pp_alimentazione_benessere_vita_eng_ES_ANNEX by BARILLA G. e R. Fratelli S.p.A.

Nutrition & Well-Being for healthy living 3. ANALYSIS OF THE

DIETARY GUIDELINES OF THE MOST INFLUENTIAL SCIENTIFIC SOCIETIES AND INTERNATIONAL INSTITUTIONS (SUPPLEMENT)

A.3.1 Dietary guidelines for the prevention of cardiovascular diseases

Figure A.3.1. Recommendations concerning the consumption of fat TYPE OF FATTY ACID

DAILY QUANTITY

Saturated fatty acids

<10% for all individuals <7% for individuals at high risk

Trans-fatty acids

<1% for all individuals

Trans-fatty acids

1%<x<9% for all individuals

Polyunsaturated fatty acids 6%<x<10% for all individuals, composed thus per - 5%<x8% n-6 Polyunsaturated fatty acids for all individuals - 1%<x2% n-3 polyunsaturated fatty acids for all individuals

Saturated, unsaturated and trans-fatty acids - The results of the studies show that the intake of saturated fatty acids increases the risk of developing cardiovascular disease. - To nourish oneself so that this risk is reduced, ordinary people must have 10% maximum intake of their daily calories from saturated fats, while the threshold is reduced to 7% for individuals at high risk. In this context, moreover, if an individual already regularly consumes less than 10% of daily calories with saturated fats, they should not increase them, but maintain the current level. - With the objective to promote and facilitate smooth functioning of the cardiovascular system, the diet should be composed of a low content of trans-fatty acids, that is, the consumption of hydrogenated fatty acids must be avoided, and should be contained below 1% of daily total calories. - Furthermore, the diet should be composed of between 6% and 10% polyunsaturated fatty acids. The optimal balance can be achieved by consuming between 5% and 8% of n-6 polyunsaturated fatty acids and between 1% and 2% of n-3 polyunsaturated fatty acids. - Because the evidence reveals that the fat in the diet should be a percentage between 15% and 30% of the total daily calories, the remaining portion should be consumed through the caloric intake of monounsaturated fats such as oleic acid (a rich source of which is found in extra virgin olive oil). - In conclusion, the recommendations concerning the percentages and amount of fat to consume per day will vary depending on the features of each individual (age, sex, lifestyle, etc.). In general, it is desirable to restrict the amount of fat to prevent overweight or obesity that can increase the risk of developing cardiovascular disease.

Fiber and phytonutrients - Fiber and phytonutrients (found mainly in fruits and vegetables) contribute to cardiovascular health. - The results of the studies recommend ingesting a quantity between 400 and 500 grams of fruit and vegetables per day in order to reduce the risk of coronary heart disease, stroke and high blood pressure.

* The percentages refer to the daily calories. Source: elaboration by The European House-Ambrosetti of study results by Hu, Mensink, Katan, Kris-Etherton Sundram, Anisah, Hayes, Jeyamalar, Pathmanathan, Hornstra, Houwelingen, Kester, Willett, Ascherio, Hennekens, Buring, Koletzko, Oomen.

Sodium and potassium - The intake of sodium and potassium in the diet influence blood pressure; therefore, the amount should be controlled to reduce the risk of coronary heart disease and stroke. - The amount of salt (sodium chloride) recommended to maintain a healthy cardiovascular system is between 5 and6 grams per day.1 - Since sodium tends to raise blood pressure, unlike potassium which tends to lower it, the amount of potassium should be set at a level that maintains the ratio between the amount of sodium ingested and the amount of potassium ingested 1.2

Eicosapentaenoic and docosaesaeonico acid - Regular consumption of fish (foods rich in eicosapentaenoic acid and docosaesaeonico acid), equivalent to 1 to 2 servings per week, has beneficial effects on coronary heart disease and, more generally, on the prevention of cardiovascular disease. - The ideal portion should provide 200-500 milligrams of eicosapentaenoic acid and docosaesaeonico acid3 and can be found in salmon, trout, sardines, mackerel, herring and tuna. For vegetarians, the intake of an adequate amount of alpha-linolenic acid is strongly recommended.

Alcohol - Low or moderate alcohol consumption protects against coronary heart disease, while the occurrence of other cardiovascular disease appears to be adversely affected by alcohol consumption. - Therefore, the scientific literature is inconclusive on alcoholâ&#x20AC;&#x2122;s impact on cardiovascular diseases. Some studies point to a protective effect provided by moderate consumption of alcohol, while other studies have found that some cardiovascular diseases are caused or worsened by alcohol consumption. As a result, the scientific community cannot make positive recommendations about alcohol consumption.

