MODULE I

Overview of Nutrition
Lesson 1: Nutrition Concepts

Lesson 2: Digestion, Absorption and Utilization of

Nutrients

Lesson 3: Nutrition Tools, Standards and Guidelines,

Nutrient Recommendations

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MODULE I

OVERVIEW OF NUTRITION

 INTRODUCTION

This module includes lessons on the relationship of nutrition and health;

planning a healthy diet; digestion, absorption, and metabolism; and nutrition tools,
standards and guidelines, nutrient recommendations.

LEARNING OBJECTIVES

After studying the module, you should be able to:

1. Describe ways in which nutrition and health are related

2. Describe the processes of digestion, absorption, and metabolism
3. Define the four categories of the DRI, and the Acceptable Macronutrient
Distribution Ranges (AMDR), and explain their purposes.
4. Compare the information on food labels to make selections that meet
specific dietary and health goals
5. Discuss the nutrition guidelines for Filipinos.

 DIRECTIONS/ MODULE ORGANIZER

There are three lessons in the module. Read each lesson carefully then answer
the questions/activities to find out how much you have benefited from it. Work on
these exercises carefully and submit your output to your instructor or to the CCHAMS
Office.

In case you encounter difficulty, discuss this with your instructor during the
face-to-face meeting. If not contact your instructor at the CCHAMS office.

Good luck and happy reading!!!

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Lesson 1

 NUTRITION CONCEPTS

NUTRITION
• Nutrition is the science that links foods to health and disease. It is the study of
food and how the body makes use of it.
• Nutrition deals not only with the quantity and quality of food consumed bur
also with the process of receiving and utilizing it for the growth and renewal of
the body and for the maintenance of the different body functions.

Function of Nutrition

The basic function of nutrition is to maintain life by allowing an individual to

grow and be in a state of optimum health.
The following are reasons why nutritional science is applied to nursing care:

1. the recognition of the role of nutrition in preventing diseases or illnesses;

2. the concern for adapting food patterns of individuals to their nutritional needs
within the framework of their cultural, economic, and psychological situations
and styles; and
3. the awareness of the need in specified disease states to modify nutritional
factors for therapeutic purpose.

NUTRIENTS
• Nutrients are components of food that are needed by the body in adequate
amounts in order to grow, reproduce and lead a normal, healthy life. Since
nutrients are found primarily in natural foods, adequate intake of these
nutrients is necessary to carry out physiological functions.
• Nutrients are classified according to the following:
1. Function – Those that form tissues in the body are body building nutrients
while those that furnish heat and energy are fats, carbohydrates, and
proteins.
2. Chemical properties – Nutrients are either organic or inorganic
3. Essentiality – Nutrients are classified based on their significant contribution
to the body’s physiological functioning.
4. Concentration – Nutrients are either in large or little amounts.
• Water, carbohydrates, fats, proteins, vitamins, and minerals are the six classes
of nutrients.
• There are over 40 essential nutrients supplied by food, which are used to
produce literally thousands of substances necessary for life and physical
fitness.

Adequate, Optimum and Good Nutrition

• These are expressions used to indicate that the supply of the essential
nutrients is correct in amount and proportion. It also implies that the
utilization of such nutrients in the body is such that the highest level of
physical and mental health is maintained throughout the life-cycle.

FOOD
• Food is that which nourishes the body.
• Food may also be defined as anything eaten or drunk, which meets the needs
for energy, building, regulation and protection of the body.
• Intake of the right kinds and amounts of food can ensure good nutrition and
health, which may be evident in our appearance, efficiency and emotional
well-being.

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FACTORS INFLUENCING FOOD
Functions of Food CHOICES

1. Physiological functions of food Preference

• To provide energy Habit
• To build the body Associations
• To regulate activities of the body Ethnic Heritage and Regional
• To improve the body’s resistance to disease Cuisines
2. Social functions of Food Values
• Used as an expression of love, friendship and Social Interaction
social acceptance Emotional State
• Used as a symbol of happiness at certain Availability, Convenience, and
events in life Economy
3. Psychological Functions of Food Age
Body Weight and Image
• Satisfies sense of security, love and attention
Medical Conditions
Health and Nutrition
NUTRITIONAL STATUS
• The state of our body as a result of the foods consumed and their use by the
body. Nutritional status can be good, fair or poor.
• Good nutritional status
o alert, good natured personality, a well-developed body, with normal
weight for height, well developed and firm muscles, healthy skin, and
reddish pink color of eyelids and membranes of mouth, good layer of
subcutaneous fat, clear eyes, smooth and glossy hair, good appetite and
excellent general health.
• Poor nutritional status
o may be the result of poor food selection, irregularity in schedule of
meals, work, sleep and elimination.
o evidenced by a listless, apathetic or irritable personality, undersized
poorly developed body, abnormal body weight (too thin or fat and
flabby body), muscles small and flabby, pale or sallow skin, too little or
too much subcutaneous fat, dull or reddened eyes, lusterless and rough
hair, poor appetite, lack of vigor and endurance for work and
susceptibility to infections. Poor nutritional status may be the result of
poor food selection, irregularity in schedule of meals, work, sleep and
elimination
• Dietary status
o describes what a client has been eating. Although a client’s dietary
status may be adequate, his or her nutritional status may be poor

HEALTH
• The WHO (World Health Organization) has defined health as the ‘state of
complete physical, mental and social well-being and not merely the absence of
disease or infirmity’.
• Malnutrition results from a lack, excess or imbalance of nutrients in the diet. It
includes undernutrition and overnutrition.
• Undernutrition is a state of an insufficient supply of essential nutrients.
• Overnutrition refers to an excessive intake of one or more nutrients, which
creates a stress in the bodily function.

UNDERNUTRITION
• Underweight: a child has low weight for age. Composite measure includes
chronic and acute malnutrition.
• Stunting: child short for their age as a result of chronic under nutrition
during the most critical periods of growth and development in early life.
• Wasting: child’s weight is too low for their height as a result of acute
under nutrition, can vary with the seasons. Reflects loss of muscle tissue
and fat.

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• In the Philippines, malnutrition is one of the problems that the Philippine

Health Agenda 2016-2020 aims to resolve.
• Diet refers to whatever you eat and drink each day. It includes the normal diet
you consume and the diet people consume in groups (hostel diet). Diet may
also be modified and used for ill persons as part of their therapy (therapeutic
diets).

CUMULATIVE EFFECTS OF NUTRITION

• Cumulative effects are the results of something that is done repeatedly over

OVERNUTRITION
• Overweight: BMI is 25.0 to <30
• Obese: BMI is 30.0 or higher
many years. For example, eating excessive amounts of saturated for many
years contributes to atherosclerosis, which leads to heart attacks.
• Years of overeating can cause obesity and may also contribute to
hypertension, type 2 (non-insulin-dependent) diabetes, gallbladder disease,
foot problems, certain cancers, and even personality disorders.
• The practice of good nutrition habits would help eliminate many health
problems caused by malnutrition.

Concept Check!
1. Food is considered as our energy source. Apart from the
energy it gives, how does food influence you?
2. In 3- 5 sentences, state ways on how nutrition and health
are related.

Laboratory Activity
1. Ask your parents or grandparents about any food which they think your
family represents. What does that food symbolize?
2. Who usually does market or grocery shopping in your family? How does
he/she ensure the quality of foods or products he/she buys?
3. When preparing a meal, what are the things you or your family considers
(e.g. cost, nutritional value)?
4. Is there any nutritional practice your family employs? Enumerate.

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Lesson 2

Metabolism
 DIGESTION, ABSORPTION AND
UTILIZATION OF NUTRIENTS

• All the nutrition processes which take place in the cell.

• Anabolism
o involves synthesis of compounds needed for use in the body
• Catabolism
o Breakdown of complex substances to simpler ones
• Preparing food for the body’s use involves many steps, including digestion,
absorption, transport, and metabolism.

The Gastrointestinal (GI) Tract

• a flexible, muscular tube extending from the mouth to the anus. Along the
entire GI tract secretions of mucus lubricate and protect the mucosal tissues.
• The entire human gastrointestinal (GI) tract is approximately 30 feet in length.
The time it takes to go through all of the process (or phases) mentioned about
will vary depending on the person, and the type and quantity of food ingested.
• The process of digestion is typically in the range of taking between 24 and 72
hours.

THE DIGESTIVE ORGANS

Mechanical processes
• involved in digestion include chewing of food, swallowing of food, churning
action in the stomach and rhythmic contraction of the intestinal tract

Chemical reactions
• In digestion process: The first reaction is hydrolysis or splitting with the help of
water. Carbohydrates, fats and proteins break up with the addition of water
into smaller molecules, which the tissues can use.
• Some enzymes need another group, known as a coenzyme, to be attached to it
to aid their function. For example, B-vitamins serve as coenzymes in the
reactions, which release energy from glucose.
• In enzyme reactions, mineral elements are essential as cofactors. Thus normal
body metabolism is dependent on the presence of appropriate enzymes,
coenzymes and cofactors specific to each reaction

Mouth to the Esophagus

• Bolus - mouthful of food that has been chewed and swallowed
• Each bolus first slides across your epiglottis, bypassing the entrance to your
lungs. During each swallow, the epiglottis closes off your trachea, the air
passageway to the lungs, so that you do not choke.

Esophagus to the Stomach

• The esophagus has a sphincter muscle at each end. During a swallow, the upper
esophageal sphincter opens. The bolus then slides down the esophagus, which
conducts it through the diaphragm to the stomach. The lower esophageal
sphincter closes behind the bolus so that it cannot slip back. The stomach
retains the bolus for a while, adds juices to it, and transforms it into a
semiliquid mass called chyme. Then, bit by bit, the stomach releases the
chyme through another sphincter, the pyloric sphincter, which opens into the
small intestine and then closes after the chyme passes through.

The Small Intestine

• At the beginning of the small intestine, the chyme passes by an opening from
the common bile duct, which secretes digestive fluids into the small intestine
from two organs outside the GI tract—the gallbladder and the pancreas. The

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chyme travels on down the small intestine through its three segments—the
duodenum, the jejunum, and the ileum. Together, the segments amount to a
total of about 10 feet of tubing coiled within the abdomen. Digestion is
completed within the small intestine.

The Large Intestine (Colon)

• Having traveled the length of the small intestine, what remains of the
intestinal contents passes through another sphincter, the ileocecal valve, into
the beginning of the large intestine (colon) in the lower right-hand side of the
abdomen. Upon entering the colon, the contents pass another opening. Should
any intestinal contents slip into this opening, they would end up in the
appendix, a blind sac about the size of your little finger. Normally, the
contents bypass this opening, however, and travel up the right-hand side of the
abdomen, across the front to the left-hand side, down to the lower left-hand
side, and finally below the other folds of the intestines to the back side of the
body above the rectum.

The Rectum
• As the intestinal contents pass to the rectum, the colon withdraws water,
leaving semisolid waste. The strong muscles of the rectum hold back this waste
until it is time to defecate. Then the rectal muscles relax, and the last
sphincter in the system, the anus, opens to allow the wastes to pass. Thus,
food travels through the digestive tract in this order: mouth, esophagus, lower
esophageal sphincter (or cardiac sphincter), stomach, pyloric sphincter,
duodenum (common bile duct enters here), jejunum, ileum, ileocecal valve,
large intestine (colon), rectum, and anus.

The Involuntary Muscles and the Glands

Gastrointestinal Motility
• Once you have swallowed, materials are moved through the rest of the GI tract
by involuntary muscular contractions. This motion, known as gastrointestinal
motility, consists of two types of movement, peristalsis and segmentation.
Peristalsis propels, or pushes; segmentation mixes, with more gradual pushing.

Peristalsis
• Peristalsis begins when the bolus enters the esophagus. The entire GI tract is
ringed with circular muscles, which are surrounded by longitudinal muscles.
When the rings tighten and the long muscles relax, the tube is constricted.
When the rings relax and the long muscles tighten, the tube bulges. These
actions alternate continually and push the intestinal contents along. Peristalsis,
aided by the sphincter muscles located at key places, keeps things moving
along. However, factors such as stress, medicines, and medical conditions may
interfere with normal GI tract contractions.

Segmentation
• The intestines not only push but also periodically squeeze their contents. This
motion, called segmentation, forces the contents back a few inches, mixing
them and promoting close contact with the digestive juices and the absorbing
cells of the intestinal walls before letting the contents slowly move along
again.

Liquefying Process
• Besides forcing the intestinal contents along, the muscles of the GI tract help
to liquefy them to chyme so that the digestive juices will have access to all
their nutrients. The mouth initiates this liquefying process by chewing, adding
saliva, and stirring with the tongue to reduce the food to a coarse mash
suitable for swallowing. The stomach then further mixes and kneads the food.

Stomach Action
• The stomach has the thickest walls and strongest muscles of all the GI tract
organs. In addition to circular and longitudinal muscles, the stomach has a third

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layer of diagonal muscles that also alternately contract and relax. These three
sets of muscles work to force the chyme downward, but the pyloric sphincter
usually remains tightly closed, so that the stomach’s contents are thoroughly
mixed and squeezed before being released. Meanwhile, the gastric glands are
adding juices. When the chyme is thoroughly liquefied, the pyloric sphincter
opens briefly, about three times a minute, to allow small portions through. At
this point, the intestinal contents no longer resemble food in the least.

THE PROCESS OF DIGESTION

Digestion in the Mouth

• Digestion of carbohydrate begins in the mouth, where the salivary glands
secrete saliva, which contains water, salts, and enzymes (including salivary
amylase) that break the bonds in the chains of starch. Saliva also protects the
tooth surfaces and linings of the mouth, esophagus, and stomach from attack
by molecules that might harm them. The enzymes in the mouth do not, for the
most part, affect the fats, proteins, vitamins, minerals, and fiber that are
present in the foods people eat.

Digestion in the Stomach

• Gastric juice, secreted by the gastric glands, is composed of water, enzymes,
and hydrochloric acid. The acid is so strong that it burns the throat if it
happens to reflux into the upper esophagus and mouth. The stomach’s strong
acidity prevents bacterial growth and kills most bacteria that enter the body
along with food. You might expect that the stomach’s acid would attack the
stomach itself, but the cells of the stomach wall secrete mucus, a thick, slimy,
white polysaccharide that coats and protects the stomach’s lining.

Digestion in the Small and Large Intestines

• By the time food leaves the stomach, digestion of all three energy-yielding
nutrients has begun, but the process gains momentum in the small intestine.
There, the pancreas and the liver contribute additional digestive juices through
the duct leading into the duodenum, and the small intestine adds intestinal
juice. These juices contain digestive enzymes, bicarbonate, and bile.
Digestive Enzymes Pancreatic juice contributes enzymes that digest fats, proteins,
and carbohydrates. Glands in the intestinal wall also secrete digestive enzymes.

Bicarbonate Pancreatic juice also contains sodium bicarbonate, which neutralizes

the acidic chyme as it enters the small intestine. From this point on, the digestive
tract contents are neutral or slightly alkaline. The enzymes of both the intestine
and the pancreas work best in this environment.

Bile is secreted continuously by the liver and is concentrated and stored in the
gallbladder. The gallbladder squirts bile into the duodenum whenever fat arrives
there. Bile is not an enzyme but an emulsifier that brings fats into suspension in
water. After the fats are emulsified, enzymes can work on them, and they can be
absorbed.

The Rate of Digestion The rate of digestion of the energy nutrients depends on the
meal contents. If the meal is high in simple sugars, digestion proceeds fairly rapidly.
On the other hand, if it is rich in fat, digestion is slower.

Protective Factors The intestines contain bacteria that produce a variety of vitamins,
including biotin and vitamin K (although bacteria alone cannot meet the need for
these vitamins).

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FIGURE 2.1. Figure 2.1 shows the actions and end-products of the digestive tract -
also called the Gastrointestinal (G.I) tract or the alimentary canal.
THE ABSORPTIVE SYSTEM
The Small Intestine
• Villi and Microvilli -the villi are as
numerous as the fibers on velvet fabric. A
single villus, magnified still more, turns
out to be composed of several hundred
cells, each covered with microscopic hairs
called microvilli.
• Specialization in the Intestinal Tract -
the nutrients that are ready for
absorption early are absorbed near the
top of the tract; those that take longer to
be digested are absorbed farther down.
The lowly “gut” turns out to be one of
the most elegantly designed organ
systems in the body.
Absorption of Nutrients
• Once a molecule has entered a cell in a
villus, the next step is to transmit it to a
destination elsewhere in the body by way
of the body’s two transport systems—the
bloodstream and the lymphatic system.
• Through these vessels, the nutrients leave
the cell and enter either the lymph or the
blood.
• The water-soluble nutrients (and the
smaller products of fat digestion) are
released directly into the bloodstream by
way of the capillaries, but the larger fats
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The Myth of “Food
Combining”
Some popular fad diets advocate the
idea that people should not eat
certain food combinations (for
example, fruit and meat) at the
same meal, because the digestive
system cannot handle more than one
task at a time. This is a myth. The
art of “food combining” (which
actually emphasizes “food
separating”) is based on this idea,
and it represents faulty logic and a
gross underestimation of the body’s
capabilities. In fact, the opposite is
often true: foods eaten together can
enhance each other’s use by the
body. For example, vitamin C in a
pineapple or citrus fruit can enhance
the absorption of iron from a meal of
chicken and rice or other iron-
containing foods.
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and the fat-soluble vitamins find direct access into the capillaries impossible
because these nutrients are insoluble in water (and blood is mostly water).
• The intestinal cells assemble the products of fat digestion into larger molecules
called triglycerides. These triglycerides, fat-soluble vitamins (when present),
and other large lipids (cholesterol and the phospholipids) are then packaged for
transport.

Transport of Nutrients
The Vascular System
• Blood is carried to the digestive system Health Implications of
(as it is to all organs) by way of an LDL and HDL
artery, which (as in all organs)
branches into capillaries to reach every The distinction between
cell. Blood leaving the digestive system LDL and HDL has implications for
goes by way of a vein. The hepatic the health of the heart and blood
portal vein, however, directs blood not vessels. High concentrations of
back to the heart but to another LDL in the blood are associated
organ—the liver. This vein again
with an increased risk of heart
branches into a network of small blood
vessels (sinusoids) so that every cell of
disease, as are low concentrations
the liver has access to the newly of HDL. Factors that lower LDL
absorbed nutrients that the blood is concentrations and raise HDL
carrying. Blood leaving the liver then concentrations include:
again collects into a vein, called the 1. Weight management
hepatic vein, which returns the blood 2. Polyunsaturated or
to the heart. The route is thus heart to monounsaturated, instead
arteries to capillaries (in intestines) to of saturated, fatty acids in
hepatic portal vein to sinusoids (in the diet
liver) to hepatic vein to heart. 3. Soluble fibers
The Lymphatic System
4. Physical activity
• The lymphatic system is a one-way
route for fluids to travel from tissue
spaces into the blood. The lymphatic system has no pump; instead, lymph is
squeezed from one portion of the body to another like water in a sponge, as
muscles contract and create pressure here and there.
• fat-soluble nutrients absorbed into the lymphatic system from the GI tract
finally enter the bloodstream
Transport of Lipids: Lipoproteins
• Within the circulatory system, lipids always travel from place to place bundled
with protein, that is, as lipoproteins. When physicians measure a person’s
blood lipid profile, they are interested in both the types of fat present (such as
triglycerides and cholesterol) and the types of lipoproteins that carry them.

Clinical Application
1. People who experience malabsorption frequently have the most
difficulty digesting fat. Considering the differences in fat,
carbohydrate, and protein digestion and absorption, can you
offer an explanation?
` 2. How might you explain the importance of dietary fiber to a
client who frequently experiences constipation?

Laboratory Activity
Draw and label the digestive system. Include the enzymes and other
substances in each structure involved in the process of digestion and absorption of
nutrients.

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Lesson 3


NUTRITION TOOLS, STANDARDS AND
GUIDELINES

NUTRITION POLICY AND NATIONAL HEALTH PROBLEMS

Diet, Health, and Public Policy

• Public policy refers to the laws, regulations, and government programs
surrounding a certain topic.
• Nutrition policies are concerned with food guidance for the public, nutrition
standards for government food programs, and the health and well-being of the
population.
• nutritious diet has the six characteristics:
1. adequacy - the characteristic of a diet that provides all the essential
nutrients, fiber, and energy necessary to maintain health and body weight.
2. Balance - the dietary characteristic of providing foods in proportion to one
another and in proportion to the body’s needs
3. kcalorie (energy) control - management of food energy intake
4. nutrient density - a measure of the nutrients a food provides relative to
the energy it provides. The more nutrients and the fewer kcalories, the
higher the nutrient density.
5. moderation - the provision of enough, but not too much, of a substance
6. variety - consumption of a wide selection of foods within and among the
major food groups (the opposite of monotony).

RECOMMENDATIONS FOR DIETARY ENERGY INTAKE

• Growth Periods
o The most rapid growth occurs
during infancy and adolescence,
with continuous but slower
growth taking place between
these periods.
o The rapid growth of the fetus and
the placenta as well as other
maternal tissues makes increased
energy intake during pregnancy
and lactation highly important.
• Adulthood
o With full adult growth achieved,
energy needs level off to meet
requirements for tissue
maintenance and usual physical
activities.
o As the aging process continues, a
gradual decline in BEE and
physical activity decreases the
total energy requirement
o A more rapid decline occurs
around 40 years of age in men and
50 years of age in women.
NUTRIENT AND FOOD GUIDES FOR HEALTH
PROMOTION
Healthy People 2020
• Established science-based, national
objectives for promoting health
• Examples of nutrition-related targets
from healthy people 2020:
a. Increase the contribution of total
vegetables to the diets of individuals
aged 2 and older from 0.8 cups
equivalent per 1000 calories to 1.1
cups equivalent per 1000 calories.
b. Reduce consumption of calories from
added sugars from 15.7% of total
calories to 10.8% of total calories in
the diets of individuals aged 2 and
older.
c. Increase the proportion of infants who
are breast-fed at 6 months from
43.5% to 60.6%.
d. Reduce the proportion of U.S.
households reporting food insecurity
from 14.6% to 6.0%.
e. Reduce the proportion of adults aged
18 years and older with hypertension
from 30% to 27% (10% reduction).

Food Guide – helps Americans meet their nutritional needs by preventing

undernutrition and controlling chronic diseases related to overnutrition

Three Types of Nutrition/Food Guide

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1. NUTRITION STANDARDS
a. Dietary Reference Intakes
▪ The U.S. framework of nutrient standards that provide reference
values for use in planning and evaluating diets for healthy people.
▪ Categories of reference data:
i. Recommended Dietary Allowance (RDA): The average daily
intake of a nutrient that will meet the requirement of 97% to
98% (or two standard deviations of the mean) of healthy
people of a given age and sex.
ii. Adequate Intake (AI): A suggested daily intake of a nutrient
to meet body needs and support health. The AI is used when
there is not sufficient research available to develop an RDA
but the nutrient appears to have a strong health benefit. The
AI serves as a guide for intake when planning diets
iii. Tolerable Upper Intake Level (UL): The highest amount of a
nutrient that can be consumed safely with no risk of toxicity
or adverse effects. The UL is used to evaluate the nutrient
content of dietary supplements or review total nutrient
intake from food and supplements. Intakes exceeding the UL
usually result from concentrated supplements, not food.
iv. Estimated Average Requirement (EAR): The average daily
intake of a nutrient that will meet the requirement of 50% of
healthy people of a given age and sex. The EAR is used to
plan and evaluate the nutrient intakes of groups rather than
individuals.
v. Acceptable Macronutrient Distribution Range (AMDR): The
AMDR guides the division of kcalories among carbohydrate,
fat, and protein in ranges supportive of health; carbohydrate
should provide 45% to 65% of total kcalories, fat should
provide 20% to 35% of total kcalories, and protein should
provide 10% to 35% of total kcalories
2. DIETARY GUIDELINES
• provide the basis for nutrition messages and consumer materials
developed by government agencies
• Important dietary concepts in the 2010 Dietary Guidelines
Recommendations:
o Substitute lower calorie, nutrient-dense foods for refined grains
and snack foods high in solid fat and sugar (SoFAS).
o The minerals sodium and potassium are known to have opposite
effects on blood pressure, with potassium blunting the blood-
pressure-raising effect of sodium. All population groups are
encouraged to consume two servings of seafood each week to
obtain important fatty acids, selecting from fish low in mercury
content.
3. FOOD GUIDES
• Food guides are intended to help individuals with day-today meal
planning.
• They provide a practical interpretation of nutrition standards and
dietary guidelines that are useful in daily food selection.
• The most commonly used food group guides are
o USDA (United States Department of Agriculture) MyPlate
(ChooseMyPlate.gov)
o Choose Your Foods: Food Lists for Diabetes
o Pinggang-Pinoy

USDA Food Guide

• the USDA’s food group plan for ensuring dietary adequacy that assigns
foods to five major food groups.

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USDA Food Patterns: Recommended Daily Amounts from Each Food Group

FIGURE 3.1. In the figure above, a person needing 2000 kcalories a day, would select 2
cups of fruit; 2½ cups of vegetables; 6 ounces of grain foods; 5½ ounces of protein
foods; and 3 cups of milk or milk products. Additionally, a small amount of
unsaturated oil, such as vegetable oil or the oils of nuts, olives, or fatty fish, is
required to supply needed nutrients.

MyPlate (ChooseMyPlate.gov)
• icon released in 2010, illustrates the five major food groups using a
familiar mealtime visual—a place setting
• The general themes of MyPlate are eat smaller portions, and choose
lower calorie, nutrient-dense foods.

FIGURE 3.2. MyPlate

Note that vegetables and fruits
occupy half the plate and that the
grains portion is slightly larger than
the portion of protein foods.

Source: USDA,
www.chosemyplate.gov

• Pinggang-Pinoy - A visual too guide for Filipinos that tells how much you
should eat in one meal in order to be healthy

FIGURE 3.3. Pinggang-Pinoy

Source:https://www.fnri.dost.go
v.ph/index.php/tools-and-
standard/pinggang-pinoy

MyPyramid
- The general messages in the MyPyramid symbol are: physical activity, variety,
proportionality, moderation, gradual improvement, and personalization.

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- The specific messages are about healthy eating and physical activity, which
apply to everyone.
- MyPyramid helps consumers find the kinds and amounts of foods they should
eat each day
- Food groups included are:
o Calories and Physical Activity
o Grains
o Vegetables
o Fruits
o Milk, Yogurt, and Cheese
o Meat, Poultry, Fish, Dry
Beans, Eggs, and Nuts
o Fats and Oils
o Sugars and Sweets
o Salt
o Alcohol

FIGURE 3.4. MyPyramid

Source: https://www.fns.usda.gov/mypyramid

See Appendix C for information on Daily Nutritional Guide Pyramid for Filipinos
or you can check this website, https://www.fnri.dost.gov.ph/index.php/tools-and-
standard/nutritional-guide-pyramid for supplementary data.

Food Lists for Meal Planning

• The Food Lists for Diabetes (formerly called the Exchange Lists) were
introduced in 1950 by the American Diabetes Association and the
American Dietetic Association as a meal-planning tool for people with
diabetes
• Choose Your Foods: Food Lists for Diabetes are grouped in three:
1. Carbohydrates: includes starches (grains, starchy vegetables,
crackers, snacks, and legumes), fruits, milk, sweets, and
nonstarchy vegetables.
2. Proteins: includes animal protein foods arranged by fat content
(lean, medium fat, and high fat) and plant-based proteins
3. Fats: includes both animal and plant fats arranged by degree of
saturation—unsaturated (monounsaturated and polyunsaturated)
and saturated.

Food Labels
• appear on virtually all packaged foods, and posters or brochures provide
similar nutrition information for fresh fruits, vegetables, and seafoods
• Contents:
o The Ingredient List
- All packaged foods must list all ingredients on the label in
descending order of predominance by weight
o Nutrition Facts Panel
- provides such information as serving sizes, Daily Values,
and nutrient quantities
- Serving Sizes
• must be based on the amounts of food or beverage
people actually consume, not what they “should”
consume
- The Daily Values
• set adequacy standards for nutrients that are
desirable in the diet such as protein, vitamins,
minerals, and fiber
• set moderation standards for other nutrients that
must be limited, such as fat, saturated fat,
cholesterol, and sodium

Module I
 - Nutrient Quantities
• Nutrition Facts panel must provide the nutrient
amount, percent Daily Value, or both for the
following:
o Total food energy (kcalories)
o Total fat (grams and percent Daily Value)—
note that the proposed revision does not
include kcalories from fat
o Saturated fat (grams and percent Daily
Value)
o Trans fat (grams)
o Cholesterol (milligrams and percent Daily
Value)
o Sodium (milligrams and percent Daily
Value)
o Total carbs, including starch, sugar, and
fiber (grams and percent Daily Value)
o Dietary fiber (grams and percent Daily
Value)
o Sugars, which includes both those naturally
present in and those added to the foods
(grams)
o Added sugars (grams)—note that the
original label does not include a line for
added sugars
o Protein (grams)
o The following vitamins and minerals
(percent Daily Value): vitamin D,
potassium, iron, and calcium
- Front-of-Package Labels
• presentation of nutrient information called
Facts Up Front which provides easier and
quicker way to interpret information and
select product

FIGURE 3.5. This example of front-of-package labeling presents key nutrient facts.

• Claims on Labels
o Nutrient Claims
- statements that characterize the quantity of a nutrient in a
food
- e.g. “rich in calcium” on a package of cheese; “good source
of fiber” on a box of cereal

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FIGURE 3.6. Nutrient

claims characterize the
level of a nutrient in the
food—for example, “fat
free” or “less sodium.”

o Health Claims
- statements that characterize the relationship between a
nutrient or other substance in food and a disease or health-
related condition.
FIGURE 3.7. Health claims
o characterize the relationship
o of a food or food component
o to a disease or health-
o related condition—for
o example, “soluble fiber from
o oatmeal daily in a diet low in
saturated fat and cholesterol
may reduce the risk of heart
disease” or “a diet low in
total fat may reduce the risk
of some cancers.”
o Structure-
o
o
o Function Claims
- statements that describe how a product may affect a
structure or function of the body; for example, “calcium
builds strong bones.” Structure-function claims do not
require FDA authorization
- The only criterion for a structure-function claim is that it
must not mention a disease or symptom

FIGURE 3.8. Structure-

function claims
describe the effect that
a substance has on the
structure or function of
the body and do not
make reference to a
disease—for example,
“supports immunity and
digestive health” or
“calcium builds strong
bones.”

