|MARY JANE DITTMAR is senior associate editor of Fire Engineering. Before joining the magazine in January 1991, she served as editor of a trade magazine in the health/nutrition market and held various positions in the educational and medical advertising fields. She has a bachelor’s degree in English/journalism and a master’s degree in communication arts.|
One finding stands out when analyzing research related to the factors that have been contributing to fire-fighter cardiovascular-related line-of-duty deaths (LODDs) over the past decade: Members of the fire service may have more control over their health and these LODD statistics than they realize. These events need not necessarily be accepted as inevitable. With the proper interventions, the number of such deaths and illnesses can be decreased.
“Clogged arteries are a societal disease and heart disease primarily a disease of choice, of lifestyle,” says Richard Milani, director of preventive cardiology at the Ochsner Institute in New Orleans. He was commenting on a study headed by Dr. Salim Yusuf, head of the Population Health Research Institute at McMaster University in Hamilton, Canada. Dr. Yusuf and his colleagues identified nine risk factors that “account for 90 percent of the heart disease in every population on earth: smoking, high blood pressure, diabetes, obesity, stress, a desk job (sedentary lifestyle), a diet rich in processed foods and low in fruit and fiber, fats, and ‘failure to take a thimbleful of alcohol.’”
“The important issue is that the vast majority of the risk factors outlined in this [the Yusuf] study are modifiable,” says Toronto cardiologist Anthony Graham, a spokesman for the Heart and Stroke Foundation of Canada 1.
Making changes to reduce health hazards demands the same commitment as efforts to overcome safety hazards, as well as a similar approach: Learn, size up, preplan, and prevent. It is also important for firefighters to recognize that their health can be in jeopardy not only when they are fighting fires but also during the considerable downtime between fires, depending on their lifestyle choices.
In its Alert, “Heart Attacks Leading Cause of On-Duty Texas Fire-fighter Deaths,” sent to the state’s fire departments, the Texas State Fire Marshal’s Office asserted: “Every fire department (paid and volunteer), fire chief, and firefighter must take the initiative in reducing the number of on-duty heart attack deaths.” The Texas Fire Marshal’s Office has been investigating the state’s firefighter LODDs since 2001.
The Alert referred to President Bush’s Healthier U.S. Initiative (www.whitehouse.gov/infocus/fitness), which identifies the “four keys for a healthier America: Be physically active every day, eat a nutritious diet, get preventive screenings, and make healthy choices.” 2
“Firefighters and their families can take simple, affordable steps to work physical activity, good nutrition, and behavior changes into their daily routine. Your health will improve with modest but regular physical activity and better eating habits,” the Alert stated 3.
A firefighter with precarious health, for whatever reason—lack of fitness, dehydration, uncontrolled stress, untreated high blood pressure, undiagnosed cardiovascular disease, or anything that will interfere with job performance—can be as much of a hazard for crew members as a hose about to burst during a firefight or a tire about to blow out while en route to a call. A firefighter at less than optimal health can affect crew safety by various means, including a rapid rate of air consumption or the inability to move/carry hose or climb.
1. Make use of the standards and guidelines at your disposal; what you don’t know can kill you.
The Centers for Disease Control and Prevention (CDC) recommends that the fire service adopt and enforce standards covering mandatory medical examinations and fitness. It advocates mandatory preplacement and annual medical evaluations in accordance with National Fire Protection Association (NFPA) 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments . This standard also recommends that asymptomatic firefighters with two or more risk 4.
Such evaluations and tests may make a significant difference when you consider an NFPA study that involved 1,006 on-duty firefighter fatalities over the 10-year period 1995 to 2004. Of these deaths, 440 were caused by sudden cardiac death (an umbrella term that includes heart attacks but not strokes or aneurysms). According to the report, the medical histories, available for 308 of the 440 victims of sudden cardiac death, showed that there had been prior knowledge of their heart-related conditions for 134 (43.5%) of the fatalities. They previously had had heart attacks, bypass surgery, or angioplasty/stent placement. For another 97 (31.5%), there was evidence of arteriosclerotic heart disease (arterial occlusion of at least 50 percent). Although this is a detectable condition, it is not known if the victims were aware of it 5.
