) Phosphorus (mg/day) Selenium (g/day)



Recommended Intakes of Selected Minerals for Various Age Groups (continued)

Life Stage Infants 06 mo 712 mo Children 13 yrs 48 yrs Male s 913 yrs 1418 yrs 1930 yrs 3150 yrs 5170 yrs >70 yrs Females 913 yrs 1418 yrs 1930 yrs 3150 yrs 5170 yrs >70 yrs Pregnancy 18 yrs 1930 yrs 3150 yrs Lactation 18 yrs 1930 yrs 3150 yrs 14 12 12 1.5 1.5 1.5 2.3 2.3 2.3 5.1 5.1 5.1 13 11 11 1.5 1.5 1.5 2.3 2.3 2.3 4.7 4.7 4.7 8 9 8 8 8 8 1.5 1.5 1.5 1.5 1.3 1.2 2.3 2.3 2.3 2.3 2.0 1.8 4.5 4.7 4.7 4.7 4.7 4.7 8 11 11 11 11 11 1.5 1.5 1.5 1.5 1.3 1.2 2.3 2.3 2.3 2.3 2.0 1.8 4.5 4.7 4.7 4.7 4.7 4.7 3 5 1.0 1.2 1.5 1.9 3.0 3.8 2 3 0.12 0.37 0.18 0.57 0.4 0.7 Zinc (mg/day) Sodium (g/day) Chloride (g/day) Potassium (g/day)

Note: This table presents Recommended Dietary Allowances (RDAs) in bold type and Adequate Intakes (AIs) in ordinary type. Source: Adapted from Dietary Reference Intake Tables: The Complete Set. Institute of Medicine, National Academy of Sciences. Available online at www.nap.edu.

appendIx b
heaLthy body WeIGhts body mass Index (bmI)
Body mass index, or BMI, is the measurement of choice for determining health risks associated with body weight. BMI uses a mathematical formula that takes into account both a persons height and weight. BMI equals a persons weight in kilograms divided by height in meters squared (BMI=kg/m2).

RIsk of assoCIated dIsease aCCoRdInG to bmI and WaIst sIze foR aduLts
bmI Waist less than or equal to 40 in. (men) or 35 in. (women) Underweight Normal Overweight Obese Obese Extremely Obese --Increased High Very High Extremely High Waist greater than 40 in. (men) or 35 in. (women) N/A N/A High Very High Very High
Extremely High

18.5 or less 18.5 24.9

25.0 29.9 30.0 34.9 35.0 39.9 40 or greater

determining your body mass Index (bmI)

To use the table on the following page, find the appropriate height in the left-hand column. Move across the row to the given weight. The number at the top of the column is the BMI for that height and weight. Then use the table above to determine how at risk you are for developing a weight-related disease.


BMI (kg/m2 ) 21 22 23 24 25 26 27 28 29 30 35




Height (in.) Weight (lb)

100 105 110 115 119 124 129 134 138 143




Appendix B

59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 104 107 111 115 118 122 126 130 134 138 142 146 150 154 159 163 168 172 109 112 116 120 124 128 132 136 140 144 149 153 157 162 166 171 176 180 114 118 122 126 130 134 138 142 146 151 155 160 165 169 174 179 184 189 119 123 127 131 135 140 144 148 153 158 162 167 172 177 182 186 192 197 124 128 132 136 141 145 150 155 159 164 169 174 179 184 189 194 200 205 128 133 137 142 146 151 156 161 166 171 176 181 186 191 197 202 208 213 133 138 143 147 152 157 162 167 172 177 182 188 193 199 204 210 216 221 138 143 148 153 158 163 168 173 178 184 189 195 200 206 212 218 224 230 143 148 153 158 163 169 174 179 185 190 196 202 208 213 219 225 232 238

94 97 100 104 107 110 114 118 121 125 128 132 136 140 144 148 152 156

99 102 106 109 113 116 120 124 127 131 135 139 143 147 151 155 160 164

148 153 158 164 169 174 180 186 191 197 203 207 215 221 227 233 240 246

167 173 179 185 191 197 204 210 216 223 230 236 243 250 258 265 272 279 287

191 198 204 211 218 225 232 240 247 255 262 270 278 286 294 302 311 319 328


Source: Adapted from Partnership for Healthy Weight Management, http://www.consumer.gov/weightloss/bmi.htm.


Nutrition and Weight Management

BMI-for-Age Growth Charts

Appendix B




appendIx C
bLood vaLues of nutRItIonaL ReLevanCe
Red blood cells Men Women White blood cells Calcium Iron Men Women Zinc Potassium Sodium Vitamin A Vitamin B12 Vitamin C Folate pH Total protein Albumin Cholesterol Glucose 75175 g/100 mL 65165 g/100 mL 0.751.4 g/mL 3.55.0 mEq/L 136145 mEq/L 2080 g/100 mL 200800 pg/100 mL 0.62.0 mg/100 mL 220 ng/mL 7.357.45 6.68.0 g/100 mL 3.04.0 g/100 mL less than 200 mg/100 mL 60100 mg/100 mL blood, 70120 mg/100 mL serum
Source: Handbook of Clinical Dietetics, American Dietetic Association (New Haven, Conn.: Yale University Press, 1981); and Committee on Dietetics of the Mayo Clinic, Mayo Clinic Diet Manual (Philadelphia: W. B. Saunders Company, 1981), pp. 275277.

4.66.2 million/mm3 4.25.2 million/mm3 5,00010,000/mm3 911 mg/100 mL


usdas mypyRamId

appendIx d


Source http://www.mypyramid.gov/downloads/MyPyramid_Anatomy.pdf.

absorption the body The process of taking substances into the interior of adaptive thermogenesis The change in energy expenditure induced by factors such as changes in ambient temperature and food intake adenosine triphosphate (atP) The high-energy molecule used by the body to perform energy-requiring processes adequate intakes (ai) Intakes recommended by the DRIs that should be used as a goal when no RDA exists. These values are an approximation of the average nutrient intake that appears to sustain a desired indicator of health. adipocytes Fat-storing cells adipose tissue Tissue found under the skin and around body organs that is composed of fat-storing cells amino acids The building blocks of proteins; each contains a carbon atom bound to a hydrogen atom, an amino group, an acid group, and a side chain. anorexia nervosa An eating disorder characterized by self-starvation, a distorted body image, and low body weight appetite The integrated response to the sight, smell, taste, or thought of food that initiates or delays eating atherosclerosis A type of cardiovascular disease that involves the buildup of fatty material in the artery walls bariatric The branch of medicine that deals with the causes, prevention, and treatment of obesity basal energy expenditure (Bee) The minimum amount of energy that an awake resting body needs to maintain itself; it is measured after 12 hours without food or exercise. basal metabolic rate (BMr) The rate at which energy is used by an awake resting body to maintain itself


