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Chapter 18 – Diet and Health
Learning Objectives
After completing Chapter 18, the student will be able to:
18.1 Identify factors that protect people from the spread of infectious diseases and describe the role of nutrition
18.3 Describe how atherosclerosis develops and strategies to lower blood cholesterol levels.
18.4 Present strategies to lower blood pressure.
18.6 Differentiate among cancer initiators, promoters, and antipromoters and describe how nutrients or foods
might play a role in each category.
18.8 Present arguments for and against the use of complementary and alternative medicine.
a. Describe alternative/complementary medicine and nutrition-related alternative therapies.
b. Identify herbal remedies and the risks and benefits of each.
Assignments and Other Instructional Materials
The following ready-to-use assignments are available in this chapter of the instructor’s manual:
• Case Study 18: Diets for Disease Prevention
• New! Critical thinking questions with answers
Other instructional materials in this chapter of the instructor’s manual include:
• Answer keys for How To (pp. 592, 594) activities and study card questions
• Classroom activities
• Worksheet answer keys (as appropriate)
Visit the book’s instructor companion website to download:
Lecture Presentation Outline
4
Key to instructor resource annotations (shown to the right of or below outline topics):
TRA = Transparency acetates: 13e = 13th edition, 12e = 12th edition, 11e = 11th edition, 10e = 10th edition
Website = Available for download from book companion website: HN = student handout
IM = Included in this instructor’s manual: CS = case study, WS = worksheet, CA = classroom activity
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I. Nutrition and Infectious Diseases
A. The Immune System Website HN 18-1
1. Organs of the immune system fight antigens
2. Phagocytes: Neutrophils and Macrophages
3. Lymphocytes: B-cells
a. Antibodies
4. Lymphocytes: T-cells
a. Release powerful chemicals to destroy foreign particles
b. Highly specific
c. Defend against fungi, viruses, parasites, some bacteria, and cancer cells
d. Rejection of transplanted tissue
B. Nutrition and Immunity 10e TRA 164; Website HN 18-2
1. Malnutrition compromises immunity
2. Immunity and infectious disease increase nutrient needs
II. Nutrition and Chronic Diseases (Figures 18-2 & 18-3; Table 18-2) 13e TRA 22; 12e TRA 25; 10e TRA 166
III. Cardiovascular Disease (CVD)
A. How Atherosclerosis Develops 10e TRA 168
1. Atheromatous plaque
2. Inflammation
a. Cells lining the blood vessels incur damage
3. Plaques – Fibrous coating can be torn away with a surge in blood pressure
4. Blood Clots
a. Platelets
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c. Higher blood pressure results in further damages
6. The Result: Heart Attacks and Strokes
a. Angina
1. Modifiable vs. non-modifiable risk factors
2. Age, Gender, and Family History
a. Cannot change these factors
3. High LDL and Low HDL Cholesterol
a. Excess LDL (low-density lipoproteins) become available for oxidation; high risk
b. HDL (high-density lipoproteins) represent cholesterol being carried back to the liver; reduced risk
4. High Blood Pressure (Hypertension)
5. Diabetes
a. Risk similar to people with established CHD
b. CHD risk equivalents
6. Obesity and Physical Inactivity
7. Cigarette Smoking
8. Atherogenic Diet
9. Other Risk Factors
a. Emerging risk factors
b. Elevated triglycerides are a marker for other risk factors
c. Diabetes and overweight
10. Metabolic Syndrome
1. Abdominal obesity
3. HDL: 40 mg/dL in men, 50 mg/dL in women
4. Blood pressure: 130/85 mm Hg
5. Fasting glucose: 100 mg/dL
C. Recommendations for Reducing Coronary Heart Disease Risk
1. Cholesterol Screening
2. Lifestyle Changes (Table 18-5)
IV. Hypertension
A. How Hypertension Develops 11e TRA 29
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5. Cardiac output increases, increasing the work of the heart
B. Risk Factors for Hypertension
1. Aging
C. Treatment of Hypertension (Table 18-6)
1. Weight Control
2. Physical Activity – Will help
3. The DASH Diet – Dietary Approaches to Stop Hypertension (Table 18–7) Website HN 12-1
V. Diabetes Mellitus (Figure 18–4) 11e TRA 30
A. How Diabetes Develops (Table 18–8) 11e TRA 31
1. Prediabetes
2. Type 1 Diabetes
a. 5-10% prevalence in diabetic population
3. Type 2 Diabetes
