Commissioning

Total Building Commissioning is the Public Buildings Service process for quality assurance in new construction and facility modernization. It is the process for achieving, validating and documenting that the performance of the total building and its systems meet the design needs and requirements of the owner.

Malocclusion: Disease of Civilization, Part VIII

Three Case Studies in Occlusion

In this post, I'll review three cultures with different degrees of malocclusion over time, and try to explain how the factors I've discussed may have played a role.

The Xavante of Simoes Lopes

In 1966, Dr. Jerry D. Niswander published a paper titled "The Oral Status of the Xavantes of Simoes Lopes", describing the dental health and occlusion of 166 Brazilian hunter-gatherers from the Xavante tribe (free full text). This tribe was living predominantly according to tradition, although they had begun trading with the post at Simoes Lopes for some foods. They made little effort to clean their teeth. They were mostly but not entirely free of dental cavities:

Approximately 33% of the Xavantes at Simoes Lopes were caries free. Neel et al. (1964) noted almost complete absence of dental caries in the Xavante village at Sao Domingos. The difference in the two villages may at least in part be accounted for by the fact that, for some five years, the Simoes Lopes Xavante have had access to sugar cane, whereas none was grown at Sao Domingos. It would appear that, although these Xavantes still enjoy relative freedom from dental caries, this advantage is disappearing after only six years of permanent contact with a post of the Indian Protective Service.

The most striking thing about these data is the occlusion of the Xavante. 95 percent had ideal occlusion. The remaining 5 percent had nothing more than a mild crowding of the incisors (front teeth). Niswander didn't observe a single case of underbite or overbite. This would have been truly exceptional in an industrial population. Niswander continues:

Characteristically, the Xavante adults exhibited broad dental arches, almost perfectly aligned teeth, end-to-end bite, and extensive dental attrition. At 18-20 years of age, the teeth were so worn as to almost totally obliterate the cusp patterns, leaving flat chewing surfaces.

The Xavante were clearly hard on their teeth, and their predominantly hunter-gatherer lifestyle demanded it. They practiced a bit of "rudimentary agriculture" of corn, beans and squash, which would sustain them for a short period of the year devoted to ceremonies. Dr. James V. Neel describes their diet (free full text):

Despite a rudimentary agriculture, the Xavante depend very heavily on the wild products which they gather. They eat numerous varieties of roots in large quantities, which provide a nourishing, if starchy, diet. These roots are available all year but are particularly important in the Xavante diet from April to June in the first half of the dry season when there are no more fruits. The maize harvest does not last long and is usually saved for a period of ceremonies. Until the second harvest of beans and pumpkins, the Xavante subsist largely on roots and palmito (Chamacrops sp.), their year-round staples.

From late August until mid-February, there are also plenty of nuts and fruits available. The earliest and most important in their diet is the carob or ceretona (Ceretona sp.), sometimes known as St. John's bread. Later come the fruits of the buriti palm (Mauritia sp.) and the piqui (Caryocar sp.). These are the basis of the food supply throughout the rainy season. Other fruits, such as mangoes, genipapo (Genipa americana), and a number of still unidentified varieties are also available.

The casual observer could easily be misled into thinking that the Xavante "live on meat." Certainly they talk a great deal about meat, which is the most highly esteemed food among them, in some respects the only commodity which they really consider "food" at all... They do not eat meat every day and may go without meat for several days at a stretch, but the gathered products of the region are always available for consumption in the community.

Recently, the Xavante have begun to eat large quantities of fish.

The Xavante are an example of humans living an ancestral lifestyle, and their occlusion shows it. They have the best occlusion of any living population I've encountered so far. Here's why I think that's the case:

• A nutrient-rich, whole foods diet, presumably including organs.
  
• On-demand breast feeding for two or more years.
• No bottle-feeding or modern pacifiers.
• Tough foods on a regular basis.
  

I don't have any information on how the Xavante have changed over time, but Niswander did present data on another nearby (and genetically similar) tribe called the Bakairi that had been using a substantial amount of modern foods for some time. The Bakairi, living right next to the Xavante but eating modern foods from the trading post, had 9 times more malocclusion and nearly 10 times more cavities than the Xavante. Here's what Niswander had to say:

Severe abrasion was not apparent among the Bakairi, and the dental arches did not appear as broad and massive as in the Xavantes. Dental caries and malocclusion were strikingly more prevalent; and, although not recorded systematically, the Bakairi also showed considerably more periodontal disease. If it can be assumed that the Bakairi once enjoyed a freedom from dental disease and malocclusion equal to that now exhibited by the Xavantes, the available data suggest that the changes in occlusal patterns as well as caries and periodontal disease have been too rapid to be accounted for by an hypothesis involving relaxed [genetic] selection.

The Masai of Kenya

The Masai are traditionally a pastoral people who live almost exclusively from their cattle. In 1945, and again in 1952, Dr. J. Schwartz examined the teeth of 408 and 273 Masai, respectively (#1 free full text; #2 ref). In the first study, he found that 8 percent of Masai showed some form of malocclusion, while in the second study, only 0.4 percent of Masai were maloccluded. Although we don't know what his precise criteria were for diagnosing malocclusion, these are still very low numbers.

In both studies, 4 percent of Masai had cavities. Between the two studies, Schwartz found 67 cavities in 21,792 teeth, or 0.3 percent of teeth affected. This is almost exactly what Dr. Weston Price found when he visited them in 1935. From Nutrition and Physical Degeneration, page 138:

In the Masai tribe, a study of 2,516 teeth in eighty-eight individuals distributed through several widely separated manyatas showed only four individuals with caries. These had a total of ten carious teeth, or only 0.4 per cent of the teeth attacked by tooth decay.