Behavior modification A process used to gradually and permanently change habitual behaviors Binge eating disorder An eating disorder that is part of the category Eating Disorders Not Otherwise Specified (EDNOS) and characterized by periods of binge eating in the absence of purging Bioelectric impedance analysis A technique for estimating body composition that calculates body water by directing electric current through the body and measuring resistance to flow Body composition The term used to describe the different components (lean versus fat tissues) that when taken together make up an individuals body weight Body mass index (BMI) An index of weight in relation to height that is used to compare body size with a standard Bomb calorimeter An instrument used to determine the energy content of food. It measures the heat energy released when a food is combusted. Bulimia nervosa An eating disorder characterized by the consumption of large amounts of food at one time (bingeing), followed by purging behavior such as vomiting and the use of laxatives to eliminate calories from the body Calorie The amount of heat needed to raise 1 gram of water 1 degree Celsius. It is commonly used to refer to a kilocalorie, which is 1,000 calories. Carbohydrates A group of organic compounds that includes sugars, starches, and fibers and serves as a major energy source in the diet Cardiovascular disease Any disease affecting the heart and blood vessels Cellular respiration The reactions that break down glucose, fatty acids, and amino acids in the presence of oxygen to produce carbon dioxide, water, and energy in the form of ATP Cholecystokinin A hormone secreted by the upper portion of the intestine that stimulates contraction of the gallbladder and increases secretion of pancreatic juice



Nutrition and Weight Management

Cholesterol A lipid made only by animal cells that consists of multiple chemical rings Daily Value (DV) A nutrient reference value used on food labels to help consumers see how foods fit into their overall diets Diabetes mellitus A disorder of carbohydrate metabolism characterized by inadequate production or utilization of insulin and resulting in excessive amounts of glucose in the blood Dietary Guidelines for Americans A set of nutrition recommendations designed to promote population-wide dietary changes to reduce the incidence of nutrition-related chronic disease Dietary Reference Intakes (DRIs) A set of reference values for the intake of energy, nutrients, and food components that can be used for planning and assessing the diets of healthy people in the United States and Canada Diet-induced thermogenesis The energy required for the digestion of food and the absorption, metabolism, and storage of nutrients; it is equal to approximately 10% of daily energy intake. Digestion The process of breaking food into components small enough to be absorbed into the body Direct calorimetry A method of calculating energy use that measures the amount of heat produced by the body Doubly-labeled water method A technique for measuring energy expenditure that is based on the distribution of hydrogen and oxygen labeled with isotopes Electron transport chain The final stage of cellular respiration in which electrons are passed down a chain of molecules to oxygen to form water and produce ATP Energy balance A state in which body weight remains stable because the amount of energy consumed in the diet equals the amount expended Energy-yielding nutrients Nutrients that can be metabolized to provide energy in the body; they include carbohydrates, fats, and proteins. Enzymes Protein molecules that accelerate the rate of specific chemical reactions without being changed themselves

Essential nutrients Nutrients that must be supplied in the diet because they cannot be made in sufficient quantities in the body to meet needs Estimated Average Requirements (EARs) Intakes recommended by the DRIs that meet the estimated nutrient needs (as defined by a specific indicator of adequacy) of 50% of individuals in a gender and life-stage group. Estimated Energy Requirements (EERs) Energy intakes recommended by the DRIs to maintain body weight Fat-soluble vitamins Vitamins that do not dissolve in water; includes vitamins A, D, E, and K Fatty acid An organic molecule made up of a chain of carbons linked to hydrogens with an acid group at one end Fiber Nonstarch polysaccharides in plant foods that are not broken down by human digestive enzymes Fortification The addition of nutrients to food Free radicals One type of highly reactive molecule that causes oxidative damage Gallstones Stones in the gallbladder or biliary passages that form when substances in the bile harden Gastrointestinal tract A hollow tube consisting of the mouth, pharynx, esophagus, stomach, small intestine, and large intestine in which digestion of food and absorption of nutrients occur; also called the alimentary canal and digestive tract Gene A length of DNA that contains the instructions for making a protein Ghrelin A hormone produced by the stomach that helps regulate food intake Gluconeogenesis The synthesis of glucose from simple noncarbohydrate molecules. Amino acids from protein are the primary source of carbons for glucose synthesis. Glycerol The backbone molecule of triglycerides to which the three fatty acids attach Glycogen The storage form of carbohydrates in animals, made of branching chains of glucose molecules



Nutrition and Weight Management

Homeostasis A physiological state in which a stable internal body environment is maintained Hormones Chemical messengers that are produced in one location, released into the blood, and elicit responses at other locations in the body Hunger Internal signals that stimulate the acquisition and consumption of food Hypertension Elevated blood pressure Hypothalamus The region of the brain that monitors and regulates conditions and activities in the body, including food intake and energy expenditure Indirect calorimetry A method of estimating energy use that compares the amount of oxygen consumed with the carbon dioxide expired Insulin A hormone produced by the pancreas that is involved in blood sugar regulation Insulin resistance A condition in which the normal amount of insulin produces a subnormal effect in the body Isotopes Alternative form of an element that has a different atomic mass, which may or may not be radioactive Ketones or ketone bodies Molecules formed when there is not sufficient carbohydrates to completely metabolize the acetyl-CoA produced from fat breakdown Ketosis Elevated blood ketone levels Kilocalorie (kcalorie) The amount of heat required to raise the temperature of 1 kilogram of water 1 degree Celsius Kilojoule (kjoule) The amount of work required to move an object weighing 1 kilogram a distance of 1 meter under the force of gravity Lactation The production and secretion of milk in mammals Large for gestational age A term for a baby born weighing more than 8.8 pounds (4 kg) at birth Lean body mass Body mass attributed to nonfat body components such as bone, muscle, and internal organs. It is also called fat-free mass.