a. 90-95% prevalence in diabetic population
1. Diseases of the Large Blood Vessels
a. Atherosclerosis
b. Benefits of intensive therapy outweigh the risks
2. Diseases of the Small Blood Vessels
3. Diseases of the Nerves
a. Hands and feet
b. Must be careful of injuries and infections
c. Gangrene may develop and amputation may be required
C. Recommendations for Diabetes
1. Total Carbohydrate Intake
2. Carbohydrate Sources
3. Dietary Fat
a. Saturated fat: <7% of total kcalories
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b. Cholesterol: <200 mg/day
4. Protein
5. Alcohol
6. Recommendations for Type 1 Diabetes
1. Keep carbohydrate intake at meals and snacks consistent
2. Achieve desirable blood lipids
3. Control blood pressure
4. Prevent and treat complications
c. Physical activity
1. Be careful of hypoglycemia
2. Monitor blood glucose
7. Recommendations for Type 2 Diabetes
a. Moderate weight loss is helpful (5-10% of body weight)
b. Regular, long-term physical activity
VI. Cancer
A. How Cancer Develops 10e TRA 172
1. Carcinogenesis (Figure 18-6)
2. Environmental Factors
3. Dietary Factors—Cancer Initiators
a. Additives and pesticides
4. Dietary Factors—Cancer Promoters
5. Dietary Factors—Antipromoters (Table 18–9)
B. Recommendations for Reducing Cancer Risks (Table 18-10)
VII. Recommendations for Chronic Diseases (Table 18–11) 13e TRA 23, 24; IM CS 18, CA 18-4
A. Recommendations for the Population – Making dietary changes to forestall or prevent disease is the
preventive or population approach
VIII. Highlight: Complementary and Alternative Medicine IM CA 18-5
A. Defining Complementary and Alternative Medicine
1. Complementary and alternative medicine: diverse medical and health care systems, practices, and
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B. Sound Research, Loud Controversy
1. Little research
2. Placebo Effect
C. Nutrition-Related Alternative Therapies
1. Foods
a. Potential health benefits of soy
b. More research is needed on phytoestrogens of soy
2. Vitamin and Mineral Supplements
3. Herbal Remedies (Figure H18-1 & Table H18–1)
a. Used throughout history
4. Herbal Precautions
1. True identification of herbs
D. Internet Precautions
1. Advertising and marketing of their own products
2. Quotations from researchers and physicians may be taken out of context
Case Study 18: Diets for Disease Prevention
5
Ellen is a 55-year-old woman with multiple medical problems, including chronic back pain. She is 5 feet 6 inches
tall and weighs 236 pounds. She takes medications for high blood pressure and hypercholesterolemia, both of which
are currently under control. She also takes pain medications every day and has difficulty walking, although she
occasionally attends a water exercise class at the local sports center. She states that she has been overweight most of
her life and confesses that food, especially sweet foods, are a comfort to her when she experiences physical or
emotional pain. Her diet history reveals an intake of 2 or 3 cans of ginger ale or root beer each day. Her usual meals
with her husband include meat or chicken (she does not like fish) and vegetables such as corn or potatoes. She
snacks on several types of frozen desserts between meals. She enjoys milk on occasion but admits that it is not a part
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Contributed by Barbara Quinn.
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of her regular diet. A recent visit to her doctor reveals a weight gain of 15 pounds over the past 6 months and an
increase in her fasting blood glucose level into the “pre–diabetes” range. She has no family history of diabetes. Her
doctor has recommended she lose weight and make lifestyle changes to prevent her from developing diabetes.
1. Using the information in Table 18-2, list the risk factors for chronic diseases that are evident from Ellen’s
history.
2. According to Table 18–3, which of Ellen’s risk factors for CHD might be related to her diet?
3. What advice would you give Ellen regarding her intake of sweetened beverages as it relates to her obesity and
blood glucose levels?
4. Using strategies suggested in Table 18–5, and the “How To” feature on page 594, suggest 2 or 3 dietary changes
that would help Ellen reduce her risk for heart disease.
5. What dietary plan would help Ellen control her blood pressure as well as her blood cholesterol levels? What are
the main features of this diet?
