All credits appearing on page or at the end of the book are considered to be an extension of the copyright page.
Library of Congress
Cataloging-in-Publication Data
Names: Williams, Melvin H. | Rawson, Eric S. | Branch, J. David, 1956Title: Nutrition for health, fitness, and sport / Melvin H. Williams, Old Dominion University, Eric S. Rawson, Bloomsburg University, J. David Branch, Old Dominion University.
Description: Eleventh edition. | New York, NY : McGraw-Hill, [2017] | Includes index.
Identifiers: LCCN 2015038385 | ISBN 9780078021350 (alk. paper)
Classification: LCC QP141 .W514 2017 | DDC 613.2—dc23 LC record available at http://lccn.loc.gov/2015038385
The Internet addresses listed in the text were accurate at the time of publication. The inclusion of a website does not indicate an endorsement by the authors or McGraw-Hill Education, and McGraw-Hill Education does not guarantee the accuracy of the information presented at these sites.
To Jeanne, Sara, Nik, Katy, Lucy, and Jake May
Serena, Jeff, Daniel, and David Newsom
—Melvin H. Williams
To Carol, David, Anne Randolph, Ellie, Gracie, and the rest of my family —J.David Branch
To Debbie, Christopher, Matthew, and Erica —Eric S. Rawson and
To our teachers, colleagues, and students Mel, David and Eric
Brief Contents
CHAPTER ONE Introduction to Nutrition for Health, Fitness, and Sports Performance 1
CHAPTER TWO Healthful Nutrition for Fitness and Sport: The Consumer Athlete 37
CHAPTER THREE Human Energy 90
CHAPTER FOUR Carbohydrates: The Main Energy Food 125
CHAPTER FIVE Fat: An Important Energy Source during Exercise 175
CHAPTER SIX Protein: The Tissue Builder 223
CHAPTER SEVEN Vitamins: The Organic Regulators 277
CHAPTER EIGHT Minerals: The Inorganic Regulators 327
CHAPTER NINE Water, Electrolytes, and Temperature Regulation 370
CHAPTER TEN Body Weight and Composition for Health and Sport 428
CHAPTER ELEVEN Weight Maintenance and Loss through Proper Nutrition and Exercise 476
CHAPTER TWELVE Weight Gaining through Proper Nutrition and Exercise 539
CHAPTER THIRTEEN Food Drugs and Related Supplements 565
Contents
Preface xiii
CHAPTER ONE
Introduction to Nutrition for Health, Fitness, and Sports Performance 1
Health-Related Fitness: Exercise and Nutrition 4
Exercise and Health-Related Fitness 4
What is health-related fitness? 4
What are the basic principles of exercise training? 4
What is the role of exercise in health promotion? 6
How does exercise enhance health? 6
Do most of us exercise enough? 8
How much physical activity is enough for health benefits? 8
Am I exercising enough? 11
Can too much exercise be harmful to my health? 11
Nutrition and Health-Related Fitness 12
What is nutrition? 12
What is the role of nutrition in health promotion? 13
Do we eat right? 14
What are some general guidelines for healthy eating? 15
Am I eating right? 16
Are there additional health benefits when both exercise and diet habits are improved? 16
Sports-Related Fitness: Exercise and Nutrition 17
What is sports-related fitness? 17
What is sports nutrition? 18
Is sports nutrition a profession? 18
Are athletes today receiving adequate nutrition? 19
Why are some athletes malnourished? 19
How does nutrition affect athletic performance? 20
What should athletes eat to help optimize sport performance? 20
Ergogenic Aids and Sports Performance: Beyond Training 21
What is an ergogenic aid? 21
Why are nutritional ergogenics so popular? 22
Are nutritional ergogenics effective? 22
Are nutritional ergogenics safe? 22
Are nutritional ergogenics legal? 23
Where can I find more detailed information on sports supplements? 23
Nutritional Quackery in Health and Sports 24
What is nutritional quackery? 24
Why is nutritional quackery so prevalent in athletics? 25
How do I recognize nutritional quackery in health and sports? 25
Where can I get sound nutritional information to combat quackery in health and sports? 26
Research and Prudent Recommendations 27
What types of research provide valid information? 28
Why do we often hear contradictory advice about the effects of nutrition on health or physical performance? 29
What is the basis for the dietary recommendations presented in this book? 30
How does all this relate to me? 31
Application Exercises 32
Review Questions—Multiple Choice 32
Review Questions—Essay 33
References 33
CHAPTER TWO
Healthful Nutrition for Fitness and Sport: The Consumer Athlete 37
Essential Nutrients and Recommended Nutrient Intakes 39
What are essential nutrients? 39
What are nonessential nutrients? 39
How are recommended dietary intakes determined? 40
The Balanced Diet and Nutrient Density 42
What is a balanced diet? 42
What foods should I eat to obtain the nutrients I need? 43
What is the MyPlate food guide? 43
What is the Food Exchange System? 45
What is the key-nutrient concept for obtaining a balanced diet? 46
What is the concept of nutrient density? 47
Will using the MyPlate food guide or the Food Exchange System guarantee me optimal nutrition? 49
Healthful Dietary Guidelines 49
What is the basis underlying the development of healthful dietary guidelines? 49
What are the recommended dietary guidelines for reducing the risk of chronic disease? 50
Vegetarianism 56
What types of foods does a vegetarian eat? 56
What are some of the nutritional concerns with a vegetarian diet? 57
Is a vegetarian diet more healthful than a nonvegetarian diet? 59
How can I become a vegetarian? 61
Will a vegetarian diet affect physical performance potential? 62
Consumer Nutrition—Food Labels and Health
Claims 63
What nutrition information do food labels provide? 63
How can I use this information to select a healthier diet? 63
What are the proposed changes to the current food label? 65
What health claims are allowed on food products? 67
What are functional foods? 68
Consumer Nutrition—Dietary Supplements and Health 69
What are dietary supplements? 69
Will dietary supplements improve my health? 70
Can dietary supplements harm my health? 71
Consumer Nutrition—Food Quality and Safety 72
Is current food biotechnology effective and safe? 72
Do pesticides in food present significant health risks? 73
Are organic foods safer and healthier choices? 74
Does commercial food processing affect food quality and safety? 74
Does home food processing affect food quality and safety? 75
What is food poisoning? 76
Are food additives safe? 77
Why do some people experience adverse reactions to some foods? 78
Healthful Nutrition: Recommendations for Better Physical Performance 79
What should I eat during training? 79
When and what should I eat just prior to competition? 80
What should I eat during competition? 81
What should I eat after competition? 81
Should athletes use commercial sports foods? 81
How can I eat more nutritiously while traveling for competition? 82
How do gender and age influence nutritional recommendations for enhanced physical performance? 84
What apps are available to help me in my quest to develop a diet plan to improve both my health and my sports performance? 85
Application Exercise 85
Review Questions—Multiple Choice 86
Review Questions—Essay 86
References 87
CHAPTER THREE
Human Energy 90
Measures of Energy 91
What is energy? 91
How do we measure physical activity and energy expenditure? 92
What is the most commonly used measure of energy? 95
Human Energy Systems 97
How is energy stored in the body? 97
What are the human energy systems? 98
What nutrients are necessary for operation of the human energy systems? 101
Human Energy Metabolism during Rest 102
What is metabolism? 102
What factors account for the amount of energy expended during rest? 102
What effect does eating a meal have on the metabolic rate? 102
How can I estimate my daily resting energy expenditure (REE)? 103
What genetic factors affect my REE? 103
How do dieting and body composition affect my REE? 104
What environmental factors may also influence the REE? 104
What energy sources are used during rest? 104
Human Energy Metabolism during Exercise 105
How do my muscles influence the amount of energy I can produce during exercise? 105
What effect does muscular exercise have on the metabolic rate? 106
How is energy expenditure of the three human energy systems measured during exercise? 106
How can I convert the various means of expressing exercise energy expenditure into something more useful to me, such as Calories per minute? 107
How can I tell what my metabolic rate is during exercise? 109
How can I determine the energy cost of my exercise routine? 109
What are the best types of activities to increase energy expenditure? 110
Does exercise affect my resting energy expenditure (REE)? 111
Does exercise affect the thermic effect of food (TEF)? 112
How much energy should I consume daily? 112
Human Energy Systems and Fatigue during Exercise 115
What energy systems are used during exercise? 115
What energy sources are used during exercise? 116
What is the “fat burning zone” during exercise? 117
What is fatigue? 118
What causes acute fatigue in athletes? 119
How can I delay the onset of fatigue? 120
How is nutrition related to fatigue processes? 120
Application Exercise 122
Review Questions—Multiple Choice 122
Review Questions—Essay 123
What terms are used to quantify work and power during exercise? 92
References 123
CHAPTER FOUR
Carbohydrates: The Main Energy
Food 125
Dietary Carbohydrates 126
What are the different types of dietary carbohydrates? 126
What are some common foods high in carbohydrate content? 128
How much carbohydrate do we need in the diet? 129
Metabolism and Function 130
How are dietary carbohydrates digested and absorbed and what are some implications for sports performance? 130
What happens to the carbohydrate after it is absorbed into the body? 131
What is the metabolic fate of blood glucose? 132
How much total energy do we store as carbohydrate? 135
Can the human body make carbohydrates from protein and fat? 136
What are the major functions of carbohydrate in human nutrition? 136
Carbohydrates for Exercise 138
In what types of activities does the body rely heavily on carbohydrate as an energy source? 138
Why is carbohydrate an important energy source for exercise? 138
What effect does endurance training have on carbohydrate metabolism? 139
How is hypoglycemia related to the development of fatigue? 139
How is lactic acid production related to fatigue? 141
How is low muscle glycogen related to the development of fatigue? 141
How are low endogenous carbohydrate levels related to the central fatigue hypothesis? 143
Will eating carbohydrate immediately before or during an event improve physical performance? 144
When, how much, and in what form should carbohydrates be consumed before or during exercise? 147
What is the importance of carbohydrate replenishment after prolonged exercise? 151
Will a high-carbohydrate diet enhance my daily exercise training? 152
Carbohydrate Loading 154
What is carbohydrate, or glycogen, loading? 154
What type of athlete would benefit from carbohydrate loading? 154
How do you carbohydrate load? 154
Will carbohydrate loading increase muscle glycogen concentration? 155
How do I know if my muscles have increased their glycogen stores? 156
Will carbohydrate loading improve exercise performance? 157
Are there any possible detrimental effects relative to carbohydrate loading? 158
Carbohydrates: Ergogenic Aspects 159
Do the metabolic by-products of carbohydrate exert an ergogenic effect? 159
Dietary Carbohydrates: Health Implications 161
How do refined sugars and starches affect my health? 161
Are artificial sweeteners safe? 162
Why are complex carbohydrates thought to be beneficial to my health? 164
Why should I eat foods rich in fiber? 164
Do some carbohydrate foods cause food intolerance? 166
Does exercise exert any beneficial health effects related to carbohydrate metabolism? 167
Application Exercise 168
Review Questions—Multiple Choice 168
Review Questions—Essay 169
References 170
CHAPTER FIVE
Fat: An Important Energy Source during Exercise 175
Dietary Fats 176
What are the different types of dietary fats? 176
What are triglycerides? 176
What are some common foods high in fat content? 177
How do I calculate the percentage of fat Calories in a food? 178
What are fat substitutes? 179
What is cholesterol? 180
What foods contain cholesterol? 180
What are phospholipids? 180
What foods contain phospholipids? 181
How much fat and cholesterol do we need in the diet? 181
Metabolism and Function 183
How does dietary fat get into the body? 183
What happens to the lipid once it gets in the body? 183
What are the different types of lipoproteins? 185
Can the body make fat from protein and carbohydrate? 186
What are the major functions of the body lipids? 186
How much total energy is stored in the body as fat? 187
Fats and Exercise 188
Are fats used as an energy source during exercise? 188
Does gender or age influence the use of fats as an energy source during exercise? 189
What effect does exercise training have on fat metabolism during exercise? 190
Fats: Ergogenic Aspects 191
High-fat diets 191
High-fat diets and weight loss 193
Does exercising on an empty stomach or fasting improve performance? 194
Can the use of medium-chain triglycerides improve endurance performance or body composition? 194
Is the glycerol portion of triglycerides an effective ergogenic aid? 195
Are phospholipid dietary supplements effective ergogenic aids? 195
Omega-3 fatty acid and fish oil supplements 196
Can carnitine improve performance or weight loss? 197
Can hydroxycitrate (HCA) enhance endurance performance? 198
Can conjugated linoleic acid (CLA) enhance exercise performance or weight loss? 198
What’s the bottom line regarding the ergogenic effects of fat burning diets or strategies? 198
Dietary Fats and Cholesterol: Health Implications 199
How does cardiovascular disease develop? 199
How do the different forms of serum lipids affect the development of atherosclerosis? 201
Can I reduce my serum lipid levels and possibly reverse atherosclerosis? 203
What should I eat to modify my serum lipid profile favorably? 204
Can exercise training also elicit favorable changes in the serum lipid profile? 211
Application Exercise 215
Review Questions—Multiple Choice 215
Review Questions—Essay 216
References 216
CHAPTER
Dietary Protein 224
What is protein? 224
Is there a difference between animal and plant protein? 225
What are some common foods that are good sources of protein? 226
How much dietary protein do I need? 226
How much of the essential amino acids do I need? 228
What are some dietary guidelines to ensure adequate protein intake? 228
Metabolism and Function 229
What happens to protein in the human body? 229
Can protein be formed from carbohydrates and fats? 230
What are the major functions of protein in human nutrition? 231
Proteins and Exercise 232
Are proteins used for energy during exercise? 232
Does exercise increase protein losses in other ways? 234
What happens to protein metabolism during recovery after exercise? 234
What effect does exercise training have upon protein metabolism? 234
Does exercise Increase the Need for Dietary Protein? 236
What are some general recommendations relative to dietary protein intake for athletes? 237
Are protein supplements necessary? 239
Before Sleep Protein Intake 240
Protein: Ergogenic Aspects 241
What types of special protein supplements are marketed to physically active individuals? 241
Do high-protein diets or protein supplements increase muscle mass and strength in resistance-trained individuals? 242
Do high-protein diets or protein supplements improve aerobic endurance performance in endurance-trained individuals? 243
Are amino acid, amine, and related nitrogen-containing supplements effective ergogenic aids? 245
Dietary Protein: Health Implications 262
Does a deficiency of dietary protein pose any health risks? 262
Does excessive protein intake pose any health risks? 263
Does the consumption of individual amino acids pose any health risks? 265
Application Exercise 266
Review Questions—Multiple Choice 266
Review Questions—Essay 267
References 267
CHAPTER SEVEN
Vitamins: The Organic Regulators 277
Basic Facts 278
What are vitamins and how do they work? 278
What vitamins are essential to human nutrition? 280
In general, how do deficiencies or excesses of vitamins influence health or physical performance? 280
Fat-Soluble Vitamins 283
Vitamin A (retinol) 283
Vitamin D (cholecalciferol) 284
Vitamin E (alpha-tocopherol) 288
Vitamin K (menadione) 290
Water-Soluble Vitamins 291
Thiamin (vitamin B1) 291
Riboflavin (vitamin B2) 292
Niacin 293
Vitamin B6 (pyridoxine) 294
Vitamin B12 (cobalamin) 295
Folate (folic acid) 296
Pantothenic acid 297
Biotin 298
Choline 298
Vitamin B complex 299
Vitamin C (ascorbic acid) 300
Vitamin Supplements: Ergogenic Aspects 302