Nutrition & Well-Being for healthy living

WHO â&#x20AC;&#x201C; WORLD HEALTH ORGANIZATION

Physical activity - One of the most important ways to prevent cardiovascular disease is through regular physical activity for at least 30 minutes a day, most days of the week. - A lifestyle that includes adequate physical activity is inversely related to the onset of cardiovascular disease, especially coronary disease.

AMERICAN HEART ASSOCIATION, EUROPEAN SOCIETY OF CARDIOLOGY, ITALIAN SOCIETY OF CARDIOLOGY With reference to the style of life adopted, the most authoritative international institutions and scientific societies4 have identified certain behavior to promote the well-being of the cardiovascular system in line with the recommendations above.

Lifestyles and behavior to be adopted - Engage in physical activity for at least 30 minutes a day5. - Know your caloric needs in terms of calories ingested each day, for adopting a diet that maintains and promotes a healthy weight. - Know the calorie content of foods you eat. - Reduce the time spent watching television and in front of a computer as much as possible. - Weigh yourself regularly and get physical exercise. - Try to insert physical movement into daily activities (use the stairs instead of the elevator, walk, or ride a bicycle for short distances, etc.). - Do not smoke. - For those who are not teetotalers, try not to exceed a dose of two glasses of alcohol (beer, wine, etc.) per day for men and one glass per day for women. The international scientific community is well aligned on how diet can reduce the risk of developing cardiovascular disease. Their recommendations include advice about how a healthy diet can promote the proper functioning of the cardiovascular system.

FOOD

DIET FOR REDUCING HYPERTENSION

DIET FOR HELPING TO CHANGE LIFESTYLE

EXAMPLE OF SERVINGS

6-8 servings a day

7 servings a day

1 slice of bread, 30 grams of cereal, 60 grams of pasta or rice

4-5 servings a day

5 servings a day

120 grams of raw leafy vegetables, 60 grams of cooked vegetables

4-5 servings a day

4 servings a day

1 average size fruit, half a fruit juice

2-3 servings a day

A cup of milk, a yogurt, 45 grams of cheese

CEREALS

VEGETABLES

FRUIT

MILK AND DAIRY PRODUCTS

MEAT, POULTRY AND FISH

Less than 170 grams a day

less than 140 grams a day

4-5 servings a day

included under vegetables

30 grams of seeds, legumes, 10 grams of dried fruit

2-3 servings a day

dependent on daily intake of calories

1 serving equivalent* of margarine, mayonnaise or oil

5 servings maximum a week

no recommendations

1 serving equivalent of sugar, half a serving of ice cream

DRIED FRUIT, NUTS, SEEDS AND LEGUMES

OILS AND FATS

Guidelines for a diet that reduces the risk of cardiovascular disease SWEETS

- Check the nutrition labels (carbohydrates, proteins and fats) before purchasing food, favoring those with less fat. - Eat fresh fruits and vegetables regularly, possibly without the addition of salt and sugar. - For snacks, replace foods with high caloric content with fruits and vegetables. - Increase consumption of dietary fiber by consuming legumes and cereals. - Choose vegetable oil instead of animal fats (butter and lard).

* An equivalent portion measures the caloric equivalent of a portion of salad. SOURCE: Diet and Lifestyle Recommendations Revision 2006: A Scientific Statement From the American Heart Association Nutrition Committee.

Nutrition & Well-Being for healthy living

As we have seen so far, scientific studies of various types in the field of cardiovascular diseases have made recommendations concerning individual nutrients or individual molecules, rather than foods. In this way, if you are not an expert in the field, but want to adopt a style of eating aimed at the prevention of cardiovascular diseases, it is difficult to understand what one should eat.

Figure A.3.2. Two examples of diets consistent with the reduced risk of developing cardiovascular disease

Nutrition & Well-Being for healthy living

- Serve students and/or employees foods with a limited content of calories, sugar, transfatty acids and sodium; - Adopt a policy aimed at discouraging cigarette smoking on the premises where activities take place; - For the schools, add different physical activities to the weekly programs, even after school hours. Finally, with regard to the government authorities, their contribution is essential for the following: - Developing and implementing courses and education programs in schools and businesses that can raise awareness of the risks linked to poor nutrition; - Constructing bicycle and pedestrian paths to facilitate the movement of individuals with non-motorized vehicles; - Promoting policies that increase the chances of access to healthy food (which is usually more expensive) to low-income individuals.

A.3.2 Dietary guidelines for the prevention of diabetic pathology Following are the guidelines for diabetes prevention proposed mainly by WHO (summarized in the aforementioned report, Diet, Nutrition and the Prevention of Chronic Diseases), the European Association for the Study of Diabetes (EASD), the American Diabetes Association (ADA), and by groups working in Italy, the Diabetic Physicians Association, Italy Diabetes, and the Italian Society of Diabetes (AMD-DI-SID).

