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Nutrition and the Metabolic Syndrome   Gail Underbakke, RD, MS UW Preventive Cardiology Program
 
Metabolic Syndrome  in Children and Adolescents <ul><li>Prevalence of metabolic syndrome is high among obese children and ...
Definition: <ul><li>The Metabolic Syndrome consists of multiple, interrelated risk factors of metabolic origin that appear...
ATP III: The Metabolic Syndrome* *Diagnosis is established when   3 of these risk factors are present. † Abdominal obesit...
 
Country/Ethnic Values for Waist Circumference Defining Central Obesity,  International Diabetes Federation <ul><li>Male Fe...
Atherogenic Dyslipidemia Risk of coronary heart disease Despres J-P. Dyslipidemia and obesity.  Baillere’s Clin Endocrinal...
Underlying Causes of Metabolic Syndrome <ul><li>There are multiple underlying factors – </li></ul><ul><li>abdominal obesit...
Post-prandial Dysmetabolism <ul><li>Inflammation plays a role in the development of chronic disease - heart disease, diabe...
Effects of a beverage containing 75 gm glucose with 75 gm fat as whipping cream. Nitrotyrosine indicates oxidant stress, C...
Daily Activity Reduces Post-Prandial Glucose O’Keefe, et. al. JACC 2008; 51:249
Inflammation <ul><li>Triggers include  </li></ul><ul><ul><li>oxidized LDLs in artery intima  </li></ul></ul><ul><ul><li>lo...
AHA Recommendations for Management of the Metabolic Syndrome <ul><li>Lifestyle First! </li></ul><ul><li>Reduce weight by 7...
Lifestyle Recommendations to: <ul><li>Reduce Triglycerides   </li></ul><ul><li>Weight loss, exercise, total carbohydrate <...
Carbohydrate and Triglycerides <ul><li>High carb diets can overwhelm normal metabolism, increase synthesis of fatty acids ...
Effects of Lifestyle Modification to Manage Hypertension <ul><li>  Approximate Reduction in  </li></ul><ul><li>Modificatio...
Dietary Approaches to Stop Hypertension (DASH and DASH-Sodium) <ul><li>Moderate sodium use (2400 mg per day or less) </li>...
Overall Lifestyle Recommendations for Metabolic Syndrome <ul><li>Exercise </li></ul><ul><li>Weight Loss </li></ul><ul><li>...
The Continuum of Diets to Reduce CVD Risk <ul><li>Total Fat  30-40%   34%   <30%  <30%  <10% </li></ul><ul><li>Sat Fat   <...
One Diet for All? <ul><li>Case # 1 </li></ul><ul><li>62 y.o. male </li></ul><ul><li>CAD </li></ul><ul><li>BMI - 24 </li></...
Copyright restrictions may apply. Gardner, C. D. et al. JAMA 2007;297:969-977. Which Diet Works?
Dansinger, JAMA 2005; 293:43-53 
 
Change From Baseline (%) P <0.001 LDL-C TG
Fish Sources of Omega-3 Fatty Acids <ul><li>Salmon, Atlantic, farmed, 3 oz 1.09-1.83 gm </li></ul><ul><li>Herring, Atlanti...
Plant Sources of Omega-3 Fatty Acids, Per gram of fat <ul><li>Flax seed oil 0.66  </li></ul><ul><li>Fish body oil 0.3  </l...
Contains: 180 mg EPA 120 mg DHA Per capsule For more information: Fish Oil Supplements www.heartdecision.org
Facts about the Glycemic Index <ul><li>Defined as the area under the blood glucose curve for a test food, compared to the ...
Glycemic Index of Selected Foods   <ul><li>Potatoes  80-100 Baked beans  48 </li></ul><ul><li>Corn flakes  84 Orange, Grap...
Glycemic Index of Mixed Foods <ul><li>White rice   100 </li></ul><ul><li>with pickled cucumber 73 </li></ul><ul><li>with y...
Alcohol – What’s a serving? 12 oz beer 5 oz of wine 1.5 oz of 80 proof liquor Size of typical wine glass  -  10-14 oz. Rec...
Benefits of Nuts <ul><li>Low in saturated fat, good source of monounsaturated fat </li></ul><ul><li>No cholesterol </li></...
Nuts - Fat Content, 1 ounce <ul><li>  Calories   Total   Sat.   MUF   PUF </li></ul><ul><li>Almonds, 24 170   14.5   1.5  ...
