illness related to consumption of foods or beverages containing disease-causing bacteria, viruses, marine organisms, fungi, toxins, parasites, or other contaminants

-most common are bacteria and viruses 

1-salmonella

2-campylobacter

3-e.coli 

4-norwalk-like 

-through contaminated food, raw food- milk, shellfish, meat, eggs, spreads

nausea, vomiting, abdominal cramps, diarrhea

-more severe in people with weakened immune systems or certain chronic illnesses, pregnant women, or old/young people

danger zone for bacterial growth is between 40F and 135F

-store frozen foods below 0F

-store refrigerated food below 40F

Clean

Separate 

Cook

Chill

cross contamination 

from the inside (fruits/veggies with broken skin)

through feces

many cases go unreported 

-mandatory for most processed foods

-voluntary for fresh meat, poultry, fish, milk, eggs, and produce

-established standardized nutrition facts panel

-set standard portion sizes as commonly consumed 

-not required for :

bakery foods

packaging with label too small to fit

on restaurant menus unless nutrition claims

Nutrition act panel that provides details of nutrient content and ingredients on food

-simplifies comparison to other foods

required to show content of fat, trans fat, sat fat, cholesterol, sodium, dietary fiber, vitamins A and C, calcium, and iron

-nutrients associated with health or nutrition claim on package label must be included

levels for nutrients development specifically for nutrition labeled based on Recommended Dietary Allowances

-based on 2000 calorie diet  

both must have FDA approval to be used on label

must conform to standard definitions

-free, low, reduced, less ,fewer, light, lean, extra, good source of

may be used for food components scientifically agreed upon to have benefits of disease prevention 

"FDA approves health claims for food products that are not high in fat,  saturated fat, cholesterol, or sodium

vitamin and mineral content of food is increased

-helps prevent deficiency in diseases such as rickets, pellagra, and goiter

-regular use of vitamin and mineral supps and liberal intake of fortified foods raises chance of excessive amounts

pertains only to refined grain products where thiamin, riboflavin, niacin, and iron lost in milling are added

-1998 law required folate to be added to refined grains

-refers to the addition of one or more vitamins and/or minerals to a food product 

-reduce risk of chronic diseases such as osteoporosis, cancer and heart disease

all must be listed in descending order of amount present

-ingredient that is greatest portion of weight listed first

-ingredients causing allergic reaction must be listed (milk, solids, peanuts, sulfites, egg whites)

-% of fruit juice content must be listed

new in 2011

-replaces MyPyramid 

-provides calories, nutrients, and other components in the right proportion 

-diets that provide too many calories than to maintain healthy body weight are not balanced

Carboyhydrates: 45-65% of total calories

Fat- 20-35% total calories

Protein: 10-35% total calories

-number of calories in a gram of food

-number of calories in a portion divided by the food's weight in grams 

-tend to be nutrient poor while nutrient-rich foods tend to not be energy dense

US diets tend to be high in energy dense diets

-associated with overeating, weight gain, obesity, type 2 diabetes

-published by USDA and HHS

-updated every 5 years

-evidence based guidelines to promote health and reduce risk for major chronic disease

-for people 2 and older

-basis for federal food and nutrition edu programs

-stresses consumption of nutrient-dense food, balance of caloric intake/output, and increasing physical activity

-balance calories with physical activity to manage weight

-consume more of certain foods and nutrients such as fruits, veggies, whole grains, fat-free, and low fat dairy products, and seafood

-consume fewer foods with sodium, saturated fat, trans fat, cholesterol, added sugars, and refined grains

-helps control mild/moderate hypertension 

-limits fats, red meats, sweets, sugary drinks

-a unit of measure of energy

-amount of energy needed to raise 1 kilogram of water 1C

carbs, proteins, fats (the energy nutrients)

-fats provide twice as many calories per unit as carbs/proteins

-most foods are a mixture

when calorie intake greater than need for energy

basal metabolism 

physical activity 

dietary thermogenesis 

-used 60-80% of total calories for ongoing activities to sustain life and health

-growth is component

-calories for BM highest during growing years

-continuous activities the body performs to sustain life

-energy need for BM is measured when body is in complete physical and emotional rest

for men- body weight in lbs x 11

for women- body weight in lb x 10.1 (round to 10)

physical activity level

muscle mass, height, health status, genetic traits

-calories needed for physical activity vary according to how active you are

-energy cost of inactive lifestyle 30% of calories for basal metabolism 

-average activity level requires roughly 50%

-active level requires approx 75%

-calories for dietary thermogenesis are about 10% of sum of basal metabolic and physical activity calories