Should physically active individuals take vitamin supplements? 303
Can the antioxidant vitamins prevent fatigue or muscle damage during training? 303
How effective are the special vitamin supplements marketed for athletes? 305
What’s the bottom line regarding vitamin supplements for athletes? 307
Vitamin Supplements: Health Aspects 308
Can I obtain the vitamins I need through my diet? 308
Why are vitamin supplements often recommended? 308
Why do individuals take vitamin megadoses? 310
Do foods rich in vitamins, particularly antioxidant vitamins, help deter chronic disease? 310
Do vitamin supplements help deter disease? 311
How much of a vitamin supplement is too much? 314
If I want to take a vitamin-mineral supplement, what are some prudent guidelines? 315
Application Exercises 317
Review Questions—Multiple Choice 317
Review Questions—Essay 318
References 318
CHAPTER EIGHT
Minerals: The Inorganic Regulators 327
Basic Facts 328
What are minerals, and what is their importance to humans? 328
What minerals are essential to human nutrition? 329
In general, how do deficiencies or excesses of minerals influence health or physical performance? 329
Macrominerals 331
Calcium (Ca) 331
Phosphorus (P) 339
Magnesium (Mg) 342
Trace Minerals 344
Iron (Fe) 344
Copper (Cu) 349
Zinc (Zn) 350
Chromium (Cr) 352
Selenium (Se) 354
Boron (B) 356
Vanadium (V) 357
Manganese (Mn) 357
Other Trace Minerals 358
Mineral Supplements: Exercise and Health 360
Does exercise increase my need for minerals? 360
Can I obtain the minerals I need through my diet? 360
Are mineral megadoses or some nonessential minerals harmful? 361
Should physically active individuals take mineral supplements? 362
Application Exercise 363
Review Questions—Multiple Choice 363
Review Questions—Essay 364
References 364
CHAPTER NINE
Water, Electrolytes, and Temperature
Regulation 370
Water 372
How much water do you need per day? 372
What else is in the water we drink? 372
Where is water stored in the body? 374
How is body water regulated? 374
How do I know if I am adequately hydrated? 376
What are the major functions of water in the body? 376
Can drinking more water or fluids confer any health benefits? 377
Electrolytes 378
What is an electrolyte? 378
Sodium (Na) 378
Chloride (Cl) 380
Potassium (K) 380
Regulation of Body Temperature 381
What is the normal body temperature? 381
What are the major factors that influence body temperature? 382
How does the body regulate its own temperature? 382
What environmental conditions may predispose an athletic individual to hyperthermia? 383
How does exercise affect body temperature? 384
How is body heat dissipated during exercise? 385
Exercise Performance in the Heat: Effect of Environmental Temperature and Fluid and Electrolyte Losses 385
How does environmental heat affect physical performance? 386
How do dehydration and hypohydration affect physical performance? 387
How fast may an individual dehydrate while exercising? 389
How can I determine my sweat rate? 389
What is the composition of sweat? 390
Is excessive sweating likely to create an electrolyte deficiency? 390
Exercise in the Heat: Fluid, Carbohydrate, and Electrolyte Replacement 390
Which is most important to replace during exercise in the heat—water, carbohydrate, or electrolytes? 391
What are some sound guidelines for maintaining water (fluid) balance during exercise? 391
What factors influence gastric emptying and intestinal absorption? 393
How should carbohydrate be replaced during exercise in the heat? 395
How should electrolytes be replaced during or following exercise? 396
What is hyponatremia and what causes it during exercise? 396
Are salt tablets or potassium supplements necessary? 398
What are some prudent guidelines relative to fluid replacement while exercising under warm or hot environmental conditions? 398
Ergogenic Aspects 402
Does oxygen water enhance exercise performance? 403
Do pre-cooling techniques help reduce body temperature and enhance performance during exercise in the heat? 403
Does sodium loading enhance endurance performance? 403
Does glycerol supplementation enhance endurance performance during exercise under warm environmental conditions? 404
Health Aspects: Heat Illness 406
Should I exercise in the heat? 406
What are the potential health hazards of excessive heat stress imposed on the body? 406
What are the symptoms and treatment of heat injuries? 409
Do some individuals have problems tolerating exercise in the heat? 409
How can I reduce the hazards associated with exercise in a hot environment? 411
How can I become acclimatized to exercise in the heat? 412
Health Aspects: High Blood Pressure 413
What is high blood pressure, or hypertension? 413
How is high blood pressure treated? 413
What dietary modifications may help reduce or prevent hypertension? 415
Can exercise help prevent or treat hypertension? 418
Application Exercises 419
Review Questions—Multiple Choice 420
Review Questions—Essay 420
References 421
CHAPTER TEN
Body Weight and Composition for Health and Sport 428
Body Weight and Composition 430
What is the ideal body weight? 430
What are the values and limitations of the BMI? 431
What is the composition of the body? 431
What techniques are available to measure body composition and how accurate are they? 433
What problems may be associated with rigid adherence to body fat percentages in sport? 438
How much should I weigh or how much body fat should I have? 438
Regulation of Body Weight and Composition 440
How does the human body normally control its own weight? 440
How is fat deposited in the body? 444
What is the cause of obesity? 444
Can the set point change? 449
Why is prevention of childhood obesity so important? 449
Weight Gain, Obesity, and Health 451
What health problems are associated with overweight and obesity? 451
How does the location of fat in the body affect health? 453
Does being obese increase health risks in youth? 455
Does losing excess body fat reduce health risks and improve health status? 455
Does being physically fit negate the adverse health effects associated with being overweight? 455
Excessive Weight Loss and Health 457
What health problems are associated with improper weight-loss programs and practices? 457
What are the major eating disorders? 459
What eating problems are associated with sports? 461
Body Composition and Physical Performance 464
What effect does excess body weight have on physical performance? 464
Does excessive weight loss impair physical performance? 465
Application Exercise 466
Review Questions—Multiple Choice 466
Review Questions—Essay 467
References 467
CHAPTER ELEVEN
Weight Maintenance and Loss through Proper Nutrition and Exercise 476
Basics of Weight Control 478
How many Calories are in a pound of body fat? 478
Is the caloric concept of weight control valid? 479
How many Calories do I need per day to maintain my body weight? 479
How much weight can I lose safely per week? 483
How can I determine the amount of body weight I need to lose? 483
Behavior Modification 484
What is behavior modification? 484
How do I apply behavior-modification techniques in my weight-control program? 484
Dietary Modifications 488
How can I determine the number of Calories needed in a diet to lose weight? 488
How can I predict my body-weight loss through dieting alone? 489
Why does a person usually lose the most weight during the first week on a reducing diet? 489
Why does it become more difficult to lose weight after several weeks or months on a diet program? 490
What are the major characteristics of a sound diet for weight control? 490
Is it a good idea to count Calories when attempting to lose body weight? 493
How often should i weigh myself? 494
What is the Food Exchange System? 494
How can I determine the number of Calories I eat daily? 495
What are some general guidelines I can use in the selection and preparation of foods to promote weight loss or maintain a healthy body weight? 497
How can I plan a nutritionally balanced, low-Calorie diet? 501
Are very low-Calorie diets effective and desirable as a means to lose body weight? 504
Are weight-loss dietary supplements effective and safe? 504
Is it harmful to overeat occasionally? 506
Exercise Programs
506
What role does exercise play in weight reduction and weight maintenance? 506
Does exercise affect the appetite? 508
Does exercise affect the set point? 509
What types of exercise programs are most effective for losing body fat? 509
If I am inactive now, should I see a physician before I initiate an exercise program? 513
What other precautions would be advisable before I start an exercise program? 513
What is the general design of exercise programs for weight reduction? 514
What is the stimulus period of exercise? 515
What is an appropriate level of exercise intensity? 515
How can I determine the exercise intensity needed to achieve my target HR range? 519
How can I design my own exercise program? 519
How much exercise is needed to lose weight? 522
From what parts of the body does the weight loss occur during an exercise weight-reduction program? 523
Should I do low-intensity exercises to burn more fat? 523
Is spot reducing effective? 524
Is it possible to exercise and still not lose body weight? 525
What about the 5 or 6 pounds a person may lose during an hour of exercise? 526
Comprehensive Weight Control Programs 526
Which is more effective for weight control—dieting or exercise? 526
If I want to lose weight through a national or local weight-loss program, what should I look for? 527
What type of weight-reduction program is advisable for young athletes? 529
What is the importance of prevention in a weight-control program? 529
Application Exercise 531
Review Questions—Multiple Choice 531
Review Questions—Essay 532
References 532
CHAPTER TWELVE
Weight Gaining through Proper Nutrition and Exercise 539
Basic Considerations 541
Why are some individuals underweight? 541
What steps should I take if I want to gain weight? 541
Nutritional Considerations 542
How many Calories are needed to form 1 pound of muscle? 542
How can I determine the amount of Calories I need daily to gain 1 pound per week? 542
Is protein supplementation necessary during a weight-gaining program? 542
Are dietary supplements necessary during a weight-gaining program? 544
What is an example of a balanced diet that will help me gain weight? 545
Would such a high-Calorie diet be ill advised for some individuals? 545
Exercise Considerations 546
What are the primary purposes of resistance training? 547
What are the basic principles of resistance training? 547
What is an example of a resistance-training program that may help me to gain body weight as lean muscle mass? 550
Are there any safety concerns associated with resistance training? 551
How does the body gain weight with a resistance-training program? 555
Is any one type of resistance-training program or equipment more effective than others for gaining body weight? 557
If exercise burns Calories, won’t I lose weight on a resistancetraining program? 557
Are there any contraindications to resistance training? 558
Are there any health benefits associated with resistance training? 558
Can I combine aerobic and resistance-training exercises into one program? 559
Application Exercise 560
Review Questions—Multiple Choice 561
Review Questions—Essay 561
References 562
CHAPTER THIRTEEN
Food Drugs and Related Supplements 565
Alcohol: Ergogenic Effects and Health Implications 567
What is the alcohol and nutrient content of typical alcoholic beverages? 567
What is the metabolic fate of alcohol in the body? 567
Is alcohol an effective ergogenic aid? 568
What effect can drinking alcohol have upon my health? 570
Caffeine: Ergogenic Effects and Health Implications 576
What is caffeine, and in what food products is it found? 576
What effects does caffeine have on the body that may benefit exercise performance? 576
Does caffeine enhance exercise performance? 577
Does drinking coffee, tea, or other caffeinated beverages provide any health benefits or pose any significant health risks? 581
Ephedra (Ephedrine): Ergogenic Effects and Health Implications 585
What is ephedra (ephedrine)? 585
Does ephedrine enhance exercise performance? 585
Do dietary supplements containing ephedra pose any health risks? 585
Sodium Bicarbonate: Ergogenic Effects, Safety, and Legality 587
What is sodium bicarbonate? 587
Does sodium bicarbonate, or soda loading, enhance physical performance? 587
Is sodium bicarbonate supplementation safe and legal? 589
Anabolic Hormones and Dietary Supplements: Ergogenic Effects and Health Implications 590
Is human growth hormone (HGH) an effective, safe, and legal ergogenic aid? 590
Are testosterone and anabolic/androgenic steroids (AAS) effective, safe, and legal ergogenic aids? 591
Are anabolic prohormone dietary supplements effective, safe, and legal ergogenic aids? 593
Ginseng, Herbals, and Exercise and Sports Performance 595
Does ginseng or ciwujia enhance exercise or sports performance? 595
What herbals are effective ergogenic aids? 596
Sports Supplements: Efficacy, Safety, and Permissibility 598
What sports supplements are considered to be effective, safe, and permissible? 598
Application Exercise 599
Review Questions—Multiple Choice 599
Review Questions—Essay 600
References 600
APPENDIX A Units of Measurement: English System—Metric System Equivalents 609
APPENDIX B Approximate Caloric Expenditure per Minute Based on the Metabolic Equivalents (METS) for Physical Activity 611
APPENDIX C Determination of Healthy Body Weight 614
APPENDIX D Exchange Lists for Meal Planning 619
APPENDIX E Nutrient Content of Food Products from Selected Fast-Food Restaurants 631
APPENDIX F Energy Pathways of Carbohydrate, Fat, and Protein 633
APPENDIX G Sample Menu for a 2,000-Calorie Food Pattern 637
Glossary 641
Photo Credits 665
Index 666
Preface
According to the World Health Organization, better health is the key to human happiness and well-being. Many factors influence one’s health status, including some provided by various government and health agencies, such as safe living environments and access to proper health care. However, in general, one’s personal health over the course of a lifetime is dependent more on personal lifestyle choices, two of the most important being proper exercise and healthy eating.
In the twenty-first century, our love affair with fitness and sports continues to grow. Worldwide, although physical inactivity is still very prevalent in developed nations, more of us are joining fitness facilities or initiating fitness programs, such as bicycling, running, swimming, walking, and weight training. Improvement in health and fitness is one of the major reasons that more and more people initiate an exercise program, but many may also become more interested in sports competition, such as age-group road racing; running and walking race competitions have become increasingly popular, and every weekend numerous road races can be found within a short drive. Research has shown that adults who become physically active also may become more interested in other aspects of their lifestyles—particularly nutrition—that may affect their health in a positive way. Indeed, according to all major health organizations, proper exercise and a healthful diet are two of the most important lifestyle behaviors to help prevent chronic disease.
Nutrition is the study of foods and their effects upon health, development, and performance. Over the years, nutrition research has made a significant contribution to our knowledge of essential nutrient needs. During the first part of the twentieth century, most nutrition research focused on identification of essential nutrients and amounts needed to prevent nutrient-deficiency diseases, such as scurvy from inadequate vitamin C. As nutrition science evolved, medical researchers focused on the effects of foods and their specific constituents as a means to help prevent the major chronic diseases, such as heart disease and cancer, that are epidemic in developed countries. Nutriceutical is a relatively new term used to characterize the drug, or medical, effects of a particular nutrient. Recent research findings continue to indicate that our diet is one of the most important determinants of our health status. Although individual nutrients are still being evaluated for possible health benefits, research is also focusing on dietary patterns, or the totality of the diet, and resultant health benefits. However, we should note that research relative to the effects of diet, including specific nutrients, on health is complex and dietary
recommendations may change with new research findings. For example, as shall be noted later in the text, the guidelines regarding dietary intake of cholesterol have been modified after being in effect for more than 50 years.