Oxidative Stress <ul><li>An imbalance of pro-oxidants and antioxidants results in </li></ul><ul><ul><li>generation of reac...
Foods / Nutrients with Antioxidant Effects <ul><li>Omega-3 fatty acids </li></ul><ul><li>Dietary fiber </li></ul><ul><li>M...
Phytochemicals are measured in ORAC Units <ul><li>ORAC per 100 grams   ORAC per calorie </li></ul><ul><li>Cloves, ground 1...
To Minimize Post-Prandial Dysmetabolism <ul><li>Minimally processed, high-fiber, plant-based foods (whole grains, vegetabl...
Sample Mediterranean Menu <ul><li>B  - Cooked cracked wheat cereal with walnuts </li></ul><ul><li>  and yogurt   Melon </l...
DASH - Sample Menu (2000 calories) <ul><li>Breakfast Dinner </li></ul><ul><li>Orange Juice   Baked cod </li></ul><ul><li>O...
 
Resources <ul><li>American Institute for Cancer Research - Veggies </li></ul><ul><li>http://www.aicr.org/site/PageServer?p...
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  • Lipid Management in Clinical Practice - Section 1
  • Lipid Management in Clinical Practice - Section 1
  • Transcript of "PowerPoint"

    1. 1. Nutrition and the Metabolic Syndrome Gail Underbakke, RD, MS UW Preventive Cardiology Program
    2. 3. Metabolic Syndrome in Children and Adolescents <ul><li>Prevalence of metabolic syndrome is high among obese children and adolescents and it increases with worsening obesity. </li></ul><ul><li>439 subjects, ages 4-20, BMIs > 97 th percentile </li></ul><ul><li>38.7% of moderately obese subjects had Met Syn </li></ul><ul><li>49.7% of severely obese subjects had Met Syn </li></ul><ul><li>New England Journal of Medicine 2004; 350:2362. </li></ul>
    3. 4. Definition: <ul><li>The Metabolic Syndrome consists of multiple, interrelated risk factors of metabolic origin that appear to directly promote the development of atherosclerotic cardiovascular disease (  risk 2x), and are strongly associated with type 2 diabetes mellitus (  risk 5 x). </li></ul><ul><li>Metabolic risk factors include atherogenic dyslipidemia, elevated blood pressure, elevated plasma glucose, a prothrombotic state, and a proinflammatory state. </li></ul>
    4. 5. ATP III: The Metabolic Syndrome* *Diagnosis is established when  3 of these risk factors are present. † Abdominal obesity is more highly correlated with metabolic risk factors than is  BMI. ‡ Some men develop metabolic risk factors when circumference is only marginally increased. Waist circumference measured at iliac crest. <40 mg/dL or on meds <50 mg/dL or on meds Men Women >40 in >35 in Men Women  100 mg/dL or on meds Fasting glucose  130/  85 mm Hg or on meds Blood pressure HDL-C  150 mg/dL or on meds Triglycerides Abdominal obesity † (Waist circumference ‡ ) Defining Level Risk Factor
    5. 7. Country/Ethnic Values for Waist Circumference Defining Central Obesity, International Diabetes Federation <ul><li>Male Female </li></ul><ul><li>USA  102 cm (40”)  88 cm (35”) </li></ul><ul><li>Europids  94 (37”)  80 (31.5”) </li></ul><ul><li>South Asians  90 (35.5”)  80 (31.5”) </li></ul>
    6. 8. Atherogenic Dyslipidemia Risk of coronary heart disease Despres J-P. Dyslipidemia and obesity. Baillere’s Clin Endocrinal Metab. 1994;8-636
    7. 9. Underlying Causes of Metabolic Syndrome <ul><li>There are multiple underlying factors – </li></ul><ul><li>abdominal obesity* </li></ul><ul><li>insulin resistance* </li></ul><ul><li>physical inactivity </li></ul><ul><li>aging </li></ul><ul><li>genetic or ethnic predisposition </li></ul>