WHO â&#x20AC;&#x201C; WORLD HEALTH ORGANIZATION - Prevention and treatment of overweight conditions and obesity, especially in individuals at risk. - Maintain an optimal body mass index (BMI),6 (at the lower limit of the range of values considered normal). For the adult population, this means maintaining a BMI between 21 and 23 kg/m2 and to avoid gaining weight (> 5 kg) during adult life. - Reduce the weight voluntarily in overweight or obese individuals with glucose intolerance. - Engage in regular physical exercise at a moderate or very intense level (e.g., walking briskly) for one hour or more per day, for most of the days of the week. - Ensure that the intake of saturated fatty acids does not exceed 10% of total daily caloric intake and, for high-risk individuals, that the caloric intake from fat as a whole is less than 7% of the total calories.

Nutrition & Well-Being for healthy living

- Limit your intake of beverages with high sugar concentrations - Reduce the consumption of confectionery and bakery products. - Choose milk and dairy products with low fat content. - Reduce salt intake in the diet, including through the reduction of sodium in sauces. - Remove the skin before eating poultry. - Choose the consumption of fruit, rather than fruit juice. The American Heart Association has also formulated two types of diets consistent with the reduced risk of cardiovascular disease: the first with the objective of reducing hypertension in individuals with high blood pressure, and the second with the aim of promoting change in the lifestyle of individuals. It will take all the groups involved in the food chain (including institutions, local authorities and health care practitioners), in different ways, to promote action in support of a healthy balanced diet. In this context, effective policy not only includes informing the consumer about the benefits or risks from the consumption of particular foods or nutrients, but also needs to have an active, participatory and proactive role from the entire agro-food production chain, food services, the health system, and local and national government authorities. These subjects must be aware and appropriately informed about potential problems for public health resulting from poor nutrition and the benefits of proper nutrition. Based on their expertise they are responsible for adopting guidelines and directions emerging from international scientific and medical studies to improve the health of citizens. The main recommendations by type of subject are listed below. Professionals, including doctors and nutritionists, should do the following: - Follow the recommendations above for the type of diet to be followed; - Encourage and facilitate regular physical activity among young people and adults; - Calculate the body mass index and verify consistency with the patientâ&#x20AC;&#x2122;s age and height; - Discourage cigarette smoking; - Point to a moderate consumption of alcohol for those people who drink regularly. In line with the evidence emerged, food services should: - List the calories of every dish served and also include information about the recommended daily intake of selected nutrients in the dish in a simple and understandable way ; - Reduce serving sizes; - Rethink recipes, in order to reduce calories, sodium, and saturated fat and trans-fatty acids; - Expand the choice of dishes based on vegetables; - Increase the choice of fruit dishes; - Give diners the option of replacing fried foods with boiled or steamed options (such as potatoes); - Prepare meals with whole grain (pasta, rice or bread) and encourage their consumption. For the food industry, the main recommendations are to: - Reduce sugars and salt in the food preparation process; - Reduce or eliminate hydrogenated fats (the main source of trans-fatty acids); - Increase mono- and polyunsaturated fats at the expense of saturated fatty acids; - Increase the type of whole-grain foods available to consumers; - Package food in individual servings; - Develop packaging systems that preserve freshness and taste to promote the consumption of fresh fruits and vegetables, without adding preservatives or substances such as sodium. Concerning the schools and in workplaces, the main recommendations are:

- Eat adequate amounts of dietary fiber through the regular consumption of whole grains, legumes, fruits and vegetables. A minimum daily intake of 20 grams of fiber is recommended.

EUROPEAN ASSOCIATION FOR THE STUDY OF DIABETES (EASD)

In particular, in relation to macro- and micronutrients, the European guidelines mainly indicate that: Energy balance and body weight - In overweight people (BMI> 25 kg/m2), the caloric intake should be reduced and the energy expenditure must be increased to bring the BMI within the recommended limits. - It is important to prevent the recovery of body weight that was lost. - In general, for adult subjects with a BMI within the normal range (18.5 to 25 kg/m2) it is not necessary to specify the optimal caloric intake. - The total caloric intake should take the individual’s level of physical activity into account. - The reduction in the consumption of energy-dense foods, especially those rich in saturated fats and simple sugars, can allow for losing weight without having to specify the caloric content. Carbohydrates - The intake of carbohydrates can vary from 45 to 60% of the total energy. - The most appropriate contribution in this range depends on the metabolic characteristics of the individual. - Vegetables, legumes, fruits and whole grains should be part of the diet. - When the intake of carbohydrates is in the upper limit of the recommendations, it is particularly important to recommend foods rich in fiber and with a low glycemic index. - There is no reason to recommend diets with a very low content of carbohydrates. - Among the foods that contain carbohydrates, those high in complex carbohydrates and with a low glycemic index should be preferred when the other nutritional characteristics are appropriate. - If so desired, and if the glucose levels are satisfactory, a moderate intake of added sugars (up to 50 g/day) may be included in the diet. However, for the general population, the intake of added sugars should not exceed 10% of the total energy. A restriction may be more useful for those who need to lose weight. - The consumption of foods naturally rich in fiber should be encouraged. The fiber intake should, ideally, be 40 grams per day (or 20 g/1,000 kcal/day) or more, and about half should be of the water-soluble type. Beneficial effects may also be obtained with lower amounts that, for some, are also more acceptable. A daily consumption of at least 5 portions of fruit or vegetable high in fiber and at least 4 servings of veg-