Other than the health benefits of exercise and fitness, many physically active individuals also are finding the joy of athletic competition, participating in local sports events such as golf tournaments, tennis matches, triathlons, and road races. Individuals who compete athletically are always looking for a means to improve performance, be it a new piece of equipment or an improved training method. In this regard, proper nutrition may be a very important factor in improving sports performance. Various sports governing agencies indicate today’s athletes need accurate sports nutrition information to maximize sports performance. Although the effect of diet on sports and exercise performance was studied only sporadically prior to 1970, subsequently numerous sports scientists and sports nutritionists have studied the performance-enhancing effects of nutrition, such as diet composition and dietary supplements. Results of these studies have provided nutritional guidance to enhance performance in specific athletic endeavors. In the United States, many universities and professional sports teams, such as those in Major League Baseball and the National Football League, employ registered dietitians as well as culinary chefs to provide dietary guidance to their athletes.
With the completion of the Human Genome Project, gene therapies are being developed for the medical treatment of various health problems. Moreover, some contend that genetic manipulations may be used to enhance sports performance. For example, gene doping to increase insulin-like growth factor, which can stimulate muscle growth, may be applied to sport.
Our personal genetic code plays an important role in determining our health status and our sports abilities, and futurists speculate that one day each of us will carry our own genetic chip that will enable us to tailor food selection and exercise programs to optimize our health and sports performance. Such may be the case, but for the time being we must depend on available scientific evidence to provide us with prudent guidelines.
Each year thousands of published studies and reviews analyze the effects of nutrition on health or exercise and sports performance. The major purpose of this text is to evaluate these scientific data and present prudent recommendations for individuals who want to modify their diet for optimal health or exercise/sports performance.
Textbook Overview
This book uses a question-answer approach, which is convenient when you may have occasional short periods to study, such as riding a bus or during a lunch break. In addition, the questions are arranged in a logical sequence, the answer to one question often leading into the question that follows. Where appropriate, crossreferencing within the text is used to expand the discussion. No deep scientific background is needed for the chemical aspects of nutrition and energy expenditure, as these have been simplified. Instructors who use this book as a course text may add details of biochemistry as they feel necessary.
Chapter 1 introduces you to the general effects of exercise and nutrition on health-related and sports-related fitness, including the importance of well-controlled scientific research. Chapter 2 provides a broad overview of sound guidelines relative to nutrition for optimal health and physical performance. Chapter 3 focuses on energy and energy pathways in the body, the key to all exercise and sports activities.
Chapters 4 through 9 deal with the six basic nutrients— carbohydrate, fat, protein, vitamins, minerals, and water—with emphasis on the health and performance implications for the physically active individual. Chapters 10 through 12 review concepts of body composition and weight control, with suggestions on how to gain or lose body weight through diet and exercise, as well as the implications of such changes for health and athletic performance. Chapter 13 covers several drug foods, such as alcohol and caffeine, and other related dietary supplements regarding their effects on health and exercise performance. Several appendixes complement the text, providing data on caloric expenditure during exercise; detailed metabolic pathways for carbohydrate, fat, and protein; methods to determine body composition; nutritional value of fast foods; and other information pertinent to physically active individuals.
New to the Eleventh Edition
The first edition of this textbook, titled Nutrition for Fitness and Sport, was published in 1983. I am joined in this eleventh edition by two professors who are actively involved in the disciplines of exercise physiology and sports nutrition, and who have used this text over the years to teach their university classes. J. David Branch is an associate professor in the Department of Human Movement Sciences at Old Dominion University in Virginia. His e-mail address is dbranch@odu.edu. Eric Rawson is a professor in the Department of Exercise Science at Bloomsburg University in Pennsylvania. His e-mail address is erawson@ bloomu.edu. Dr. Branch revised chapters 6, 9, 10, 11, 12, and 13; Dr. Rawson revised chapters 4, 5, and 6; and I revised chapters 1, 2, 3, and 8.
The content throughout each chapter of the book has been updated, where merited, based on contemporary research findings regarding the effects of nutritional practices on health, fitness, and sports performance. Many sections throughout the text were completely rewritten in attempts to improve presentation
and clarity, such as the use of bullet points to summarize key points. More than 700 new references, including clinical studies, reviews, and meta-analyses, have been added to the text. Major changes include incorporation of the new Dietary Guidelines for Americans. The MyPlate model is designed to be more user friendly for the American population and is discussed in several chapters. New information from authoritative position statements dealing with exercise and nutrition issues has been incorporated into various chapters where relevant. These position statements have been developed by such prominent groups as the Academy of Nutrition and Dietetics, the American College of Sports Medicine, the American Academy of Pediatrics, the American Heart Association, the American College of Cardiology, the European College of Sport Science, the European Food Safety Authority, and Sports Dietitians Australia. Additionally, numerous Websites have been listed to help students explore various exercise and nutrition issues in more depth.
Chapter 1—Introduction to Nutrition for Health, Fitness, and Sports Performance
∙ New information on the use of various applications for health promotion
∙ Increased discussion of the use of various exercise gadgets, such as fitness bands and fitness watches, to help document daily amounts of physical activity and other aspects of lifestyle
∙ Update on the role of exercise to enhance health
∙ Introduction of high-intensity interval training (HIIT) and its possible application to exercise for health
∙ Introduction of the Compendium of Physical Activities, which is used in various chapters referring to energy expenditure during physical activities
∙ Increased use of reputable Websites to provide more detailed information on exercise and diet for health
∙ Discussion of new position stands, as related to a healthy diet by the Academy of Nutrition and Dietetics, the new name for the American Dietetic Association
∙ Introduction to the 2015 Dietary Guidelines for Americans, the most recent report of the 2015 Dietary Guidelines Advisory Committee
∙ New application exercise for diet appraisal using several Website-based diet analyses by the Academy of Nutrition and Dietetics and other health profession groups
∙ Over 40 new references added and numerous dated citations deleted
Chapter 2—Healthful Nutrition for Fitness and Sport: The Consumer Athlete
∙ Updated discussion of dietary guidelines, including the debate over research with saturated fatty acids and the proposed new guidelines for cholesterol
∙ Introduction to the Academy of Nutrition and Dietetics position stand on the total diet approach to healthy eating
∙ Discussion of several smartphone applications (apps) to help you eat a healthier diet
∙ More details on how to use the MyPlate program to plan a healthier diet
∙ How to become an ambassador for ChooseMyPlate and healthy eating on your college campus
∙ Presentation of the Harvard Medical School modified MyPlate to present more specific recommendations for healthy eating
∙ Discussion of the proposed new food labels designed to make food shopping easier to select healthier foods
∙ An update on the controversy concerning use of GMO foods
∙ Use of various Websites to stay current, such as fruits and vegetables that fall into those with the lowest and highest pesticide content
∙ Over 40 new references, most of them reviews and meta-analyses
Chapter 3—Human Energy
∙ Enhanced discussion of techniques to measure energy expenditure, including the use of various commercial apps
∙ Presentation of more details on the use of the MET system to measure energy expenditure
∙ Presentation of a link to calculate your daily energy expenditure via five methods
∙ Over 30 new references
Chapter 4—Carbohydrates: The Main Energy Food
∙ Updated information on the role of the glycemic index in the risk of cardiovascular disease
∙ New data on the effectiveness of carbohydrate mouthrinse on endurance exercise performance
∙ New information on the effects of carbohydrate supplementation on exercise performance
∙ Updated information on the role of carbohydrate ingestion and resistance training
∙ New data on the effects of cycling carbohydrate intake on training adaptations and performance
∙ Update on approved sugar substitutes and artificial sweeteners and the effects on performance and weight gain
∙ Latest data on the effects of dietary fiber on morbidity and mortality
∙ Over 20 new references
Chapter 5—Fat: An Important Energy Source during Exercise
∙ Update on the effect of saturated fat on health
∙ New data on the effects of conjugated linoleic acid supplementation on body composition
∙ Update on the effects of omega fatty acid consumption on disease
∙ New data on avocado intake and cardiovascular health
∙ New research on the effects of dietary medium-chain triglycerides on weight loss and body composition
∙ Update on the effects of ketogenic diets on satiety and appetite
∙ Updated information on low-carbohydrate diets and weight loss
∙ Discussion of the potential effects of high-fat diets in endurance athletes
∙ Update on fasting and endurance exercise performance
∙ Over 20 new references
Chapter 6—Protein: The Tissue Builder
∙ Updated data on the effects of protein supplements on muscle mass, strength, and power
∙ New information on the effects of protein supplements on muscle damage, soreness, and recovery
∙ New data on the effects of protein plus carbohydrate ingestion on acute and repeated endurance exercise performance
∙ The latest protein intake recommendations on postexercise and before-sleep protein supplementation
∙ Update on the importance of dietary protein in satiety and weight loss
∙ Newest data on the safety of high protein intakes
∙ New data on creatine supplementation and muscle strength
∙ Latest information on beta-alanine supplementation
∙ Updated information on the effectiveness of HMB supplementation
∙ Update on the role of beetroot/nitrate ingestion on endurance exercise performance
∙ Over 20 new references
Chapter 7—Vitamins: The Organic Regulators
∙ New data on deficiency prevalence rates for folate and vitamins B6, D, B12, A, C, and E
∙ New information on vitamin D status, deficiency, and supplementation in athletes
∙ New information on vitamin E status and exercise performance
∙ New information on the effects of certain medications on vitamin B12 deficiency
∙ New information on pantothenic acid and choline supplementation and performance
∙ Link to current comments from the American College of Sports Medicine regarding vitamin/mineral supplementation and exercise
∙ New information on the role of antioxidant supplementation in the older athlete
∙ New reviews on the ergogenic effects of coenzyme Q10 and quercetin
∙ New studies of the role of vitamin B supplementation on homocysteine levels and primary and secondary stroke prevention
∙ New information on vitamin supplementation and the management of age-related macular degeneration and cataracts
∙ New information on the roles of antioxidant vitamins and vitamin D in mental health
∙ Over 50 new references
Chapter 8—Minerals: The Inorganic Regulators
∙ New information on who may be at risk for calcium deficiency.
∙ New data on research involving the ergogenic aspects of phosphate salt supplementation, including new studies and reviews
∙ New information on all trace minerals, including iron, zinc, copper, chromium, and others
∙ New section on manganese as a trace mineral
∙ New discussion of the metal hypothesis of Alzheimer’s disease, which suggests some minerals may be protective but others may increase the risk
∙ Over 100 new references
Chapter 9—Water, Electrolytes, and Temperature Regulation
∙ Extensive revision to introduction and other parts of the text
∙ Several revised or new figures
∙ Updated information on U.S. and global sodium intake.
www.mhhe.com/williams11e xv
∙ Updated discussion of theoretical mechanisms of heat-related central nervous fatigue
∙ Updated information on glycerol’s status as a WADA banned substance
∙ Updated U.S. and global prevalence rates for hypertension
∙ Updated information on evolving guidelines for dietary sodium intake
∙ Over 70 new references
Chapter 10—Body Weight and Composition for Health and Sport
∙ Several revised or new figures
∙ Updated global prevalence rates for obesity
∙ New photograph of bioelectrical impedance procedure for body-composition assessment
∙ Inclusion of BMI categories representing apparent chronic energy deficiency
∙ Inclusion of body fat categories by gender and age, modified from American College of Sports Medicine’s Guidelines for Exercise Testing and Prescription, 9th edition, and The Cooper Institute, Dallas, Texas
∙ Updated discussion of brown adipose tissue
∙ Updated discussion of non-exercise activity thermogenesis (NEAT)
∙ Updated discussion of genetic contributions to obesity from genome-wide association studies (GRAS)
∙ Discussion of socioeconomic factors contributing to energy balance, such as more fast-food restaurants and unhealthy food choices in low-income areas
∙ New information on Calories consumed as sugar-sweetened beverages
∙ Expanded discussion of stress, environmental, viral exposure, and epigenetic factors and the built environment as contributors to obesity
∙ Discussion of the role of disruptions of normal intestinal bacteria in obesity
∙ Discussion of models other than the set-point theory as theoretical regulators of energy balance
∙ Expanded discussion of “screen-based” behaviors in impacting energy expenditure (sedentary activity) and intake (advertisements for energy-dense foods) in children and adults
∙ Expanded discussion of the health impacts of obesity to include increased risk for Alzheimer’s disease and other dementia
∙ Updated information on prescription weight-loss drugs approved by the U.S. Food and Drug Administration
∙ Updated information reflecting the four clinical eating disorders currently described in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders V
∙ Discussion of the controversy surrounding replacing the term “female athlete triad” with “relative energy deficiency in sport (RED-S)”
∙ Over 140 new references
Chapter 11—Weight Management and Loss through Proper Nutrition and Exercise
∙ New information on a gastric stimulation device approved by the U.S. Food and Drug Administration
∙ New and revised figures throughout the chapter
∙ Incorporation of the Compendium of Physical Activities, which lists MET intensity values of many leisure and recreational activities as well as activities of daily living
∙ Discussion of the conversion of MET values into caloric expenditure to complement appendix B
∙ Incorporating the energy expenditure based on MET values from the Compendium with Physical Activity Levels and Coefficients in the National Academy of Sciences Estimated Energy Requirement formulas
∙ Inclusion of a web link to 171 small steps to a healthier diet and increased physical activity
∙ Inclusion of the proposed requirement by the U.S. Food and Drug Administration to include “added sugars” on Nutrition Facts labeling
∙ Inclusion of selected Websites listing caloric and nutritive value of fast-food restaurant foods to complement appendix E
∙ Inclusion of the current list of risk factors and signs/symptom of possible disease according to the American College of Sports Medicine
∙ Discussion of high-intensity interval training (HIIT) as a physical activity component of weight loss and weight maintenance
∙ Expanded discussion and figure for the “fat burning” myth in the selection of exercise intensity for fat loss and weight loss
∙ Recent studies comparing the efficacy of commercial weightloss programs
∙ Over 90 new references
Chapter 12—Weight Gaining through Proper Nutrition and Exercise
∙ Updated Healthy People 2020 information on the prevalence of resistance training among U.S. adults
∙ Added information on the importance of the branch-chain amino acid leucine in muscle growth
∙ New research on the effects of resistance training in the older adult
∙ New research on the efficacy of creatine supplementation combined with resistance training in the older adult
∙ Additional information on regulatory factors and cell signaling pathways in adaptations to resistance training
∙ New research on nutrient timing to facilitate postexercise muscle growth
∙ Revised sample weekly resistance training record sheet
∙ New research on the potential efficacy of higher protein intake in maintaining lean mass and reducing fat mass
∙ Over 20 new references
Chapter 13—Food Drugs and Related Supplements
∙ Revised figures throughout the chapter
∙ Updated World Health Organization data on the global effects of alcohol abuse on health and mortality
∙ Information on potential interactions between alcohol and prescribed pharmacological agents, especially in older adults
∙ Information on a potential role of coffee in decreasing alcoholic cirrhosis
∙ A link to recent alcohol-impaired traffic safety data
∙ Updated data on the health, academic, and psychological effects of alcohol in high school and college students
∙ Updated information from studies by the World Cancer Research Fund (WCRF)/ American Institute of Cancer Research (AICR) and the International Agency for Research of Cancer (IARC) on the link between alcohol and breast and other cancers
∙ Discussion of American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders V alcohol use disorder (AUD) diagnosis
∙ Links to online screening questionnaires for possible alcohol use disorder
∙ New information on the association of alcohol and Alzheimer’s disease, mental health, and cognitive function
∙ Updated information on the role of alcohol and other ingredients in alcoholic drinks (e.g., polyphenols) on lipid metabolism, vascular function
∙ Research on the role of genetic variants in alcohol dehydrogenase in cardiovascular disease risk
∙ Updated data on the prevalence of coffee/caffeine use in the United States
∙ Updated information on the prevalence of energy drink use and concerns about the use of such products that also contain alcohol
∙ Updated research on the role of coffee/caffeine consumption and blood pressure and cardio-metabolic health
∙ Updated research on the role of coffee/caffeine in mental health, cognitive function, and multiple sclerosis
∙ Updated information on caffeine use in pregnancy and in infant health
∙ Updated information in recent discovery of amphetamine isomers in over-the-counter dietary supplements
∙ Updated status of pseudoephedrine (in addition to ephedrine, ephedra, and ma huang) as substances that are prohibited for use in competition by the WADA
∙ Updated information on U.S. Food and Drug Administration–mandated warnings about testosterone replacement therapy and increased risk for heart attacks and strokes
∙ Updated Centers for Disease Control and Prevention data on the prevalence of steroid use by teenagers
∙ Updated information on the efficacy of various herbals in improving body composition or performance
∙ Updated Australian Institute of Sports Classification System of Nutritional Supplements
∙ Over 110 new references
Appendices
∙ Updated several appendices, including those dealing with energy expenditure during exercise and the nutrient composition of products sold in fast-food restaurants
Enhanced Pedagogy
Each chapter contains several features to help enhance the learning process. Chapter Learning Objectives are presented at the beginning of each chapter, highlighting the key points and serving
as a studying guide. Key Terms also are listed at the beginning of each chapter, along with the page number on which they are first highlighted and defined. Although some terms may appear in the text before they are defined, a thorough glossary includes the key terms as well as other terms warranting definition. Key Concepts provide a summary of essential information presented throughout each chapter. Students are encouraged to participate in several practical activities to help reinforce learning. Check for Yourself includes individual activities, such as checking food labels at the supermarket or measuring one’s own body fat percentage. The Application Exercise at the end of each chapter may require more extensive involvement, such as a case study in weight control involving yourself or a survey of an athletic team. Students may wish to peruse all application exercises at the beginning of the course, as some may take several weeks or months to complete.