    8. 10. Post-prandial Dysmetabolism <ul><li>Inflammation plays a role in the development of chronic disease - heart disease, diabetes, dementia, and probably more </li></ul><ul><li>High calorie, easily digestible, quickly absorbable foods and drinks lead to exaggerated post-prandial spikes in glucose and lipids (triglycerides) </li></ul><ul><li>Exaggerated spikes in glucose and lipids generate excess free radicals and increase inflammation and endothelial dysfunction </li></ul><ul><li>Fasting glucose and triglyceride values may be normal, while post-meal values are high. </li></ul>
    9. 11. Effects of a beverage containing 75 gm glucose with 75 gm fat as whipping cream. Nitrotyrosine indicates oxidant stress, CRP indicates inflammation, FMD = Flow-mediated dilation. Ceriello et al, Circ 2005; 111:2518 Post Prandial Stress
    10. 12. Daily Activity Reduces Post-Prandial Glucose O’Keefe, et. al. JACC 2008; 51:249
    11. 13. Inflammation <ul><li>Triggers include </li></ul><ul><ul><li>oxidized LDLs in artery intima </li></ul></ul><ul><ul><li>low HDL levels (HDL inhibits inflammation) </li></ul></ul><ul><ul><li>hypertension (via angiotensin) </li></ul></ul><ul><ul><li>diabetes (via advance glycation end products) </li></ul></ul><ul><ul><li>obesity (adipose produces cytokines) </li></ul></ul><ul><ul><li>infection </li></ul></ul><ul><li>Testing? – HS (high sensitivity) C reactive protein </li></ul><ul><li>Anti-inflammatory diet? </li></ul><ul><ul><li>More omega-3 fats, less omega-6, more antioxidants in food </li></ul></ul><ul><li>Circulation. 2002; 105:1135-1143 </li></ul>
    12. 14. AHA Recommendations for Management of the Metabolic Syndrome <ul><li>Lifestyle First! </li></ul><ul><li>Reduce weight by 7-10% during first year. Continue weight loss to goal of BMI < 25. </li></ul><ul><li>30-60 minutes moderate intensity aerobic activity, preferably daily, supplemented by daily lifestyle activity. Resistance training 2x per week. </li></ul><ul><li>Saturated fat <7% of calories, dietary cholesterol <200 mg/day, total fat 25-35% of calories. Limit simple sugars. </li></ul><ul><li>Circulation 2005;112:2735-52 </li></ul>
    13. 15. Lifestyle Recommendations to: <ul><li>Reduce Triglycerides </li></ul><ul><li>Weight loss, exercise, total carbohydrate <60% of calories, limit alcohol </li></ul><ul><li>Increase HDL </li></ul><ul><li>Exercise, weight loss, smoking cessation, total carbohydrate <60% of calories </li></ul><ul><li>Reduce blood pressure </li></ul><ul><li>Weight loss, exercise, DASH diet, limit alcohol </li></ul><ul><li>Reduce blood sugar </li></ul><ul><li>Weight loss, exercise, consistent moderate carbohydrate </li></ul>
    14. 16. Carbohydrate and Triglycerides <ul><li>High carb diets can overwhelm normal metabolism, increase synthesis of fatty acids </li></ul><ul><li>Sugar, especially fructose, has greatest effect, but all carbohydrates matter </li></ul><ul><li>Goal <60% of calories from carbohydrate </li></ul><ul><ul><li>Fat intake should be 25-35% of calories. Cutting carbs may mean adding fat. </li></ul></ul><ul><li>Higher fiber diet can help minimize effects of carbohydrate </li></ul>
    15. 17. Effects of Lifestyle Modification to Manage Hypertension <ul><li> Approximate Reduction in </li></ul><ul><li>Modification Systolic BP, mmHg </li></ul><ul><li>Weight reduction 5-20 w/ 10-kg wt loss </li></ul><ul><li>DASH Diet 8-14 </li></ul><ul><li>2400 mg sodium/d 2-8 </li></ul><ul><li>Physical activity 4-9 </li></ul><ul><li>Moderate alcohol 2-4 </li></ul><ul><li>JNC 7, May 2003 </li></ul>