Another example is a National Institute for Occupational Safety and Health (NIOSH) investigatory report covering the 2004 death of a 28-year-old male volunteer chief who died in his sleep while attending an emergency medical services (EMS) conference in another state. The autopsy identified “accidental multiple drug intoxication” as the cause of death. The chief had been on numerous medications to control severe back pain from an injury suffered on the job in 2001 (he had undergone three back surgeries), insomnia, depression, and anxiety. However, his medical records, dating back to 1993, showed he had had intermittent hypertension and had begun smoking cigarettes in 1994. The autopsy also showed an enlarged heart (which NIOSH said could not be ruled out as a cause of death), mild atherosclerosis, and moderate to marked pulmonary edema. His body mass index (BMI) was 33 kilograms per square meter; 30-39 is considered obese.
NIOSH noted that the medical history revealed preexisting conditions that could have affected job performance and the firefighter’s health/longevity. Although the firefighter’s department policy requires that volunteer firefighter applicants complete a job task assessment (physical ability test) and pass a written test related to ? re service tasks before selection, it has no preplacement or periodic medical evaluation. Applicants self-report that they are in excellent health and physically fit. No SCBA medical clearance is required, but annual fit tests are performed. There is no required annual physical agility test.
The NIOSH report pointed out that: “NFPA 1582 was developed to reduce the risk of sudden cardiac arrest or other incapacitating medical conditions among firefighters. The standard considers that ... the use of narcotics or muscle relaxants could prevent a firefighter from safely performing essential job tasks such as firefighting, wearing SCBA, climbing six or more fiights of stairs while wearing turnout gear and equipment weighing 50 pounds or more, victim search and rescue, advancing charged hoselines, climbing ladders, and functioning as an integral part of the two-in/two-out team.” (The chief did not perform these functions; he had been on light duty since his injury.)
Among NIOSH’s recommendations was that fire departments, although they are not legally required to do so, follow standards and guidance regarding content and frequency of periodic medical evaluations and examinations for structural firefighters as found in NFPA 1582, the International Association of Fire Fighters (IAFF)/International Association of Fire Chiefs (IAFC) Wellness/Fitness Initiative, and the National Volunteer Fire Council (NVFC) Health and Wellness Guide.
The agency also recommended that fire departments phase in a mandatory wellness/fitness program for firefighters, institute an annual physical performance (physical ability) evaluation to ensure fire- 50 performance (physical ability) evaluation to ensure fire- fighters are physically capable of performing the essential job tasks of structural ? refighting, and “ensure that firefighters are cleared for duty by a physician knowledgeable about the physical demands of firefighting, the personal protective equipment used by firefighters, and the various components of NFPA 1582.” NIOSH proposed that fire departments retain a fire department physician to critically review all medical clearances 6.
2. Identify your personal health risks; take steps to modify them.
Coronary artery disease patients under 55 years old can benefit substantially from cardiac rehabilitation and exercise training programs (CRETP), according to a report in Archives of Internal Medicine, Sept. 25, 2006. Dr. Carl J. Lavie, Ochsner Medical Center, New Orleans, Louisiana, found that these patients have “a very abnormal risk profile, characterized by more obesity, dyslipidemia, and much higher psychological distress,” which is “markedly improved following formal cardiac rehabilitation.” 7
In addition to the risks for heart disease that apply to the overall population, firefighters are subjected to “job-related” hazards, which must also be factored into the firefighter health-risk assessment. Among those identified by McClusky Bilyk are the following:
Most scenarios in which the injuries occur cannot be changed, but the procedure on how to prevent each injury can, McClusky Bilyk says. She recommends that firefighters receive training and in-service education in nutrition in areas such as achieving adequate fluid intake for better hydration and reducing daily total caloric and fat intake. Regular exercise that includes aerobic and anaerobic training can be another “precaution,” she adds 8.
McClusky Bilyk says continuous fiuid consumption is important. “Because firefighters never know when they will be called to a fire, it is important that they drink appropriate fluids throughout their entire shift. They should not rely on their thirst mechanism,” she advises. “Sporadic fluid intake and a high consumption of caffeine, combined with the high-temperature work environment can result in a life-threatening situation.” (8)
Following are some ways to incorporate physical activity into everyday life. Examples of some fire departments fitness “interventions” are discussed later.
Exercise burns calories, builds stamina, improves balance, strengthens your lungs, and boosts the way you feel 9.