The reference lists have been completely updated for this edition, with the inclusion of more than 700 new references, and provide the scientific basis for the new concepts or additional support for those concepts previously developed. These references provide greater in-depth reading materials for the interested student. Although the content of this book is based on appropriate scientific studies, a reference-citation style is not used, that is, each statement is not referenced by a bibliographic source. However, names of authors may be used to highlight a reference source where deemed appropriate.
This book is designed primarily to serve as a college text in professional preparation programs in health and physical education, exercise science, athletic training, sports medicine, and sports nutrition. It is also directed to the physically active individual interested in the nutritional aspects of physical and athletic performance.
Those who desire to initiate a physical training program may also find the nutritional information useful, as well as the guidelines for initiating a training program. This book may serve as a handy reference for coaches, trainers, and athletes. With the tremendous expansion of youth sports programs, parents may find the information valuable relative to the nutritional requirements of their active children.
In summary, the major purpose of this book is to help provide a sound knowledge base relative to the role that nutrition, complemented by exercise, may play in the enhancement of both health and sports performance. We hope that the information provided in this text will help the reader develop a more healthful and performance-enhancing diet. Bon appetit!
Acknowledgments
This book would not be possible without the many medical/health scientists and exercise/sports scientists throughout the world who, through their numerous studies and research, have provided the scientific data that underlie its development. We are fortunate to have developed a friendship with many of you, and we extend our sincere appreciation to all of you.
We would like to acknowledge deep gratitude to Mandy Clark, Product Developer at McGraw-Hill, for her dedicated support throughout the revision process. Mandy was always available to address queries regarding various facets of the production process, and her responses were very prompt. We would also like to thank Anna Hoppmann, Digital Asset Librarian, for her assistance in navigating the photo database of McGraw-Hill, and Jessica Portz, our project manager. Our deep gratitude to Marija Magner, Brand Manager.
Melvin H. Williams
Norfolk, Virginia
J. David Branch
Norfolk, Virgina
Eric S. Rawson
Bloomsburg, Pennsylvania
MH Campus® integrates all of your digital products from McGraw— Hill Education with your school LMS for quick and easy access to best—in—class content and learning tools.
Fueled by LearnSmart—the most widely used and intelligent adaptive learning resource— LearnSmart Prep® is designed to get students ready for a forthcoming course by quickly and effectively addressing prerequisite knowledge gaps that may cause problems down the road.
Instructor Resources
Available at www.mhhe.com/williams11e are a number of instructor and student resources to accompany the text. For students, these include a BMI calculator, animations, daily food log, and more. For instructors, resources include PPT lecture outlines, image PowerPoint files, and more.
McGraw—Hill CreateTM is a self—service website that allows you to create customized course materials using McGraw—Hill Education’s comprehensive, cross—disciplinary content and digital products.
Inspire behavior change. NutritionCalc Plus is an online suite of powerful dietary self—assessment tools that help students track their food intake and activity and analyze their diet and health goals. Students and instructors can trust the reliability of the ESHA database while interacting with a robust selection of reports.
Required=Results
McGraw-Hill Connect®
Learn Without Limits
Connect is a teaching and learning platform that is proven to deliver better results for students and instructors.
Connect empowers students by continually adapting to deliver precisely what they need, when they need it, and how they need it, so your class time is more engaging and effective.
88% of instructors who use Connect require it; instructor satisfaction increases by 38% when Connect is required.
Analytics
Connect Insight®
Connect Insight is Connect’s new one-of-a-kind visual analytics dashboard—now available for both instructors and students—that provides at-a-glance information regarding student performance, which is immediately actionable. By presenting assignment, assessment, and topical performance results together with a time metric that is easily visible for aggregate or individual results, Connect Insight gives the user the ability to take a just-intime approach to teaching and learning, which was never before available. Connect Insight presents data that empowers students and helps instructors improve class performance in a way that is efficient and effective.
Connect’s new, intuitive mobile interface gives students and instructors flexible and convenient, anytime–anywhere access to all components of the Connect platform.
Adaptive
More students earn A’s and B’s when they use McGraw-Hill Education Adaptive products.
SmartBook®
Proven to help students improve grades and study more efficiently, SmartBook contains the same content within the print book, but actively tailors that content to the needs of the individual. SmartBook’s adaptive technology provides precise, personalized instruction on what the student should do next, guiding the student to master and remember key concepts, targeting gaps in knowledge and offering customized feedback, and driving the student toward comprehension and retention of the subject matter. Available on smartphones and tablets, SmartBook puts learning at the student’s fingertips—anywhere, anytime.
THE FIRST AND ONLY ADAPTIVE READING EXPERIENCE DESIGNED TO TRANSFORM THE WAY STUDENTS READ
Over 4 billion questions have been answered, making McGraw-Hill Education products more intelligent, reliable, and precise.
Introduction to Nutrition for Health, Fitness, and Sports Performance
LEARNING OBJECTIVES
After studying this chapter, you should be able to:
KEY TERMS
antipromoters 13
cytokines 7
doping 23
epidemiological research 28
epigenetics 2
epigenome 2
ergogenic aids 21
exercise 4
experimental research 28
health-related fitness 4
high-intensity interval training (HIIT) 9 malnutrition 20
meta-analysis 30
nutrient 12
CHAPTER ONE
nutrition 12
physical activity 4
1. Explain the role of both genetics and environment, particularly nutrition and exercise, in the determination of optimal health and successful sport performance.
2. List each of the components of health-related fitness and then identify the potential health benefits of an exercise program designed to enhance both aerobic and musculoskeletal fitness.
3. Define sports-related fitness and compare it to health-related fitness, noting similarities and differences.
4. List the seven principles of exercise training and explain the importance of each.
5. List the 12 guidelines underlying the Prudent Healthy Diet and discuss, in general, the importance of proper nutrition to optimal health.
6. Understand the importance of proper nutrition, including the role of dietary supplements as ergogenic aids, to sports performance.
7. Define nutritional quackery and understand the various strategies you can use to determine whether claims regarding a dietary supplement are valid.
8. Explain what types of research have been used to evaluate the relationship between nutrition and health or sport performance, and evaluate the pros and cons of each type.
physical fitness 4 promoters 13
Prudent Healthy Diet 15 quackery 24
risk factor 2
Sedentary Death Syndrome (SeDS) 6
sports nutrition 18
sports-related fitness 17
sports supplements 22
structured physical activity 4
unstructured physical activity 4
Introduction
There are two major focal points of this book. One is the role that nutrition, complemented by physical activity and exercise, may play in the enhancement of one’s health status. The other is the role that nutrition may play in the enhancement of fitness and sports performance. Many individuals today are physically active, and athletic competition spans all ages. Healthful nutrition is important throughout the life span of the physically active individual because suboptimal health status may impair training and competitive performance. In general, as we shall see, the diet that is optimal for health is also optimal for exercise and sports performance.
Nutrition, fitness, and health. Health care in most developed countries has improved tremendously over the past century. Although some rather rare diseases, such as Ebola, are a cause for concern, primarily because of the dedicated work of medical researchers we no longer fear the scourge of major acute infectious diseases such as polio, smallpox, or tuberculosis. However, we have become increasingly concerned with the treatment and prevention of chronic diseases. The World Health Organization (WHO) indicates that chronic diseases are now the major cause of death and disability worldwide. According to the U.S. Department of Health and Human Services (HHS), unhealthy eating and physical inactivity are leading causes of death in the United States. Given with rank in parentheses, they include (1) diseases of the heart, (2) cancer, (3) stroke, (4) chronic lung diseases, (6) diabetes, (8) Alzheimer’s disease, and (9) chronic kidney diseases. These diseases cause more than 85 percent of all deaths, and this figure is destined to rise as the U.S. population becomes increasingly older, particularly during the first quarter of this century when the baby boomers of the 1940s and 1950s reach their senior years.
The two primary factors that influence one’s health status are genetics and lifestyle. According to Simopoulos, all diseases have a genetic predisposition. The Human Genome Project, which deciphered the DNA code of our 80,000 to 100,000 genes, has identified various
genes associated with many chronic diseases, such as breast and prostate cancer. Genetically, females whose mothers had breast cancer are at increased risk for breast cancer, while males whose fathers had prostate cancer are at increased risk for prostate cancer.
Completion of the Human Genome Project is believed to be one of the most significant medical advances of all time. Although multiple genes are involved in the etiology of most chronic diseases and research regarding the application of the findings of the Human Genome Project to improve health is still in its initial stages, the future looks bright. For individuals with genetic profiles predisposing them to a specific chronic disease, such as cancer, genetic therapy eventually may provide an effective treatment or cure.
Although genetic influences may play an important role predisposing an individual to a chronic disease, so, too, does lifestyle. The CDC notes that although chronic diseases are among the most common and costly health problems, they are also among the most preventable by adopting a healthy lifestyle. Over the years, scientists in the field of epidemiology have identified a number of lifestyle factors considered to be health risks; these lifestyle factors are known as risk factors. A risk factor is a lifestyle behavior that has been associated with a particular disease, such as cigarette smoking being linked to lung cancer.
A major risk factor is being overweight or obese, a condition which affects almost two-thirds of Americans and is increasing worldwide. The Department of Health and Human Services recently listed the leading lifestyle-related causes of premature death in the United States. The combination of an unhealthy diet and physical inactivity, which may contribute to being overweight or obese, was ranked as the leading cause, followed by tobacco use and alcohol abuse.
In a recent review, Hall noted that our genes harbor many secrets to a long and healthy life but also noted that genes alone are unlikely to explain all the secrets of longevity. The role of a healthful diet and exercise are intertwined with your genetic profile. What you eat and how you exercise may influence your genes. Epigenetics is a relatively new field of research involving the role of the epigenome, a structure located just outside the genome that may activate or deactivate DNA and subsequent genetic and cellular activity. Cloud noted that various factors in our environment, such as substances in the foods we eat, may interact with the epigenome and thus modify cell functions—either in a positive or negative manner. Exercise, as noted later, also stimulates release of substances from muscle cells that may affect the epigenome. Cloud notes that comparable to the Human Genome Project, a Human Epigenome Project is under way,
and epigenetics may eventually lead to many beneficial health-related applications. For example, if personal genetic code indicates that your genetic profile predisposes you to certain forms of cancer, and if your genetic profile indicates that you will respond favorably to specific nutritional or exercise interventions, then a preventive diet and an exercise plan may be individualized for you. Genomics represents the study of genetic material in body cells, and the terms nutrigenomics and exercisenomics have been coined to identify the study of the genetic aspects of nutrition and exercise, respectively, as related to health benefits. Sportomics involves study of the metabolic response of the athlete in an actual sport environment, not in a laboratory. Treatment of chronic diseases is very expensive. Foreseeing a financial health-care crisis associated with an increasing prevalence of such diseases during the first half of this century, most private and public health professionals have advocated health promotion and disease prevention as the best approach to address this potential major health problem. Martinez-Perez and others note that with more than 1 billion smart phones around the world, the use of various applications for health promotion has great potential. The HHS, beginning in the 1980s, has published a series of reports designed to increase the nation’s health; the latest version is entitled Healthy People 2020: National Health Promotion/Disease Prevention Objectives. Physical activity/fitness and overweight/obesity are two of the major focus areas. These reports emphasize that lifestyle behaviors that promote health and reduce the risk of chronic diseases are basically under the control of the individual. The role of diet and
exercise in health promotion has become a worldwide priority, as documented in the WHO report Global Strategy on Diet, Physical Activity and Health. The guidelines presented in these reports underlie the recommendations presented in this book. For both reports, see web addresses below.
As we shall see, proper exercise and proper nutrition, both individually and combined, may reduce many of the risk factors associated with the development of chronic diseases. These healthful benefits will be addressed at appropriate points throughout the book.
Nutrition, fitness, and sport. Sport is now most commonly defined as a competitive athletic activity requiring skill or physical prowess, for example, baseball, basketball, soccer, football, track, wrestling, tennis, and golf. As with health status, athletic ability and subsequent success in sport are based primarily upon genetics and epigenetics. In a review of epigenetics in sport, Ehlert and others note that natural genetic endowment with characteristics important to a specific sport must be maximized through epigenetic modifications by appropriate type and amount of training.
To be successful at high levels of competition, athletes must possess the appropriate biomechanical, physiological, and psychological genetic characteristics associated with success in a given sport.
