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Fitness

A brief literature review completed in the spring of 2016, P Callahan.

A short "Hero's Journey" to perhaps make the idea of fitness a more memorable experience.

The definition of fitness has evolved as we have evolved from hunter-gatherers to a highly industrialized society. By the mid-twentieth century the definition of fitness had advanced from individuals who “judged by accomplishments, are fit to carry on their jobs,” to include the supportive qualities of personality to complete the task without undue fatigue or exhaustion.1,2

Fitness, specifically physical fitness, brought focus to guidelines and measurement of proficiency. Fitness expanded beyond the workplace to consider leisure time.3,4 Greater recognition of the measurement and the scope of fitness encouraged educational focus and clarification of definition. Physical activity was defined as any bodily movement produced by skeletal muscles resulting in the expenditure of energy as measured in kilocalories (Cal). This physical activity could be further categorized into, for example, occupational, sports, conditioning, household, or other activities. Exercise was now defined as the physical activity that is planned, structured, and repetitive with the objective of maintaining or improving physical fitness.5,6

The concept of physical fitness emerged as both health and skill-related as characterized by the ability to perform daily activities with vigor with the benefit of lowering the risk of those conditions associated with physical inactivity.7 Health-related physical activity shows more desirable health outcomes across a variety of physical conditions. In general, exercise and physical activity are associated with better quality of life and health outcomes.8 Conversely, physical inactivity is one of the most decisive risk factors for cardiovascular disease (CVD) prevalence and mortality in adults.9

A brief look across lifespan argues for the importance of physical activity. And, one of the best strategies for improving the longterm health is to live healthy from an early life. Exposing children to the enjoyment of physical exercise and creating a pattern of regular physical activity is more desirable than simply promoting childhood physical fitness.10 Active children are generally leaner, have higher peak bone masses, and display healthier cardiovascular profiles. There is also a carryover effect into adulthood with improved health and the likelihood of continuing as a more active adult.11

A twenty-one country analysis of university students showed that regular physical exercise was consistent with a healthy lifestyle and emotional well-being.12 Similarly, in a survey of over 175 000 adults, the proportion of adults reporting fourteen or more unhealthy physical or mental days was lower among those who attained moderate levels of physical activity than physically inactive adults for all age, ethnic, and sex groups.13,14

Even in sedentary older adults, fitness training is found to have benefits for cognition, with the largest benefits occurring for executive-control processes, such as coordination, inhibition, scheduling, planning, and working memory.15,16 There are arguments that regular exercise is associated with a lower risk for dementia.17 Both dietary and exercise modification seem to be strong promoters of healthy aging.18 Physical exercise leads to improved mood, self-concept, self-esteem, and work behavior. It also appears to improve social skills and cognitive functioning.19,20 The evidence suggests that physical activity and exercise probably alleviate some symptoms associated with mild to moderate depression and reduce the symptoms of anxiety and physiological response to stressors.21 Though, excessive physical activity may lead to overtraining and generate psychological symptoms that mimic depression.22

In contrast to depression, emotional well-being is the subjective state of wellness, happiness, and life satisfaction.23 Well-being might be defined as a positive evaluation of one’s life to include positive emotion, engagement, satisfaction, and meaning.24 Quality of life (QOL) is a broad multidimensional concept that usually includes subjective evaluations of both positive and negative aspects of life that extend the definition of quality of health.25 Health-related quality of life (HRQOL) includes aspects of life that affect perceived physical or mental health. Emotional well-being is a primary component of HRQOL and may be independently associated with the incidence of morbidity, or disease, and mortality.26 A growing body of research supports physical exercise as a lifestyle factor that might lead to increased physical and mental health throughout life.27,28 The recommendation by the World Health Organization (WHO) is that adults 18–64 years should do about 150 minutes of moderate-intensity aerobic physical activity throughout the week, or do 75 minutes of vigorous-intensity aerobic physical activity throughout the week.29 Much of the research appears to support the notion of 30 minutes of moderate leisure time physical activity per day on a regular basis may be beneficial on HRQOL. Higher intensity leisure time physical activity is associated with greater HRQOL.30,31

