According to the myplate daily food plan, preschoolers age 4 and 5 need about

MyPlate

The USDA MyPlate (www.choosemyplate.gov) is a basis for building an optimal diet for children and adults (Fig. 56.2). MyPlate is based on the 2010Dietary Guidelines for Americans and replaced MyPyramid. MyPlate provides a visual representation of the different food groups and portion sizes designed for the general public. In addition to food group information, the website provides discretionary calorie information, weight management strategies, and tools to track calories and physical activity goals. A personalized eating plan based on these guidelines provides, on average over a few days, all the essential nutrients necessary for health and growth, while limiting nutrients associated with chronic disease development. MyPlate can also be used as an interactive tool that allows customization of recommendations, based on age, sex, physical activity, and for some populations, weight and height. Print materials from the USDA are also available for families without internet access.

Recommendations based on MyPlate emphasize making half the plate vegetables and fruits and half the plate protein and grains, with protein having the smallest section. Protein replaces the meat category since many protein sources are not from animals. A separate dairy section is included. Physical activity recommendations to achieve a healthful energy balance are not visually displayed but are provided on the website. MyPlate has removed foods that have low nutritional value, such as sweetened sugar beverages and sweetened bakery products.

In the United States and an increasing number of other countries, the vast majority of children and adolescents do not consume a diet that follows the recommendations of MyPlate. The intake of discretionary calories is much higher than recommended, with frequent consumption of sweetened sugar beverages (soda, juice drinks, iced tea, sport drinks), snack foods, high-fat meat (bacon, sausage), and high-fat dairy products (cheese, ice cream). Intake of dark-green and orange vegetables (vs fried white potatoes), whole fruits, reduced-fat dairy products, and whole grains is typically lower than recommended. Furthermore, unhealthful eating habits, such as larger-than-recommended portion sizes; food preparation that adds fat, sugar, or salt; skipping breakfast and/or lunch; grazing; or following fad diets are prevalent and associated with a poorer diet quality. MyPlate offers a helpful and customer-friendly tool to assist pediatricians counseling families on optimal eating plans for short- and long-term health.

Myplate Food Guidance System

The MyPlate Food Guidance System is a pictorial representation of the USDA’s daily food recommendations. Released in 2012, MyPlate replaced the nation’s previously well-known nutrition education tool, MyPyramid (2005). In MyPlate, the five food groups are visually represented by a place setting in which each of the food groups (fruits, vegetables, proteins, dairy, and grains) is depicted proportionally according to the current recommendations. In addition, the website ChooseMyPlate.gov offers numerous educational resources and practical guidance for consumers, educators, and health professionals in building a healthful diet. For example, one can develop an individualized nutrition plan based on personal factors such as age, gender, and physical activity by utilizing the online tools, such as SuperTracker, and the Daily Food Plan and Worksheets6 (//choosemyplate.gov). The site offers several food plans for special populations, such as vegetarians, moms, and preschoolers. The SuperTracker tool can help plan, analyze, and track one’s diet, weight, and physical activity; it can also be further personalized by using the goal setting, virtual coaching, and journaling features. Health and nutrition information for children over the age of 5 years is also provided on the site and includes activities, coloring pages, and interactive games as well as tips for caregivers concerning children’s nutrition and meal planning (Fig. 8-1).

Low-fat diets

The Dietary Guidelines for Americans and the MyPlate program provide examples of low-fat diets. Eating a diet that consists of 20%–35% fats helps manage weight, promote health, and reduce risks of chronic disease. Foods to reduce include saturated and trans fats, cholesterol, sodium, added sugar, refined grains, and alcohol. Foods to increase include fruits, vegetables, whole grains, low-fat dairy and protein foods, and oils. This helps maximize nutrient content and the health promotion potential of the diet. Additional low-fat diets include the DASH diet and the diets recommended by the American Diabetes Association, American Heart Association, and American Cancer Society. The commercial Weight Watchers program is also a low-fat diet.

Focus on the Dietary Guidelines for Americans

The Dietary Guidelines for Americans is now in its eighth edition and consists of five suggestions that should be followed. They are as follows:

Follow a healthy eating pattern across the life span. Maintain a healthy weight, support nutrient adequacy, and reduce risks of chronic disease.