International-class athletes have such genetic traits. In recent reviews, Tucker and others highlighted the genetic basis for elite running performance while Eynon and others discussed the role of genes for elite power and sprint performance. Moreover, Wolfarth and others have
www.health.gov/healthypeople Check for the full report of Healthy People 2020. www.who.int/dietphysicalactivity/en/ Check for the World Health Organization report on diet and physical activity for health. www.ncbi.nlm.nih.gov/genome/guide/human/ For the interested reader, this site accesses the human genome map and the National Institutes of Health Epigenetics Roadmap.
assembled a human gene map for performance and health-related fitness.
To be successful at high levels of competition, athletes must also develop their genetic characteristics maximally through proper biomechanical, physiological, and psychological coaching and training. Whatever the future holds for genetic enhancement of athletic performance, specialized exercise training will still be the key to maximizing genetic potential for a given sport activity. Training programs at the elite level have become more intense and individualized, sometimes based on genetic predispositions. Modern scientific training results in significant performance gains, and world records continue to improve. David Epstein, in his book The Sports Gene, provides a fascinating account of the role both genes and the training environment play relative to elite sport performance. Proper nutrition also is an important component in the total training program of the athlete. Certain nutrient deficiencies can seriously impair performance, whereas supplementation of other nutrients may help delay fatigue and improve performance. Over the past 50 years, research has provided us with many answers about the role of nutrition in athletic performance, but unfortunately some findings have been misinterpreted or exaggerated so that a number of misconceptions still exist.
The purpose of this chapter is to provide a broad overview of the role that exercise and nutrition may play relative to health, fitness, and sport, and how prudent recommendations may be determined. More detailed information regarding specific relationships of nutritional practices to health and sports performance is provided in subsequent chapters.
Key Concepts
c Many chronic diseases in major developed countries (heart diseases, cancer, stroke, lung diseases, and diabetes) may be prevented by appropriate lifestyle behaviors, particularly proper exercise and a healthy diet.
c The two primary determinants of health status are genetics and lifestyle.
c Several of the key health promotion objectives set by the U.S. Department of Health and Human Services in Healthy People 2020 are increased levels of physical activity, a healthier diet, and reduced levels of overweight and obesity. c Sports success is dependent on biomechanical, physiological, and psychological genetic characteristics specific to a given sport, but proper training, including proper nutrition, is essential to maximize one’s genetic potential.
Check for Yourself
c Discuss with your parents any health problems they or your grandparents may have, such as high blood pressure or diabetes, to determine whether you may be predisposed to such health problems in the future. Having such knowledge may help you develop a preventive exercise and nutrition plan early in life. Please use the following website to create your own family history.
www.hhs.gov/familyhistory Create your own family health history.
Health-Related Fitness: Exercise and Nutrition
Physical fitness may be defined, in general terms, as a set of abilities individuals possess to perform specific types of physical activity. The development of physical fitness is an important concern of many professional health organizations, including the Society of Health and Physical Educators (SHAPE), which has classified fitness components into two different categories. In general, these two categories may be referred to as health-related fitness and sports-related fitness. Both types of fitness may be influenced by nutrition and exercise.
Exercise and Health-Related Fitness
What is health-related fitness?
As mentioned previously, one’s health status or wellness is influenced strongly by hereditarian predisposition and lifestyle behaviors, particularly appropriate physical activity and a high-quality diet. As we shall see in various sections of this book, one of the key factors in preventing the development of chronic disease is maintaining a healthful body weight.
Proper physical activity may certainly improve one’s health status by helping to prevent excessive weight gain, but it may also enhance other facets of health-related fitness as well. Healthrelated fitness includes not only a healthy body weight and composition but also cardiovascular-respiratory fitness, adequate muscular strength and muscular endurance, and sufficient flexibility (figure 1.1). As one ages, other measures used as markers of health-related fitness include blood pressure, bone strength, postural control and balance, and various indicators of lipid and carbohydrate metabolism.
Several health professional organizations, such as the American College of Sports Medicine (ACSM) and American Heart Association (AHA), have indicated that various forms of physical activity may be used to enhance health. In general, physical activity involves any bodily movement caused by muscular contraction that results in the expenditure of energy. For purposes of studying its effects on health, some epidemiologists classify physical activity as either unstructured or structured.
Unstructured physical activity, also known as leisure-time activity, includes many of the usual activities of daily living, such as leisurely walking and cycling, climbing stairs, dancing, gardening and yard work, various domestic and occupational activities, and games and other childhood pursuits. These unstructured activities are not normally planned to be exercise. However, as will be noted in chapter 11, these so-called nonexercise activities may play an important role in body weight control.
Structured physical activity, as the name implies, is a planned program of physical activities usually designed to improve physical fitness, including health-related fitness. For the purpose of this book, we shall refer to structured physical activity as exercise, particularly some form of planned moderate or vigorous exercise, such as brisk, not leisurely, walking.
What are the basic principles of exercise training?
Exercise training programs may be designed to provide specific types of health-related fitness benefits and/or enhance specific types of sports-related fitness. However, no matter what the purpose, several general principles are used in developing an appropriate exercise training program.
Principle of Overload Overload is the basic principle of exercise training, and it represents the intensity, duration, and frequency of exercise. For example, a running program for cardiovascular-respiratory fitness could involve training at an intensity of 70 percent of maximal heart rate, a duration of 30 minutes, and a frequency of 5 times per week. The adaptations the body makes are based primarily on the specific exercise overload. The terms moderate exercise and vigorous exercise are often used to quantify exercise intensity and are discussed later in this chapter and in more detail in chapter 11.
Principle of Progression Progression is an extension of the overload principle. As your body adapts to the original overload, the overload must be increased if further beneficial adaptations are desired. For example, you may start lifting a weight of 20 pounds, increase the weight to 25 pounds as you get stronger, and so forth. The overloads are progressively increased until the final health-related or sports-related goal is achieved or exercise limits are reached.
Principle of Specificity Specificity of training represents the specific adaptations the body will make in response to the type of exercise and overload. For example, running and weight lifting impose different demands on muscle energy systems, so the body adapts accordingly. Both types of exercise may provide substantial, yet different, health benefits. Exercise training programs may be designed specifically for certain health or sports-performance benefits.
FIGURE 1.1 Healthrelated fitness components. The most important physical fitness components related to personal health include cardiovascular-respiratory fitness, body composition, muscular strength, muscular endurance, and flexibility.
Principle of Recuperation Recuperation is an important principle of exercise training. Also known as the principle of recovery, it represents the time in which the body rests after exercise. This principle may apply within a specific exercise period, such as including rest periods when doing multiple sets during a weight-lifting workout. It may also apply to rest periods between bouts of exercise, such as a day of recovery between two long cardiovascular workouts.
Principle of Individuality Individuality reflects the effect exercise training will have on each individual, as determined by genetic characteristics. The health benefits one receives from a specific exercise training program may vary tremendously among individuals. For example, although most individuals with high blood pressure may experience a reduction during a cardiovascular-respiratory fitness training program, some may not.
Principle of Reversibility Reversibility is also referred to as the principle of disuse, or the concept of use it or lose it. Without the
use of exercise, the body will begin to lose the adaptations it has made over the course of the exercise program. Individuals who suffer a lapse in their exercise program, such as a week or so, may lose only a small amount of health-related fitness gains. However, a total relapse to a previous sedentary lifestyle can reverse all health-related fitness gains.
Principle of Overuse Overuse represents an excessive amount of exercise that may induce some adverse, rather than beneficial, health effects. Overuse may be a problem during the beginning stages of an exercise program if one becomes overenthusiastic and exceeds her capacity, such as developing shin splints by running too far. Overuse may also occur in elite athletes who become overtrained, as discussed in chapter 3.
Specific exercise programs for healthy body weight and composition, cardiovascular-respiratory fitness, and muscular strength and muscular endurance are detailed in chapters 11 and 12, and several of these principles are discussed in more detail.
Muscular endurance
Flexibility
Cardiovascular-respiratory fitness
Body composition
Muscular strength
What is the role of exercise in health promotion?
The beneficial effect of exercise on health has been known for centuries. For example, Plato noted that “lack of activity destroys the good condition of every human being while movement and methodical physical exercise save and preserve it.” Plato’s observation is even more relevant in contemporary society. Frank Booth, a prominent exercise scientist at the University of Missouri, has coined the term Sedentary Death Syndrome, or SeDS, and he and his colleagues recently noted that physical inactivity is a primary cause of most chronic diseases, the major killers in the modern era. Slentz and others discussed the cost of physical inactivity over time. The short-term cost of physical inactivity is metabolic deterioration and weight gain; the intermediate-term cost is an increase in disease, such as type 2 diabetes, whereas the long-term cost is increased premature mortality.
Reduces stress and improves self-image; helps prevent mental depression
Increases strength, flexibility, and balance; reduces risk of falling
Improves immune function
To help promote the health benefits of physical activity, the American College of Sports Medicine and the American Medical Association (AMA) launched a program, entitled Exercise Is MedicineTM, designed to encourage physicians and other health-care professionals to include exercise as part of the treatment for every patient. Clinical, epidemiological, and basic research evidence clearly supports the inclusion of regular physical activity as a tool for the prevention of chronic disease and the enhancement of overall health. Booth and others note that physical activity/exercise has been studied as a primary prevention against 35 chronic health problems, and numerous studies and reviews have documented the manifold health benefits, which are highlighted in the following list and in figure 1.2.
∙ Control body weight
∙ Reduce risk of metabolic syndrome
∙ Reduce risk of high blood pressure
∙ Reduce risk of type 2 diabetes
∙ Enhance blood lipid profile
∙ Reduce risk of heart disease
∙ Promote recovery from heart disease
∙ Reduce risk of stroke
∙ Reduce risk of breast cancer
∙ Reduce risk of colon cancer
∙ Improve self-image
∙ Reduce risk of mental depression
∙ Enhance cognitive functions in the elderly
∙ Reduce risk of falls in the elderly
∙ Delay onset and severity of Alzheimer’s disease
∙ Strengthen bones and muscles
∙ Reduce arthritis pain
∙ Improve immune functions
Reduces risk of colon cancer, prostate cancer, and likely breast cancer
Reverses brain deterioration with aging; helps prevent, or delay, Alzheimer’s disease; improves executive functioning
Increases cardiovascular function and improves blood lipid profile; helps prevent heart disease and stroke
Aids in weight loss/weight control
Increases muscle mass, muscular strength, and muscular endurance
Promotes a healthy pregnancy
Improves sleep (if activity is done in the morning or afternoon)
FIGURE 1.2 Exercise is medicine. Here are some of the benefits of regular moderate physical activity and exercise. See text for discussion.
∙ Promote healthy pregnancy of mother and fetus
∙ Improve quality of sleep
∙ Improve quality of life
∙ Increase longevity
These benefits may accrue to males and females of all races across all age spans. You are never too young or too old to reap some of these health benefits of exercise.
In essence, physically active individuals enjoy a higher quality of life, a joie de vivre, because they are less likely to suffer the disabling symptoms often associated with chronic diseases, such as loss of ambulation experienced by some stroke victims. As noted in the next section, physical activity may also increase the quantity of life. As quoted by Greider, James Fries, an emeritus professor who studies healthy aging at the Stanford University School of Medicine’s Center on Longevity, said, “If you had to pick one thing, one single thing that came closest to the fountain of youth, it would have to be exercise.”
How does exercise enhance health?
Recent news reports made headlines around the world, such as one entitled Exercise Benefits: Rivals Drugs for Stroke, Heart Disease Treatment. The question is, How?
The specific mechanisms whereby exercise may help to prevent the development of various chronic diseases are not completely understood but are involved with changes in gene expression that modify cell structure and function. Physical inactivity is a major risk factor for chronic diseases. As noted previously, Booth and Neufer indicated physical inactivity causes genes to misexpress proteins, producing the metabolic dysfunctions that result in overt clinical disease if continued long enough. In contrast, exercise may cause the expression of genes with favorable health effects.
Most body cells can produce and secrete small proteins known as cytokines, which are similar to hormones and can affect tissues throughout the body. Cytokines enter various body tissues, influencing gene expression that may induce adaptations either favorable or unfavorable to health (figure 1.3). Two types of cytokines are of interest to us. Muscle cells produce various cytokines called myokines (referred to as exerkines when produced during exercise), whereas fat (adipose) cells produce cytokines called adipokines. Muscle cells also produce heat shock proteins (HSPs), which may have beneficial health effects. The following represent several important cytokines produced in muscle and fat cells:
Overall, Brandt and Pederson theorize that exercise-induced cytokine effects on genes reduce many of the traditional risk factors associated with development of chronic diseases; Geiger and others note similar effects for HSPs. In particular, McAtee notes
that one of the common causes of various chronic diseases is an inflammatory environment created by the presence of excess fat, particularly within blood vessels. Local inflammation is thought to promote the development of heart disease, cancer, diabetes, and dementia. According to Nimmo and others, exercise produces an anti-inflammatory cytokine that may help cool inflammation and reduce such health risks. They note that the most marked improvements in the inflammatory profile are conferred with exercise performed at higher intensities, with combined aerobic and resistance exercise training potentially providing the greatest benefit.
Cytokines and heat shock proteins may prevent chronic diseases in other ways as well, such as increasing the number of glucose receptors in muscle cells, improving insulin sensitivity, and helping to regulate blood glucose and prevent type 2 diabetes. There are also other health-promoting mechanisms of exercise. One of the most significant contributors to health problems with aging is sarcopenia, or loss of muscle tissue. In their review, Landi and others conclude that regular exercise is the only strategy found to consistently prevent frailty and improve sarcopenia and physical function in older adults. The following are some other examples:
∙ Loss of excess body fat may reduce production of cytokines that may impair health.
∙ Loss of excess body fat may reduce estrogen levels, reducing risk of breast cancer.
∙ Reduction of abdominal obesity may decrease blood pressure and serum lipid levels.
∙ Increased mechanical stress on bone with high-impact exercise may stimulate increases in bone density.
∙ Production of some cytokines, such as BDNF, may enhance neurogenesis and brain functions.
gene expression, which changes the amounts of proteins in
FIGURE 1.3 Exercise may induce adaptations that have favorable health effects in various body tissues. One suggested mechanism is the effect that various hormones or cytokines, which are produced during exercise, may have on gene regulation in body cells. (1 ) The hormone or cytokine binds to a cell receptor that activates a signal within the cell, (2 ) the signal is transmitted along a specific pathway, (3) the signal may alter gene expression and induce changes within the cell. Cell signals may also affect enzymes or other cell structures that may induce beneficial health effects.
Some healthful adaptations may occur with a single bout of exercise. Nimmo and others reported that single bouts of exercise have a potent anti-inflammatory influence, while others have noted that a single exercise session can acutely improve the blood lipid profile, reduce blood pressure, and improve insulin sensitivity, all beneficial responses. However, such adaptations will regress unless exercise becomes habitual. Thus, to maximize health benefits, exercise should be done most days of the week because many of its benefits stem from the most recent exercise sessions. The role that exercise may play in the prevention of some chronic diseases, such as heart disease and diabetes, and associated risk factors, such as obesity, are discussed throughout this book where relevant.
Do most of us exercise enough?