Good nutrition promotes Health-Related Quality of Life (HRQOL) by averting malnutrition, preventing dietary deficiency disease and promoting optimal functioning.32 Though it may seem obvious, it is important to recognize that food security is considered an important risk factor for child health.33 At the opposite end of the age range, older adults are at risk for poor nutrition and frequently experience declining health related quality of life. Nutritional risk along with social support appear to be significant factors associated with HRQOL.34

There appear to be core aspects of a healthy diet that may lower the risk of mortality outcomes for both men and women. These programs include a diet associated with the Healthy Eating Index of 2010 (HEI-2010).35 The Healthy Eating Index (HEI) is a measure of diet quality in terms of conformance with federal dietary guidance. The HEI-2010 captures the key recommendations of the 2010 Dietary Guidelines and, like earlier versions, is used to assess the quality of a given dietary pattern, set of foods, or menu.36 An index, such as HEI-2010, allows measurement relative to the established index criteria and an associated diet forming the basis for meaningful research. Young women whose diets most closely meet the 2010 Dietary Guidelines for Americans, for example, showed lower adiposity.37

Another healthy diet, Harvard’s Healthy Eating Plate, is associated with the Alternative Healthy Eating Index of 2010 (AHEI-2010). Similarly, a Mediterranean diet associated with the Alternate Mediterranean Diet or aMED, and the DASH Eating Plan, associated with the DASH score, lower the risk of mortality. These diets tend to support whole grains, vegetables, fruit, and plant-based proteins.38,39 Other dietary research suggests that high intakes of fruit, vegetables, fish, and whole grains may be associated with a reduced depression risk.40

Currently, in the United States, the U.S. Department of Health and Human Services has forwarded the Healthy People (HP) initiative that provides science-based, 10-year national objectives for improving health. The current HP2020 iteration measures progress toward target attainment of over one thousand health-related objectives and the elimination of health disparities. Specifically, HP2020 seeks to attain longer lives, achieve health equity, create social and physical environments that promote good health, and promote quality of life, healthy development, and healthy behaviors across all life stages.41,42

Process of Fitness

Arguably one of the earliest and more meaningful definitions of fitness might be captured in the statement “run for your life” as having the personal resources to be able to escape danger. Run for your life can also have a different meaning as in promoting physical and other activities to improve the sustainment and quality of life, or the lifelong run for wellness.

Wellness is often defined as a process of learning new life skills and making conscious choices to improve health and quality of life, prolong life, and achieve total well-being. The World Health Organization (WHO) describes these lifestyle changes as occurring across seven dimensions: social, physical, emotional, career, intellectual, environmental, and spiritual.43,44

Exercise

Physical wellness is the process of making choices to create strong bodies with consideration of exercise, nutrition, rest and sleep, responsible sexual choices, and management of stress, injury and illness.45 An essential aspect of physical wellness is that of exercise. A foundational physical fitness plan might begin with consideration of the 2008 Physical Activity Guidelines for Americans. The associated research on the benefits of physical activity is summarized in the following.46

• Regular physical activity reduces the risk of many adverse health outcomes.
• Some physical activity is better than none.
• For most health outcomes, additional benefits occur as the amount of physical activity increases through higher intensity, greater frequency, and/or longer duration as brisk walking. Additional benefits occur with more physical activity.
• Both aerobic (endurance) and muscle-strengthening (resistance) physical activity are beneficial.
• Health benefits occur for children and adolescents, young and middle-aged adults, and older adults although the exercise process may differ between groups.
• The health benefits of physical activity occur for people with disabilities.
• The benefits of physical activity far outweigh the possibility of adverse outcomes.