6. Prepare a sample one-day menu with 3 meals and 1 or 2 snacks for Ellen that includes the minimum servings of
each food group for the DASH eating plan as outlined in Table 18-7.
Answer Key
1. Ellen’s diet is high in added sugars, which contributes to obesity; low in fruits, vegetables, and other foods rich
in fiber and phytochemicals, which increases risk for cancer, diabetes, atherosclerosis, obesity, and stroke; and
Suggested Classroom Activities
Some instructors present information from this chapter throughout the course; others prefer to cover this chapter
separately. If you would like to spread this information throughout the course, you may want to present information
about heart disease when discussing Chapter 5 and information about AIDS and immunity when discussing Chapter
6.
Classroom Activity 18-1: What Disease Term Am I?
Key concept: Disease terminology Class size: Small or medium
Materials needed: Index cards/slips of paper with disease names (prepared prior to class time), tape
Instructions: Before class, prepare “Post–its,” index cards, or slips of paper by writing one new disease term on each
Post-it, card, or slip of paper. (You may also include other terms that appear in the chapter.) Tape an index card to
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the back of each student. The goal of the activity is for students to find out what disease or related term is written on
their backs.
To discover “What Term Am I?” have students circulate throughout the room asking other students questions about
the term written on their backs. They are permitted to ask each student two “yes or no” type questions. After asking
a student two questions, they approach another student and ask two more questions. For example, one question
could be “Do I often result from excess body fatness?” After each student has discovered what term is on her or his
card, she/he can tell the class how she/he figured it out and what questions she/he asked during the activity.
Classroom Activity 18-2: Student Health Profile
Key concept: Preventive health measures Class size: Any
Instructions: Instruct students to schedule a physical to screen for potential health problems. These are some possible
measures that can be obtained: height, weight, body mass index, percent body fat, age, resting heart rate, target heart
rate, maximal heart rate, resting systolic blood pressure, resting diastolic blood pressure, total cholesterol, HDL, and
LDL.
Classroom Activity 18-5: Exploring CAM
6
Key concept: Complementary and alternative medicine Class size: Small to medium
Instructions: There is perhaps no area more controversial than the area of alternative therapies, including the use of
herbs, supplements, mind-body therapies, and even alternative dietary approaches to treating disease and aliments
such as pain, anxiety, and inability to sleep. A large part of the problem is the lack of research devoted to
demonstrating the efficacy of each specific therapy for each specific medical problem. Given that western medicine
is science and evidence based whereas many eastern countries rely on the advice of centuries of experienced
practitioners, these two traditions approach patient care from completely different perspectives. As health
professionals more closely embrace the importance of evidence–based practice, the science to justify the practice of
experience can now become published for all health care professionals in the United States to benefit from.
For this exercise, have the class make an exhaustive list of herbal therapies, supplements, and diet therapies that they
have heard of that they would like to study more closely. Allow each student to select three to four choices among
the group or whatever number per student provides for an equal number of options per student. Ask the students to
pursue a peer-reviewed literature search of each therapy and then write a consensus abstract of their findings. Have
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Activity provided by Kathleen Rourke.
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the student compare his or her abstract findings from the scientific literature with a search from popular literature
and again prepare a consensus abstract on his/her findings from the consumer or popular literature.
What are the differences in findings between the two sets of literature? Would the student recommend the therapy to
his/her clients? What do the other members of class think about the therapy? Allow everyone in class to share their
findings, allowing everyone to learn from the other students’ literature reviews.
Hint: One of the best resources in the area of herbal therapies is Mark Blumenthal. The students will be well guided
by his writings, books, and work in this area and he is a popular speaker for the American Dietetic Association and
the Dietetic Practice Group focused in this area.
One other exercise that can be fun on this topic is to ask students to either write a paper on or debate in class the pros
and cons of alternative therapies, including nutrition as an alternative therapy. The RD must remain flexible to a
client’s perspective or choice of taking supplements, etc. Some dietitians are of the mind that when an individual
does consume a well-balanced diet, supplementation or herbals are not necessary. While this may be true, it is
important to maintain the perspective of the consumer. Students studying the field of nutrition come with many very
strong opinions, including strong opinions about alternative therapies with supplements and herbals. Allowing
students to voice their opinions and allowing them to hear both sides of the argument is a valuable lesson while they
are still in school and can benefit from hearing the potential future arguments that their clients will soon voice to
them as practitioners.
