Best Dx/Best Rx: Diet and Exercise

From: Subject: Best Dx/Best Rx: Diet and Exercise Date: Wed, 3 Jun 2009 21:49:10 -0700 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_025B_01C9E495.205BFFD0" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.5579 This is a multi-part message in MIME format. ------=_NextPart_000_025B_01C9E495.205BFFD0 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.acpmedicine.com/acp/newrxdx/rxdx/dxrx0004.htm Best Dx/Best Rx: Diet and Exercise

Diet and = Exercise=20

Harvey B. Simon, M.D., F.A.C.S. Harvard = Medical=20 School

Dieta= ry=20 Recommendations
Vitam= ins
Essen= tial=20 Minerals and Trace Elements
Exerc= ise
Best = References=20

Dietary=20 Recommendations

General = Dietary=20 Guidelines for Healthy Adults

Eat more vegetable products than animal = products=20
Eat more fresh and homemade foods than = processed=20 foods=20
< 30% of calories should come from fat, = < 10% from=20 saturated fat (< 7% for those with atherosclerosis, diabetes,=20 hyperlipidemia, or obesity), and the remainder from unsaturated fat in = vegetables, fish, legumes, and nuts=20
Limit cholesterol to < 300 mg a day (< = 200 mg for=20 those with atherosclerosis, diabetes, hyperlipidemia, or obesity) =
Eat ≥ 30 g of fiber a day=20
55%=9665% of calories should come from complex = carbohydrates=20
10%=9615% of calories should come from = protein=20
Limit sodium to < 2,300 mg a day=20
Obtain 1,200=961,500 mg of calcium a day from = food or=20 supplement=20
Eat ≥ 6 servings of grain products a = day=20
Eat 3=965 servings of vegetables and legumes a = day=20
Eat 2=964 servings of fruit a day=20
Eat two 4 oz servings of fish a week=20
Eat ≤ two 4 oz servings of red meat a = week=20
Chicken and turkey should be eaten in = moderation with=20 skin removed=20
Eat ≤ 1 egg yolk a day, including those = used in cooking=20 and baking=20
Use vegetable oils, preferably olive and = canola oils, in=20 moderation=20
Have ≤ 2 alcoholic drinks a day=20
Adjust caloric intake and exercise level to = maintain a=20 desirable body weight=20
Avoid fad diets and extreme or unconventional = nutrition=20 schemes=20
Avoid untested nutritional supplements, = including=20 megavitamins, herbs, food extracts, and amino acids =

Alcohol=20

Calorie-dense=20
Low to moderate consumption substantially = reduces the=20 risk of coronary artery disease, peripheral vascular disease, and = all-cause=20 mortality=20
Protective doses: 1=962 drinks a day (5 oz of = wine, 12 oz=20 of beer, or 1.5 oz of spirits is the equivalent of one drink)=20

Caffeine=20

Can trigger migraines in sensitive = individuals=20
Withdrawal can precipitate headaches or = depression in=20 habitual consumers=20
Can cause anxiety, insomnia, and = gastroesophageal=20 reflux=20
Brewed coffee may increase blood cholesterol = levels, but=20 filtered coffee does not=20
Consumption should be discouraged in = pregnancy=20

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Vitamins=20

Sources and Recommended Daily Allowances for = Nonpregnant=20 Adults=20

A (retinol, retinoic acid)=20
- Liver, dairy products, eggs; dark-green and=20 yellow-orange vegetables (carotenoids)=20
- Men, 3,000 IU or 900 =B5g; women, 2,333 IU = or 700 =B5g=20
B₁ (thiamine)=20
- Grains, legumes, nuts, poultry, meat=20
- Men, 1.2 mg; women, 1.1 mg
B₂ (riboflavin)=20
- Grains, dairy products, meat, eggs, = dark-green=20 vegetables=20
- Men, 1.3 mg; women, 1.1 mg
B₃ (niacin, nicotinic acid)=20
- Meat, poultry, fish, grains, peanuts; = synthesized from=20 tryptophan in foods=20
- Men, 16 mg; women, 14 mg
B₆ (pyridoxine)=20
- Meat, poultry, fish, grains, soybeans, = bananas,=20 nuts=20
- Men: 19=9650 yr, 1.3 mg; 50 yr and older, = 1.7 mg=20
- Women: 19=9650 yr, 1.3 mg; 50 yr and older, = 1.5=20 mg
B₁₂ (cobalamin)=20
- Meat (especially liver), poultry, fish, = dairy=20 products=20
- 2.4 =B5g
Folic acid=20
- Vegetables, legumes, grains, fruit, poultry, = meat=20
- 400 =B5g
Biotin=20
- Many foods=20
- 30 =B5g
Pantothenic acid=20
- Many foods=20
- 5 mg
C (ascorbic acid)=20
- Fruits, green vegetables, potatoes, = cereals=20
- Men, 90 mg; women, 75 mg
D (calciferol)=20
- Fortified dairy products, fatty fish, egg = yolks,=20 liver=20
- < 50 yr, 200 IU; 50=9670 yr, 400 IU; > = 70 yr, 600=20 IU
E (a-tocopherol)=20
- Vegetable oils, wheat germ, nuts, = broccoli=20
- 15 mg
K=20
- Leafy green vegetables (K₁), = intestinal=20 bacteria (K₂)=20
- Men, 120 =B5g; women, 90 =B5g =