The basis of the Physical Activity Guidelines for Americans program is aerobic physical activity whereby adults do 2 hours and 30 minutes a week of moderate-intensity, or 1 hour and 15 minutes (75 minutes) a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic physical activity. Aerobic activity is performed in episodes of at least 10 minutes, preferably spread throughout the week. Additional health benefits may be provided by increasing activity to 5 hours a week of moderate-intensity aerobic physical activity, or 2 hours and 30 minutes a week of vigorous-intensity physical activity, or an equivalent combination of both. Muscle-strengthening activities, that involve all major muscle groups, on two or more days per week, is encouraged.

As much as possible, older adults (65 and older) should adhere to the 2 hours and 30 minutes a week of moderate-intensity aerobic physical activity. If chronic conditions exist, then the adult should be as physically active as abilities and conditions allow. Find a level of effort based on understanding of how personal chronic conditions affect ability. Certainly, consider exercises that maintain or improve balance for risk of falling.

Children and adolescents, aged 6 to 17, should exercise 60 or more minutes a day performing moderate- or vigorous-intensity aerobic physical activity, with vigorous-intensity physical activity at least 3 days a week. A part of daily physical activity should include muscle-strengthening on at least 3 days of the week. For example, unstructured exercises, such as playing on playground equipment, climbing trees, and playing tug-of-war. Or structured, such as lifting weights or working with resistance bands. Additionally, part of the daily physical activity should include bone-strengthening on at least 3 days of the week. Common bone-strengthening impact activities include running, jumping rope, basketball, tennis, and hopscotch.47

How does one translate the guidelines into a meaningful exercise program? One method might be to consider your general intentions, preferences and limitations.48

• What are your goals -- Are your interests health, fitness, or performance related?
• What do you enjoy -- Do you prefer team or solitary activities?
• What are your time limits -- How much time can you devote?
• What gear do you need -- What is your budget?

How do we better define these guidelines into something more specific and measurable? We can numerically evaluate just how much activity is occurring across the course of a week. The metabolic equivalent of task (MET), or metabolic equivalent, is a physiological measure describing the energy used for physical activity. More specifically, the MET is the ratio of the rate of energy (calories) expended during an activity to the rate of energy expended at rest. One MET is the energy equivalent expended by an individual while at rest. A 3 MET activity, for example, expends 3 times the energy used by the body at rest. If you were to do an activity of 3 METs intensity for 20 minutes, you would have done 3 × 20 = 60 MET-minutes of physical activity. A range from 500 to 1,000 MET-minutes per week is considered the amount of physical activity necessary to produce health benefits. But, recognize that the higher the minutes the more beneficial the effect.49

Thus, the specific intensity of an aerobic exercise factors into the calculation.

• Light-intensity activities are defined as 1.1 MET to 2.9 METs.
• Moderate-intensity activities are defined as 3.0 to 5.9 METs. For example, walking at 3.0 miles per hour requires 3.3 METs of energy expenditure and is therefore considered a moderate-intensity activity.
• Vigorous-intensity activities are defined as 6.0 METs or more. For example, running at 10 minutes per mile is a 10 MET activity and is therefore classified as vigorous intensity.

There are associated MET values for particular exercises. Some common MET values are 2.5 for gardening, 3.5 for moderate pace walking, 6.0 for swimming, 7.0 for jogging, and 7.5 for general bicycling. You are encouraged to search the extensive Compendium of Physical Activities online to find the MET value for a number of different activities as well as more detailed information on variations of exercises.50

Beyond MET value though, you may be interested in the number of calories you are burning. To convert your body weight from pounds to kilograms divide by 2.2.

(MET value x 3.5 x weight in kg)/200 = calories burned per minute.

For example, consider a 150 lb. (68 kg) person who runs for 30 minutes at a 6 mph pace (10 METs).

(10 mets x 3.5 x 68 kg)/200 = 2380/200 = 11.9 calories burned per minute 11.9 x 30 min = 357 calories burned per 30 minute run.