In general, NO. Surveys reveal that most adult Americans and Canadians have little or no physical activity in their daily lives. For example, the Healthy People 2020 report from the United States Department of Health and Human Services indicates that more than 80 percent of adults do not meet the guidelines for both aerobic and muscle-strengthening activities. Similarly, a recent study by Song and others indicated more than 80 percent of adolescents do not do enough aerobic physical activity to meet the guidelines for youth. Harvey and others reported the majority of older adults are sedentary, many sitting for prolonged periods. Thus, one of the major goals of Healthy People 2020 is to decrease the amount of physical inactivity, such as television viewing, and increase the amount of physical activity in both adults and youth.
How much physical activity is enough for health benefits?
In general, there is a curvilinear relationship between the amount of physical activity (dose) and related health benefits (response), as depicted by the dose-response graph in figure 1.4. A sedentary lifestyle has no health benefits, but health benefits increase rapidly with low to moderate levels of weekly activity. Beyond moderate levels of weekly physical activity, the increase in health benefits will continue to increase gradually and then plateau. Excessive exercise may actually begin to have adverse effects on some health conditions. However, as noted by Bouchard, there may be other specific dose–response curves. Some health conditions may improve rapidly with low to moderate weekly levels of physical activity, whereas others may necessitate increased levels. As an example of the latter, the ACSM Position Stand on physical activity and weight loss has noted that while moderate-intensity exercise between 150 and 250 minutes weekly will provide only modest weight loss, greater amounts of physical activity, averaging more than 250 minutes weekly, have been associated with clinically significant weight loss. Dependent on the desired health outcome, the dose (intensity, duration, frequency) of physical activity may vary accordingly, as will type of physical activity. To reap the health benefits of exercise, most health professionals recommend a comprehensive program of physical activity, including aerobic exercise and resistance training. Flexibility and balance exercises become increasingly important for older adults. In general, the
FIGURE 1.4 Significant health benefits may occur at low to moderate levels of physical activity with diminishing returns at higher levels. Excessive amounts or intensity of exercise, depending on the individual, may predispose to various types of health problems. See text for discussion.
following recommendations for adults have been formatted into a MyActivity Pyramid, a graphic depicting exercise guidelines. The latest version, developed by Stephen Ball at the University of Missouri, is presented in figure 1.5.
Numerous reports providing exercise recommendations for health benefits have been released by various professional and governmental health-related organizations, including the Physical Activity Guidelines for Americans from the U.S. Department of Health and Human Services and the National Physical Activity Plan, a coalition report from the American Heart Association, the American College of Sports Medicine, the Centers for Disease Control and Prevention, and many other such organizations. Here are some of the key points to help you reap the many health benefits of physical activity.
∙ Individualization. Exercise programs should be individualized based on physical fitness level and health status. Claude Bouchard, an expert in genetics, exercise, and health, noted that due to genes, physical activity may benefit some, but not others. For example, although most sedentary individuals will respond favorably to an aerobic exercise training program, such as an improved insulin sensitivity, others will not respond and have no change in insulin sensitivity. Currently, there is no gene profile for responders and nonresponders to exercise training, but that may change in the future so that specific exercise programs may be designed for individuals.
∙ Leisure-time activity. A key component of a fitness plan is simply to reduce the amount of daily sedentary activity. One important modification to your daily lifestyle is to sit less and
Another random document with no related content on Scribd:
Of this he says: “To insure still further the sterilization of the paraffin, I have devised a tin (nickle-plated) receptacle supported on an attached tripod, which raises the bottom an inch from any plane surface on which it is placed, and is closed with a detachable lid. This arrangement prevents the paraffin from burning or browning. Into this I pour the paraffin from the test tube, after melting, and place this receptacle into a sterilizer, or any ordinary boiler—surround it almost entirely with water and then boil. After I have boiled it for a few minutes I remove the receptacle and permit it to cool until the paraffin therein is about 120° F I then draw it up into the syringe, which has been sterilized in the same boiler with the paraffin. When sufficient is withdrawn, I evacuate the air bubbles from the syringe by pressing the piston upward and run my set screw into place. Some two or three minutes are now allowed for the paraffin to assume equal consistency throughout and to cool down to a semisolid state. When the paraffin reaches this consistency it may be kept many hours ready for use, at the temperature of the room, if only the precaution to warm the needle is taken each time before attempting the injection.”
17. Hypersensitiveness of the Skin.—A permanent hypersensitiveness of the skin over the site of a subcutaneous paraffin injection has never been definitely shown. While it is true there is some pain and feeling of stress and fullness over and about such area, immediately after the operation, this has subsided in about twenty-four hours in the average case, except in those where a very hot liquid paraffin and of large amount has been injected, when several days are required to overcome these symptoms.
Smith claims a numbness over the site of the injected area which soon passes away, but this is perhaps more a feeling of fullness rather than one of anesthesia.
The author has observed, however, in several cases a period of extreme discomfort, fullness and cephalalgia in cases of subcutaneous injections about the root of the nose. Peculiarly these attacks appear only after the filling has become organized; that is, after the connective tissue has displaced the paraffin. The secondary tumor in such cases appears to be slightly larger superiorly than the original size at the time of injection.
The irregularity of these attacks, with edema of the forehead and slight puffing of the upper eyelids, points to a disturbance of the circulation and is undoubtedly due to pressure on the angular vessels, and the venous arch across the root of the nose. The symptoms usually appear in the early morning and moderate toward night, reappearing
again the next morning or not again until the next attack, which may be expected at any time.
This condition of affairs is an unfortunate one, since we cannot look to the avoidance of the trouble nor foresee it at the time of operation. In one case the symptoms did not develop until nearly two years after the injection was made and became so troublesome that the only relief had was by opening the skin of the nose laterally and excising as much as seemed necessary of the newly formed connective tissue with a fine pair of curved scissors. None of the injected matter was discovered except two fine scalelike disks of glistening paraffin of a diameter of one sixteenth inch. These were evidently all that remained of the injected mass, and were undoubtedly held in the innermost meshes of the new tissue Immediate relief followed the operation, but no appreciable difference in the size of the tumor could be noticed.
Cold applications or ice cloths relieve the temporary pain following an injection of paraffin, but in most cases this is rarely necessary except in extremely nervous and expectant patients.
On the whole the author believes the secondary neuroses and circulatory difficulties are now practically overcome by the more conservative use of the matter to be injected, coupled with a repetition of the injection of smaller amounts at each sitting and not repeating the same until the first has become organized.
18. Redness of the Skin.—Redness of the skin following an injection of the nature under consideration was one of the early objections made by various operators.
That redness, more or less permanent, has been found in many cases in which these injections were made is true, but such redness was found particularly when the injections were those of liquid paraffin of high melting points and in which the operator was overzealous in bringing about an absolute correction of a deformity, with the result that when the paraffin had been molded and set, it was generally pinched or shaped up or outward, thus causing a great deal of pressure upon the circulatory vessels of the skin.
The redness in such cases did not appear until several days after the operation, becoming worse gradually instead of better even in spite of the efforts to reduce it by external applications. Not unusually, in the permanent cases, distended capillaries can be seen in the skin resembling the condition in acne rosacea chronica, especially when the injection had been made to correct a saddle nose.
Smith says: “Redness is present in a good many cases. I have seen a case in which the redness lasted over a year, but it gradually disappeared. There seems to be a tendency on the part of nature to take care of a foreign body, and I think the reënforcement of connective tissue that grows into this mass requires an increased blood supply, and later, when the blood supply is no longer necessary, the redness will disappear.”
The latter is true where the hyperemia is either acute or subacute, but in chronic cases where the capillaries have become distended and show plainly there is little to be hoped through the effort of nature.
Eckstein, the advocate of “Hart-paraffin” method of high melting point, states that a redness of the parts develops a few days after the injection that disappears after a time,
but that this redness is more marked and of longer duration when the injections are made intracutaneous instead of subcutaneous.
These injections should be made subcutaneous in all cases, and there is no excuse for deviating from this method.
With the use of semisolid and cold paraffin mixtures, as heretofore advocated, redness rarely if ever follows the injection unless undue pressure has been made, in which case necrosis is more liable to follow unless the adjacent tissue will gradually allow the mass to become relieved by a change in form and position.
Such subsequent hyperemias are not now as common as when the injections were at first attempted, and the author may say freely that they never occur when the proper method and material is used.
Paget says: “In a few cases—but only in a few—some reddening of the skin has followed the injection, and in a few this has been very slow to fade.
“The few referred to are of a record of twenty-two nasal cases, but no data is given whether the operator used paraffin of high or low melting points. F. Connell found that redness in that case continued for a year, diminishing very little in that time. It appeared on the second time after the operation for a correction of a saddle nose, and remained stationary for about one month. Twenty drops of paraffin were injected. It very gradually increased, so gradually, in fact, that there is still a distinct reddened area over the bridge of the nose. On pressure this redness will disappear, but returns immediately after the removal of the pressure. A few dilated and tortuous capillaries course their way over the area. The condition is still present fourteen months after the injection.
“There has been practically no change or decrease in the redness during the last six or seven months, it is not as marked as it was during the first few months, but still requires the profuse application of face powder in order to prevent her nose from being conspicuously red.”
The above case has been cited because it is typical of such condition, and while the amount as stated was quite small, one is almost nonplussed for an explanation of the result, yet it undoubtedly must have been due to a close attachment of the skin to the underlying structures, necessitating pressure, which is known to cause it.
However, it is possible to have such redness develop weeks or months after the injections are made. In such cases it is not due to the primary pressure of the injection, but to that of the newly developed tissue which has taken its place, but which is slightly overdeveloped for the same unaccountable reason already referred to.
Almost every surgeon who has used this method of restoring the contour of parts of the face has observed redness, more or less permanent, follow the method used, but in most cases liquid paraffin of high melting points had been forced into the tissues at great pressure.
In one case, that of a southern operator, the entire tip of the nose had become injected by primary diffusion or direct filling.
It became inflamed immediately after, and some weeks later, when the swelling had subsided, the lobule was found to be very hard, tense, and extremely red. Two years after the author saw this case, and the tip of the nose still appeared like a red cherry with
numerous capillaries showing over its area, while the rest of the nose, although much broadened by secondary displacement of the paraffin, was natural in color
This proves that as the pressure was relieved by absorption and displacement, the tissue took on a normal appearance, whereas in the lobule of the nose, where there was no relief from the pressure, nature could do nothing to relieve the inevitable result.
In cases where the redness is suspected it may not be too late, a day or two after the injection, to remold the mass into such form as to relieve the acute tension.
If the redness develops early, cold applications of an antiseptic nature or ice cloths can be used to advantage. Antiphlogistin or other similar preparations applied externally give good results.
Later ichthyol, twenty-five-per-cent solution, may be applied; acetate of alumen in saturated solution seems to do well. Some operators apply hydrogen peroxid, but it gives only temporary benefit. When the capillaries have become distended and the redness is practically chronic the vessels should be destroyed with a fine electric needle, using about 20 milliampères—direct current.
Sometimes when the redness is acute and seems to persist depletion of the part does some good. This is done by nicking the skin here and there with a fine bistoury and allowing the part to bleed freely Care should be taken not to puncture the skin too deeply, so as not to allow the injected mass to escape.
In some cases it is allowable to open the filled cavity early and remove enough of the filling to overcome the difficulty, injecting later, after the filling has become organized, to make up the deficiency.
When the redness is secondary—that is, when it develops after the connective tissue has replaced the paraffin—it is best to open up the part and excise enough of the tissue to overcome the pressure.
In a case where the author injected for a deep furrow in the forehead with a cold semisolid paraffin mixture, a secondary redness developed three months after the injection had been made, no redness having been noticed in the meantime. There was more or less swelling for two or three weeks, undoubtedly due to pressure phlebitis, which eventually subsided.
The redness in this case was only reduced by an excision of the tissue causing the trouble. The result was satisfactory.
19. Secondary Diffusion of the Injected Mass.—This is a condition that no operator can foretell, although it might be caused by a primary diffusion due to hyperinjection of so small an extent that it escaped the surgeon’s attention at the time.
Again, a site injected may at the time of operation present all the indications of a satisfactory result—that is, the tissues at the place of operation and its immediate vicinity appear perfectly loose and elastic; the injection being made easily and the contour of the defect being remedied either partially or entirely as the operator may desire; there being no mechanical anemia post-operatio, and no decided effort on the part of the tissues to cause primary elimination after the withdrawal of the needle; yet it is possible that, by such an injection, sufficient pressure may be caused upon some of the blood vessels within the limitations of the injection as to cause a decided reaction a few hours after the
operation, as evidenced by a swelling, too great for the disturbance occasioned, and associated with all the signs of a fairly active inflammation.
It is possible that such a reaction may cause a displacement or diffusion, post-primary, of the mass injected, especially if the mass be merely vaselin or a mixture of vaselin and paraffin at a melting point too low for the purpose. Nevertheless, it is practically impossible to foresee such result and the operator can only use the same care as with any or all such injections.
It is possible, when the reaction is too marked, to mitigate, to a great extent, this diffusion of the injected mass, by using such methods as reduce the inflammatory symptoms.
As a rule, these cases exhibit considerable ecchymosis after this active reaction has subsided, lasting from one to two weeks.
Secondary diffusion, as the author uses the term, signifies an extension of the injected mass beyond the intended area. This may occur in two or three weeks or be proportionate to the activity of the production of fibrous connective tissue that is supplanting the mass.
Leonard Hill has reported a case in which he injected vaselin to correct a saddle nose for æsthetic or cosmetic reasons. The result was very satisfactory to both operator and patient, and continued so for nearly twelve months, when secondary diffusion of the mass began to be noticeable. Eventually the diffusion became so great in the upper eyelids as to close both eyes completely.
The worst case of such secondary diffusion the author has ever heard of or seen came to his attention early this year The patient had been subjected to a subcutaneous injection of oils for the cosmetic correction of an abnormal deepening of the inner clavicular notch. The injected mixture, as far as the author could learn, was made up of sweet almond, peanut, and olive oils with two others that had been forgotten. Her physician had made two injections several days apart with a satisfactory result. The reaction was trifling and the parts returned to the normal in two weeks.
Five months later the part injected became tender to the touch and began to enlarge daily. With the increase in size a gradual inflammation involved the whole lower region of the anterior region about the root of the neck. Various applications were made to the part to reduce the inflammation, but at the end of ten days a region of skin that had indicated the pointing of an abscess burst, allowing the escape of about eight ounces of pus. Under the most careful surgical attention this discharge continued for about three months, until under the influence of gauze packing the wound was made to heal from the bottom, leaving an ugly irregular scar at the site of the opening. With the healing of this fistular wound, however, the size of the tumor did not diminish whatever, but continued to grow until, at the present time, one and one half years after the injections had been made, the size of this peculiar hyperplastic growth of ovate form measures nearly five inches across its horizontal diameter and three and one half inches through the vertical. It is closely adherent to the overlying thickened skin, which has undergone a yellow pigmentary change to be considered in the next text subdivision. The tumor is hard, painless, and freely movable beyond the limitation of its skin attachment and rests upon the sternal thirds of the clavicles, extending upward and forward with evidences of traction on the whole anterior skin of the neck. Laryngoscopy discloses nothing abnormal. The deformity
is hideous, and necessitates a mode of dress to conceal it. The patient has not as yet been operated on for the extirpation of the growth, owing to her present physical condition, the result of melancholia.