Fats - The total consumption of fat should not exceed 35% of total daily calories. For overweight individuals, a total consumption of fat below 30% of daily calories can facilitate weight loss. - Saturated fatty acids and trans-unsaturated fatty acids should provide less than 10% of total daily energy. A lower consumption (<8%) is recommended if LDL cholesterol levels are high. - The oils rich in monounsaturated fatty acids are a beneficial source of fat and, depending on one’s preference, can provide 10 to 20% of the total energy. - Polyunsaturated fatty acids should not exceed 10% of the total energy. - The consumption of 2-3 servings of fish per week (preferably fat-rich fish) and n-3 fatty acids of vegetable origin (for example, rapeseed oil, soybean oil, walnuts and some green leafy vegetables) will help to achieve an adequate consumption of n-3 fatty acids. - The intake of cholesterol should not exceed 300 milligrams per day and must be further reduced in the presence of high concentrations of LDL cholesterol. Proteins - The protein intake should provide 10-20% of total daily energy (in people who show no signs of nephrosis). - There is not enough evidence to make recommendations on the type of protein to be preferred. Micronutrients: antioxidants, vitamins and minerals - Consumption should be encouraged of foods naturally rich in antioxidants (tocopherols, carotenes, vitamin C, flavonoids, polyphenols and phytic acid), trace elements (iron, zinc, iodine and selenium) and other vitamins. - The daily consumption of a wide variety of vegetables and fruits should be encouraged because these foods are a rich source of vitamins and antioxidants. - A regular consumption of whole wheat bread, cereals and fish rich in fat helps to cover the need for other water-soluble and fat soluble vitamins. - The general population and people with or at risk of diabetes should reduce their salt intake to less than 6 grams per day. A further restriction may be appropriate for people with high blood pressure.

Alcohol - Moderate consumption of alcohol (up to 10g/day for women and 20g/day for men) is acceptable. - Alcohol intake should be limited in those who are overweight, hypertensive and hypertriglyceridemic.

DIABETOLOGISTS WORKING GROUP ASSOCIATION ITALY DIABETES – ITALIAN DIABETOLOGY SOCIETY (AMD-DI-SID) - Avoid excess weight and engaging in regular physical activity (20 to 30 minutes per day or 150 minutes per week) represent the most appropriate means to reduce the risk of

Nutrition & Well-Being for healthy living

- Avoiding excess weight and engaging in regular physical activity are the most appropriate means to reduce the risk of developing type 2 diabetes. - In overweight subjects, weight loss and maintenance of this loss are the central lifestyle changes needed for reducing the risk of developing type 2 diabetes. - The macronutrient composition of the diet to reduce the risk of type 2 diabetes should include the following: total fat should be less than 30% of the energy intake; saturated fat should be less than 10% of the energy intake; and finally, total fiber intake should be more than 15g/1000 kcal of fibers.

etables a week will help to provide the minimum amount of fiber recommended. - Cereals should be whole grain and rich in fiber, as much as possible.

Nutrition & Well-Being for healthy living

In particular, in relation to macro- and micronutrients, the Italian guidelines indicate mainly that: Overweight condition and obesity - Weight loss is recommended for all adults who are overweight (BMI 25.0-29.9 kg/m2) or obese (30.0 kg/m2). - The main approach to weight loss is the modification of lifestyle, which includes a reduction in caloric intake and increased physical activity. A moderate reduction in caloric intake (300-500 kcal/day) and a modest increase in energy expenditure (200-300 kcal/day) allow for a slow but progressive weight loss (0.45 to 0.90 kg/week). - The recommended amount of physical activity is 30 to 45 minutes per day of moderate aerobic activity 3 to 5 days per week (target: 150 min/week). Higher levels of physical activity, equal to at least one hour per day of moderate activity (walking) or 30 minutes a day of more vigorous activities (jogging) may be required to achieve effective weight loss in the long term.