For health benefits for most adults, the national guidelines suggest burning 1,000 Calories per week. For weight loss and even greater health benefits an expenditure of 2,000 Calories per week is suggested.51

Need some motivation? Some research suggests we can calculate our “fitness age” based on our peak oxygen intake (V02). V02 is correlated to life span. V02 and fitness age can be calculated without a treadmill by using several measurements that include: waist size, resting heart rate, age, sex, and frequency and intensity of exercise.52 An online calculator to determine fitness age can be found at the Norwegian University of Science and Technology, NTNU CERG Fitness Calculator.53

Nutrition

Another aspect of physical wellness is that of nutrition. A foundational dietary plan might begin with a look at several diets that may lower the risk of mortality.54.

HEI-2010 and the 2015-2020 Dietary Guidelines for Americans

A diet adhering to HEI-2010 captures the key recommendations of the 2010 Dietary Guidelines and can be used to assess the quality of a menu. The 2015-2020 Dietary Guidelines for Americans is a revision to the 2010 guidelines and reflects research that demonstrates eating patterns and physical activity can help people achieve and maintain good health and reduce the risk of chronic disease throughout the lifespan. Several terms used throughout the 2015-2020 Dietary Guidelines provide an orientation to the guidelines. A dietary pattern or eating pattern describes a customary way of eating or a combination of foods recommended for consumption. Nutrient dense describes foods and beverages that provide vitamins, minerals, and other substances that contribute to adequate nutrient intakes or may have positive health effects, with little or no solid fats and added sugars, refined starches, and sodium. This includes all vegetables, fruits, whole grains, seafood, eggs, beans and peas, unsalted nuts and seeds, fat-free and low-fat dairy products, and lean meats and poultry. Variety describes an assortment of foods and beverages across and within all food groups and subgroups selected to fulfill the recommended amounts without exceeding the limits for calories and other dietary components. The term shift is used to emphasize the need to make substitutions, that is, choose nutrient-dense foods and beverages in place of less healthy choices rather than increasing the overall intake. This focus on shifts in eating patterns is intended to align current dietary intake with recommendations and highlight multiple strategies across all segments of society to promote healthy eating and physical activity behaviors.55, 56 There are five guidelines.

• Follow a healthy eating pattern across the lifespan. Choose a healthy eating pattern at an appropriate calorie level to help achieve and maintain a healthy body weight, support nutrient adequacy, and reduce the risk of chronic disease.
• Focus on variety, nutrient density, and amount. Choose a variety of nutrient-dense foods across and within all food groups in recommended amounts.
• Shift to healthier food and beverage choices. Choose nutrient-dense foods and beverages across and within all food groups in place of less healthy choices. Consider cultural and personal preferences to make these shifts easier to accomplish and maintain.
• Support healthy eating patterns for all. Everyone has a role in helping to create and support healthy eating patterns. These social determinants of health and the economics of public health and prevention are similarly echoed in a global manner by the World Health Organization.57

Additionally, the following 2015-2020 Dietary Guidelines recommendations for healthy eating patterns should be applied in their entirety due to the interconnected relationship of each dietary component.

• Consume a healthy eating pattern that accounts for all foods and beverages within an appropriate calorie level.
• A healthy eating pattern includes: a variety of vegetables from all of the subgroups—dark green, red and orange, legumes (beans and peas), starchy, and other; fruits, especially whole fruits; grains, at least half of which are whole grains; fat-free or low-fat dairy, including milk, yogurt, cheese, and/or fortified soy beverages; a variety of protein foods, including seafood, lean meats and poultry, eggs, legumes, and nuts, seeds, and soy products; and oils.
• A healthy eating pattern limits saturated fats and trans fats, added sugars, and sodium.

There are recommended numerical limits in calories to help individuals achieve healthy eating patterns based on their desired weight and lifestyle. These include consuming less than 10 percent of calories per day from added sugars, less than 10 percent of calories per day from saturated fats, less than 2,300 milligrams (mg) per day of sodium, and if alcohol is consumed, it should be consumed in moderation of one drink per day for females and two for males.