Focus on variety, nutrient density, and amount. Meet nutrient needs, but stay within calorie limits.

Limit calories from added sugars and saturated fats, and reduce sodium intake. These include sodas, snacks, desserts, sandwiches, and pizza.

Shift to healthier food and beverage choices. For example, instead of fried chicken, eat chicken baked with herbs. Instead of canned peaches in syrup, eat fresh or frozen peaches without added sugars.

Support healthy eating patterns for all. Work with others to encourage better diet at home, at school, or in the workplace.

Focus on MyPlate

The US government’s MyPlate program suggests that each meal should consist of the following:

50%—approximately 20% fruits and 30% vegetables—vary your vegetables, and focus on whole fruits. Whole fruits can be fresh, frozen, dried, or canned in 100% juice. Eat colorful fruits and vegetables because they provide more vitamins and minerals and are usually lower in calories. Fruits can be eaten with meals, as snacks, or as desserts. Fresh, frozen, or canned vegetables are acceptable, and they can be steamed, sautéed, roasted, or raw.

50%—approximately 20% proteins and 30% grains—mix up protein foods to include seafood, beans, peas, unsalted nuts and seeds, soy products, lean meats, and poultry. Make half your grains whole grains, which should be listed first or second on the ingredients list—such as oatmeal, whole-grain bread, and brown rice. Limit grain-based desserts and snacks, such as cakes, cookies, and pastries.

Drink low-fat or fat-free milk, or eat similar types of yogurt. Soymilk is also great. Replace sour cream, cream, and regular cheese with low-fat yogurt, milk, and cheese. Drink beverages that have less sodium, saturated fat, and added sugars. For oils, use vegetable oils instead of butter, and oil-based sauces and dips instead of those with butter, cream, or cheese. Drink water as much as possible, and avoid nondiet soda, energy or sports drinks, and other sugar-sweetened drinks.

There has been more in-depth study of low-fat diets than on any other type of diet. In many studies, low-fat diets have shown significantly greater weight loss than people who did not follow these diet plans. Low-fat diets also provided improvements in hemoglobin A1c (HbA1c), blood pressure (BP), high-density lipoprotein (HDL), and triacylglycerides (TAG). The Women’s Health Initiative Dietary Modification Trial revealed that a low-fat diet without any instructions for calorie restriction helped maintain weight loss slightly better than following a diet that was higher in fat. Therefore it can be stated that a low-fat diet is an effective weight control strategy over any length of time, as long as it is followed correctly.

Overnutrition in the elderly

Overnutrition is described as excess nutrient and energy intake over time. It is a form of malnutrition if it leads to morbid obesity. Overnutrition is identified by a BMI of 25.1–29.9 (overweight) or over 30 (obese). It is linked to increases in all causes of mortality, along with morbidity that is related to dyslipidemia, hypertension, type 2 diabetes, and various chronic diseases. There are, however, some studies suggesting that the mortality risk of obesity may actually decrease with age. There may be a small advantage to being overweight for men and women who are aged 65 or older. Recommendations for older adults about weight loss are made on an individual basis. Any patient who has a high-risk profile for cardiovascular disease or diabetes, or if there is a decrease in quality of life because of excessive weight, will probably benefit from weight loss. This must be accomplished with caution. The patient must receive enough calcium and vitamin D via supplements, along with exercise to prevent decreases in bone density and loss of muscle mass.

According to nutrition scientists at Tufts University, a MyPlate for Older Adults has been constructed that includes important age-specific components as follows:

bright-colored vegetables (broccoli, carrots)

deep-colored fruits (berries, peaches)

whole, enriched, and fortified grains and cereals (brown rice, 100% whole wheat bread)

low-fat and nonfat dairy products (yogurt, low-lactose milk)

dry beans and nuts

fish

poultry

lean meat

eggs

liquid vegetable oils

soft spreads that are low in saturated fats

spices instead of salt

fluids (water and fat-free milk)

physical activity (walking, resistance training, light house cleaning)

The MyPlate for Older Adults recommendations take into account the needs for exercise, adequate fluid intake, and requirements for vitamin B12 and D. This MyPlate can be adopted for vegetarians as well. Vegetable subgroups include dark green (such as kale and broccoli), starchy (such as corn and plantains), red/orange (such as sweet potatoes and carrots), beans/peas (soy beans and split peas), and “others” (onions, green peppers, cucumbers, mushrooms, and beets). Grains and fruits are also included in the MyPlate for vegetarians. Proteins include legumes, nuts, and seeds. There is less dairy included in this diet, and many people use calcium-fortified soy milk instead of cow milk.