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FIGURE 3.9. Original and proposed nutrition facts panel

Terms Used on Food Labels

General Terms
• Free: “nutritionally trivial” and unlikely to have a physiological consequence;
synonyms include without, no, and zero. A food that does not contain a
nutrient naturally may make such a claim but only as it applies to all similar
foods (for example, “applesauce, a fat-free food”).
• good source of: the product provides between 10 and 19 percent of the Daily
Value for a given nutrient per serving.
• healthy: a food that is low in fat, saturated fat, cholesterol, and sodium, and
that contains at least 10 percent of the Daily Values for vitamin D, iron,
calcium, potassium, protein, or fiber.
• high: 20 percent or more of the Daily Value for a given nutrient per serving;
synonyms include rich in or excellent source of.
• less: at least 25 percent less of a given nutrient or kcalories than the
comparison food (see individual nutrients); synonyms include fewer and
reduced.
• light or lite: one-third fewer kcalories than the comparison food; 50 percent or
less of the fat or sodium than the comparison food; any use of the term other
than as defined must specify what it is referring to (for example, “light in
color” or “light in texture”).
• low: an amount that would allow frequent consumption of a food without
exceeding the Daily Value for the nutrient. A food that is naturally low in a

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nutrient may make such a claim but only as it applies to all similar foods (for
example, “fresh cauliflower, a low-sodium food”); synonyms include little, few,
and low source of.
• more: at least 10 percent more of the Daily Value for a given nutrient than the
comparison food; synonyms include added and extra.
• organic (on food labels): at least 95 percent of the product’s ingredients have
been grown and processed according to USDA regulations defining the use of
fertilizers, herbicides, insecticides, fungicides, preservatives, and other
chemical ingredients.
Energy
• kcalorie-free: fewer than 5 kcalories per serving.
• low kcalorie: 40 kcalories or less per serving.
• reduced kcalorie: at least 25 percent fewer kcalories per serving than the
comparison food.
Fat and Cholesterol
• percent fat free: may be used only if the product meets the definition of low
fat or fat free and must reflect the amount of fat in 100 grams (for example, a
food that contains 2.5 grams of fat per 50 grams can claim to be “95 percent
fat free”).
• fat free: less than 0.5 gram of fat per serving (and no added fat or oil);
synonyms include zero-fat, no-fat, and nonfat.
• low fat: 3 grams or less fat per serving.
• less fat: at least 25 percent less fat than the comparison food.
• saturated fat free: less than 0.5 gram of saturated fat and 0.5 gram of trans
fat per serving.
• low saturated fat: 1 gram or less saturated fat and less than 0.5 gram of trans
fat per serving.
• less saturated fat: at least 25 percent less saturated fat and trans fat
combined than the comparison food.
• trans fat free: less than 0.5 gram of trans fat and less than 0.5 gram of
saturated fat per serving.
• cholesterol free: less than 2 milligrams cholesterol per serving and 2 grams or
less saturated fat and trans fat combined per serving.
• low cholesterol: 20 milligrams or less cholesterol per serving and 2 grams or
less saturated fat and trans fat combined per serving.
• less cholesterol: at least 25 percent less cholesterol than the comparison food
(reflecting a reduction of at least 20 milligrams per serving), and 2 grams or
less saturated fat and trans fat combined per serving.
• extra lean: less than 5 grams of fat, 2 grams of saturated fat and trans fat
combined, and 95 milligrams of cholesterol per serving and per 100 grams of
meat, poultry, and seafood.
• lean: less than 10 grams of fat, 4.5 grams of saturated fat and trans fat
combined, and 95 milligrams of cholesterol per serving and per 100 grams of
meat, poultry, and seafood. For mixed dishes such as burritos and sandwiches,
less than 8 grams of fat, 3.5 grams of saturated fat, and 80 milligrams of
cholesterol per reference amount customarily consumed.
Carbohydrates:
• Fiber and Sugar high fiber: 5 grams or more fiber per serving. A high-fiber
claim made on a food that contains more than 3 grams fat per serving and per
100 grams of food must also declare total fat.
• sugar-free: less than 0.5 gram of sugar per serving.
Sodium
• sodium free and salt free: less than 5 milligrams of sodium per serving.
• low sodium: 140 milligrams or less per serving.

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• very low sodium: 35 milligrams or less per serving

THE NUTRITIONAL GUIDELINES FOR FILIPINOS (NGF)

• The Nutritional Guidelines for Filipinos (NGF) is a set of dietary guidelines
based on the eating pattern, lifestyle, and health status of Filipinos.
• The NGF contains all the nutrition messages to healthy living for all age
groups from infants to adults, pregnant and lactating women, and the
elderly.
• The first NGF released in 1990 was composed of five messages called
“Dietary Guidelines for Filipinos.”
• The 2012 NGF now includes the basis and justification for each of the ten
nutritional and health message.

Below are the new messages of the 2012 NGF:

1. Eat a variety of foods everyday to get the nutrients needed by the body.
- There is no single food that contains all the nutrients that our body
needs so eating a variety of food ensures that daily nutritional needs
are met.
- Based on the said survey, the Filipino household diet fell below the
recommended levels except for niacin, which is above the
recommended.
- all nutrients and energy were below the 100 percent adequacy levels
2. Breastfeed infants exclusively from birth up to six months and then give
appropriate complementary foods while continuing breastfeeding for two
years and beyond for optimum growth and development.
3. Eat more vegetables and fruits to get the essential vitamins, minerals, and
fiber for regulation of body processes.
- There was also a decrease in consumption of fruits from 77 grams in
205 to 54 grams in 2008 and also a decrease in milk consumption from
44 grams to 42 grams.
4. Consume fish, lean meat, poultry, egg, dried beans or nuts daily for growth
and repair of body tissues.
5. Consume milk, milk products, and other calcium-rich food such as small fish
and shellfish, everyday for healthy bones and teeth.
- Vegetables and fruits are the main sources of vitamins, minerals, and
fiber, while milk is a good source of calcium.
6. Consume safe foods and water to prevent diarrhea and other food-and
water-borne diseases.
7. Use iodized salt to prevent Iodine Deficiency Disorders.
- Low urinary iodine excretion is still a prevalent problem among
pregnant and lactating mothers, indicating to low iodine intake. Iodine
is important during pregnancy because it is needed for the brain
development of the infant while lactating mothers must have
adequate supply of iodine in their breastmilk
8. Limit intake of salty, fried, fatty, and sugar-rich foods to prevent
cardiovascular diseases.
- heart diseases ranked first among the causes of death based on the
2005 Department of Health survey
- Salt and soy sauce were among the top 10 widely used miscellaneous
food items used by Filipinos
- Excessive intake of salt and soy sauce can result to high blood pressure
especially to salt-sensitive individuals. Persistent high blood pressure
can result to cardiovascular diseases.

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- High cholesterol level may be attributed to the high consumption of

sodium rich foods by Filipinos
- The total cholesterol level among Filipino adults increased from 8.5
(mg/dL) in 2003 to 10.2 (mg/dL) in 2008.
9. Attain normal body weight through proper diet and moderate physical
activity to maintain good health and help prevent obesity.
- There is also a decreasing trend of physical inactivity among Filipinos
and also a large percentage of Filipino smokers at 31.0% and drinkers
at 26.9%.
10. Be physically active, make healthy food choices, manage stress, avoid
alcoholic beverage, and do not smoke to help prevent lifestyle-related non-
communicable disease.
- People are always encouraged to exercise at least thirty minutes a
day, three to five times a week.
- Limit alcohol drinking to one drink per day for women and two drinks
for men is also advised.
- One alcoholic drink is equivalent to one and half ounce distilled
beverage such as gin or 12 ounces or a bottle of beer or four ounces
wine or half glass wine or an ounce of 100 proof whiskey.

Concept Check!
1. What are the various categories within the DRIs? What is the
purpose of each?
2. Compare nutrient standards, dietary guidelines, and food
guides: (a) list an example of each, (b) the intended audience
(professional or consumer), (c) the type of information
included, and (d) a professional situation in which you would
use it.

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 MODULE SUMMARY

In Module I, you have learned about important nutrition concepts, how food
is processed in the digestive system and the tools and standards used for nutrient
recommendations.

There are three lessons in module I. Lesson I consists of basic nutrition

concepts. Health and malnutrition are defined and overnutrition and undernutrition
are differentiated.

Lesson II entails the process of digestion, the function of each digestive

organ and the enzymes and other substances involved.

Lesson III deals with the nutritional tools and standards, dietary guidelines
and food labels. It defined the four categories of the DRI, the Estimated Energy
Requirement (EER), and the Acceptable Macronutrient Distribution Ranges (AMDR),
and explain their purposes.

Congratulations! You have just studied Module I. now you are ready to
evaluate how much you have benefited from your reading by answering the
summative test. Good Luck!!!

 SUMMATIVE TEST
Multiple Choice

1. Once food is swallowed, it travels through the digestive tract in this order:
a. esophagus, stomach, large intestine, liver.
b. esophagus, stomach, small intestine, large intestine.
c. small intestine, stomach, esophagus, large intestine.
d. small intestine, large intestine, stomach, esophagus.

2. Once chyme travels the length of the small intestine, it passes through the
ileocecal valve at the beginning of the:
a. large intestine.
b. stomach.
c. esophagus.
d. jejunum.

3. An enzyme in saliva begins the digestion of:

a. starch.
b. vitamins.
c. protein.
d. minerals.

4. Bile is:
a. an enzyme that splits starch.
b. an alkaline secretion of the pancreas.
c. an emulsifier made by the liver that prepares fats and oils for digestion.
d. a stomach secretion containing water, hydrochloric acid, and the enzymes
pepsin and lipase.

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5. Which of the following passes through the large intestine mostly unabsorbed?
a. Fiber
b. Vitamins
c. Minerals
d. Starch

6. The two major nutrient transport systems in the body are:

a. LDL and HDL.
b. the digestive and absorptive systems.
c. lipoproteins and chylomicrons.
d. the vascular and lymphatic systems.

7. Within the circulatory system, lipids travel from place to place bundled with
proteins as:
a. microvilli.
b. chylomicrons.
c. lipoproteins.
d. phospholipids.

8. Elevated LDL concentrations in the blood are associated with:

a. a high-protein diet.
b. a low risk of diabetes.
c. regular physical activity.
d. a high risk of heart disease.

9. Three factors that lower the concentration of LDL and raise the concentration of
HDL in the blood are:
a. polyunsaturated fat, rest, and dietary HDL.
b. antioxidants, insoluble fibers, and dietary HDL.
c. saturated fat, antioxidants, and insoluble fibers.
d. weight control, soluble fibers, and physical activity

12. The nutrient standards in use today include all of the following except:
a. Recommended Dietary Allowances (RDA).
b. Adequate Intakes (AI).
c. Daily Minimum Requirements (DMR).
d. Tolerable Upper Intake Levels (UL).

Answer the following questions.

1. What are the factors that influence our food choices?
2. How do we define nutrition? Why is it important to health?
3. What are the 10 guidelines in NGF?

Laboratory Activity

Gather at least 10 food labels with health claims, nutrient claims or

structure-function claims and paste it in a long coupon bond. Choose at least one
(1) food label which you think will benefit you most and why.

Module I
 MODULE II
Classification of Nutrients:
Macronutrients
Lesson 1: Carbohydrates

Lesson 2: Lipids

Lesson 3: Proteins

Lesson 4: Energy Balance

Module II
 2

MODULE II

CLASSIFICATION OF NUTRIENTS: MACRONUTRIENTS

 INTRODUCTION

This module includes lessons on the macronutrients, carbohydrates,

proteins and fats as well as energy balance. Importance, sources deficiency at
excess conditions associated with macronutrients will be discussed.

LEARNING OBJECTIVES

After studying the module, you should be able to:

1. Apply knowledge of physical, social, natural and health sciences,

humanities and other sciences to the principles of nutrition with special
emphasis on macronutrients (carbohydrates, fats, proteins, alcohol, and
energy).
2. Explain the role of macronutrients in maintaining normal body
metabolism and functions as well as in the prevention and treatment of
chronic diseases.

 DIRECTIONS/ MODULE ORGANIZER

There are four lessons in the module. Read each lesson carefully then
answer the exercises/activities to find out how much you have benefited from it.
Work on these exercises carefully and submit your output to your instructor or to
the CCHAMS Office.

In case you encounter difficulty, discuss this with your instructor during the
face-to-face meeting. If not contact your instructor at the CCHAMS office.

Good luck and happy reading!!!

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Lesson 1

 Classification of Nutrients:
Macronutrients

MACRONUTRIENTS
• they are consumed in large amounts
• the three macronutrients are:
1. Carbohydrates
2. Proteins
3. Lipids/Fats
• Nutrients are considered as:
1. Essential nutrient - one that the human body requires but cannot
manufacture in sufficient amounts to meet bodily needs.
2. Nonessential nutrients - not needed in the diet because the body
can make them from other substances like amino acid alanine
3. Conditionally essential nutrients- are those that, under most
circumstances, a healthy body can manufacture in sufficient
quantities but in certain situations of physiological status or disease,
the body cannot produce optimal amounts. The amino acid tyrosine
is an example of a conditionally essential nutrient.

Composition of Nutrients
1. Molecule – the smallest quantity into which a substance may be divided
without loss of its characteristics; Molecules are made of elements. In the
case of water, H2O, the elements are hydrogen and oxygen.
2. Element – a substance that cannot be separated into simpler parts by
ordinary means
3. Atom – the smallest particle of an element that retains its physical
characteristics

Functions of Nutrients:
1. Serve as a source of energy or heat
2. Support the growth and maintenance of tissue
3. Aid in the regulation of basic body processes

CARBOHYDRATES Saccharide comes

• Carbohydrates are organic compounds from the Latin
(saccharides—starches and sugars) composed of word saccharum,
carbon, hydrogen, and oxygen (C6H12O6 or simply which means
CHO). “sugar.”
• Manufactured from green plants during a process
called photosynthesis - In this process, carbon dioxide from the air and
water from the soil are transformed into sugars and starches. Sunlight and
the green pigment chlorophyll are necessary for this conversion.
• Carbohydrates are a main fuel source for some cells, especially those in the
muscles, brain, nervous system, and red blood cells.
• Carbohydrates provide approximately 4 kcal per gram. It is recommended
that 45% t0 65% of the calories we consume each day come from
carbohydrates.

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Concept Check

Why are carbohydrates considered our most valuable energy source?

Classification of Carbohydrates
A. Monosaccharides - single sugar units/simple carbohydrates
1. Glucose – known as the blood sugar in the body or dextrose; the sugar
common to all disaccharides and polysaccharides
2. Fructose – found in fruits and honey; also known as the fruit sugar or
levulose; the sweetest of all sugars
3. Galactose – a product of lactose (milk sugar) digestion
B. Disaccharides – formed when to monosaccharides combine
1. Sucrose – ordinary white table sugar; combined glucose and fructose
2. Maltose – present in malt, malt products, beer, some infant formulas, and
sprouting seeds; consist of two units of glucose
3. Lactose - milk sugar; combined glucose and galactose
▪ Lactose is the only common sugar that is not found in plants.
▪ Lactose Intolerance – inability to digest lactose due to insufficiency
of enzyme lactase.
o Signs/Symptoms: bloating, flatulence, abdominal cramps, and
diarrhea after drinking milk or consuming a milk-based food
C. Polysaccharides – composed of various numbers of monosaccharides and
disaccharides; also called complex carbohydrates
1. Starch - major source of carbohydrate in the diet; derived from digestion of
starch; found primarily in grains, starchy vegetables, and legumes and in
foods made from grains—cereals, breads, and pasta
2. Glycogen – storage form of glucose; animal starch
▪ Glycogen is built up and stored in muscle and the liver when blood
glucose levels are high after infusion from the diet.
3. Fiber – comes mostly from plants; called roughage or bulk, fiber adds
almost no fuel or energy value to the diet
▪ The recommended daily adequate intake (AI) for fiber is based on
14 grams of fiber per 1000 kcalories consumed or:
■ Men: 38 grams ■ Women: 25 grams
▪ Insoluble Fiber – does not dissolve in water
o sources include the woody or structural parts of plants
(lignins), such as fruit and vegetable skins, and the outer
coating (bran) of wheat kernels, cellulose, some
hemicellulose
o promote regularity of bowel movements and reduce the risk
of diverticular disease and some forms of cancer
▪ Soluble Fiber – dissolves in water
o include beans, oatmeal, barley, broccoli, and citrus fruits;
oat bran, gums, pectins, some hemicellulose, and mucilages
o benefits of soluble fibers include reduced cholesterol levels,
regulated blood sugar levels, and weight loss (by helping
dieters control their appetites)

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Let’s Talk About Grains

Whole grain is used for food products such as flours, breads, or

cereals that are produced from unrefined grain. Unrefined grains
retain the outer bran layers, the inner germ, and the endosperm and
thus the nutrients found within (i.e., dietary fiber, vitamins, and
minerals).
Enriched grains are refined grain products to which some (but not
all) vitamins and minerals that were removed during the refining
process—for example, riboflavin, niacin, thiamin, folate, iron—have
been added back to some extent.
Fortified foods are those that have nutrients added to them that
would not naturally occur in that food regardless of how it was
processed (e.g., calcium fortified orange juice).

SPOTLIGHT on Life Cycle

Many adults can benefit from consuming quality fiber in
their meals, as diets high in fiber have been shown to be
beneficial in disease prevention. The possible benefits are
decreased weight and decreases in the risks of colon
cancer, rectal cancer, heart disease (decreases serum
cholesterol levels), dental caries, constipation, and
diverticulosis. To follow a fiber-rich diet, counsel the adult
to:
• Eat fresh foods instead of processed foods.
• Eat whole-grain flour and breads.
• Increase water intake; minimum is 6 to 8 glasses per day.
• Obtain fiber from the diet rather than from supplements.

Functions of Carbohydrates
1. Basic fuel supply
2. Reserve fuel supply
3. Provide fiber - Fiber creates a soft, bulky stool that moves quickly through
the large intestine
4. Lactose remains in the intestine longer than other disaccharides, and this
encourages the growth of the beneficial bacteria, resulting in a laxative
action.
5. Special tissue functions
a. Liver – glycogen stores protect cells from depressed metabolic
function and resulting injury
b. Central Nervous System - Constant carbohydrate intake and
reserves are necessary for the proper functioning of the central
nervous system
c. Protein and fat sparing - protein-sparing action of carbohydrate
protects protein for its major roles in tissue growth and maintenance
- with sufficient carbohydrate for energy, fat is not needed to
supply large amounts of energy, sparing rapid breakdown of fats
which may lead to production of ketones (antiketogenic effect)

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-
Digestion and Absorption of Carbohydrates
• Mouth – Starch is mechanically broken down (mastication/chewing), mixes
with salivary amylase or ptyalin and further broken down into dextrins
• Monosaccharides travel unchanged into the stomach and small
intestines for absorption.
• Stomach – through peristalsis, food particles mix with gastric secretions
including hydrochloric acid which inhibits the action of salivary amylase
• Small Intestines - The chemical digestion of carbohydrate is completed in
the small intestine by specific enzymes from both the pancreas and the
intestine
▪ Enzymes include pancreatic amylase, sucrase, lactase and maltase

Metabolism and Elimination of Carbohydrates

• All carbohydrates are changed to the simple sugar glucose before
metabolism can take place in the cells.
• The process of glucose metabolism is controlled mainly by the hormone
insulin, which is secreted by the islets of Langerhans in the pancreas and
which maintains normal blood glucose at 70–110 mg/dl.
• When insulin production is impaired or high, hyperglycemia or blood
glucose more than 126 mg/dl results
• When blood glucose is low, hypoglycemia or blood glucose less than 70
mg/dl results
• With the exception of cellulose, the only waste products of carbohydrate
metabolism are carbon dioxide and water.

Storage of Carbohydrates
• Stored in limited amounts in liver (glycogen) and muscles
• Most excess is converted and stored as fat in unlimited amounts

Dietary Requirements
• Adults should get 45% to 65% of their calories from carbohydrates.
• Recommended Daily Allowance:
✓ above 1 year: 130 grams CHO/day
✓ pregnant: 175 grams CHO/day
✓ lactating : 210 grams CHO/day
• Minimum intake to prevent ketoacidosis: 50-100 grams CHO/day

Sources of Carbohydrates
1. Starches - whole-grain starches such as rice, wheat, corn, and potatoes
2. Sugars
a. Fruit sugar provides fiber, water, and vitamins
b. Empty Calories - excess added sugar in the diet; examples are
candies, sweets, desserts, soda
3. Milk – the only dietary source of lactose

GLYCEMIC INDEX (GI) AND GLYCEMIC LOAD

Glycemic Index – the ranking of foods according to the level to which a food raises
blood glucose levels compared with a reference food such as a 50-g
glucose load or white bread containing 50 g carbohydrate
- a ranking of 100 is the highest index level – it raises blood glucose the
highest

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- the GI of a food is affected by the following factors:

1. the physical form such as baked potato compared with mashed
potato
2. the fat and protein content in addition to carbohydrate, which slows
digestion
3. the ripeness, such as in fruit and vegetables, which increases glucose
content
4. the fiber content, which slows digestion
5. the botanic variety of a food, such as the different glycemic indexes
of ripe species

Glycemic Load – total glycemic index effect of a mixed meal or dietary plan
- calculated as the sum of the products of glycemic index for each of the
foods multiplied by the amount of carbohydrate in each food calculated
as the sum of the products of glycemic index for each of the foods
multiplied by the amount of carbohydrate in each food

Limiting consumption of foods that produce a high GL and overall high glycemic
load reduces the risk of chronic diseases, cardiovascular diseases and diet-
related cancers of the colon and breast.

Alternative Sweeteners
1. Sugar Alcohols/Nutritive Sweeteners
• are absorbed more slowly and do not
increase the blood sugar level as rapidly LOW-CARBOHYDRATE DIETS
as glucose MIGHT DAMAGE KIDNEYS
• provide 2 to 3 kcal/g as compared with
other carbohydrates, which provide 4 In a recent study,
kcal/g participants came into this
• Sorbitol – alcohol form of sucrose; used research project having eaten
as a sucrose substitute in various foods,
their normal diet and were
candies, chewing gum, and beverages
then severely restricted in
• Mannitol – alcohol form of mannose
carbohydrates for 2 weeks
• Xylitol – alcohol from of xylose
• The downside of using excessive
followed by 4 weeks of eating
amounts of sugar alcohols in food a moderate carbohydrate diet
products is that the slowed digestion while increasing their protein
may result in osmotic diarrhea. intake. Researchers found
2. Nonnutritive Sweeteners that a low
• specifically manufactured to be used as carbohydrate–high-protein
alternative or artificial sweeteners in diet increases the acid load
food products to the kidneys, thus causing
• they provide the sweet taste without damage.
contributing to an individual’s total
energy intake (Source: Adapted from Chait,
• most commonly used are acesulfame-K, 2003.)
aspartame (Equal), luohan guo (monk
fruit extract), neotame, saccharin,
stevia, and sucralose

Health Implications
Included among the associations of sugar and other carbohydrates and
health problems are the following:

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1. Obesity – Sugar is often named as being the cause of obesity but it is probably
an overall excess intake rather than sugar alone
2. Cardiovascular disease – Except for certain types of lipid disorder, in which an
individual exhibits abnormal glucose tolerance along with an elevation of blood
triglycerides, research studies cannot prove any correlation between sugar
intake and cardiovascular disorder. In contrast, consumption of whole grain rich
carbohydrates can protect an individual against heart disease and stroke.
3. Diabetes – heredity and obesity plays a role in pancreatic malfunction and
increased sugar intake increases the risk of developing diabetes. In contrast, a
high-carbohydrate (complex) and low-fat diets help control weight.
4. Dental caries – sugar contributes to development of dental caries. Good oral
hygiene prevents dental caries.
5. Cancer – heavy use of saccharine is increases risk of bladder cancer. In
contrast, high fiber diet and carbohydrates rich in whole grains can help
prevent many types of cancer.
6. Fiber – Low-fiber diets are believed to play a major role in the onset of
diverticulosis and may contribute to appendicitis. Dietary fibers enhance the
health of large intestine.
7. Nutrient Deficiency – empty calories provide glucose and energy but with few
other nutrients

Recommended Sugar Intakes

• The USDA Food Patterns suggest about 8 teaspoons of sugar, about the
amount in one 12-ounce soft drink
• World Health Organization agrees that people should restrict their
consumption of added sugars to less than 10 percent of total energy and
that reducing added sugar intake to less than 5 percent of total energy
would have additional health benefits.

Review
Multiple choice. Select the letter that precedes the best answer.
1. The three main groups of 3. The simple sugar to which all forms
carbohydrates are of carbohydrates are ultimately
converted is
a. fats, proteins, and minerals
b. glucose, fructose, and galactose a. sucrose
c. monosaccharides, disaccharides, b. glucose
and polysaccharides c. galactose
d. sucrose, cellulose, and glycogen d. maltose

2. Galactose is a product of the 4. A fibrous form of carbohydrate that

digestion of cannot be digested is

a. milk a. glucose
b. meat b. glycogen
c. breads c. cellulose
d. vegetables d. fat

5. Glycogen is stored in the

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a. heart and lungs 11. Insoluble dietary fiber

b. liver and muscles
c. pancreas and gallbladder a. can increase blood glucose
d. small and large intestines b. can decrease blood cholesterol
c. commonly causes diverticular
6. Glucose, fructose, and galactose disease
are d. is preferably provided by
commercially prepared fiber products
a. polysaccharides
b. disaccharides 12. The enzyme in the mouth that
c. enzymes begins the digestion of starch is
d. monosaccharides
a. salivary ptyalin
7. Before carbohydrates can be b. salivary amylase
metabolized by the cells, they must c. sucrase
be converted to d. lipase

a. glycogen 13. Cellulose is

b. glucose
c. polysaccharides a. not digestible by humans
d. sucrase b. not to be included in the human
diet
8. The only form of carbohydrate that c. a monosaccharide
the brain uses for energy is d. an excellent substitute for
dextrose
a. glycogen
b. galactose 14. Carbohydrates
c. glucose
d. glucagon a. are rich in fat
b. are generally expensive
9. Substances to which fatty acids are c. should provide approximately half
broken down in the liver are of the calories in the our diet
d. frequently are an excellent
a. galactose substitute for proteins in the human
b. estrogen diet
c. thyroxin
d. ketones 15. Glucose metabolism is

10. Starch is a. controlled mainly by the hormone

a. the form in which glucose is stored
in plants
b. a monosaccharide
c. an insoluble form of dietary fiber
d. found only in grains
insulin
b. not affected by any secretion of
the islets of Langerhans in the
pancreas
c. managed entirely by glucagon
d. not related to human energy levels

Laboratory Activity
Search the Web for information on carbohydrate-reducing diets and
products. Is the information provided at these sites accurate? If a client came to
you with questions about a product such as these, how would you respond? Create
a fact sheet that lists myths surrounding carbohydrates and the facts that dispel
the myths.

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Lesson 2

 LIPIDS

LIPIDS/FATS
• Fats are a concentrated fuel source for the human energy system.
• A large amount of energy can be stored in a relatively small space within
adipose tissue as compared with carbohydrates that are stored as glycogen.
• In food, fats occur in the form of either solid fat or liquid oil. Fats are not
soluble in water, and they have a greasy texture.
• Fat is a member of the class of compounds called lipids.
• Lipids comes from Greek word “lipos” meaning fat.
• Fats, like carbohydrates contain carbon, hydrogen and oxygen but the
proportion of oxygen to carbon and hydrogen is lower in fats.
• Fats provide approximately 9 kilocalories per gram.
.
Composition of Fats
1. Glycerides - the chemical group name for fats; fats are formed from a glycerol
base with one, two, or three fatty acids attached to make monoglycerides,
diglycerides, and triglycerides, respectively; glycerides are the principal
constituents of adipose tissue, and they are found in animal and vegetable fats
and oils
2. Fatty acids - the major structural components of fats; attached to glycerol
• Glycerol is derived from a water-soluble form of carbohydrates
• Most natural fats, whether in animal or plant sources, have three fatty
acids attached to their glycerol base, thus the chemical name of
triglyceride.
Classification of Fats/Lipids
A. Simple Lipids – also called neutral fats; includes fats and oils
• The chemical name for these basic fats is triglycerides
B. Compound Lipids – are various combinations of fats with other components
• Three types:
a. Phospholipid – compounds of fatty acids, phosphoric acids, and
nitrogenous bases.
1. Lecithins – most widely distributed of phospholipids. Traces
are placed in liver and egg yolk and in raw vegetable oils such
as corn oil. They are added to food products such as cheese,
margarine, and confections to aid emulsification
2. Cephalins – are needed to form thromboplastin for the blood
clotting process
3. Sphingomyelins are found in the brain and other nerve
tissues as components of myelin sheath
* Egg yolk and liver are good sources of theses
phospholipids.
2. Glycolipids – are compounds of fatty acids combined with
carbohydrates and nitrogenous bases.
a. Cerebrosides – components of nerve tissue and certain
cell membranes where they play a vital role in fat
transport. Their carbohydrate component is galactoise.

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b. Gangliosides – are made up of certain glucose, galactose

and a complex compound containing an amino sugar.
2. Lipoproteins - lipids combined with proteins. They are formed
primarily in the liver and are found in cell organelle membranes,
mitochondria, and lysosomes. They are insoluble in water and are
combined in protein complex for their transport and activity in
aqueous medium. They contain cholesterol, neutral fat, and fatty
acids.
• Four Groups of Lipoproteins:
i. Chylomicrons - Transport exogenous triglycerides from
intestines to blood stream; Formed in small intestine; present
in blood only after a meal
ii. Low Density Lipoproteins (LDL) - carry fat and cholesterol to
cells; major culprit of cardiovascular diseases; contain 60%–
70% of the total serum cholesterol
iii. High Density Lipoproteins (HDL) - carry free cholesterol
from body tissues to the liver for breakdown and excretion;
contain 20%–30% of the total cholesterol
iv. Very Low Density Lipoproteins (VLDL) - largely composed of
triglycerides, contain 10%–15% of the total serum cholesterol;
delivers endogenous triglycerides to cells and tissue
throughout the body
v. Intermediate Density Lipoproteins (IDL) – like VLDL, it
delivers endogenous triglycerides to cells and tissue
throughout the body (after VLDL degradation)

Concept Check!
From the groups of lipoproteins, which of them is considered the
“good cholesterol” and the “bad cholesterol”?

C. Derived Lipids – simple derivatives from fat digestion or other complex

products. They are fat substances produced from fats and fat compounds during
digestive breakdown.
1. Fatty Acids – they key refined fuel forms of fat that the cell burns
for energy. They are the basic structural units of fat and may be
saturated of unsaturated in nature.