Leptin A protein hormone produced by adipocytes that signals information about the amount of body fat Lipid A group of organic molecules, most of which do not dissolve in water. They include fatty acids, triglycerides, phospholipids, and sterols. Macronutrients Nutrients needed by the body in large amounts. These include water and the energy-yielding nutrients carbohydrates, lipids, and proteins. Major minerals Minerals needed by the body in amounts greater than 100 grams per day Malnutrition Any condition resulting from an energy or nutrient intake either above or below that which is optimal Menarche The onset of menstruation, which usually occurs between the ages of 10 and 15 Metabolic syndrome A syndrome of high blood pressure, abdominal obesity, high cholesterol, and insulin resistance, which is linked to an increased risk of cardiovascular disease and type 2 diabetes Metabolism The sum of all the chemical reactions that take place in a living organism Micronutrients Nutrients needed by the body in small amounts; these include vitamins and minerals. Minerals Elements needed by the body in small amounts for structure and to regulate chemical reactions and body processes Morbid obesity A condition in which body weight is 100 pounds (45.5 kg) above desirable body weight or body mass index is greater than 40 kg/m2 MyPyramid: Steps to a Healthier You A food group system developed by the USDA as a guide to the amounts of different types of foods needed to provide an adequate diet and comply with current nutrition recommendations Neurotransmitter A chemical substance produced by a nerve cell that can stimulate or inhibit another cell Non-exercise activity thermogenesis (NEAT) The energy expended in activity other than intentional sports-like exercise



Nutrition and Weight Management

Nutrient density A measure of the nutrients provided by a food relative to the energy it contains Nutrients Chemical substances in foods that provide energy, structure, and regulation for body processes Nutrition A science that studies the interactions that occur between living organisms and food Nutrition transition The shift in dietary pattern that occurs as incomes increasefrom a diet high in unrefined carbohydrates and fiber to a more varied diet adequate in protein, vitamins, and minerals, but higher in calories, fat, and sugar Obese A condition characterized by excess body fat. It is defined as a body mass index of 30 kg/m2 or greater. Obesity genes Genes that code for proteins involved in the regulation of body fat; when they are abnormal, the result is abnormal amounts of body fat. Osteoarthritis The most common form of arthritis, marked by the breakdown of cartilage in the joints leading to pain, stiffness, and swelling Osteoporosis A bone disorder characterized by a reduction in bone mass, an increase in bone fragility, and an increased risk of fractures Overnutrition Poor nutritional status resulting from a dietary intake in excess of that which is optimal for health Overweight A body mass index of 25 to 29.9 kg/m2 Peptide (PYY) An appetite-suppressing hormone released from the gastrointestinal tract after a meal Physical Activity (PA) value A numeric value based on typical activity level used in estimating energy expenditure Phytochemical A substance found in plant foods that is not an essential nutrient but may have health-promoting properties Prebiotic A substance that passes undigested into the colon and stimulates the growth and/or activity of certain types of bacteria Probiotic A product that contains live bacteria, which when consumed temporarily live in the colon and confer health benefits on the host

Protein-sparing modified fast A very-low-kcalorie diet of high protein content designed to maximize the loss of fat and minimize the loss of protein from the body Recommended Dietary Allowances (RDAs) Intakes recommended by the DRIs that are sufficient to meet the nutrient needs of almost all healthy people in a specific life stage and gender group Resting energy expenditure (REE) An estimate of basal energy expenditure that has been measured after five to six hours without food or activity Resting metabolic rate (RMR) An estimate of basal metabolic rate that is determined by measuring energy utilization after five to six hours without food or exercise Saturated fat or fatty acid A fatty acid in which the carbon atoms are bound to as many hydrogens as possible and that therefore contains no carbon-carbon double bonds Simple carbohydrates Carbohydrates known as sugars that include monosaccharides and disaccharides Sleep apnea A condition characterized by pauses in breathing during sleep Starches Carbohydrates made of many glucose molecules linked in straight or branching chains; the bonds that hold the glucose molecules together can be broken by the human digestive enzymes. Subcutaneous fat Adipose tissue located under the skin that is not associated with a great increase in the risk of chronic diseases Sugars The simplest form of carbohydrate Thermic effect of food (TEF) See Diet-induced thermogenesis. Thyroid hormones Hormones produced by the thyroid gland that are important in the regulation of energy expenditure Tolerable Upper Intake Level (UL) The maximum daily intake by an individual that is unlikely to pose risks of adverse health effects to almost all individuals in the specified life-stage and gender group



Nutrition and Weight Management

Total energy expenditure (TEE) The sum of basal energy expenditure, the thermic effect of food, and the energy used in physical activity, regulation of body temperature, and deposition of new tissue Trace elements Minerals required in the body in amounts of 100 mg per day or less Trans fat A type of unsaturated fat that is formed by hydrogenation of oils; it increases the risk of heart disease Triglyceride (triacylglycerol) The major form of lipid in food and in the body; consists of three fatty acids attached to a glycerol molecule Undernutrition Poor nutritional status resulting from a dietary intake below that which meets nutritional needs Underwater weighing A technique that uses the difference between body weight under water and body weight on land to estimate body composition Underweight A body mass index of less than 18.5 kg/m2 Unsaturated fat or fatty acid A fatty acid that contains one or more carbon-carbon double bonds Very-low-calorie diet A weight-loss diet that provides fewer than 800 calories per day Visceral fat Adipose tissue deposited in the abdominal cavity around the internal organs. High levels are associated with an increased risk of heart disease, high blood pressure, stroke, diabetes, and breast cancer. Vitamins Organic compounds needed in the diet in small amounts to promote and regulate the chemical reactions and processes needed for growth, reproduction, and the maintenance of health. Water-soluble vitamins Vitamins that dissolve in water; includes the B vitamins and vitamin C Weight cycling or yo-yo dieting The cycle of repeatedly losing and regaining weight

American Dietetic Association. Position of the American Dietetic Association: Weight Management. Journal of the American Dietetic Association 109 (2009): 330-346. American Heart Association. Fad Diet Guide. Available online at http://www.amhrt.org/Health/Risk_Factors/Overweight/Fad_Diets/ fadguide.html. Babio N., J. Canals, A. Pietrobelli, S. Prez, and V. Arija. A Two-phase Population Study: Relationships between overweight, body composition and risk of eating disorders. Nutricin Hospitalaria 24 (2009): 485-491. Batada, A., M. Seitz, M.G. Wotan, et al. Nine Out of Ten Food Advertisements Shown During Saturday Morning Childrens Television Programming Are for Food High in Fat, Sodium, or Added Sugars, or Low in Nutrients. Journal of the American Dietetic Association 108 (2008): 673678. Batterham, R.L., M.A. Cowley, C.J. Small, et al. Gut Hormone PYY(3-36) Physiologically Inhibits Food Intake. Nature 418 (2002): 650654. Centers for Disease Control and Prevention. About BMI for Children and Teens. 2009. Available online at http://www.cdc.gov/healthyweight/assessing/bmi/childrens_BMI/about_childrens_BMI.html. Centers for Disease Control and Prevention. Defining Childhood Overweight and Obesity. Available online at http://www.cdc.gov/obesity/ childhood/index.html. Accessed September 1, 2009. Centers for Disease Control and Prevention. Diabetes Fact Sheet: General information and national estimates on diabetes in the United States, 2007. Available online at http://www.cdc.gov/diabetes/pubs/ factsheet07.htm. Centers for Disease Control and Prevention. Differences in Prevalence of Obesity Among Black, White, and Hispanic Adults, United