Focus on avoiding overnutrition in the elderly

Elderly people should be educated about what each meal should contain. At least half of each meal should be fruits and vegetables, and at least half of grains that are consumed must be whole grains. Smaller portions of foods are important, and foods that can potentially have extremely high levels of sodium—such as bread, soup, and frozen meals—must be replaced with low-sodium choices. The basics of avoiding overnutrition are simple. The Dietary Approach to Stop Hypertension diet, for example, includes the following basic daily recommendations: grains (7–8 oz), meat and beans (6 oz or less of chicken, other meat, and fish plus 4–5 servings of nuts, seeds, and/or dried beans per week), milk (2–3 cups), vegetables (2–2.5 cups), fruits (2–2.5 cups), and oils (2 teaspoons).

Management

All successful pediatric weight management programs include four components: (1) dietary component, (2) exercise, (3) behavior modification, and (4) family component. Among these, dietary intervention and regular exercise combined are the cornerstones of weight management. Only through behavior modification can long-term healthy eating and activity patterns can be established; attempts at using diet and exercise for quick weight loss usually fail. Without involvement of the parents and family, behavior modification of children and adolescents is difficult to achieve. Currently, no pharmacologic agents have been shown to be safe and effective for long-term weight management in children and adolescents. Presently, the FDA has approved only two drugs, sibutramine (Meridia) and orlistat (Xenical), that may be used for treating severely obese children. Consultations with registered dietitians, psychologists, and exercise specialists may be sought or a referral to a multidisciplinary weight management program may become necessary.

Assessment of usual diet and activity patterns of overweight children and adolescents is important. Selected questions (or assessments) and appropriate counseling are listed below.

Diet

The following questions are helpful in assessing the dietary habits of the child and family.

How often vegetables and fruits are eaten as main meal or snack

How often high calorie drinks (soda pops, fruit punches, fruit juices) are consumed

Numbers and types of fast foods eaten per week

How often the child eats fish, chicken, and red meats

Type of milk, bread, and butter consumed

How often fried foods are eaten in a week

The counseling should include at least the following:

The diet of choice is a diet low in saturated fat and cholesterol and includes five or more daily servings of vegetables and fruits and 6 to 11 servings of whole-grain and other complex carbohydrate foods.

A new Food Guide System, MyPlate, should be introduced. Half of a plate is filled with fruits and vegetables, a quadrant with grains (e.g., bread, wheat, rice), and the last quadrant with protein (e.g., meat, poultry, fish, soy).

To help people better understand what constitutes healthy habits for controlling obesity, some simple guidelines have been developed, such as the “5-2-1-0” message (which includes physical activity). This message developed by the New Hampshire Health Department has been endorsed by the American Academy of Pediatrics as basic healthy lifestyle counseling tool. The message is simple to understand and remember and can be given in a few minutes. The 5-2-1-0 message stands for:

5: Eating at least five servings of fruits and vegetables most days.

2: Limiting screen time to 2 hours or less daily.

1: Participating in at least 1 or more hours of physical activity every day.

0: Encouraging no soda and sugar-sweetened drinks. Instead, drink water and low-fat or fat-free milk.

Physicians may consider using the following as handout materials for counseling.

Box 33-8 (dietary strategies) and Box 33-9: Tips for parents)

Table C-4, Appendix C: Specific foods to choose and to decrease

Table C-5, Appendix C: Serving size of various food groups according to age and gender

Physicians may recommend parents to read about the new food guide system (MyPlate) recommended by the US Department of Agriculture (//teamnutrition.usda.gov/myplate.html).

Physical activity

Exercise is another integral part of weight management. Without regular exercise, dietary modification alone is insufficient for successful weight management. Physicians should first assess the level of physical activity of overweight children and use their influential position to counsel children and their family to adopt a healthy lifestyle.

The following questions are useful in assessing physical activity in children.