ÂŠ Corbis

Carbohydrates - The total quantity of carbohydrates introduced daily with the diet should provide 45% to 60% of the total daily calories. - Within these limits, the metabolic characteristics of individuals suggest the most appropriate consumption. - Low-carbohydrate diets (diets that restrict carbohydrates to below 130 g/day) are not advised for people with diabetes or at risk of diabetes. - Both the quantity and the quality of the carbohydrate content in foods can affect the glycemic response. Controlling the amount of total carbohydrates, through the use of diet exchanges or with the carbohydrate count, is a key strategy for glycemic control. - For people with diabetes or diabetes risk, as well as the general population, the total sucrose intake should not exceed 10% of total daily energy supplied by food. A more stringent approach may be useful for people who need to lose weight. - Sweeteners without calories (saccharin, aspartame, acesulfame, potassium K and sucralose) are safe when consumed in moderate amounts daily.

- The glycemic index can be a useful indicator for choosing which carbohydrates can be included in the diet. - Consumption of foods high in fiber should be encouraged. The fibers introduced in the diet should ideally be more than 40 grams a day (or 20 g/1,000 kcal/day), most of which should be soluble. - The daily consumption of 5 servings of vegetables or fruit and 4 servings of legumes a week may be useful to provide the minimum requirement of fibers. Proteins - In subjects with no history of kidney disease, the protein intake should provide 10% to 20% of total daily energy supplied by food. - In subjects with any degree of chronic kidney disease, protein intake should be limited to the recommended dose (0.6-0.8 g/kg), in order to reduce the risk of progression of nephrosis. Fats - The intake of fat should not contribute more than 30% of total daily energy supplied by food. In overweight patients, a fat intake of less than 30% of the total daily energy can help them lose weight. - The daily intake of saturated fats should be less than 10% of total calories. Introduction of less (<7%) can be useful if the LDL cholesterol is greater than 100 mg/dl. - The oils rich in monounsaturated fatty acids are an important source of fat and, depending on the preferences of individual patients, can provide 10 to 20% of the total daily energy introduced with food. - The intake of trans-fatty acids should be minimized (<1%). - Polyunsaturated fatty acids should contribute no more than 10% of total daily energy supplied by food. - Cholesterol introduced with the diet should not exceed 300 milligrams per day and can be further reduced if LDL cholesterol is greater than 100 mg/dl. Alcohol - A moderate consumption of alcohol (up to 10 g/day for females and 20 g/day for males) is acceptable. Micronutrients: antioxidants, vitamins, minerals - The consumption of foods naturally rich in antioxidants, vitamins and other micronutrients should be encouraged. For this, the daily consumption of fruit and vegetables should be promoted. - The regular supplementation with antioxidants including vitamins E and C and betacarotene is not recommended due to a lack of evidence of efficacy and safety in the long term. - A daily intake of salt of less than 6 grams per day is recommended for people with diabetes or at risk for diabetes, as well as the general population.

AMERICAN DIABETES ASSOCIATION (ADA) - Individuals with diabetes or at risk of diabetes should receive an individualized medical nutritional therapy, preferably prepared by a qualified dietitian with expertise in nutritional therapy for diabetics.

Nutrition & Well-Being for healthy living

developing diabetes mellitus type 2 in patients with impaired glucose tolerance. - People with diabetes or impaired glucose tolerance must be given individualized medical and nutritional guidance by a knowledgeable dietitian, preferably as part of the diabetes medical treatment. - The nutritional counseling must take into account the individual needs and readiness for change in people with impaired glucose tolerance or diabetes mellitus. - People with impaired glucose tolerance should be encouraged to change their eating habits according to these guidelines: - reduce the intake of total fat (<30% of daily energy intake) and in particular saturated fatty acids (<10% of daily caloric intake); - increase the intake of vegetable fiber (at least 15 g/1,000 kcal). - Vegetables, legumes, fruits and cereals, and foods typical of the Mediterranean diet should be included in the diet. It is important to encourage the use of foods rich in fiber and with a low glycemic index, particularly if the diet is rich in carbohydrates. - There is no evidence to recommend the use of diet foods for diabetics. - In subjects with obesity and impaired glucose tolerance in whom a lifestyle intervention has failed or is not applicable, drug therapy may be considered although it is less effective than a lifestyle intervention.

- Nutritional indications should take into account the needs, the propensity to change and the ability to change habits of the individuals with diabetes or at risk of diabetes. - For persons with a high risk of developing type 2 diabetes, structured programs that emphasize a change in lifestyle are recommended, including moderate weight loss (7% of body weight) and regular physical activity (150 minutes/week), in combination with dietary strategies, including a reduction of the intake of calories and fat in the diet; such programs may, in fact, reduce the risk of developing diabetes. - Individuals at high risk for type 2 diabetes should be encouraged to follow the recommendations on the consumption of fiber (14 g fiber/1,000 kcal) and foods with whole grain flour (half of the grains consumed) by the U.S. Department of Agriculture (USDA).

