Doctor Steve Abel

Nutritional Considerations Reduction of Sodium Intake

Sodium reduction typically results in lower blood pressure in industrialized societies. Current guidelines in the United States suggest reducing the daily intake of sodium to approximately 100mmol, or approximately 2.4 g of sodium or less per day.

The DASH-Sodium trial demonstrated that reduction of sodium intake from 100 to 50mmolperday (approximately 1.5 g) significantly reduced blood pressure in individuals following either the common US diet or the DASH diet. In addition, TOHP2 (phase 2 of the Trials of Hypertension Prevention) and TONE (Trials of Nonpharmacologic Interventions in the Elderly) documented that reducing sodium can either prevent hypertension or facilitate hypertension control. It should also be noted that salt sensitivity increases with age, so those who demonstrate this sensitivity should maintain a reduced salt diet.

Consumers should either eliminate or limit salt added to foods in cooking and at the table as a means of reducing sodium intake. Nutrition facts labels require sodium content to be listed so that consumers can be more prudent about their diets. The amount of sodium in processed food, such as convenience foods (e.g., boxed products one would prepare at home), soups, and processed meats (e.g., sausage, ham, and other meat products), is often alarming. If there is not a nutrition label on a processed food product, one should assume sodium content is high. Canned products generally contain more sodium than fresh or frozen items, unless a product is specifically labeled as 'no salt added.' The consumption of fresh, unprocessed foods should be promoted.

Moderation of Alcohol Intake

The relationship between high consumption of alcohol (typically three or more drinks per day) and elevated blood pressure has been shown in numerous epidemiologic studies. A drink is defined as 12 oz. of beer, 5 oz. of wine, or 1.5 oz. of distilled spirits. Most evidence indicates that alcohol should be limited to two drinks per day for men and one drink per day for women. Ideally, daily alcohol consumption should be avoided. Whenever possible, alcohol, if consumed, should be done so with meals.

Consumption of a DASH Diet (Increasing Potassium, Magnesium, Calcium, and Fiber Intakes by Increasing Intakes of Fruits, Vegetables, and Low-Fat Dairy Foods)

The contribution of minerals, particularly potassium, magnesium, and calcium, and fiber was identified by contributions from fruits, vegetables, low-fat dairy products, whole grains, and nuts in the DASH eating plan. The DASH diet effectively used these components through an ideal dietary pattern to lower blood pressure.

Increased intakes of potassium have been associated with lower blood pressure. A meta-analy-sis of several trials suggested that 60-120 mmol per day of supplemental potassium reduces systolic and diastolic blood pressure by 4.4 and 2.5 mmHg, respectively, in hypertensive individuals. In normo-tensive individuals, systolic and diastolic blood pressure was reduced by 1.8 and 1.0 mmHg, respectively. Dietary intake of potassium can be easily achieved through consumption of various foods.

The DASH diet, while promoting dietary patterns, was developed very carefully with particular attention paid to the use of specific foods within categories that contribute more to the intakes of desired nutrients. As an example, consider the rank-ordered listing of potassium content of fruits and fruit juices presented in Tables 2 and 3. Dried fruits typically have the highest potassium content, followed by raw fruits and frozen fruits. Canned fruit products generally do not contain as high potassium content as other forms. There is less potassium contained in fruit juices and generally the

Table 2 Fruits, ranked by potassium content (mg/100g)