    16. 18. Dietary Approaches to Stop Hypertension (DASH and DASH-Sodium) <ul><li>Moderate sodium use (2400 mg per day or less) </li></ul><ul><li>Maintain a healthy weight </li></ul><ul><li>Increase intake of fruits and vegetables to 8-10 servings per day and include 2-3 servings of low-fat dairy products per day </li></ul><ul><li>Emphasize whole grains, poultry and fish, lean red meats, vegetarian proteins and some nuts </li></ul><ul><li>SBP decreased 11 mm Hg, DBP 6 mm Hg </li></ul><ul><li>NEJM 1997;336;1117-24 </li></ul>
    17. 19. Overall Lifestyle Recommendations for Metabolic Syndrome <ul><li>Exercise </li></ul><ul><li>Weight Loss </li></ul><ul><li>Total carbohydrate <60% of calories </li></ul><ul><li>DASH diet </li></ul><ul><li>Limit alcohol </li></ul><ul><li>Smoking cessation </li></ul>
    18. 20. The Continuum of Diets to Reduce CVD Risk <ul><li>Total Fat 30-40% 34% <30% <30% <10% </li></ul><ul><li>Sat Fat < 7% 11% <10% <7% -- </li></ul><ul><li>Cholesterol < 200 256 <300 <200 <5 mg </li></ul><ul><li>MUF 15-20% -- 10-15% 10-15% -- </li></ul><ul><li>PUF <10% -- <10% <10% -- </li></ul><ul><li>CHO 45-55% 50% 55-65% 55-65% 75% </li></ul><ul><li>      </li></ul><ul><li> “ Mediterranean” Current AHA AHA Ornish, </li></ul><ul><li> Average Step TLC Pritikin </li></ul><ul><li> American One </li></ul><ul><li> </li></ul><ul><li> </li></ul>
    19. 21. One Diet for All? <ul><li>Case # 1 </li></ul><ul><li>62 y.o. male </li></ul><ul><li>CAD </li></ul><ul><li>BMI - 24 </li></ul><ul><li>Waist circumference - 34” </li></ul><ul><li>Cholesterol - 285 </li></ul><ul><li>Triglycerides - 78 </li></ul><ul><li>HDL - 47 </li></ul><ul><li>LDL - 222 </li></ul><ul><li>Fasting Glucose – 87 </li></ul><ul><li> Saturated and trans fat </li></ul><ul><li> Soluble fiber </li></ul><ul><li>Add plant sterols </li></ul><ul><li>Case #2 </li></ul><ul><li>62 y.o. male </li></ul><ul><li>CAD </li></ul><ul><li>BMI - 31 </li></ul><ul><li>Waist circumference - 42” </li></ul><ul><li>Cholesterol - 217 </li></ul><ul><li>Triglycerides - 283 </li></ul><ul><li>HDL - 30 </li></ul><ul><li>LDL - 130 </li></ul><ul><li>Fasting Glucose – 122 </li></ul><ul><li>Control carbohydrates and calories </li></ul><ul><li> Saturated and trans fat </li></ul><ul><li> Soluble fiber </li></ul>
    20. 22. Copyright restrictions may apply. Gardner, C. D. et al. JAMA 2007;297:969-977. Which Diet Works?
    21. 23. Dansinger, JAMA 2005; 293:43-53 
    22. 25. Change From Baseline (%) P <0.001 LDL-C TG
    23. 26. Fish Sources of Omega-3 Fatty Acids <ul><li>Salmon, Atlantic, farmed, 3 oz 1.09-1.83 gm </li></ul><ul><li>Herring, Atlantic, 3 oz 1.71 </li></ul><ul><li>Sardines, canned, 3 oz 0.98-1.70 </li></ul><ul><li>M ackerel, Atlantic, 3 oz 0.34-1.57 </li></ul><ul><li>Salmon, Atlantic, wild, 3 oz 0.9-1.56 </li></ul><ul><li>Tuna, fresh, 3 oz 0.24-1.28 </li></ul><ul><li>Salmon, pink, 3 oz 1.09 </li></ul><ul><li>Rainbow trout, farmed, 3 oz 0.98 </li></ul><ul><li>Rainbow trout, wild, 3 oz 0.84 </li></ul><ul><li>Salmon, sockeye or chum, 3 oz 0.68 </li></ul><ul><li>Tuna, canned, white, 3 oz 0.73 </li></ul><ul><li>Tuna, canned, light, 3 oz 0.26 </li></ul><ul><li>Cod, Atlantic, 3 oz 0.24 </li></ul><ul><li>Catfish, wild, 3 oz 0.2 </li></ul><ul><li> Kris –Etherton. Circulation 2002; 106:2747 </li></ul>