Nutrition and Weight Management

States, 2006-2008. Morbidity and Mortality Weekly Report 58 (2009): 740-744. Centers for Disease Control and Prevention, National Center for Health Statistics. Mean Body Weight, Height, and Body Mass Index, United States 1960-2002. Available online at http://www.cdc.gov/ nchs/pressroom/04news/americans.htm. Accessed September 12, 2009. Centers for Disease Control and Prevention. Obesity and Overweight, Health Consequences. Available online at http://www.cdc.gov/obesity/causes/health.html. Accessed September 12, 2009. Centers for Disease Control and Prevention. Prevalence of Overweight and Obesity Among Adults, United States 19992000. Available online at http://www.cdc.gov/nchs/releases/02news/obesityonrise. htm. Accessed September 12, 2009. Centers for Disease Control and Prevention. Trends in Intake of Energy and Macronutrients, United States, 19712000. Morbidity and Mortality Weekly Report. 53:8082, 2004. Chagnon,Y.C., T. Rankinen, E. E. Snyder, et al. The Human Obesity Gene Map: The 2002 Update. Obesity Research 11 (2003): 313367. Committee to Reexamine IOM Pregnancy Weight Guidelines, Institute of Medicine, National Research Council. Weight Gain During Pregnancy: Reexamining the Guidelines. Washington D.C.: National Academies Press, 2009. Considine, R.V., M.K. Sinha, M.L. Heiman, et al. Serum Immunoreactive-leptin Concentrations in Normal Weight and Obese Humans. New England Journal of Medicine. 334:292295, 1996. Conway, J. M. Ethnicity and Energy Stores. American Journal of Clinical Nutrition 62 (suppl) (1995): 1067S1071S. Coon, K.A. and K.L. Tucker. Television and Childrens Consumption Patterns: A review of the literature. Minerva Pediatrica 54 (2002): 423436. Cummings, D.E. and J. Overduin. Gastrointestinal Regulation of Food Intake. The Journal of Clinical Investigation. 117 (2007): 13-23.

Cummings, D.E., D.S. Weigle, R.S., Frayo, et al. Plasma Ghrelin Levels After Diet-induced Weight Loss or Gastric Bypass Surgery. New England Journal of Medicine 346 (2002): 16231630. Eisenmann, J.C., R.T. Bartee, and M.Q. Wang. Physical Activity, TV Viewing, and Weight in U.S. Youth: 1999 Youth Risk Behavior Survey. Obesity Research 10 (2002): 379385. Enriori, P.J., A.E. Evans, P. Sinnayah, and M.A. Cowley. Leptin Resistance and Obesity. Obesity 14 (2006): 254S258S. Fairburn, C.G. and P.J. Harrison. Eating Disorders. The Lancet 36 (2003): 407-416. Field, A., S. Austin, and C. Taylor, et al. Relation Between Dieting and Weight Change Among Preadolescents and Adolescents. Pediatrics (2003) 112: 900-906. Fields, D.A., G.R. Hunter, and M.I. Goran. Validation of the BOD POD with Hydrostatic Weighing: Influence of body clothing. International Journal of Obesity and Related Metabolic Disorders 24 (2000): 200205. Flegal, K.M., B.I. Graubard, D.F. Williamson, and M.H. Gail, Excess Deaths Associated with Underweight, Overweight, and Obesity. JAMA 293 (2005): 18611867. Ford, E.S., W.H. Giles, and W.H. Dietz. Prevalence of Metabolic Syndrome Among U.S. Adults: Findings from the Third National Health and Nutrition Examination Survey. Journal of the American Medical Association 287 (2002): 356-359. Gallagher, D., S. Heymsfield, M. Heo, et al. Healthy Percentage Body Fat Ranges: An approach for developing guidelines based on body mass index. American Journal of Clinical Nutrition 72 (2000): 694701. Gill, H. and J. Prasad. Probiotics, Immunomodulation, and Health Benefits. Advances in Experimental Medicine and Biology 606 (2008): 423454. Harrington, S. The Role of Sugar-sweetened Beverage Consumption in Adolescent Obesity: A review of the literature. The Journal of School Nursing. 24 (2008): 3-12.



Nutrition and Weight Management

Hess, A.M. and D.L. Sullivan. Potential for Toxicity with Use of Bitter Orange Extract and Guarana for Weight Loss. The Annals of Pharmacotherapy 39 (2005): 574-575. Hill, J.O. Can a Small-changes Approach Help Address the Obesity Epidemic? A report of the Joint Task Force of the American Society for Nutrition, Institute of Food Technologists, and International Food Information Council. American Journal of Clinical Nutrition 89 (2009): 477-84. Hill, J.O. Understanding and Addressing the Epidemic of Obesity: An energy balance perspective. Endocrine Reviews 27 (2006): 750-61. Hill, J.O. and H.R. Wyatt. Role of Physical Activity in Preventing and Treating Obesity. Journal of Applied Psychology 99 (2005): 765-770. Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Energy, Carbohydrates, Fiber, Fat, Protein, and Amino Acids. Washington, D.C.: National Academies Press, 2002. Karra, E. and R.L. Batterham. The Role of Gut Hormones in the Regulation of Body Weight and Energy Homeostasis. Molecular and Cellular Endocrinology. [Epub ahead of print] 27 Jun 2009. Key, T.J., N.E. Allen, E.A. Spencer, and R.C. Travis. The Effect of Diet on Risk of Cancer. The Lancet 360 (2002): 861868. Klok, M.D., S. Jakobsdottir, and M.L. Drent. The Role of Leptin and Ghrelin in the Regulation of Food Intake and Body Weight in Humans: A review. Obesity Reviews 8 (2007): 21-34. Knner, A.C., T. Klckener, and J.C. Brning. Control of Energy Homeostasis by Insulin and Leptin: Targeting the arcuate nucleus and beyond. Physiology & Behavior 97(2009): 632-638. Kroke, A., A.D. Liese, M. Schulz, et al. Recent Weight Changes and Weight Cycling as Predictors of Subsequent Two-Year Weight Change in a Middle-aged Cohort. International Journal of Obesity and Related Metabolic Disorders 26:403409, 2002. Lanningham-Foster, L., R.C. Foster, S.K. McCrady, et al. Activitypromoting Video Games and Increased Energy Expenditure. Pediatrics 154 (2009): 819-823.