Dried

Apricots, dehydrated (low moisture) 1850

Bananas, dehydrated, or banana powder 1491

Peaches (low moisture) 1351

Apricots 1162

Litchis 1110

Prunes (low moisture) 1058

Peaches 996

Currants, zante 892

Persimmons, Japanese 802

Raisins 746-825

Plums (prunes) 732

Dates, medjool 696

Figs 680

Longans 658

Dates, deglet noor 656

Apples (low moisture) 640

Pears 533

Jujube 531

Apples 450 Raw

Tamarinds 628

Plantains 499

Breadfruit 490

Avocados 485

Durian, raw or frozen 436

Custardapple (bullock's heart) 382

Bananas 358

Passion-fruit, (granadilla), purple 348

Sapotes (marmalade plum) 344

Currants, European black 322

Kiwi fruit, (Chinese gooseberries) 312

Persimmons, native 310

Abiyuch 304

Jackfruit 303

Rhubarb 288

Guavas, common 284

Elderberries 280

Soursop 278

Currants, red and white 275

Cherimoya 269

Melons, cantaloupe 267

Longans 266

Loquats 266

Carissa (natal-plum) 260

Apricots 259

Pomegranates 259

Papayas 257

Jujube 250

Sugar apples (sweetsop) 247

Figs 232

Melons, honeydew 228

Cherries, sweet 222

Prickly pears 220

Pummelo 216

Roselle 208

Nectarines 201

Gooseberries 198

Quinces 197

Crabapples 194

Mulberries 194

Sapodilla 193

Grapes 191

Peaches 190

Kumquats 186

Melons, casaba 182

Cherries, sour, red 173

Litchis 171

Oranges 166-196

Carambola (starfruit) 163

Blackberries 162

Persimmons, Japanese 161

Plums 157

Tangerines (mandarin oranges) 157

Mangos 156

Feijoa 155

Strawberries 153

Raspberries 151

Acerola, (West Indian cherry) 146

Lemons 138-145

Rowal 131

Grapefruit 127-150

Rose apples 123

Pears, asian 121

Pears 119

Limes 117

Pineapple 115-125

Watermelon 112

Apples, with skin 107

Pitanga, (surinam cherry) 103

Apples, without skin 90

Cranberries 85

Java plum (jambolan) 79

Blueberries 77

Mammy apple (mamey) 47

Oheloberries 38

Fruits, frozen

Strawberries 148

Loganberries 145

Boysenberries 139

Cherries, sour, red 124

Raspberries, red 114

Rhubarb 108

From U.S. Department of Agriculture, Agricultural Research Service (2003) USDA National Nutrient Database for Standard Reference, Release 16. Available atwww.nal.usda.gov/fnic/foodcomp.

fresh forms of the juices have incrementally more than the processed forms. Fruits and juices in general contain some magnesium, another mineral of interest to the DASH investigators. Most fruits contain 2-30 mg of magnesium per 100 grams, but dried fruits contain much more (30-90 mg) and the amounts vary greatly. Fruit juices contain less than 20 mg of magnesium per 100 grams, with most containing less than 10 mg. Fiber content of fruit ranges from approximately 7 to 14 g of fiber for dried fruits on a per 100 gram basis and between 1 and 5g for other fruits per 100 grams. Generally, fruit juices contribute less than 1 g of dietary fiber per 100 grams, but high-pulp varieties of juices provide slightly more dietary fiber.

Table 3 Fruit juices, ranked by potassium content	(mg/100 g)
Fruit juice	K (mg)
Passion fruit juice, fresh	278
Prune juice, canned	276
Orange juice, fresh	200
Orange juice, from concentrate	190
Tangerine juice, fresh or canned	178
Orange juice, canned	175
Grapefruit juice, white or pink, fresh or canned	162
Pineapple juice, canned or from concentrate	134
Grape juice, canned or bottled, unsweetened	132
Apple juice, from frozen concentrate, unsweetened	126
Lemon juice, fresh	124
Apple juice, canned or bottled, unsweetened	119
Apricot nectar	114
Lime juice, fresh	109
Lemon juice, canned or bottled	102
Acerola juice, fresh	97
Cranberry juice, unsweetened	77
Lime juice, canned or bottled	75
Peach nectar	40
Papaya nectar	31
Grape juice, from frozen concentrate, sweetened	21
Pear nectar	13

From U.S. Department of Agriculture, Agricultural Research Service (2003) USDA National Nutrient Database for Standard Reference, Release 16. Available at www.nal.usda.gov/fnic/ foodcomp.

Table 4 contains a rank-ordered listing of vegetables (including beans) by content of potassium. Magnesium content is also shown. The data are presented for vegetables and beans in the raw form generally. It is important to remember that many fresh forms are concentrated in terms of weight when cooked, especially spinach and other greens, and it is thus possible to obtain a higher mineral content from cooked vegetables (especially in the case of potassium). The magnesium content differs less from the fresh to the cooked state for most vegetables and beans. Most vegetables contain approximately 1-3 g of dietary fiber per

Table 4 Potassium and magnesium content of vegetables (including beans), rank ordered by potassium content (mg/ 100 g; presented for raw vegetables unless otherwise specified)

Vegetable	K (mg)	Mg (mg)
Tomatoes, sun-dried	3427	194
Palm hearts	1806	10
Arrowhead	922	51
Yam	816	21
Beet greens	762	70
Lemon grass (citronella)	723	60
Butterbur (fuki)	655	14
Taro leaves	648	45
Epazote	633	121
Soybeans, green	620	65