Scanes-Spicer injected some vaselin to correct a saddle nose with satisfactory immediate result, but after several days the upper lids became slightly edematous, and soon after a small hard lump, the size of a grain of shot, was felt in the left upper lid.
Harmon Smith observed a secondary diffusion in two cases in which the abnormality in one occurred on the side of the nose and in the other at the inner canthus following the course of the angular vein.
While in the foregoing cases the difficulty may have been overcome by using the cold, semisolid paraffin mixture and reducing the amount injected, it is questionable if the diffusion could thus have been entirely overcome.
The author points to the fact that undoubtedly this fault is observed more when the tissues at the side of the nose, or about the alæ, are injected, and that the cause here is one of an unequal pressure of the parts—the skin more or less bound down above and the ungiving cartilage below
In such cases great care should be exercised in the amount injected, and if, after introducing the needle, the tissue be found to be unduly adherent and inelastic, to withdraw the needle and with a fine tenotome divide or dissect up the skin before the mass is injected. At no time would an operator be justified to inject more than ten drops of the mass, at a single operation, into the parts referred to.
As already mentioned, there is not only danger of diffusion of the mass in such region of the nose, including the lobule and the subseptum, but there is a special danger of gangrene from pressure where the tissues are less supportative than where muscular tissue or greater mobility of the skin is found.
After the immediate attempts to reduce a reactive inflammation, nothing can be done to overcome secondary diffusion except excision of the amount not wanted. This should not be undertaken until at least three months after the time of injection.
The mass of connective tissue must be entirely excised as thoroughly as possible, and slightly beyond the border of the abnormal elevation. A sharp curette is practically of no use for this purpose, and only wounds the skin, and by reason of retentive shreds of tissue may cause infective inflammation.
The opening into the skin should be made with a fine bistoury, the skin be dissected off from the elevated connective tissue, and the latter extirpated by dipping cuts of a fine small, sharp-pointed, half-rounded scissors. The operation can be done neatly and painlessly under eucain anesthesia.
The wound may be sutured with fine silk or be allowed to unite of its own accord.
It is advisable to supply a small pressure dressing, made of a circular gauze pad, over the site to assure of the best union between the dissected or undersurface of the skin and the floor of the wound.
Dry dressings are to be preferred, since moisture would tend to soften the skin and permit it to crawl, which would not improve the ultimate result.
20. Hyperplasia of the Connective Tissue following the Organization of the Injected Matter.—The overproduction of connective tissue replacing the injected mass is rarely observed, yet a few cases have been noted.
Sebileau has reported a true case of diffuse fibromatosis following an injection of paraffin. This not only included the site of the injection, but extended to the surrounding or adjacent tissue, making the secondary defect much more disfiguring than the first.
The author has observed in one case of hyperplasia following the correction of a saddle nose, that the area injected presented no unusual appearance for six months, when the nose at its middle third began to enlarge slowly until it resembled a marked Roman shape, the enlargement extending laterally and as far down as the nasogenian furrows at the end of nine months.
The injection used was a cold, semisolid paraffin mixture, and only sufficient to barely correct the defect was injected, the skin being thoroughly flexible at the time of operation.
No reason can, therefore, be given for this unusual result, except, perhaps, a peculiar idiosyncrasy of the tissues, that may be compared, somewhat, with the external tissue changes in hypertrophic or keloidal scars, especially noted in the wounds of negroes—a condition for which we have, as yet, found no attributable cause.
While we cannot definitely prevent such a result, following an injection of a hydrocarbon, we may at least be sure that hyperinjection is not the cause.
The hyperplasia as exhibited in these cases is one of true fibromatosis. The microscopical examination may show the retention of paraffin in small, round, pearllike masses lying in cells of varying size, but with specimens of such tissue removed after a number of years’ standing does not show the paraffin in situ.
In a specimen taken from a chin five years after the injection of paraffin the Lederle Laboratory makes the following report accompanied by microphotographs of sections taken from the fibromatous area as shown in Figs. 288a and 288b:
“A D —The specimen consists of several pale, tough masses of tissue removed from the chin covered on the outside by normal skin.
“H D —The various layers of the epidermis—i. e., the strata corneum, lucidum, and granulosum—are unthickened and practically normal. In the corium the papillary and reticular layers are apparently normal, showing no thickening nor round-cell infiltration.
“The glandular elements in this area and the hair follicles appear normal.
“Toward the deeper layers and the subcutaneous connective tissues appear isolated areas of round-cell infiltration separated by masses of fibrous connective tissue, much of which is of new formation, as indicated by the nucleated character of the elongated cells. There are areas of diffuse round-cell infiltration.
“In this portion of the corium there is also to be found a large number of vacuolated areas varying very greatly in size, and which are surrounded by membranous fibroustissue elements, much of which is likewise of new formation, as indicated by the character of its cells.
“These vacuoles doubtless represent the areas containing the masses of paraffin which have been split up by the new formation of fibrous tissue. Between the vacuolated areas can be seen actual infiltration by true fat cells.
“In many spots the fibrous-tissue formation has proceeded to the point of thick bands containing but few nucleated cells. Fig. 288a, which is a photomicrograph of this portion of the section, shows these changes.
“In one of the foci of round-cell infiltration which have been surrounded and invaded by bands of new fibrous tissue there are numerous giant cells of the so-called ‘foreign-body’ type. This is shown in Fig. 288b.
“S Histological Diagnosis.—Diffuse fibromatories with fatty infiltration and giant-cell formation in a vacuolated area produced by paraffin injection.”
Once the hyperplasia is established the surgeon must simply wait until he believes the activity of the abnormal growth has subsided and then remove the superabundant tissue with the knife.
With another case, in which the patient was operated on by another surgeon, the author was called upon to remove the growth. A part of the coarse, yellowish pale and cartilagelike tissue was excised, sufficient to restore the parts to a normal contour. After an uneventful recovery the patient went away, greatly pleased, only to return in six months, presenting a similar condition as before the extirpation.
F 288b M
F × 40
A second operation was done, this time more extensively, the entire yellowish connective tissue being removed by the aid of a long median incision on the anterior aspect of the nose.
The wound healed readily and showed very little scar, and the patient was discharged. One year after the last operation the nose was still normal in appearance and the growth had not reappeared.
From this it is deemed absolutely necessary to remove practically all of the newly formed tissue to warrant a nonrecurrence of the fibromatosis.
21. A Yellow Appearance and Thickening of the Skin after Organization of the Injected Mass Has Taken Place.—This condition of the skin is evidenced some time after the injected mass has become organized, beginning about the sixth month after the time of injection. It has been especially noticed with the hard paraffin fillings of the nose, but also with other injections, even of the lowest melting points, about the sternoclavicular regions of the neck.
The skin becomes at first streaked with a superficial and irregularly defined patch of red, the forerunning indication of the size of the ultimate pathological change. The red color subsides slowly, leaving the area pale, which thereafter gradually thickens, taking on the appearance of a light yellow stain in the skin.
Practically opposite to the condition in xanthalasma, where the yellow area is slightly elevated and occurs in the loose tissue of the eyelids.
The cause seems to be a degenerative change in the skin dependent on pressure upon its underlying tissues. Evidently the pressure of an overproduction of the connective tissue which has sprung up to replace the injected mass.
Seemingly the cause is due to an injection being made too close to the derma where the latter is bound down to the subcutaneous tissue, or a desire on the part of the surgeon to prevent an injection into the deeper areolar tissue, especially when the injection is made in the vicinity of the larger blood vessels, for fear of causing embolisms or phlebitis.
Excluding the use of hard paraffin for such injection, the operator should be sufficiently experienced to use these injections properly and without fear, and at all times avoid injecting into the skin instead of subcutaneously.
Making the puncture first and observing if blood flows freely or trickles from the detached needle will assure the operator into what tissues he has thrust his needle.
Should active bleeding follow the puncture, he should withdraw the needle and wait to inject the site at a later sitting, using the same precaution; at no time should he be in doubt as to the absolute placing of the injected mass.
When the injections are done about the lower neck or shoulders great care must be exercised to avoid the blood vessels, and small quantities be only injected to prevent reactions that may cause phlebitis of these vessels; furthermore, the injected mass must be carefully molded to prevent the formation of uneven elevations or lumps. Without doubt an injection into one of the blood vessels of the neck would mean certain death.
Kofman lost a patient by pulmonary embolism twenty-four hours after an injection of 10 c.c. of paraffin. How many punctures he made to inject this amount is not stated, but
certain it must be that he introduced part of the mass directly into some blood vessel.
The author advises, when injecting about the neck, to use a stout, dull-pointed needle introduced under local ethyl chloride anesthesia and to elevate the tissue with the needle as the injection is made. In this way the operator can observe the behavior or placing of the injected mass, at the same time stretching the skin to permit of the injection without encroaching upon the blood vessels. The mass is immediately molded after each injection. The further question of the practical method of making these injections will be fully considered later.
If, however, the pigmentation under consideration has taken place, electrolysis with a fine needle may be resorted to, with the object of whitening the discoloration by producing scar tissue, in the form of punctations, in the discolored area.
While the numerous white spots so caused are objectionable, they are better borne by patients than the pigmented appearance. A thorough needling of the spot in this way eventually brings about an improvement, and if, for æsthetic reasons, the patient objects to the unsightliness of the result thus obtained, the white area may be carefully tattooed with an appropriate color to match the rest of the skin of the face or neck.
If the pigmented area is not too large, it can be excised with the knife and the healthy skin be brought together with a fine silk suture, thus leaving a thin linear scar which can be dealt with as the punctate scar area, if desired; the electrolysis being a painful procedure at all times, since sufficient milliampères must be used to cause scar-tissue formation, which is between 20 to 30 milliampères in such cases.
22. The Breaking Down of Tissue and Resultant Abscess Due to the Pressure of the Injected Mass upon the Adjacent Tissue after the Injection Has Become Organized.—The above result is particularly noticeable when the injections have been made into the cheek or the breast. It is understood that the suppurative changes under consideration herein are not attributable to imperfect sterilization of the injected matter, although it is possible, and perhaps is the cause in fifty per cent of the suppurative elimination of the infected mass from the cheek, that a nucleus of infection is carried into the tissues and is held in suspense for a time, because of its imbedment in a neutral media that does not readily permit of bacteriological propagation, but eventually this nucleus must come in contact with tissue which it can affect, and only then may its infection be taken up.
The author believes that such secondary affections are accountable to pressure effects upon the blood vessels or glandular structure, as in the case of breast injections, the new connective tissue causing a lack of nourishment in the part or gland, and a resultant breaking down of the tissue, directly influenced in some instances by external violence.
Tuffier reports the elimination of paraffin injected into the breast several weeks after the injection. If this elimination had been caused by primary infection an acute reaction would have taken place at least within forty-eight hours, ending in abscess shortly after.
A case which came to the author’s attention was that of a lady who had been operated upon for the correction of a saddle nose three months before. The result had been satisfactory. The day previous to consulting the author she had injured her nose in an automobile accident. The nose was much swollen, very painful, and red over the entire upper and middle third. The use of external cold did not relieve the condition much, and on the fourth day the skin broke open at one point, allowing pieces of the paraffin to
escape. Immediate relief followed, the wound healed with a marked sinking of the middle third of the nose. After three weeks the nose was again injected with no further untoward symptoms, the result being satisfactory for two years past.
In this case undoubtedly the exciting cause was directly due to violence, which may be the forerunner in many of such cases, but there is a number of such eliminations directly due to a breaking down of the tissue from internal pressure alone.
There is no way to overcome this difficulty, except to await the definite formation of the abscess and then to puncture the skin directly over the soft fluctuating area and to drain the cavity.
Once relieved, the condition quickly subsides, leaving a certain amount of loss of contour, which can, however, be corrected several weeks after by a secondary injection.
When the abscess occurs in the cheek it is not advisable to open interiorly, but to make the puncture through the skin, on account of the danger of infection from the buccal cavity and of the imperfect evacuation thus attained.
A trocar and cannula of proper size will be found to be the most suitable, the parts being gently manipulated to evacuate the contents of the abscess.
Aspiration can also be resorted to, but for the breast a small linear incision, made under local anesthesia at the most dependent point, best answers the purpose.
A small gauze strip drain may be employed for a few days to insure of perfect drainage in the latter case, the wound being brought together eventually by a delicate cosmetic operation if desirable.
THE PROPER INSTRUMENTS FOR THE SUBCUTANEOUS INJECTION OF HYDROCARBON PROTHESES
Although Gersuny advocated the use of a Pravaz syringe for injecting the liquefied vaselin mixture for prothetic purposes, it was soon found that such an instrument was practically useless, especially when the parts to be injected offered more or less resistance to the introduction of the foreign matter.
Other operators, following the advice of Eckstein, who advised the employment of “Hart paraffin” of high melting point liquefied by heat, raised the objection that the metal needle became so easily obstructed by the rapid setting of the paraffin in its distal end that the great force necessary to eject the contents of the syringe usually resulted in a breakage of the glass barrel in the hands of the operator, or, as in some types of the syringe, a separation of needle and syringe at the point where the former was slipped upon the ground point of the latter, with the annoyance of the paraffin squirting over the faces of both patient and operator.
Eckstein tells us how to overcome the first difficulty with this same style of syringe as used by him. He covers the syringe with a rubber insulating sleeve and draws several drops of hot, sterilized water into the needle to overcome the plugging up of the latter; an illustration of his syringe has been shown on page 232. Mention has also been made of the various methods used to overcome this difficulty by other operators.
It was presently found that such an instrument was not only impractical, but also a detriment to procuring desirable results, the paraffin solution shooting out suddenly, in some instances causing hyperinjection, and at other times emerging so slowly that it required unusual force on the part of the operator—a painful procedure for delicate hands, inasmuch as the fingers only can be applied to operate the instrument.
With the object of overcoming this uncertainty of the amount of the injection and the unnecessary exertion to inject any given quantity, as well as to establish enough vice à tergo to keep the needle free from plugging up with cooling paraffin, various operators devised instruments, all having practically similar points of mechanical merit and usefulness. The required necessities being to invent a syringe which would have a known capacity, a piston under control of the operator at all times, and metallic needles of proper lumen, to prevent the solidification of the liquid paraffin, screwed to the syringe to prevent loosening.
With the object of overcoming these difficulties the author devised a syringe which was made for him by Tiemann & Co., early in 1902. He begs to introduce the same here, as a type similar to which most operators have built their special instrument.
The syringe at that time consisted of a glass barrel, of a size to hold 6 c.c. of liquefied paraffin. At either end of the barrel tube were placed metal ends, the distal one containing a cap with a screw thread to receive the needle, the upper cap being threaded to receive a check nut through its center and on its outer surface, on opposite sides to each other, two metallic rings to accommodate the thumb and forefinger. The center of the check nut was double threaded to receive the piston rod, the piston or plunger being held in place by two, upper and lower, washer nuts, the lower being threaded to receive a small rod passing through the bored-out center of the piston rod, and which ended in a check nut, in the handle, threaded upon the outer or manual end of the piston rod, in such a way that the fiber or asbestos piston washer could be tightened and loosened at will.