So where does one begin constructing a healthy diet in accord with these guidelines? While the entire guidelines are downloadable, these guidelines can be implemented on such online tools as My Plate (MyPlate) which provides the opportunity to establish personal baseline measures, create a healthy diet, and track fitness related results.58 A basic 2000 Calorie daily menu might look like the following derived from Supertracker.59

• Breakfast
  • 1 ounce(s) Grains
  • ½ cup Fruits
  • ½ cup( Dairy
• Morning Snack
  • 1 ounce(s) Grains
  • ½ cup Fruits
• Lunch
  • 2 ounce(s) Grains
  • 1 cup Vegetables
  • ½ cup Fruits
  • 2½ ounce(s) Protein Food
  • 1 cup Dairy
• Afternoon Snack
  • ½ cup Vegetables
  • ½ cup Dairy
• Dinner
  • 2 ounce(s) Grains
  • 1 cup Vegetables
  • 3 ounce(s) Protein Food
  • 1 cup Dairy

The menu presumes a 2000 Calorie daily plan. Based on variables such as activity, gender, age, height, and weight, an individual can calculate the appropriate baseline caloric intake for more accurately determining meal and snack quantities. We want to regulate the total amount of energy, which the body receives through food intake, and balance this with the total amount of energy that the body expends. Food energy comes into the body in the form of solids and fluids. The body expends energy through its process of maintaining life, its digestion and absorption of food, and through physical activity. Overall, we are seeking an energy balance, where energy balance is the difference between the number of Calories (1000 calories = 1 kilocalories = 1 kcal = 1 Calorie) you eat (intake) and the number of Calories you burn (output). The term Calorie generally refers to the kilogram calorie. The convention of using the capital C for the kilogram calorie and the lower case c for the gram calorie is advocated by some, but is not universally followed.

For men, the following calculation can be used to obtain your Basal Metabolic Rate (BMR) in kcal/day.
66 + (6.23 x weight in pounds) + (12.7 x height in inches) - (6.8 x age in years) or
66 + (13.75 x weight in kg) + (5 x height in cm) - (6.8 x age in years)
For example, a 27-year-old who is 5’11” (71”) tall and weighs 190 lbs.
66 + (6.23 x 190) + (12.7 x 71) – (6.8 x 27) =
66 + 1184 + 902 – 184 = 1,968

For women, the following calculation can be used to approximate the BMR.
655 + (4.35 x weight in pounds) + (4.7 x height in inches) - (4.7 x age in years) or
655 + (9.56 x weight in kilos) + (1.8 x height in cm) - (4.7 x age in years)
For example, a 27-year-old who is 5’ 4” (64”) tall and weighs 120 lbs.
655 + (4.35 x 120) + (4.7 x 64) – (4.7 x 27) =
655 + 522 + 301 – 127 = 1,351

Once the BMR is determined, an activity estimate is identified.
Very Light Seated, standing, driving, computer work 1.2
Light Walking, light stretching, woodworking 1.4
Moderate Jogging, dancing, swimming, biking 1.6
Strenuous Running, soccer, rowing, digging, carrying 1.9

The Harris-Benedict equation can be used to estimate the daily caloric requirement by multiplying the BMR times the Activity Factor. The obtained value indicates your energy needs or Estimated Energy Requirement (EER) with the number of Calories of energy you need per day in order to meet your expected body needs.

EER = BMR x Activity Factor
For example, consider again the 27-year-old male who is 5’11” tall and weighs 190 lbs., his BMR is determined to be 1968 Cal. and we will assume his Activity Factor is 1.4. Thus, his EER is 1968 x 1.4 or 2755 Cal/day.