Latner, J., and A. Stunkard. Schoolchildren, Stigma, and Obesity. Obesity Research 9 (2001): 94S. Levine, J.A., N.L. Eberhardt, and M.D. Jensen. Role of Nonexercise Activity Thermogenesis in Resistance to Fat Gain in Humans. Science 283 (1999): 212214. Li, J.J., C.J. Huang, and D. Xie. Anti-obesity Effects of Conjugated Linoleic Acid, Docosahexaenoic Acid, and Eicosapentaenoic Acid. Molecular Nutrition & Food Research 52 (2008):631-645. Mammal Society. Mammal Record Breakers. Available online at http:// abdn.ac.uk/mammal/fattest.shtmll Accessed September 5, 2009. Must, A. and S. Anderson. Effects of Obesity on Morbidity in Children and Adolescents. Nutrition in Clinical Care 6 (2003): 412. National Cancer Institute. Cancer Facts. Obesity and Cancer: Questions and Answers. Available online at http://www.cancer.gov/cancertopics/factsheet/Risk/obesity. Accessed September 5, 2009. National Center for Health Statistics. Health United States, 2008. Available online at http://www.cdc.gov/nchs/data/hus/hus08.pdf#070. Accessed September 11, 2009. NCHS. About Healthy People 2010. Available online at http://www.cdc. gov/nchs/about/otheract/hpdata2010/abouthp.htm Accessed September 10, 2009. National Institutes of Health, National Heart, Lung, and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Available online at: http:// www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm. National Institutes of Health, National Heart, Lung, and Blood Institute. The Practical Guide: Identification, evaluation, and treatment of overweight and obesity in adults. NIH NHLBI, NIH Publication (2000) 02-4084. Nordmann, A.J., A. Nordmann, M. Briel, et al. Effects of low-carbohydrate vs. low-fat diets on weight loss and cardiovascular risk factors: a meta-analysis of randomized controlled trials. Archives of Internal Medicine 166 (13 Feb 2006): 285-293.



Nutrition and Weight Management

Norman, R. A., D. B. Thompson, T. Foroud, et al. Genomewide Search for Genes Influencing Percent Body Fat in Pima Indians: Suggestive linkage at chromosome 11q21q22. American Journal of Human Genetics 60 (1997): 166173. Ogden, C.L., M.D. Carroll, and L.R. Curtin, et al. Prevalence of Overweight and Obesity in the United States, 19992004. Journal of the American Medical Association 295 (2006): 15491555. Ogden, C.L., M.D. Carroll, and K.M. Flegal. High Body Mass Index for Age among U.S. Children and Adolescents, 2003-2006. Journal of the American Medical Association 299 (2008): 2401-2405. Onyike, C.U., R.M. Crum, H. B. Lee, et al. Is Obesity Associated with Major Depression? Results from the third NHANES. American Journal of Epidemiology 158 (2003): 11391147. Pempek, T.A. and S.A. Calvert. Tipping the Balance: Use of advergames to promote consumption of nutritious foods and beverages by lowincome African American children. Archives of Pediatrics & Adolescent Medicine 163 (2009): 633637. Pittler, M.H., and E. Ernst. Dietary Supplements for Body-weight Reduction: A systematic review. American Journal of Clinical Nutrition 79 (2004): 529536. Popkin, B.M. The Nutrition Transition: An overview of world patterns of change. Nutrition Reviews 62 (2004): S140S143. Redinger, R.N. The Physiology of Adiposity. Journal of the Kentucky Medical Association 106 (2008): 5362. Remick, D., K. Chancellor, J. Pederson, et al. Hyperthermia and Dehydration-related Deaths Associated with Intentional Rapid Weight Loss in Three Collegiate Wrestlers: North Carolina, Wisconsin, and Michigan, NovemberDecember, 1997. MMWR Morbity and Mortality Weekly Report 47 (1998): 105108. Richardson, S.A., A.H. Hastorf, N. Goodman, and S.M. Dornsbusch. Cultural Uniformity in Reaction to Physical Disabilities. American Sociological Review 202 (1961): 241247. Rolls, B.J., E.L. Morris, and L.S. Roe. Portion Size of Food Affects Energy Intake in Normal-weight and Overweight Men and Women. American Journal of Clinical Nutrition 76 (2002): 12071213.

Rosenbaum, M., J. Hirsch, D.A. Gallagher, and R.L. Leibel. Long-term Persistence of Adaptive thermogenesis in Subjects Who Have Maintained a Reduced Body Weight. American Journal of Clinical Nutrition 88 (2008): 906-912. Saper, R.B., D.M. Eisenberg, and R.S. Phillips. Common Dietary Supplements for Weight Loss. American Family Physician 70 (2004): 17311738. Schutz, L.O., P.H. Bennett, E. Ravussin, et al. Effects of Traditional and Western Environments on Prevalence of Type 2 Diabetes in Pima Indians in Mexico and the U.S. Diabetes Care 29 (2006): 1866-1871. Smith, G.P. Controls of Food Intake. Modern Nutrition in Health and Disease, 10th ed., eds. M. E. Shils, A.C. Ross, B. Caballero, R.J. Cousins. Philadelphia: Lipincott Williams & Wilkens, 2006, pp. 751770. Stewart, H., N. Blisard, and D. Jolliffe. Lets Eat Out: America weighs taste, convenience, and nutrition. Economic Information Bulletin-19. Washington, DC: Economic Research Service, U.S. Department of Agriculture, 2006.


USDA/Center for Nutrition Policy and Promotion. The Quality of Childrens Diets in 2003-04 as Measured by the Healthy Eating Index, 2005. Nutrition Insight 43, April 2009.
U.S. Congress. Personal Responsibility in Food Consumption Act of 2005. HR 554. Available online at http://www.govtrack.us/congress/bill. xpd?bill=h109-554. Accessed September 14, 2009. U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans. Washington, D.C.: Department of Health and Human Services, 2008. U.S. Department of Health and Human Services, Office of the Surgeon General. The Surgeon Generals Call to Action to Prevent and Decrease Overweight and Obesity. Available online at www. surgeongeneral.gov/topics/obesity. Accessed September 10, 2009. Vander Wal, J. and M. Thelen. Eating and Body Image Concerns Among Obese and Average-weight Children. Addict Behaviors 25 (2000): 775-778.