Amaranth leaves	611	55
Cress, garden	606	38
Taro, tahitian	606	47
Yautia (tannier)	598	24
Taro	591	33
Winged bean tuber	586	24
Waterchestnuts, Chinese (matai)	584	22
Wasabi, root	568	69
Chrysanthemum, garland	567	32
Chrysanthemum leaves	567	32
Jute, potherb	559	64
Spinach	558	79
Lotus root	556	23
Parsley	554	50
Pigeonpeas, immature seeds	552	68
Bamboo shoots	533	3
Coriander (cilantro) leaves	521	26
Sweetpotato leaves	518	61
Mushroom, oyster	516	20
Vinespinach (basella)	510	65
Purslane	494	68
Fireweed, leaves	494	156
Mushrooms, portabella	484	11
Soybeans, mature seeds	484	72
Borage	470	52
Lima beans, immature seeds	467	58
Horseradish tree, pods	461	45
Corn salad	459	13
Squash, zucchini, baby	459	33
Cowpeas, leafy tips	455	43
Potatoes, red, flesh and skin	455	22
Arrowroot	454	25
Lambsquarters	452	34
Kale, scotch	450	88
Mustard spinach (tendergreen)	449	11
Mushrooms, brown, Italian or Crimini	448	9
Kale	447	34
Pumpkin leaves	436	38
Cowpeas (blackeyes), immature seeds	431	51
Jerusalem artichokes	429	17
Potato, flesh and skin	421	23
Chicory greens	420	30
Mountain yam, Hawaii	418	12
Potatoes, russet, flesh and skin	417	23
Ginger root, raw	415	43
Fennel, bulb, raw	414	17
Potatoes, skin	413	23
Potatoes, white, flesh and skin	407	21
Garlic	401	25
Cardoon	400	42
Dandelion greens	397	36
Dock	390	103
Brussels sprouts	389	23
Peas, mature seeds, sprouted	381	56
Mushrooms, enoki	381	16
Salsify (vegetable oyster)	380	23
Chard, Swiss	379	81
Parsnips	375	29
Artichokes (globe or French)	370	60
Fiddlehead ferns	370	34
Arugula	369	47
Seaweed, laver	356	2
Mustard greens	354	32
Squash, winter, butternut	352	34

Table 4 Continued

Vegetable	K(mg)	Mg
Kohlrabi	350	19
Squash, winter, all varieties	350	14
Pumpkin	340	12
Eppaw	340	32
Peppers, hot chili, green	340	25
Horseradish tree leafy tips	337	147
Rutabagas	337	23
Sweet potato	337	25
Shallots	334	21
Taro shoots	332	8
Beans, fava, in pod	332	33
Celtuce	330	28
Watercress	330	21
Beets	325	23
Broccoli, leaves	325	25
Broccoli, flower clusters	325	25
Broccoli, stalks	325	25
Lentils, sprouted	322	37
Peppers, hot chili, red	322	23
Carrots	320	12
Squash, winter, hubbard	320	19
Broccoli	316	21
Endive	314	15
Mushrooms	314	9
Swamp cabbage (skunk cabbage)	312	71
Burdock root	308	38
Beans, navy, mature seeds	307	101
Beans, pinto, mature seeds	307	53
Pepper, Serrano	305	22
Cauliflower	303	15
Okra	303	57
Radicchio	302	13
Celeriac	300	20
Cauliflower, green	300	20
Balsam pear (bitter gourd), pods	296	17
Chives	296	42
Turnip greens	296	31
Chicory roots	290	22
Radishes, white icicle	280	9
Onions, spring or scallions	276	20
Grape leaves	272	95
Cassava	271	21
Corn, sweet, yellow or white	270	37
Tomatillos	268	20
Squash, summer, all varieties	262	17
Celery	260	11
Tomatoes, yellow	258	12
Nopales	257	52
Pepper, banana	256	17
Cabbage, Chinese (pak-choi)	252	19
Hyacinth beans, immature seeds	252	40
Broadbeans, immature seeds	250	38
Broccoli, frozen	250	16
Lettuce, cos or romaine	247	14
Cabbage	246	15
Peas, green	244	33
Cabbage, red	243	16
Pokeberry shoots (poke)	242	18
Yardlong bean	240	44
Cabbage, Chinese (pe-tsai)	238	13
Lettuce, butterhead	238	13
Tomatoes, red, ripe	237	11