Degree of saturation of fatty acids:

a. Saturated fatty acids - filled with as many hydrogen atoms
as the carbon atoms can bond with and has no double bonds
between carbons; makes fat harder and solid at room
temperature; most are animal origin
b. Unsaturated fatty acid - a fatty acid with one or more
points of unsaturation where hydrogen atoms are missing;
less heavy and less dense making it liquid at room
temperature; mostly plant origin
i. Monounsaturated fatty acids (MUFA)– a fatty acid
with only one carbon-to-carbon double bond; e.g.
oleic acid found in olive oil, other vegetable oils
ii. Polyunsaturated fatty acid (PUFA)- a fatty acid
with more than one carbon-to-carbon bond; e.g.
linoleic acid and linolenic acid (fish oil)

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c. Trans-fatty acid - Composed of partially hydrogenated

fatty acids; artificial fats with trans configuration
detrimental to health
• Trans-fat raises LDL, lowers HDL and produces
inflammation – poses risk to the health of the heart and
arteries
• naturally occurring trans fats are unlikely to have
adverse effects on blood lipids and may even have
health benefits
• Foods high in trans-fat:
▪ Commercially baked goods
▪ Fried foods in restaurants
▪ Hard margarines and shortenings
▪ Crackers
▪ Biscuit and some cake mixes
▪ Some candy
▪ Animal crackers and cookies
▪ Frozen waffles and pancakes
▪ Microwave popcorn

Hydrogenation - a chemical process by which hydrogen atoms are added

to monounsaturated or polyunsaturated fats to reduce the number of
double bonds, making the fats more saturated (solid) and more resistant
to oxidation (protecting against rancidity). Hydrogenation produces
trans-fatty acids.
• Advantages:
1. it protects against oxidation (thereby prolonging shelf life)
2. alters the texture of foods by increasing the solidity of fats
• Disadvantage:
1. It makes polyunsaturated fats more saturated, any health
advantages of using polyunsaturated fats instead of saturated
fats are lost with hydrogenation.
• When partially hydrogenated, vegetable oils become spreadable
margarine. Hydrogenated fats make piecrusts flaky and puddings
creamy

Essential Fatty Acids

• Fatty acids which cannot be synthesized by the body and thus
obtained from food.
• Both essential fatty acids serve important functions related to
tissue strength, cholesterol metabolism, muscle tone, blood
clotting, and heart action.
• They are precursors of eicosanoids, a group of important
metabolites which regulate vascular function, one of these are
prostaglandins.
• Deficiency of EFAs: diarrhea, flaky skin, development of itchy
sores on scalp, hair loss and retardation of growth

Two Essential Fatty Acids:

1. Linoleic Acid: An Omega-6 Fatty Acid
- found in the seeds of plants and in the oils produced
from the seed (except coconut oil)
- has major role in the transport and metabolism of
cholesterol

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- prolongs blood clotting time, hasten fibrolytic

activity, and are involved in brain development
2. Linolenic Acid and other Omega-3 Fatty Acid
- belongs to a family of polyunsaturated fatty acids
known as omega-3 fatty acids, a family that also
includes EPA (eicosapentaenoic acid) and DHA
(docosahexaenoic acid)
- EPA and DHA, found primarily in fish oils and also in
human milk, are needed for eye and brain
development and are also essential in the prevention
and treatment of heart disease
- Sources: Green leafy vegetables, cabbage and lettuce,
fatty fish, such as tuna, sardines and salmon
2. Glycerol – a water-soluble component of triglycerides and is
inconvertible with carbohydrate. After it becomes broken off in
digestion, it becomes available for the formation of glucose in the
diet.
3. Sterols – are subgroup of steroids; they are large, complex molecules
consisting of interconnected rings of carbon;
• Phytosterols – sterols made by plants
• Zoosterols – sterols produced by animals
• Three sterols with functions associated with nutrition are
Ergosterol, a plant sterol, 7-dehydrocholesterol, an animal
sterol and Cholesterol, the most significant animal sterol.
• Ergosterol and 7-dehydrocholesterol are two precursors of
vitamin D.
What is Cholesterol? ➢
➢ The most important zoosterol
➢ Cholesterol is vital to membranes; it is a precursor for some hormones,
and it plays other important roles in human metabolism.
➢ sources of cholesterol are egg yolks, organ meats (e.g., liver, kidney),
and other meats
➢ the human body synthesizes endogenous cholesterol in many body
tissues, particularly in the liver as well as in small amounts in the
adrenal cortex, the skin, the intestines, the testes, and the ovaries
➢ Each day our liver makes about 800 mg of cholesterol, which circulates
through the blood stream and is used wherever it is needed.
➢ The hormones made from cholesterol include corticosteroids,
estrogens, testosterone and calcitriol (the active vitamin D hormone).
Bile acids needed for fat digestion, are formed from cholesterol.
➢ Fat should not be restricted in the diet of children up to five years of
age, because cholesterol is also needed for the formation brain tissue.
➢ Cholesterol can be harmful to the body when it forms deposits in the
artery walls, a condition called atherosclerosis.

Concept Check!
What is the difference between fats and oils?

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Functions of Fats
Fat in Foods
1. Energy. Being the most concentrated source of energy (9 kcal/g),fats also
provide much of the energy to fuel muscular work.
2. Essential Nutrients. Dietary fat supplies the body with the essential fatty acids
(linoleic and alpha-linolenic acid). Also, foods high in fat are generally a good
source of fat-soluble vitamins.
3. Flavor and Satisfaction. Fat in the diet adds flavor to foods and contributes to
a feeling of satiety after a meal.
4. Fat Substitutes. Several fat substitutes, which are compounds that are not
absorbed and thus contribute little or no kilocalories, are available to provide
improved flavor and physical texture to low-fat/fat-free foods and to help
reduce total dietary fat intake
5. Transport. Fats carry fat-soluble vitamins A, D, E, and K along with some
phytochemicals and assist in their absorption.

Fat in the Body

1. Adipose Tissue. A weblike padding of fat tissue supports and protects vital
organs, and a layer of fat directly under the skin is important for the regulation
of body temperature.
2. Cell Membrane Structure. Fat forms the fatty center of cell membranes,
thereby creating the selectively permeable lipid bilayer. In addition, the
protective myelin sheath that surrounds neurons is largely composed of fat.
3. Raw materials. Fats are converted to other compounds, such as hormones,
bile, and vitamin D, as needed.
4. Lubrication. The human body manufactures oil in structures called sebaceous
glands. Secretions from the sebaceous glands lubricate the skin to retard loss of
body water to the outside environment.

Digestion, Absorption and Storage of Fats

• Mouth – lingual lipase, an enzyme secreted by Ebner’s gland initiates fat
breakdown in infants. In adults, only mechanical process, (chewing) happen
with fats.
• Stomach - General muscle action continues to mix the fat with the stomach
contents. Gastric lipase (tributyrinase) acts on emulsified butterfat
• Small Intestines - Fat digestion largely occurs in the small intestine, where
the major enzymes that are necessary for the chemical changes are
present. These digestive agents come from three major sources: an
emulsification agent from the gallbladder and two specific enzymes from
the pancreas and the small intestine itself.
o Bile acts as emulsifier
o Pancreatic lipase breaks of one fatty acid at a time from glycerol
o Cholesterol esterase acts on cholesterol esters (not free
cholesterol) to form a combination of free cholesterol and fatty
acids in preparation for absorption into the lacteals (lymph vessels)
and finally into the bloodstream
o Lecithinase breaks down lecithin for absorption
• The products of digestion, fatty acids, monoglycerides, and glycerol are
absorbed through the walls of the small intestine and circulated through the
lymph. Some of these are used to synthesize important lipid compounds
needed for body function. Some fat is used to supply energy. The rest is
stored as fat in the adipose tissues for future use.

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Metabolism and Elimination of Fats

• Lipid metabolism entails oxidation of fatty acids to either generate energy
(lipolysis) or synthesize new lipids
• If carbohydrates are low, fats undergo oxidation to produce ketone bodies
(ketogenesis) to serve as fuel source in place of glucose. This happens
during prolonged starvation and in patients with uncontrolled diabetes.
Ketones are broken down into CO2 and acetone – causing acetone breath
and diabetic ketoacidosis, a dangerous condition in diabetics.
• Some fats are partially digested; the rest pass through unchanged, exiting in
feces.

Dietary Requirements
• The current DRIs recommend that the fat content of the diet not exceed
35% of the total kilocalories, that less than 10% of the kilocalories come
from saturated fats, and that dietary cholesterol be limited to a maximum
of 300 mg/day.
• The DRI for linoleic acid, which is found in polyunsaturated vegetable oils,
is set at 17 g/day for men and 12 g/day for women.
• The recommendation for alpha-linolenic acid intake is 1.6 and 1.1 g/day for
men and women, respectively.

Guidelines for Dietary fat Intake:

1. Consume less than 10% of calories from saturated fatty acids by replacing them
with unsaturated fatty acids.
2. Consume as little dietary cholesterol as possible while consuming a healthy
eating pattern.
3. Keep trans-fatty acid consumption as low as possible by limiting foods that
contain synthetic sources of trans fats (e.g., partially hydrogenated oils) and by
limiting other solid fats.
4. Choose fat-free or low-fat milk and milk products.
5. Choose protein foods that are lean and nutrient dense.
6. Use oils to replace solid fats where possible.

Food Sources of Fats:

1. Animal Fats – supplies mostly saturated fats
• Meat fats (bacon, sausage, lard)
• Dairy fats (cream, ice cream, butter, cheese)
• Egg yolk
2. Plant Fats – supplies monounsaturated and polyunsaturated fats
• vegetable oils (e.g., safflower, corn, cottonseed, soybean, peanut, olive)
• coconut and palm oil supplies saturated fats
• avocado
Other sources:
Saturated fats
• whole milk and products made from whole milk; chocolate; regular
margarine; and hydrogenated vegetable shortenings
Unsaturated fats
• fatty fish such as mackerel, salmon, and herring; olive oil and most nuts

Characteristics of Food Fat Sources

• Visible Fats - obvious fats are easy to see and include butter, margarine,
separate cream, salad oils and dressings, lard, shortening, fatty meats

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(e.g., bacon, sausage, salt pork), and the visible fat of any meat. Visible
fats are easier to control in the diet than those that are less apparent.
• Invisible Fats - include cheese, the cream portion of homogenized milk,
nuts, seeds, olives, avocados, and lean meat. Basically, invisible fats are
those that you cannot cut out of the food

`Health Implications
1. Cardiovascular Disease. Higher blood concentration of LDL and low blood
concentration of HDL signifies higher disease risk. High LDL comes from high
intake of saturated fats and trans fat. Cholesterol in foods contributes less
of a risk.
• LDL is known as the “bad cholesterol” and HDL as the “good
cholesterol”.
2. Cancer. Fat does not instigate cancer development but can promote it once
it has risen.
3. Obesity. High-fat diets tend to store body fat ably.
4. Fish, not fish oil supplement, is the preferred source of omega-3 fatty
acids. High intakes of omega-3 polyunsaturated fatty acids may increase
bleeding time, interfere with wound healing, raise LDL cholesterol, and
suppress immune function.

Concept Check!
Now that you have learned about the unhealthy effects of fat
intake, would you restrict fat in your diet?

Review
Multiple choice. Select the letter that precedes the best answer.
1. Margarine usually is made by a b. omega-6 fatty acids.
process called _____, in which
c. omega-9 fatty acids.
hydrogen atoms are added to carbon-
carbon double bonds in the d. prostacyclins.
polyunsaturated fatty acids found in
vegetable oils.
3. Cholesterol is

a. saturation
a. an essential nutrient.
b. esterification
b. found in foods of plant origin.
c. isomerization
c. an important part of human cell
d. hydrogenation membranes.
d. all of the above.
2. Fatty acids that cause a decrease
in blood clotting are
4. Which of the following groups of
foods are rich sources of saturated
a. omega-3 fatty acids. fatty acids?

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b. HDL
a. Olive oil, peanut oil, canola oil c. Chylomicrons
b. Palm oil, palm kernel oil, coconut d. Cholesterol
oil
c. Safflower oil, corn oil, soybean oil
8. High blood concentrations of _____
d. All of the above decrease the risk for cardiovascular
disease.

5. Lipoproteins are important for

a. transport of fats in the blood and
lymphatic system.
b. synthesis of triglycerides.
c. synthesis of adipose tissue.
d. enzyme production.
6. Which of the following foods is the
best source of omega-3 fatty acids?
a. Fatty fish
b. Peanut butter
c. Lard and shortenings
d. Beef and other red meats
a. low-density lipoproteins
b. chylomicrons
c. high-density lipoproteins
d. cholesterol
9. Phospholipids such as lecithin are
used extensively in food preparation
because they
a. provide the agreeable feel of fat
melting on the tongue.
b. are excellent emulsifiers.
c. carry fat-soluble vitamins.
d. impart delicate flavors.

10. The main form of lipid found in

7. Immediately after a meal, newly the food we eat is
digested and absorbed dietary fats
appear in the lymph and then the
blood as part of which of the a. cholesterol.
following?
b. phospholipids.
c. triglycerides.
a. LDL
d. plant sterols.

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Lesson 3

 PROTEINS

PROTEINS
• Proteins are the basic material of every body cell.
• An adequate supply of proteins in the daily diet is essential for normal growth
and development and for the maintenance of health.
• The term protein is of Greek word “protos” meaning “of first importance.”
• Like fats and carbohydrates, it contains carbon, hydrogen and oxygen. In
addition, and most important, they are the only nutrient group that contains
nitrogen.
• Proteins contain 4 kilocalories per gram.

Composition of Proteins
• Amino acids
- building blocks of protein
- amino refers to compounds that contain nitrogen
- each contains an amino group, an acid group, a hydrogen atom, and a
distinctive side group, all attached to a central carbon atom.
- Dipeptides contain two amino acids; Tripeptides contain three amino
acids; Polypeptides contain four or more amino acids
- A single protein may consist of a polypeptide comprising from 50 to
thousands of amino acids

Classification of Amino Acids

a. Indispensable/Essential - the nine amino acids that must be obtained from
the diet because the body does not make adequate amounts to support body
needs.
1. Histidine 6. Phenylalanine
2. Isoleucine 7. Threonine
3. Leucine 8. Tryptophan
4. Lysine 9. Valine
5. Methionine
a. Dispensable - amino acids that the body can synthesize from other amino
acids that are supplied through the diet and thus do not have to be consumed
on a daily basis.
1. Alanine 4. Glutamic acid
2. Asparagine 5. Glycine
3. Aspartic acid 6. Serine
b. Conditionally indispensable - amino acids that are normally considered
dispensable amino acids because the body can make them; however, under
certain circumstances (e.g., illness), the body cannot make them in high
enough quantities, and they become indispensable (cannot do without) in the
diet.
1. Arginine 4. Proline
2. Cysteine 5. Tyrosine
3. Glutamine

Classification of Proteins
a. Complete/Incomplete Proteins

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1. Complete proteins
• are foods that supply all nine essential amino acids in sufficient
quantity to maintain tissue and support growth
• come from animal sources such as meat, poultry, fish, eggs, milk,
and cheese
• Soybeans are one plant source of complete protein
2. Incomplete proteins
• lack one or more of the essential amino acids
• Grains, vegetables, legumes, nuts, and seeds contain incomplete
protein
• Different types of plant foods can be combined to provide all the
essential amino acids

The Vegetarian Diet

1. Lacto-vegetarians: These vegetarians accept only dairy products from
animal sources to complement their basic diet of plant foods. The use of
milk and milk products (e.g., cheese) with a varied mixed diet of whole or
enriched grains, legumes, nuts, seeds, fruits, and vegetables in sufficient
quantities to meet energy needs provides a balanced diet.
2. Ovo-vegetarians: The only animal foods included in the ovo-vegetarian diet
are eggs. Because eggs are an excellent source of complete proteins,
individuals who are following this diet do not have to be overly concerned
with complementary proteins if eggs are consumed consistently.
3. Lacto-ovo-vegetarians: These are vegetarians who follow a food pattern
that allows for the consumption of dairy products and eggs. Their mixed
diet consists of plant and animal food sources that exclude meat, poultry,
pork, and fish only.
4. Vegans: Vegans follow a strict vegetarian diet and consume no animal
foods. Their food pattern consists entirely of plant foods (e.g., whole or
enriched grains, legumes, nuts, seeds, fruits, vegetables). The use of
soybeans, soy milk, soybean curd (tofu), and processed soy protein products
enhances the nutritional value of the diet. Careful planning and sufficient
food intake ensure adequate nutrition.

Health Benefits and Risk

Some of the most notable benefits of vegetarianism include the following:
• Lower levels of dietary saturated fat and cholesterol consumption
• Higher intake of fruits, vegetables, whole grains, nuts, soy products, fiber,
and phytochemicals
• Lower prevalence of obesity
• Better lipid profiles and lower rates of death from cardiovascular disease,
including ischemic heart disease and hypertension
• Lowered risk of renal disease from high glomerular filtration rates as
compared with long-term high animal protein intake
• Effective management of type 2 diabetes and lowering of the risk for
developing type 2 diabetes and some forms of cancer (e.g., prostate,
gastrointestinal tract, female specific cancer)
• Overall, better quality diet for macronutrient and micronutrient intake as
indicated by the Healthy Eating Index
• Other possible benefits include a lowered risk of dementia, diverticulitis,
and gallstones

b. Simple, Conjugated, Derived Proteins

1. Simple Proteins

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• yield only amino acids on hydrolysis

• includes the following:
o Albumins – soluble in water and coagulated by heat
o Globulins – insoluble in water, soluble in dilute salt solution, and
coagulated by heat
o Glutelins – insoluble in neutral solvents but soluble in weak acids
and alkalis; they are coagulated by heat
o Prolamins – soluble in 70% to 80% alcohol but insoluble in absolute
alcohol, water, and salt solutions
o Albuminoids – insoluble in all neutral solvents and in dilute acids and
alakalis
o Histones and protamines – basic polypeptides; soluble in water but
not coagulated by heat; they are found in the nuclei of cells
2. Conjugated Proteins
• combinations of simple proteins with non-protein substances
• Includes the following:
o Lipoproteins - (proteins + lipids) found in blood plasma (HDL, LDL,
VLDL, etc.).
o Nucleoproteins - (proteins + nucleic acids) found in cells (RDA,
DNA).
o Mucoproteins and glycoproteins - (proteins + polysaccharides)
found in gastric secretion (mucin).
o Phosphoproteins - (proteins + phosphoric acid) are found in milk,
e.g., casein.
o Metalloproteins - (proteins + metals) are found in ferritin,
hemosidirin.
o Chromoproteins – proteins and non-protein pigments found in in
flavoproteins, hemoglobin and cytochromes
3. Derived Proteins
• Products formed in the various stages of hydrolysis of a protein molecule
• proteoses, peptones and peptides formed in the various stages of
protein metabolism.

Functions of Proteins in the Body

1. Provision of Structure
• Contractile proteins, actin and myosin, are found in skeletal, smooth, and
cardiac muscles.
• Fibrous proteins, such as collagen, elastin, and keratin, are found in blood
vessels, bone, cartilage, hair, nails, tendons, skin, and teeth
2. Maintenance and Growth
• Anabolism and Catabolism
o Anabolism is the building up of tissues as occurs in growth or healing.
o Catabolism is the breaking down of tissues into simpler substances that
the body can reuse or eliminate
o tissue proteins are constantly being broken down into amino acids,
which are then reused for building new tissue and repairing old tissue
o Protein Turnover - The process by which cells break down old proteins
and resynthesize new proteins. In this way, the cell will have the
proteins it needs to function at that time.
o Only the brain resists protein breakdown.
o Excess protein in the diet does not enhance the synthesis of these body
components, but eating too little protein can prevent it.
• Nitrogen Balance

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oA person is in nitrogen equilibrium or nitrogen balance when the amount

of nitrogen taken in equals the amount excreted
o Positive Nitrogen Balance
▪ A person consumes more nitrogen than he or she excretes
▪ The body is building more tissue than it is breaking down, a normal
state during periods of growth such as infancy, childhood,
adolescence, and pregnancy.
o Negative Nitrogen Balance
▪ A person consumes less nitrogen than he or she excretes
▪ a person is receiving insufficient protein and/or the body is breaking
down more tissue than it is building
▪ Situations marked by negative nitrogen balance include
undernutrition, illness, and trauma
3. Regulation of Body Processes
• Hormones
o chemicals secreted directly into the bloodstream by various organs to
regulate body processes
▪ Insulin and glucagon are two important hormones that help control
glucose metabolism
▪ The hormone melatonin that influences sleep–wake cycles is
produced in the brain from the amino acid tryptophan
• Enzymes
o protein catalysts that facilitates chemical reactions without itself being
changed in the process

EXAMPLES OF ENZYMES AND HORMONES

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• Nucleoproteins
o regulatory complexes are located in the cell nucleus, where they direct
the maintenance and reproduction of the cell.
o Deoxyribonucleic acid (DNA) and ribonucleic acid (RNA) are
nucleoproteins that control the protein synthesis in the cell
▪ A gene is a part of the DNA that carries the code to direct the
synthesis of a single protein. The kinds of proteins the cell makes
vary with the nature of the cell—for example, whether an intestinal
or skin cell or an ovum or sperm cell.
4. Immunity
• Antibody
o A protein produced in the body in response to the presence of a foreign
substance or a substance that the body senses to be foreign (antigen)
o The body designs an antibody that neutralizes the harmful effects of a
particular species or strain of organism.
5. Circulation
• Albumin
o The main protein in blood which maintain blood volume by drawing fluid
back into the veins from body tissues
o Proteins, such as albumin, act as buffers, maintaining the acid–base
balance of the blood and body fluids by gathering up extra acid
(hydrogen) ions when there are too many in the surrounding medium and
by releasing them when there are too few
▪ Acidosis (excess acid in blood) or alkalosis (excess of base) causes
proteins to undergo denaturation, where proteins loses its shape
and ability to function
• Lipoproteins
o Proteins attached to fats to facilitate movement of lipids in the
bloodstream
• Hemoglobin
o A transport protein, the oxygen-carrying part of the red bl;ood cell;
globin part is a protein
6. Energy Source
• When the body has insufficient glucose available for nervous system energy
needs, the body will utilize body protein tissue to meet the energy needs of
the brain and spinal cord.
• Gluconeogenesis – derivation of glucose from other sources such as fats and
proteins
• Adequate carbohydrate intake is necessary to:
a. Spare protein for its unique contribution to tissue building
b. Avoid the undesirable consequences—ketosis and muscle loss—of
obtaining energy from the less efficient sources: fat and protein
• Loss of more than about 30% of body protein is likely to be fatal due to
reduced muscle strength for breathing, impaired immune function, and
decreased organ function.

Digestion and Absorption

• Mouth – only mechanical mastication
• Stomach
a. pepsin is activated by hydrochloric acid from pepsinogen and converts
protein into proteoses and peptones
o In infants, enzyme rennin converts casein into coagulated curd
• Small Intestine
a. Pancreas

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i. Trypsin – activated by enetrokinase from trypsinogen and converts

proteins into proteoses and peptones into polypeptides and peptides
ii. Chymotrypsin - activated by trypsin from chymotrypsinogen and
converts proteoses and peptones into polypeptides and dipeptides;
also coagulates milk
iii. Carboxypeptidase – activated by trypsin from procarboxypeptidase
and converts polypeptides into simpler peptides, dipeptides and
amino acids
b. Intestine
i. Aminopeptidase converts polypeptides into peptides and amino
acids
ii. Dipeptidase converts dipeptides into amino acids

• The amino acids formed are absorbed either by the stomach wall, the
intestinal walls or by the colon. Most of the amino acids are, however,
absorbed in the small intestine. After passing through the walls of the
digestive tract, the amino acids are picked up by the circulating blood
stream and transported to the liver and to the various body tissues.
Metabolism and Elimination
• Some of the amino acids are split off by a process known as deamination.
The nitrogenous byproducts, if not utilized, are excreted in urine as urea,
uric acid and creatinine.
Storage
• Proteins in the form of amino acids are the building blocks of the body.
Protein as such is not stored; therefore, a daily intake is required.

Protein Quality
• Protein quality depends on the kinds and amounts of the essential amino
acids present in the food proteins.
• Various foods when eaten together in a meal, complement each other and
improve the quality of protein supplied to the body.
Measurement of Protein Quality
1. Biological Value (BV): the percentage of the absorbed nitrogen (N) retained by
the body; it measures the effectiveness of protein quality in supporting the
body’s needs
• Eggs, with a BV of 100, have the highest quality of any dietary proteins.
Milk, at 93, follows a close second.
• Most meats, fish, and poultry have a BV of about 75.
• Any BV of 70 or above is considered sufficient for sustaining growth and
maintenance of body tissue.
2. Net Protein Utilization (NPU): digestibility of protein multiplied by its BV;
measures how capably a protein is used by the body; NPU measures retention of
food nitrogen consumed while BV measures food nitrogen absorbed
3. Protein Efficiency Ratio (PER): measures the increase in weight of a growing
animal and compares it with intake
4. Chemical Score: Chemical score is based on the comparison of amino acid
composition of the food protein with the amino acid of a reference protein such
as milk, egg or FAO reference protein

Dietary Requirements
• Children and adults should obtain 10% to 35 % of their caloric intake from
proteins

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• Dietary recommendations are higher for infants and for pregnant and
breastfeeding women in order to meet metabolic needs.
o Pregnant – 66 grams/day
o Lactating – 81 grams/day for first 6 months and 76 grams/day for
the next 6 months
o Infants – 9 grams/day from birth to 6 months and 14 grams/day
for 6 months to 12 years

The figure above shows the metabolism of an amino acid. The amino acid pool in a
cell can be used to form body proteins, as well as a variety of other possible
products. When the carbon skeletons of amino acids are metabolized to produce
glucose or fat, ammonia (NH3) is a resulting waste product. The ammonia is
converted into urea and excreted in the urine.

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• The standard on which the adult RDA is based is 0.8 grams of protein per
kilogram of body weight; Teens 14 to 18 years old is 0.85 grams
• To maximize an adult’s health, all essential amino acids should be supplied
in adequate amounts by diet daily or at least every 2 to 3 days.
• To calculate individualized protein requirement:

Weight in pounds = Weight in kilograms × 0.8 = protein RDA in grams

• 2.2lb/kg

Concept Check!
Considering your weight, how many grams of protein should
you take every day?

Sources
1. High Quality Proteins - meat, seafood, poultry, cheese, eggs, and milk and
milk products, soybeans
2. Other sources (may be o be limiting in one or more essential amino acids) -
legumes, grains, nuts, seeds, and vegetables

Complementary Proteins - two or more proteins whose amino acid assortments

complement each other in such a way that the essential amino acids limited in one
are supplied by the other.
Complementary Proteins
In general, legumes provide
plenty of isoleucine (Ile) and
lysine (Lys) but fall short in
methionine (Met) and
tryptophan (Trp). Grains
have the opposite strengths
and weaknesses, making them
a perfect match for legumes.

Protein Sparing
• Dietary protein—no matter how high the quality—will not be used efficiently
and will not support growth when energy from carbohydrate and fat is
lacking, a major reason why people must have ample carbohydrate and fat
in the diet is to prevent this wasting of protein.
• Carbohydrate and fat allow amino acids to be used to build body proteins –
this is known as the protein-sparing effect of carbohydrate and fat.
Health Implications
A. Protein Deficiency
- When the diet supplies too little protein or lacks a specific essential
amino acid relative to the others (a limiting amino acid), the body slows
its synthesis of proteins while increasing its breakdown of body tissue
protein to liberate the amino acids it needs to build other proteins of
critical importance.

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- Consequences: slow growth in children, impaired brain and kidney

functions, weakened immune defenses, and impaired nutrient
absorption from the digestive tract.

Protein-Energy Malnutrition (PEM) - condition that develops when the diet

delivers too little protein, too little energy, or both
• Severe Acute Malnutrition (SAM) - malnutrition caused by recent
severe food restriction; characterized in children by underweight for
height (wasting).
• Chronic Malnutrition - malnutrition caused by long-term food
deprivation; characterized in children by short height for age
(stunting).
a. Kwashiorkor
• a Ghanaian word meaning a “sickness that infects the first
child when the second child is born”
• rapid onset protein deficiency
• Signs and Symptoms:
o Edema because of low blood albumin;
o Loss of hair color because melanin dark pigment, is
made from the amino acid tyrosine;
o patchy and scaly skin develops, often with sores that
fail to heal
o underweight
o thin muscle
b. Marasmus
• from the Greek word meaning “dying away,” reflects a
prolonged, unrelenting deprivation of food observed in
children living in impoverished nations
• gradually developed protein and calorie deficiency
• “skin and bones”
• impairs brain development and learning ability.
• Signs and Symptoms:
o Emaciated appearance
o Thin muscles, thin fat
o Old mans’ face
o Very underweight
o Below normal temperature
Rehabilitation
• optimal breastfeeding and improved complementary feedings
• supplemental foods
• SAM requires hospitalization for intensive nursing care, diet, and medication
Other Problems Related to Proteins
1. Maple Syrup Urine Disease (MSUD)
• caused by defective metabolism of branched chain amino acids
• Normal development is expected if dietary isoleucine, leucine, and
valine are restricted to 20% to 40% of the Recommended Dietary
Allowance during infancy
• Manifestations:
o vomiting and lethargy, and progressing to seizures, coma, and
death within 10 days if untreated
o Irreversible brain damage may occur within the first week of
life

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•Management: Exchange Transfusion, peritoneal dialysis, liver

transplantation
2. Phenylketonuria (PKU)
• Persons with PKU are unable to convert the essential amino acid
phenylalanine to tyrosine because the enzyme phenylalanine
hydroxylase (PAH) is lacking or defective.
• Manifestations:
o Mental retardation
o Irreversible brain damage occurs if treatment is not initiated
before the second week of life

B. Protein Excess
- Overconsumption of protein offers no benefits and may pose health risks for
the heart and weakened kidneys

1. Heart Disease
• Protein foods of animal origin are often also high in saturated fat
and cholesterol
• High fats meat consumption contributes to obesity, heart disease
and diabetes
2. Kidneys and Kidney Disease
• In people with chronic kidney disease, a high-protein diet may
accelerate the kidneys’ decline - excess dietary protein results in
inflammation and apoptosis in the glomerular cells of the kidney
• High-protein diets increase urine output, which can lead to
dehydration, especially in athletes
3. Bones
o High protein consumption has recently been cited as one factor
in bone demineralization, especially if coupled with low calcium
intake
o loss of calcium in the urine is increased with high protein intake
4. Food Allergies
• food allergies occur in up to 8% of children 4 years of age or
younger and in up to 2% of adults.
• Eight foods account for 90% of food-related allergies - soy,
peanuts, tree nuts, wheat, milk, eggs, fish, and shellfish

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5. If a person fills up on high-protein foods, little room is left for fruits,

vegetables, and other whole grains, which are packed with essential
vitamins, minerals, and fiber.