    24. 27. Plant Sources of Omega-3 Fatty Acids, Per gram of fat <ul><li>Flax seed oil 0.66 </li></ul><ul><li>Fish body oil 0.3 </li></ul><ul><li>Cod liver oil 0.19 </li></ul><ul><li>Canola oil 0.12 </li></ul><ul><li>Walnuts 0.11 </li></ul><ul><li>Soybean oil 0.08 </li></ul>
    25. 28. Contains: 180 mg EPA 120 mg DHA Per capsule For more information: Fish Oil Supplements www.heartdecision.org
    26. 29. Facts about the Glycemic Index <ul><li>Defined as the area under the blood glucose curve for a test food, compared to the area under the curve for a carbohydrate equivalent amount of a reference food. </li></ul><ul><li>Starches higher in amylose (some varieties of barley and corn) are more resistant than those higher in amylopectin. </li></ul><ul><li>Food processing - gelatinization of starch increase GI (most breads and cereals), crystallization of starch reduces GI. </li></ul><ul><li>Organic acids (sourdough bread, fermentation of water-soluble fiber) reduce GI. </li></ul><ul><li>GI affected by fat, protein, and fiber in the current meal, content of previous meal. </li></ul>
    27. 30. Glycemic Index of Selected Foods <ul><li>Potatoes 80-100 Baked beans 48 </li></ul><ul><li>Corn flakes 84 Orange, Grapes 43 </li></ul><ul><li>Whole Wheat bread 72 Pumpernickel bread 41 </li></ul><ul><li>White bread 70 Apple 36 </li></ul><ul><li>Rice, brown and white 70 M & Ms, peanut 33 </li></ul><ul><li>Spaghetti, 20 min. 61 Yogurt with fruit 33 </li></ul><ul><li>Ice Cream 61 Spaghetti, 5 min. 34 </li></ul><ul><li>Basmati rice 60 Lentils 28 </li></ul><ul><li>Sweet potato 54 Peach 28 </li></ul><ul><li>Sourdough bread 54 Barley 25 </li></ul><ul><li>Banana 53 Soybeans 18 </li></ul><ul><li>Glucose = 100, 50 gram carbohydrate dose. AJCN 2002; 76:5-56. </li></ul>
    28. 31. Glycemic Index of Mixed Foods <ul><li>White rice 100 </li></ul><ul><li>with pickled cucumber 73 </li></ul><ul><li>with yogurt 72 </li></ul><ul><li>with fermented soy 68 </li></ul><ul><li>with whole milk 59 </li></ul><ul><li>with ice cream 57 </li></ul><ul><li>Sushi (rice, vinegar, sea algae) 67 </li></ul><ul><li>50 gm carbohydrate test food, European J Clin Nutr (2003) 57, 743-752. </li></ul>
    29. 32. Alcohol – What’s a serving? 12 oz beer 5 oz of wine 1.5 oz of 80 proof liquor Size of typical wine glass - 10-14 oz. Recommendations: No more than 2 drinks per day for men No more than 1 drink per day for women
    30. 33. Benefits of Nuts <ul><li>Low in saturated fat, good source of monounsaturated fat </li></ul><ul><li>No cholesterol </li></ul><ul><li>Convenient source of protein </li></ul><ul><li>Rich in the amino acid arginine, may improve vasodilation </li></ul><ul><li>Rich in Vitamin E, folic acid, copper, and magnesium </li></ul><ul><li>A handful, not a can full! </li></ul>
    31. 34. Nuts - Fat Content, 1 ounce <ul><li> Calories Total Sat. MUF PUF </li></ul><ul><li>Almonds, 24 170 14.5 1.5 10 3.0 </li></ul><ul><li>Brazil, 8 190 19 5.0 7.0 7.0 </li></ul><ul><li>Cashews, 18 160 13 2.5 8.0 2.5 </li></ul><ul><li>Filberts, 12 180 18 1.0 15.0 2.0 </li></ul><ul><li>Macadamia, 12 200 20 3.0 16.5 1.0 </li></ul><ul><li>Peanuts, 35 pcs 160 13.5 2.0 7.0 4.5 </li></ul><ul><li>Pecans, 15 hlvs. 190 19 2.0 12.0 5.0 </li></ul><ul><li>Pistachios, 47 160 14 2.0 9.5 2.0 </li></ul><ul><li>Walnuts, 14 hlvs. 180 17 2.0 4.0 11.0 </li></ul><ul><li>Soy nuts, 3 Tbsp 129 6 0.9 1.4 3.5 </li></ul>