Carrots, baby	237	10
Radishes	233	10
Cabbage, savoy	230	28
Eggplant	230	14
Radishes, oriental	227	16
Seaweed, agar	226	67
Winged beans, immature seeds	223	34
Cowpeas, young pods with seeds	215	58
Peppers, jalapeno	215	19
Onions, welsh	212	23
Squash, summer	212	21
Tomatoes, orange	212	8
Peppers, sweet, yellow	212	12
Chicory, witloof	211	10
Peppers, sweet, red	211	12
Beans, snap, green	209	25
Beans, snap, yellow	209	25
Tomatoes, green	204	10
Asparagus	202	14
Peppers, Hungarian	202	16
Peas, edible, podded	200	24
Broccoli raab	196	22
Turnips	191	11
Beans, kidney, mature seeds	187	21
Lettuce, red leaf	187	12
Sesbania flower	184	12
Poi	183	24
Squash, summer, scallop	182	23
Leeks (bulb and lower leaf portion)	180	28
Winged bean leaves	176	8
Peppers, sweet, green	175	10
Pumpkin flowers	173	24
Lettuce, iceberg	152	8
Gourd, white flowered (calabash)	150	11
Yambean (jicama)	150	12
Mung beans, mature seeds	149	21
Cucumber, with peel	147	13
Onions	144	10
Gourd, dishcloth (towelgourd)	139	14
Cucumber, peeled	136	12
New Zealand spinach	130	39
Seaweed, spirulina	127	19
Chayote, fruit	125	12
Onions, sweet	119	9
Squash, winter, spaghetti	108	12
Seaweed, kelp, raw	89	121
Radish seeds, sprouted, raw	86	44
Alfalfa seeds, sprouted, raw	79	27
Seaweed, irishmoss, raw	63	144
Seaweed, wakame, raw	50	107
Jew's ear (pepeao), raw	43	25

Data source: U.S. Department of Agriculture, Agricultural Research Service. 2003. USDA National Nutrient Database for Standard Reference, Release 16. Nutrient Data Laboratory Home Page, http://www.nal.usda.gov/fnic/foodcomp.

100 grams; beans and legumes offer approximately 5 g of dietary fiber, and some dried vegetables offer more than double this amount.

Nuts were also an important part of the DASH diet, contributing potassium, magnesium, fiber, and protein. They contain fat, mostly monounsaturated, and thereby contribute energy to the diet. Table 5

Table 5 Potassium, magnesium, and fiber content of nuts and seeds per 100 grams, ranked by potassium content

Description	K (mg)	Mg (mg)	Fiber (g)
Nuts
Pistachio nuts, dry roasted	1042	120	10.3
Pistachio nuts, raw	1025	121	10.3
Ginkgo nuts, dried	998	53	9.3
Chestnuts, European, dried,	986	74	11.7
unpeeled
Almonds, dry roasted	746	286	11.8
Almonds	728	275	11.8
Almonds, oil roasted	699	274	10.5
Almonds, blanched	687	275	10.4
Hazelnuts or filberts	680	163	9.7
Cashew nuts, raw	660	292	3.3
Brazil nuts, dried,	659	376	7.5
unblanched
Hazelnuts or filberts, blanched	658	160	11.0
Cashew nuts, oil roasted	632	273	3.3
Pine nuts, pinyon, dried	628	234	10.7
Pine nuts, pignolia, dried	597	251	3.7
Chestnuts, European, roasted	592	33	5.1
Cashew nuts, dry roasted	565	260	3.0
Walnuts, black, dried	523	201	6.8
Chestnuts, European, raw,	518	32	8.1
unpeeled
Ginkgo nuts, raw	510	27	9.3
Walnuts, English	441	158	6.7
Hickorynuts, dried	436	173	6.4
Pecans, dry roasted	424	132	9.4
Butternuts, dried	421	237	4.7
Pecans	410	121	9.6
Pecans, oil roasted	392	121	9.5
Macadamia nuts, raw	368	130	8.6
Macadamia nuts,	363	118	8.0
dry roasted
Ginkgo nuts, canned	180	16	9.3
Seeds
Breadnuttree seeds, dried	2011	115	14.9
Cottonseed kernels, roasted	1350	440	5.5
(glandless)
Breadfruit seeds, roasted	1082	62	6.0
Breadfruit seeds, raw	941	54	5.2
Sunflower seed kernels, dry	850	129	9.0
roasted
Pumpkin and squash seed	807	535	3.9
kernels, dried
Pumpkin and squash seed	806	534	3.9
kernels, roasted
Sunflower seed kernels, dried	689	354	10.5
Flaxseed	681	362	27.9
Sunflower seed kernels	491	129	11.5
Sunflower seed kernels, oil	483	127	6.8
roasted
Sesame seeds, whole, dried	468	351	11.8
Sesame seed kernels, dried	407	347	12.7
(decorticated)
Sesame seed kernels,	406	346	16.9
toasted