Dr. Schwartz describes their diet:

The principal food of the Masai is milk, meat and blood, the latter obtained by bleeding their cattle... The Masai have ample means with which to get maize meal and fresh vegetables but these foodstuffs are known only to those who work in town. It is impossible to induce a Masai to plant their own maize or vegetables near their huts.

This is essentially the same description Price gave during his visit. The Masai were not hunter-gatherers, but their traditional lifestyle was close enough to allow good occlusion. Here's why I think the Masai had good occlusion:

• A nutrient-dense diet rich in protein and fat-soluble vitamins from pastured dairy.
• On-demand breast feeding for two or more years.
• No bottle feeding or modern pacifiers.
  

The one factor they lack is tough food. Their diet, composed mainly of milk and blood, is predominantly liquid. Although I think food toughness is a factor, this shows that good occlusion is not entirely dependent on tough food.

Sadly, the lifestyle and occlusion of the Masai has changed in the intervening decades. A paper from 1992 described their modern diet:

The main articles of diet were white maize, [presumably heavily sweetened] tea, milk, [white] rice, and beans. Traditional items were rarely eaten... Milk... was not mentioned by 30% of mothers.

A paper from 1993 described the occlusion of 235 young Masai attending rural and peri-urban schools. Nearly all showed some degree of malocclusion, with open bite alone affecting 18 percent.

Rural Caucasians in Kentucky

It's always difficult to find examples of Caucasian populations living traditional lifestyles, because most Caucasian populations adopted the industrial lifestyle long ago. That's why I was grateful to find a study by Dr. Robert S. Corruccini, published in 1981, titled "Occlusal Variation in a Rural Kentucky Community" (ref).

This study examined a group of isolated Caucasians living in the Mammoth Cave region of Kentucky, USA. Corruccini arrived during a time of transition between traditional and modern foodways. He describes the traditional lifestyle as follows:

Much of the traditional way of life of these people (all white) has been maintained, but two major changes have been the movement of industry and mechanized farming into the area in the last 25 years. Traditionally, tobacco (the only cash crop), gardens, and orchards were grown by each family. Apples, pears, cherries, plums, peaches, potatoes, corn, green beans, peas, squash, peppers, cucumbers, and onions were grown for consumption, and fruits and nuts, grapes, and teas were gathered by individuals. In the diet of these people, dried pork and fried [presumably in lard], thick-crust cornbread (which were important winter staples) provided consistently stressful chewing. Hunting is still very common in the area.

Although it isn't mentioned in the paper, this group, like nearly all traditionally-living populations, probably did not waste the organs or bones of the animals it ate. Altogether, it appears to be an excellent and varied diet, based on whole foods, and containing all the elements necessary for good occlusion and overall health.

The older generation of this population has the best occlusion of any Caucasian population I've ever seen, rivaling some hunter-gatherer groups. This shows that Caucasians are not genetically doomed to malocclusion. The younger generation, living on more modern foods, shows very poor occlusion, among the worst I've seen. They also show narrowed arches, a characteristic feature of deteriorating occlusion. One generation is all it takes. Corruccini found that a higher malocclusion score was associated with softer, more industrial foods.

Here are the reasons I believe this group of Caucasians in Kentucky had good occlusion:

• A nutrient-rich, whole foods diet, presumably including organs.
  
• Prolonged breast feeding.
• No bottle-feeding or modern pacifiers.
• Tough foods on a regular basis.
  

Common Ground

I hope you can see that populations with excellent teeth do certain things in common, and that straying from those principles puts the next generation at a high risk of malocclusion. Malocclusion is a serious problem that has major implications for health, well-being and finances. In the next post, I'll give a simplified summary of everything I've covered in this series. Then it's back to our regularly scheduled programming.

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Malocclusion: Disease of Civilization, Part VII

Jaw Development During Adolescence

Beginning at about age 11, the skull undergoes a growth spurt. This corresponds roughly with the growth spurt in the rest of the body, with the precise timing depending on gender and other factors. Growth continues until about age 17, when the last skull sutures cease growing and slowly fuse. One of these sutures runs along the center of the maxillary arch (the arch in the upper jaw), and contributes to the widening of the upper arch*:

This growth process involves MGP and osteocalcin, both vitamin K-dependent proteins. At the end of adolescence, the jaws have reached their final size and shape, and should be large enough to accommodate all teeth without crowding. This includes the third molars, or wisdom teeth, which will erupt shortly after this period.

Reduced Food Toughness Correlates with Malocclusion in Humans

When Dr. Robert Corruccini published his seminal paper in 1984 documenting rapid changes in occlusion in cultures around the world adopting modern foodways and lifestyles (see this post), he presented the theory that occlusion is influenced by chewing stress. In other words, the jaws require good exercise on a regular basis during growth to develop normal-sized bones and muscles. Although Dr. Corruccini wasn't the first to come up with the idea, he has probably done more than anyone else to advance it over the years.

Dr. Corruccini's paper is based on years of research in transitioning cultures, much of which he conducted personally. In 1981, he published a study of a rural Kentucky community in the process of adopting the modern diet and lifestyle. Their traditional diet was predominantly dried pork, cornbread fried in lard, game meat and home-grown fruit, vegetables and nuts. The older generation, raised on traditional foods, had much better occlusion than the younger generation, which had transitioned to softer and less nutritious modern foods. Dr. Corruccini found that food toughness correlated with proper occlusion in this population.

In another study published in 1985, Dr. Corruccini studied rural and urban Bengali youths. After collecting a variety of diet and socioeconomic information, he found that food toughness was the single best predictor of occlusion. Individuals who ate the toughest food had the best teeth. The second strongest association was a history of thumb sucking, which was associated with a higher prevalence of malocclusion**. Interestingly, twice as many urban youths had a history of thumb sucking as rural youths.