Overweight condition and obesity - Weight loss is recommended for all individuals who are overweight or obese, diabetic or at risk of diabetes. - In the short term (up to 1 year) both a diet low in carbohydrates and a diet characterized by a low fat content and limited calories may be effective. - Physical activity and behavior modification are important components of weight loss programs and can be very helpful in maintaining a healthy weight. Carbohydrates - For proper health, we recommend the adoption of a dietary profile that includes carbohydrates from fruits, vegetables, whole grains, legumes and low fat milk. - The average daily amount of carbohydrates should be around 130 grams per day. - Monitoring of carbohydrates by counting carbohydrates, exchanges, or estimates based on experience remains a key strategy to achieve glycemic control. - It has not been confirmed that diets with a low glycemic index are able to reduce the risk of diabetes. - Those foods with low glycemic index that are rich in fiber and other essential nutrients should be encouraged. - In individuals with diabetes, the use of the index and glycemic load may provide a further modest advantage in glycemic control compared to what is obtainable through considering the total amount of carbohydrates. - The foods that contains sugar are not necessarily off limits, unless they exceed the overall limit of calories. The fructose found naturally in fruits, vegetables and other foods can be a part of a healthy diet. - Along with the general population, people with diabetes or at risk of diabetes are encouraged to consume a wide variety of foods containing fiber, including legumes, cereals high in fiber (5 g fiber/serving), fruits, vegetables and whole grain products. In any case, there is no evidence for individuals with diabetes or at risk of diabetes, to consume more fiber than is recommended for the population as a whole (14 g/1,000 kcal). - The sugar in alcohol and non-nutritive sweeteners are safe when consumed within the levels established by the U.S. Food and Drug Administration (FDA). Proteins

Fats - The intake of saturated fatty acids should be less than 7% of total calories. - The intake of trans-fatty acids should be minimized. - In individuals with diabetes or at high risk of diabetes, it seems useful to limit the intake of dietary cholesterol to less than 200 milligrams a day. - The consumption of two or more servings of fish per week (excluding fried fish fillets) is recommended, as this seems to be able to ensure an adequate intake of n-3 polyunsaturated fatty acids. Alcohol - If an adult who is diabetic or highly at risk for diabetes decides to consume alcohol, the daily intake should be limited to a moderate amount (one glass per day or less for adult women and two glasses per day or less for adult men). Micronutrients: antioxidants, vitamins and minerals - There seems to be no sufficient evidence indicating a positive effect in the prevention or treatment related to diabetes resulting from increases in the intake of vitamins or minerals, if individuals do not show deficiencies. - Daily supplements with antioxidants such as vitamin E and C and carotene are not recommended because evidence is lacking about their effectiveness and there are doubts about their long-term safety. - The use of chromium-based supplements in people with diabetes or at high risk of diabetes characterized by obesity is not recommended because the benefits have not been proven.

Nutrition & Well-Being for healthy living

In particular, in relation to macro and micronutrients, the American guidelines mainly indicate that:

- For individuals with diabetes/at risk of diabetes who do not have kidney disease, there is no reason to suggest changing the normal level of protein intake (15-20% of total caloric intake). - Currently, diets high in protein are not recommended as a method for the reduction of weight since its long-term effects have not yet been properly ascertained scientifically.

A.3.3 Dietary guidelines for the prevention of cancer

The main recommendations identified are the following: - Maintain a healthy weight throughout life; - Adopt a lifestyle that includes adequate exercise; - Adopt a balanced diet aimed at the consumption of fruits and vegetables; - Restrict the consumption of alcoholic beverages. More specifically, there are more precise indications provided for each recommendation.

Maintain a healthy weight throughout life

Given the findings from the analysis of scientific studies published in literature, in this section we present the guidelines on diet and lifestyle measures to decrease the probability of the occurrence of tumors.

WHO – WORLD HEALTH ORGANIZATION Overall, the main recommendations emerging from the scientific and medical studies find that to reduce the risk of the onset of cancer, it is ideal to do the following: - Maintain a BMI in the range between 18.5 and 25kg/m2; - Carry out regular physical activity for most days of the week: 60 minutes per day of vigorous/moderate activity, such as a walking or cycling, are required to maintain a healthy weight; - Engage occasionally in more intense physical activities, such as an extended run; - Do not exceed the daily dose of a glass of wine, beer or other alcoholic beverages; - Moderate the intake of salt in your diet; - Do not undergo prolonged hormonal treatment; - Minimize exposure to toxins from fungi and molds; - Consume about 400 grams per day of fruits and vegetables; - Moderate consumption of preserved meat; - Do not eat or drink things when they are very hot. Scientific studies, selected from the most prestigious and up-to-date journals, have focused on the analysis of both the individual components and the nutrients in the diet, including beta-carotene, vitamins and calcium, but also directly on particular types of foods, such as meat or fish preserved with salt, fruits and vegetables.