Nutrition and Weight Management

van Marken Lichtenbelt, W.D., J.W. Vanhommerig, N.M. Smulders, et al.Cold-activated Brown Adipose Tissue in Healthy Men. New England Journal of Medicine 360 (2009): 1500-1508. Villareal, D. T., C.M. Apovian, R.F. Kushner, and S. Klein. American Society for Nutrition; NAASO, the Obesity Society. Obesity in Older Adults: Technical review and position statement of the American Society for Nutrition and NAASO, the Obesity Society. American Journal of Clinical Nutrition 82 (2005): 923934. Wijers, S.L., W.H. Saris, W.D. van Marken Lichtenbelt. Recent Advances in Adaptive Thermogenesis: Potential implications for the treatment of obesity. Obesity Review 10 (2009): 218-226.

Willcox, B.J., D.C. Willcox, H. Todoriki, et al. Caloric Restriction, the Traditional Okinawan Diet, and Healthy aging: The diet of the worlds longest-lived people and its potential impact on morbidity and life span. Annals of the New York Academy of Sciences 1114 (2007): 434455. WIN/National Institutes of Health. NIDDK. Gastrointestinal Surgery for Severe Obesity. Available online at win.niddk.nih.gov/publications/gastric.htm/. Accessed November 29, 2005. WIN/Weight Control Information Network, National Institutes of Diabetes and Digestive and Kidney Diseases. Statistics Related to Overweight and Obesity. Available online at www.win.niddk.nih. gov/statistics. Accessed January 12, 2009. World Health Organization Global Strategy on Diet, Physical Activity and Health. Obesity and Overweight. Available online at http:// www.who.int/dietphysicalactivity/publications/facts/obesity/en/. Accessed September 14, 2009. World Health Organization. Obesity and Overweight, September 2006. Fact sheet no. 311. Available online at www.who.int/mediacentre/ factsheets/fs311/en/print.html. Accessed July 2, 2009. Wynne, K., S. Stanley, B. McGowan, and S. Bloom. Appetite Control. Journal of Endocrinology 184 (2005): 291318.

Young, L.R. and M. Nestle. Portion Sizes and Obesity: Responses of Fast-Food Companies. Journal of Public Health Policy 28 (2007): 238248.

fuRtheR ResouRCes
Duyff, Roberta. American Dietetic Association Complete Food and Nutrition Guide. 3rd ed. New Jersey: John Wiley & Sons, 2008. Hassink, Sandra, ed. A Parents Guide to Childhood Obesity: A Roadmap to Health. Elk Grove Village, Ill. American Academy of Pediatrics, 2006. Kosharek, Susan M. If Your Child Is Overweight: A Guide for Parents. 3rd ed. Chicago: American Dietetic Association, 2006. Mullen, Mary C. and Shield, J. Childhood and Adolescent Overweight: The Health Professionals Guide to Identification, Treatment and Prevention. Chicago: American Dietetic Association, 2004. U.S. Department of Health and Human Services. A Healthier You: Based on the Dietary Guidelines for Americans. Office of Disease Prevention and Health Promotion U.S., 2005. Warshaw, Hope S. Eat Out, Eat Right: The Guide to Healthier Restaurant Eating. 3rd ed. Evanston, Ill. Surrey Books, 2008.

Web sItes
Presidents Council on Physical Fitness and Sports http://www.fitness.gov This Web site provides the latest guidelines for physical fitness for Americans. It also includes information on how you can start a physical activity program today and stay active and fit for life. We CaN! http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/ We Can! stands for Ways to Enhance Childrens Activity & Nutrition. We Can! is a national education program designed for parents and caregivers to help children 8 to 13 years old stay at a healthy weight. We Can! offers parents and families tips and fun activities to encourage healthy eating, increase physical activity, and reduce sedentary or screen time.



Nutrition and Weight Management

Weight Control Network http://win.niddk.nih.gov/index.htm The Weight-control Information Network provides the general public, health professionals, the media, and Congress with upto-date, science-based information on weight control, obesity, physical activity, and related nutritional issues.

pICtuRe CRedIts
10: Infobase Publishing 15: Infobase Publishing 21: Infobase Publishing 25: Infobase Publishing 27: Infobase Publishing 29: Drazen Vukelic/ Shutterstock 32: (left) Shutterstock; (right) Infobase Publishing 35: Infobase Publishing 40: Infobase Publishing 42: Infobase Publishing 48: Ed Andrieski/AP Images 56: Infobase Publishing 63: Biophoto Associates/Photo Researchers, Inc. 65: Infobase Publishing 69: Courtesy USDA 72: Infobase Publishing 74: Getty Images 83: Robin Nelson/PhotoEdit 94: Infobase Publishing 95: AFP Photo/Newscom 103: Infobase Publishing 108: Infobase Publishing 110: Infobase Publishing 126: Infobase Publishing 129: Infobase Publishing 133: Gusto/Photo Researchers, Inc. 152: Courtesy CDC 153: Courtesy CDC 155: Courtesy USDA


Page numbers in italics indicate photos or illustrations; page numbers followed by t indicate tables. appetite, control of 13 apple-shaped body 3437, 35 arthritis 44, 102t asthma 44 atherosclerosis 40, 40 athletes 30, 140 ATP (adenosine triphosphate) 57

absorption 5557, 56 activity levels. See also physical activity estimation of 8586, 85t, 86t of obese people 99 adaptive thermogenesis 9798 adenosine triphosphate (ATP) 57 Adequate Intakes (AIs) 61 adipocytes 74, 7475 adipose tissue 45, 74, 77, 98 adolescents body fat ratios in 29 dangerous weight-loss practices and 140 healthy weight in 129131 obesity health risks in 131135 obesity in 128129, 129 weight assessment in 26, 27 weight management for 135 139, 141142 advergames 104 African Americans. See blacks AIs (Adequate Intakes) 61 Alli 122123 amino acids 59 animals, fat levels in 34 anorexia nervosa 48, 49 antioxidants 60

bacteria, intestinal 5557 bariatric surgery 124127, 126 basal energy expenditure (BEE) 7879 basal metabolic rate (BMR) 78 behavior modification 109111, 110 benzocaine 122 bile ducts 43 binge eating disorder 135 bioelectric impedance analysis 31 bitter orange 123124 blacks 14, 30, 36 BMI. See body mass index BMR (basal metabolic rate) 78 BOD PODs 33 body energy stores adding to 7677 formation of 74, 7475 utilization of 7576 body fat decreased. See underweight excessive. See obesity; overweight factors affecting 2830 measurement of 3134 storage of 7475, 77