Not only do hunter-gatherers eat tough foods on a regular basis, they also often use their jaws as tools. For example, the anthropologist and arctic explorer Vilhjalmur Stefansson described how the Inuit chewed their leather boots and jackets nearly every day to soften them or prepare them for sewing. This is reflected in the extreme tooth wear of traditional Inuit and other hunter-gatherers.

Soft Food Causes Malocclusion in Animals

Now we have a bunch of associations that may or may not represent a cause-effect relationship. However, Dr. Corruccini and others have shown in a variety of animal models that soft food can produce malocclusion, independent of nutrition.

The first study was conducted in 1951. Investigators fed rats typical dry chow pellets, or the same pellets that had been crushed and softened in water. Rats fed the softened food during growth developed narrow arches and small mandibles (lower jaws) relative to rats fed dry pellets.

Other research groups have since repeated the findings in rodents, pigs and several species of primates (squirrel monkeys, baboons, and macaques). Animals typically developed narrow arches, a central aspect of malocclusion in modern humans. Some of the primates fed soft foods showed other malocclusions highly reminiscent of modern humans as well, such as crowded incisors and impacted third molars. These traits are exceptionally rare in wild primates.

One criticism of these studies is that they used extremely soft foods that are softer than the typical modern diet. This is how science works: you go for the extreme effects first. Then, if you see something, you refine your experiments. One of the most refined experiments I've seen so far was published by Dr. Daniel E. Leiberman of Harvard's anthropology department. They used the rock hyrax, an animal with a skull that bears some similarities to the human skull***.

Instead of feeding the animals hard food vs. mush, they fed them raw and dried food vs. cooked. This is closer to the situation in humans, where food is soft but still has some consistency. Hyrax fed cooked food showed a mild jaw underdevelopment reminiscent of modern humans. The underdeveloped areas were precisely those that received less strain during chewing.

Implications and Practical Considerations

Besides the direct implications for the developing jaws and face, I think this also suggests that physical stress may influence the development of other parts of the skeleton. Hunter-gatherers generally have thicker bones, larger joints, and more consistently well-developed shoulders and hips than modern humans. Physical stress is part of the human evolutionary template, and is probably critical for the normal development of the skeleton.

I think it's likely that food consistency influences occlusion in humans. In my opinion, it's a good idea to regularly include tough foods in a child's diet as soon as she is able to chew them properly and safely. This probably means waiting at least until the deciduous (baby) molars have erupted fully. Jerky, raw vegetables and fruit, tough cuts of meat, nuts, dry sausages, dried fruit, chicken bones and roasted corn are a few things that should stress the muscles and bones of the jaws and face enough to encourage normal development.


* These data represent many years of measurements collected by Dr. Arne Bjork, who used metallic implants in the maxilla to make precise measurements of arch growth over time in Danish youths. The graph is reproduced from the book A Synopsis of Craniofacial Growth, by Dr. Don M. Ranly. Data come from Dr. Bjork's findings published in the book Postnatal Growth and Development of the Maxillary Complex. You can see some of Dr. Bjork's data in the paper "Sutural Growth of the Upper Face Studied by the Implant Method" (free full text).

** I don't know if this was statistically significant at p less than 0.05. Dr. Corruccini uses a cutoff point of p less than 0.01 throughout the paper. He's a tough guy when it comes to statistics!

*** Retrognathic.

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Health

Health has been defined by the World Health Organization as "a state of complete physical, mental and social well-being". It thus transcends the absence of death, disease and disability, and incorporates concepts of well-being and quality of life; measures of health must likewise transcend mortality and morbidity. However, health does not exist in isolation, but rather it is the product of the interaction of our natural and built physical environments, socio-economic status, psycho-social conditions and cultural norms and beliefs with our physiological and psychological selves and our genetic inheritance.

To reflect this complexity, the Calvert-Henderson Health Indicator focuses on three basic questions: "Who gets a chance at life?", "How long will that life last?" and "How healthy will that life be?" Infant Mortality Rate is a measure of the first question, Life Expectancy is a measure of the second question and Self-Reported Health is one way of measuring the third question. All of these help to reveal inequalities in health both within the US and between the US and other countries.

These issues are important because, while the United States provides more health care services at higher costs per capita than any other country in the world, we rank below most of the wealthy nations and even some of the poorer nations in basic health statistics like infant mortality and life expectancy. In addition, the benefits of health care are spread unevenly across the population in the United States with large disparities depending on race, income and education levels. The graphs below show infant mortality rates according to the mothers' race, ethnicity and education level.

As the first graph shows, although there was progress in all the groups in reducing infant mortality rates between 1983 to 2004, the infant mortality rate for infants of Black or African American women in 2004 was more than double the rate among infants of white women and still well above the average of all women in 1983. The largest relative decline in Infant Mortality rates has been among the American Indian and Alaskan Native group, followed closely by the Hispanic and Asian/Pacific Islander groups (2004 rates declined 42% to 45% relative to their 1983 rates, see Table 1 for details) while the smallest decline was among infants of Black mothers (31% decline from 1983 rates). Thus, the comparative disadvantage of infant mortality for Black groups has actually worsened, from a ratio of 1.76 times the average rate in 1983 to nearly double the average rate in 2004 - inequality has actually worsened!

Mortality rates for infants go down as the level of education of the mother rises although even here there is a wide disparity between races as seen in this next graph.

The focus of national health efforts needs to be both on the improvement of overall health and well-being and the reduction - indeed the elimination - of disparities in health; disparities that are rooted both in the broader determinants of health and the differential access that people have to those determinants, and in biological differences. For this reason, the Calvert-Henderson Health Indicator also includes a measure of the quality of life people experience (such as self-reported health) as well as more conventional measures of mortality and or morbidity and allows an analysis and understanding of socio-economic, geographic, gender-based, ethno-cultural and other disparities, and the access - or lack of access - that people have to the fundamental determinants of he

As the graph above shows, people living below the poverty line are more than three times as likely to report their health as fair or poor compared to people with incomes at least double the poverty line. The range in the survey is a five point scale including excellent, very good, good, fair and poor, so fair and poor are below the midpoint of the scale. Poor was defined as below the poverty line, near poor had incomes between 100 and 200 percent of the poverty line and nonpoor had incomes more than twice the poverty line. In addition, there is a disparity in self-reported health in terms of race or ethnicity, as shown in the graph below.