-signal from brain, stomach, liver, fat cells indicate satiety, feeling that we've had enough to eat 

-hunger signals when cells run low on energy

How to calculate energy needs given gender, body weight, and activity level

NEED

1. body weight x 11 if man 10 if girl -- gets basal metabolism rate

2. then BMR x .3 if sedentary, .5 if moderate, .75 if active= active calories

3. (active calories + BMR)x .1 = dietary thermogenesis 

4. add the totals from each category to get the total calories the person needs

-body mechanisms encourage regular calorie intake 

-mechanisms are independent of weight

-hunger signals when cells run low on energy

-signal from brain, stomach, liver, fat cells indicate satiety, feeling that we have when we eat enough 

-appetite is urge for pleasure of eating, may or may not be related t hunger, triggered by smell or sight of food

-hunger and satiety mechanisms adjust intake 

-internal signals can be overriden

-people resist eating in spite of hunger pains

-ppl can go on eating after the "full" signal

-ppl may eat due to appetite

adults maintaing weight are in energy balance

-unchanged weight means energy input and output are balanced

-negative energy balance

-energy stores are used and people lose weight

-positive energy balance

-here energy stores are gained, more energy available than needed

-normal in growth or when regaining weight after illness

smoking

lean muscle mass

genetic makeup

-people who smoke use more calories and muscular individuals need more energy to maintain body weight

hunger- need to eatfood

satiety- absence of hunger

appetite- desire to eat food

hypertension

type 2 diabetes

coronary heart disease

gallbladder disease

certain cancers (breast, esophagus)

dyslipidemia (elevated cholesterol)

stroke

osteoarthritis 

sleep apnea

-overweight or obese is normal in US

-2/3 of US is obese- this is rising 

-obesity is our #1 health problem

-diet

-physical activity

-environmental factors

-genetic factors

-regulation of food intake and storage are in large genetically determined

-underweight was a disadvantage for our ancestors

-multiple mechanisms for enhanced intake and fat storage were key to survival

-inborn mechanisms constantly encourage food intake

-changes in availability and accessibility of food can explain why obesity is a major problem 

underweight- <18.5 kg/m2

normal- 18.5-24.9

overweight- 25-29.9

obese: greater than 30

70% of obese people have metabolic abnormalities that increase disease risk

-hypertension

-elevated triglycerides, glucose, or insulin

-low HDL- cholesterol "good cholesterol"

-high C-reactive protein (inflammation marker)

-10-15% weight loss decrease risks

body fat not BMI percentile should be used to diagnose obesity in children and adults

-use of weight charts to analyze body fat 

blood pressure, LDL cholesterol, risk of diabetes, and increases HDL cholesterol 

-weight-for-height and percent body do no always correspond 

-muscular people can have obese BMI

-if people retain fluid, BMI may show overweight but body fat may be low

-inactive normal BMI people can still have too much body fat

-health problems associated with obesity are related to where excess fat is stored

risk of abdominal body fat

fat cells of central fat deposits are larger than those around the hips and resistant to insulin

-decrease ability of insulin to lower blood glucose

-insulin and glucose increase over time

-insulin and glucose over time

-increased insulin

abdominal body fat cont.

increased insulin

-increases triglyceride levels and blood pressure, reduces levels of HDL

-increases risk hypertension and heart disease

-promotes the development of diabetes

-Metabolic syndrome

3-5% for men

10-12% for women

stronger predictor of heart disease, stroke, and diabetes than BMI

-waist less than 40 inches in men and 35 inches in women decreases risk of these diseases

essential in manufacturing hormones

required component of every cell in body

major body fat gains are most likely in ages 25 to 40

-delayed physical maturation during adolescence 

-infertility 

-accelerated bone loss

-problems that accompany starvation

worldwide, underweight is more common than obesity

-preventable cause of underweight in US is poverty

-less than 20% of body fat in adult females and 8% body fat in males

90-95% of people who lose weight gain it back

reserved for obese people (over 40 BMI)

or people with marked obesity (over 35 BMI) whose health is in jeopardy (presence of co-morbity)

good- leads to an average loss of 100 plus pounds- majority within the first year 