Amount of time regularly spent walking, bicycling, swimming, and in backyard play

Use of stairs, playgrounds, and gymnasiums and interactive physical play with other children

Number of hours per day spent watching television or videotapes and playing video or computer games

Time spent participating in organized sports, lessons, clubs, or league games

Time spent in school physical education that includes a minimum of 30 minutes of exercise

Participation in household chores

Positive role modeling for a physically active lifestyle by parents and other caretakers

The physician’s counseling and education should include the following areas.

Physicians should formally address the subject of exercise, emphasizing the health benefits of regular physical activity, which include:

Helping weight control by lowering level of weight gain

Metabolic benefits include:

Improved glucose tolerance and insulin sensitivity (even in the absence of weight loss)

Reduction in VLDL and rise in HDL-C levels

Lowering of blood pressure

Improving psychological well-being

Predisposition to increased physical activity in adulthood

Children should participate in at least 30 minutes of moderate physical activity at least 4 or more days of the week, preferably every day.

Parents should be encouraged to help their children reduce excessive time spent on sedentary behaviors such as watching television and videos, playing on a computer, listening to music, and talking on the phone. TV sets should be removed from children’s bedrooms.

More physical activity should be part of their lifestyle, such as walking or biking to school instead of driving, skating, stairs instead of elevators, and helping with active chores inside and outside of the house.

Teach parents the importance of being role models for active lifestyle and providing children with opportunities for increased physical activity.

Behavior modification is essential for permanent changes in dietary and exercise habits.

Promotion of long-term permanent changes in behavior patterns, rather than short-term diet or exercise program for rapid weight loss, should be the goal of treatment.

Emphasis should be on small and gradual behavior changes.

Early intervention and family involvement: Physicians should also talk about the importance of early intervention (beginning before adolescence) and family involvement for successful weight management.

The importance of early intervention includes:

Many lifestyle habits (eating and exercise habits) are established early in childhood. Parents have much control of their children’s behaviors in the early school years.

There is a tracking of CV risk factors from childhood to adulthood. About 80% of obese adolescents became obese adults. After it is established, obesity is difficult to cure.

Family involvement is very important in pediatric weight management programs.

Willingness on the part of both child and family to participate and involvement of the entire family and other caregivers are important.

Parents need to learn certain skills and commit themselves to the program.

Parent role modeling of healthful dietary and activity habits

Understanding the new food guide system (MyPlate)

Ability to read food labels

Appropriate ways of praising and rewarding good progress

Changes in family environment, such as removing high-calorie foods, reducing the number of meals eaten outside of the home, serving portion-controlled meals to the child, promoting active lifestyles, and discouraging a sedentary lifestyle

Inclusion of activities to help families monitor their eating and physical activity behaviors and establishing formal routine exercise program at a scheduled time each day or evening

Primary emphasis in weight control efforts should be the lifestyle change; the weight loss itself is of secondary importance. An active lifestyle improves risk factors even when weight loss is minimal. When a weight loss goal is set, it should be realistic and should not attempt to fully normalize weight. In children without complications of obesity, maintenance of the current weight or modest weight loss, while children continue to grow in height, reduces their degree of overweight. Children with complications of obesity (e.g., hypertension, hyperlipidemias, insulin resistance, hepatic steatosis) should attempt to lose weight to correct those complications.