How To “Try It!” Activities Answer Key
How to Assess Your Risk of Heart Disease
Students have the choice of adding up a heart disease risk score using the How to box itself or using the online risk
assessment tool at the American Heart Association website. Answers will be individualized.
How to Implement a Heart-Healthy Diet
Students should submit a reasonable 1-day meal plan and a nutrient analysis of the chosen foods, along with an
evaluation of the plan’s effectiveness in reducing risk. The evaluation should address whether the day’s energy
intake would be appropriate to maintain (or lose, if necessary) weight; whether it meets the recommendations for
limiting saturated/trans fat, sodium, and added sugars and providing ample soluble fiber, potassium, and omega–3
fats; and whether plant sterols/stanols, soy foods, or alcohol are incorporated for their potential benefits.
Study Card 18 Answer Key
8. In type 1 diabetes, the less common type of diabetes (about 5 to 10 percent of all diagnosed cases), the pancreas
loses its ability to synthesize the hormone insulin. Type 1 diabetes is an autoimmune disorder. In most cases,
the individual inherits a defect in which immune cells mistakenly attack and destroy the insulin-producing beta
cells of the pancreas at rates that vary from person to person. Type 2 diabetes is the most prevalent form of
diabetes, accounting for 90 to 95 percent of cases. The primary defect in type 2 diabetes is insulin resistance, a
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Critical Thinking Questions
7
1. List and describe lifestyle factors that contribute to the development of chronic diseases.
2. Several of the ten leading causes of death depicted in your textbook are identified as being related to nutrition,
including cardiovascular diseases, cancers, and diabetes mellitus. Which of the other leading causes of death
may be affected by nutritional considerations?
3. Examining the relationship between risk factors and chronic disease, which risk factors provide the strongest
correlation with increased incidence of chronic disease? What methods can be used to mitigate the effect of
potential risk factors?
4. Analyze each variable included in the charts from the Framingham Heart Study and used to determine risk of
developing heart disease for its relative impact.
5. Compare and contrast therapeutic dietary interventions for type 1 and type 2 diabetes. Discuss potential issues
that may arise in real world environments that can affect food choices for diabetic individuals.
6. Much has been stated about the influence of diet on the prevention of certain cancers and yet manufacturers still
make food products that are linked to cancer development. Provide an argument that could be presented to a
food manufacturer in the hopes of getting a company to stop making a carcinogenic food available to the
consumer market.
Answer Key
1. Lifestyle patterns can be associated with the development of chronic diseases. They can predispose and/or
contribute to altered pathophysiological mechanisms. It is important to recognize and understand significant
lifestyle factors for their relative contribution to chronic diseases.
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Overweight: Clinical evidence supports the relationship between development of chronic disease and obesity.
Increased weight affects the body’s ability to function, making it harder to achieve and/or maintain circulation
and perfusion. In addition, being overweight places an extra burden on internal organs as well as the
musculoskeletal system as the body attempts to maintain homeostasis. Increased demands placed on internal
organs such as the heart and lungs may lead to accelerated abnormal pathophysiological mechanisms. Being
overweight places a burden on joints of the body that can affect mobility and functional status.
2. The occurrence of influenza and pneumonia can be impacted by nutritional factors related to the baseline status
of the individual. Respiratory compromise can affect intake of nutrients and impede delivery of needed nutrients
to body tissues. Chronic lung disease affects nutrient intake in terms of altered oxygenation and perfusion.
3. According to the textbook, diets high in saturated fats and/ or trans fat, genetics, and sedentary lifestyle have
the strongest correlations with increased incidence of chronic diseases: cancers, hypertension, type 2 diabetes
mellitus, atherosclerosis, obesity, and stroke. In terms of dietary control, an individual can potentially modify
his/her intake of food items, thus decreasing and/or limiting the amount of saturated fats and trans fat in the
4. When determining one’s potential risk to develop heart disease, the following variables are considered: age,
HDL, systolic blood pressure, total cholesterol, and smoking. Higher scores are indicative of increased risk
based on correlations observed in research. Assessment of variables is also based on recognition of gender
differences. In terms of age, as one ages, regardless of gender, there is increased risk. As one’s HDL level
5. Type 1 diabetes results from loss of beta cell function in the pancreas. This leads to the requirement for
exogenous sources of insulin as a replacement therapy in order for the individual to maintain adequate blood
glucose levels. In addition to insulin replacement therapy, a type 1 diabetic must maintain consistent
carbohydrate intake. Lipid intake must be adjusted so that saturated fats, trans fat, and cholesterol are
maintained at lower prescribed levels (saturated fat less than 7% of total calories, decreased trans fat, and
sources are important in disease management as well. Physical activity also is recognized as a key factor in
helping to facilitate weight loss and decrease blood pressure. In the presence of obesity, there is added risk for
the individual to develop hypertension and as such be at increased risk to develop heart disease. This combined
with the potential to develop dyslipidemia also increases the diabetic client’s risk for heart disease. Therefore, a
diet that is low in saturated fats, decreased/limited in trans fat, and low in cholesterol is advised.