The indicator offers a model of the current U.S. healthcare system to help clarify a systemic set of issues. Health is being redefined beyond the medical intervention model. Today, Americans are focusing on prevention, stress-reduction, and lifestyle choices. Tobacco and alcohol use, and even the availability of guns, are issues entering the public health debate. More Americans now consult "complementary" and "alternative" health providers than visit conventional medical doctors and facilities. This is a paradigm shift, which is restructuring the entire medical-industrial complex and its technocratic, bureaucratic approach that represents some 14 percent of GDP. New statistics are needed as the U.S. integrates these two very different approaches to health. The Calvert-Henderson Health Indicator is a first step towards an expanded concept of health to include acute intervention, remediation, disease prevention (and root cause diagnosis), education, and ultimately, behavior patterns to promote long-term health.

Does America Have the Best Health Care in the World?

Americans don't think so:

According to Americans, the United States does not have the best health care in the world. Most see our health care as average (32%) or below average (27%) when compared with health care in other industrialized countries. Only 15% support the often-used political talking point that America has the best health care in the world; 23% say it is above average.

If anything, they're being too generous. If you include the value we get for our dollar, and the grim landscape for the un- and underinsured, America's health care is far below average.

That paragraph, by the way, comes via Adam Serwer, who points out the "the survey also notes that the more money you make, the more likely you are to believe that America does have the best health care system in the world. That, I think, says a great deal about the inherent class bias present in our national debate on health care."

Health Insurance

Without health insurance, citizens often are unable to pay for the medical care they need, and frequently forego preventive measures that would make that care unnecessary. Approximately 13 percent of Hampton Roads residents under 65 years of age are uninsured.

Why is This Important?

Health insurance is defined as insurance against loss by illness or bodily injury. Health insurance generally provides coverage for medicine, visits to the doctor or emergency room, hospital stays, and other medical expenses. Policies differ in what they cover, the size of the deductible and/or co-payment, limits of coverage, and the options for treatment available to the policyholder. The uninsured population lacks coverage by any private or public health insurance. Research has shown individuals without health insurance have great difficulty accessing the health care system and frequently do not participate in preventive care programs.

How is Hampton Roads Doing?

Within Virginia in 2005, the Hampton Roads (13.3 percent) region had the lowest rate of uninsured residents under the age of 65 years. The Eastern region was highest at 19.1 percent and the state average was 14.5.

What Influences Health Insurance?

More than 200,000 people were estimated to be without health insurance in the Hampton Roads region in 2006 (Burris). Influences on health insurance in all regions include:

• Income Level: People with income at or below 200 percent of poverty (2008: $20,800 for an individual) are nearly twice as likely to be uninsured as people at higher income levels.

• Race and Ethnicity: Racial and ethnic minority groups are less likely to be insured than White Virginians.

• Age: Young adults are at greater risk for being uninsured than children and older adults.

• Employment Status: Unemployed individuals, part-time workers, and homemakers are at greater risk of being uninsured.

• Firm Size: Employees of very small firms are typically at greater risk of being uninsured.