body mass index (BMI) 2428, 25, 27, 36t, 100101 body shape 3437, 35 body weight BMI assessment of 2428, 25, 27 body fat ratios and 2834 body shape and 3437, 35 genes and 9091 healthy 26, 37, 129131 regulation of 9195 bomb calorimeter 73 breathing problems 44, 102t, 134 brown adipose tissue 98 bulimia nervosa 135 establishing healthy habits in 19 exercise levels in 1617 healthy weight in 129131 obesity health risks in 131135 obesity in 128129, 129 starvation in 49 weight assessment in 26, 27 weight loss in 105 weight management for 135 139, 141142 cholesterol 59, 131132 chromium 123 computerized axial tomography (CT) 34 conjugated linoleic acid 123


caffeine 122 caloric expenditures. See energy expenditures caloric intake recommendations 61 caloric intake reduction 18. See also food intake restriction calorie, defined 53 calorimetry 8284, 83 cancer 43, 102t carbohydrates 5859, 58t cardiovascular disease 3941, 40, 102t, 131132 cellular respiration 84 Centers for Disease Control (CDC) 9 Cheeseburger Bill 46 childbirth complications 45 children dangerous weight-loss practices and 140 diets of American 115

Daily Value (DV) 6566 dandelion 124 dangerous weight-loss practices 140 dehydration for weight loss 140 developing countries, obesity in 22 diabetes 4143, 42, 102t, 132 diabetes mellitus. See diabetes diet. See nutrition Dietary Guidelines 6768, 67t Dietary Reference Intakes (DRIs) 61 dietary supplements 52, 62, 64 diet-induced thermogenesis 82 dieting. See weight-loss plans diet plans. See weight-loss plans digestion of nutrients 5557, 82 digestive enzymes 57 digestive system 5557, 56


Nutrition and Weight Management

dilution method for body fat determination 33 direct calorimetry 8283 disease risks. See health risks diuretics 122, 124 doubly labeled water method 84 drinks 73, 137 DRIs (Dietary Reference Intakes) 61 drugs, weight-loss 121123 Dual-energy X-ray absorptometry (DXA) 3334 DV (Daily Value) 6566 energy stores. See body energy stores energy-yielding nutrients 5354 environmental factors 1213, 30 enzymes, digestive 57 ephedra 123 epidemics 12 essential nutrients 52 Estimated Average Requirements (EARs) 61 Estimated Energy Requirements (EERs) 61, 8488, 85t, 86t, 87t estrogen 45 exchange plans 116117 exercise calories burned during 7982, 8081t changes in levels of 1617, 1819 and energy needs 98 recommendations for 17, 19, 88 in weight loss 108109, 137139

EARs (Estimated Average Requirements) 61 eating disorders 48, 49, 135 EERs. See Estimated Energy Requirements elderly, weight loss in 105106 electrical current flow, for body fat determination 31 electron transport chain 98 energy body stores of 74, 7477 sources of 7277 energy balance 11, 54, 71, 72 energy deficiency. See starvation energy expenditures energy balance and 71, 72 during exercise 7982, 8081t measurement of 8284 metabolic requirements 7879 total energy expenditure 7778 energy needs. See Estimated Energy Requirements

fast food 14, 15, 16, 46 fat dietary 58t, 59, 77. See also fatty acids storage of 7475, 77. See also body fat fat burner supplements 123124 fattest man record 34 fatty acids 59, 76, 77 fertility, reduced 4445 fever, and basal energy needs 78 fiber 5859 fibers, for weight loss 122

food caloric content determination 73 constituents of 5152. See also nutrition digestion and absorption of 5557, 82 food consumption in America 1316 food exchanges 116117 Food for Young Children 66 food guides 66 food intake restriction involuntary. See starvation for weight loss 106107, 108, 136 food labels 18, 6467, 65 fortification 52 free radicals 60 futile cycling 98 glycogen 74 growth charts 26, 27 growth patterns in children 130131 guarana 124


health care costs, obesity and 11 health effects 9, 11 health risks 3850 arthritis 44, 102t body mass index and 25 breathing problems 44, 102t, 134 cancer 43, 102t in children and teens 131135 diabetes 4143, 42, 102t, 132 gallbladder disease 4344, 102t heart disease 3941, 40, 102t, 131132 hypertension 132 overview 4950 reproductive problems 4445, 49 of underweight 4749, 48 waist circumference and 36t and weight loss assessment 101, 102t healthy body weight 26, 37, 129131 healthy diet, characteristics of 114115 Healthy People 2010 14 heart, function of 39 heart disease 3941, 40, 102t, 131132 herbal supplements 123124 high blood pressure 132

gallbladder disease 4344, 102t gallstones 43 gastric banding 126 gastric bypass 126 gastrointestinal (GI) tract 56, 5657 genetics and body shape 36 and obesity 1112, 9091 of Pima Indians 96, 97 GI (gastrointestinal) tract 56, 5657 global obesity trends 2023, 21 globesity 20, 23 gluconeogenesis 76 glucose 41, 42, 74 glycerol 77


Nutrition and Weight Management

Hispanics, obesity in 14, 30 homeostasis 54 hydroxycitric acid 123 hypertension 132 hyperthyroidism 79 hypothyroidism 79 leanness, natural 47. See also underweight leptin 45, 95, 9596 lifestyle and body fat percentage 30 and body shape 36 and obesity 1213, 96 lipids 58t, 59. See also fatty acids liposuction 127 liquid formula diets 117 low-birthweight infants 49 low-carbohydrate diets 120121 low-fat diets 120

imaging, for body fat determination 3334 indirect calorimetry 83, 8384 infants, low-birthweight 49 infertility 4445 insulin 41, 120 insulin resistance 41 international obesity trends 2023, 21 international public health strategies 2223 intestinal bacteria 55 iron, overdose of 62, 64 isotopes 84

macronutrients 57, 58t magnetic resonance imaging (MRI) 34 malnutrition nutrient deficiency and 62 overnutrition and 62, 64 marriage, and obesity 30 medications, weight-loss 122123 men body fat in 29, 31 disease risk in 36t obesity in 30 menarche, early 134 Meridia (sibutramine) 122 metabolic syndrome 4142 metabolism 57, 97 mice, obese strain of 34, 95, 9596 micronutrients 57, 58t minerals 58t, 60 minority populations, obesity in 14, 30 morbid obesity, defined 26

junk-food tax 111

ketones 76, 121 ketosis 76 kilocalories 53

large intestine, bacteria of 55 lawsuits, fast food 46 laxatives 124 lean body mass 2829, 78