Dietary Treatment of Constipation

Due to lack of details about DF intake in CFC guidelines, the author’s dietary advice is based on theoretical knowledge about the effects of DF on bowel habits,73,74 other literature data,1,12,13,41,46–48,78,79,99–102 and clinical experience.7,67 Thus, the recommended diet is that according to the Food Guide Pyramid/MyPlate for all food groups,46,90 with an emphasis on fruits with peel/bagasse, and on pulses, vegetables, seeds, and nuts. At least five daily portions of fruits/vegetables, one of non-sifted pulses and of seeds/nuts, are recommended. A written leaflet listing the DF-dense foods within each food group is provided, while those with almost no DF, such as melon, watermelon, and cucumber without skin, are also indicated. Non-refined cereals are included in the advice, but, apart from corn, these are relatively expensive in Brazil. Therefore, taking into account that whole grain foods like bread, pasta, and rice are not part of the usual Brazilian diet, plain wheat bran is recommended in approximate amounts: 5–10 g per day for age < 1 year, 10–20 g per day for ages 1–2 years, and 20 g per day for older children. Wheat bran is cheap and tested by governmental entities for food security in Brazil, and it has the best weight/weight ratio among foods (g food intake/g increase in fecal weight).73 It can be used – in the proportion 2 parts of refined flour to 1 part of bran – to prepare bread, desserts, cakes, pancakes, and “farofa” (manioc flour roasted with varied ingredients, which is very popular in the country). Otherwise, it can be slightly roasted and added to a humid (but solid) food constituent. Bran is usually not well accepted in fluids such as soups and beverages. Adequate fluid intake has to be ensured, but this is not usually a problem. Fruit juice is allowed, as long as it contains the whole fruit, is non-sifted, and has no added sugar. Suggestions for “good” snacks (between meals) and for “good” sweets (after meals) are given: olives, popcorn, mixed nuts, dried fruits, coconut-filled chocolate, pumpkin compote, passion fruit mousse with seeds, and so forth. Gaseous beverages and junk food are discouraged. A decrease in protein intake is advised whenever excess is reported.103 A prospective evaluation throughout 24 months confirmed that this recommendation is a feasible, cheap, and effective tool for treating constipated children (along with the other treatment tools) in everyday clinical attendance.103

Published reviews and selected works

There is significant academic activity focusing on AI in this burgeoning domain. A recent review on AI utilization in precision medicine discussed the importance of data quality and relevance [209]. The authors contend that much of the effort to advance AI in precision medicine has been focused on algorithms and generation of genomic sequence data and EHR but should also be on physiological genomic readouts in disease-relevant tissues as well. Another review discussed advances in ML and AI are vital for the understanding of epigenetic processes, specifically DL for the generation and simultaneous computation of novel genomic features [210]. Grapov et al. reviewed DL in the context of omics and EHR and astutely pointed out that the challenges of DL is akin to those observed in biological message relay systems such as gene, protein, and metabolite networks [211]. In biomedical diagnostics, medical geneticists are often frustrated by the tedious nature of genotype-phenotype interrelationships among syndromes, especially for extremely rare syndromes. Now, medical geneticists are able to use a visual diagnostic system that employs ML algorithms and digital imaging processing techniques in a hybrid approach for automated diagnosis in medical genetics, especially in rare diseases [212]. One such proposal is the BioIntelligence Framework proposed by Farley et al. [213]. In this model a scalable computational framework leverages a hypergraph-based data model and query language that may be suited for representing complex multilateral, multiscalar, and multidimensional relationships. This hypergraph-like store of public knowledge is coupled with an individual’s genomic and other patient information (such as imaging data) to drive a personalized genome-based knowledge store for clinical translation and discovery. Patients of very similar genomic and clinical elements can be discovered and matched for diagnostic and therapeutic strategies (see Fig. 8.16) [214].

Artificial intelligence (AI) and nutrition—a personalized diet strategy

Since the proverb “An apple a day keeps the doctor away” originated in the 19th century [1], almost every child has come across it since parents use it as a rule of thumb to encourage fruit and vegetable consumption. To promote consumption the United States Department of Agriculture issues food guides. Eight guides have released since 1916 [2], including the well-known “Food Guide Pyramid” published in 1992. The most recent food guide “MyPlate” issued in 2011 illustrates fruits, grains, vegetables, protein, and dairy as five food groups that are building blocks for a healthy diet using a familiar mealtime symbol. “My” in “MyPlate” emphasizes the personalization approach to finding a lifelong healthy, balanced eating style shaped by many factors and choices. Other popular diet and nutrition planning approaches exist including a reduced calorie diet, ketogenic diet, intermittent fasting, Whole30, and Paleo [3]. Some of these approaches require elimination of entire food groups that may cause serious nutrient deficiencies over time. The emergence of meal plan varieties and personal diet planning tools point to an increasing awareness that no universal diet plan fits all. AI has started to play a significant role in this field. Recent findings suggest the way we build models and collect data can push the edge of diet planning to be more personal than ever.

