Sana Shah, Usman Mahboob, Syed Muhammad Junaid, Sana Siddiqui, Brekhna Jamil, Saadia Rehman
Challenges faced by teachers of postgraduate health professions blended learning programs: a qualitative analysis
BMC medical education
homecirculationvol 119 8implementing american heart association pediatric adult nutrition guidelines free accessreview articlepdfepubaboutview pdfview epubsections toolsadd favoritesdownload citationstrack citationspermissions shareshare onfacebooktwitterlinked inmendeleyreddit jump tofree accessreview articlepdfepubimplementing american heart association pediatric adult nutrition guidelinesa scientific statement american heart association nutrition committee council nutrition physical activity metabolism council cardiovascular disease young council arteriosclerosis thrombosis vascular biology council cardiovascular nursing council epidemiology prevention council high blood pressure research samuel gidding alice h lichtenstein myles faith allison karpyn julie mennella barry popkin jonelle rowe linda van horn laurie whitsel samuel giddingsamuel gidding alice h lichtensteinalice h lichtenstein myles faithmyles faith allison karpynallison karpyn julie mennellajulie mennella barry popkinbarry popkin jonelle rowejonelle rowe linda van hornlinda van horn laurie whitsellaurie whitsel originally published3 mar 2009httpsdoiorg101161circulationaha109191856circulation 200911911611175cardiovascular disease mortality rates fallen 50 past 50 60 years however cardiovascular disease prevalence remains high cardiovascular disease still leading cause death disability united states12 estimated preventive efforts contributed least half decline primary contribution coming declines mean blood cholesterol concentrations mean blood pressure levels tobacco use rates regrettably past decade increased prevalence obesity diabetes mellitus dramatically slowed secular decline cardiovascular mortality rates134 fact united states contribution prevention decline cardiovascular mortality much lower industrialized countries united states historically15the continuing challenge preventing development cardiovascular disease especially early life nutrition remains cornerstone effort modernization industrialization food supply distribution patterns lifestyles produced many benefits also unanticipated consequences6 decline saturated fat cholesterol intake influenced public awareness adverse health consequences coupled increased availability foods lower cholesterol saturated fat associated reductions cardiovascular disease however recent studies trends dietary patterns united states suggest significant drift toward less healthful eating patterns overconsumption energy associated increases prevalence obesity metabolic syndrome type 2 diabetes mellitus14 data strongly suggest additional emphasis needed ways implement current guidelines contemporary society great benefit achieved adopting hearthealthy nutrition pattern young age thereby preventing rise cholesterol blood pressure levels associated excess saturated fat trans fat salt ingestion minimizing development obesity establishing lifelong dietary habits78current american heart association aha diet lifestyle recommendations children adults emphasize goals aim healthy body weight recommended levels blood lipids lipoprotein blood pressure glucose engage regular physical activity avoid use exposure tobacco products consume diets rich vegetables fruits whole grains lowfat nonfat dairy products legumes fish least 2 times per week lean meat coupled food choices minimize intakes excess energy saturated fat trans fat cholesterol salt910 importance focusing overall diet quality dietary pattern rather individual foods nutrients balancing energy intake expenditure engaging regular physical activity increasing importance following aha diet recommendations eating outside home emphasized pediatric adult recommendations follow guiding principles throughout lifespan lacking badly needed specific guidelines best implement recommendationsthe purpose scientific statement summarize current strategies implement aha nutrition recommendations cardiovascular disease stroke prevention throughout life cycle well providing suggestions practical examples strengthening efforts similar approach developed recently obesity11 emphasized importance healthful overall dietary pattern within complex nutrition environment contemporary life figure adapted several sources presents conceptual model complex environment identifies facilitators barriers attaining aha diet lifestyle recommendations figure shows nested concentric circles beginning individual level working toward macroenvironmental level1216 level offers potential avenue change helping individuals families communities achieve aha diet lifestyle recommendations provides framework understanding complexity nutrition choices organizing existing literature nutrition interpreting future research impact report follows approach suggested figure developed recent aha statement obesity developing implementation argument11 broad nature topic report meant suggest new approaches implementing healthful diet within context contemporary eating patterns rather developing new specific nutrition recommendations download figuredownload powerpointfigure concentric circles influence eating behaviors1116 individual level refers biological genetic demographic learning history influences within person individual level nested within family environment includes influences role modeling feeding styles provision availability foods aspects home food environment third level microenvironmental level refers local environment community family home immediately nested includes local schools playgrounds walking areas shopping markets enable impede healthful eating behaviors level 4 macroenvironmental level level refers broader economic policies laws industry policies operate regional state national international levels