The syringe permitted of being used as an ordinary syringe by unscrewing the cap check nut or be made into a screw drop syringe by screwing the same nut into place. By turning the handle end of the piston rod the contents of the syringe were forced out smoothly and evenly in any quantity desired.
With the later employment of the cold, semisolid preparation of vaselin and paraffin, as heretofore considered, it was found necessary to reënforce this syringe, so that the greater pressure necessary to eliminate the wormlike thread of hydrocarbon would not force off the lower cap or break the barrel of the syringe at its needle end.
This was done for the author by the Kny-Scheerer Company, December 6, 1902, when metallic strips were added to opposite sides of the glass barrel connecting the lower with the upper cap.
The instrument as then made is shown in Fig. 289
F . 289. A ’ D S .
At the same time the same firm made the author a syringe entirely of metal, similar in construction, except that the barrel was made larger in diameter and shorter in proportion to bring the instrument near to the seat of operation. The regulating washer rod was not needed, since in this instrument no washers were required, the piston head being made of solid metal throughout and the rod being soldered to the plunger, thus overcoming any objectionable fault in sterilization.
This type of syringe was found to be most suitable for the cold, semisolid injections, and is of the type now universally used except for the slight modifications of the various operators. It is illustrated in Fig. 290
F 290 A ’ A -M D S
Since there were no objections to making the barrel large enough to permit of injections, such as are required for restoring the contour of the cheek and the neck and shoulder, it was made to contain 10 c.c. working capacity, overcoming the necessity of constant refilling, when comparatively large injections had to be made—a fact worth remembering from a practical standpoint, although two or three of these syringes, specially prepared for each patient, might be found desirable by some operators. Yet the simplicity and ready facility with which this instrument can be used and refilled renders it useful and sufficient for performing operations of this nature to any judicious extent.
Syringes holding small quantities of the paraffin mixture are found to be a nuisance.
The following operators employ syringes of the capacity given:
Brœckært 3 c.c. 50 mm.
Eckstein 5 c.c. 80 mm.
Freeman 5.6 c.c. 90 mm.
Downie 10 c.c. 150 mm.
The instrument employed by Brœckært, holding less than one dram, would be of little use except to correct very slight deformities about the brow or nose, or dressing up or completing the contour of parts previously filled by larger injections.
Another syringe similar in type to the author’s, but of a capacity of 5.6 c.c., was introduced by Harmon Smith.
The principles of the syringe are alike, but the style of handles, two flat metal bars at opposite sides, offers no objection when comparatively hard mixtures of paraffin and vaselin are used.
While operating the syringe the narrow blades are brought in contact with the soft flexor sides of the thumb and forefinger, indenting the flesh deeply, and with the least unexpected move on the part of the patient permitting it to slip out of the grasp of the surgeon. Its incapacity for large injections also offers some objection, but for correcting smaller defects it is both practical and compact. It is illustrated in Fig. 291
It is obvious that with the screw drop type of syringe the cold semisolid paraffin mixture contained in its barrel is always under the full command of the operator, nor can there be a plugging of the needle, since the great force that can be exerted with a turn of the piston handle would free it, even if the mixture were of a comparatively high melting point, although the force to be applied would naturally increase in proportion to the hardness of the mass within the syringe.
The turning of the screw piston forces out the contents of the syringe in the form of a white thread of a diameter equal to the diameter of the lumen of the needle.
To facilitate this ejection, the needles should be of ample diameter, not over one inch long and having knife-edged points. Longer needles are not necessary, and only add to the force required to turn the screw handle.
Curved needles, used by some operators, are never needed, and the author does not see how they could be applied at any time in preference to the straight.
As much of the paraffin mixture can be forced out of the syringe as may be desired by screwing the piston down into the barrel.
F 291 S A -M D S
The piston rod may be graduated in five- or ten-drop divisions, but the operator rarely ever refers to the scale. He judges the amount required by the elevation of the tissues brought about by the presence of the paraffin thus forced under the tissue. Experience soon teaches him the amounts necessary or judicious in each case, always remembering that it is better to do a second and later injection than to hyperinject.
The entire instrument being of metal permits it to be sterilized as readily and in the same manner as any other metallic instrument.
It is understood that the syringe must be taken apart for sterilization at all times.
Lubrication, to facilitate operation, is never required, since the nature of the mixture used in the syringe answers this purpose in every way.
Owing to the greater amount of metal in the solid piston itself, the latter is very likely to expand under dry heat sterilization or boiling, so much so that for a moment it cannot be introduced within the barrel. This can be quickly overcome by dipping it into cold sterile water or absolute alcohol, which brings about its contraction.
After using, the syringe should be emptied entirely, unscrewed and sterilized, and placed in the metal case furnished for it. A screw cap is furnished to take the place of the needle when not in use.
The method of filling and using the syringe will be considered later
PREPARATION OF THE SITE OF OPERATION
The same surgical precautions should be observed when a paraffin injection is to be undertaken, as with a minor surgical operation.
It is hardly found necessary to prepare the site of operation the day before, nor need the patient be detained for such time for the purpose of making him ready.
With careful observance of ordinary surgical technique, both as to surgeon and patient, all of this class of operations can be performed in any physician’s office, providing that both instruments and the mass to be injected have been rendered sterile.
Especial care should be given to the operator’s hands, for with these he not only handles the instruments, but must also mold the mass injected, thus frequently coming in contact with the needle opening or openings made in the skin.
When injections are to be made in the cheeks of the patient, the mouth should be prepared by cleansing the teeth thoroughly and washing out the buccal cavity with warm boric acid or hydrogen peroxid solution, or any of the preparations of the Listerine composition.
This rinsing should be continued every few minutes for at least ten minutes before the operation is undertaken.
This is necessary, as the surgeon must introduce his finger into the mouth and behind the cheek to mold out the mass injected subcutaneously, and infection could easily be introduced by his fingers during this procedure.
Externally a generous field of the operation is scrubbed with a brush dipped into green soap and water.
The skin is then thoroughly washed with gauze sponges steeped in absolute alcohol, followed with spongings with a 1-5,000 solution of bichlorid of mercury The whole surface is then wiped off with a sponge dipped in ether and covered for the time being with a pad of sterilized gauze until the operator is ready to proceed with the operation.
PREPARATION OF THE INSTRUMENTS FOR OPERATION
The manner of preparing the necessary mixture of paraffin has been described on page 244. After such preparation, the mixture, still hot, may be poured into test tubes, which are sealed and put away for further use, each tube holding just enough to fill the syringe two thirds full.
When a syringe is to be filled, one of the tubes is opened and the contents are again boiled over a spirit flame, or simply liquefied and poured into one of the types of heaters already described for the same purpose of resterilization.
From the test tubes or the heater, the boiling mixture may be drawn up into the sterilized syringe to the required amount or it may be poured into the opened piston screw cap end.
In the latter event the ready cooling of the mixture as it enters the needle will permit it to be retained in the barrel, or the needle may be immersed in sterile water as the paraffin is poured into the syringe, yet even if a few drops escape from the needle in the former method, no harm is done, as such loss amounts to nothing and helps to eventually fill the syringe evenly and free of air
If the mixture is drawn up into the barrel to the required height, more or less air enters, which must be removed by turning the syringe, needle up, and screwing up the piston rod until either the liquid or cylindrical thread of the cooled mixture appears.
If the mixture is poured into the syringe the piston is slowly pressed into the barrel, thus allowing the air to escape along its sides if the mixture is set, or if warm the syringe is turned up and the piston screwed into place. As this is done the few drops of cooled paraffin will be forced from the needle before the air is exhausted. The screw is turned until the paraffin emerges evenly from the needle.
The syringe must now be laid aside, or placed in sterile water of the temperature of the room, to allow the liquid within to set evenly and become uniform in consistency
The operator will follow what method he pleases in filling his syringe, but at no time should he fill it with the cooled product with a spatula, or other such means, as he is sure to fill it unevenly in this way, incorporating a number of air spaces. The air issues from time to time during an operation with sudden sputtering outbursts, that not only tend to annoy the patient, but also to frighten him—the shock being unusual and unexpected, while the air thus forced into the subcutaneous tissues puffs out the parts and interferes with a perception of the proper amount to be injected and adds to the danger of air embolisms.
Slipshod methods are inexcusable, and should not be tolerated. The best results possible should be given the patient, and only from the best results obtained with the best care can the most reliable data be attained, all helping to fix the reliability, efficacy, and exactitude of this branch of cosmetic surgery.
THE PRACTICAL TECHNIQUE
The field of operation and the instruments having been properly prepared, as described, the modus operandi must next be considered.
Since the various parts of the face to be injected demand specific procedure, they will be considered somewhat individually hereafter, whereas the general technique, applicable in as far as the method of injection is concerned and applying similarly in all cases, may tersely be first taken up.
Various and noted surgeons point out that these subcutaneous injections should be made under general anesthesia, i. e., ether, while others consider the hypodermic use of cocaine or Eucain β solution in one to four per cent necessary to accomplish good results.
The author considers the method in the first case objectionable both as to patient and operator, entailing much discomfort to the one operated on and demanding an unnecessary waste of time for the etherizing and recovery Likewise is the employment of a local anesthetic not indicated or demanded, since the operation to be undertaken necessitates only the pain associated with the prick of the needle through the skin.
The objection to etherization is obvious, while the hypodermic employment of any local anesthetic, by the very fact of its presence of volume and its physiological action upon the tissue, tends to interfere with the proper injection of the parts by reason of temporary swelling of the parts, not caused by the later injections of the prothetic mass.
If in nervous irritable patients an anesthetic is required to allay fear it is best to use the ethyl-chlorid spray upon the skin sufficiently to overcome the sharp sting of the needle insertion. For this purpose the ether spray is used only to the point of blanching the skin, and no longer.
This mode of procedure is especially useful when a number of injections are to be made, as in the rounding out of a cheek or of the shoulders, in which the contour cannot be restored from one point of injection, as will hereinafter be described.
The patient, being now in readiness, the skin over the area is lifted or pinched up with the fingers of the left hand of the operator as a guide to its mobility and to steady the part.
The point of the needle is now forced through the skin and into the subcutaneous tissue at a point along the periphery of the deformity and pushed a little beyond the center of the cavity to be filled.
The elevation of the skin is in the meantime partly kept up with the needle itself, while the syringe is grasped with the freed hand, the thumb and forefinger of the right hand being placed upon the handle of the screw or piston rod, which they must rotate to force the semisolid mass from the instrument.
Before beginning the injection an assistant is instructed to press with his fingers the tissue about the margin of the defect to prevent the filling from becoming misplaced or being forced into undesirable channels, especially if the skin over the defect is found to be thick and inelastic.
The screw handle is now rotated evenly and slowly, discharging the mass to be injected, which will soon be evidenced by the rise of the skin over the depression to be
corrected.
Only sufficient of the mass must be injected to fairly correct, never to overcorrect, the defect.
Experience alone will assure the surgeon when this point has been attained, since he cannot immediately judge the necessary amount injected, as it will appear as a round or irregular lump under the skin, until it has been molded or worked out into shape.
Owing to the pressure exerted upon the contents of the syringe, which will continue to emerge from the needle for a time, the needle is left in place for a few seconds before withdrawal, so that the needle canal through the skin will not become filled with the semisolid mixture.
Such blocking up of the opening causes a cystic development or enlargement about the opening in the skin by this backing up or exuding, ofttimes crowding itself in between the layers of the skin and necessitating later removal with the knife. If not this fault it tends to keep the wound open unnecessarily after the operation, preventing healing and permitting the escape of a certain amount of the injected mass, if a mixture of low melting point has been utilized.
The needle, having been allowed to remain as advised, is now withdrawn. The tip of one finger is placed over the opening in the skin and held there gently, but firmly, while the mass is molded into the shape required or desired with the fingers of the right hand.
If it now appears that the injection is insufficient the needle may again be introduced through the same opening and more is injected, remembering, however, that if the correction is quite normal no more should be added for several days, or until the injected mass has become organized, which should take place in about three weeks.
If it is found that the skin over the defect is inflexible and bound down, it will be found advisable to sever or dissect subcutaneously the adhesions that bind it down with the use of a fine tenotome or a spear-headed paracentesis knife.
This may be done two or three days before the parts are injected to assure the surgeon of an absolute cleanliness of the wound.
Mayo advocates the injection of a saline solution into subcutaneous wounds thus made as a guide to the extent of dissection and to further loosen the tissues.
When the parts, thus loosened, show little tendency to bleed, the author advocates immediate injection, as the waiting for several days permits the throwing out of new connective-tissue cells that interfere to a certain extent with the proper injection of the part.
It is with such wounds that secondary elimination is most likely to take place, especially if “Hart paraffin” or paraffin of a high melting point has been employed.
This is undoubtedly due to the healing down and contraction of the margins of the wound, which seems to progress more and more, encroaching eventually upon the hard mass and ending in inflammation of the overlying skin and ultimate elimination. With injections of softer consistency this is less frequent and, in fact, may be entirely overcome by limiting the amount of the injection at the first sitting, relying upon a full correction for later operations, when the periphery of the wound has become more or less influenced by the presence of the neutral mass between the wounded surfaces.
The subcutaneous dissection referred to must, of course, be done under local anesthesia, preferably the Schleich mixture or a one-per-cent solution of Eucain β.
The injection of the paraffin, or hydrocarbon mixture, in semisolid form, having been made and properly molded into shape, is set or fixed by spraying the part with ether or by the application of sterile ice cloths. When liquid paraffin has been injected it will be noted that the paraffin in setting contracts upon itself considerably, leaving less of a correction than anticipated.
The needle opening in the skin is next washed off with a twenty-five-per-cent solution of hydrogen peroxid and closed over with a drop of collodion.
The patient may then be discharged for the time being, with the instruction to apply ice cloths to the part for at least twelve hours to reduce, as far as possible, the reactive resultant inflammation.
On the third day the collodion patch may be removed and replaced with isinglass adhesive plaster applied with an antiseptic solution. The latter is allowed to remain on the skin until it falls off.
SPECIFIC CLASSIFICATION FOR THE EMPLOYMENT AND INDICATION OF HYDROCARBON PROTHESES ABOUT THE FACE
Reference has been made heretofore to the general indications for which subcutaneous injections of paraffin or its compounds may be employed. With the object of systematizing such indications and to further bring out the practicability and judicious use of the method under consideration the author submits the following tabulated arrangement, with the hope that it may lead to a more concise and better knowledge of the possibilities within the reach of the plastic or cosmetic surgeon.
The face will be considered in such grand divisions as are easily and readily understood, the defects of each part being shown under its distinctive regional heading.
D A F
Transverse Depressions
Deficient or Receding Forehead: (Exhibition of Undue Superciliary Ridges.)