MRI (magnetic resonance imaging) 34 MyPyramid 68, 69, 116, 136 health risks of. See health risks metabolism efficiency and 97 trends in 9, 10, 2022, 21 obesity epidemic 923 causes of 1117 health effects of 9, 11 management of 1720 in minorities 14 in other countries 2023, 21 overview 23 prevalence data 9, 10, 2022, 21 obesity genes 91 older adults, weight loss in 105106 orlistat (Xenical) 122 osteoarthritis 44, 102t osteoporosis 49 overdosage of dietary supplements 62, 64 overnutrition 23, 62, 64 over-the-counter medications 122123 overweight defined 26, 37 health risks of. See health risks prevalence of 9, 10


non-exercise activity thermogenesis (NEAT) 82, 99 nutrient density 114 nutrients classes of 5760, 58t deficiency or excess of 6264, 63 digestion and absorption of 5557, 56, 82 essential 52 functions of 5254 recommended intake amounts 6062 utilization of 57 nutrition 5170. See also nutrients Dietary Guidelines 6768, 67t food constituents 5152 food labels and 6468, 65 healthy diet characteristics 114115 MyPyramid 68, 69 overview 6769 nutrition transition 22

PA (Physical Activity) value 86t, 88 PCOS (polycystic ovary syndrome) 45 pear-shaped body 3437, 35 Personal Responsibility in Food Consumption Act 46 phentermine 122 physical activity. See exercise

obesity activity levels and 99 adaptive thermogenesis and 9798 causes of 95, 9599 in children 128129, 129 defined 26


Nutrition and Weight Management

Physical Activity (PA) value 86t, 88 phytochemicals 52 Pima Indians 96, 97 polycystic ovary syndrome (PCOS) 45 portion size 1416, 15, 18, 75 poverty, and obesity 30 prebiotics 55 pregnancy, weight loss during 105 pregnancy and childbirth complications 45, 49 prepackaged food 14, 64 preportioned meal plans 117 prescription medications 122 probiotic therapy 55 proteins 58t, 59 protein-sparing modified fast 119 psychological consequences 4647, 134

saturated fats 59 schools, foods available in 19 serving size. See portion size sibutramine (Meridia) 122 skinfold thickness 3132, 32 sleep apnea 44, 134 social consequences 4647, 134 soft-drink consumption 137 special foods or food combinations 117119 starches 58 starvation 4749, 48, 62 structural nutrients 54 subcutaneous fat 3132, 3435 substrate cycling 98 sugars 58 supplements, weight-loss 123124 surgery, bariatric 124127, 126 sweetened beverages 137 syndrome X 4142

Recommended Dietary Allowances (RDAs) 61 REE (resting energy expenditure) 78 regulatory nutrients 54 reproductive problems 4445, 49 respiratory problems 44, 102t, 134 resting energy expenditure (REE) 78 resting metabolic rate (RMR) 78 restricted food intake. See food intake restriction rickets 62, 63 RMR (resting metabolic rate) 78

TEE (total energy expenditure) 7778 teens. See adolescents television 139 thermic effect of food (TEF) 82 thyroid hormones 79 Tolerable Upper Intake Levels (ULs) 61 total energy expenditure (TEE) 7778 toxicity, from dietary supplements and vitamins 62 trans fat 59 triglycerides 59, 74, 76, 77

Index U
U.S. Surgeon Generals Call to Action 18, 19 ULs (Tolerable Upper Intake Levels) 61 undernutrition 22 underwater weighing 33 underweight defined 26 health risks of 4749, 48 populations at risk 30 weight gain strategies 111112 unsaturated fats 59 drugs and supplements for 121124 evaluation of 106111, 107t evaluation of claims 118 exchange plans 116117 goal for 104 liquid formula diets 117 low-carbohydrate 120121 low-fat 120 overview 127 preportioned meal plans 117 reduced calorie plans 115119 special foods or food combinations 117119 very-low-calorie plans 119 weight-loss practices, dangerous 140 weight management 100111 for children and teens 135139 dieting and 113114 life stages and 105106 overview 112 overweight. See weight loss underweight 111112 weight assessment 100103 weight statistics 30 Weight Watchers 116 whales, fat levels in 34 women body fat in 29, 31 disease risk in 36t obesity in 30


very-low-calorie diets 119 video games, activity promoting 109 visceral fat 35, 3637 vitamin A, deficiency of 62 vitamin D, deficiency of 62, 63 vitamin overdose 62, 64 vitamins 58t, 60

waist circumference 36t, 37 water 5960 water tanks 33 weight cycling 103, 103 weight gain 111112 weight loss calories per pound of 105 goal for 104 recommended rate of 104 weight-loss plans 113127 bariatric surgery 124127, 126 dieting and 113114

Xenical (orlistat) 122

about the authoRs

LoRI a. smoLIn, ph.d., received her B.S. degree from Cornell University, where she studied human nutrition and food science. She received her doctorate from the University of Wisconsin at Madison. Her doctoral research focused on B vitamins, homocysteine accumulation, and genetic defects in homocysteine metabolism. She completed postdoctoral training both at the HarborUCLA Medical Center, where she studied human obesity, and at the University of California at San Diego, where she studied genetic defects in amino acid metabolism. She has published in these areas in peer-reviewed journals. She and Mary Grosvenor are coauthors of several well-respected college-level nutrition textbooks and contributing authors for a middle school text. Dr. Smolin is currently at the University of Connecticut, where she teaches in the Department of Nutritional Science. Courses she has taught include introductory nutrition, life-cycle nutrition, food preparation, nutritional biochemistry, general biochemistry, and introductory biology. maRy b. GRosvenoR, m.s., R.d., received her B.A. degree in English from Georgetown University and her M.S. in nutrition sciences from the University of California at Davis. She is a registered dietitian (R.D.) with experience in public health, clinical nutrition, and nutrition research. She has published in peer-reviewed journals in the areas of nutrition and cancer and methods of assessing dietary intake. She and Lori Smolin are the coauthors of several well-respected college-level nutrition textbooks and contributing authors of a middle school text. Grosvenor has taught introductory nutrition to community college and nursing school students. In addition to writing and teaching, she counsels patients as a hospital dietitian and certified diabetes educator and advises other health professionals in the area of clinical nutrition.