3. Recognize the presence of stress, and work to control it.
A study headed by Dr. Richard D. Lane, a professor of psychiatry at the University of Arizona in Tucson, showed that survivors of unexplained cardiac arrest likely had been through a highly stressful event the day before or had dealt with a severely or moderately stressful event during the 24 hours before they went into cardiac arrest. In addition, 20 of the cardiac arrest patients said they had been through significant stress in the six months prior to their heart trouble. The researchers noted that some people may have a genetic defect that makes them vulnerable to the heart arrhythmia that could trigger ventricular fibrillation. 10 Mental stress can negatively affect the refiexive (autonomic) control of heart action over which we have no conscious control 11.
Firefighters face a considerable amount of mental stress, says McClusky Bilyk. “They are always anticipating the alarm. It’s similar to being on a roller coaster. Once the alarm sounds, an automatic adrenaline ‘rush’ causes an increase in their heart rate before they even get to the fire. This emotional stress combined with the health stresses of being overweight and having low cardiovascular fitness and the physical stress of fighting fire add up to a candidate for a heart attack,” she explains. (8)
A study showed that although a significant minority of patients with heart failure, myocardial infarction (MI), or coronary heart disease have psychological distress, only about one-third of them consulted a mental health professional. In analyzing data from the 2002 National Health Interview Survey involving 17,541 U.S. citizens, Dr. Amy K. Ferketich, Ohio State University School of Public Health in Columbus, and Dr. Philip F. Binkley, Ohio State University of Public Health and Medicine, found that the prevalence of psychological distress among patients with heart failure, MI, and coronary heart disease was 10 percent, 6.4 percent, and 4.1 percent, respectively. The estimated rate of psychological distress among individuals without cardiovascular disease was 2.8 percent 12.
Physicians should address the mental health needs of these patients as well as their cardiac condition, researchers say.
Music was found to modulate stress and induce changes in the cardiovascular and respiratory systems in a study by Luciano Bernardi, MD, University of Pavia in Italy, and colleagues. In previous research, acute MI patients had reductions in heart rate, respiratory rate, and myocardial oxygen demand after music was added to a quiet, restful environment. Tempo appeared to be the most significant factor associated with the changes in cardiorespiratory responses 13.4. Follow the American Heart Association Dietary and Lifestyle Guidelines.
These guidelines include the following:
The recreational use of tobacco in any form exposes smokers to contaminants firefighters might encounter in fire-caused smoke and other calls involving hazardous materials. The question arises: When do “little” continual and “mixed” exposures elevate the potential health threat to the level of definite hazard within an individual?
The NIOSH/OSHA Occupational Health Guidelines for Chemical Hazards state: “Persons with a history of coronary heart disease, anemia, pulmonary heart disease, cerebrovascular disease, thyrotoxicosis, and smokers would be expected to be at increased risk from [chemical] exposure.” 15
A retrospective study of 1,212 tunnel officers exposed to carbon monoxide, resulting in less than 5 percent carboxyhemoglobin, were found to have a significantly elevated risk of dying from arteriosclerotic heart disease. 16 Levels at fires may reach 10 percent, which can raise carboxyhemoglobin levels in active firefighters without respiratory protection to 75 percent within one minute. 17 Heavy cigarette smokers may have carboxyhemoglobin levels as high as 15 to 17 percent 18.
Nearly 40 percent of patients with moderate to severe carbon monoxide (CO) poisoning will have cardiovascular manifestations, according to Dr. Timothy D. Henry, Minneapolis Heart Institute Foundation. Myocardial injury is common in moderate to severe CO poisoning 19.
Cigarette smoking can add two to four micrograms of cadmium per pack. Firefighters might be exposed to this heavy metal also through batteries and alloys, pigments, soldering processes, and burning fossil fuels. A direct link between low-dose cadmium exposure and an increased risk of breast cancer was found in studies involving rats, and previous studies in male rats showed changes in the prostate after the administration of cadmium 20.
Formaldehyde vapors are also present in tobacco smoke, as well as in vehicle exhaust. Consider that these vapors are also present at occupancies that make chemical resins, wrinkleproof fabrics, rubber products, latex paints, dyes, plastics, paper products, and cosmetics and are found in insulation materials, plywood, particleboard, adhesives, glues, paint primers, and fingernail products. If you respond to fires in such occupancies, you can easily be “overexposed” to these vapors. Cal/OSHA and Cal/EPA regulate formaldehyde as a carcinogen 21.
