Milk, yogurt, and cheese (dairy) group— preferably fat free or low fat




Dry beans, eggs, nuts, fish, and meat and poultry group— preferably lean or low fat

2, for a total of 5 oz

2, for a total of 6 oz

3, for a total of 7 oz

Source: Adapted from U.S. Department of Agriculture, Center for Nutrition Policy and Promotion. The Food Guide Pyramid, Home and Garden Bulletin Number 252, 1996.

*These are the calorie levels if low-fat, lean foods are chosen from the 5 major food groups and foods from the fats, oil, and sweets group are used sparingly.

**Older children and teenagers (ages 9-18 yrs) and adults over the age of 50 need 3 servings daily. During pregnancy and lactation, the recommended number of dairy group servings is the same as for nonpregnant women.

TABLE 3-3 ■ Rapid Screen for Dietary Intake

Portions Consumed by Patient Recommended

Grains, cereals, bread group __6-11

Fruit group __2-4

Vegetable group __3-5

Meat/meat substitute group __2-3

Dairy group __2-3

Alcoholic beverages __<2

Instructions. Ask the patient for a 24-hour dietary recall (perhaps two of these) before completing the form.

Source: Nestle M. Nutrition. In: Woolf SH, Jonas S, Lawrence RS, eds. Health Promotion and Disease Prevention in Clinical Practice. Baltimore: Williams & Wilkins, 1996.

TABLE 3-4 ■ Nutrition Screening Checklist

I have an illness or condition that made me change the kind and/or amount of food I eat.

Yes (2 pts)

I eat fewer than 2 meals per day.

Yes (3 pts)

I eat few fruits or vegetables, or milk products.

Yes (2 pts)

I have 3 or more drinks of beer, liquor, or wine almost every day.

Yes (2 pts)

I have tooth or mouth problems that make it hard for me to eat.

Yes (2 pts)

I don't always have enough money to buy the food I need.

Yes (4 pts)

I eat alone most of the time.

Yes (1 pt)

I take 3 or more different prescribed or over-the-counter drugs each day.

Yes (1 pt)

Without wanting to, I have lost or gained 10 pounds in the last 6 months.

Yes (2 pts)

I am not always physically able to shop, cook and/or feed myself.

Yes (2 pts) TOTAL

Instructions. Check "yes" for each condition that applies, then total the nutritional score. For total scores between 3-5 points (moderate risk) or >6 points (high risk), further evaluation is needed (especially for the elderly).

Source: The Nutrition Screening Initiative, American Academy of Family Physicians. e-check1.html. Accessed 7/22/01.

How Many Servings Do You Need?

The Food Guide Pyramid shows a range of daily servings for each food group. The number of servings that is right for you depends on how many calories you need. Calories are a way to measure food energy. The energy your body needs depends on your age, sex, and size. It also depends on how active you are. In general, daily intake should be:

■ 1,600 calories for most women and older adults

■ 2,200 calories for children, teen girls, active women, and most men

■ 2,800 calories for teen boys and active men.

Those with lower calorie needs should select the lower number of servings from each food group. Their diet should include 2 servings of protein for a total of 5 ounces. Those with average calorie needs should select the middle number of servings from each food group. They should include 2 servings of protein for a total of

6 ounces. Those with higher calorie needs should select the higher number of servings from each food group. Their diet should include 3 servings of protein for a total of 7 ounces. Also, pregnant or breast-feeding women, teens, and young adults up to age 24 should consume 3 servings of dairy foods daily.

The amount of food that counts as one serving is listed below. If you eat a larger portion, it is more than one serving. For example a slice of bread is one serving. A hamburger bun is two servings.

For mixed foods, estimate the food group servings of the main ingredients. For example, a large piece of sausage pizza would count in the bread group (crust), the milk group (cheese), the meat group (sausage), and the vegetable group (tomato sauce). Likewise, a helping of beef stew would count in the meat group and the vegetable group.

What Counts as a Serving?