Let the Pyramid guide your food choices

Different foods contain different nutrients and other healthful substances. No single food can supply all the nutrients in the amounts you need. For example, oranges provide vitamin C and folate but no vitamin B12; cheese provides calcium and vitamin B12; but no vitamin C. To make sure you get all the nutrients and other substances you need for health, build a healthy base by using the Food Guide Pyramid as a starting point. Choose the recommended number of daily servings from each of the five major food groups (box 7). If you avoid all foods from any of the five food groups, seek guidance to help ensure that you get all the nutrients you need. Box 7 HOW MANY SERVINGS DO YOU NEED EACH DAY? Food group Children ages 2 to 6 years, women, some older adults (about 1,600 calories) Older children, teen girls, active women, most men (about 2,200 calories) Teen boys, active men (about 2,800 calories) Bread, Cereal, Rice, and Pasta Group (Grains Group)—especially whole grain 6 9 11 Vegetable Group 3 4 5 Fruit Group 2 3 4 Milk, Yogurt, and Cheese Group (Milk Group)—preferably fat free or low fat 2 or 3* 2 or 3* 2 or 3* Meat, Poultry, Fish, Dry Beans, Eggs, and Nuts Group (Meat and Beans Group)—preferably lean or low fat 2, for a total of 5 ounces 2, for a total of 6 ounces 3, for a total of 7 ounces Adapted from U.S. Department of Agriculture, Center for Nutrition Policy and Promotion. The Food Guide Pyramid, Home and Garden Bulletin Number 252, 1996. * The number of servings depends on your age. Older children and teenagers (ages 9 to 18 years) and adults over the age of 50 need 3 servings daily. Others need 2 servings daily. During pregnancy and lactation, the recommended number of milk group servings is the same as for nonpregnant women. Figure 2 Click on image for full view of the "Food Guide Pyramid" Box 8 WHAT COUNTS AS A SERVING? Bread, Cereal, Rice, and Pasta Group (Grains Group)—whole grain and refined 1 slice of bread About 1 cup of ready-to-eat cereal 1/2 cup of cooked cereal, rice, or pasta Vegetable Group 1 cup of raw leafy vegetables 1/2 cup of other vegetables cooked or raw 3/4 cup of vegetable juice Fruit Group 1 medium apple, banana, orange, pear 1/2 cup of chopped, cooked, or canned fruit 3/4 cup of fruit juice Milk, Yogurt, and Cheese Group (Milk Group)* 1 cup of milk** or yogurt** 1 1/2 ounces of natural cheese** (such as Cheddar) 2 ounces of processed cheese** (such as American) Meat, Poultry, Fish, Dry Beans, Eggs, and Nuts Group (Meat and Beans Group) 2-3 ounces of cooked lean meat, poultry, or fish 1/2 cup of cooked dry beans# or 1/2 cup of tofu counts as 1 ounce of lean meat 2 1/2-ounce soyburger or 1 egg counts as 1 ounce of lean meat 2 tablespoons of peanut butter or 1/3 cup of nuts counts as 1 ounce of meat NOTE: Many of the serving sizes given above are smaller than those on the Nutrition Facts Label. For example, 1 serving of cooked cereal, rice, or pasta is 1 cup for the label but only 1/2 cup for thePyramid. * This includes lactose-free and lactose-reduced milk products. One cup of soy-based beverage with added calcium is an option for those who prefer a non-dairy source of calcium. ** Choose fat-free or reduced-fat dairy products most often. # Dry beans, peas, and lentils can be counted as servings in either the meat and beans group or the vegetable group. As a vegetable, 1/2 cup of cooked, dry beans counts as 1 serving. As a meat substitute, 1 cup of cooked, dry beans counts as 1 serving (2 ounces of meat). Use plant foods as the foundation of your meals There are many ways to create a healthy eating pattern, but they all start with the three food groups at the base of the Pyramid: grains, fruits, and vegetables. Eating a variety of grains (especially whole grain foods), fruits, and vegetables is the basis of healthy eating. Enjoy meals that have rice, pasta, tortillas, or whole grain bread at the center of the plate, accompanied by plenty of fruits and vegetables and a moderate amount of low-fat foods from the milk group and the meat and beans group. Go easy on foods high in fat or sugars. Keep an eye on servings Compare the recommended number of servings in box 7 and the serving sizes in box 8 with what you usually eat. If you don't need many calories (because you're inactive, for example), aim for the lower number of servings. Notice that some of the serving sizes in box 8 are smaller than what you might usually eat or see on food labels. For example, many people eat 2 slices of bread in a meal, which equal 2 servings. So it's easy to meet the recommended number of servings. Young children 2 to 3 years old need the same number of servings as others, but smaller serving sizes except for milk. Also, notice that many of the meals and snacks you eat contain items from several food groups. For example, a sandwich may provide bread from the grains group, turkey from the meat and beans group, and cheese from the milk group. Choose a variety of foods for good nutrition. Since foods within most food groups differ in their content of nutrients and other beneficial substances, choosing a variety helps you get all the nutrients and fiber you need. It can also help keep your meals interesting from day to day. There are many healthful eating patterns Different people like different foods and like to prepare the same foods in different ways. Culture, family background, religion, moral beliefs, the cost and availability of food, life experiences, food intolerances, and allergies affect people's food choices. Use the Food Guide Pyramid as a starting point to shape your eating pattern. It provides a good guide to make sure you get enough nutrients. Make choices from each major group in the Food Guide Pyramid, and combine them however you like. For example, those who like Mexican cuisine might choose tortillas from the grains group and beans from the meat and beans group, while those who eat Asian food might choose rice from the grains group and tofu from the meat and beans group. If you usually avoid all foods from one or two of the food groups, be sure to get enough nutrients from other food groups. For example, if you choose not to eat milk products because of intolerance to lactose or for other reasons, choose other foods that are good sources of calcium (see box 9), and be sure to get enough vitamin D. Meat, fish, and poultry are major contributors of iron, zinc, and B vitamins in most American diets. If you choose to avoid all or most animal products, be sure to get enough iron, vitamin B12, calcium, and zinc from other sources. Vegetarian diets can be consistent with the Dietary Guidelines for Americans, and meet Recommended Dietary Allowances for nutrients. Box 9 SOME SOURCES OF CALCIUM* Yogurt# Milk**# Natural cheeses such as Mozzarella, Cheddar, Swiss, and Parmesan# Soy-based beverage with added calcium Tofu, if made with calcium sulfate (read the ingredient list) Breakfast cereal with added calcium Canned fish with soft bones such as salmon, sardines† Fruit juice with added calcium Pudding made with milk# Soup made with milk# Dark-green leafy vegetables such as collards, turnip greens * Read food labels for brand-specific information. ** This includes lactose-free and lactose-reduced milk. # Choose low-fat or fat-free milk products most often. † High in salt. Growing children, teenagers, women, and older adults have higher needs for some nutrients Adolescents and adults over age 50 have an especially high need for calcium, but most people need to eat plenty of good sources of calcium for healthy bones throughout life. When selecting dairy products to get enough calcium, choose those that are low in fat or fat-free to avoid getting too much saturated fat. Young children, teenage girls, and women of childbearing age need enough good sources of iron, such as lean meats and cereals with added nutrients, to keep up their iron stores (see box 10). Women who could become pregnant need extra folic acid, and older adults need extra vitamin D. Box 10 SOME SOURCES OF IRON* Shellfish like shrimp, clams, mussels, and oysters Lean meats (especially beef), liver** and other organ meats** Ready-to-eat cereals with added iron Turkey dark meat (remove skin to reduce fat) Sardines† Spinach Cooked dry beans (such as kidney beans and pinto beans), peas (such as black-eyed peas), and lentils Enriched and whole grain breads * Read food labels for brand-specific information. ** Very high in cholesterol. † High in salt. Click on image for full view of "How to Read a Nutrition Facts Label" Check the food label before you buy Food labels have several parts, including the front panel, Nutrition Facts, and ingredient list. The front panel often tells you if nutrients have been added—for example, "iodized salt" lets you know that iodine has been added, and "enriched pasta" (or "enriched" grain of any type) means that thiamin, riboflavin, niacin, iron, and folic acid have been added. The ingredient list tells you what's in the food, including any nutrients, fats, or sugars that have been added. The ingredients are listed in descending order by weight. See figure 3 to learn how to read the Nutrition Facts. Use the Nutrition Facts to see if a food is a good source of a nutrient or to compare similar foods—for example, to find which brand of frozen dinner is lower in saturated fat, or which kind of breakfast cereal contains more folic acid. Look at the % Daily Value (%DV) column to see whether a food is high or low in nutrients. If you want to limit a nutrient (such as fat, saturated fat, cholesterol, sodium), try to choose foods with a lower %DV. If you want to consume more of a nutrient (such as calcium, other vitamins and minerals, fiber), try to choose foods with a higher %DV. As a guide, foods with 5%DV or less contribute a small amount of that nutrient to your eating pattern, while those with 20% or more contribute a large amount. Remember, Nutrition Facts serving sizes may differ from those used in the Food Guide Pyramid (see box 8). For example, 2 ounces of dry macaroni yields about 1 cup cooked, or two (1/2 cup) Pyramid servings. Use of dietary supplements Some people need a vitamin-mineral supplement to meet specific nutrient needs. For example, women who could become pregnant are advised to eat foods fortified with folic acid or to take a folic acid supplement in addition to consuming folate-rich foods to reduce the risk of some serious birth defects. Older adults and people with little exposure to sunlight may need a vitamin D supplement. People who seldom eat dairy products or other rich sources of calcium need a calcium supplement, and people who eat no animal foods need to take a vitamin B12 supplement. Sometimes vitamins or minerals are prescribed for meeting nutrient needs or for therapeutic purposes. For example, health care providers may advise pregnant women to take an iron supplement, and adults over age 50 to get their vitamin B12 from a supplement or from fortified foods. Supplements of some nutrients, such as vitamin A and selenium, can be harmful if taken in large amounts. Because foods contain many substances that promote health, use the Food Guide Pyramid when choosing foods. Don't depend on supplements to meet your usual nutrient needs. Dietary supplements include not only vitamins and minerals, but also amino acids, fiber, herbal products, and many other substances that are widely available. Herbal products usually provide a very small amount of vitamins and minerals. The value of herbal products for health is currently being studied. Standards for their purity, potency, and composition are being developed. ADVICE FOR TODAY Build a healthy base: Use the Food Guide Pyramid to help make healthy food choices that you can enjoy. Build your eating pattern on a variety of plant foods, including whole grains, fruits, and vegetables. Also choose some low-fat dairy products and low-fat foods from the meat and beans group each day. It's fine to enjoy fats and sweets occasionally. Choose a variety of grains daily, especially whole grains Foods made from grains (wheat, rice, and oats) help form the foundation of a nutritious diet. They provide vitamins, minerals, carbohydrates (starch and dietary fiber), and other substances that are important for good health. Grain products are low in fat, unless fat is added in processing, in preparation, or at the table. Whole grains differ from refined grains in the amount of fiber and nutrients they provide, and different whole grain foods differ in nutrient content, so choose a variety of whole and enriched grains. Eating plenty of whole grains, such as whole wheat bread or oatmeal (see box 11), as part of the healthful eating patterns described by these guidelines, may help protect you against many chronic diseases. Aim for at least 6 servings of grain products per day—more if you are an older child or teenager, an adult man, or an active woman (see box 7)—and include several servings of whole grain foods. See box 8 for serving sizes. Why choose whole grain foods? Vitamins, minerals, fiber, and other protective substances in whole grain foods contribute to the health benefits of whole grains. Refined grains are low in fiber and in the protective substances that accompany fiber. Eating plenty of fiber-containing foods, such as whole grains (and also many fruits and vegetables) promotes proper bowel function. The high fiber content of many whole grains may also help you to feel full with fewer calories. Fiber is best obtained from foods like whole grains, fruits, and vegetables rather than from fiber supplements for several reasons: there are many types of fiber, the composition of fiber is poorly understood, and other protective substances accompany fiber in foods. Use the Nutrition Facts Label to help choose grains that are rich in fiber and low in saturated fat and sodium. Box 11 HOW TO INCREASE YOUR INTAKE OF WHOLE GRAIN FOODS Choose foods that name one of the following ingredients first on the label's ingredient list (see sample in figure 4). brown rice oatmeal whole oats bulgur (cracked wheat) popcorn whole rye graham flour pearl barley whole wheat whole grain corn Try some of these whole grain foods: whole wheat bread, whole grain ready-to-eat cereal, low-fat whole wheat crackers, oatmeal, whole wheat pasta, whole barley in soup, tabouli salad. NOTE: "Wheat flour," "enriched flour," and "degerminated corn meal" are not whole grains. Figure 4 SAMPLE INGREDIENT LIST FOR A WHOLE GRAIN FOOD INGREDIENTS: WHOLE WHEAT FLOUR, WATER, HIGH FRUCTOSE CORN SYRUP, WHEAT GLUTEN, SOYBEAN AND/ OR CANOLA OIL, YEAST, SALT, HONEY. Enriched grains are a new source of folic acid Folic acid, a form of folate, is now added to all enriched grain products (thiamin, riboflavin, niacin, and iron have been added to enriched grains for many years). Folate is a B vitamin that reduces the risk of some serious types of birth defects when consumed before and during early pregnancy. Studies are underway to clarify whether it decreases risk for coronary heart disease, stroke, and certain types of cancer. Whole grain foods naturally contain some folate, but only a few (mainly ready-to-eat breakfast cereals) contain added folic acid as well. Read the ingredient label to find out if folic acid and other nutrients have been added, and check the Nutrition Facts Label to compare the nutrient content of foods like breakfast cereals. ADVICE FOR TODAY Build a healthy base by making a variety of grain products a foundation of your diet. Eat 6 or more servings of grain products daily (whole grain and refined breads, cereals, pasta, and rice). Include several servings of whole grain foods daily for their good taste and their health benefits. If your calorie needs are low, have only 6 servings of a sensible size daily ( see box 8for examples of serving sizes). Eat foods made from a variety of whole grains—such as whole wheat, brown rice, oats, and whole grain corn—every day. Combine whole grains with other tasty, nutritious foods in mixed dishes. Prepare or choose grain products with little added saturated fat and a moderate or low amount of added sugars. Also, check the sodium content on the Nutrition Facts Label.