-can improve blood sugar control, reduce risk for heart disease and lower blood pressure

bad- reduces vitamin B12 absorption and increases osteoporosis risk

eat a diet low in total fat

frequent self-monitoring of body weight and food intake

-high levels of regular physical activity 

any bodily movement by skeletal muscles that results in energy expenditure  about resting (basal) levels

-broadly encompasses exercise, sports, and physical activities done as part of daily living, occupation, leisure, and active transportation 

cardio respiratory fitness

muscular strength and endurance

body composition

flexibility

balance

agility

reaction time

power

unit used to estimate the amount of oxygen used by the body during physical activity

-1 MET is the energy (oxygen) used by the body at rest

-the harder your body works, the higher the MET

activity that involves little or no movement or physical activity

-sitting, watching tv, playing video games

engage in moderate-intensity cardio respiratory exercise training for 30 min/day, on 5 d/week, total of 150 min a week

-engage in vigorous activity cardio respiratory intensity to achieve a total energy expenditure of 500-100 MET-min-wekk or 100kcal/week

any physical activity that burns 3.5 - 7 calories per min (3-6 METS)

-walking briskly, mowing lawn, dancing, swimming

-modest breathing, light sweat

-calories expended through activity

-increased lean body mass (increase metabolic rate)

- strength, endurance, flexibility 

-stretching major muscle groups increases range of motion of joints and muscles

-helps protect muscles and connective tissues from injury, stiffness and pain

-critical to maintain joint range movement

-do 2 or more day/week series of flexibility excercises

-endurance

-oxygen use = aerobic fitness

-able to exercise longer and harder

-jogging, basketball, swimming, other low- or moderate intensity activities

measuring maximal oxygen consumption 

-people can perform phys activity at 100% of VO2 max for only a few minutes

-estimate of VO2 max uses % of maximal heart rate (MHR)

-220-age = MHR

muscles can use fat, glucose, and amino acids for enrgy

-proportions and amount of each used depends on intensity of exercise

required to convert fat into energy

-activities of low-to-moderate intensity are aerobic or oxygen requiring

-fat-burning, oxygen-requiring exercises are the type used to increase aerobic fitness

glucose that comes from glycogen

-stored in muscles and liver and are rapidly converted to glucose when needed

conversion of glucose to energy for intesnse activity that doesnt require oxygen

-people can do intensive activity only as long as stores of glucose last

best diet for phy fitness includes veggies, fruits, whole grains, lean meats and fish, low fat dairy

-maintains normal weight and prevents chronic disease (heart disease)

-supply adequate vitamins, minerals, essential fatty acids, fiber, fluid, and phytochemicals

-incluse well-planned vegetarian diets

-studies show active ppl have beet diets than sedentary ppl

physical activity increases need

-drink to replace fluid lost in respiration, sweat, and urine 

-water lost during exercise equal weight lost during exercise 

-adequately hydrated means urine is pale yellow, normal volume

ACSM and CDC recommend levels that benefit health or contribute to decline in obesity in US

-children/adolescents- one plus hour of moderate or vigorous aerobic activity a day and vigorous at least 3 days a week

-adults- 2 1/2 hours of moderate aerobic per week or 1 hr 15 min of vigorous 

adenosine triphosphate 

-energy rich compound used for all energy-requiring processes in the body

ATP formed anaerobically (without oxygen) or aerobically (with oxygen)

-source of energy for muscle

athletes in short events stay hydrated from two cups of water 15-20 minutes before the event

-for longer events or hot and humid conditions should maintain fluid balance

-fluid balance maintained when no weight is lost and urine remains pale yellow and normal volume 

loss above 2% of body weight (2-4 pounds) during an event indicates body is dehydrated 

-any amount impairs performance

-extreme can leads to heat exhaustion or heat stroke

sodium deficiency

-occurs when only water is consumed during long events

advantages of low body weight and fat vanish when they are too low

-body fat levels less than 3% in men and less than 12% is women seriously interfere with health

women at high risk of bone fractures are those with female athlete triad of disordered eating, amenorrhea and osteoporosis