includes the potassium, magnesium, and fiber content of some common nuts and seeds. Although this is presented based on a rank-ordered content of potassium, it is easy to see that some nuts and seeds are a significant source of magnesium and dietary fiber and their consumption was therefore encouraged in the DASH diet.

Low-fat dairy products were also an important part of the DASH diets. These were used primarily to increase the calcium content of the diets from a low content of approximately 450 mg on the control and fruit and vegetable diets to approximately 1250 mg on the DASH diet at the 2000 kcal (8368 kJ) level. Calcium has frequently been reported to have an inverse relationship with blood pressure, but studies utilizing supplemental calcium have been inconsistent. With supplements, effects on blood pressure reduction have been negligible. Nonetheless, the blood pressure lowering effect of the DASH diet has been suggested to be in part related to the calcium content of the diet. It should be noted that the DASH diet also was lower in fat and higher in protein, and therefore it is not easily attributable to one factor alone but rather a combination of several factors, as depicted in Figure 1.

The final point regarding composition of the DASH diet is that it included specific food choices. The diet contained whole grains, poultry, and fish (in addition to the fruits, vegetables, low-fat dairy, and nuts previously mentioned). Although it was reduced in total and saturated fat, it was also reduced in meats, sweets, and sugar-containing beverages. Food was consumed as an overall pattern in which it is quite possible that the interaction between food items is as important as the specific foods in reducing blood pressure. Thus, the DASH diet contained dietary patterns promoted by the National Institutes of Health, National Heart, Lung, and Blood Institute. The dietary patterns of DASH are presented at three energy levels in Table 6.

From U.S. Department of Agriculture, Agricultural Research Service (2003) USDA National Nutrient Database for Standard Reference, Release 16. Available at www.nal.usda.gov/fnic/ foodcomp.

T Fruits T Vegetables I Sodium I Fat T Protein T Dairy products ? Other nutrients _ ? Nutrient interactions

Figure 1 Assessing the effects of the DASH-Sodium diet on blood pressure. The figure depicts the fact that there is some certainty associated with the increases in fruits and vegetables and reduction in sodium. The gray areas represent the other components of the diet and the possible contribution of each, alone or in combination with other factors.

Table 6 Food group servings for the DASH diet at three energy levels

Food group Daily servings (except as noted)

1600 kcal or 2000kcal or 3100 kcal or

Table 6 Food group servings for the DASH diet at three energy levels

Food group Daily servings (except as noted)

1600 kcal or 2000kcal or 3100 kcal or

	6694 kJ	8368kJ	12970 kJ
Grains and grain	6	7-8	12-13
products
Vegetables	3-4	4-5	6
Fruits	4	4-5	6
Low-fat or fat-free	2-3	2-3	3-4
dairy foods
Meats, poultry,	1-2	2 or less	2-3
fish
Nuts, seeds, dry	3perweek	4-5	1
beans		per week
Fats and oils	2	2-3	4
Sweets	0	5 per week	2

Dietary Protein Consumption

Results of meta-analyses from several investigators indicate an inverse association between dietary protein and blood pressure levels. However, data have not been conclusive. The DASH diet contained approximately 18% of energy from protein compared to 15% of energy from protein in the other diets tested. Because of the addition of low-fat dairy foods and the reduced emphasis on high-fat meats, it can be assumed that this elevation in protein was brought about by foods that contributed protein from perceived beneficial sources. This is an area of dietary intake that requires more research.