AI strengthens the ability of scientific studies in gathering, analyzing, interpreting, and eventually predicting the best diet plan a person needs to achieve a certain health goal. While we know a model is not a perfect description or a prediction of reality, we are getting closer to reality with data science, ML, and more thoughtful interpretation. For example, Habit is a company that looks at 70+ health markers and uses ML algorithms to inform users how their body handles macronutrients. Users learn what their ideal plate looks like and receive a personalized food guide and list of recipes. Passio, an ML company that uses image recognition to provide real-time on-device food recognition, enables users to have seamless food tracking and nutrition insights.

Currently, most diet planning service providers use AI technologies that quantify each participant who contributes to their research as a number in a dataset; the sample of one participant is likely to be evened out by thousands of other participants. Predictions from participant data will be made based on general results of the pros and cons of a food type to a group of people with a certain biomarker type. Data predictions cannot include every factor or measure some factors that may influence the user’s actual reaction to different food types. Or, how a user’s health condition changes over time, including lifestyle, medical conditions, immune system, anatomy, physiology, medications, and environment. It is possible that a typical diet plan would miss out on these factors. One example of a medical condition in a study shows a postmeal evaluation can be as important as premeal planning.

Research conducted by Weizmann Institute “Personalized Nutrition by Prediction of Glycemic Responses” [4] found people eating identical meals present high variability in postmeal blood glucose response. Personalized diets created with the help of an accurate predictor of blood glucose response that integrate parameters such as dietary, habits, physical activity, and gut microbiota may successfully lower postmeal blood glucose and its long-term metabolic consequences. In this study, 800 healthy and prediabetic individuals were continuously monitored and responses measured to 46,898 meals. Participants were also measured with other blood parameters, anthropometrics, physical activity, self-reported lifestyle behaviors, and gut microbiota composition and function. The research group devised a machine-learning algorithm that accurately predicted personalized postprandial glycemic response to real-life meals. Weizmann Institute validated these predictions in an independent 100-person cohort. Finally, a blinded randomized controlled dietary intervention based on this algorithm resulted in significantly lower postprandial responses and consistent alterations to gut microbiota configuration (Fig. 1). A recent study “Assessment of a Personalized Approach to Predicting Postprandial Glycemic Responses to Food Among Individuals Without Diabetes” [5] conducted by Mayo Clinic echoed this finding.

In these studies, one person is no longer a single data in a dataset; they become the center of new data generated over time. By using a key indicator that reflects potential factors that may affect one person’s unique relationship to a type of food, feeding this second set of user’s individual data into the model after predictions based on a dataset from the population sample, diet planning for each user is differentiated. In other words the same usage of ML can generate a more personalized selection of diet components if we add a tier of algorithm modification with the user’s personal response data over time.

Many AI-based diet planning services are trying to improve their algorithms by collecting more data from more users. However, for each individual, a person’s unique connection to foods may be more effective in building diet planning. For example, Whisk’s Culinary Coach uses AI to provide personalized food recommendations based on flavor preferences and food avoidance. Another example is Plant Jammer, a recipe-generating app, that uses AI to help users build personalized recipes and improve low kitchen confidence by pairing ingredients together based on factors (e.g., food likes/dislikes) and setting different filters (e.g., season and region). Although AI is smart enough to perform calculations that humans cannot compete with, its utility highly depends on where it was built in a hypothesis. AI may give a better explanation about a view of how a mechanism runs, but it cannot create the view for us. In diet planning, volume and quality of data are critical, but another dimension to consider is data validity to the individual case. The time horizon of each data generator may be too valuable to ignore.

In 100 years, we have evolved from static food guides to automated nutrition planning. AI’s role and value as a tool in the future of personalized nutrition and meal planning to help people live healthier and balanced lifestyles will increase.