-higher risk of iron-deficiency anemia than other females

substances that claim to increase the capacity for muscular work

-relatively few work, most are not tested for safety

duration of pregnancy, prenatal weight gain, pre-pregnancy weight status, smoking

other factors include- poverty, poor nutrition, limited access to healthcare, maternal lifestyle such as drugs or excessive alcohol intake

underweight women and those who fail to gain weight during pregnancy deliver low birth weight and preterm infants

-risk of LBW reduced by healthful.adequate diet and sufficient weight gain

body composition changes

maternal support tissues

products of conception 

underweight- 28-40 lbs

normal weight- 25-35 lbs

overweight - 15-25

obese - 11-20

pregnant with twins - 37-54

times when cells are multiplying

-nutrients required for cell multiplication must be available during specific time intervals 

-if not, developing tissue has fewer cells, forms abnormally or functions poorly 

-most intense in the first trimester when tissues/organs form

basal metabolic rate (BMR) increases 2-5%

-maternal adaption to fat as primary fuel- fetus prefers glucose as primary fuel

-increased plasma volume 50-100% by term

-hemodilution effect- lab values appear low due to increased blood volume 

healthy diet can provide all nutrients women need except iron 

-foods recommended over supps, b/c provide fiber, antioxidants, and other stuff

-fiber and fluids

-regular meals and snacks

-no alc

-coffee in moderation

-basic food groups

-preggers need more calories, protein, and essential nutrients

-need only 15% more calories but 50% more macronutrients

-high nutrient requirements mean preggers should increase intake of nutrient-dense food

-increased in first

-extra 340 calories in second

-extra 450 in third

-more accurate to determine adequate calorie consumption by monitoring weight gain than by counting calories

deficiency associated with fetal growth failure, malformations, and neural tube defects

-adequate intake before and early preggers reduces neural tube defects

-600 mcg needed daily

-neural tube forms during first 30 days following conception 

-mandatory fortification grain-based products with folic acid

an overdoes before and early pregnancy increase risk that babies have malformations of facial features and heart

-beta carotene does not appear to be harmful

-needed for mineralization of bones in fetus and to maintain mother's bone health

-low intake means calcium losses from bones during pregnancy

most common deficiency in pregnant women

-needs increase significantly during preggers due to increases in maternal hemoglobin production and storage by fetus

-difficult to get sufficient iron from foods

deficiency associated with long labors and small and malformed infants

-absorption reduced when consumed with supplemental iron

multivitamins-minerals pills recommended for..

-women that do not consume adequate diet

-high risk categories

FAS- women who drink heavily during pregnancy at hgih risk for infants with malformations and retarded physical and mental development

-no amount is safe

-should avoid fish with high levels of mercury like shark, swordfish, king mackerel, and tilefish

-excessive mercury is associated with...

-damage to CNS

-slower cognitive development

pica- ingestion of nonfood substances like clay, plaster, ice chips

-health risks associated with eating types of nonfood substances

-young children and preggers are most likely to practice

defined as the production and secretion of breast milk for purpose of nourishing an infant 

carbohydrate- lactose

proteins- digestible

rich vitamin content, except vit D

ideal mineral content- low in sodium, iron and zinc efficiently absorbed

-antibodies and immunity factors

-enhanced immunity for the infant

-convient and less expensive

-reduces risk of food allergy, diarrhea and vomiting in first months, chronic disease, postpartum bleeding/hemorrhage, breast and ovarian cancer

-promotes infant oral motor development, high IQs, mother-infant bonding, contraction of uterus, return to pre-preggers weight

-hormones signal milk production at delivery

-emptying breasts causes hormones release

-hormone stimulates production of milk for next feeding

-takes about two hours to produce enough milk for next feeding

-few women unable to produce enough

-milk production can catch up with need - supply = demand

BMR returns to pre-pregancy level

-cost of milk- 500-800 calories per day

-fluid- replace milk produced plus usual needs

-failure to consume enough calories can decrease milk production 

-low cal diets and weight loss exceeding 2 lbs/week reduce milk production

-loss of 1 lb per week after delivery safe, desirable

-women should - limit coffee to a few cups a day, avoid or limit alc, take meds only on med advice

growth and development fastest in infancy

-infants double birth weight by 4 months

-infants triples birth weight by 1 year

-length increases by 50% in first year

energy and nutrient needs

developmental readiness of infants for solid food

prevention of food allergies 

impacts mental development most during this critical period 

-beginning at conception and ends after first year

-main causes- poverty, neglect, illnesses, and psychological problems are main causes of malnutrition and poor mental development 

infant nutrition 

iron

infant has iron stores through 4 months

- iron supplementation after 4

-iron deficiency anemia common ages 6 months to 3 years

-fluoride supplements after six months if water supply is not fluoridated

-vitamin D in breast-fed infants if not regularly exposed to sunlight

-do not offer formula while milk supply is being established in breastfed infants