6. This question will allow the student to reflectively think about several important factors, one being the
designation of a food product that has been linked to cancer development. A second is the consideration of the
responsibility of the food manufacturer (corporate entity) to provide healthy foods in the context of social
responsibility. For example, consider drinks with added sugars as a potential carcinogenic source. It has long
been recognized that added-sugar drinks contribute not only to dental caries but to increased blood glucose
levels. They are a source of empty calories providing poor nutritional value and increased glucose burden.
In preparing an argument to be made to the food manufacturer, one should consider the following factors: (1)
Can the food product be processed and/or made differently to decrease the amount of added sugar? (2) Besides
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IM Worksheet Answer Key
Worksheet 18-2: Therapeutic Diets
Clinical Condition
Type of Diet
Indication
Adequate or
Transitional?
nutrient density
(CAD)
functional foods
Hypertension
DASH diet
Adequate
Diabetes
RM – CHO, fat, & fiber
Adequate
transitional
client
to soft or regular diet
vomiting
Renal failure
RM
RM – individualized
Adequate
Worksheet 18-3: Chapter 18 Crossword Puzzle
1. saturated fats
4. increases
7. DASH
10. A: fruits, vegetables;
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Worksheet 18-1: Fats Facts and Obesity Trends (Internet Exercise)
1. Sat and Trans are considered to be the Better Fats Sisters.
a. True
b. False
2. What are the major dietary fats? Select ALL that apply.
3. As long as foods have 0 trans fat they are considered to be healthy.
4. An alternative fat source to replace saturated fat in the diet is to use stick margarine.
a. True
b. False
5. A saturated fat provides more calories than an unsaturated fat.
a. True
b. False
6. Obesity-related health care costs in 2008 totaled an estimated $150 billion.
a. True
b. False
7. Which of the following are considered to be health consequences of obesity? Select all that apply.
8. According to the map for the year 2009, in the state of Florida the percentage of adults who are obese falls
9. According to the map for the year 2009, the lowest percentage of obese adults was found in Colorado.
a. True
b. False
10. According to the map for the year 2009, Florida and New York had the same percentage of obese adults.
a. True
b. False
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Worksheet 18-2: Therapeutic Diets
For each of the following clinical conditions, indicate the type of diet that is required (AC for altered consistency,
RM for restricted/modified, and/or S for supplemented), and whether it is nutritionally adequate or deemed a
transitional diet (a diet that is not considered to be nutritionally adequate but can be used for a limited amount of
time).
Clinical Condition
Type of Diet
Indication
Adequate1 or
Transitional2?
HIV/AIDS
Coronary artery disease
(CAD)
1 Lifestyle changes along with weight reduction and increased physical activity contribute to a therapeutic diet
pattern.
2 Is viewed as nutritionally inadequate but medical condition can necessitate revision and/or timing of following this
type of dietary pattern.
Hypertension
Postoperative surgical
client
Child with nausea &
vomiting
Renal failure
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Worksheet 18-3: Chapter 18 Crossword Puzzle
1
2
3
4
5
6
7
8
9
10
11
Across:
Down:
1. Limiting dietary intake of _____ is associated with
5. _____ are known to have an important role in
immune cell multiplication.
9. Combination of conventional and complementary
and alternative medicine
11. A consistent intake of _____ throughout the day is
recommended to manage both types of diabetes.
2. _____ intake is associated with the development of
recommend for individuals with hypertension.
4. Risk for coronary heart disease _____ with age.
8. Limiting _____ intake to 15-20% of total kcalories
is recommended for managing both types of
States are diet related.