Information visualization across interfaces

Evaluation of AR visualization techniques has often focused on perception (e.g., depth and spatial perception; Avery, Sandor, & Thomas, 2009; Sandor, Cunningham, Dey, & Mattila, 2010). Mendez and Schmalstieg (2009) developed a variety of techniques to create visualizations and warned against “naive” augmentations, designed to reveal hidden structures inside a physical object that inadvertently obscure context or lack depth cues. They concluded that an effective augmentation considers what parts of the physical world should be occluded by the virtual content and then controls the information added to the physical scene. Similarly, Kalkofen, Mendez, and Schmalstieg (2009) framed the relationship of real and virtual objects in AR visualization as one of focus+context; the goal is to either provide virtual context to a physical object or for the user to focus on a virtual object embedded in a physical context. For example, an empty plate could have overlaid virtual representations for the portion size of fruits, grains, vegetables, and proteins, as recommended by MyPlate (www.choosemyplate.gov; USDA, 2017), giving user a virtual context to guide their physical portioning. In almost the same task, a virtual food item could be shown alongside actual food already on a plate to encourage the right choices, using the physical context of other foods to add more meaning to the virtual content. And these augmentations approaches can adapt throughout the experience, changing as the user interacts with the physical and virtual content and explore it in different ways (e.g., adding more food to the plate, pointing at a virtual or physical item, moving the plate closer to the camera etc.). Others such as Zollmann et al. (2012) have used these “focus+context” interaction techniques to guide the design of 4-D AR elements that show changes over time.

AR visualization techniques have been explored in the medical domain, ranging from a full-body system to teach ultrasound techniques (Blum, Heining, Kutter, & Navab, 2009), to delicate needle biopsies (State et al., 1996), down to laparoscopy (Bichlmeier, Heining, Rustaee, & Navab, 2007). The results have shown that virtual augmentations situated on the body at a variety of scales are an effective presentation method for physiological information and that medical professionals and trainees can use AR systems efficiently. For example, Navab, Mitschke, and Schütz (1999) first demonstrated the use of AR for more accuracy using a C-arm, which is a device used to guide a needle to a specific area of the body. Traditionally, to do this, physicians watch an ultrasound screen to see where the needle is in relation to the body. Providing the context of the body with AR allowed for higher accuracy and lower time to perform the procedure. Additional iterations on the design later revealed that users experienced increased depth perception when the virtual content was reduced to a small virtual “window” that allowed the user to look through the person’s body (Erat et al., 2013). This work highlighted the importance of not overwhelming the user with virtual augmentations, but rather striking a delicate balance with the visual design between the virtual imagery and critical physical context.

Caution must be taken in assuming these medical visualization studies will apply directly to older adults’ understanding of medicine and health. The target user in those systems was typically a medical expert, such as a doctor, nurse, or technician. The systems were designed either to train these experts or for use during live procedures. As a result, the virtual representations needed to be realistic and absolutely precise in registration representation. For example, one such study examined the use of VR and AR for a specific medical imaging procedure in 52 live surgeries (Okur, Ahmadi, Bigdelou, Wendler, & Navab, 2011). This visualization was used to guide medical professionals to specific areas in which a radioactive material was present to allow for a more accurate SPECT scan. These researchers found that AR visualization was used more often than VR visualization; however, they also noted that AR was used for more “big-picture” visualizations of what was happening in the body and more precise tasks were associated with more VR use.

Such system requirements differ from those for older adults managing health conditions, where the goal is for the user to gain a general understanding of their condition and knowledge and skills that will help them manage the condition. However, the medical domain does provide examples of proven techniques for conveying complex visual data of bodily process via AR and which rendering techniques work well in that context. For example, the Mirracle system is an AR mirror for teaching anatomy. The user sees a volumetric rendering of a CT dataset overlaid on their body and gestures to browse through “slices” of the self, augmented with 3D models of organs, text information, and images (Blum, Kleeberger, Bichlmeier, & Navab, 2012). This system works with the camera from the Kinect but is still a proof of concept rather than a system tested to see if it helps anatomy students learn. However, users were successful in interacting with the system to browse their body, showing that the interaction techniques were sound.

Substitute lower-energy-dense foods for higher-energy-dense food

In order to emphasize the importance of eating low-energy-dense foods, the dietary guidelines include MyPlate to communicate to the public (//www.choosemyplate.gov).37 MyPlate reminds people that half of their meal should be vegetables and fruits. An advantage to emphasizing the proportions of dietary components that comprise a healthy diet is that the message can be applied regardless of absolute energy needs.