Protein and Amino Acid Supplementation

• Protein and amino acid supplements are used primarily by those
trying to lose weight and by athletes hoping to build muscle
• Dietary protein is necessary for building muscle tissue, and
consuming protein in conjunction with resistance exercise helps
muscles build new proteins. Protein supplements do not improve
athletic performance beyond the gains from well-timed meals of
ordinary foods.
• The body’s gastrointestinal system is adapted to handle whole
proteins as a dietary source of amino acids, individual amino acid
supplements can overwhelm the absorptive mechanisms in the small
intestine.
• The amino acids methionine, cysteine, and histidine are most likely
to cause toxicity when consumed in large amounts.
• Amino acid supplements are not recommended for the following
reasons:
o Potential imbalanced absorption caused by competition for
common carrier systems
o Nitrogen assimilation from protein-containing foods is
superior to that from free amino acids
o Expense and unpalatability
o Possible gastrointestinal distress

Review
Multiple Choice. Select the letter that precedes the best answer.
1. For which of the following offering the best source of
functions of protein can other protein?
nutrients be substituted?
a. Energy source a. Bran muffins with raisins
b. Immunity b. Red beans and rice
c. Maintenance and growth c. Green bean, onion, and
d. Regulation of body processes mushroom casserole
d. Sweet potatoes and cornbread
2. Which of the following foods is a
complete protein? 4. Which of the following people
a. Baked beans would the nurse regard as being in
b. Broccoli a catabolic state?
c. Beef kabobs
d. Bread sticks a. Adolescent boy who is into
bodybuilding
3. If a person has difficulty b. Lactating mother
purchasing meat to serve every c. Pregnant woman in the second
day, which of the following foods trimester
should the nurse suggest as d. Surgical client, first day after a
stomach resection

Module II
Clinical Application
1. Considering the health effects of too little dietary protein, what suggestions
would you have for a teenage girl who reports the following information
about her food intake?
a. She never eats any meat or other animal-derived foods because she is a
vegan. On a typical day, she consumes toast and juice for breakfast;
chips, a soft drink, and a piece of fruit for lunch; and a small amount of
plain pasta with tomato sauce or steamed vegetables for dinner, along
with a glass of water or tea.
b. She takes amino acid supplements because a friend told her that the
only way to get amino acids if she doesn’t eat meat is to take them as
supplements.
2. Considering the health effects of excess dietary protein, what advice would
you have for a college athlete who tells you he wants to bulk up his muscles
and reports the following information about his food intake?
a. He eats large portions of meat (usually red meat) at least twice a day.
He drinks whole milk two or three times a day and eats eggs and bacon
for breakfast almost every day.
b. He avoids breads, cereals, and pasta in order to save room for protein-
rich foods such as meat, milk, and eggs.
c. He eats a piece of fruit once in a while but seldom eats vegetables
because they are too time consuming to prepare.

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Lesson 4

 ENERGY BALANCE

HUMAN ENERGY SYSTEM

Energy
• The capacity of a system to do work
• Four forms of energy
o Chemical
o Electrical
o Mechanical
o Thermal
• In the brain, chemical energy is changed to electrical energy for transmitting
nerve impulses and carrying out brain activities. Chemical energy is changed
to mechanical energy when muscles contract; it is changed to thermal energy
in the regulation of body temperature. Chemical energy is needed to form
new tissues and molecules for growth and metabolism. Throughout all of this
work, heat is given off to the surrounding atmosphere and larger biosphere.
• Energy is present in the body as
o free energy - the energy being used at any given moment in the
performance of a task
o potential energy - energy that is stored or bound in a chemical
compound and can be converted to free energy when needed

ENERGY BALANCE: INPUT AND OUTPUT

• Energy Balance occurs when the number of kilocalories eaten equals the
number used to produce energy.
• The total overall energy balance within the body depends on the energy intake
in relation to the energy output.
• Energy Input:
o Food is the external fuel source of the human energy system
o The body relies on stored energy when food is not available.
▪ Glycogen – stored glucose
▪ Adipose Tissue – fat storage
▪ Muscle Mass – proteins are converted into energy in long
fasting/starvation
o Estimated Energy Requirement (EER)
▪ Formulas to estimate energy needs published by Food and
Nutrition Board

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RECOMMENDED DAILY ALLOWANCES FOR ENERGY

• Energy Output:
o Energy requirement is determined by:
▪ basal energy expenditure (BEE) or basal metabolic rate (BMR)
- refers to the sum of all internal working activities of the
body while at total rest; it is expressed in kilocalories
per day
- BEE must be measured when an individual is at absolute
digestive, physical, mental, thermal, and emotional rest
- REE (resting energy expenditure) is up to 10% higher
than a true BEE measurement.

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- For the average person, 60% to 75% of their total energy

expenditure (TEE) will be used to meet basal energy
demands.
- indirect calorimetry – measures BEE and REE
- A basic formula for calculating basal energy needs is to
multiply 0.9 or 1 kcal/ kg body weight by the number of
hours in a day
o this simple equation does not take into account
age, height, activity level, fitness, or any other
factor that would alter energy needs
▪ E.g. For a 154-lb man:

1 kcal × kg body weight × 24 hours

1. Convert pounds to kilograms: 154÷ 2.2 lb =70 kg
2. 1 kcal * 70 kg *24 hr =1680 kcal/ 24 hr
▪ For a 121-lb woman:

0.9 kcal kg body weight hours × × 24

1. Convert pounds to kilograms : 121÷2.2 lb = 55 kg
2. 0.9 kcal *55 kg 24 hr =1188 kcal /24 hr

- The Mifflin-St. Jeor equations, the Harris-Benedict

equations, and the equations that were used for the
2002 Dietary Reference Intake values provide an
alternate method of estimating the REE or BEE that is
more specific to the individual, and Mifflin-St. Jeor
equation to give the most reliable REE measurement.
- thyroid function tests may be used as an indicator of BEE
because the thyroid hormone plays a significant role in
regulating metabolism
- Factors that influence basal energy expenditure:
o Lean body mass
▪ The more lean body mass a person has,
the higher the person’s BEE
o Growth periods
▪ BEE is elevated in growth spurts during
childhood and adolescence
o Body temperature
▪ Fever increases BEE by approximately 7%
for each 1° F rise above normal body
temperature.
▪ In states of starvation and malnutrition,
BEE decreases.
▪ In cold weather, especially in freezing
temperatures, BEE rises
o Hormonal status
▪ Thyroid hormone plays a significant role in
regulating metabolism.
▪ The fight-or-flight reflexes increase
metabolic rate in response to the
hormone epinephrine.

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▪ Growth hormone increases metabolism.

▪ Other hormones (e.g., insulin, cortisol)
also increase metabolism, and they may
fluctuate daily
o Disease state
▪ BEE may be increased or decreased
depending on the disease
▪ BEE in such patients is to use direct or
indirect calorimetry measurements
▪ physical activity (PA)
- exercise has positive effects on both physical and mental
quality of life
- The energy expenditure that is used for physical activity
goes above and beyond the BEE
- standard values : 1.0 to 2.5, depending on lifestyle
▪ thermic effect of food
- an increase in energy expenditure caused by the
activities of digestion, absorption, transport, and
metabolism of ingested food; a meal that consists of a
usual mixture of carbohydrates, protein, and fat
increases the energy expenditure equivalent to
approximately 10% of the food’s energy content (e.g., a
300-kcal piece of pizza would elicit an energy
expenditure of 30 kcal to digest the food).
-

The contributions of basal

energy expenditure,
physical activity, and the
thermic effect of food to
total energy expenditure

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Energy Expenditure per Pound per Hour during Various Activities

FACTORS THAT AFFECT THE BMR

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FACTORS FOR CALCULATING DAILY ENERGY EXPENDED IN PHYSICAL ACTIVITY

▪ Total Energy Expenditure (TEE)

o A person’s TEE is comprised of the energy needs for BEE, the
physical activities of the person, and the thermic effects of
food
o To maintain energy balance, food energy intake must match
body energy output as an average over time. An energy
imbalance (i.e., when energy intake exceeds energy output)
can lead to weight gain).

Concept Check!
CASE STUDY:
You have a 32-year-old female patient with the following anthropometric
measurements: Weight: 120 lb Height: 5 ft 4 in BMI: 20.6 kg/m2 She has been keeping
a diet record; and after analyzing it, you find that her average energy intake for each
meal/snack is as follows:
Breakfast: 450 kcal
Midmorning snack: 175 kcal
Lunch: 600 kcal

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Afternoon snack: 250 kcal

Dinner: 610 kcal
Evening snack: 200 kcal

Thus, her total energy intake averages 2285 kcal/day.

You calculate her basal energy needs according to the Mifflin-St. Jeor
equation and find that her BEE is 1240.5 kcal/ day. She reports a very active
lifestyle. Therefore, you multiply her BEE by a physical activity factor of 1.725.
Her total energy expenditure is: 2140 kcal/day.
You explain to your patient that she eats more kcals than she is using in a
given day; thus she has a positive energy balance of 145 kcal/day.

Questions to consider:
1. If she continues to consume and burn the same amount of energy, how long will it
take for her to gain a pound of fat? (1 lb of fat = 3500 kcal)
2. How would you recommend that she change her lifestyle to maintain her current
weight?

ENERGY IMBALANCE
▪ Feasting – consuming more energy than expending
o Excess Carbohydrate
• Once glycogen stores are filled, most of the additional carbohydrate is
burned for energy, displacing the body’s use of fat for energy and
allowing body fat to accumulate.
o Excess Fat
• Surplus dietary fat contributes more directly to the body’s fat stores.
After a meal, fat is routed to the body’s adipose tissue, where it is
stored until needed for energy. Thus, excess fat from food easily adds
to body fat.
o Excess Protein
• If not needed to build body protein (as in response to physical activity)
or to meet energy needs, amino acids will lose their nitrogens and be
converted, through intermediates, to triglycerides. These, too, swell
the fat cells and add to body weight
o Excess alcohol
• Alcohol has 7 kilocalories/gram
• excess energy from alcohol is also stored as fat
• Alcohol has also been shown to slow down the body’s use of fat for
fuel, causing more fat to be stored, much of it as abdominal fat tissue.
Alcohol therefore is fattening, both through the kcalories it provides
and through its effects on fat metabolism.
• Fasting – energy deficit
o Glycogen used first
o Glucose has to be present to permit the brain’s energy-metabolizing
machinery to work
o Protein Breakdown and Ketosis
▪ In the first few days of a fast, body protein provides about 90 percent
of the needed glucose, and glycerol provides about 10 percent. If body
protein losses were to continue at this rate, death would ensue within
about three weeks.

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▪ Loss of body protein occurs in rapid weight loss and in body wasting or
cachexia
▪ Ketone bodies (produced by the liver during fat breakdown) serve as
fuel for some brain cells
- Ketonemia - high blood concentration of ketone bodies
- Ketonuria - ketone bodies in the urine
- Ketosis – ketonemia + Ketonuria
▪ in fasting, muscle and lean tissues give up protein to supply amino
acids for conversion to glucose
▪ Slowed Metabolism
- As fasting continues and the nervous system shifts to partial
dependence on ketone bodies for energy, the body simultaneously
reduces its energy output (metabolic rate) and conserves both fat
and lean tissue.
▪ Hazards of Fasting
o Wasting of lean tissues
o Impairment of disease resistance
o Lowering of body temperature
o Disturbances of the body’s fluid and electrolyte balances
o Stunted growth

MEASUREMENT OF ENERGY
• Calorie - a measure of heat; the energy necessary to do work is measured as
the amount of heat produced by the body’s work; the energy value of a food is
expressed as the number of kilocalories that a specified portion of the food
will yield when it is oxidized in the body.
• Kilocalorie - used to designate the large calorie unit that is used in nutrition
science to avoid dealing with too many zeros; abbreviated as kcalorie or kcal,
is the amount of heat that is necessary to raise 1 kg of water 1° C; 1
kilocalorie = 1000 calories
• Joule - international unit of measure for energy
o To convert kilocalories (kcal) into kilojoules (kJ), multiply the number
of kilocalories by 4.184
▪ e.g., 200 kcal × 4.184 = 836.8 kJ

BODY WEIGHT AND BODY COMPOSITION

Body Weight Management
• A healthy normal person reaches the desirable weight for his/her height by 25
years of age
• When energy intake is equal to body needs, body weight is maintained at a
fairly constant level, in a healthy adult.
• Consistent intake of inadequate food, which is unable to meet the body’s need
for energy, leads to use of body fat to make up the deficit and there is loss of
weight.
• Continuous intake of energy in excess of one’s needs, results in deposition of
fat.

Body Composition
• Individuals have different body shapes and sizes depending on their age,
gender, genes, body type, and state of health.

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• Body Types:
o Ectomorph - generally slender and fragile
o Mesomorph - have prominent muscle and
bone development
o Endomorph - have a soft, round physique
with some accumulation of body fat
• Body Weight and Body Fat
o Overweight - weighs more than the
average person of similar height; may
have lower proportion of body fat but
with exceptionally large amount of
muscles, e.g. athletes
o Overfat/Obese - overweight as a result of
excessive body fat rather than enhanced
muscle or skeletal tissue
• Body Compartments
o defined on the basis of their comparative
size and metabolic activity
o The four-compartment model for
evaluating body composition includes:
1. Lean body mass (LBM)
- made up of active cells from muscle and vital organs and
largely determines the BMR and related nutrient needs;
- LBM contains cell protein, cell water, and a very small
amount of fat found in membranes, while FFM includes cell
protein, all body water both inside and outside of cells, and
bone mineral mass—all body tissues except for fat.
- In adults it makes up 30% to 65% of total body weight
2. Body Fat
- Total body fat reflects both the number and size of the fat
cells (adipocytes) that form the adipose tissue.
- In an adult man of normal weight, fat comprises 13% to 21%
of body weight.
- In a woman of normal weight, the range of body fat content
is 23% to 31%.
- amounts vary with age, body type, exercise, and fitness,
and many people have body fat levels markedly greater than
or less than these ranges
- one half of all body fat is located in the subcutaneous fat
layers under the skin, where it serves as insulation
- As individuals grow older, body fat is deposited on the trunk
rather than on the extremities; thus waist circumference,
waist-to-hip ratio, and waist-to-height ratio become useful
tools to evaluate body fatness and health risk
3. Body Water
- Total body water includes both intracellular and
extracellular water
- Total body water varies with relative leanness or fatness,
age, hydration status, and health status
- water makes up about 50% to 65% of body weight

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- Muscle tissue has high water content, whereas adipose

tissue has low water content; thus men have a higher
proportion of body water than women because they have
more muscle and less fat
- Infants have a relatively high proportion of body water,
which drops to adult levels by age 2. This makes them
especially vulnerable to the dangers of dehydration with
continued vomiting or diarrhea.
4. Mineral mass
- Body minerals found largely in the skeleton account for only
4% to 6% of body weight
- Major minerals are calcium and phosphorus located in bone
and other body cells and in fluids. Sodium is the major
mineral in extracellular fluid (ECF), and potassium is the
major mineral in intracellular fluid (ICF).
o The following factors influence the relative sizes of body
compartments:
1. Gender - Women have more adipose tissue, and men have more
lean tissue, particularly muscle tissue.
2. Age - Young adults have more LBM and less fat than older adults.
3. Physical activity - Persons who are physically active have less fat
and more LBM than individuals who are sedentary.
4. Race - African Americans have relatively more bone mineral than
Caucasians or Hispanics; Caucasian men tend to have more body fat
than African-American men of similar height and weight; Mexican-
American women tend to have more body fat than African-
American women with similar heights and weights.
5. Climate - Individuals living in very cold climates develop more
subcutaneous fat to insulate against heat loss.

Importance of Body Fat

• for reproductive capacity women require a body fat of about 20%
• The initiation of menstruation or menarche occurs when the female
body attains a certain size or, more precisely, the critical
proportion of body fat.
• Body fat gained during pregnancy serves as an important energy
reserve for lactation, and the production of breast milk with its
high energy cost usually brings about a gradual loss of these fat
stores

• Measuring Body Compartments

o Specialized Method
▪ hydrostatic weighing using Archimedes’ principle
▪ air displacement method
▪ Dual-energy x-ray absorptiometry (DEXA)
o Development of Height-Weight Tables
▪ Early height-weight tables presented adult reference weights
according to age, based on the assumption that weight gain
continued throughout adult life.
o Reference Tables for Clinical Evaluation
▪ Body Mass Index

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• An index of a person’s weight in relation to height; determined

by dividing the weight (in kilograms) by the square of the height
(in meters).
• Developed by Quetelet in 1871
• BMI does not provide a quantitative estimate of body fat and
cannot distinguish between excess body fat and increased
muscle in persons who weigh more than the standard
• Formula for BMI:
o To convert pounds to kilograms, divide by 2.2. To convert
inches to meters, divide by 39.37.

o Interpretation of BMI result:

o Abdominal Fat/Waist Circumference

▪ Pear/Gynoid Shape - characteristic of younger women and controlled
to some extent by the female hormone estrogen
▪ Apple/Android Shape - more fat around the abdomen, is common in
men and postmenopausal women
▪ abdominal (visceral) fat raises blood lipid levels and increases the risk
of cardiovascular disease, thus extra weight around one’s middle is of
greater harm than extra weight on the hips or thighs
▪ An appropriate waist-to-hip ratio (WHR) is 0.9 or less for men and 0.8
or less for women - indicates a smaller waist and a larger hip
measurement
▪ The threshold for abdominal obesity as defined by waist circumference
is greater than or equal to 88 cm (35 inches) in women and greater
than or equal to 102 cm (40 inches) in men.

OBESITY
• Obesity/weight-related health problems can be divided into four categories:
1. Metabolic: Type 2 diabetes, hypertension, elevated blood lipids, and the
constellation of conditions associated with metabolic syndrome often
accompany obesity. Regardless of total body fat, abdominal fat increases
the risk of metabolic disorders.

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2. Degenerative: Obesity and physical disability are strongly linked.

Osteoarthritis and joint problems, atherosclerotic changes, and pulmonary
diseases are more serious in obese persons.
3. Neoplastic: Many forms of cancer including colorectal, breast, prostate,
esophageal, and ovarian cancer are more frequent in higher weight
categories.
4. Anatomic: Individuals who exceed a healthy weight have a greater risk of
gastroesophageal reflux disease (GERD) and obstructive sleep apnea.

Eating Disorders
• Eating disorders have an emotional/behavioral component and a
neurophysiologic/genetic component, although genes appear to play a
significant role.
• Levels of serotonin and other neurotransmitters are altered, and changes in
the hypothalamus affect appetite.
• Personality traits such as perfectionism and obsessive-compulsive behavior are
common among individuals with eating disorders
• Eating disorders often coexist with other psychiatric and anxiety-related
disorders, and the longer the nutritional deficits and emotional problems
continue, the more severe they become
• Types:
1. Anorexia Nervosa
- Extreme psychophysiologic aversion to food resulting in life-
threatening weight loss. An eating disorder accompanied by a
distorted body image considered to reflect fat when the body is
actually malnourished and thin from self-starvation
- body weight only 85% of average or a BMI of less than 17.5
- they never see themselves as underweight and emaciated but
always as fat
- Low bone mass is a frequent complication because amenorrhea
usually accompanies this condition.
2. Bulimia Nervosa
- An eating disorder in which cycles of gorging on large quantities of
food are followed by self-induced vomiting and use of diuretics or
laxatives or extreme levels of exercise to avoid weight gain
- meaning “ox hunger,” describes the massive amounts of food
consumed
- body weight is usually normal or even above normal
- often associated with depression or difficulty in meeting social or
role expectations
- sometimes referred to as the binge and purge syndrome
3. Binge-eating Disorder
- An eating disorder in which individuals consume large amounts of
food in a short period of time, but without the purging behavior of
bulimia nervosa
- occurs in response to stress or anxiety, or may soothe or relieve
painful feelings
- Many of these patients are overweight and have the same medical
problems as obese individuals who do not binge eat
4. Eating Disorders Not Otherwise Specified (EDNOS)

Module II
 42

- may include a combination of the conditions described above or a

frequency of symptoms that differ from established diagnostic
criteria.
- Includes eating problems such as purging syndrome and night-eating
syndrome
• Signs associated with development of eating disorders in adolescents:
o Behavioral Signs
- Obsession with dieting
- Extreme level of exercise
- Dissatisfaction with body size or shape
- Overestimation of kcalorie intake (anorexia nervosa)
o Clinical Signs (Anorexia Nervosa)
- Arrested growth and maturation
- Underweight: body mass index (BMI) < 17.5
- Dry and yellowish skin
- Growth of fine hair over body (e.g., lanugo)
- Drop in internal body temperature; person feels cold
- Severe constipation
- Low blood pressure, slowed breathing and pulse
o Clinical Signs (Bulimia Nervosa)
- Chronically inflamed and sore throat
- Swollen glands in the neck and below the jaw
- Worn tooth enamel and decaying teeth
- Intestinal distress and irritation from laxative abuse
- Severe dehydration from purging of fluids

UNDERWEIGHT
• defined as a BMI of less than 18.5 kg/m2
• Underweight springs from poverty, poor living conditions, long-term illness, or
physiologic dysfunction
• Resistance to infection is lower, general health is poorer, and physical
strength is decreased in seriously underweight individuals
• General Causes:
o Poor food intake
- Lack of sufficient and appropriate food results in failure to
thrive in children and older adults.
- Medications such as digoxin and chemotherapeutic agents
contribute to the devastating weight loss known as cachexia
seen in cardiac failure and cancer.
o Increase in energy requirements
- Long-term hypermetabolic conditions such as cancer, acquired
immunodeficiency syndrome (AIDS), advanced heart disease, or
infection impose energy demands that drain the body’s
resources.
o Poor utilization of available nutrients
- Malabsorption associated with prolonged diarrhea,
gastrointestinal disease, or laxative abuse depletes nutrient
stores.
- Cytokines produced by the immune system in response to
chronic conditions such as cancer, chronic kidney disease,

Module II
 43

congestive heart failure, and AIDS accelerate the breakdown of

body protein and fat.
• Nutritional Care
o Food plans must be adapted to the individual’s personal preferences,
financial situation, and household concerns, and address any existing
disease.
o The dietary recommendation should be
- high in kcalories (at least 50% beyond standard needs);
- high in protein to rebuild tissue;
- high in carbohydrate to provide a primary energy source in an
easily digested form;
- moderate in unsaturated fats to add kcalories but not exceed
recommended limits;
- optimum in vitamins and minerals, including supplements when
deficiencies require them
o In extreme cases, tube feeding or total parenteral nutrition (TPN) may
be necessary

Module II
 44

 MODULE SUMMARY

This module consisting of four lessons discussed the macronutrients and how
energy is balanced in our body.
Lesson 1 tackled carbohydrate and how important its intake is to the body.
Lesson 2 presented the family of lipids and how the small amount of intake
when neglected affects body functioning.
Lesson 3 tackled proteins, its effect on the growth of the body, and deficiency
problems related to it.
Lesson 4 discussed how excessive and deficient intake of energy distresses the
body.
Congratulations! You have just studied Module II. Now you are ready to
evaluate how much you have benefited from your reading by answering the
summative test. Good Luck!!!

 SUMMATIVE TEST
Questions for Discussion:
1. What is the importance of the following to the body:
a. Insoluble fibers
b. Soluble Fibers
2. What is ketosis?
3. What are the harmful effects of excessive fiber intake?
4. How does the body make glucose from protein?
5. Differentiate biological value (BV) from net protein utilization (NPU).
6. What are the health effects of protein?
7. Differentiate acute protein-energy malnutrition (PEM)
from chronic PEM.
8. Why are ecosapentanoic acid (EPA) and
docosexahexanoic acid (DHA) important?
9. What are the health effects of lipids?
10. What are the benefits derived from omega-3
polyunsaturated fats?
11. Which is better, butter or margarine? Why?
12. Define anorexia nervosa and bulimia nervosa. What is
the difference between the two?

Laboratory Activity
I. Using the food label on the right, compute the following:
1. Total calories from fat
2. Total calories from carbohydrates
3. Total calories from protein
4. Total calories of one (1) serving

Module II
 45

5. Total calories from one (1) container

II. Computation. Compute according to your age, weight and height.

A. Calculate Your Total Energy Expenditure
Your total energy output per day is the sum of three uses of energy:
1. Resting metabolic rate (RMR).
2. Thermic effect of food (TEF). (The factors we are using to calculate physical
activity include the TEF so for this exercise we will not calculate it separately.)
3. Physical activity.

1. Resting Metabolic Rate

Calculate your RMR using one of the following
Women: 0.9 kcal/kg/hr
Men: 1.2 kcal/kg/hr

Convert your body weight from pounds (lb) to kilograms (kg): 1 kg = 2.2 lb.
Body weight in pounds _______÷ 2.2 = _______ kg.

RMR (kcalories) = 0.9 (for women) or 1.2 (for men) × kg body weight × 24 (hours
in day) = _______

2. Physical Activity
Calculate your physical activity expenditure:
Calculate the energy cost of your physical activity using your RMR and the activity
factor from physical activity factors in page 46 that best fits your current activity
level.
Physical activity kcalories = RMR × physical activity factor = _________

3. Total Energy Expenditure

To calculate your total energy expenditure (kcalories):
RMR kcalories ______ + physical activity kcalories _______ = _______

4. Compute for your average energy intake.

To get started, keep a detailed record of everything you eat and drink for 3 days: 2
weekdays and 1 weekend day. List the type and amount of food in household
measures (e.g., cups, tablespoons, or dimensions), how it was prepared, and
brand name, if applicable. Be specific: was your milk nonfat, 1% fat, 2% fat, or
whole? Include butter, margarine, salad dressings, condiments, and additions to
coffee or tea.
Consider the following:
carbohydrates – 4kcal/gram
Protein – 4 kcal/gram
Fats – 9 kcal/gram

Module II
 46

Alchol – 7kcal/gram

Breakfast:
Morning snack:
Lunch:
Afternoon snack:
Dinner:
Evening snack:
Total kcalories:
*If you want to check the chemical and nutritional composition of food, as well as
their calorie content, register first at http://i.fnri.dost.gov.ph/ and you may
check the DOST FNRI PhilFCT database at http://i.fnri.dost.gov.ph/fct/library.
Questions:
a. How does your energy intake compare with your estimated total energy
expenditure completed above? Are you taking in more kcalories, fewer kcalories,
or about the same number of kcalories as you are using each day?
b. What will be the effect on your body weight if you continue this pattern? What will
be the effect on your health status?
B. Evaluate Your Body Weight Using the Body Mass Index
Determine your body mass index (BMI) using the formula discussed in page 53.
BMI = _______
a. What is your assessment of your weight status using the BMI? Are you
underweight, overweight, or in the healthy range?
b. If you are not in the healthy range, how might you begin to improve your
status? (Consider underweight to be as needful of attention as overweight.)
C. Evaluate Your Health Status Using Waist Circumference
Measure your waist circumference (WC) using a non-stretch tape.
WC = _______
If you are a woman, then your waist circumference should not exceed 88 cm (35
inches); if you are a man, it should not exceed 102 cm (40 inches).
a. What is your assessment of your chronic disease risk based on your waist
circumference?
b. If you are not in the healthful range, how might you begin to improve your
status?

Module II
 MODULE III
Classification of Nutrients:
Micronutrients
Lesson 1: Vitamins

Lesson 2: Minerals

Lesson 3: Water
 MODULE III
CLASSIFICATION OF NUTRIENTS: MICRONUTRIENTS

 INTRODUCTION

This module includes lessons on the micronutrients vitamins and minerals as

well as water. Importance of each micronutrient will be discussed.

LEARNING OBJECTIVES

After studying the module, you should be able to:

1. Describe the characteristics, biochemical and physiological roles and food

sources of a range of micronutrients.
2. Explain the functions of the common minerals and vitamins that people
require in their diet.

 DIRECTIONS/ MODULE ORGANIZER

There are three lessons in the module. Read each lesson carefully then answer
the questions/activities to find out how much you have benefited from it. Work on
these exercises carefully and submit your output to your instructor or to the CCHAMS
Office.

In case you encounter difficulty, discuss this with your instructor during the
face-to-face meeting. If not contact your instructor at the CCHAMS office.

Good luck and happy reading!!!

Module III Page 76

Lesson 1

 VITAMINS

VITAMINS
 Vitamins are organic substances needed by the body in small amounts for normal
metabolism, growth, and maintenance.
 Vitamins are not sources of energy nor do they become part of the structure of the
body.
 Vitamins act as regulators or adjusters of metabolic processes and as coenzymes
(substances that activate enzymes) in enzymatic systems. Because the body only
needs vitamins in small amounts, they are considered micronutrients.
 Discovered by Casimir Funk, a Polish chemist working at the Lister Institute in
London in 1911, called the nitrogen containing substance as vitamin, meaning vital
amine, and dropped the “e” when it was found out that not all vital substances are
amine
 To be classified as a vitamin, a compound must meet the following criteria:
1. the body is unable to synthesize enough of the compound to maintain health
2. Absence of the compound from the diet for a defined period produces
deficiency symptoms that, if caught in time, are quickly reversed when the
compound is reintroduced. A compound does not qualify as a vitamin merely
because the body cannot make it. Evidence must suggest that health declines
when the substance is not consumed

Functions of Vitamins
1. Metabolism: Enzymes and Coenzymes
 Coenzymes that are derived from vitamins are an integral part of some
enzymes, without which these enzymes cannot catalyze their metabolic
reactions.
2. Tissue Structure and Protection
 Some vitamins are involved in tissue or bone building. For example, vitamin C
is involved in the synthesis of collagen, which is a structural protein in the skin,
ligaments, and bones.
o The word collagen comes from a Greek word meaning “glue.”
 Vitamins (e.g., A, C, and E) also act as antioxidants to protect cell structures
and to prevent damage caused by free radicals.
3. Prevention of Deficiency Diseases
 When a vitamin deficiency becomes severe, the specific function of that
vitamin becomes apparent because the vitamin’s function is no longer
preformed.