Bread, Cereal, Rice, & Pasta



Milk, Yogurt, & Cheese

Meat, Poultry, Fish, Dry Beans, Eggs, & Nuts

Fats, Oils & Sweets

1 slice bread 1 tortilla

V2 c cooked rice, pasta or cereal 1 oz ready-to-eat cereal V2 hamburger roll, bagel or English muffin 3-4 plain crackers (sm)

1 pancake (4") V2 croissant (lg) V2 doughnut or danish (med) Vi6 cake (average)

V2 c chopped raw or cooked vegetables 1 c raw, leafy vegetables % c vegetable juice V2 c scalloped potatoes V2 c potato salad 10 French fries

1 piece fruit or melon wedge % c fruit juice V2 c chopped, cooked or canned fruit \ c dried fruit

1 c milk or yogurt 1V2 oz natural cheese

2 oz process cheese 1V2 c ice cream or ice milk 1 c frozen yougurt

2 V2 to 3 oz cooked lean beef, pork, lamb, veal, poultry or fish V2 c cooked beans or 1 egg or 2 T peanut butter or V3 c nuts count as 1 oz of meat

Lean Beef Choices

Eye of round Top round Round tip Top sirloin Bottom round Top loin Tenderloin

Use sparingly

Adapted from U.S. Department of Agriculture, Human Nutrition Service. The Food Guide Pyramid, Home and Garden Bulletin Number 252, 1996.

TABLE 3-6 ■ Eating Disorders and Excessively Low BMI

In the United States an estimated 5 to 10 million women and one million men suffer from eating disorders. These severe disturbances of eating behavior are often difficult to detect, especially in teens wearing baggy clothes, or in individuals who binge then induce vomiting or evacuation. Be familiar with the two principal eating disorders, anorexia nervosa and bulimia nervosa. Both conditions are characterized by distorted perceptions of body image and weight. Early detection is important, since prognosis improves when treatment occurs in the early stages of these disorders.

Clinical Features

Anorexia Nervosa

■ Refusal to maintain minimally normal body weight (or BMI above 17.5 kg/m2)

■ Afraid of appearing fat

■ Frequently starving but in denial; lacking insight

■ Often brought in by family members

■ May present as failure to make expected weight gains in childhood or adolescence, amenorrhea in women, loss of libido or potency in men

■ Associated with depressive symptoms such as depressed mood, irritability, social withdrawal, insomnia, decreased libido

■ Additional features supporting diagnosis: self-induced vomiting or purging, excessive exercise, use of appetite suppressants and/or diuretics

■ Biological complications

■ Neuroendocrine changes: amenorrhea, increased corticotropin-releasing factor, cortisol, growth hormone, serotonin; decreased diurnal cortisol fluctuation, luteinizing hormone, follicle-stimulating hormone, thyroid-stimulating hormone

■ Cardiovascular disorders: bradycardia, hypotension, arrhythmias, cardiomyopathy

■ Metabolic disorders: hypokalemia, hypochloremic metabolic alkalosis, increased BUN, edema

■ Other: dry skin, dental caries, delayed gastric emptying, constipation, anemia, osteoporosis

Bulimia Nervosa

■ Repeated binge eating followed by self-induced vomiting, misuse of laxatives, diuretics or other medications, fasting; or excessive exercise

■ Overeating at least twice a week during 3-month period; large amounts of food consumed in short period (~2 hrs)

■ Preoccupation with eating; craving and compulsion to eat; lack of control over eating; alternating with periods of starvation

■ Dread of fatness but may be obese

■ Purging: bulimic episodes accompanied by self-induced vomiting or use of laxatives, diuretics, or enemas

■ Nonpurging: bulimic episodes accompanied by compensatory behavior such as fasting, exercise but without purging.

■ Biological complications

See changes listed for anorexia nervosa, especially weakness, fatigue, mild cognitive disorder; also erosion of dental enamel, parotitis, pancreatic inflammation with elevated amylase, mild neuropathies, seizures, hypokalemia, hypochloremic metabolic acidosis, hypomagnesemia

Sources: World Health Organization: The ICD-10 Classification of Mental and Behavorial Disorders: Diagnostic Criteria for Research. At World Health Organization, Geneva, 1993. American Psychiatric Association: DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. American Psychiatric Association, Washington, DC, 1994. Halmi, KA: Eating Disorders: In: Kaplan, HI, Sadock BJ, eds. Comprehensive Textbook of Psychiatry, 7th ed. Philadelphia, Lippincott Williams & Wilkins; 2000:1663-1676.

TABLE 3-7 ■ Nutrition Counseling: Sources of Nutrients


Food Source


Dairy foods such as yogurt, milk, and natural cheeses

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