Fish Oil Supplementation

Studies suggest that an intake of fish oil at a level of approximately 4 g per day reduces systolic blood pressure by approximately 1.7-2.1 mmHg and diastolic blood pressure by 1.5-1.6 mmHg. These effects tend to be larger in individuals older than 45 years of age and in populations with blood pressure readings greater than 140/90 mmHg. Generally, there have been differences associated with fish oil capsules compared to naturally occurring sources of EPA and DHA from fatty fish, again indicating dietary pattern rather than consumption of individual items may be crucial. The DASH diet had a relatively high fish content (compared to animal meats) and this may be yet one more factor contributing to the lowering of blood pressure in individuals on the DASH diet.

The American Heart Association recommends eating two servings of fish per week and emphasizes that the choice should be a fatty fish (such as salmon, herring, or mackerel). Not all fish have the same content of omega-3 fatty acids. Table 7 provides a listing of amounts of combined EPA/ DHA in fish and other seafood sources and the amount of consumption (in ounces of product) necessary to provide a 4-g intake. Descriptors include common raw and canned products, but the intakes given are rough estimates due to potential variability in oil content within species, season, and diet. Cooking methods and other preparation techniques may affect the final concentrations in raw fish.

Other Fatty Acid Effects

Monounsaturated fatty acids, particularly olive oil, may help lower blood pressure. Olive oil has typically been associated with the popularized Mediterranean diet, which has been promoted as a treatment for cardiovascular disease. Other oils (e.g., canola and peanut oil) have a high monounsa-turated fat content. Nuts, which are part of the DASH diet, contain significant amounts of monounsaturated fats and fit well in the Mediterranean diet.

Caffeine

Although a link between caffeine consumption (particularly coffee) and hypertension may exist, effects of coffee drinking on blood pressure appear to be dependent on the time of consumption and subsequent determination of blood pressure values. Generally, a role for caffeine intake and development of hypertension is not believed to be significant.

Weight Reduction

Obesity and overweight are considered independent risk factors for cardiovascular disease and are closely associated with hypertension. This linkage was demonstrated in the 1960s by the Framingham Heart Study investigators in the United States. Obesity in the industrialized world has been increasing at epidemic proportions. The relationship between increasing body weight and increasing blood pressure has been termed obesity hypertension, and treatment requires consideration of physiologic changes related to this disorder. Although efforts have been under way in the United States to reduce overweight and obesity, it is estimated that the age-adjusted prevalence of overweight and obesity (body mass index (BMI) >25.0) among adults aged 20 or older is 64%; for those considered obese (BMI >30.0) it is 30%. During a 25-year period in the United States, this reflects approximately a 36% increase in the combined levels of overweight and obesity and essentially a doubling of obesity rates.

Table 7 Eicosapentaenoic (EPA, 20:5 n-3) and docosahexaenoic (DHA, 22:6 n-3) acid in fish/seafood (per 100 grams) and the amount of consumption (in ounces) required to provide ~4g of EPA + DHAperday (ranked in order of content)