influence level 4 factors pervasive project individual choices model recognizes importance nesting levels within one another reciprocal influences among levelscurrent aha dietary guidelinestables 1 5 summarize current aha dietary recommendations children adolescents adults strategies implementation910 adults emphasis dietary management achieve optimal lipid lipoprotein profiles blood pressure blood glucose levels body weight addition importance engaging regular physical activity avoidance use exposure tobacco products emphasized table 1 2 children 2 years age emphasis dietary pattern meets nutrition requirements growth development minimizing development cardiovascular risk factors primarily high blood cholesterol blood pressure glucose levels excessive body weight gain table 4 birth breastfeeding strongly recommended infants ages adequate caloric intake emphasized maintain appropriate growth development minimizing excess weight gain individuals diagnosed risk factors require therapeutic lifestyle changes address risk factors often multifactorial beyond scope present statement1718table 1 aha 2006 diet lifestyle goals cardiovascular disease risk reductionconsume overall healthy dietaim healthy body weightaim recommended levels lowdensity lipoprotein cholesterol highdensity lipoprotein cholesterol triglyceridesaim normal blood pressureaim normal blood glucose levelbe physically activeavoid use exposure tobacco productstable 2 aha 2006 diet lifestyle recommendations cardiovascular disease risk reductionbalance calorie intake physical activity achieve maintain healthy body weightconsume diet rich vegetables fruitschoose wholegrain highfiber foodsconsume fish especially oily fish least twice weeklimit intake saturated fat 7 energy trans fat 1 energy cholesterol 300 mgd choosing lean meats vegetable alternatives selecting fatfree skim 1 fat lowfat dairy products minimizing intake partially hydrogenated fatsminimize intake beverages foods added sugarschoose prepare foods little saltif consume alcohol moderationwhen eat food prepared outside home follow aha diet lifestyle recommendationstable 3 practical tips implement aha 2006 diet lifestyle recommendations lifestyleknow caloric needs achieve maintain healthy weightknow calorie content foods beverages consumetrack weight physical activity calorie intakeprepare eat smaller portionstrack whenever possible decrease screen time eg watching television surfing web playing computer gamesincorporate physical movement habitual activitiesdo smoke use tobacco productsif consume alcohol moderation equivalent 1 drink women 2 drinks men dayfood choices preparation use nutrition facts panel ingredients list choosing foods buy eat fresh frozen canned vegetables fruits without highcalorie sauces added salt sugars replace highcalorie foods fruits vegetables increase fiber intake eating beans legumes wholegrain products fruits vegetables use liquid vegetable oils place solid fats limit beverages foods high added sugars common forms added sugars sucrose glucose fructose maltose dextrose corn syrups concentrated fruit juice honey choose foods made whole grains common forms whole grains whole wheat oatsoatmeal rye barley corn popcorn brown rice wild rice buckwheat triticale bulgur cracked wheat millet quinoa sorghum cut back pastries highcalorie bakery products eg muffins doughnuts select milk dairy products either fat free low fat reduce salt intake comparing sodium contents similar products eg different brands tomato sauce choosing products less salt choosing versions processed foods including cereals baked goods reduced salt limiting condiments eg soy sauce ketchup use lean cuts meat remove skin poultry eating limit processed meats high saturated fat sodium grill bake broil fish meat poultry incorporate vegetablebased meat substitutes favorite recipes encourage consumption whole vegetables fruits place juicestable 4 aha pediatric dietary strategies individuals 2 years age recommendations patients familiesbalance dietary calories physical activity maintain normal growthengage 60 min moderate vigorous play physical activity dailyeat vegetables fruits daily limit juice intakeuse vegetable oils soft margarines low saturated fat trans fatty acids instead butter animal fats dieteat wholegrain breads cereals rather refinedgrain productsreduce intake sugarsweetened beverages foodsuse nonfat skim lowfat milk dairy products dailyeat fish especially oily fish broiled bakedreduce salt intake including salt processed foodstable 5 tips parents implement aha pediatric dietary guidelinesreduce added sugars including sugarsweetened drinks juicesuse canola soybean corn oil safflower unsaturated oils place solid fats food preparationuse recommended portion sizes food labels preparing serving fooduse fresh frozen canned vegetables fruits serve every meal careful added sauces sugarintroduce regularly serve fish entreremove skin poultry eatinguse lean cuts meat reducedfat meat productslimit highcalorie sauces alfredo cream sauces cheese sauces hollandaiseeat wholegrain breads cereals rather refined products read labels ensure whole grain first ingredient food label productseat legumes beans tofu place meat entreesbreads breakfast cereals prepared foods including soups may high salt andor sugar read food labels contents choose highfiber lowsaltsugar alternativesto achieve dietary goals aha recommends consumption overall diet rich wide variety fruits vegetables grain products especially whole grains fatfree lowfat dairy products legumes poultry lean meats fish preferably oily fish least twice week tables 3 4 aim moderate fat intake 25 35 energy primary sources added fats coming vegetable oils soybean canola corn olive sunflower safflower oils within category choices minimize intake excess calories saturated hydrogenated trans fatty acids fats cholesterol salt sugar emerging area research useful help better understand importance