INTERNATIONAL AGENCY FOR RESEARCH ON CANCER, AMERICAN CANCER ASSOCIATION, FEDERATION OF EUROPEAN CANCER SOCIETIES For adopting healthier lifestyles, the most authoritative international institutions and scientific societies7 have identified and defined guidelines that are clear and understandable, both for individuals as well as local and national government bodies. These guidelines translate the results of studies that specifically indicate which kinds of lifestyle habits reduce the risk of developing cancer.

Adopt a lifestyle that includes adequate exercise - For adults: physical activity of medium to high intensity8 for at least 30 minutes a day, for at least 5 days a week. It is preferable, however, to reach the target of 45 to 60 minutes per day. - For adolescents: at least 60 minutes of daily physical activity of medium to high intensity, at least 5 days a week. - Use the stairs instead of the elevator whenever possible. - Use the bicycle or walk to get to your destinations whenever possible. - Take a break from work to perform a stretching exercise or a rapid walk. - Personally visit colleagues to communicate your information, rather than write emails. - Dance with your partner or with friends. - Choose vacations that provide sports activities instead of those that do not provide them (“chair and umbrella” vacations). - Wear a pedometer every day with the goal of increasing the number of steps taken. - Participate in sport activities. - Use a treadmill and a stationary bike while watching television. - Play with your children or with your friends. - Plan the activities above with the aim of gradually increasing the duration and number of occasions you engage in physical activity.

Adopt a balanced diet aimed at the consumption of fruits and vegetables - Eat few and small servings of foods that are high in calories. - Be aware of fact that food that is low in fat is not synonymous with food that is low in calories. - Choose the consumption of fruits and vegetables during breaks, instead of potato chips, ice cream, donuts and pastries. - Eat at least 5 servings of fruit each day, varying the quality. - Choose low-calorie foods when eating away from home and at restaurants. - Limit consumption of fried food. - Choose the consumption of pasta and bread made of whole wheat flour, rather than pasta and bread made of white flour. - Limit the consumption of sweets and confectionery products. - Limit consumption of red meat and sausages. - Choose the consumption of fish and chicken instead of beef, pork and lamb. - Familiarize yourself with the recommended serving sizes for each food.

Nutrition & Well-Being for healthy living

- Know the calorie content of foods consumed and balance the energy intake with physical activity (energy expenditure). - Avoid high increases in body weight, even if there is a later return to the ideal weight.

Figure A.3.3. Recommendations concerning the consumption of food for the preventionof cancer FOOD FRUIT

AMOUNT CORRESPONDING TO A SERVING 1 banana, 1 apple, 1 orange Half cup of fruit salad 1 fruit juice

VEGETABLES

As a result, the food industry, food services and local and national government bodies need to take on an active, participatory and proactive role. Therefore, it would be appropriate to: - Limit working days that are excessively long so as to not neglect the time spent preparing meals; - Increase the time devoted to recreation and leisure; - Increase the availability and accessibility of parks, bike paths and pedestrian trails; - Promote actions and policies to increase the ability to purchase healthy food (usually more expensive) for those individuals with low incomes; - Promote actions and policies to increase the availability and accessibility to sports facilities.

CEREALS

1 slice of bread 30 grams of cereal Half plate of rice or pasta LEGUMES

Half plate of dried legumes 10 grams of dried fruit DAIRY PRODUCTS AND EGGS

A.3.4 Guidelines on Nutrition for the prevention of osteoporosis

Nutrition & Well-Being for healthy living

1 plate of raw salad Half plate of cooked vegetables

solutely necessary that interested parties should implement measures to facilitate the achievement of these objectives.

1 glass of milk 1 serving of yogurt 45 grams of cheese 1 egg

MEAT

60-80 grams of red meat, chicken or fish

Source: American Cancer Association.

With reference to this last point, the Figure A.3.3. indicates the ideal serving sizes for different foods. The serving indicates the ideal amount of each type of food that should be eaten at each meal throughout the day.