Choose a variety of fruits and vegetables daily

Fruits and vegetables are key parts of your daily diet. Eating plenty of fruits and vegetables of different kinds, as part of the healthful eating patterns described by these guidelines, may help protect you against many chronic diseases. It also promotes healthy bowel function. Fruits and vegetables provide essential vitamins and minerals, fiber, and other substances that are important for good health. Most people, including children, eat fewer servings of fruits and vegetables than are recommended. To promote your health, eat a variety of fruits and vegetables—at least 2 servings of fruits and 3 servings of vegetables—each day. Why eat plenty of different fruits and vegetables? Different fruits and vegetables are rich in different nutrients (see box 12). Some fruits and vegetables are excellent sources of carotenoids, including those which form vitamin A, while others may be rich in vitamin C, folate, or potassium. Fruits and vegetables, especially dry beans and peas, also contain fiber and other substances that are associated with good health. Dark-green leafy vegetables, deeply colored fruits, and dry beans and peas are especially rich in many nutrients. Most fruits and vegetables are naturally low in fat and calories and are filling. Some are high in fiber, and many are quick to prepare and easy to eat. Choose whole or cut-up fruits and vegetables rather than juices most often. Juices contain little or no fiber. Box 12 WHICH FRUITS AND VEGETABLES PROVIDE THE MOST NUTRIENTS? The lists below show which fruits and vegetables are the best sources of vitamin A (carotenoids), vitamin C, folate, and potassium. Eat at least 2 servings of fruits and at least 3 servings of vegetables each day: Sources of vitamin A (carotenoids) Orange vegetables like carrots, sweet potatoes, pumpkin Dark-green leafy vegetables such as spinach, collards, turnip greens Orange fruits like mango, cantaloupe, apricots Tomatoes Sources of vitamin C Citrus fruits and juices, kiwi fruit, strawberries, cantaloupe Broccoli, peppers, tomatoes, cabbage, potatoes Leafy greens such as romaine lettuce, turnip greens, spinach Sources of folate Cooked dry beans and peas, peanuts Oranges, orange juice Dark-green leafy vegetables like spinach and mustard greens, romaine lettuce Green peas Sources of potassium Baked white or sweet potato, cooked greens (such as spinach), winter (orange) squash Bananas, plantains, dried fruits such as apricots and prunes, orange juice Cooked dry beans (such as baked beans) and lentils NOTE: Read Nutrition Facts Labels for product-specific information, especially for processed fruits and vegetables. Aim for Variety Try many colors and kinds. Choose any form: fresh, frozen, canned, dried, juices. All forms provide vitamins and minerals, and all provide fiber except for most juices—so choose fruits and vegetables most often. Wash fresh fruits and vegetables thoroughly before using. If you buy prepared vegetables, check the Nutrition Facts Label to find choices that are low in saturated fat and sodium. Try serving fruits and vegetables in new ways: raw vegetables with a low- or reduced-fat dip vegetables stir-fried in a small amount of vegetable oil fruits or vegetables mixed with other foods in salads, casseroles, soups, sauces (for example, add shredded vegetables when making meatloaf) Find ways to include plenty of different fruits and vegetables in your meals and snacks Buy wisely. Frozen or canned fruits and vegetables are sometimes best buys, and they are rich in nutrients. If fresh fruit is very ripe, buy only enough to use right away. Store properly to maintain quality. Refrigerate most fresh fruits (not bananas) and vegetables (not potatoes or tomatoes) for longer storage, and arrange them so you'll use up the ripest ones first. If you cut them up or open a can, cover and refrigerate afterward. Keep ready-to-eat raw vegetables handy in a clear container in the front of your refrigerator for snacks or meals-on-the-go. Keep a day's supply of fresh or dried fruit handy on the table or counter. Enjoy fruits as a naturally sweet end to a meal. When eating out, choose a variety of vegetables at a salad bar. ADVICE FOR TODAY Enjoy 5 a day—eat at least 2 servings of fruit and at least 3 servings of vegetables each day (see box 8 for serving sizes). Choose fresh, frozen, dried, or canned forms and a variety of colors and kinds. Choose dark-green leafy vegetables, orange fruits and vegetables, and cooked dry beans and peas often.