High blood pressure (140/90) increases the risk of heart attacks, strokes, kidney damage, blindness, and dementia. “The challenge from a clinical point of view is to screen these patients to prevent long-term cardiac complications in this high-risk population,” says Dr. Paul Poirier, Hospital Laval, Sainte-Foy, Quebec, Canada. 23 Losing weight (if needed), increasing physical activity, cutting down on sodium (salt), and eating more fruits and vegetables are the most effective lifestyle changes you can make to lower blood pressure. Most hypertension patients may need medications as well 24.
Balancing omega-3 fats with other fats in the diets has been shown to reduce substances that stimulate inflammation that may increase the risk for heart disease and related chronic illnesses. Omega-3 fatty acids are found predominantly in cold-water fish and a few vegetable oils (fiaxseed, walnuts, and canola). Other food sources of omega- 3 include whole grains, legumes, nuts, and green leafy vegetables. These fatty acids are blood thinners and help keep the coronary arteries elastic and fiexible, reduce high blood pressure, keep triglyceride levels down, and reduce the risk of blood clots.
The literature stresses that the intake of omega-3 fats and omega-6 fats, found in many vegetable oils, must be balanced. The American diet seems to include a much greater ratio of omega-6 fatty acids. Many of today’s chronic diseases are related to the effects of an imbalance in omega-6 and omega-3-fats. Higher levels of omega-6s tend to increase the risk of many inflammatory and autoimmune diseases, or they make these problems harder to treat.
Nutrition experts disagree on the optimal ratio between omega-6 and omega-3 fatty acids. Some recommend consuming equal quantities (a 1:1 ratio); others recommend no more than 10 omega-6s to each omega-3. The current American diet contains roughly 10 to 20 times as much omega-6 as omega-3 fatty acids.
Flaxseed is the best source of omega-3s in the vegetable kingdom. Additional food sources of omega-3 fatty acids include walnuts, Brazil nuts, butternuts, chia seeds, hickory nuts, macadamia nuts, roasted or cooked soybeans, soybean sprouts, beans of various types, peanuts, olives, spirulina, and spinach 25.
Trans-fats are destructive to health because the body misreads them as omega-3s and omega-6s and uses them for the same purposes. But because the structure of trans fat is straight instead of bent, the part of the cell membrane that needs to be porous becomes tight and rigid, which causes a variety of health problems—including insulin resistance, which can lead to type 2 diabetes.
The U.S. Food and Drug Administration began requiring food labels to list trans fats in January. “Artificial trans fats are very toxic, and they almost surely cause tens of thousands of premature deaths each year,” says Dr. Walter Willett, chairman of the Department of Nutrition at the Harvard University School of Public Health. “The federal government should have done this long ago.” 26
Some companies have been working to eliminate trans fats. Wendy’s, for example, has switched to a new cooking oil that contains no trans fatty acids. Crisco now sells a shortening that contains zero trans fat. Frito-Lay removed trans fats from its Doritos and Cheetos, Kraft took trans fats out of its Oreos. (26)
Be a more discerning shopper. Read labels. Let food suppliers know you want more healthful foods. Keep asking for them. Purchase foods without trans fats.
BE AWARE OF WHAT YOU ARE EATINGby Hope McCLusky Bilyk, MS, RD, LD
“Confused and frustrated” is the best way to describe how most people feel about nutrition and health. With new, sometimes conflicting, information coming out on an almost daily basis, what’s a person to do? Firefighters, just like the majority of the population, feel that they could improve their diet but don’t know where to start. Carbs are bad; carbs are good. We need more protein. We get enough in our diet. What’s the truth? Where do we begin?
FIRST THINGS FIRSTOur first realization should be that making sweeping changes in our diets all at once won’t work. It takes time to break bad habits. We all want things to improve drastically in the quickest time possible, but success comes through small changes that are made gradually. Taking it slowly and deliberately means that you will be able to adopt and stick to a new, more healthful lifestyle.
Successful change begins with clarity about your current situation. You can’t begin to make changes unless you know what you are eating now. The best way to do this is to write down everything you eat. If you’re not willing to do that, at least count to 10 before you put something in your mouth. Think about what you are eating. Too many times, you pass a plate of cookies or other snacks and grab a few. After all, “a couple won’t hurt.”