Limit consumption of alcoholic beverages - Do not consume alcoholic beverages. - For those who drink alcohol, try not to exceed the dose of two glasses of alcoholic beverages (beer, wine, etc.) a day for men and one for women. To reduce the risk of cancer, as well as cardiovascular disease, it is important that the results of studies become widespread and accessible to the public. In addition, it is ab-

ITALIAN OSTEOPOROSIS LEAGUE, ITALIAN DIETETIC ASSOCIATION, INTERNATIONAL OSTEOPOROSIS FOUNDATION, NATIONAL INSTITUTE OF HEALTH WHO has defined osteoporosis â&#x20AC;&#x153;a systemic skeletal disease characterized by low bone mass and micro-structural deterioration of bone tissue, resulting in increased bone fragility and susceptibility to fractures.â&#x20AC;? The consumption of milk and dairy products (cheese, milk, yogurt, etc.) is very important because these foods are particularly rich in calcium, phosphorus, magnesium. and proteins of high biological value, from which the body can derive the amino acid precursor of collagen, a protein widespread in the body, which, together with minerals, makes up the bone structure. Therefore, to reduce the risk of osteoporosis, the Italian and international associations indicate that one should regularly consume: - A high quantity of milk, a half a liter per day, from childhood on; - Dairy products high in vitamin D, which helps concentrate the absorption of calcium in the body; - Fish, particularly sardines and salmon for their high calcium content; - Fruits and vegetables because they contain substances that are particularly suitable for bone health. Moreover, to reduce the risk of developing osteoporosis, it is necessary to adopt behavior aimed at: - Controlling (and limiting) the intake of proteins of animal origin because they promote the urinary excretion of calcium itself (essential for the calcification of the bones);

Figure A.3.4. Type of diet that regulates the optimal calcium intake in the different age groups, according to the National Institute of Health

AGE

RECOMMENDED DAILY INTAKE OF CALCIUM (MG)

Up to one year of age

400/600

1/5 years of age

800

6/10 years of age

800/1200

11/24 years of age

1200/1500

Pregnant or nursing women

1200-1500

Postmenopausal women taking estrogen

1000

Postmenopausal women not taking estrogen

1500

Men aged < 65

1000

Men aged > 65

1500

Source: Consensus Conference: Optimal Calcium Intake, in â&#x20AC;&#x153;Journal of the American Medical Association,â&#x20AC;? 1994).

Adopt a lifestyle that includes adequate physical exercise To combat osteoporosis, the adoption of a lifestyle characterized by regular exercise is strongly recommended. The benefits of regular physical activity are highlighted for all age groups, with the following indications: - In adolescence, exercises with weights, weight-bearing exercises and muscle-strengthening exercises are recommended: these exercises will achieve the maximum effect in terms of change of peak bone mass; - As people age, they need to eliminate physical activity that stresses the skeleton and, instead, perform muscle strengthening exercises; - In the elderly, exercises that place weight on the axial skeleton should be further reduced until they are completely eliminated, while maintaining muscle strengthening exercises that best suited for the maintenance of bone mass.

NOTEs and BIBLIOGRAphic references

1. Diet Nutrition and the Prevention of Chronic Disease, WHO, 2003. 2. Diet Nutrition and the Prevention of Chronic Disease, WHO, 2003. 3. Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are found in fatty fish (100 grams of salmon, trout, sardines, mackerel, herring or tuna contain an amount ranging from 1.5 to 3 grams of omega 3). 4. American Heart Association, European Society of Cardiology, Italian Cardiology Society. 5. The most important factor in reducing the risk of cardiovascular disease is physical activity which, as these studies have found, is inversely correlated with cardiovascular disease, especially coronary ones. Thus, an increase in physical activity corresponds to a decreased risk of developing cardiovascular disease. 6. The Body Mass Index is a biometric identifier, expressed as the ratio between the mass and height of an individual and is used as an indicator of healthy weight. The range values are the same for men and women. 7. International Agency for Research on Cancer, American Cancer Association, Federation of European Cancer Society. 8. Medium-intensity physical activity includes walking, dancing, bike riding, horseback riding, playing golf, mowing the lawn and gardening. High-intensity physical activity includes running, bicycle racing, doing aerobic dance exercises in the gym, jumping, swimming, playing football, tennis, basketball and performing manual labor such as cutting down the trees in the yard, constructing furniture or walls, digging and carrying heavy weights.

Nutrition & Well-Being for healthy living

- Avoid excessively salty foods because salt induces a loss of calcium in the body; - Avoid excessive consumption of caffeine that can slow the absorption of calcium by the body; - Avoid the abuse of alcoholic beverages, as these reduce the intestinal absorption of calcium and reduce the activity of cells that make up bone. Dietary and behavioral modifications can optimize peak bone mass achieved during adulthood and prevent its subsequent decline, with the aim of preventing fractures from osteoporosis. Attention to diet and lifestyle are essential strategies for primary prevention of fractures. The National Institute of Health has formulated a type of diet that regulates the optimal calcium intake in the different age groups (Figure A.3.4.).