Keep food safe to eat

Foods that are safe from harmful bacteria, viruses, parasites, and chemical contaminants are vital for healthful eating. Safe means that the food poses little risk of foodborne illness (see box 13). Farmers, food producers, markets, food service establishments, and other food preparers have a role to keep food as safe as possible. However, we also need to keep and prepare foods safely in the home, and be alert when eating out. Box 13 WHAT IS FOODBORNE ILLNESS? Foodborne illness is caused by eating food that contains harmful bacteria, toxins, parasites, viruses, or chemical contaminants. Bacteria and viruses, especially Campylobacter, Salmonella,and Norwalk-like viruses, are among the most common causes of foodborne illness we know about today. Eating even a small portion of an unsafe food may make you sick. Signs and symptoms may appear within half an hour of eating a contaminated food or may not develop for up to 3 weeks. Most foodborne illness lasts a few hours or days. Some foodborne illnesses have effects that go on for weeks, months, or even years. If you think you have become ill from eating a food, consult your health care provider. Follow the steps below to keep your food safe. Be very careful with perishable foods such as eggs, meats, poultry, fish, shellfish, milk products, and fresh fruits and vegetables. If you are at high risk of foodborne illness, be extra careful (see box 14). Box 14 TIPS FOR THOSE AT HIGH RISK OF FOODBORNE ILLNESS Who is at high risk of foodborne illness? Pregnant women Young children Older persons People with weakened immune systems or certain chronic illnesses Besides following the guidance in this guideline, some of the extra precautions those at high risk should take are: Do not eat or drink unpasteurized juices, raw sprouts, raw (unpasteurized) milk and products made from unpasteurized milk. Do not eat raw or undercooked meat, poultry, eggs, fish, and shellfish (clams, oysters, scallops, and mussels). New information on food safety is constantly emerging. Recommendations and precautions for people at high risk are updated as scientists learn more about preventing foodborne illness. If you are among those at high risk, you need to be aware of and follow the most current information on food safety. For the latest information and precautions, call USDA's Meat and Poultry Hotline, 1-800-535-4555,or FDA's Food Information Line, 1-888-SAFE FOOD, or consult your health care provider. You can also get up-to-date information by checking the government's food safety website athttp://www.foodsafety.gov. Clean. Wash hands and surfaces often Wash your hands with warm soapy water for 20 seconds (count to 30) before you handle food or food utensils. Wash your hands after handling or preparing food, especially after handling raw meat, poultry, fish, shellfish, or eggs. Right after you prepare these raw foods, clean the utensils and surfaces you used with hot soapy water. Replace cutting boards once they have become worn or develop hard-to-clean grooves. Wash raw fruit and vegetables under running water before eating. Use a vegetable brush to remove surface dirt if necessary. Always wash your hands after using the bathroom, changing diapers, or playing with pets. When eating out, if the tables, dinnerware, and restrooms look dirty, the kitchen may be, too—so you may want to eat somewhere else. Separate. Separate raw, cooked, and ready-to-eat foods while shopping, preparing, or storing Keep raw meat, poultry, eggs, fish, and shellfish away from other foods, surfaces, utensils, or serving plates. This prevents cross-contamination from one food to another. Store raw meat, poultry, fish, and shellfish in containers in the refrigerator so that the juices don't drip onto other foods. Cook. Cook foods to a safe temperature Uncooked and undercooked animal foods are potentially unsafe. Proper cooking makes most uncooked foods safe. The best way to tell if meat, poultry, or egg dishes are cooked to a safe temperature is to use a food thermometer(figure 5). Several kinds of inexpensive food thermometers are available in many stores. Reheat sauces, soups, marinades, and gravies to a boil. Reheat leftovers thoroughly to at least 165° F. If using a microwave oven, cover the container and turn or stir the food to make sure it is heated evenly throughout. Cook eggs until whites and yolks are firm. Don't eat raw or partially cooked eggs, or foods containing raw eggs, raw (unpasteurized) milk, or cheeses made with raw milk. Choose pasteurized juices. The risk of contamination is high from undercooked hamburger, and from raw fish (including sushi), clams, and oysters. Cook fish and shellfish until it is opaque; fish should flake easily with a fork. When eating out, order foods thoroughly cooked and make sure they are served piping hot. Chill. Refrigerate perishable foods promptly When shopping, buy perishable foods last, and take them straight home. At home, refrigerate or freeze meat, poultry, eggs, fish, shellfish, ready-to-eat foods, and leftovers promptly. Refrigerate within 2 hours of purchasing or preparation—and within 1 hour if the air temperature is above 90ş F. Refrigerate at or below 40ş F, or freeze at or below 0ş F. Use refrigerated leftovers within 3 to 4 days. Freeze fresh meat, poultry, fish, and shellfish that cannot be used in a few days. Thaw frozen meat, poultry, fish, and shellfish in the refrigerator, microwave, or cold water changed every 30 minutes. (This keeps the surface chilled.) Cook foods immediately after thawing. Never thaw meat, poultry, fish, or shellfish at room temperature. When eating out, make sure that any foods you order that should be refrigerated are served chilled. Follow the label Read the label and follow safety instructions on the package such as "KEEP REFRIGERATED" and the "SAFE HANDLING INSTRUCTIONS." Serve safely Keep hot foods hot (140ş F or above) and cold foods cold (40ş F or below). Harmful bacteria can grow rapidly in the "danger zone" between these temperatures. Whether raw or cooked, never leave meat, poultry, eggs, fish, or shellfish out at room temperature for more than 2 hours (1 hour in hot weather 90ş F or above). Be sure to chill leftovers as soon as you are finished eating. These guidelines also apply to carry-out meals, restaurant leftovers, and home-packed meals-to-go. When in doubt, throw it out If you aren't sure that food has been prepared, served, or stored safely, throw it out. You may not be able to make food safe if it has been handled in an unsafe manner. For example, a food that has been left at room temperature too long may contain a toxin produced by bacteria—one that can't be destroyed by cooking. So if meat, poultry, fish, shellfish, or eggs have been left out for more than 2 hours, or if the food has been kept in the refrigerator too long, don't taste it. Just throw it out. Even if it looks and smells fine, it may not be safe to eat. If you have doubt when you're shopping or eating out, choose something else. For more information, contact USDA's Meat and Poultry Hotline, 1-800-535-4555, or FDA's Food Information Line, 1-888-SAFE FOOD. Also, ask your local or state health department or Cooperative Extension Service Office for further guidance. ADVICE FOR TODAY Build a healthy base by keeping food safe to eat. Clean. Wash hands and surfaces often. Separate. Separate raw, cooked, and ready-to-eat foods while shopping, preparing, or storing. Cook. Cook foods to a safe temperature. Chill. Refrigerate perishable foods promptly. Check and follow the label. Serve safely. Keep hot foods hot and cold foods cold. When in doubt, throw it out.