-do not introduce cows milk before one year

-fat in cows milk is less digestible than breast

-contains less iron, more sodium, more protein 

-risk of dehydration- due to high solutes

-poor source of vitamin C, essential fatty acids, zinc, other trace minerals

-early intro increases risk of allergy

-may introduce after 1 year when at least 2/3 of energy needs supplied by other foods

solid foods too early

problems with intro-excessive calorie intake, overweight

-food allergies

-gastrointestinal upest

-replaces well-balanced nutrients in breast milk or formula

-may be added 4-6 months of age

-may be used to compliment breast milk or formula

honey- infantile clostridium botulinum

-hot dogs, grapes, hard candies, raw carrots, popcorn, nuts, peanut butter (choking)

-skim milk (insufficient cals)

-cow milk (allergy, may replace better suited nutrients in breast milk or formula)

-egg whites (allergen)

older infants and young children should make decision on how much they eat

-infants don't instinctively know what to eat

-food preferences are learned

sedentary lifestyles and reduced energy requirements

-overeating

-obesity

-early childhood feeding can affect school performance, adult intelligence, bone strength, height, risk of disease

deceleration in growth during childhood

varying hunger levels that reflect physiological need

-adults are responsible for what and when food is offered to the child- quality, frequency, environment

-children are responsible for how much food provided is eaten- quantity

-avoid pressure tactics

-not inborn

-food likes and dislikes almost totally shaped by environment- which foods are offered, how they are offered, frequency

-number of taste buds diminish with age

-parents may have to offer new food many times- rule of 15

-restricting access to foods may result in neg effects on food preferences and health

-between ages 2 and 10 children can ~ 5 lbs and 2 to 3 inches in height per year- gains occur in accelerated growth periods or "spurts"

-during this accelerated growth period fat stores supply energy for growth

girls- 11 to 15

boys 12-17

teens gain 50% of adult weight, 20-25% of adult height, 45% of total bone mass

-at peak, girls gain 18 lbs/year; boys 20 lbs/yr

normal growth and positive health seen in children eating 21-35% of total calories from fat 

-less than 21% of calories from fat correlated with impaired growth and development

-fat intake greater than 35% correlated with obesity, low folate and vit C, high saturated fat intake

-for children over 3, 25-35% of calories from fat recommended

children's diets

of children over 2 years have:

-too few vegetables and fruits

-too little calcium, zinc, vitamins E D C B

-too little dietary fiber

-only ~9% eat 5 servings of veggies and fruit per day, most eat 2.5 or less

children only get half of recommended daily fiber

-recommended intake age 1-3 years : 19 g/day

age 4-8 years- 25 g/day

girls 9-13 years - 26 g/day

boys 9-13 years- 31 g/day

has replaced milk as national beverage

-consequences- less calcium and vitamin D, compromised bone growth and health, more refined sugar and obesity

-being overweight has more than tripled since 1960s in US children and adolescents

-displaces physical activity

-increases caloric consumption - during tv viewing, response to advertising

-reduces resting metabolic rate

-children and adolescents consume too few fruits, veggies, whole grains, calcium, vitamin D

-only get about half the recommended dietary fiber

heart disease

-high LDL cholesterol

-low HDL cholesterol

-increased blood pressure

type II diabetes

heart disease

bone and joint disoreders

hypertension

some cancers

-**nutrition is related to both current and future health and quality of life for people of all ages

nutrition in adults

(general slide)

-life expectancy varies based on sex and race

-age does not predict health status- poor health not inevitable consequence of age

-health status with age influenced by dietary intake, body weight, physical activity

-medications, diseases, biological processes influence adults' requirements for essential nutrients

regular consumption of fruits and veggies

above average intake of whole grain products

lower consumption of saturated fats

alcohol in moderation 

eating breakfast

-** physical activity

age related physiological changes 

decreased ... 