Terms Associated with Vitamins

Bioavailability
 The rate and extent to which a nutrient is absorbed and used

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  Determining the bioavailability of a vitamin is more difficult because it
depends on many factors, including:
o Efficiency of digestion and time of transit through the GI tract.
o Previous nutrient intake and nutrition status. Other foods consumed at the
same time.
o The method of food preparation (raw or cooked, for example).
o Source of the nutrient (naturally occurring, synthetic, or fortified).
Megadose
 A dose 10 times the RDA
Precursors or Provitamins
 compounds that can be converted into other compounds; with regard to
vitamins, compounds that can be converted into active vitamins
Preformed Vitamins
 naturally occurring vitamins that are in inactive form and ready for biological
use
Avitaminosis
 condition resulting from lack of a vitamin
Hypervitaminosis
 vitamin toxicity; excessive accumulation of vitamin in the body
Functional Foods
 Foods that have health benefits beyond basic nutrition
Two Categories:
1. Zoochemicals - health-promoting compounds found in animal food
2. Phytochemicals - health-promoting compounds found in plant foods (phyto
means “plant” in Greek)
 responsible for the unique colors, flavors, and odors observed in plants
 Examples are carotenoids, allicin, phytosterols, isothiocyanates, lignans,
stanols, ellagic acid, flavonoids, saponins, glucosinolates, polyphenols,
phytoestrogens, sulphides, lectins
 Health Benefits of Phytochemicals:
o Stimulate the immune system
o Reduce inflammation Prevent DNA damage and aid in DNA repair
o Reduce oxidative damage to cells
o Regulate intracellular signaling of hormones and gene expression
o Activate insulin receptors Inhibit the initiation and proliferation of
cancer, and stimulate spontaneous cell death
o Alter the absorption, production, and metabolism of cholesterol
o Mimic or inhibit hormones and enzymes
o Decrease the formation of blood clots
 Examples of foods that are rich sources of phytochemicals include fruits,
vegetables, whole grains, leagumes, beans, herbs, spices, nuts, and seeds.

Classification of Vitamins
a. Water-Soluble Vitamins
 The water-soluble vitamins are vitamin C and the B-complex family. These
vitamins are more easily absorbed and transported, but unlike the fat-soluble
vitamins, they cannot be stored except in the general sense of tissue
saturation.
b. Fat-Soluble Vitamins
Module III Page 78
  The fat-soluble vitamins are A, D, E, and K. They are closely associated with
body lipids and are easily stored. Their functions are usually related to
structural activities with proteins. They are found in the liver the fatty tissues
of the body where they are stored and used.
OMPARISON OF FAT-SOLUBLE AND WATER-SOLUBLE VITAMINS

Vitamin Toxicity
 For most water-soluble vitamins, when you consume more than the RDA or AI,
the kidneys efficiently filter the excess from the blood and excrete these
compounds in urine, except vitamin B-6 and vitamin B-12, which are stored in
the liver, may accumulate to toxic levels.
 In contrast to the water-soluble vitamins, fat-soluble vitamins are not readily
excreted, so some can easily accumulate in the body and cause toxic effects.

Preservation of Vitamins in Food

 Storage time and environmental factors can affect vitamin content of foods.
 Fully ripe food contains more vitamins, but substantial amounts of vitamins can
be lost from the time a fruit or vegetable is harvested until it is eaten.
 The water-soluble vitamins, particularly thiamin, vitamin C, and folate, can be
destroyed with improper storage and excessive cooking.
 H eat, light, exposure to the air, cooking in water, and alkalinity are factors
that can destroy vitamins.

FAT SOLUBLE VITAMINS

VITAMIN A (RETINOL)
 the first fat-soluble vitamin to be discovered

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  Retinol was given its name based on its specific function in the retina of the
eye.
 Soluble in fat and fat solvents
 Because retinol is insoluble in water, it is Did you know that…?
fairly stable in cooking
 Forms in the body: retinol (alcohol from),
Red Light Conserves Rhodopsin
retinal (aldehyde form), retinoic acid
(acid form), retinyl palmitate, and beta-
Red light breaks down rhodopsin
carotene (precursor form)
(visual purple) more slowly than do
other wavelengths of light. This is the
Functions:
reason aviators spend time in a red-
 Enables eye to adjust to changes in light lit room before flying at night. In the
(retinal and opsin = formation of rhodopsin presence of red light, a buildup of
in the retina). rhodopsin occurs in the retina. Vision
 Helps maintain healthy skin and mucous in dim light is thus enhanced. Red
membranes (goblet cells, which produce light is used on navigational
mucus, become fewer in the absence of instruments for the same reason.
vitamin A) as well as the cornea of the
eye.
 Develops healthy teeth and bones.
 Aids reproductive processes.
 Synthesizes glycogen in the liver.
 Regulates fat metabolism in formation of cholesterol.
 Aids formation of cortisone in the adrenal gland.
 Retinoic acid is used to regulate the expression of the gene for growth hormone

Food Sources/Recommended Intake

 For adults 19–30 years RDA,
o male: 900 µg/d Vitamin A and Cancer
o female: 700 µg/d
o Tolerable upper intake: 3000 µg/d Fifty percent of fatal
 Excellent Sources
cancer begins with
o liver
o eggs
abnormal differentiation of
o carrots epithelial cells. Vitamin A
o cantaloupe contributes to normal cell
o sweet potato differentiation. It also
o winter squash functions as an antioxidant
o pumpkin to neutralize free radicals,
o apricots which can damage DNA,
o broccoli with resultant abnormal
o green pepper cell growth.
o dark green leafy vegetables

Module III Page 80

  Good Sources
o tomatoes (and juice)
o butter
o margarine
o peaches

Results of Deficiency or Excess

 Deficiency
o night blindness (inability to see in dim light)
o keratinization (formation of a horny layer of skin (xerosis), cracking of
skin)
o xerophthalmia (cornea of eye becomes opaque, causing blindness)
o faulty bone growth,
o defective tooth enamel,
o less resistance to decay decreased resistance to infection, impaired
wound healing
 Excess (Hypervitaminosis A)
o highly toxic in excessive doses (1– 3,000 µg RE/kg/ body weight) or 10
times the RDA
o accumulates in liver, causing enlargement, vomiting, skin rashes, hair
loss, diarrhea, cramps, joint pain, dry scaly skin, anorexia, abnormal
bone growth, cerebral edema

Conditions Requiring Increase in intake

 Self-neglect due to psychiatric disturbances, old age, alcoholism, lack of
nutritional knowledge
 Pregnancy and lactation
 Protein-deficient diets
 Any condition of fat malabsorption
 Infectious hepatitis
 Gallbladder diseases
 Children and pregnant women in poverty

Specific Characteristics
1. Preformed vitamin A (retinol) is found only in animal sources.
2. Provitamin A (beta carotene) is found in plant sources and is a yellow-orange group
of pigments. It is called a precursor.
3. Xerophthalmia is an important world health problem: more than 1,000,000 children
go blind yearly, especially in developing countries.
4. Very low-fat diets decrease absorption.
5. Vitamin A must be bound to protein for transport.
6. Bile salts must be in the intestine for absorption.
7. Is stable at usual cooking temperatures. Cover pan recommended.
8. Processing and advance preparation cause only minimal loss.
9. Hypervitaminosis is usually from megavitamin supplements.
10. Excess intake of foods with beta carotene may discolor skin
(carotenosis/carotenemia) but is not harmful.
11. Beta carotene is being considered for prevention of certain types of skin cancer.

Module III Page 81

12. Excess preformed vitamin A from animal products or supplements taken during
pregnancy is known to cause birth defects. Provitamin A carotenes are not known
to cause birth defects.

VITAMIN D (CHOLECALCIFEROL)
 Vitamin D was first named in 1922 by researchers who learned of a fat soluble
substance that played an important role in bone growth
 Activated by ultraviolet light
 regulates calcium and phosphorus to make bones strong
 Vitamin D is unusual because its most active form is one of the most powerful
hormones in the human body.
 Forms: Vitamin D3 , cholecalciferol, is made in the skin or taken as a
supplement, Calcidiol is the storage and circulating form of vitamin D.
Calcitriol is the active form of vitamin D. Vitamin D2 , ergocalciferol, is made
by irradiating fungi

Functions
 Promotes the absorption of calcium and phosphorus in the intestine.
 Helps maintain blood calcium and phosphorus levels for normal bone
calcification.
 Aids in formation of bone matrix.
 The calcitriol made in tissues outside of the kidneys may play an anticancer
role by slowing cell division.

Food Sources/Recommended Intake

 For adults 19–30 years AI, male, female: 5 µg/d
 Sources:
o irradiated fortified vitamin D o egg yolk
milk o butter
o minimal amounts present in fish
 Primary food source
o Fish
o liver (cod liver, halibut liver) oils
 Synthetic form
o from irradiation of plants
o used most in supplements and dairy products
 Principal source
o Sunlight; ultraviolet rays penetrate a cholesterol-like substance in the
skin which is converted to active vitamin D in the kidneys

Results of Deficiency or Excess

 Deficiency
o rickets, serious decalcification of bones in children, osteomalacia
(tender, painful bones in adults), tooth decay
 Excess/ (Hypervitaminosis D)
o high blood calcium levels o vomiting, diarrhea,
o kidney damage weight loss
o growth retardation

Module III Page 82

Conditions Requiring Increase in intake
 Invalids (housebound)
 Individuals who are rarely exposed to sunlight
 Premature infants
 Children of strict vegetarians who drink no fortified milk
 Pregnancy and lactation
 Early childhood
 Breast-fed infants
 Any disease that interferes with fat absorption or vitamin D absorption
 Chronic renal failure
 Certain drug therapies that interfere with absorption
 Dark-skinned people

Specific Characteristics
1. Ultraviolet light is filtered out by smog, fog, smoke, and window glass.
2. Can be classified as a hormone since it can be made by the body.
3. Milk, unless fortified, is a poor source of vitamin D.
4. As much as 95% of ultraviolet rays for conversion to vitamin D may be prevented in
dark skinned races.
5. Vitamin D permits 30 to 35% absorption of ingested calcium: without it only 10% is
absorbed.
6. Fifteen minutes of summer sun in a bathing suit makes an average of 20,000 IU of
vitamin D— 100 times the adequate daily intake.
7. UVB does not penetrate glass, so time in a closed car is not helpful.

VITAMIN E (TOCOPHEROL)
 Tocopherols were discovered at the University of California at Berkeley in
1922, where they were found to be essential to maintain fertility.
 The word tocopherol means “to bear offspring” and derives from the Greek
root phero, which means “to bring forth,” and the Greek root tos, which
means “childbirth.”
 Forms: alpha-tocopherol (only form of vitamin E that the human body actively
works to keep in the bloodstream), beta-tocopherol, gamma-tocopherol
(potent anticoagulant), and delta-tocopherol
 Tocotrienols
o alpha- tocotrienol, beta- tocotrienol, gamma- tocotrienol, and delta-
tocotrienol
 The principal fat-soluble antioxidant

Functions
 The only demonstrated function is as an antioxidant
o protects vitamin A and unsaturated fats from destruction; protects red
and white blood cells from destruction by preventing oxidation of cell
membrane
o Tocopherols and tocotrienols have the ability to donate a hydrogen
atom to neutralize free radicals

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 o Vitamin E is built into LDL for protection from oxidation that can lead to
clogged arteries
 Protects vitamin C and fatty acids.
 Believed to enter into biochemical changes that release energy.
 Assists in cellular respiration.
 Helps synthesize other body substances.
 Helps maintain intact cell membranes.

Food Sources/Recommended Intake

 For adults 19–30 years
o RDA, male, female: 15 mg/d
o Tolerable upper intake level of 1000 IU daily prevents excess bleeding
 Supplemented as acetate ester form and the succinate ester form
 Best Sources (plant)
o vegetable oils o wheat germ
o margarines o nuts
o shortenings o whole grains
o sunflower seeds o almonds
 Good Sources (animal)
o liver o butter
o codfish o human milk
Results of Deficiency or Excess
 Deficiency
o none observed except in premature infants or small-for-gestational-age
(SGA) infants
o Severe deficiency:
 Can cause rupture of RBC membranes
 neurological problems including impaired vision and poor muscle
coordination (prolonged deficiency)
 Excess
o headache o blurred vision
o nausea o skin changes
o fatigue o thrombophlebitis
o dizziness

Conditions Requiring Increase in Intake

 Premature infants (or SGA)
 Whenever greater amounts of polyunsaturated fats are ingested
 Possibly in disorders resulting in fat malabsorption

Special Characteristics
1. Does not travel well across placenta of pregnant women.
2. Is usually given with vitamin A when there is a vitamin A deficiency.
3. Vitamin E content of breast milk is adequate for the infant.
4. Many animal disorders have responded to vitamin E therapy but have not been
effective for humans. For this reason, vitamin E is the most controversial of all
vitamin therapies.
5. Contrary to popular opinion, excess intake creates side effects.

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6. The role of vitamin E as an antioxidant is being linked to retardation of the aging
process.
7. Vitamin E is easily destroyed by heat and oxidation.

VITAMIN K (Quinone)
 Vitamin K was discovered by a Danish scientist, Henrik Dam, in the late 1920s.
He discovered a factor that was causing excessive bleeding and was missing
from some diets. He published his work in a German journal and called the new
coagulation vitamin Koagulations vitamin. The initial letter in this word is how
vitamin K got its name.
 Forms: Phylloquinone as Vitamin K1(synthesized by plants); Menaquinone as
Vitamin K2 (synthesized by the bacteria in large intestines); Menadione as
Vitamin K3 (no longer used)

Functions
 Prothrombin formation (prothrombin is a protein that converts eventually to
fibrin, the key substance in blood clotting) in the liver
 Blood coagulation
 Vitamin K is needed to enable osteocalcin to bind minerals to bones for bone
mineralization

Food Sources/Recommended Intake

 For adults 19–30 years
1. AI male: 120 µg/d AI
2. AI female: 90 µg/d
3. Supplemental Vitamin K is in the form of phylloquinone
 The two sources are:
1. intestinal bacteria
2. food sources: dark green vegetables, cauliflower, tomatoes, soybeans,
wheat bran, kale, collards, canola oil, spinach, beet greens
 small amounts in:
o egg yolk o cheese
o organ meats

Results of Deficiency or Excess

 Deficiency
o hemorrhaging when blood does not clot
o In infants, vitamin K deficiency can cause intracranial hemorrhage
(bleeding inside the skull) and can be life-threatening
 Infants are given 1000 mcg of vitamin K1 (phylloquinone) at birth
 Excess
o irritation of skin and respiratory tract with the synthetic form,
menadione
o toxicity found only in newborns who are administered doses above 5 mg
o causes excessive breakdown of red blood cells
o brain damage

Conditions Requiring Increase in Intake

 Newborn infants

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  Persons on antibiotics
 Persons with diseases where there is chronic diarrhea or poor absorption
 Possibly prior to surgery

Special Characteristics
1. Deficiency is rare since it is synthesized by intestinal bacteria. Food sources not
usually needed by healthy people.
2. The intestinal tract of the newborn may be free of bacteria for several days.
3. Antibiotics kill the natural bacteria in the intestine.
4. Higher vitamin K levels may be protective against osteoporosis and age-related
fracture.
5. Vitamin K is absorbed from the intestines with the help of bile salts.

Concept Check!

1. List the fat soluble vitamins and their precursors. What are their main
sources?
2. Explain the role played by
(a) Vitamin A in vision.
(b) Sunlight in synthesis of Vitamin D.
(c) Vitamin K in the blood clotting process.
3. Why should an overdosage of vitamins A and D be avoided?
4. Explain what happens when there is a deficiency of vitamin A in the diet.

WATER SOLUBLE VITAMINS

B VITAMINS
 The primary role of the B vitamins is catalyzing energy production in the body
 The B vitamins are needed for healthy nerve conduction and thus muscle action
 They are needed for the synthesis of many important neurotransmitters, such
as acetylcholine, serotonin, dopamine, and norepinephrine.
 B vitamins are also indispensable for the synthesis of fats used in the myelin
sheaths of nerve cells
 The vitamin B complex is vital for the synthesis of fatty acids.
 Some of the B vitamins are useful in protecting us from free radical attack.
 B vitamins can lower homocysteine levels to reduce our risk of heart disease.
 B vitamins help us eliminate certain drugs, carcinogens, and steroid hormones.
VITAMIN B1 —THIAMIN
 Thiamin was first discovered in Japan in the early 1900s, when the lack of
thiamin in white rice caused beriberi.
 Thiamin is part of the coenzyme Thiamin PyroPhosphate (TPP), which helps
convert pyruvate to acetyl-coenzyme A (also known as acetyl-CoA) – necessary
for the production of energy from carbohydrates
 Thiamin Coenzyme forms are: Thiamin PyroPhosphate (TPP) and Thiamin
Triphosphate (TTP) (found in nerve and muscle cells)
 Thiamin is easily destroyed by heat and leached by cooking water
Module III Page 86
Functions
 Releases energy from fat and carbohydrate.
 Helps transmits nerve impulses.
 Breaks down alcohol.
 Promotes better appetite and functioning of the digestive tract.

Food Sources/Recommended Intake

 For adults 19–30 years
o RDA, male: 1.2 mg/d
o RDA, female: 1.1 mg/d
 Excellent Sources
o sunflower seeds o peanuts
o sesame seeds o animal sources: liver,
o soybeans kidney, pork
o wheat germ
 Good Sources
o enriched cereals o whole grains
o enriched pasta o oatmeal animal
o enriched or brown rice o sources:
o eggs, poultry

Results of Deficiency or Excess

 Deficiency/
o acute: beri-beri - means “I cannot”, major symptoms are paralysis,
heart, and vessel impairment
o subacute: loss of appetite, vomiting, leg cramps, mental depression,
edema, weight loss
o Wernicke’s encephalopathy - Alcohol induced thiamin deficiency which
affects mental alertness, short-term memory, and muscle coordination.
 Excess
o No evidence of toxicity in excess amounts. May create a shortage of
other B vitamins if taken exclusively

Conditions Requiring Increase in Intake

 Any condition that increases metabolic rate
 Alcoholism
 Old age (whether elderly are on low-calorie diets or not)
 Pregnancy and lactation growth periods
 People on fad diets
 Illness/stress conditions
 Athletic training (whenever extra need for kcal)

Special Characteristics
The B vitamins have four common properties:
1. All of them function as coenzymes in biochemical reactions.
2. All are water soluble.
3. All are natural parts of yeast and liver.

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 4. All promote the growth of bacteria.
5. If there is a deficiency in one of the B vitamins, there will be deficiencies in
the others.
6. The B vitamins function together— excess of one creates greater need for the
others.
7. Converted rice contains more thiamin than other types of rice.

VITAMIN B2—RIBOFLAVIN
 discovered as a growth factor in the early nineteenth century
 has a greenish-yellow color, which led to one of its early names, vitamin G
 easily destroyed by light, especially ultraviolet light

Functions
 Releases energy from fat, carbohydrate, and protein.
 Essential for healthy skin and growth.
 Promotes visual health.
 Functions in the production of corticosteroids and red blood cells.
 Riboflavin does its primary work as part of a coenzyme named Flavin Adenine
Dinucleotide (FAD)
 Coenzymes derived from riboflavin are called flavins and are needed for the
metabolism of carbohydrates, fats, and proteins
 Flavins derived from riboflavin play a vital role in the metabolism and
elimination of toxins, drugs, carcinogens, and steroid hormones.
 FAD is needed to reduce (recharge) the glutathione (an antioxidant) and return
the glutathione to its protective state
 Another coenzyme made from riboflavin is Flavin MonoNucleotide (FMN). FMN is
needed for the activation of pyridoxine (vitamin B6).

Food Sources/Recommended Intake

 For adults 19–30 years
o RDA, male: 1.3 mg/d
o RDA, female: 1.1 mg/d
 Excellent Sources
o milk o yeast
o cheese o liver and kidney
o wheat germ
 Good Sources
o meat, o dark green leafy
o poultry, vegetables
o fish eggs o dry beans and peas
o nuts
Results of Deficiency or Excess
 Deficiency (Ariboflavinosis)
o lesions around the mouth and nose hair loss
o scaly skin
o failure to thrive (children)
o light sensitivity clouding of the cornea of the eye
o weight loss

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 o glossitis
o A deficiency of riboflavin will reduce the efficiency of glutathione
 Excess
o no evidence yet that this nutrient is toxic in large amounts
o When it is taken in excess of needs, riboflavin is responsible for the
bright yellow color of urine

Conditions Requiring Increase in Intake

 Increase in body size, metabolic rate, or growth rate, such as pregnancy,
lactation, and growth
 Alcoholism
 Poverty
 Old age
 Strict vegetarian diets that prohibit meat, eggs, and milk
 Stress and malabsorption of nutrients
 Any condition where there is loss of gastric secretions (achlorhydria) may
precipitate a deficiency
 Following burns or any surgical procedure where there is extensive protein loss

Special Characteristics
1. No evidence that the requirement for B2 goes up as kcal rise.
2. Few individuals in the U.S. show any deficiency.
3. Foods high in calcium are usually high in B2.
4. Before riboflavin is absorbed it must be phosphorylated (combined with
phosphorus). Both are found in milk and cheeses.
5. Is sensitive to light; should be kept in opaque containers.
6. Cooking and drying may enhance the availability.
7. Only partially water-soluble.
8. If a deficiency occurs, multiple B vitamins are given because of their
interrelationships.
9. B2 is destroyed by alkaline.

VITAMIN B3 —NIACIN
 can be found in two different forms, niacin and niacinamide
 Niacin is chemically known as nicotinic acid
 Niacinamide is chemically known as nicotinamide
 there is no chemical relationship to the nicotine in tobacco
 Niacin is used in two coenzyme forms, Nicotinamide Adenine Dinucleotide
(NAD) and Nicotinamide Adenine Dinucleotide Phosphate (NADP)
 Niacin can be made in the body from the essential amino acid tryptophan.

Functions
 Releases energy from carbohydrates, protein, fat.
 Synthesizes proteins and nucleic acids.
 Synthesizes fatty acids from glucose.
 Nicotinic acid has been used to lower blood cholesterol in large doses of 3000
mg or more per day

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Food Sources/Recommended Intake
 For adults 19–30 years
o RDA, male: 16 mg/d
o RDA. female: 14 mg/d
 Excellent Sources
o yeast o sunflower seeds
o peanuts and peanut o animal sources: beef,
butter poultry, fish, organ
o soybeans meats especially high
o sesame seeds
 Good Sources
o meats o enriched cereals,
o nuts o bread,
o wheat germ o pasta

Results of Deficiency or Excess

 Deficiency
o acute: Pellagra- 3 Ds of Pellagra symptoms: 1. Dermatitis (inflammation
of the skin); 2. Diarrhea (inflammation of the gastrointestinal tract); 3.
Dementia (mental confusion); (if untreated: add death)
o subacute: weakness, indigestion, anorexia, lack of energy, cracked skin,
sore mouth and tongue, failure to thrive (children), insomnia,
irritability, mental depression; damage to the skin, gastrointestinal
tract, and central nervous system
 Excess (megadose treatment for certain conditions)
o severe flushing
o glucose intolerance because of decreased insulin sensitivity
o gastrointestinal disorders
o irregular heartbeat
o vision disturbances
o liver damage

Conditions Requiring Increase in Intake

 Whenever more kcal are consumed, e.g., pregnancy/lactation
 illness
 stress
 chronic alcoholism
 intestinal disorders

Special Characteristics
1. Niacin is synthesized in the body from tryptophan, an essential amino acid. Diets
adequate in protein are adequate in niacin.
2. Niacin is stable in foods; it can withstand reasonable periods of heat, cooling, and
storage.
3. Niacin is water soluble; use the cooking liquids (do not drain off).

VITAMIN B5 - PANTOTHENIC ACID

 It has been found in every living cell including plant and animal tissues as well
as in microorganisms.

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  Pantothenic acid was first identified in 1933 when Roger Williams detected it
as a growth factor for yeast.
 Pantothenic acid forms a large part of coenzyme A, which is essential for the
chemical reactions that generate energy from carbohydrates, fats, and proteins
 easily destroyed by freezing, canning, and refining

Functions
 Helps release energy from carbohydrates, fat, and protein.
 Aids in formation of cholesterol, hemoglobin, and other hormones.
 Assists in synthesizing certain fatty aids.

Food Sources/Recommended Intake

 For adults 19–30 years
o AI, male, female: 5 mg/d
 Richest Sources
o liver, o whole grains
o kidney o Is found in every plant
o fish and animal food

Results of Deficiency or Excess

 Deficiency
o uncommon; not observed under normal conditions
o Induced deficiencies cause headaches, insomnia, nausea, vomiting,
tingling of hands and feet poor coordination
 Excess
o no toxicity observed
Conditions Requiring Increase in Intake
1. Rare Situations
o severe malnutrition (e.g., prisoner of war, starving children)
Special Characteristics
1. Most commonly occurring of all the vitamins
2. Name taken from the Greek word pantos and means “everywhere”

VITAMIN B6 (PYRIDOXINE)
 discovered in the 1930s
 Vitamin B6 Coenzyme form is: Pyridoxal Phosphate (PLP)
 PLP is a coenzyme to the enzyme glycogen phosphorylase, which catalyzes the
release of glucose from glycogen, and is also needed in the convertion of
protein into glucose (gluconeogenesis)
 Serotonin is synthesized from tryptophan in the brain with the help of PLP.
 The vitamin B6 coenzyme PLP is needed to convert tryptophan to niacin.
 easily destroyed by heat and can be leached out into cooking water.

Functions
 Forms reactions that break down and rebuild amino acids.
 Produces antibodies and red blood cells.
 Aids functioning of the nervous system and regeneration of nerve tissue.
 Changes one fatty acid into another.

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Food Sources/Recommended Intake
 For adults 19–30 years
o RDA, male, female: 1.3 mg/d
 Excellent Sources
o yeast o avocado
o sunflower seeds o banana
o wheat germ o animal source: liver
o wheat bran
 Good Sources
o Meats o whole grains
o poultry o nuts
o fish

Results of Deficiency or Excess

 Deficiency
o decreased antibody production
o anemia
o vomiting
o failure to thrive (children)
o skin lesions
o liver and kidney problems
o central nervous system abnormalities: confusion irritability depression
convulsions
 Excess
o no toxicity reported with megadoses, but dependency may be induced
with large doses

Conditions Requiring Increase in Intake

 Increased protein intake
 Pregnancy
 Use of oral contraceptive agents, isoniazid
 Advancing age

Special Characteristics
1. B6 deficiencies occur almost entirely in wealthy, developed countries.
2. The essential fatty acid, linoleic, is converted to arachidonic acid.
3. Converts tryptophan to niacin.
4. Involved in conversions and catabolism of all the amino acids.
5. Alcohol and isonicotinic acid hydrazide (INH, drug used to treat tuberculosis)
depletes B6 in the body

VITAMIN B7 BIOTIN
 The name biotin is taken from the Greek word bios, which means life
 Also known as Vitamin H, means “Haar und Haut” – German words for “hair and
skin”
 Biotin was discovered in late 1930s when animals developed skin problems
when fed only egg whites.

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  Biotin can only be synthesized by bacteria, algae, yeasts, molds, and a few
plant species.
 Biotin Coenzyme forms are:
o Acetyl-CoA carboxylase helps make fatty acids
o Pyruvate carboxylase helps make blood sugar from fats and protein
o Methylcrotonyl-CoA carboxylase helps metabolize the amino acid
leucine
o Propionyl-CoA carboxylase helps burn fats

Functions
 Acts as a coenzyme in metabolism of fat and carbohydrate.

Food Sources/Recommended Intake

 For adults 19–30 years
o AI, male, female: 30 µg/d
 Richest Sources
o liver/kidney o yeast
o egg yolk o Is found in almost all
o milk foods

Results of Deficiency or Excess

 Deficiency
o Uncommon; intestinal bacteria produces biotin. can be induced large-
scale use of raw eggs as in tube feedings, etc., may cause development
of symptoms such as:
 nausea  glossitis
 muscle pain  abnormal EKG (electrocardiogram)
 dermatitis  elevated cholesterol level

Conditions Requiring Increase in Intake

 Anyone consuming raw eggs in quantity
 Some infants under age of 6 mo.

Special Characteristics
1. Biotin can be bound by avidin, a protein in raw egg, and becomes unavailable
to the body. Cooking inactivates this bond, so cooked egg whites do not bind
biotin.

VITAMIN B9 FOLIC ACID (FOLACIN, FOLATE)

 Folates were first extracted from dark leafy vegetables and given the name
folic acid from the Latin word for leaf.
 Folate Coenzyme form is: Tetra HydroFolate (THF)
 Folate coenzymes act as acceptors and donors of one-carbon units in a variety
of reactions needed in the metabolism of amino acids and also nucleic acids.
 easily destroyed by oxygen and heat

Functions
 Synthesizes the nucleic acids (RNA,DNA).
 Essential for breakdown of most of the amino acids.
Module III Page 93
  Necessary for proper formation of red blood cells.
 Folate, along with vitamin B12, is needed in the synthesis of methionine and
methionine is needed to synthesize S-adenosylmethionine (SAMe),
o SAMe is used as a methyl donor at many sites within both DNA and RNA.
A methyl donor is any substance that can transfer a methyl group (CH3)
to another substance.
o These methyl groups can protect DNA against the changes that might
lead to cancer.
o Synthesis of methionine from homocysteine (an amino acid) is also
important to prevent a buildup of homocysteine in the blood.

Food Sources/Recommended Intake

 For adults 19–30 years
o RDA, male, female: 400 µg/d
 Excellent Sources
o liver/kidney o asparagus
o yeast o broccoli
o oranges/orange juice o wheat germ
o green leafy vegetables o nuts
 Good Sources
o melons o pumpkin
o sweet potato

Results of Deficiency or Excess

 Deficiency
o slows growth, interferes with cell regeneration
o Macrocytic Anemia (red blood cells are large and too few and have less
Hgb than normal)
o Megoblastic Anemia (young red blood cells fail to mature, reduction in
white blood cells; also histidine, an amino acid, not utilized)
o Neural Tube Defects (NTDs) – e.g. anencephaly (brain fails to develop),
spina bifida (neural tube fails to close during embryonic development
and the spinal cord remains on the outside of the body)
o Increase in homocysteine levels in blood which is associated with
thickening of arterial walls, arterial wall deterioration, and blood clot
formation
 Excess
o no toxic effect from megadose, but will mask pernicious anemias,
vitamin supplements may not contain more than 0.1 mg/folacin (by law)

Conditions Requiring Increase in Intake

 Whenever the metabolic rate is high: pregnancy/lactation infections/fever
growth of malignant tumors hyperthyroidism anemias
 Excess alcohol intake
 Use of oral contraceptive agents
 Malabsorptive disorders
 Certain other diseases, e.g., leukemia
 Hodgkin’s disease cancer
 Use of drugs in anticonvulsant therapy
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  When chemotherapy is used for cancer

Special Characteristics
1. When there is a folic acid deficiency, the diet must include all the other nutrients
needed to produce red blood cells, i.e., protein copper iron B12/vitamin C
2. Persons with macrocytic or megoblastic anemia have sore mouths and tongues; soft
bland foods or liquids may be needed.
3. Prolonged cooking destroys most of the folacin.
4. Folic acid deficiency is common in the third trimester of pregnancy; the
requirement is six times the normal amount.
5. High levels of folic acid supplementation, especially above 1000 mcg daily, can
mask symptoms of vitamin B12 deficiency
6. Drugs that can interfere with folate include aspirin, anticancer drugs, antacids,
and oral contraceptives.