But does such advice affect behavior? Numerous studies show that the portion of a food that is served affects intake, such that the bigger the portion, the greater the intake.4,38–41 Increasing the proportion and, thus, the portion size of vegetables and fruits can increase their intake; but it is important that they are relatively palatable compared with the other foods available.42 Thus, when advising patients to adopt MyPlate, they should be encouraged to find strategies to increase the palatability while not greatly increasing the energy density of the vegetables and fruits. The addition of herbs and spices or the use of moderate amounts of healthy fats and sauces can encourage vegetable consumption.43,44 Providing a variety of vegetables has been shown to increase vegetable intake compared with just offering one.45 Although increasing the portion of vegetables at a meal can increase vegetable intake, it will not necessarily reduce energy intake. In order to decrease energy intake at the meal, larger portions of vegetables or fruits must be substituted for foods higher in energy density so that the overall energy density of the meal is lowered.46 See Fig. 3 for an example of how substituting lower-energy-dense foods for higher-energy-dense foods can create a more satisfying meal.

Dietary Advice and Restrictions

Pregnant women should eat a variety of foods from all the food groups as outlined in the MyPyramid45 program or in the newer MyPlate program.45 Women should seek to achieve a normal BMI before pregnancy and follow the weight gain guidelines during pregnancy. Consuming a prenatal vitamin helps ensure that any minimal to mild deficiencies will be remedied. Women should avoid alcohol during pregnancy to avoid any chance of fetal alcohol syndrome. About 100 to 300 cal extra per day are all that is required.46 Folic acid supplementation and iron supplements were discussed previously. Calcium consumption should be about 1000 mg/d before, during, and after pregnancy to ensure strong maternal bones, healthy fetal skeleton, and adequate calcium for lactation postpartum.

What about foods to avoid? In general, according to the Food and Drug Administration, there are 4 areas for concern in the food market that pertain especially to pregnant women and their fetuses (aside from alcohol as mentioned earlier).

The first substance is methylmercury from consumption of top-end fish predators. The ocean-going food chain results in the meat from top-end predators (king mackerel, swordfish, tilefish, and shark) containing high levels of methylmercury. Methylmercury poisoning (extreme example is Minamata disease in Japan) can result in microcephaly, cerebral palsy, developmental delay and/or mental retardation, blindness, muscle weakness, and seizures. In general, however, consumption of cold-water fish provides valuable sources of protein and omega-3 fatty acids. “The FDA suggests that pregnant patients may safely eat 12 ounces a week (340 g, or two average meals) of most types of cooked fish including store bought small ocean fish (salmon, Pollock, catfish), shellfish (king crab, shrimp), or canned fish (including light tuna) Fish sticks and fast-food fish are likely made from fish with lower levels of methylmercury.”47

Toxoplasmosis is an often discussed food contaminant; however, it seems that in pregnant patients, the main source of toxoplasmosis is exposure to cat feces.48–53 That being said, it is important to thoroughly cook foods (eg, pork or bear) that might be contaminated with the cysts of toxoplasmosis so that they may be killed and new infection prevented. (Also, although this is not a nutritional topic, someone else should change the litter box for the pregnant patient, or, if the woman must do the changing, she should thoroughly clean her hands with hot soapy water afterward; pregnant women should wear gloves when gardening or handling sand from a sandbox and should not get themselves any new pet cats while pregnant.) Toxoplasmosis is relevant in pregnancy because it can cause infection of the fetal central nervous system or ocular system with significant long-term damage.49

Listeria is a bacterium that can grow even at refrigerated temperatures and can be found in luncheon meats. The rules for handling these foods and preventing disease transmission are as follows: (1) do not eat hot dogs or luncheon meats unless they are reheated steaming hot, (2) avoid soft cheeses unless they are made with pasteurized milk (and avoid other milk or milk-containing foods with unpasteurized milk in them), (3) avoid refrigerated meat spreads, and (4) do not eat refrigerated smoked seafood unless it is in a cooked dish. Although listeria is usually not harmful to pregnant mothers, it can cause stillbirth, miscarriage, premature delivery, or a life-threatening neonatal infection.

All pregnant women should be aware of the dangers of excess caffeine use. Recently studies have shown that ingestion of large amounts of caffeine may lead to miscarriage. The exact “dose” of caffeine necessary to cause miscarriage is unknown, but there is at least a 1.9-fold increase with caffeine ingestion more than 300 to 500 mg daily. The confounder is that the dosing of caffeine in caffeine-containing beverages is extremely variable depending on brewing times and formulations. In general, moderation is wise in this regard.54