Another useful baseline measure is to obtain an approximation of one’s body composition. The Body Mass Index (BMI) provides an estimate of whether one’s weight is in accord with one’s height. BMI has often been associated with stress related research. Those with a very low BMI tend to lose weight when stressed and, conversely, those with a high BMI tend to gain weight when stressed.60,61 Work-related stress should also be taken into account as having potential impact on weight gain and loss.62 Metabolic Syndrome is the name for a group of risk factors that raises the likelihood for heart disease and other health problems, such as cancer and diabetes. Characteristics of the metabolic syndrome include abdominal obesity and high blood pressure.63,64,65,66

BMI = body weight in pounds x 705 / height in inches squared

Alternatively, using an online tool, such as MyPlate Super Tracker, will automatically calculate your caloric intake and further allow you to set goals such as establishing a preferred body weight and tracking your results as you progress to your goal. Goal setting shows great promise as a tool that can be incorporated into weight reduction programs by health care professionals and researchers.67

AHEI-2010 and Harvard’s Healthy Eating Plate
Harvard School of Public Health developed the Alternate Healthy Eating Index (AHEI) with a scoring system similar to the USDA’s index. AHEI assesses on eleven components to include dairy products, vegetables, fruit, cholesterol, fat, sodium, alcohol, multivitamins, nuts and seeds, bread and grains, and fish, poultry and meat.

Copyright © 2011, Harvard University. For more information about The Healthy Eating Plate, please see The Nutrition Source, Department of Nutrition, Harvard School of Public Health, www.thenutritionsource.org, and Harvard Health Publications, www.health.harvard.edu.

The Healthy Eating Plate template serves as a concise and functional guide for creating high quality meals. Based on the plate template, half of your plate is vegetables and fruit. You are encouraged to omit potatoes, but otherwise aim for color and variety. A quarter of your plate should be whole and intact grains to include whole wheat, barley, wheat berries, quinoa, oats, brown rice, and foods made with them such as whole wheat pasta. A quarter of your plate should be protein to include fish, chicken, beans, and nuts and foods made with them such as salads. Limit red meat, and avoid processed meats such as bacon and sausage. Healthy plant oils can be used in moderation. Consider olive, canola, soy, corn, sunflower, peanut, and other oils, but avoid partially hydrogenated oils containing trans fats. Drink water, coffee, or tea. Omit sugary drinks and limit juice to one small glass per day and milk and dairy products to one to two servings per day. Finally, you are encouraged to be active for health and weight control.68

aMED and the Mediterranean Diet
The Mediterranean Diet (MED) and alternate Mediterranean Diet (aMED) are conformity scales for measuring characteristics of a Mediterranean and modified Mediterranean Diet. There are variations to the diet with the healthier variants sharing common characteristics as being higher in fresh fruits, root and green vegetables, whole grains, and fish that is rich in omega-3 fatty acids, but much lower in red meat. The Mediterranean diets also substitute low or non-fat dairy products for the high-fat, and further substitute butter and fats for olive oil, nuts or margarines blended with rapeseed or flaxseed oils.69,70

A sample one-day sub-2000 Calorie diet might appear much like the following.

• Breakfast
  • slice of whole-grain bread
  • spread with a tablespoon of nut butter or 2 ounces of avocado
  • cup of sliced strawberries with a cup of fruit yogurt
• Lunch
  • tossed salad with one-half cup of beans and 1/2 ounce of nuts
  • dressing with a tablespoon of olive oil with vinegar or lemon juice and herbs
• Dinner
  • baked or grilled, with olive oil, fish, 3 ounces cooked (about 4 ounces raw)
  • half-plate serving of vegetables
  • ½ cup of whole grain such as brown rice
• Snacks
  • cup of plain Greek yogurt with 1/2 cup of blueberries, or
  • 1-ounce handful of nuts plus a plate of raw vegetables, or
  • 2 Tbsp hummus with 5 whole-grain crackers and a cup of vegetables

There is strong evidence for a beneficial effect of the Mediterranean dietary patterns on risk of death from all causes, including deaths due to cardiovascular disease and cancer, in a US population.71,72 Similarly, the Mediterranean diet, modified so as to apply across nine European countries, was associated with increased survival among older people.73

DASH and the DASH Eating Plan
The Dietary Approaches to Stop Hypertension (DASH) diet is a lifelong approach to healthy eating that is designed primarily to treat or prevent hypertension, but is also consistent with dietary recommendations to help prevent osteoporosis, cancer, heart disease, stroke and diabetes.74