Fish/seafood		EPA (g)	DHA (g)	EPA + DHA (g)	Oz. to
F	sh, caviar, black and red, granular	2.74	3.80	6.54	2.2
F	sh, mackerel, salted	1.62	2.97	4.58	3.1
F	sh, roe, mixed species, cooked	1.26	1.75	3.01	4.7
F	sh, shad, American, raw	1.09	1.32	2.41	5.9
F	sh, roe, mixed species, raw	0.98	1.36	2.35	6.0
F	sh, mackerel, Atlantic, raw	0.90	1.40	2.30	6.1
F	sh, anchovy, European, canned in oil	0.76	1.29	2.06	6.9
F	sh, salmon, chinook, raw	1.01	0.94	1.95	7.2
F	sh, salmon, Atlantic, farmed, raw	0.62	1.29	1.91	7.4
F	sh, herring, Pacific, raw	0.97	0.69	1.66	8.5
F	sh, salmon, pink, canned	0.85	0.81	1.65	8.5
F	sh, herring, Atlantic, raw	0.71	0.86	1.57	9.0
F	sh, anchovy, European, raw	0.54	0.91	1.45	9.7
F	sh, mackerel, Pacific and jack, raw	0.51	0.93	1.44	9.8
F	sh, salmon, Atlantic, wild, raw	0.32	1.12	1.44	9.8
F	sh, sablefish, raw	0.68	0.72	1.40	10.1
F	sh, mackerel, spanish, raw	0.33	1.01	1.34	10.5
F	sh, whitefish, mixed species, raw	0.32	0.94	1.26	11.2
F	sh, salmon, coho, farmed, raw	0.39	0.82	1.21	11.7
F	sh, salmon, chum, canned	0.47	0.70	1.18	12.0
F	sh, tuna, fresh, bluefin, raw	0.28	0.89	1.17	12.0
F	sh, salmon, sockeye, raw	0.52	0.65	1.17	12.0
F	sh, salmon, sockeye, canned	0.49	0.66	1.16	12.2
F	sh, salmon, coho, wild, raw	0.43	0.66	1.09	13.0
F	sh, salmon, pink, raw	0.42	0.59	1.01	14.0
F	sh, sardine, Atlantic, canned in oil	0.47	0.51	0.98	14.4
F	sh, trout, rainbow, farmed, raw	0.26	0.67	0.93	15.2
F	sh, halibut, Greenland, raw	0.53	0.39	0.92	15.4
F	sh, tuna, white, canned in water	0.23	0.63	0.86	16.4
F	sh, shark, mixed species, raw	0.32	0.53	0.84	16.7
F	sh, bluefish, raw	0.25	0.52	0.77	18.3
F	sh, bass, striped, raw	0.17	0.59	0.75	18.7
F	sh, trout, mixed species, raw	0.20	0.53	0.73	19.3
F	sh, smelt, rainbow, raw	0.28	0.42	0.69	20.4
Mollusks, oyster, Pacific, raw		0.44	0.25	0.69	20.5
Fish, swordfish, raw		0.11	0.53	0.64	22.1
Fish, spot, raw		0.22	0.41	0.63	22.4
Fish, salmon, chum, raw		0.23	0.39	0.63	22.5
Fish, wolffish, Atlantic, raw		0.31	0.32	0.62	22.6
Fish, bass, freshwater, mixed species, raw		0.24	0.36	0.60	23.7
Fish, sea bass, mixed species, raw		0.16	0.43	0.60	23.7
Fish, trout, rainbow, wild, raw		0.17	0.42	0.59	24.0
Fish, pompano, florida, raw		0.18	0.39	0.57	24.8
Mollusks, oyster, eastern, wild, raw		0.27	0.29	0.56	25.2
Fish, drum, freshwater, raw		0.23	0.29	0.52	27.3
Mollusks, squid, mixed species, raw		0.15	0.34	0.49	28.9
Crustaceans, shrimp, mixed species, raw		0.26	0.22	0.48	29.4
Fish, sucker, white, raw		0.19	0.29	0.48	29.5
Mollusks, mussel, blue, raw		0.19	0.25	0.44	32.0
Fish, tilefish, raw		0.09	0.35	0.43	32.8
Fish, pollock, Atlantic, raw		0.07	0.35	0.42	33.5
Mollusks, oyster, eastern, farmed, raw		0.19	0.20	0.39	36.1
Fish, pollock, walleye, raw		0.15	0.22	0.37	37.9
Fish, seatrout, mixed species, raw		0.17	0.21	0.37	37.9
Crustaceans, crab, queen, raw		0.26	0.11	0.37	37.9
Fish, catfish, channel, wild, raw		0.13	0.23	0.36	38.8
Fish, halibut, Atlantic and Pacific, raw		0.07	0.29	0.36	38.9
Crustaceans, crab, blue, canned		0.19	0.17	0.36	38.9
Fish, carp, raw		0.24	0.11	0.35	40.1
Fish, cisco, raw		0.10	0.26	0.35	40.1