Supplements=20

Women of childbearing age, the elderly, and = people with=20 suboptimal nutrition should take a single multivitamin tablet = daily=20
Strict vegetarians and those > 60 yr should = take the=20 RDA of vitamin B₁₂
Multivitamin supplements can avert vitamin D=20 deficiencies, particularly in the elderly=20
Antioxidants with zinc can slow the = progression of=20 age-related macular degeneration=20
Discourage use of megadose vitamins=20

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Essential = Minerals and=20 Trace Elements

RDA for Healthy Adults=20

Macrominerals=20

Sodium: no RDA; recommended daily maximum = amounts:=20
- AHA: 2,400 mg=20
- Dietary Guidelines for Americans 2005: 2,300 = mg=20
- Institute of Medicine: 1,500 mg
- Substantially lower intake may be beneficial = in=20 hypertension, congestive heart failure, cirrhosis, nephrotic = syndrome,=20 etc.
Calcium=20
- < 50 yr, 1,000 mg=20
- ≥ 50 yr, 1,200 mg
Phosphorus: 700 mg=20
Magnesium=20
- Men, 350 mg; women, 280 mg
Potassium: 1,700=965,100 mg =

Trace Elements=20

Iron=20
- Men and postmenopausal women, 8 mg=20
- Premenopausal women, 18 mg=20
- Pregnant women, 27 mg
Chromium=20
- Men: 19=9650 yr, 35 =B5g; ≥ 50 yr, 30 = =B5g=20
- Women: 19=9650 yr, 25 =B5g; ≥ 50 yr, = 20 =B5g
Copper: 900 =B5g=20
Fluoride=20
- Men, 4 mg; women, 3 mg
Iodine: 150 =B5g=20
Manganese=20
- Men, 2.3 mg; women, 1.8 mg
Molybdenum: 45 =B5g=20
Selenium: 55 =B5g=20
Zinc=20
- Men, 11 mg; women, 8 mg
Cobalt: required in small amounts as a = component of=20 vitamin B₁₂

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Exercise

Effects=20

Protective effects against coronary artery = disease,=20 hypertension, stroke, type 2 diabetes mellitus, obesity, anxiety, = depression,=20 osteoporosis, and cancers of the colon and breast=20
Increases insulin sensitivity of muscle =
Improves glucose tolerance in diabetic = patients=20
Increases serum levels of HDL cholesterol =
Reduces blood levels of C-reactive protein and = other=20 inflammatory markers=20
Endurance exercise produces improvements in = mood,=20 self-esteem, and work behavior in healthy people and in patients = undertaking=20 cardiac rehabilitation=20
Increases functional status and decreases = mortality in=20 the elderly

Isotonic = Excercise=20

Shortening of muscle fibers with little = increase in=20 tension (swimming, bicycling, running)=20
Increases muscle endurance=20
Lowers total peripheral resistance, but heart = rate and=20 cardiac output rise; systolic blood pressure rises substantially, = diastolic=20 pressure changes little, resulting in a small increase in mean = arterial=20 pressure=20
Imposes a volume load on the heart=20
Enhances endurance and can produce adaptive=20 cardiovascular changes in healthy individuals and cardiac = patients=20

Isometric Exercise=20

Increase in muscle tension without a = significant change=20 in fiber length (handgrip exercises, pushing or pulling against a = fixed=20 resistance, holding a heavy weight)=20
Increases total peripheral resistance; = systolic and=20 diastolic blood pressure rise substantially, with relatively little = increase=20 in stroke volume or cardiac output=20
Places a pressure load on the heart=20
Increases muscle strength and bulk=20
Produces minimal cardiovascular conditioning;=20 circulatory demands of intense isometric work can be hazardous to = patients=20 with heart disease=20
Unsupervised isometric exercising should be = avoided by=20 patients with cardiovascular disease; with appropriate precautions, it = can be=20 safe for selected cardiac patients and can produce favorable effects = on=20 muscular function and blood pressure