The problem is that every time you pass that plate, you grab a few more. The next thing you know, you’ve eaten several hundred calories that you don’t even remember. And did you really enjoy the multiple handfuls as much as that first decadent bite? In short, you must become aware of what you are eating. Counting to 10 (and not by 2s) before you eat something will help considerably. At the end of counting, you may find (hopefully!) that your craving was a passing sensation. With time, you’ll find it easier and easier to keep your hand out of the cookie jar, without feeling confused or frustrated about what you really need or want.
WHAT’S THE NEXT STEP?The next step is to start making small changes in your diet. The first thing I would recommend for any firefighter is to drink a tall glass of water with each meal. You know the importance of proper hydration. It also wouldn’t hurt to pick certain times between meals several times during the day to also enjoy a tall, cool glass of water, NOT coffee, soda, or energy drinks. In your profession, hydration is of utmost importance. Remember, your urine should be the color of pale lemonade. Also void your bladder on an hourly basis. You never know when that call is going to come in! The next change I would recommend is that you eat seconds of vegetables—the darker the green or orange, the better. Vegetable intake is consistently associated with significant reductions in cardiovascular disease. Studies have also shown that consuming five to nine servings of vegetables and fruits each day lowers blood pressure in people with hypertension. And still another perk for eating vegetables is all the antioxidants they supply. Antioxidants are very important in protecting the body’s cells, which is especially important considering all the environmental toxins to which firefighters are exposed.
Remember these three simple steps. That’s all it will take to start you on the way to a more healthful body, a benefit not only for you but also for the other members of your team. And, with the crucial role you play in the safety of your communities, your improved health is good news for everyone.
We are slowly seeing changes in the nutritional status of firefighters, as with the general population, but it is still not as healthful as it should be. In most cases, intake is still well below the overall minimum recommendations of three-plus servings of vegetables per day. We are especially deficient in the intake of dark colored vegetables. This is especially alarming now that we have preliminary studies that support that poor nutrition, especially the lack of antioxidants in the diet, can have a negative effect on overall lung health, an area of concern for firefighters. This makes consuming at least the minimum number of servings of vegetables even more important for firefighters. I believe in the future we will be moving toward planned diets based on the needs of the individual firefighter, just as is now done for the elite athletes.
HOPE McCLUSKY BILYK, MS, RD, LD, is a registered dietitian who comes from a family of firefighters. She is an instructor at Rosalind Franklin University of Medicine and Science in the School of Medicine and the College of Health Professionals in Illinois. Her master’s research thesis was on the eating habits of firefighters. She lectures and has been published internationally.
The department developed a voluntary dietary cooperative program between labor and management that promotes healthy hearts and bodies. The recently initiated second phase includes hiring a nutritional expert to teach healthful eating habits. Chief Mike Roberts has fresh fruit delivered to firehouses for snacks. During training sessions, they discuss eating habits and cardiovascular health. 28
Program components include an annual firefighter occupational medical certification (OMC) exam, an annual work-related incumbent physical ability test (IPAT), and general health-related fitness services (HRFS), the centerpiece of the wellness program, which is offered continuously to help firefighters achieve and maintain a health and fitness level commensurate with the job demands.
A team of peer fitness trainers delivers the services, available to individuals and groups. Participation is voluntary. Group health, fitness, and nutrition (weight management and basic nutrition) open enrollment classes are part of the company training schedule and are also offered at the fire station at the crews’ request. Special group wellness services are offered occasionally to promote and stimulate greater participation—for example, a 16-week departmentwide weight loss challenge was held in January 2006. Some 30 department employees (sworn and civilian) participated. Nutrition and behavior modification classes were combined with biweekly weigh-ins. The group lost more than 340 pounds.
Crews may attend a class on-duty with battalion chief approval or individually off-duty. Exercise sessions focus on exercise technique; when possible, work-related functional training is incorporated. Work Hardening, a popular firefighter exercise class, combines core strength exercises (push-ups, crunches) and work-related job tasks (climbing stairs with high pack, pulling hose, dragging mannequins, sledgehammer work, and other tasks). The 30- to 40-minute sessions are designed to improve aerobic capacity and muscular endurance. Firefighters work in pairs and move through the course at their own pace, but continuously.