VITAMIN B12 (COBALAMIN)

 Vitamin B12 is unusual for a vitamin in that it contains cobalt.
 The name, cobalamin, derives from “cobal” from the word cobalt plus “amin”
from the word vitamin (cobal-amin).
 Cobalamin Coenzyme forms are: Methylcobalamin and Deoxyadenosyl
Cobalamin

Functions
 Aids proper formation of red blood cells.
 Part of the RNA-DNA nucleic acids; is therefore essential for normal function of
all body cells, especially gastrointestinal tract, nervous system.
 Bone marrow formation.
 Used in folacin metabolism.
 Prevention of pernicious anemia.
 Convert homocysteine (a risk factor for cardiovascular disease) to methionine.

Food Sources/Recommended Intake

 For adults 19–30 years
o RDA, male, female: 2.4 µg/d
 Animal products are the main food sources: clams/oysters organ meats eggs
shrimp chicken pork hot dogs

Results of Deficiency or Excess

 Deficiency
o glossitis
o anorexia
o weakness
o weight loss
o mental and nervous symptoms
o abdominal pain
o constipation/diarrhea
o macrocytic anemia and if intrinsic factor also missing: pernicious
anemia (a form of megaloblastic anemia that is caused by destroyed
gastric parietal cells that produce intrinsic factor)
Module III Page 95
  Excess
o no toxicity observed; but at high doses, vitamins are considered drugs
and often create imbalances in the functioning of other nutrients.

Conditions Requiring Increase in Intake

 Strict vegetarian diet (vegans)
 Malabsorption
 Stomach injury
 Total gastrectomy
 Pregnancy and lactation
 Old age

Special Characteristics
1. The normal liver will store enough B12 to last for two to five years.
2. B12 is made only by microorganisms in the intestines.
3. Only 30%–70% of what is consumed is absorbed.
4. B12 must bind to the intrinsic factor, which is a protein secreted by the stomach
lining.
5. Calcium is also necessary in this reaction.
6. Absorption of B12 is influenced by body levels of B6.
7. The elderly are at highest risk of developing pernicious anemia.
8. Smooth, bland foods are indicated for megaloblastic and pernicious anemia (the
mouth is sore).
9. All foods needed for blood cell production included.
10. Circulating vitamin B12 is recovered by the liver and returned to the intestines in
bile. Most of this vitamin B12 is reabsorbed from the intestines.

OTHER B VITAMINS (But might not be a vitamin)

Vitamin B4 – Choline
 Choline is synthesized in the body, but enough is not always made to meet
needs.
 In order to make choline, the body needs sufficient methionine, vitamin B12,
and folic acid.
 Most of the choline in the body is found in phospholipids.
 Choline is also a precursor for acetylcholine, an important neurotransmitter
involved in muscle control, and memory.
 Without choline to make lecithin, the liver cannot rid itself of fats and
cholesterol, which can lead to a condition known as “fatty liver.”
 adequate daily intake (AI):550 mg for men;425 mg for women
 food sources include Brussels sprouts, broccoli, peanut butter, and salmon
 tolerable upper intake level for choline is 3.5 grams per day for adults
 Very high levels of choline can disturb the neurotransmitter balance in the
brain.

Vitamin B10 – Bara-aminobenzoic acid (PABA)

 Para-Aminobenzoic Acid (PABA) is sometimes referred to as a B vitamin.
 not a vitamin and is not essential for nutrition

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  a non-protein amino acid.
 found in many sunscreen lotions

Vitamin B13 – Orotic Acid

 Orotic acid has not been proven to be essential for human nutrition so it is not
officially a vitamin. Its functions are similar to vitamin B12 and it enhances the
usefulness of vitamin B12 and folate

Vitamin B20 – L-carnitine

 a derivative of the essential amino acid lysine
 named after meat (carnus) because it was first isolated from meat in 1905
 L-carnitine is important in energy metabolism. It assists activated fatty acids
into the mitochondria for energy production. It also assists in transporting
metabolic debris out of the mitochondria.
 One of the early symptoms of vitamin C deficiency is fatigue, which may be
related to decreased synthesis of L-carnitine.

Alpha-Lipoic Acid
 Alpha-lipoic acid is needed for several important mitochondrial enzyme
complexes for energy production and the breakdown of amino acids.
 An antioxidant itself, alpha-lipoic acid is able to recharge other antioxidants
such as vitamin C and glutathione.
 Lipoic acid, like thiamin and biotin, contains sulfur.
 Alpha-lipoic acid is approved for the treatment of diabetic neuropathy and is
available by prescription in Germany.

Bioflavonoids
 Bioflavonoids are excellent antioxidants found in many plant foods.
 As potent antioxidants, they protect us from arterial damage and cancer
formation.
 Parsley and elderberry have the highest content of bioflavonoids.

Coenzyme Q10
 not a vitamin, but plays many necessary biological roles in the body.
 can be synthesized in the body and so it cannot be considered a vitamin
 a powerful fat-soluble antioxidant found in virtually all cell membranes.
 needed for mitochondrial energy production.

Inositol
 can be made in the body from glucose, so it is not a vitamin.
 Inositol consumption from the average diet is about one gram daily.
 In the form of phosphatidylinositol, inositol makes up a small but important
part of cell membranes.
 Inositol is widely found in cereals and legumes and is a component of dietary
fiber.

VITAMIN C

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  Discovered by Albert Szent-Györgyi, first found a six-carbon compound,
hexuronic acid, which he named later as ascorbic acid (chemical name)
 Named after it’s ability to cure scurvy
o a – “without”
o scorbic – “having scurvy”

Functions
 Essential in formation of collagen, a protein that binds cells together.
 Needed to heal wounds build new tissue, and provide strength to supporting
tissue.
 Aids formation of bone matrix and tooth dentin.
 Absorbs iron, which promotes prothrombin formation.
 Helps maintain elasticity of blood vessels and capillaries.
 Acts as an antioxidant, protecting the cells from oxidation.
 Has a sparing effect on several vitamins, especially A, B, and E.
 Vitamin C works in two ways to lower cholesterol. Vitamin C is needed to
change cholesterol into bile in the liver. Vitamin C helps contract the
gallbladder to release bile.

Food Sources/Recommended Intake

 For adults 19–30 years
o RDA, male: 90 mg/d
o RDA. female: 75 mg/d
 Excellent Sources
o chili peppers o strawberries o grapefruit (and
o green peppers o papaya juice)
o parsley o oranges (and o guava
o broccoli juice) o tangerines
o kale o lemons o cantaloupe
o cabbage o watermelon
 Good Sources
o tomatoes (and juice) o sweet potatoes
o white potatoes (with skin o honeydew melon
on) pineapple
 The only animal source of vitamin C is liver.

Results of Deficiency or Excess

 Deficiency
o acute deficiency
 scurvy (a hemorrhagic disease where muscles degenerate, skin
becomes rough, brown, scaly, and dry)
 delayed wound healing
 failure to thrive (children)
 decayed and breaking teeth
 iron deficient
 gingivitis
 anemia (if iron intake is also low)
 low resistance to infection (especially infants)
 small vessel hemorrhage seen under skin easy bruising
Module III Page 98
  Excess (specific effects depend on the individual’s tolerance level)
o rebound scurvy
o interference with certain drugs
o gastrointestinal upsets and diarrhea
o bladder irritations
o kidney stones
o interference with anticoagulant drug therapy

Conditions Requiring Increase in Intake

 Pregnancy and lactation
 Malnutrition
 Alcoholism/drug addiction
 Infections, burns, injuries, fever
 Certain drug therapies, e.g., isoniazid, oral contraceptives agents
 High stress condition

Special Characteristics
1. Humans, along with other primates, guinea pigs, some birds, and fruit-eating
bats, cannot synthesize vitamin C.
2. Vitamin C is easily destroyed by heat, storage, exposure to air, dehydration
alkali (such as baking soda), and lengthy exposure to copper and iron utensils.
3. Vitamin C deficiency is rare in developed countries, but can occur in any cases
of serious neglect such as psychiatric problems, substance abuse, advanced
age, and lack of knowledge about nutrition.
4. Ascorbation is a process where an acidic vitamin is combined chemically with
an alkaline mineral. Calcium ascorbate and sodium ascorbate are the most
common forms.
5. Extra care must be taken in preparation of foods containing vitamin C to
prevent excessive loss:
a. use small amount water
b. avoid prolonged cooking
c. cut up just before use
d. avoid leftovers
e. cook quickly, covered or steamed
f. use any cooking liquid (do not drain)

Concept Check!

1. List the main sources of (a) Thiamin (b) Riboflavin (c) Niacin.
2. Describe the symptoms of deficiency of (a) Thiamin (b) Riboflavin (c) Niacin.
3. Discuss the functions of pyridoxine, folic acid and cyanocobalamin in the body.
4. Discuss the functions of vitamin C.
5. What are the sources of vitamin C?
6. Describe the symptoms of vitamin C deficiency.

Module III Page 99

 Laboratory Activity
Search and discuss the following and write the answers in table form.
1. Vitamin-related diseases
2. Symptoms
3. Causes
4. Prevalence
5. Dietary changes

Diseases Symptoms Causes Prevalence Dietary

Changes

Module III Page 100

Lesson 2

 MINERALS

MINERALS
 minerals that are necessary to human nutrition are elements widely distributed
in nature
 Of the 118 elements on the periodic table, 25 are essential to human life.
These 25 elements, in varying amounts, perform a variety of metabolic
functions.
 Some minerals, when taken in excess, induce a relative deficiency of other
minerals. For example, excessive sodium causes calcium losses. The body needs
every one of the nutritional minerals. Deficiency of even one mineral should be
avoided.
 Because the body cannot make minerals, all minerals must be consumed in the
foods that we eat.

Classes of Minerals
1. Major Minerals/Macrominerals
 essential mineral nutrients required in the adult diet in amounts greater
than 100 milligrams per day
 The seven major minerals are calcium (Ca), phosphorus (P), sodium
(Na), potassium (k), magnesium (Mg), chloride (Cl), and sulfur (S).
2. Trace Minerals/Microminerals
 Microminerals are frequently referred to as “trace elements” because
they are present in the body in such small quantities (less than .005% of
body weight).
 essential mineral nutrients required in the adult diet in amounts less
than 100 milligrams per day
 The microminerals are iron (Fe), zinc (Zn), manganese (Mn), fluorine
(F), copper (Cu), cobalt (Co), iodine (I), selenium (Se), chromium (Cr),
and molybdenum (Mo).

Functions of Minerals
1. Structure
 Calcium and phosphorus give strength to bones and body frame.
 Iron provides the core for the heme in hemoglobin that carries oxygen
to the tissues and returns carbon dioxide to the lungs for excretion.
2. Metabolic
 Ionized sodium and potassium exercise control over body water.
 Iodine is a necessary constituent of the thyroid hormone that sets the
rate of metabolism in the cells.
 Iron is a cofactor in the mitochondrial enzyme system that supplies our
body with energy.

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Bioavailability of Minerals
 refers to the proportion of a food nutrient that can be successfully absorbed
and made available for body use
 Bioavailability is influenced by the food source and the host, as follows:
o Binding substances: In some plants, minerals are bound in chemical
complexes and not easily released. Oxalates in green leafy vegetables
and phytates in whole grains bind minerals and prevent their
absorption.
o Gastric acidity: Most minerals are better absorbed in an acid
environment.
o Chemical form: Iron cannot be absorbed in the ferric form; it must first
be reduced to ferrous iron for absorption to take place.
o Other foods in the meal: Some foods, such as tea, contain substances
that interfere with the absorption of certain minerals.
o Body need: Various minerals such as iron are absorbed at higher rates in
periods of active growth, pregnancy, and lactation.

Mineral Metabolism
 Digestion
- Minerals do not require a great deal of mechanical or chemical digestion
before absorption occurs.
 Absorption
- minerals from animal sources are usually more readily absorbed than those
from plant sources
- more is absorbed if the body is deficient than if the body has sufficient
quantities
- if the absorbing intestinal surface is affected by disease, its absorptive
capacity is greatly diminished
- Compounds found in foods may also affect the absorptive efficiency. For
example, the presence of fiber, phytate, or oxalate—all of which are found
in a variety of whole grains, fruits, and vegetables—can bind certain
minerals in the gastrointestinal tract, thereby inhibiting or limiting their
absorption.
 Transport
- Minerals enter the portal blood circulation and travel throughout the body
bound to plasma proteins or mineral-specific transport proteins (e.g., iron
is bound to transferrin in the circulation).
 Tissue Uptake
- The uptake of some minerals into their target tissue is controlled by
hormones, and excess minerals are excreted into the urine
- E.g. thyroid-stimulating hormone (TSH) controls the uptake of iodine from
the blood into the thyroid gland depending on the amount that the thyroid
gland needs to make the hormone thyroxine
 Occurrence in the body
- Minerals are found in several forms throughout body tissues.
- The two basic forms in which minerals occur in the body are as free ions in
body fluids (e.g., sodium in tissue fluids, which influence water balance)
and as covalently bound minerals that may be combined with other
minerals (e.g., calcium and phosphorus in hydroxyapatite) or with organic

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 substances (e.g., iron that is bound to heme and globin to form the organic
compound hemoglobin).

Mineral Alkalinity/Acidity
 Sodium (Na), magnesium (Mg), potassium (K), iron (Fe), and calcium (Ca) are
the minerals that produce an alkaline (base) residue (ash)
 The acid-forming elements are sulfur (S), phosphorus (P), and chlorine (Cl).

MAJOR MINERALS

CALCIUM (Ca)
 Present in largest amount in the body
 Ninety-nine percent of it is found in the bones and teeth. The remainder (1%) is
in body fluids, soft tissue, and membranes.
 Calcium balance:
o the intake-absorption-excretion balance,
o the bone-blood balance
o the calcium-phosphorus blood serum balance

Functions
 Aids bone and tooth formation.
 Maintains serum calcium levels.
 Aids blood clotting.
 Aids muscle contraction and relaxation.
 Aids transmission of nerve impulses.
 Maintains normal heart rhythm.

Food Sources/Recommended Intake

 AI (mg/d) Male & female (19–30 y): 1000
 Milk Group
o milk and cheeses o yogurt
 Meat Group
o egg (yolk) o salmon
o sardines,
 Vegetable Group
o green leafy vegetables o legumes nuts
 Grain Group
o whole grains

Results of Deficiency or Excess

 Deficiency (hypocalcemia)
o rickets (childhood disorder of calcium metabolism from a vitamin D
deficiency resulting in stunted growth, bowed legs, enlarged joints,
especially legs, arms, and hollow chest)
o osteomalacia (adult form of rickets: a softening of the bones)

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 o osteoporosis (widespread disorder, especially in women, wherein bones
become thin, brittle, diminish in size, and break)
o slow blood clotting
o tetany - marked by severe, intermittent spastic muscle contractions and
muscular pain, seizure and convulsions if not treated
o poor tooth formation
 Excess
o renal calculi
o hypercalcemia (deposits in joints and soft tissue)
Conditions Requiring Increase in Intake
 Low intake (any age)
 Low serum calcium due to: growth pregnancy lactation
 Any condition that causes excess withdrawal, such as:
o body casts
o immobility
o low estrogen levels

Special Characteristics
1. Body need is major factor governing the amount of calcium absorbed. Normally 30
to 40% of dietary calcium is absorbed.
2. Presence of vitamin D and lactose (milk sugar) enhance absorption.
3. An acid environment in the gastrointestinal tract enhances absorption (see acid
base balance).
4. Calcium in the bones and teeth are constantly withdrawn and replaced to keep the
serum level stable.
5. The parathyroid hormone controls regulation.
6. The intake of calcium and phosphorus should be 1:1 ratio for optimal absorption.
7. Tetany is a condition resulting from a deficiency of calcium that causes muscle
spasms in legs, arms.
8. Renal calculi are kidney stones. Ninety-six percent of all stones consist of calcium.
9. Overdoses of vitamin D can cause hypercalcemia, as can prolonged intake of
antacids and milk.
10. Acute calcium deficiency does not usually occur without a lack of vitamin D and
phosphorus also.
11. A high protein intake over extended periods of time can decrease the absorption
and increase the excretion of calcium.
12. Less calcium will be absorbed and deposited when body estrogen decreases.

PHOSPHORUS (P)
 “lightbearer”, from Greek word phÔs, meaning light and phoros, meaning
bearer
 Forms in the body: as free phosphorus ions in blood, in phospholipids, and in
hydroxyapatite in bones.

Functions
 Aids bone and tooth formation.

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  Maintains metabolism of fat and carbohydrates.
 Part of the compounds that act as buffers to CELL MEMBRANE POTENTIAL
control pH of the blood.
The sodium-potassium pumps in
Food Sources/Recommended Intake cell membranes maintain
 RDA (mg/d) Male & female (19–30 y): 700 concentrations of sodium and
 Meat Group (Best Source) potassium, which are very
o cheeses (especially cheddar, peanuts, different inside the cell than
beef, pork, poultry, fish, eggs they are outside the cell. Sodium
 Milk Group concentrations are 10 times
o milk and milk products higher outside cells than inside
 Vegetable/Fruit Group
cells. Potassium concentrations
o all foods in this group
are thirty times higher inside
 Grain
o wheat, oats, barley, rice
cells than outside cells, as shown
 Other carbonated drinks contain large amounts of in Figure 8-4. The active
phosphorus pumping of sodium and
potassium requires energy. It has
Results of Deficiency or Excess been estimated that about 30
 Deficiency - Hypophosphatemia percent of the energy used in
o rickets the body at rest is used to
o osteomalacia maintain this pumping action.
o osteoporosis The different concentrations of
o slow blood clotting these minerals create an
o poor tooth formation electrochemical gradient known
o disturbed acid–base
as the membrane potential. The
balance
control of cell membrane
 Excess (Hyperphosphatemia) same as calcium
potential is critical for heart
function, nerve impulse
Conditions Requiring Increase in Intake transmission, and muscle
 Low intake, especially of protein foods, due to: contraction.
o growth
o pregnancy
o lactation o illness

Special Characteristics
1. Approximately 80% of phosphorus is in bones and teeth in a ratio with calcium of
2:1.
2. Most of the phosphorus in the body is found in the form of phosphates. Phosphates
are the salts of phosphorus.
3. Aids in producing energy by phosphorylation (addition of a phosphate (PO4) group
to a molecule, usually a protein).
4. Phospholipids (phospho is phosphorus and lipids, fats) assist in transferring
substances in and out of the cells.
 The addition of a phosphate to a protein can change a protein from
hydrophobic (“water-hating”) to hydrophilic (“water-loving”).

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5. Phosphorus is more efficiently absorbed than calcium; approximately 70% is
absorbed. Some factors that enhance or decrease the absorption of calcium affect
phosphorus the same way.
6. Consumption of antacids lowers phosphorus absorption.
7. Both calcium and phosphorus are released from bone when serum levels are low.
8. Diets containing enough protein and calcium will be adequate in phosphorus.

SODIUM (Na)
 Na is from Latin name for sodium, Natrium
 Salt, which is essential for life , contains sodium and chlorine
 One teaspoon of salt weighs about five grams, and contains 2000 mg sodium (40
percent sodium)
 Sodium is important for maintaining blood pressure and fluid balance

Functions
 Maintains water balance.
 Normalizes osmotic pressure.
 Balances acid base.
 Regulates nerve impulses.
 Regulates muscle contraction.
 Aids in carbohydrate and protein absorption.

Food Sources/Recommended Intake

 Estimated minimum requirement: 2000 mg for a 24-year-old adult
 The maximum safe amount of sodium per day is set at 2400 mg sodium, just
over a teaspoon of salt
 table salt (40% sodium)
 milk and dairy foods
 protein foods (fish, shellfish, meat, poultry, eggs)
 processed foods: any containing baking soda, baking powder, and preservative
additives
 some drinking water is high in sodium
 some vegetables contain fair sources of sodium: spinach, celery, beets, carrots

Results of Deficiency or Excess

 Deficiency
o hyponatremia (low serum sodium): nausea, headache, anorexia, muscle
spasms, mental confusion, fluid and electrolyte imbalance
 Excess
o hypernatremia (high serum sodium)
o cardiovascular disturbances
o hypertension (Sodium retention in the kidneys can result in increased
water retention, which can result in increased blood pressure.)
o edema
o mental
o confusion

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Conditions Requiring Increase in Intake
 Excessive loss of body fluids: heavy use of diuretics, vomiting/diarrhea, heavy
perspiring, burns
 Certain diseases: cystic fibrosis
 Addison’s disease

Special Characteristics
1. More than half the body sodium is in the fluid surrounding the cells. It is the major
cation of the extracellular fluid. Its functions are very similar to potassium.
2. The kidneys remove all sodium from the blood and then add back just the right
amount of sodium to the blood. To adjust acid-alkaline balance and lower blood
acidity, the kidneys can excrete hydrogen ions (H+) and exchange them for sodium
ions (Na+).
3. Sodium is absorbed directly from the intestinal tract. Sodium travels freely in
blood and interstitial fluid. Excess sodium causes thirst, which triggers extra water
intake. This extra water flushes the extra sodium out through the kidneys.
4. Most Americans consume far more sodium than the RDA.
5. Extracellular fluids include fluid in the blood vessels, veins, arteries, and
capillaries.
6. Sodium is well conserved by the body.
7. Hyponatremia due to inadequate intake is uncommon. A condition causing excess
fluid loss such as described in column 4 (Conditions Requiring Increase) would be
necessary.
8. Hypernatremia is related to high incidence of hypertension in the United States.
9. Dietary guidelines for Americans encourage less consumption of sodium, especially
for those at high risk of developing high blood pressure.
10. Often a reduction in intake can be done simply by omitting salt added to food in
preparation or at the table. Elimination of high-salt snack foods and foods
preserved in salt also is helpful.
11. Certain drugs can cause lowered sodium levels. These drugs include some
diuretics, ibuprofen, naproxen, Prozac, and Elavil.
12. Processed food often contains too much sodium.
13. There is an increase in calcium loss with higher salt intakes, making excess salt a
risk factor in osteoporosis.

POTASSIUM (K)
 K is from Latin word, kalium
 Kalium comes from Arabic word alkali, which means cooked ashes

Functions
 Maintains protein and carbohydrate metabolism.
 Maintains water balance.
 Normalizes osmotic pressure.
 Balances acid base.
 Regulates muscle activity.

Food Sources/Recommended Intake

 AI (g/d); male & female (19–30 y): 4.7
 Milk Group
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 o all foods
 Meat Group
o all foods (best sources: red meats, dark meat, poultry)
 Vegetable/Fruit
o Group all foods (especially oranges, bananas, prunes)
 Grain Group
o especially whole grains Other coffee (especially instant)

Results of Deficiency or Excess

 Deficiency
o Hypokalemia – caused by excessive and prolonged vomiting, certain
drugs, and some forms of kidney disease
 fluid and electrolyte imbalances
 tissue breakdown
 Fatigue
o Severe hypokalemia: muscular paralysis or abnormal heart rhythms that
can be fatal
 Excess
o hyperkalemia
 renal failure
 severe dehydration
 shock
 weakness and tingling sensations
 cardiac arrest in extreme cases
 Gastrointestinal disturbance: nausea, vomiting, and diarrhea

Conditions Requiring Increase in Intake

 Inadequate intake (starvation, imbalanced diets)
 Gastrointestinal disorders, especially diarrhea
 Burns, injuries
 Diabetic acidosis
 Chronic use of diuretics
 Adrenal gland tumors

Special Characteristics
1. The major cation in the intracellular fluid.
2. Balances with sodium to maintain water balance and osmotic pressure.
3. When there are excess acid elements, potassium combines and neutralizes, thus
maintaining acid–base balance.
4. Potassium is poorly conserved by the body.
5. Hypokalemia is a condition where there is low serum potassium. It manifests itself
in muscle weakness, loss of appetite, nausea, vomiting, and rapid heartbeat
(tachycardia).
6. Hyperkalemia is a condition that causes serum potassium to rise to toxic levels. It
results in a weakened heart action that causes mental confusion, poor respiration,
numbness of extremities, and heart failure.
7. Potassium-rich foods, such as fruits and vegetables, increase the available acid
buffers in blood, especially bicarbonate which reduces blood acidity.

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MAGNESIUM (Mg)
 Magnesium in blood cells has three forms: bound to proteins, in stable
compounds, and as ionized magnesium (Mg++).
 Most of the magnesium in the body, about 60 percent, is used as part of the
structure of the bones.
 magnesium is found in the center of chlorophyll

Functions
 Assists in regulation of body fluids.
 Activates enzymes.
 Regulates metabolism of carbohydrate, fat, and protein.
 Necessary for formation of ATP (energy production).
 Component of chlorophyll.
 Works with Ca, P, and vitamin D in bone formation.
 Holds calcium in teeth to make teeth more resistant to cavities.
 Offsets calcium for properly controlled blood clotting.
 Magnesium and calcium work together to coordinate muscle contraction and
relaxation.

Food Sources/Recommended Intake

 RDA (mg/d) Male (19–30 y): 400 Female (19–30 y): 310
 grains, green vegetables, soybeans, milk, meat, poultry

Results of Deficiency or Excess

 Deficiency (Hypomagnesemia)
o fluid and electrolyte o spasms, muscle tremors
imbalance o digestive problems
o skin breakdown o personality changes
 Excess (Hypermagnesemia)
o possible from supplement use and may result in diarrhea

Conditions Requiring Increase in Intake

 Alcoholism
 Inadequate intake of Ca, P, or any disease affecting their use
 Growth Pregnancy
 Lactation Prolonged use of diuretics

Special Characteristics
1. Magnesium deficiencies occur most often in disease states such as cirrhosis of the
liver, severe renal disease, and toxemia of pregnant women.
2. American diets may be low in magnesium compared to RDAs if diet is low in
calories or contains mostly highly refined and processed foods.
3. Magnesium and calcium share a control system in the kidneys.
4. Magnesium is a potent vasodilator, opening blood vessels and lowering blood
pressure.

CHLORINE/CHLORIDE (Cl‾)

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  Chlorine is a poisonous, greenish-yellow gas in the halogen family of elements
and is used to disinfect water and is used as bleach.
 When chlorine is combined with sodium or hydrogen, it becomes a stable ion
called chloride.
 Chloride is the principal anion (negatively charged ion) in the extracellular
fluid that works with sodium to maintain the cellular membrane potential.

Functions
 Aids in maintaining fluid electrolyte balance and acid–base balance.
 Aids in digestion and absorption of nutrients as a constituent of gastric
secretion.

Food Sources/Recommended Intake

 AI (g/d); male & female (19–30 y): 2.3
 table salt (60% chloride)
 protein foods: seafood, meats, eggs, milk

Results of Deficiency or Excess

 Deficiency (temporary): heavy sweating, vomiting, or diarrhea, relieved by
normal food and water
o Intake is not usually a problem unless a condition as in next column
exists.
 Excess (rare): may increase risk of high blood pressure

Conditions Requiring Increase in Intake

 Excessive vomiting
 Aging (decreased gastric secretions)

Special Characteristics
1. Chloride is the chief anion of the fluid outside the cells.
2. The gastric (stomach) contents are primarily hydrochloric acid (HCI).
3. Chloride is a buffer in a reaction in the body known as the chloride shift. This
has the effect of maintaining the delicate pH balance of the blood.

SULFUR (S)
 Sulfur is part of biotin and vitamin B1 (thiamin).
 Forms in the body: found in glutathione, coenzyme A, methionine, cysteine,
and SAMe.

Functions
 Participates in detoxifying harmful compounds.
 Component of amino acids.

Food Sources/Recommended Intake

 RDA: not established
 protein foods that contain the amino acids methionine, cysteine, and cystine
(cheeses, eggs, poultry, and fish)

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Results of Deficiency or Excess
 No specific descriptions of a deficiency or excess, but may happen in cases of
severe protein deficiency.

Conditions Requiring Increase in Intake

 No specific conditions requiring an increase

Special Characteristics
1. Much information remains to be learned about the role of sulfur in human
physiology.
2. Greatest concentration is in hair and nails.
3. The pungent smell of burning hair is due to the sulfur compounds in hair.

TRACE MINERALS
 Trace elements have two major functions:
1. to catalyze chemical reactions
2. to serve as structural components of larger molecules
 They can be separated into two groups:
1. those that are known to be essential
2. those for which additional research is needed

IRON (Fe)
 From Latin word, ferrum, which means iron
 Three Forms of Iron
o Ferritin is used to store extra iron.
o Transferrin transports iron in the blood plasma.
o Hemosiderin is a compact storage of iron.

Functions
 Plays essential role in formation of hemoglobin.
 Is found in myoglobin, the iron-protein molecule in muscles.
 Iron is used to transport and store oxygen in blood and to store oxygen in
muscles.
 Iron is needed for the synthesis of DNA. This synthesis of DNA is vital to support
growth, healing, reproduction, and immune function.
 Iron is also required by enzymes involved in synthesizing collagen,
neurotransmitters, and hormones.

Food Sources/Recommended Intake

 RDA (mg/d) Male (19–30 y): 8 Female (19–30 y): 18
 liver, kidneys, lean meats, whole grains, parsley, enriched breads, cereals,
legumes, almonds
 dried fruit: prunes (and juice), raisins, apricots
 approximately 2 to 10% of iron in vegetables and grains can be absorbed,
compared with 10 to 30% absorption of iron from animal protein

Results of Deficiency or Excess

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  Deficiency
o Iron-deficiency anemia (IDA) - After iron stores are depleted, blood
cells begin to have less hemoglobin and the blood cells start to become
smaller than usual. With less hemoglobin than needed, oxygen delivery
to the cells becomes inadequate, especially during exertion.
 Symptoms: fatigue, rapid heart rate, reduced work capacity, and
rapid breathing upon exertion, limited ability to maintain body
temperature in cold conditions.
o Severe iron deficiency anemia can result in spoon-shaped, brittle
nails, taste bud atrophy, and mouth sores.
 Excess
o hemosiderosis: a focal deposition of iron that does not cause tissue or
organ damage
o hemochromatosis: a condition where iron is deposited in the liver and
body tissues; he cell becomes distorted and dies; the liver is damaged

Conditions Requiring Increase in Intake

 Girls and women of childbearing age due to menstrual losses (about 30 mg per
month lost)
 Pregnancy (supplementation with iron and folacin needed)
 Acute or chronic blood loss
 Inadequate protein intake
 Athletes

Special Characteristics
1. Approximately 3 ⁄4 of functioning iron in the body is in hemoglobin.
2. Hemoglobin is the principal part of the red blood cell, and carries oxygen from the
lungs to the tissues. It assists in returning CO2 (carbon dioxide) to the lungs.
3. Iron is only absorbed in an acid medium. Absorption is enhanced by ascorbic acid.
4. Milk is a very poor source of iron, containing only a trace.
5. Iron is not well absorbed in the body, even under good conditions. Generally about
10% in a mixed diet is absorbed.
6. Iron is the most difficult nutrient to meet through diet for women.
7. The following nutrients are essential for the manufacture of red blood cells:
a. iron, vitamin B6, and copper for hemoglobin formation
b. protein for globin formation
c. vitamin C to aid the absorption of iron
8. The populations at risk for iron deficiency anemia are: infants (6–12 months)
adolescent girls menstruating women pregnant women.
9. Iron deficiency is probably the most common nutrient deficiency in the United
States and the world. Iron deficiency affects about one billion people worldwide.
10. The body lowers blood iron in response to infections.
11. Absorption controls body supply; favored by body need, acidity, and reduction
agents such as vitamin C; hindered by binding agents, reduced gastric HCl,
infection
12. Transported as transferrin, stored as ferritin or hemosiderin
13. Excreted in sloughed cells, bleeding; no body mechanism for excretion

IODINE (I)

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  Iodine is the name of the element in food and iodide is the name of the ion
form found in the body. Only tiny amounts of dietary iodine are needed.