(10 changes)

1- saliva production

2- digestive secretions

3- lactase secretion

4- GI motility

5- cardiac output

6- blood volume

7-kidney functions

8- liver functions

9- immune function

10- vitamin absorption  

age related physiological changes 

increased....

(3 changes)

blood pressure

body fat

bone loss

chronic diseases and nutrition

what does the following do in general ?

correcting obesity

high fruit and veggie intake

adequate calcium and vitamin D

-correcting obesity and stabilizing weight may lengthen life expectancy 

-high fruit and veggie intake may delay or prevent- cancer, heart disease, stroke, cataract

-adequate calcium and vitamin D (along with physical activity) help prevent osteoporosis 

osteoporosis

lifestyle reasons?

dietary reasons?

gender reasons?

genetic and age related

lifestyle- sedentary, excessive alc, smoking

dietary- insufficient calcium intake/absorption, vitamin D (diet and sunlight), too much protein, sodium, caffeine

-or dietary restriction, weight loss, or thinness

gender- female, diminished estrogen level at menopause

nutrient needs in general for older adults

-increases and decreases with age

decrease- need for calories

increase- need for protein, vitamin D, C, B12, calcium, water

a complex illness that develops over time from a combo of psychological, interpersonal, cultural, and physiological factors resulting in a disturbance of thoughts and behaviors about food and weight, and a distorted body image

-progressive in nature for males and females

-requires multidisciplinary team approach for treatment

-refusal to maintain normal body weight through self-imposed starvation

-distorted body image- obsession with body shape and weight

-chronic restive dieting interspersed with self-starvations (occasional bulimic and binge)

-denial of condition or weight change

anorexia nervosa stats

% of pop affects?

college pop?

mortality rate? 

% of males and females?

affects 0.2-1.3% population

5-10% mortality

10-25% of college females

~1% of young women

0.1% of young males

anorexia nervosa

causes

cause is not clear

begins during adolescents

tends to be perfectionist, introverted, reserved, possibly socially insecure

many conditions, psychological and biological, predispose an individual 

-results excellent if treated early although most postpone for years and deny problem

repetitive food binges accompanied by purging or compensatory behaviors

-obsession with body shape and weight

-chronic restrictive dieting

-unlike anorexia nervosa, not usually underweight or emaciated 

-full recovery higher for women than with anorexia

-most achieve partial recovery

binge- consuming large amount of food in relatively short time with feeling of loss of control

purges- laxatives, diuretics, self-induced vomitng

compensatory- fasting, diet pills, excessive excercise

causes- depression, abnormal regulation of food intake, feast and famine cycles

tend to have poor coping skills, depression, other addictive behaviors/conditions

weight flucuations

amenorrhea

fatigue

dental caries and enamel erosion

dehydration and electrolyte imbalance

metabolic acidosis form laxative abuse

gastric rupture, esophageal tears, cardiac arrhythmias

metabolic alkalosis, swollen salivary glands, sore throat, hormonal imbalance, broken blood vessels in face and eyes, cardiac abnormalities

binge eating behavior not accompanied by purge or compensatory behaviors 

-individuals are overweight or obese, 1/3 are male

-usually in private setting with a feeling of loss of control 

-to be diagnosed- behavior occurs twice or more weekly over a 6 months period

triggered by stressful events or dysphoric moods

tend to have poor coping skills 

before episode- stress, depression, anger anxiety, other neg emotions

after- poor selfesteem, shame, depression, remorse, self-hatred

obesity

-increased risk for: joint pain, breathing difficulties, cardiovascular disease, elevated blood cholesterol, high blood pressure, gastrointestinal disturbances

three key features: disordered eating, amenorrhea, osteoporosis

-literally "fixation on righteous eating"

 Name of professional organization in US for Registered Dietitians/Nutritionists 

carbs- 9 per gram

proteins - 4

fats - 4 

-why? - b/c shown that increase LDL, risk of coronary heart disease, gov suggests to limit intake so ppl must know whether its in their food

how?- if less than .5 g can right not big source of trans fat on label 

- influence by diet and training

-muscle and liver

-converted by ATP anaerobically to convert into glucose for intense, short physical activities

-athlete doesn't need oxygen until the glycogen stores run out 

gets stored as fat

-also causes dehydration in athletes

25-26.9 - diet, behavior therapy, physical activity 

27-29.9- pharmaco-therapy with co-morbidity

35-40- surgery with co morbidity

40 or greater- surgery