comprehensive approach diet analysis overall dietary patterns opposed studies individual foods nutrients association patterns chronic disease risk1920current us diet eating patternsdata us eating patterns previously monitored us department agriculture usda collected national center health statistics part joint nutrition monitoring system usda nutrition monitoring system focused dietary intake assessed detailed measures eating behavior longer periods time surveys performed 1965 1977 1978 1989 1991 last time 1994 1998 national center health statistics began national health nutrition examination survey using 24hour dietary recalls survey called eat america2124 methodological differences among surveys include major differences number passes approaches questioning respondents different coding foods shifting sources food composition tables lack bridging methodology usda national center health statistics surveys problems partially overcome25 another important limitation data presented section trends eating behavior last 5 years publishedavailable data suggest recommended intake fruits vegetables achieved fluid milk whole grains percent energy intake decreased dietary fiber intake recommended levels age groups26 caloric intake increased consistent increased body weight us population27 trends seen across age groups including infants toddlers significant increases consumption sugarcontaining beverages2830 adolescents young adults important note increased intake snack foods sugarsweetened beverages place milk may compromising overall nutritional diet quality31equally important dietary patterns supporting trends table 6 include following dimensions eating behavior increased number eating events per day snacks larger portion sizes greater proportion food consumed away home higher energy intakes weekend days friday sunday higher consumption sugarsweetened beverages3239table 6 also includes strategies empirically evaluated table 6 caloric intake nutrient qualityeating patterns associated increased caloric intake poorer nutrient quality increased frequency caloric density daily eating occasions low nutrient quality food choices increased portion size eating away home often particularly fastfood restaurants changing different food pattern weekends increased intake calorically sweetened beveragestargets teaching reducing caloric intake improving nutrient quality teach caloric content snacks knowadvertise healthy snacking options including use noncaloric beverages especially water teach portion size provide caloric information related serving size public establishments encourage eating home provide nutrition information point purchase teach constitutes meal including incorporation vegetables fruits whole grains leanvegetable protein sources encourage balancing occasions increased eating eg weekends holidays celebrations reduced caloric intake returning baseline weight teach limiting calorically sweetened beverage intake regulating portion size restricting availability sweetened beveragessnacks defined eating times traditional mealtimes represent 21 25 total caloric intake increased 18 last several decades3234 particular note energy density snack foods increased time period whereas energy density meals common snacks sugarsweetened beverages salty prepared foods chips low nutrient density studies smaller populations elementary students trends toward increased snacking observed despite participation highquality dietary intervention program suggesting altering snacking behavior difficult40over past 20 years substantial shift eating location significant decline meals eaten home increase meals eaten restaurants fastfood establishments particularly among younger individuals37 associated shift foods consumed significant increases sugarsweetened beverages fruit juice french fries pizza salty snacks declines reducedfat whole milkshifts patterns beverage intake contributed doubling per capita intake beverage calories adults since 1965 soda fruit drinks accounted 70 increase caloric intake2930 significant rise use lowfat presweetened dairy drinks interval however dairy drink consumption overall fallen similar changes seen children adolescents recent data suggesting continuing increases sugarsweetened beverage intake 10 15 caloric intake source41 impact dairy additives coffeetea drinks difficult analyze may another source increased caloric intake component increase caloric intake related beverages may lower relative satiety beverages compared solid foods4245with respect specific eating patterns consistent evidence eating breakfast including consumption highfiber readytoeat cereals milk associated improved overall nutrition weight maintenance4649 families regularly consume dinners together generally healthier diet patterns clear studies whether secondary better family knowledge50 least 1 largescale prospective study adolescents concluded frequency eating family dinner inversely associated overweight prevalence baseline predict likelihood becoming overweight51for young infants 4 6 months age daily energy intake obtained milk either breast milk formula transition solid food starts continues throughout second year child moves milk feeding baby foods adult foods nationally representative study infants data derived study based telephone interviews 24hour dietary recalls found 20 infants toddlers consume 1 fruit vegetable given day28 contrast 60 infants 6 11 months 80 12 24 months least 1 fruit drink day 2 years age parents reported 10 total energy came sugarsweetened beverages fruit juice french fries common vegetable consumed none top 5 vegetables consumed 2 years age green leafy vegetable frequency consumption nutrientpoor energydense snacks increases age5253taste preferencesit important understand development taste preferences devising strategies improve overall quality diet individual level taste preference critical food choice basic biology human sensory systems determines