There are two versions of the diet where the standard DASH diet allows up to 2,300 milligrams (mg) of sodium a day and the lower sodium diet up to 1,500 mg of sodium a day. The diet tends to be low in saturated fat and cholesterol and therefore encourages vegetables, fruits and low-fat dairy foods with moderate amounts of whole grains, fish, poultry and nuts.75

• Eat vegetables, fruits, and whole grains Including fat-free or low-fat dairy products, fish, poultry, beans, nuts, and vegetable oils.
• Limit foods that are high in saturated fat, such as fatty meats, full-fat dairy products, and tropical oils such as coconut, palm kernel, and palm oils.
• Limit sugary beverages and sweets.

Because of the emphasis on lowering blood pressure, the foods are lower in sodium but higher in potassium, magnesium and calcium. A sample one-day 2000 Calorie diet would assume low salt and might appear much like the following.76

• Breakfast
  • whole-wheat bagel with 2 tablespoons peanut butter (no salt added)
  • medium orange
  • cup fat-free milk
  • Decaffeinated coffee
• Lunch
  • Spinach salad made with: 4 cups of fresh spinach leaves, sliced pear, 1/2 cup canned mandarin orange sections, 1/3 cup slivered almonds, & 2 tablespoons red wine vinaigrette
  • 12 reduced-sodium wheat crackers
  • cup fat-free milk
• Dinner
  • Herb-crusted baked cod, 3 ounces cooked (about 4 ounces raw)
  • 1/2 cup brown rice pilaf with vegetables
  • ½ cup fresh green beans, steamed
  • small sourdough roll
  • 2 teaspoons olive oil
  • cup fresh berries with chopped mint
  • Herbal iced tea
• Snacks
  • cup fat-free, low-calorie yogurt
  • 4 vanilla wafers

A more accurate caloric intake can be calculated by factors such as activity level, age, gender, height, and weight. The number of servings is determined based on the number of calories you are allowed each day. The caloric intake, can be adjusted upward to gain weight or downward to loose weight. If you intend to loose weight, it is typically desirable to include exercise as a part of your plan. The following chart, adapted from the NIH DASH Eating Plan, can be used to determine your servings and serving sizes based on your nearest caloric grouping.77

DASH Eating Plan Servings Per Day Reference

Food Group	1600	2000	2600	Serving Size
Grains	6	6-8	10-11	1 slice bread, 1 oz cereal, ½ cup cooked rice, pasta, or cereal
Vegetables	3-4	4-5	5-61	1 cup raw leafy vegetable, ½ cup raw or cooked vegetable. ½ cup vegetable juice
Fruits	4	4-5	15-6	1 medium fruit, ¼ cup dried fruit, ½ cup fresh, frozen, or canned fruit. ½ cup juice
Fat-free or low-fat milk products	2-3	2-3	3	1 cup milk or yogurt, 1½ oz cheese
Lean meats, poultry & fish	3-6	6 or less	6	1 oz cooked meats, poultry, or fish, 1 egg
Nuts, seeds & legumes	3 per week	4-5 per weekr	1	⅓ cup nuts, 2 Tbsp peanut butter, 2 Tbsp seeds, ½ cup cooked legumes
Fats & oils5	2	2-3	3	1 tsp soft margarine, 1 tsp vegetable oil, 1 Tbsp mayonnaise, 2 Tbsp salad dressing
Sweets & sugars	0	2 or less	5 or less	1 Tbsp sugar, 1 Tbsp jelly or jam, ½ cup sorbet, gelatin 1 cup lemonade

DASH diet with a low sodium level has demonstrated a significant reduction of systolic blood pressure of around 7 mmHg lower in people without hypertension, and around 11 mmHg lower in people with hypertension.78,79 Even larger blood pressure reductions occur for overweight or obese persons with the addition of exercise and weight loss to the DASH diet.80,81

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