Preexercise Evaluation=20

Careful history and physical exam with = particular=20 attention to the following:=20
- Family history of coronary disease, = hypertension,=20 stroke, or sudden death=20
- Symptoms suggestive of cardiovascular = disease=20
- Cigarette smoking, sedentary living, = hypertension,=20 diabetes, obesity=20
- Physical findings suggestive of pulmonary, = cardiac, or=20 peripheral vascular disease=20
- Musculoskeletal health
Screening tests for apparently healthy=20 individuals=20
- Complete blood count=20
- Urinalysis=20
- Blood glucose level=20
- Serum cholesterol level=20
- Creatinine level=20
- Valsalva maneuver=20
- Isometric handgrip=20
- ECG not required for asymptomatic, low-risk=20 patients=20
- Exercise testing useful for detecting = exercise-induced=20 arrhythmias, establishing maximal heart rate for exercise = prescription, and=20 determining work capacity
Evaluation of patients with known or suspected = cardiovascular abnormalities=20
- Pulmonary function tests=20
- Exercise ergometry=20
- Holter or telemetric monitoring during = exercise=20
- Echocardiography =

Exercise Advice for Patients=20

Get a medical check-up before beginning a = formal=20 exercise program=20
Warm up before each exercise session; cool = down=20 afterward with 10 min of stretching and light calisthenics=20
Start slowly and build up to 30 min of = moderate to=20 intense exercise or 45=9660 min of mild to moderate exercise=20
Begin with aerobic-type exercise; later, add = stretching=20 exercises for flexibility and low-resistance weight training for=20 strength=20
Exercise daily if possible; alternate harder = workouts=20 with easier ones=20
Dress comfortably=20
Use good equipment, especially good = shoes=20
Do not eat during the 2 hr before you = exercise, but=20 drink plenty of water before, during, and after exercise, particularly = in=20 warmer weather=20
Do not ignore aches and pains that may signify = injury=20
Do not exercise if you are feverish or = ill=20
Learn warning signals of heart disease, = including chest=20 pain or pressure, disproportionate shortness of breath, fatigue, = sweating,=20 erratic pulse, light-headedness, indigestion=20
Consider getting instruction or joining a = health=20 club

Prescribing = Exercise=20

Healthy persons=20
- Exercise without supervision =
Patients with ischemic heart disease or other=20 significant cardiovascular abnormalities=20
- Medically supervised, graded exercise = programs or mild=20 exercise=20
  - Walking, bicycling, with appropriate=20 precautions
Physical exertion contraindicated for patients = with the=20 following conditions:=20
- Decompensated congestive heart = failure=20
- Complex ventricular irritability=20
- Unstable angina=20
- Significant aortic valve disease=20
- Aortic aneurysm=20
- Uncontrolled diabetes=20
- Uncontrolled seizure disorders =
Most health benefits of regular exercise can = be attained=20 by 30=9645 min daily of moderate exercise at intensities well below = the=20 aerobic-intensity level (gardening, walking)=20
Aerobic fitness can be developed and = maintained in=20 healthy adults with 3=965 exercise sessions a week=20
Sedentary persons and those with = cardiopulmonary disease=20 must initiate training at lower intensities and shorter durations and = build up=20 gradually=20
Brisk walking, jogging, swimming, = cross-country skiing,=20 skating, bicycling, vigorous singles racket sports provide good=20 conditioning=20
Doubles tennis, golf, bowling, baseball are = much less=20 desirable for aerobic fitness but can still make important = contributions to=20 health=20
Activities requiring sudden bursts of intense = isometric=20 activity, such as weight lifting, provide little cardiovascular = conditioning=20 and are contraindicated for patients with hypertension or heart = disease=20
Contact sports cannot be recommended for = health=20
Swimming is particularly desirable for = patients with=20 musculoskeletal problems or exercise-induced asthma=20
Walking and bicycling are ideal for older = people or=20 those starting from a low level of fitness=20
Educate patients about safety=20

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Best References

American Heart Association:

Dietary Guidelines for Healthy Americans:

http://www.americanheart.org/presenter.jhtml?identifier=3D4= 561=20

AHA Dietary Guidelines: http://circ.ahajournals.org/cgi/content/full/102/18/2284=20

Exercise and Fitness: http://www.americanheart.org/presenter.jhtml?identifier=3D3= 004541=20

HHS/USDA Dietary Guidelines for Americans: = http://www.healthierus.gov/dietaryguidelines

Institute of Medicine, Dietary Reference Intakes: = Applications in=20 Dietary Planning: http://www.iom.edu/CMS/3788/4003/4733.aspx=20

May=20 2006