Table 7 Continued

Fish/seafood	EPA (g)	DHA (g)	EPA + DHA (g)	Oz. to provide ~4 g EPA + DHA
Fish, rockfish, Pacific, raw	0.14	0.20	0.35	40.9
Fish, mullet, striped, raw	0.22	0.11	0.33	43.4
Crustaceans, crab, blue, raw	0.17	0.15	0.32	44.1
Fish, mackerel, king, raw	0.14	0.18	0.31	45.1
Fish, pike, walleye, raw	0.09	0.23	0.31	45.4
Fish, snapper, mixed species, raw	0.05	0.26	0.31	45.4
Crustaceans, crab, dungeness, raw	0.22	0.09	0.31	46.0
Fish, ocean perch, Atlantic, raw	0.08	0.21	0.29	48.5
Fish, sturgeon, mixed species, raw	0.19	0.09	0.29	49.2
Fish, catfish, channel, farmed, raw	0.07	0.21	0.27	51.5
Fish, tuna, light, canned in water	0.05	0.22	0.27	52.3
Fish, sheepshead, raw	0.14	0.12	0.26	54.1
Fish, tuna, fresh, skipjack, raw	0.07	0.19	0.26	55.1
Fish, perch, mixed species, raw	0.08	0.17	0.25	55.8
Fish, grouper, mixed species, raw	0.03	0.22	0.25	57.1
Fish, whiting, mixed species, raw	0.09	0.13	0.22	63.0
Fish, croaker, Atlantic, raw	0.12	0.10	0.22	64.1
Fish, tuna, fresh, yellowfin, raw	0.04	0.18	0.22	64.7
Fish, cod, Pacific, raw	0.08	0.14	0.22	65.6
Fish, flatfish (flounder and sole species), raw	0.09	0.11	0.20	70.9
Mollusks, scallop, mixed species, raw	0.09	0.11	0.20	71.3
Fish, haddock, raw	0.06	0.13	0.19	76.3
Fish, cod, Atlantic, raw	0.06	0.12	0.18	76.7
Fish, burbot, raw	0.07	0.10	0.17	85.0
Mollusks, octopus, common, raw	0.08	0.08	0.16	89.9
Fish, eel, mixed species, raw	0.08	0.06	0.15	96.0
Crustaceans, crayfish, farmed, raw	0.12	0.03	0.14	98.0
Mollusks, clam, mixed species, raw	0.07	0.07	0.14	99.4
Crustaceans, crayfish, wild, raw	0.10	0.04	0.14	99.4
Mollusks, snail, raw	0.12	0.00	0.12	118.6
Fish, sunfish, pumpkin seed, raw	0.04	0.07	0.11	129.4
Fish, dolphinfish, raw	0.02	0.09	0.11	130.6
Fish, pike, northern, raw	0.03	0.07	0.11	131.9
Mollusks, cuttlefish, mixed species, raw	0.04	0.07	0.11	134.4
Turtle, green, raw	0.02	0.03	0.06	252.0
Mollusks, abalone, mixed species, raw	0.05	0.00	0.05	287.9
Frog legs, raw	0.01	0.02	0.03	415.0

From U.S. Department of Agriculture, Agricultural Research Service (2003) USDA National Nutrient Database for Standard Reference, Release 16. Available at www.nal.usda.gov/fnic/foodcomp.

The increase in obesity is seen in all ethnic, gender, and age groups. This problem is not confined to the average American; the US military reported that more than 50% of military personnel were overweight and more than 6% were obese in the late 1990s, despite high physical activity levels due to the rigors of basic training and regular field exercises. For the military, this reflects a trend that mirrors what is happening in the general population.

Globally, more than 1 billion adults are classified as overweight and approximately 300 million as clinically obese, ranging from less than 5% in China, Japan, and some African nations to more than 75% in urban Samoa. Alarmingly, this epidemic has spread to children, with 17.6 million children younger than 5 years of age estimated to be overweight worldwide. Data from the United States indicate that 15% of children and adolescents 6-19 years of age are overweight, a figure at least three times higher than that reported in the period from 1960 to 1970. Overweight children are at risk of becoming overweight adults but, more important, are likely to experience chronic health problems (including hypertension) associated typically with only adult obesity.

The World Health Organization has recommended an integrated, multifaceted, population approach be implemented to bring about effective weight management for those at risk of overweight and obesity. The key elements for developing such an environmental support include the following:

• Availability and access to a variety of low-fat, high-fiber foods

• Opportunities for physical activities

• Promotion of healthy behavior to encourage, motivate, and enable individuals to lose weight by

Eating more fruits, vegetables, nuts, and whole grains

Engaging in moderate physical activity for at least 30 minutes a day

Reducing the amounts of fat and sugar in the diet

Changing from a diet containing saturated animal fats to one emphasizing unsaturated vegetable oils

• Proper training of clinical personnel to ensure effective support for those trying to lose weight or avoid further weight gain

Obviously, it is essential to maintain a healthy body weight and thus necessary to keep a focus on energy intake in an effort to prevent overweight. Regarding hypertension, weight reduction appears to be the most promising answer in terms of potential impact on lowering blood pressure. Losing as few as 4.5 kg, or 10 pounds, of body weight can reduce blood pressure. Adopting healthy eating patterns yields additional benefits.