Functions
 Basic component of thyroxin, a hormone in the thyroid gland that regulates the
basal metabolic rate (BMR).
 Contributes to normal growth and development of the body.
Food Sources/Recommended Intake
 RDA (µg/d) Male & female (19–30 y): 150
 Iodized salt (major source)
 seafood: salt water fish food additives: dough oxidizers, dairy disinfectants,
coloring agents foods containing seaweed

Results of Deficiency or Excess

 Deficiency
o cretinism (stunted growth, dwarfism, extreme mental retardation,
resulting in intelligence quotients as low as 20)
o goiter (enlargement of thyroid gland)
o Hypothyroidism or low levels of thyroid hormones in the blood (dry
skin, swellings around the lips and nose, mental deterioration, and a
slow basal metabolic rate)
 Excess
o hyperthyroidism (toxic goiter)

Conditions Requiring Increase in Intake

 Wherever soil is low in iodine
 In areas where goiter is endemic
 In pregnant women with deficient diets

Special Characteristics
1. Certain foods contain substances that block absorption of iodine: cabbage,
turnips, rutabagas
2. Iodine-containing food additives may cause excess intake of iodine in some
areas of the United States.
3. Absorbed as iodides, taken up by thyroid gland under control of thyroid
stimulating hormone (TSH)
4. Excretion by kidney

ZINC (Zn)
 Zinc plays important roles in growth and development, neurological function,
the immune system, and in reproduction.
 Over 85 percent of the total body zinc is found in skeletal muscle and bone.

Functions
 Contributes to formation of enzymes needed in metabolism.
 Affects normal sensitivity to taste and smell.
 Aids protein synthesis.
 Aids normal growth and sexual maturation.

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  Promotes wound healing.
 May help in the treatment of acne.

Food Sources/Recommended Intake

 RDA (mg/d) Male (19–30 y): 11 Female (19–30 y): 8
 oysters, liver, meats, poultry, legumes, nuts

Results of Deficiency or Excess

 Deficiency
o associated with extreme malnutrition, severe burns and prolonged
diarrhea
o impairs wound healing
o decreases taste and smell
o dwarfism and impaired sexual development in children
o Severe zinc deficiency is normally seen only in individuals with genetic
disorders.
 Excess
o toxicity associated with ingestion of acid foods stored in zinc-lined
containers

Conditions Requiring Increase in Intake

 Following surgery, especially when diet has been inadequate prior to surgery
 Those with alterations in taste and smell
 Certain diseases of dark-skinned races, such as sickle cell anemia

Special Characteristics
1. Availability of zinc is greater from animal sources; vegetable sources contain
phytates, which bind it, causing its excretion.
2. Zinc supplementation can be added to oral rehydration therapy to significantly
increase survival with persistent childhood diarrhea. Adequate zinc can also reduce
the effect of bacterial toxins on the intestines.
3. Zinc supplementation has been found to help reduce the risk of age-related
macular degeneration in some studies.
4. Absorbed in small intestine
5. Stored in many tissues
6. Excretion largely intestinal

FLOURIDE (Fl)
 Fluoride is the ion form of the highly reactive element fluorine.
 Fluoride is not considered an essential trace mineral because it is not needed
for growth or life.
 Almost all of the fluoride in the body is found in bones and teeth.
 Forms in the body: fluoroapatite in bones and teeth

Functions
 Protects against dental caries.

Food Sources/Recommended Intake

 AI (mg/d) Male (19–30 y): 4 Female (19–30 y): 3
Module III Page 114
  seafood fluoridated drinking water (1 parts per million/PPM added to water)

Results of Deficiency or Excess

 Deficiency
o 50 to 70% cases of tooth decay from fluoride deficiency
 Excess:
o fluorosis mottled stains on teeth (children)
o dense bones mental depression (adults)

Conditions Requiring Increase in Intake

 Areas where no fluoride available
 elderly

Special Characteristics
1. Fluoride is being used to assist in regenerating bone loss due to osteoporosis in
selected studies.
2. Absorbed in small intestine; little known of bioavailability
3. Excreted by kidneys

COPPER (Cu)
o The chemical symbol for copper is Cu from the Latin name for copper, cuprum.
o There is less than one-tenth of one gram of copper in the human body.
o Forms in the body: found in cytochrome c oxidase, lysyl oxidase, and some
forms of superoxide dismutase.

Functions
 Considered “twin” to iron; aids in formation of hemoglobin and energy
production.
 Promotes absorption of iron from gastrointestinal tract.
 Aids bone formation.
 Aids brain tissue formation.
 Contributes to myelin sheath of the nervous system.

Food Sources/Recommended Intake

 RDA (µg/d) Male & female (19–30 y): 900
 liver, kidney, shellfish, lobster, oysters, nuts, raisins, legumes, corn oil

Results of Deficiency or Excess

 Deficiency
o occurs in association with disease states such as:
 PEM (protein energy  sprue (disease marked by
malnutrition) diarrhea)
 kwashiorkor (extreme protein  cystic fibrosis
deficiency)  kidney disease
 iron deficiency anemia
 Excess
o ingestion of large amounts is toxic to humans
o Menke’s Disease: a severe inborn error of metabolism; an X-linked
genetic disease of copper metabolism that currently has no treatment
Module III Page 115
 or cure. Individuals who are affected with Menkes’ disease progress
through neurodegeneration and connective tissue deterioration, and
they usually do not survive past childhood
o Wilson ’s disease: a rare autosomal recessive genetic disorder that
causes an abnormally high storage of copper in the body; can result in
liver and nerve damage that leads to death

Conditions Requiring Increase in Intake

 Disease states noted under Deficiencies

Special Characteristics
1. Copper is concentrated in the liver, brain, heart, and kidneys.
2. Absorption takes place in small intestine.
3. Other minerals can interfere with copper absorption.
4. Zinc is an antagonist to copper because it reduces absorption.

COBALT (Co)
 Cobalt (Co) is the central atom in the vitamin B12 molecule.
 While vitamin B12 is an essential nutrient, cobalt has not been established as
an essential nutrient.

Functions
 Acts as a component of vitamin B12.

Food Sources/Recommended Intake

 RDA: not established
 organ meats, muscle meat, vitamin B12

Results of Deficiency or Excess

 No specific deficiency in humans; deficient production of B12 noted in animals

Conditions Requiring Increase in Intake

 No specific conditions requiring an increase

Special Characteristics
1. RDAs for cobalt not established, but 15 mcg/day is suggested

MANGANESE (Mn)
 Manganese is essential in tiny quantities and is potentially toxic in larger
amounts.
 An adult body of approximately 150 lb contains 14 mg of manganese that is
found primarily in the brain, bone, liver, pancreas, and pituitary gland.
 Forms in the body: found in enzymes including manganese superoxide
dismutase.

Functions
 Appears necessary for bone growth and reproduction.
 Acts as an enzyme activator.

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Food Sources/Recommended Intake
 AI (mg/d) Male (19–30 y): 2.3 Female (19–30 y): 1.8
 nuts, legumes, tea, coffee, grains

Results of Deficiency or Excess

 No deficiencies noted in humans except protein energy malnutrition
 Excess:
o inhalation toxicity: an industrial occupation disease in miners and other
workers who are exposed to manganese dust over long periods,
producing severe neuromuscular symptoms that are similar to those of
Parkinson’s disease

Conditions Requiring Increase in Intake

 No specific conditions requiring an increase
 Protein energy malnutrition

Special Characteristics
1. Manganese has not been demonstrated to be an essential nutrient in humans.
2. Absorbed poorly.
3. Excretion mainly by intestine.

SELENIUM (Se)
 Selenium is a trace mineral that is essential in tiny amounts, but is toxic in
larger amounts.

Functions
 Parts of an enzyme that functions as an antioxidant (glutathione peroxidase).
 With vitamin E repairs damage caused by oxygen.

Food Sources/Recommended Intake

 AI (µg/d) Male & Female (19–30 y): 55
 Main sources
o meat, eggs, sea foods
 Other
o vegetables grown in selenium rich soil

Results of Deficiency or Excess

 Deficiency
o increased risk of cancer causes one type of heart disease
o reduced thyroid activity
 Excess
o Acute: cardiac dysfunction (hypotension, tachycardia, pulmonary
edema); nausea and vomiting, diarrhea, abdominal pain, ataxia,
tremor, confusion, loss of consciousness
o Chronic (Selenosis): nail brittleness, leuconychia, rash, alopecia,
hepatic dysfunction, hematopoietic impairment, loss of fertility,
hyperreflexia, paraesthesia, seizures, paresis

Conditions Requiring Increase in Intake

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  Pregnancy and lactation
 Children living in countries where no selenium exists in soil or water, e.g.,
parts of China

Special Characteristics
1. Found in all body cells as part of an enzyme system.
2. Adequate RDA intakes believed to have a role in cancer prevention.
3. Excess selenium toxic.
4. The line between health and overdose is very thin.
5. Daily dose should not exceed 70 µg.
6. Absorption depends on solubility of compound form
7. Excreted mainly by kidney

CHROMIUM (Cr)
 Chromium was named after the Greek word for color (chroma) because of the
colorful compounds made from it.
 Form in the body: trivalent chromium.

Functions
 Cofactor in insulin metabolism: Improves uptake of glucose
 Lower LDL cholesterol, increases HDL cholesterol

Food Sources/Recommended Intake

 AI (µg/d) Male (19–30y): 35 Female (19–30y): 25
 Liver
 Cheese
 Brewer’s yeast
 Whole grains
 Leafy vegetables

Results of Deficiency or Excess

 Deficiency:
o Impaired glucose tolerance
o Impaired function of central nervous system (TPN)
 Excess
o No symptoms of excess (trivalent chromium)
o hexavalent chromium is known to cause cancer and skin irritation

Conditions Requiring Increase in Intake

 Malnutrition
 Patients on long-term TPN or Total Parenteral Nutrition

Special Characteristics
1. Total body content small (less than 6 mg)
2. Essential component of the complex glucose tolerance factor (GTF)
3. Absorption: Small amounts absorbed in the intestine
4. Excretion: Mainly in the urine

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MOLYBDENUM (Mo)
 The name molybdenum comes from the Greek word molybdos, which means
lead-like.
 Forms in the body: found in the enzymes sulfite oxidase, xanthine oxidase, and
aldehyde oxidase.

Functions
 Catalyst in metabolic reactions
 Cofactor in certain oxidative enzymes

Food Sources/Recommended Intake

 AI (µg/d) Male & Female (19–30y): 45 UL (µg/d) Male & Female (19–30y): 2000
 Animal: organ meats (liver, kidney)
 Milk
 Legumes
 Cereal grains

Results of Deficiency or Excess

 Deficiency:
o Defects in infants, including mental retardation
o irritability
o possible coma
o dislocated lenses
 Excess
o Toxic: Causes symptoms resembling gout

Conditions Requiring Increase in Intake

 Malnutrition Patients on long-term TPN

Special Characteristics
1. Amount in body exceeding small
2. Precise occurrence and clear metabolic role under continuing investigation
3. Is rapidly excreted in urine
4. Genetic defect (inborn error of metabolism) creates deficiency with severe effects
5. Readily absorbed.
6. Excreted rapidly by kidneys.
7. Small amount excreted in bile.

OTHER TRACE MINERALS

NICKEL
 Nickel (Ni) is an essential trace mineral.
 Nickel is needed by certain enzymes used in anaerobic energy production in the
cell.
 Nickel works with iron and sulfur to release energy from carbohydrates.
SILICON
 The human body contains about 35 grams of silicon.

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  Silicon (Si) strengthens connective tissue such as bones, cartilage, blood
vessels, and tendons.
 Silicon is found in whole grains and fresh vegetables.
VANADIUM
 Vanadium (V) is named after the Norse goddess of love and beauty.
 Vanadium plays a role in bone growth.
BORON
 Boron (B) has been found to be important for mental acuity and brain function.
 Boron may also be important for the functioning of membranes.
 With further research boron may become recognized as an essential trace
mineral.

Concept Check!
1. Pull together information about the different food groups and the
significant sources of minerals shown or discussed in this module.
Consider which minerals might be lacking (or excessive) in the diet of a
client who reports the following:
a. Relies on highly processed foods, snack foods, and fast foods as
mainstays of the diet.
b. Never uses milk, milk products, or cheese.
c. Dislikes leafy green vegetables.
d. Never eats meat, fish, poultry, or even other protein foods such as
legumes.
e. What additional information would help you pinpoint problems with
mineral intake?

Laboratory Activity
Search and discuss the following and write the answers in table form.
1. Vitamin- and mineral-related diseases
2. Symptoms
3. Causes
4. Prevalence
5. Dietary changes

Diseases Symptoms Causes Prevalence Dietary

Changes

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Lesson 3

WATER
 WATER AND ELECTROLYTES

 Next to oxygen, water is the most important nutrient for the body. Lack of
water causes the cells to become dehydrated. A total lack of water can cause
death in a few days.
 If you are a woman, your body is about 50% to 55% water; if you are a man,
then it is about 55% to 60% water. Men have higher water content because they
have proportionately more muscle and less fat.
 Muscle contains more water than any other tissue except blood. Women have
proportionately less muscle and more fat, which is lower in water content.
 The concentration and distribution of particles in water (e.g., sodium,
chloride, calcium, magnesium, phosphate, bicarbonate, and protein) determine
the internal shifts and balances among the compartments of water throughout
the body.

Functions of Water
 Carries nutrients and waste products throughout the body.
 Maintains the structure of large molecules such as proteins and glycogen.
 Participates in metabolic reactions.
 Serves as the solvent for minerals, vitamins, amino acids, glucose, and many
other small molecules so that they can participate in metabolic activities.
 Maintains blood volume.
 Aids in the regulation of normal body temperature, as the evaporation of sweat
from the skin removes excess heat from the body.
 Acts as a lubricant and cushion around joints and inside the eyes, spinal cord,
and amniotic sac surrounding a fetus in the womb.

Body Water Requirements

The body’s requirement for water varies in accordance with several aspects:
 environment
o high body temperature results in water loss through sweat and requires
fluid intake for replacement
 activity level
o Heavy work and physical activity increase the water requirement for
two reasons:
 more water is lost in sweat and respiration
 more water is necessary for the increased metabolic demands of
physical activity
 functional losses
o Uncontrolled diabetes mellitus causes an excess loss of water through
urine as a result of high blood glucose levels.
o Prolonged diarrhea causes large amounts of water loss
 metabolic needs

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 o approximately 1000 mL of water is necessary for the metabolism of
every 1000 kcal consumed
 age
oHigh fluid intake (via breast milk or formula) is critical during infancy
because an infant’s body content of water is large (approximately 70%
to 75% of their total body weight) and because a relatively large amount
of this body water is outside of the cells and thus is more easily lost.
 other dietary influences
o Caffeine is known to be a diuretic
o High fiber intake requires high fluid intake
o Several medications contain diuretics specifically for the purpose of
reducing overall body fluid, as in the case of antihypertensive
medications (e.g., hydrochlorothiazide [Esidrix], furosemide [Lasix],
bumetanide [Bumex], spironolactone [Aldactone]).
o

ADEQUATE INTAKE OF WATER (Liters Per Day)

Male Female
From From Total From From Total
food beverages Water food beverages Water
Age
Birth to 6 months 0.0 0.6 0.6 0.0 0.6 0.6
7 to 12 months 0.2 0.7 0.9 0.2 0.7 0.9
1 to 3 years 0.4 0.9 1.3 0.4 0.9 1.3
4 to 8 years 0.5 1.2 1.7 0.5 1.2 1.7
9 to 13 years 0.6 1.8 2.4 0.5 1.6 2.1
14 to 18 years 0.7 2.6 3.3 0.5 1.8 2.3
>19 years 0.7 3.0 3.7 0.5 2.2 2.7
Pregnancy, 14 to 50 years 0.7 2.3 3.0
Lactation, 14 to 50 years 0.7 3.1 3.8

Body Water Storage

 No storage tanks for water exist in the body; water continually moves from one
body compartment to another and is often reused by the body to perform
different tasks.

WATER BALANCE
 the balance between water intake and water excretion that keeps the body’s
water content constant
 Water enters the body in three forms:
o As preformed water taken in as water or in other beverages
o As preformed water in food
o As metabolic water produced by cell oxidation
 Water sources:
o Hard- contains relatively high levels of the minerals calcium and
magnesium
 E.g. tap water
o Soft – high in sodium, low in calcium and magnesium

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  E.g. commercially treated water; boiled water
 Water Intake Regulation
o When the blood becomes too concentrated (having lost water but not
salt and other dissolved substances), the mouth becomes dry, and the
brain center known as the hypothalamus initiates drinking behavior.
 Water Excretion Regulation
o Water excretion is regulated by the brain and the kidneys
o Antidiuretic hormone (ADH)/ Vasopressin- secreted by pituitary gland
whenever the salts are too concentrated, or the blood volume or blood
pressure is too low
 ADH stimulates kidneys to absorb water rather than excrete it
o Renin – excreted by the kidneys when blood volume and blood pressure
is low due to excessive water loss
 Together with hormone aldosterone, water is retained by
kidneys
 Aldosterone - a hormone secreted by the adrenal glands that
stimulates the reabsorption of sodium by the kidneys; also
regulates chloride and potassium concentrations
o “The more water you need, the less you excrete.”
 Obligatory water loss – the body must excrete a minimum of about 500
milliliters each day as urine (30 mL/hr) to rid the body of metabolic wastes
 In addition to urine, some water is lost from the lungs as vapor, some is
excreted in feces, and some evaporates from the skin.
 Average water output per day: about 2.4 Liters

AVERAGE DAILY ADULT INTAKE AND OUTPUT OF WATER

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 The Antidiuretic Hormone (ADH) Mechanism

WATER IMBALANCE
 To assess fluid volume through observation of hand veins, raise the client’s
hand above the heart. Normally, the veins will collapse in 3 to 5 seconds. Then
lower the hand below the heart. The veins should refill in 3 to 5 seconds. The
veins of a person with insufficient fluid volume require more than 5 seconds to
refill. Reverse the procedure to assess excessive fluid volume in which the
veins will take more than 5 seconds to empty.
 In persons with normal organ function, a good day-to-day measure of hydration
status is the color of urine. Urine of light yellow color usually reflects normal
fluid balance, whereas concentrated urine of a deeper color may indicate
dehydration.

Fluid Volume Deficit

 Hypotonic fluids are given to replace fluid volume and correct electrolyte
imbalances orally if possible but by nasogastric tube or intravenously if
necessary
 DEHYDRATION
 excessive loss of total body water
 Initial symptoms include thirst, headache, decreased urine output, dry
mouth, and dizziness
 symptoms can progress to visual impairment, hypotension, anorexia, muscle
weakness, kidney failure, and seizures
 A fluid loss of more than 10% of body weight typically requires medical
assistance for a complete recovery.
 A loss of 20% of body water can cause circulatory failure and death.
 Chronic or Severe Dehydration

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 o associated with risk factors for several adverse health conditions
such as kidney infections, kidney stones, gallstones, and
constipation
 Osmotic Diarrhea – caused by hypertonic solutions drawing fluid from the
bowel wall into the lumen
 Xerostomia – a common physiologic condition affecting geriatric
population; caused by a severe reduction in the flow of saliva – this
condition increases the risk of dehydration in older adults
 Dehydration can occur in hot weather when one perspires excessively but
fails to drink sufficient water to replace the amount lost through
perspiration.
 Failure to replace water lost through perspiration could lead to one of the
four stages of heat illness or could progress through all four:
o Heat fatigue, which causes thirst, feelings of weakness, or fatigue.
To combat this, one should go to a cool place, rest, and drink fluids.
o Heat cramp, due to the loss of sodium and potassium, which causes
leg cramps and thirst. One should go to a cool place, rest, and drink
fluids.
o Heat exhaustion, which causes thirst, dizziness, nausea, headache,
and profuse sweating. Treatment includes sponge baths with cool
water, a 2- to 3-day rest, and the ingestion of a great deal of water.
o Heat stroke, which involves fever and could produce brain and
kidney damage. Emergency medical service should be called, and
the patient should be put in chilled water and transported to the
hospital.

Fluid Volume Excess

 Water Intoxication
 excessive intake of plain water (10 to 20 liters in few hours) may result in
the dangerous condition of hyponatremia (i.e., low serum sodium levels of
less than 136 mEq/L)
o signs of hyponatremia
 headaches, confusion, seizures, and even death
 Psychogenic polydispsia
o A psychiatric disorder characterized by excessive fluid intake in the
absence of physiological stimuli to drink.
 If untreated, may progress through the subsequent stages of delirium,
seizures, coma, and death
 Treatment: mannitol, an osmotic diuretic drug, which increases the osmotic
pressure and pulls excess fluid from the cells to be excreted by the kidney;
fluid restriction (may be limited to 1 liter per day)

Edema
 accumulation of excess fluid between cells (interstitial spaces)
 occurs when the sodium content in the extracellular fluid increases due to the
inability of the kidneys to excrete sodium
 Conditions that may cause such water retention include:
o Venous or lymphatic blockage

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 o Heart failure
o Severe protein deficiency (nutritional edema)
o Sodium retention
o Some kidney conditions
 Pitting Edema
o When finger pressure displaces excess fluid over a bony area

Distribution of water (Fluid Compartments):

 Intracellular Fluid
o fluid inside the cells
o Adults: 65%
o Infants: 46 %
 Extracellular Fluid
o All fluid outside cells
o Adults: 35%
o Infants: 54%
o Includes:
 Interstitial
 Located between the cells or surrounding the cells, interstitial
fluid assists in transporting substances between the cells and the
blood and lymph vessels.
 Intravascular
 Intravascular fluid is found within the blood vessels, arteries,
arterioles, capillaries, venules, and veins. The liquid part of the
blood is called plasma; the liquid part of the blood without the
clotting elements is called serum.
 Lymph
 fluid part of the blood that returns to the heart via lymphatic
vessels
 Transcellular fluids
 Transcellular fluids include cerebrospinal fluid, pericardial fluid,
pleural fluid, synovial fluid, intraocular fluids, and gastrointestinal
secretions.

FLUID AND ELECTROLYTES

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Solute Particles in Solution
 Two main types of particles control water balance in the body: electrolytes
and plasma proteins.

Electrolyte
 a salt that dissolves in water and dissociates into charged particles called ions
o Cations - are ions that carry a positive charge (e.g., concentrations of
sodium [Na+], potassium [K+], calcium [Ca2+], and magnesium [Mg2+]).
o Anions - are ions that carry a negative charge (e.g., concentrations of
chloride [Cl−], bicarbonate [HCO3 −], phosphate [PO4 3−], and sulfate
[SO4 2−]).

MAJOR BODY ELECTROLYTES

Electrolyte Fluid Normal Blood Function
Compartment Concentration
Cations
Sodium (Na+) Extracellular 135-145 mEq/L Major cation in extracellular
fluid. Na+ concentration in fluids
determines the distribution of
H2O by osmosis. The kidney uses
Na+ with H+ and HCO3 – to
regulate acid–base balance.
Potassium (K+) Intracellular 3.5-5.0 mEq/L Major cation in intracellular
fluid. K+ with Na+ maintains
water balance. The kidney uses
K+ with Na+ and HCO3 –, to
regulate acid–base balance.
Calcium (Ca2+) Extracellular 8.0-10.5 Participates in permeability of
mEq/L cell membranes, transmission of
nerve impulses, muscle action.
Magnesium Intracellular 1.5-2.5 mEq/L Regulates nerve stimulation and
(Mg2+) normal muscle action.
Anions
Chloride (Cl–) Extracellular 96-106 mEq/L Major anion in extracellular
fluid. With Na+, helps maintain
water balance and acid–base
balance.
Bicarbonate Extracellular 24-30 mEq/L Most important extracellular
(HCO3 –) fluid buffer.
Phosphate Intracellular 2.5-4.5 mEq/L Within the intracellular fluid,
(HPO4 2–) phosphates and proteins buffer
95% of the body’s carbonic acid
and 50% of other acids.

 Electrolyte solutions - solutions that can conduct electricity

 Measurement of Electrolytes
o electrolytes are measured according to the total number of particles in
solution
Module III Page 127
 o expressed as the number of milliequivalents per liter (mEq/L)
o Normal amount of electrolytes in the blood
 Sodium

Plasma Proteins/Colloids
 Mainly in the form of albumin and globulin, are large molecules that draw
water (primarily albumin) into the vessels to reestablish equilibrium of the
solute concentration between the fluid compartments
 exert colloidal osmotic pressure (COP) to maintain the integrity of the blood
volume
 Without the presence of plasma proteins, fluid leaks from the capillaries and
accumulates in the intercellular tissue spaces causing edema

Small Organic Compounds

 In addition to electrolytes and plasma protein, there are other small organic
compounds in body water.
 in some instances, they are found in abnormally large concentrations that do
influence water movement
o For example, glucose is a small particle that circulates in body fluids. In
the event of uncontrolled diabetes mellitus, the glucose concentration
is abnormally high, producing polyuria (excessive urination) and body
water loss

Separating Membranes
 Capillary Membranes
o thin and porous walls of the capillaries which allow water molecules and
small particles to move freely across them
 Cell membranes
o specially constructed to protect and nourish the cell’s contents
o membrane channels are highly specific to the molecules that are
allowed to pass
 For example, sodium channels only allow sodium to pass, and
chloride channels only allow chloride to pass.

FORCES MOVING WATER AND SOLUTES ACROSS MEMBRANES

 Osmosis
o Passive movement of water molecules from an area with a low solute
concentration to an area with a high solute concentration
o Osmolarity - the measure of the osmotic pressure exerted by the
number of particles per volume of liquid, usually reported in
milliosmoles per liter
o Osmolality - the measure of the osmotic pressure exerted by the
number of particles per weight of solvent, usually reported in
milliosmoles per kilogram
 The normal value for osmolality of human blood serum is about
275 to 295 milliosmoles per kilogram.
 sodium is the primary determinant of osmolality in the
extracellular fluid
 Isotonic Solution/Fluid

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  they approximate the osmolality of blood plasma
 Two commonly administered isotonic intravenous fluids
are 5% glucose in water and 0.9% sodium chloride
 Hypotonic Solution
 fluids exerting less osmotic pressure than plasma
 Hypertonic Solution
 fluids exerting greater osmotic pressure than plasma

The image above shows the effects of various ion concentrations in a fluid on human
cells. This shows the process of osmosis. Fluid is shifting into and out of the red blood
cell in response to changing ion concentrations in the fluid surrounding the cells.
 Diffusion
o As osmosis applies to water molecules, diffusion applies to the particles
in solution.
o Simple diffusion is the force by which particles move outward in all
directions from an area of greater concentration of particles to an area
of lesser concentration of particles
 Facilitated Diffusion
o follows the same principles of simple diffusion in that particles passively
move down a concentration gradient
o membrane transporters assist particles with faster crossing of the
membrane

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  The relative movement of water molecules and solute particles by osmosis and
diffusion effectively balances solution concentrations—and hence pressures—on
both sides of the membrane
 Filtration
o another form of a passive transport process where water and molecules
move down a hydrostatic pressure gradient
o both water and small permeable solute particles are filtered through
the pores of capillary membranes from an area of high hydrostatic
pressure to an area of low hydrostatic pressure
 Active Transport
o Particles in solution that are vital to body processes must move across
membranes throughout the body at all times, even when the pressure
gradients are against their flow, and they require a carrier to help ferry
the particles across the membrane
 Pinocytosis
o large molecules attach themselves to the cell membrane, and they are
then engulfed by the cell

ACID-BASE BALANCE
In addition to maintaining fluid and electrolyte balance, the body must also
maintain acid-base balance. This is the regulation of hydrogen ions in body fluids (pH
balance).

 Acids - are compounds that yield hydrogen ions when dissociated in solution.
The more hydrogen ions a solution contains, the more concentrated the acid.
 Bases or alkalis - are substances that accept hydrogen ions.
 pH - symbol for the degree of acidity or alkalinity of a solution; scales from 0 -
14
o normal pH - 7.35 to 7.45
o Neutral – pH of 7.0
o Acidic substances – pH below 7.35
o Alkalinity – pH above 7.45
 The kidneys play the primary role in maintaining the acid-base balance by
selecting which ions to retain and which to excrete.
 Buffer Systems - protective systems regulating amounts of hydrogen ions in
body fluids
o Buffers - are substances that can neutralize both acids and bases
 Proteins (hemoglobin) and the bicarbonate (HCO3 –)–carbonic
acid (H2CO3) system are the most important buffers in the
extracellular fluid
 Phosphate (HPO4 2–) and proteins are two important buffers in
the intracellular fluid.
o In a normal buffer system, the ratio of base to acid is 20:1
o For example, when a strong acid is added to a buffered solution, the
base takes up the hydrogen ions of the strong acid, thereby weakening
it. When a strong base is added to a solution, the acid of the buffer
system combines with this base and weakens it.