sensory impressions foods beverages flavor experienced food drink consumption product several sensory systems notably taste smell irritation eg coolness mint burn chili peppers foods liquids taken mouth perceptions arise senses taste smell combine determine flavor54 ability detect tastes flavors well developed birth infants start learning flavors first tastes foods flavors foods eaten mothers pregnancy lactation transmitted flavor amniotic fluid mothers milk respectively5556responses sweet salt bitter tastes evolved functional importance nutrient selection especially children whose responses salt sweet heightened salt signal nutrients sodium often accompany minerals food sufficient salt intake protects dehydration bitterness protects foods might poisonous preferences bitter foods eg dark green vegetables beverages eg coffee largely learned saltiness antagonizes bitter thus improves palatability useful foods bitter irritating taste57 sensation optimum saltiness influenced individuals salt status dietary level exposure5859children innate preference sweet group prefer 060moll sucrose concentration children like sweets sweets make feel better taste something sweet reduces pain6061 late adolescence sweet preferences decline 03 moll sucrose findings usda 1994 1996 continuing survey food intakes62 paralleled findings basic research agerelated decline sweet concentration preferences crosssectional data proportion energy obtained added sweeteners peaks adolescents 20 energy derived added sugars declines 124 energy 65 years age longitudinal data suggest consumption foods added sugar increased time63 striking individual group differences levels sweetness preferred example across age groups blacks nonhispanics prefer significantly higher levels sweetness whites6465because taste preferences drive food choice understanding source taste preferences suggest strategies dietary change lactating mothers influence taste preference infants consuming fruits vegetables transmitting flavors child555666 repeated offerings healthy foods may increase acceptance memories taste flavor smell carry emotional content derived culture rewards pleasurable past experience influences food choice thus early exposure healthy foods may influence preference67 although trying limit sweet salty food beverage consumption critical reversing obesity epidemic task difficult inherent hedonic value tastes products popular undergone rigorous taste preference testing release correspond natural taste preferences heavily marketed observations provide rationale nutrition marketing counter industry marketing concerning pleasurable normative quality unhealthy foodsindividual familybased interventions improve cardiovascular healththere substantial evidence usefulness dietary interventions improve blood pressure lipoprotein profiles1718 however meeting objectives clinical practice challenging two recent reviews obesity intervention literature concluded present significant evidence efficacy current strategies children6869 current canadian clinical practice guidelines concluded evidence recommending diet intervention obesity excellent evidence efficacy specific strategies generally lacking based largely consensus70 general qualitative metaanalytic data familybased weight loss approaches pediatric obesity administered trained behavioral therapists universitybased settings show significant reduction excess body weight compared waitlisted controls simple nutrition education7172 contrast little evidence support general efficacy informationbased strategies cause weight loss obese children73 challenge medical community making former efficacious programs cost effective available beyond current settingsapproaches implementation effective diet counselingdiet counseling historically information based like teaching counseling physicians nutritionists providing factual information underlying assumption simply learning facts patients clients change behavior significant limitations strategy first counseling may include assessment patients interest making dietary change second primary care providers notoriously low estimate selfefficacy regard nutrition counseling third providers unwilling confront patients regard weight issues finally time constraints restrictions reimbursement impose important limitations traditional medical office visits written material often provided materials may easily adapted patients specific circumstances patients literacy level may low comprehend material familys eating pattern determined diverse economic social factors may easily adapt recommended changes easy access recommended foods may exista listing many common barriers implementing nutrition advice provided table 7 many settings may useful identify barriers help families overcome possible providing specific advice dietary pattern barriers limit parents ability act role models children table 7 assess barriers families implementing nutrition adviceif present direct counseling barriers firstchaotic lifestyle characterized following families rarely eat together children multiple caregivers providing food throughout day one person oversees quality quantity food consumed eating frequently especially fastfood restaurants complex work schedules single parenting significant geographic distance traditional intact family support systemsunderdeveloped parenting skillsinadequate structuring meal times sleep schedules physical activity routineslack basic family rules enforce expectations around eating sleeping playinglimited food preparation skillslow knowledge daily caloric nutritional needsnutrition beliefsattitudes hostile healthy dietary patterncost mood convenience rather health drive food choice133chooses fast food snacks convenient comforting inexpensivesusceptible incorrect nutrition messages stream media including television computersuse commercial media source learning food portion size normal mealthink overweight physique normal