    32. 35. Oxidative Stress <ul><li>An imbalance of pro-oxidants and antioxidants results in </li></ul><ul><ul><li>generation of reactive oxygen species (free radicals) </li></ul></ul><ul><ul><li>increased inflammation </li></ul></ul><ul><li>Pro-oxidants </li></ul><ul><ul><li>Saturated and trans fats </li></ul></ul><ul><ul><li>High glycemic index carbohydrates </li></ul></ul><ul><ul><li>Excessive alcohol intake </li></ul></ul>
    33. 36. Foods / Nutrients with Antioxidant Effects <ul><li>Omega-3 fatty acids </li></ul><ul><li>Dietary fiber </li></ul><ul><li>Moderate alcohol intake </li></ul><ul><li>Antioxidants from food </li></ul><ul><ul><li>Vitamin C </li></ul></ul><ul><ul><li>Vitamin E </li></ul></ul><ul><ul><li>Vitamin D? </li></ul></ul><ul><ul><li>Carotenoids </li></ul></ul><ul><ul><li>Selenium </li></ul></ul><ul><ul><li>Polyphenols (phytochemicals) </li></ul></ul>
    34. 37. Phytochemicals are measured in ORAC Units <ul><li>ORAC per 100 grams ORAC per calorie </li></ul><ul><li>Cloves, ground 125,549 389 </li></ul><ul><li>Turmeric, ground 15,679 44 </li></ul><ul><li>Dark Chocolate 13,120 22 </li></ul><ul><li>Milk Chocolate 6740 13 </li></ul><ul><li>Prunes 5770 24 </li></ul><ul><li>Pomegranate 3307 40 </li></ul><ul><li>Raisins 2830 9 </li></ul><ul><li>Blueberries 2400 43 </li></ul><ul><li>Blackberries 2036 47 </li></ul><ul><li>Kale 1770 35 </li></ul><ul><li>Strawberries 1540 48 </li></ul><ul><li>Spinach 1260 55 </li></ul><ul><li>Raspberries 1220 24 </li></ul>ORAC = Oxygen Radical Absorbance Capacity, AJCN 2006;84:95.
    35. 38. To Minimize Post-Prandial Dysmetabolism <ul><li>Minimally processed, high-fiber, plant-based foods (whole grains, vegetables, fruits, nuts, legumes) </li></ul><ul><li>Lean protein, fish </li></ul><ul><li>Moderate calorie intake </li></ul><ul><li>Regular physical activity </li></ul>
    36. 39. Sample Mediterranean Menu <ul><li>B - Cooked cracked wheat cereal with walnuts </li></ul><ul><li> and yogurt Melon </li></ul><ul><li>Snack - Orange 2 handfuls sunflower seeds </li></ul><ul><li>L - Lentil spinach soup Tomato cucumber salad </li></ul><ul><li>Whole Wheat bread with olive oil </li></ul><ul><li>Snack - 2 oz Camembert cheese 1 mango </li></ul><ul><li>D - Spaghetti w/ tomato, peppers, Parmesan, mussels, and olive oil, </li></ul><ul><li> Lettuce salad with V and O dressing </li></ul><ul><li>Baked figs Red wine </li></ul>
    37. 40. DASH - Sample Menu (2000 calories) <ul><li>Breakfast Dinner </li></ul><ul><li>Orange Juice Baked cod </li></ul><ul><li>Oatmeal, 1 t. sugar Rice pilaf </li></ul><ul><li>1 c. 1% milk 1/2 c. broccoli </li></ul><ul><li>Banana 1/2 c. stewed tomatoes </li></ul><ul><li>WW toast, soft margarine 1 c. green salad w/ dressing Dinner roll, soft margarine </li></ul><ul><li>Lunch Melon </li></ul><ul><li>Chicken salad, pita half </li></ul><ul><li>Part-skim Farmer’s cheese Snack </li></ul><ul><li>Lettuce leaves 1/4 c. dried apricots </li></ul><ul><li>Raw carrots, celery 1/3 c. mixed nuts </li></ul><ul><li>1 c. 1% milk 3/4 c. pretzel sticks </li></ul><ul><li>Canned fruit </li></ul>
    38. 42. Resources <ul><li>American Institute for Cancer Research - Veggies </li></ul><ul><li>http://www.aicr.org/site/PageServer?pagename=pub_new_amer_plate_veg </li></ul><ul><li>DASH diet </li></ul><ul><li>http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/index.htm </li></ul><ul><li>MyPyramid from USDA </li></ul><ul><li>http:// www.mypyramid.gov </li></ul><ul><li>National Heart Lung and Blood Institute publications </li></ul><ul><li>http:// www.nhlbi.nih.gov/health/index.htm </li></ul>
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