Individual services include voluntary fitness assessments, personal exercise prescriptions, and weight management consultation. All department personnel have access to fitness facilities. Department health and fitness policy requires sworn personnel to exercise every on-duty shift; captain and battalion chiefs manage this requirement. All firefighters are required to sign a no tobacco use and health and fitness agreement at the time of hire. Health and fitness agreements spell out the annual medical and physical ability test requirements. The department contracts for a professional medical service, which performs annual comprehensive Occupational Medical Certification exams in accordance with recommended National Fire Protection Association medical standards. Each firefighter must “pass” the medical exam to maintain field operations status. If nonindustrial-related medical problems are identified, the firefighter is referred to his private physician for follow-up. The firefighter must return to the fire department physician for final clearance after the problem is corrected or under control. The annual medical exam also serves to clear firefighters for the required incumbent physical ability test (IPAT), which hired experts are developing.
Testing is expected to begin around January 2007. The goal is a 100 percent pass rate. The timed IPAT is pass or fail. Field operations work status depends on passing this fitness test. IPAT practice sessions including “test out” sessions are conducted well in advance of the scheduled annual IPAT test. Firefighters who fail the test are removed from their field operation position and placed on modified duty. The WPC performs a fitness assessment, establishes personal goals, and writes a personal rehabilitation prescription. Under the direction of the WPC, a peer fitness trainer is assigned to work with the firefighter five days a week. Periodic fitness assessments are repeated and firefighters receive an IPAT retest at specific intervals. For additional information, contact Steve Giardini at SGiardini@ScottsdaleAz.Gov.
The program components include determining current wellness and ? tness levels for department members and comparing them with national standards, identifying wellness and fitness goals, and creating a plan for achieving personal goals tailored to the user’s needs. Individual wellness and fitness test results are stored in a secured database, which the user can access. Future plans include rehabilitation (physical and psychological) efforts to be coordinated between the fire department’s medical staff and the Well eMerica© system.
Dr. Charles Regin and Dr. Jean Henry administer the program. A large percentage of their efforts recently have been directed toward testing and providing recommendations for cadets in 11 academies in three fire departments. The original program was funded by a Federal Emergency Management Agency (FEMA) grant cowritten by Local 1607 (North Las Vegas) leaders and North Las Vegas Fire Department’s management representatives.
At press time, partners in the program included kinesiologists, registered dieticians, and graduate and undergraduate student volunteers from the university; a nationally recognized computer software development company; a national computer company; fire departments in southern Nevada (North Las Vegas Fire Department, Las Vegas Fire and Rescue, and Clark County Fire Department), physical therapists and medical doctors; and a fitness club with national sites.
All members of the current partnership have committed to a multiyear timeline. The university is committed to expanding the center for research and development for firefighter wellness and ? tness with partnerships developed with additional interested fire service personnel. Information on the program is available at Wellemerica.unlv.edu, or contact Chuck Regin, Ph.D., director, at (702) 895-0856 or by email at Chuck Regin.
We are all aware of the heart-health initiatives offered through fire service organizations, and many of you are participating in them. These resources are of exceptional benefit. This article is directed more to giving you ”empowerment” over your health through daily, conscious decisions that may not be earth shattering in themselves but that continuously and collectively can make a difference, as research is showing, and create a healthier—and safer—fire service. What are you and your department doing to promote heart health? Let us know. E-mail me at Mary Jan Dittmar
NUTRITION TIPSServing size. When reading food labels, check the serving size, not the package size. (Muffins, for example, often give the information for one-half muffin. One muffin is considered two servings, which would mean double the calories, fats, and so on.)
Percentage of Daily Value. This indicates the percentage of the daily diet the food component (fat or sodium, for example) provides. A daily value of five percent or less indicates the food is relatively low in a nutrient; 20 percent or higher means the food is relatively high in the nutrient.
Food-Ranking Systems. Some supermarket chains identify diabeticfriendly, high-fiber, low-fat, low-calorie, or sugar-free foods with tags, labels, or rating systems. The stores in which you shop may have systems of their own for designating more and less healthful foods. Read labels, look for specially designated products, and ask the store to carry more healthful foods if enough are not available. “Chain uses stars to rate food for nutrition.” Sept 7, 2006, www.msnbc.msn.com/id/14715344
Meal Plate Template. The American Institute for Cancer Research recommends this template for your meal plate: one third maximum meat, poultry, or fish and two-thirds vegetables, fruits, whole grains, and beans.