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 o Acidosis - a condition where there is too much carbonic acid, or too
much of any acid, causes the lungs to automatically increase the rate
and depth of breathing, eliminating more carbon dioxide and water
 Respiratory acidosis - develops when there is too much carbon
dioxide (an acid) in the body. This type of acidosis is usually
caused when the body is unable to remove enough carbon
dioxide through breathing. Other names for respiratory acidosis
are hypercapnic acidosis and carbon dioxide acidosis. Causes of
respiratory acidosis include:
 Chest deformities such as kyphosis
 Chest injuries
 Chest muscle weakness
 Long-term (chronic) lung disease
 Neuromuscular disorder, such as myasthenia gravis,
muscular dystrophy
 Overuse of sedative drugs
 Metabolic acidosis - develops when too much acid is produced in
the body. It can also occur when the kidneys cannot remove
enough acid from the body. There are several types of metabolic
acidosis
 Diabetic ketoacidosis – when substances called ketone
bodies build up during uncontrolled diabetes
 Hyperchloremic acidosis – caused by the loss of too much
sodium bicarbonate from the body, as in severe diarrhea
 Kidney disease (uremia)
 Lactic acidosis (build-up of lactic acid)
 Poisoning by aspirin, ethylene glycol (found in
antifreeze). Or methanol
 Severe dehydration
o Alkalosis - a condition in which the body fluids have excess base (alkali)
 Respiratory Alkalosis - caused by a low carbon dioxide level in
the blood. This can be due to:
 Fever
 Being at high altitude
 Lack of oxygen
 Liver disease
 Lung disease which causes you to breathe faster
(hyperventilate)
o The first aid recommended for hyperventilation
resulting from anxiety is breathing through only one
nostril with the mouth closed. The previous
technique, breathing into a paper bag, can lead to
hypoxia (Venes, 2013)
 Aspirin poisoning
 Metabolic Alkalosis - caused by too much bicarbonate in the
blood.

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  Compensated alkalosis occurs when the body returns the acid-
base balance to near normal in cases of alkalosis, but
bicarbonate and carbon dioxide levels remain abnormal.

Concept Check!
1. List the functions of water in the body
2. How do the lungs help to prevent excess acid from developing in the
body?
3. What is alkalosis? What causes it?
4. Explain how dehydration is dangerous in adults and in infants and children.

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 MODULE SUMMARY

This module contains 3 lessons on micronutrients.

Lesson 1 discussed the types and characteristics of vitamin and the
recommended dietary intake for each vitamin.
Lesson 2 tackled the types and characteristics of minerals.
Lesson 3 discussed water and how important it is to the body.
Congratulations! You have just studied Module III. Now you are ready to
evaluate how much you have benefited from your reading by answering the summative
test. Good Luck!!!

 SUMMATIVE TEST
Multiple Choice

1. Which of the following body structures helps to regulate thirst?

a. Brainstem
b. Optic nerve
c. Cerebellum
d. Hypothalamus

2. Which of the following is not a function of water in the body?

a. Lubricant
b. Source of energy
c. Maintains protein structure
d. Participant in chemical reactions

3. Two situations in which a person may experience fluid and electrolyte

imbalances are:
a. vomiting and burns.
b. diarrhea and cuts.
c. broken bones and fever.
d. heavy sweating and excessive carbohydrate intake.

4. Which mineral is critical to keeping the heartbeat steady and plays a major
role in maintaining fluid and electrolyte balance?
a. Sodium
b. Potassium
c. Calcium
d. Magnesium

5. The two best ways to prevent age-related bone loss and fracture are to:
a. take calcium supplements and estrogen.
b. participate in aerobic activity and drink eight glasses of milk daily.
c. eat a diet low in fat and salt and refrain from smoking.

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 d. maintain a lifelong adequate calcium intake and engage in weight-bearing
physical activity.

6. Three good food sources of calcium are:

a. milk, sardines, and broccoli.
b. spinach, yogurt, and sardines.
c. cottage cheese, spinach, and tofu.
d. Swiss chard, mustard greens, and broccoli.

7. Foods high in iron that help prevent or treat anemia include:

a. green peas and cheese.
b. dairy foods and fresh fruits.
c. homemade breads and most fresh vegetables.
d. meat and dark green, leafy vegetables.

8. Two groups of people who are especially at risk for zinc deficiency are:
a. Asians and children.
b. infants and teenagers.
c. smokers and athletes.
d. pregnant adolescents and vegetarians.

9. A deficiency of ___ is one of the world’s most common preventable causes of

mental retardation.
a. zinc
b. iodine
c. selenium
d. magnesium

Laboratory Activity
1. List the seven major minerals and describe their (a) physiologic function, (b)
problems related to deficiency or excess, and (c) dietary sources.
2. List the 10 trace elements with proven essentiality for humans. Why has it been
difficult to establish DRIs for these nutrients?

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 MODULE IV
Nutrition: A Focus on Life Stages

Lesson 1: Nutrition during Pregnancy and Lactation

Lesson 2: Nutrition during Infancy, Childhood, and

Adolescence

Lesson 3: Nutrition for Adults: The Early, Middle,

and Later Years

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MODULE IV
NUTRITION: A FOCUS ON LIFE STAGES

 INTRODUCTION

In this module, we will discuss a three-lesson sequence on nutrition in health

care throughout the life cycle. In each lesson, we will relate principles of nutrition to
the remarkable process of human growth and development.

LEARNING OUTCOMES
After studying the module, you should be able to:

1. Apply knowledge of the science of nutrition to human health across the

lifespan.
2. Assess and compare diet and nutritional requirements relative to age,
developmental and disease status.
3. Describe the roles nutrition, physical activity, and other lifestyle choices
play in longevity.

 DIRECTIONS/ MODULE ORGANIZER

There are three lessons in the module. Read each lesson carefully then answer
the exercises/activities to find out how much you have benefited from it. Work on
these exercises carefully and submit your output to your instructor or to the CCHAMS
Office.

In case you encounter difficulty, discuss this with your instructor during the
face-to-face meeting. If not contact your instructor at the CCHAMS office.

Good luck and happy reading!!!

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Lesson 1

 Nutrition during
Pregnancy and Lactation

GESTATION
 characterized by exceedingly rapid growth and development. During this 38- to
42-week period, a single fertilized egg cell (ovum) grows into a fully developed
infant weighing about 3500 g, on average
 The woman who enters pregnancy with full nutrient stores, sound eating
habits, and a healthy body weight has done much to ensure an optimal
pregnancy.
 If the essential nutrients are not present to support growth during that critical
time, permanent damage to tissues and organs can occur.
 The fetal origins hypothesis supports the notion that nutrition during
gestation, or the lack thereof, sets the course for chronic disease in adulthood.
 Development of cardiovascular disease, hypertension, obesity, type 2 diabetes,
metabolic syndrome, and gestational diabetes, among other chronic diseases,
has been shown in the offspring of animals for which maternal dietary intakes
of macronutrients and micronutrients were manipulated, as well as in human
epidemiologic studies of the relationship between infant anthropometric
measurements and adult disease incidence.

NUTRITION PRIOR TO PREGNANCY

 A man’s nutrition may affect his fertility and possibly the genetic contributions
he makes to his children, but nutrition exerts its primary influence through the
woman.
 Full nutrient stores before pregnancy are essential both to conception and to
healthy infant development during pregnancy
 Proper nourishment is crucial to the following:
o Uterus – a healthy uterus supports well the growth of a healthy
placenta during the first month of gestation.
o Placenta - by way of the placenta, the mother’s digestive tract,
respiratory system, and kidneys serve the needs of the fetus as well as
her own.
 A healthy placenta is essential for the developing fetus to attain
its full potential.
 For a healthy pregnancy, a woman can establish the following habits:
o Achieve and maintain a healthy body weight.
 Underweight - An underweight woman has a high risk of having a
low-birthweight infant, especially if she is unable to gain
sufficient weight during pregnancy
 Overweight and Obesity - Infants born to obese women are
more likely to be large for gestational age, weighing more than 9
pounds.
o Choose an adequate and balanced diet.
o Be physically active.
o Receive regular medical care. Avoid harmful influences.

NUTRITION DURING PREGNANCY

 Energy (kcal): 2740-2800
o kcalories must be sufficient to perform the following two functions:
1. Supply the increased energy and nutrient demands created by the
increased metabolic workload, including some maternal fat
storage and fetal fat storage to ensure an optimal newborn size for
survival.

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2. Spare protein for tissue building.

o Energy intake,as well as key vitamins and minerals must be increased
beyond the needs of a single fetus pregnancy so that the recommended
weight gain for multiple fetuses is achieved.
 Energy (carbohydrates) Needs: 175 grams/day
o To meet this increased metabolic workload and to spare protein for
tissue building, a pregnant woman needs an extra:
 340 kilocalories per day in the second trimester
 452 kilocalories per day in the third trimester
 Fat Needs
o Long-chain polyunsaturated fatty acids (LC-PUFAs) have demonstrated
crucial importance in the development of the fetal retina and brain
o docosahexaenoic acid (DHA), and arachidonic acid (AA) accumulate in
the fetal brain rapidly during the third trimester of gestation and during
the early postnatal period
 DHA intake: 300 mg/day
 DHA sources: fish and shellfish
o The adequate intakes (AIs) for omega-6 fatty acids (linoleic acid) and
omega-3 fatty acids (alpha-linolenic acid) are increased during
pregnancy and lactation compared to amounts designated for other
women.
 Linoleic Acid sources: Corn, Safflower, Sunflower
 Alpha-Linolenic Acid sources: Canola, Flaxseed, Soybean, Walnut
o Avoid trans-fat during pregnancy
 Protein Needs: 70-73 grams/day
o The protein requirement is increased by 20% for the pregnant woman
over 25 and by 25% for the pregnant adolescent
o Proteins are essential for tissue building, and protein-rich foods are
excellent sources of many other essential nutrients, especially iron,
copper, zinc, and the B vitamins.
o Sufficient protein is required to meet the growth needs in the following
ways:
 Development of placenta
 Growth of fetus
 Growth of maternal tissue
 Increased maternal blood volume
 Amniotic fluid
o Infants born to mothers with adequate protein intake are taller, have
better brain development, and can resist diseases better.
o PIH is more common in women with a low protein intake.
 Vitamin Needs
o Water-Soluble Vitamins
 Vitamin C: 85 mg/day
 Vitamin C is essential to the formation of intercellular
cement material in developing connective tissues and
vascular systems.
 Deficiency during pregnancy may lead to easy rupture of
fetal membrane and increased newborn mortality rate.
 Excessive intake during pregnancy is suspected to lead to
a higher requirement in the newborn.
 B6: 1.9 mg/day
 There is a claim that a large dose of this vitamin can
alleviate the symptoms of morning sickness.
 B12: 2.6 mg/day
 There is a suggestion that the baby may be premature if
the mother’s body storage is very low.
 Folic Acid/Folate: 400 -600 micrograms/day
 Adequate folic acid intake during the first trimester of
pregnancy prevents Neural Tube Defects (NTDs) in fetus

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 Increase in folic acid

o Fat-Soluble Vitamins
 Vitamin A: 750 µg/day
 Excess amounts of vitamin A cause birth defects and
arrested bone growth (infant)
 Vitamin D: 15 µg/day
 Vitamin D deficiency is associated with preeclampsia,
gestational diabetes, and preterm birth
 Diseases that develop later in childhood or adulthood,
such as type 1 diabetes, multiple sclerosis, allergies,
asthma, schizophrenia, and certain types of cancer, are
associated with low vitamin D status during gestation.
 High doses have been known to cause birth defects
 Vitamin E: 15 mg α-TE
 By eating a well-balanced diet, the pregnant woman
receives an adequate intake.
 Because very little vitamin E can cross the placenta, the
infant has very little storage.
 Vitamin K: 90 mg/day
 Hemorrhage in some mothers and newborns is caused by
a lack of vitamin K. Vitamin K in the appropriate form
and dosage can alleviate the bleeding problems.
 Mineral Needs
o Calcium: 1000 mg/day
 Improved absorption of calcium supplies the needs arising from
the accelerated fetal mineralization of skeletal tissue during the
final period of rapid growth.
o Iron: 30-60 mg/day; 60-120 mg/day if with anemia
 Extra iron is needed to synthesize a greater amount of
hemoglobin during pregnancy and to provide iron stores for the
fetus.
 Negative outcomes include preterm delivery, LBW infants, and
increased risk for fetal death in the first weeks after birth.
 Iron should be taken with meals to avoid nausea and
constipation.
o Iodine:220 micrograms/day
 inadequate supply of iodine to the fetus may lead to
hypothyroidism in the newborn and is often associated with poor
and abnormal growth, deficits in cognitive development, and
poor motor function
 iodine supports fetal brain development
o Zinc: 11 mg/day
 Zinc is vital for enzymatic reactions and is essential to growth
and development because of its role in deoxyribonucleic acid
(DNA) and ribonucleic acid (RNA) synthesis and protein
production.
 Inadequate zinc consumption during gestation has been
associated with low birth weight and congenital malformations.
o Nutrient supplements
 Physicians often recommend daily multivitamin-mineral
supplements which typically provide more folic acid, iron, and
calcium than regular supplements.
 Herbal and botanical supplement use during pregnancy is
discouraged because of the potentially harmful or unknown
effects on the woman and fetus.
 Exercise
o Women who engage in prenatal exercise have been shown to have
health benefits (shown in the figure below) compared with
nonexercising women.

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SUBSTANCES TO AVOID DURING PREGNANCY

1. Alcohol
 Alcohol use during pregnancy accounts for the leading preventable cause of
birth defects and developmental disabilities.
 First recognized in 1973, fetal alcohol syndrome (FAS) is most easily
diagnosed between the ages of 4 and 14. FAS has specific diagnostic
criteria:
o Three characteristic facial features: smooth philtrum, thin upper
lip, and short palpebral fissures (see image below)
o Prenatal and postnatal growth deficits
o Central nervous system abnormalities, such as head circumference
at or below the 10th percentile, neurological problems, or
functional deficits

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 In 1996, the term fetal alcohol spectrum disorder was introduced to

encompass several diagnostic categories covering the wider range of alcohol
effects in infants and children that do not meet the criteria for FAS.
 Intake of alcohol (any amount) during pregnancy is not recommended.
 Even when a child does not develop full FAS, prenatal exposure to alcohol
can lead to less severe, but serious, mental and physical problems. The
cluster of mental problems is known as alcohol-related
neurodevelopmental disorder (ARND), and the physical malformations are
referred to as alcohol-related birth defects (ARBD).
2. Soft Cheeses and Ready-to-Eat Meats
 Listeriosis is a bacterial foodborne illness caused by Listeria
monocytogenes.
 For the mother, the symptoms of listeriosis tend to be mild and flulike, but
the bacteria can be passed via the placenta to the fetus resulting in
spontaneous abortion, premature delivery, stillbirth, neonatal meningitis,
and septicemia
 The incubation period may be 3 to 70 days after a person has eaten the
contaminated food. In addition to the general rules for safe food handling,
pregnant women should:
o Avoid soft cheeses (feta, Brie, Camembert, blue-veined, and
Mexican-style cheese like queso fresco). However, hard cheeses,
processed cheeses, cream cheese, cottage cheese, and yogurt may
be eaten safely. Eat only cheeses that are labeled as made with
pasteurized milk.
o Cook leftover foods or ready-to-eat foods (hot dogs, sausage, deli
meats) until steaming hot (165°F).
o Not eat refrigerated meat spreads at all or refrigerated smoked
seafood without cooking it.
o Not consume unpasteurized milk or foods made from it.
o Refrigerate foods within 2 hours and use leftovers within 3 to 4 days.
o Use a thermometer and keep the refrigerator at 40°F or lower and
the freezer at 0°F or lower.
3. Certain Species and Amounts of Fish
 Fish and shellfish can be a major source of methylmercury, a widespread
environmental neurotoxin that can be harmful to fetal brain development.
Other fetal effects of mercury:
o Fetal abnormalities o Visuomotor abilities
o Microcephaly o Memory and
o Severe mental and attention
physical retardation
 Pregnant women and women who may become pregnant, nursing mothers,
and young children should avoid eating:
o Shark o King mackerel
o Swordfish o Tilefish
4. Undercooked Meat, Unwashed Produce, and Cat Litter
 An infection with Toxoplasma gondii, a harmful parasite, causes an
estimated 400 to 4000 cases of congenital toxoplasmosis annually,
producing:
o Mental retardation o Epilepsy
o Blindness
5. Caffeine
 Caffeine should be limited to no more than 200 mg per day or l3ess than
300 mg per day
6. Nicotine
 Smoking has been associated with low-birth-weight (LBW) babies, SIDS
(sudden infant death syndrome), fetal death, spontaneous abortion,
complications at birth, and may also affect the intellectual and behavioral
development of the baby as it grows up.

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7. Drugs of Abuse
 Cocaine easily cross the placenta and impair fetal growth and development
 These drugs are responsible for preterm births, low-birthweight infants, and
sudden infant deaths. If these newborns survive, central nervous system
damage is evident: their cries, sleep, and behaviors early in life are
abnormal, and their cognitive development later in life is impaired.

Weight Gain during Pregnancy

 Average weight gain (Normal weight) : 25-35 pounds/11 – 16 kg
o Overweight: 15-25 pounds
o Underweight: 28 40 pounds
 1 trimester: 2 – 4 pounds
st

 2nd – 3rd trimester: 1 pound/week

Concerns during Pregnancy

a. Nausea: Eat dry toast or crackers before arising; drink fluids between meals
only; eat no fats and oils; use skim milk.
 Hyperemesis gravidarum – severe and threatening nausea and vomiting
b. Constipation: Eat high-fiber foods such as fresh fruits, vegetables, prunes, and
whole grain breads and cereals. Exercise daily (if not contraindicated).
c. Anemias: Increase intake of iron and the vitamins associated with red blood
cell formation (folacin, B6, B12, and C).
d. Pica (the practice of eating nonfood items such as laundry starch and clay):
Educate the patient about the need to discontinue the practice.
e. Heartburn: Eat bland foods; take antacids if prescribed; plan small and
frequent meals. Drink liquids between meals.
f. Urinary urgency: Generally avoid consuming tea, coffee, spices, and alcoholic
beverages.
g. Muscle cramps: Increase calcium and decrease phosphorus intake. Stay well
hydrated.
h. Bloating/cramping: Plan frequent and small meals; eat no greasy foods; reduce
roughage and cold beverages.
i. Pregnancy-Induced Hypertension (PIH). Diets poor in kcalories, protein,
calcium, magnesium, potassium, and dietary fiber have been associated with
risk of PIH. Sound nutrition through proper nourishment decreases the risk.

LACTATION
 Lactation, the production and secretion of breast milk for the purpose of
nourishing an infant, is facilitated by interplay of various hormones after
delivery of the infant.
 Prolactin is responsible for milk production, and oxytocin is involved in milk
ejection from the breast.
 Let-down reflex - infant’s sucking initiates the release of oxytocin, which
causes the ejection of milk into the infant’s mouth
 Lactation Specialist - an expert on breastfeeding and helps new mothers who
may be having problems such as the baby not latching on properly

Benefits of Breastfeeding
 Colostrum, the first milk that is produced after birth is a yellowish fluid that is
rich in antibodies, and it gives the infant his or her first immune boost.
 Breast milk contains just the right amount of lactose; water; essential fatty
acids; and amino acids for brain development, growth, and digestion
 Breastfed babies have a lower incidence of ear infections, diarrhea, allergies,
and hospital admissions.
 Breastfeeding facilitates bonding between mother and child. The skin-to-skin
(kangaroo care) contact helps a baby feel safe, secure, and loved.
 Breastfeeding is economical, always the right temperature, and readily
available—especially in the middle of the night.

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 Benefits for mother include help in losing the pounds gained during pregnancy
and stimulating the uterus to contract to its original size.
 Baby-friendly hospital initiative – launched by WHO and the United Nation
Children’s Fund to promote breastfeeding worldwide

Contraindications to Breastfeeding
 Alcohol
o Alcohol easily enters breast milk and can adversely affect the
production, volume, composition, and ejection of breast milk as well as
overwhelm an infant’s immature alcohol-degrading system.
 Tobacco and Caffeine
o Lactating women who smoke produce less milk, and milk with a lower
fat content.
o Infants of smokers gain less weight than infants of nonsmokers.
o Excessive caffeine can make an infant jittery and wakeful.
 Medications and Illicit Drugs
o Breast milk can deliver such high doses of illicit drugs as to cause
irritability, tremors, hallucinations, and even death in infants.
 Maternal Illness
o The human immunodeficiency virus (HIV), responsible for causing AIDS,
can be passed from an infected mother to her infant during pregnancy,
at birth, or through breast milk, especially during the early months of
breastfeeding
o HIV-exposed infants may be protected by receiving antiretroviral
treatment while being breastfed.

NUTRITION DURING LACTATION

 Energy (kcal): 1st 6 mos. – 2900; 2nd 6 mos. -2800
o Additional energy need for the overall total lactation process is based
on the following four factors:
 Milk content - An average daily milk production for lactating
women is 780 mL (26 oz). The energy content of human milk
averages 0.67 to 0.74 kcal/g. Thus 26 oz of milk has a value of
about 525 kcal.
 Milk production – requires 400 to 450 kcal
 Maternal adipose tissue storage - A component of the energy
need for lactation is drawn from maternal adipose tissue stores
deposited during pregnancy in normal preparation for lactation
to follow in the maternal cycle.
 Exercise - Lactating women generally balance energy
expenditure from exercise with increased energy intake and
alterations in prolactin to maintain an adequate milk supply.
 Proteins: 71 g/day
 Minerals
o Calcium: 1000 mg/day
o Iron need not be increased during lactation
 Vitamins
o Vitamin C: 120 mg/day
o Vitamin A: 1300 mcg RAE/day
o B complex increase because they are involved as coenzyme factors in
energy metabolism
 Fluids: 3000ml/day; a pale-yellow color of mother’s urine suggests adequate
fluid intake
 Food intake: In general, 7 to 8 oz of grains, at least one half of which are
whole grains; 3 cups of vegetables; 2 cups of fruits; 3 cups of fluid milk or dairy
products; 6 to 6.5 oz of lean meats, poultry, fish, dried beans, and nuts; and 6
to 7 tsp of oils per day are recommended to meet nutrient needs during
lactation.

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 Herbal or botanical products as galactogogues (agents that stimulate breast

milk production) is not recommended, however, some may be appropriate for
use within defined quantities.

Laboratory Activity
Evidence-Based Practice: Iron and Postpartum Depression
Is it possible that clinical deficiencies of nutrients cause postpartum
depression? Iron-deficiency anemia is common among women, particularly postpartum
women because of iron losses with delivery and mobilization of iron stores to support
fetal growth, development, and iron storage during the latter stages of pregnancy. An
association between low hemoglobin concentration (less than 12 g/dL) and increased
self-rated symptoms of depression were reported in eight postpartum women within
the first month after delivery. This was significantly different from lower self-rated
symptoms of depression in 29 postpartum women with hemoglobin concentration
greater than 12 g/dL. In a separate study, lower plasma ferritin concentration was
present in women reporting symptoms of postpartum depression. One randomized
controlled trial found that self-reported depression and stress significantly decreased
in 30 postpartum women with iron-deficiency anemia who were treated with 125 mg
ferrous sulfate (along with folate and vitamin C), compared with 21 untreated anemic
postpartum women (supplemented with only folate and vitamin C) and 30 nonanemic
control women.

Questions for Analysis

1. Does this evidence suggest that postpartum women should routinely be
supplemented with iron to prevent postpartum depression?
2. What additional evidence is required to establish practice guidelines regarding
nutrition and prevention or treatment of postpartum depression?

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Lesson 2


Nutrition during Infancy,
Childhood, and Adolescence

HUMAN GROWTH AND DEVELOPMENT

GROWTH
o an increase in body size
o Hyperplasia - cell multiplication
o Hypertrophy - cell enlargement

DEVELOPMENT
 process by which growing tissues and organs take on a more complex function

STAGES OF GROWTH AND DEVELOPMENT: AGE-GROUP NEEDS

NUTRITION IN INFANCY (Birth to 1 year)

 Newborn/neonate – first 28 days of life
 Infant Classifications
o According to maturity
 Term
 born between 37 and 42 weeks’ gestation
 Preterm/Premature
 born before 37 weeks’ gestation
o According to weight
 Low birth weight (LBW)
 infants weigh less than 2500 g (5 lb 8 oz)
 Very low birth weight (VLBW)
 infants weigh less than 1500 g (3 lb 5 oz)
 Extremely low birth weight (ELBW)
 babies weigh less than 100 g (2 lb 3 oz)
o According to size for gestational age
 Appropriate for gestational age (AGA)
 The infant’s weight, length, and head circumference are
all within the normal range on a growth chart.
 Large for gestational age (LGA)
 Birth weight is ≥90th percentile for their age and gender,
also known as macrosomia.
 Small for gestational age (SGA)
 Birth weight is ≤10th percentile for their age and gender.

GROWTH
 The only time humans grow faster than in infancy is the 40 weeks before they
are born.
 Birthweight: double by 4-6 months of age; triple by 1 year
 Birth length: about 30 inches by 1 year
 Loss of weight not exceeding 10% of birthweight occurs during the first few
days after birth, and regains weight within 14 days
 Brain development: occurs from conception to two years of life

DEVELOPMENT
Psychosocial Development
 psychosocial developmental task: Trust versus Distrust
o caregiver should be consistently gentle to for infant to gain trust
 Failure to thrive (FTT) – a descriptive term used to describe inadequate
growth or the inability to maintain growth

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o weight falls below the fifth percentile on multiple occasions

o commonly caused by inadequate caloric intake

Physical Development
 Gastrointestinal
o Stomach holds about 8 oz at 1 year
o Has lingual lipase to digest fat, an enzyme lacking in adults
 Nervous
o Rooting reflex (reflex that occurs when an infant’s cheek is stroked or
touched, infant will turn toward the stimuli and make sucking (or
rooting) motions in an effort to nurse) well developed
o At 6 months has hand-to-eye coordination to put food into mouth.
o At 7 months can chew appropriate foods.
 Urinary
o By end of the second month of life, kidneys can excrete the waste of
semisolid foods.
o Introduce semisolid foods preferably at 4-6 months of age
o Kidneys at full functional capacity by age 1

Nutritional Needs of Term Infant

 Term infant: born after a normal pregnancy (38 – 42 weeks)
 Energy and Macronutrients
o Resting metabolic rates of infants are high as evidenced by:
 Normal pulse rate of 120 to 150 beats/min
 Normal respiratory rate of 30 to 50 breaths/min
 Large proportion of skin surface to body size requiring energy for
temperature regulation
o Energy needs:
 1-6 months - 108 kilocalories per kilogram of body weight per
day
 6-12 months - 98 kilocalories per kilogram per day
 Micronutrients
o Vitamin K: routinely given at birth to prevent bleeding
o Minerals:
 Compared with cow’s milk, breast milk contains:
 One-third the sodium, potassium, and chloride
 One-eighth the phosphorus of cow’s milk, an amount that
accommodates the limited function of the infant’s
kidneys
 Water
o The infant’s body is about 75% water.
o By 3 years of age, the body has developed so it has the adult proportion
of about 60% water.
o The daily turnover of water in the infant is approximately 15% of body
weight.

Macronutrient Needs of Term Infants

Nutrient Breastmilk Cow’s Contraindication
Needed milk
Carbohydrate Galactose is Breast milk Honey
necessary for contains amylase
brain cell that is 40–60 times
formation. more active than
that of cow’s milk.
Fat Fat and Provides 55% of Reduced-fat milks
cholesterol are kilocalories from before age 2
necessary for fat as concentrated
rapidly growing energy source.

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brain and Contains lipase to

nervous system, begin digestion for
bile, and the infant so about
hormones. 95%–98% of the fat
in human milk is
absorbed.

These two fatty

The developing acids, essential for Not
nervous system retinal and neural present
needs development are
arachidonic and found in human
docosahexaenoi milk.
c (DHA) fatty
acids, the main
omega-6 and
omega-3 fatty
acids of the
central nervous
system.
Protein Human milk 18%
contains 70% whey whey,
(easily digested) 82%
and 30% casein. casein
The major whey
protein in breast
milk is alpha-
lactalbumin, with
an amino acid
pattern much like
that of the body
tissues.

Vitamin and Mineral Supplementation for Infants

Supplement Prescribed for Situation Rationale
Vitamin D Breastfed infants Beginning in the
Partially breastfed first few days of
infants life
Formula-fed infants
Vitamin K All infants Single Until the infant’s
intramuscular intestine becomes
dose of vitamin K colonized with
after the first Escherichia coli from the
breastfeeding and environment, he or she
within 6 hours of is at risk for bleeding
birth problems
Vitamin C 2-week-old formula- Synthetic
fed infants, if vitamin preferable to
is not in formula juices (orange
juice in particular
may be allergen)
B12 as Breastfed infant, if Growth failure and
cobalamin mother is strict neurological impairment
vegetarian due to cobalamin
deficiency occurred in
breastfeeding infants of
vegetarian mothers
Calcium Premature infants Breast milk contains

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about one-sixth to one-

quarter the calcium in
cow’s milk

67% of breast milk

calcium is absorbed vs.
25% of cow’s milk
calcium
Phosphorus Premature infants
Iron Term infant, when Iron-fortified Breast milk contains
birth weight has formula is about 0.5 mg iron/L but
doubled recommended 50% is absorbed

Formula-fed Only 10% is absorbed

premature, from onset from cow’s milk or
fortified formulas
Fortified human milk-
fed premature, when
full enteral feeding
established
Fluoride All children >6 months If drinking water
of age contains < 0.3
ppm
Children >3 years of If drinking water
age contains < 0.6
ppm

The Breastfed Infant

 Breast milk is designed for human infants and is the standard against which
substitute milks are measured.
 There is strong evidence that suggests breastfed infants have a lower risk of
later obesity than formula-fed infants.
 Benefits of breastfeeding and breastmilk are discussed in Lesson 1 of this
module.
 Breastmilk components:
o Colostrum
 Secreted 2–4 days after delivery
 Appears Thin, yellow, cloudy fluid
 Composition: high kilocalorie, high protein, antibodies, white
blood cells, fat-soluble vitamins, minerals
o Mature
 Secreted 72–96 hours after delivery and as long as breastfeeding
continues
 Appears milky
 Composition: high lactose, high vitamin E, calcium:phosphorus
ratio of 2:1 (prevents calcium deficient tetany), antibodies
(decreased at 3 months) antioxidants
 Foremilk (beginning of feeding): less fat
 Hindmilk (end of feeding): more fat to increase satiety
 At 3 months, fewer immunoglobulins
 Contraindication to breastfeeding:
o Galactosemia: an autosomal recessive trait where the infant lack of an
enzyme to metabolize galactose
 If untreated, the child will suffer growth failure, mental
retardation, or death
 Treatment involves a soy formula containing no lactose or
galactose and lifelong avoidance of milk products.

The Formula-Fed Infant

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 Commercial formulas are designed to match the qualities of human breast milk
 Formulas contain more protein than breast milk.
 Formula Preparations
o When preparing the formula, the following should be considered:
 Cleanliness/sterility of equipment
 Water to use for dilution:
 Sterility
 Fluoride content
 Possible lead contamination
 Safe storage
 Use of correct strength formula (Formula too concentrated or too
dilute can cause severe electrolyte imbalances. Some cases have
been fatal.)
 Safe heating of the formula before feeding the infant
 Discarding prepared bottles of formula unrefrigerated for 1 hour or
partially consumed
 Feeding Techniques:
o Feeding is scheduled every 4 hours (usually, by demand)
o Feeding at 2-3 months: 5 times a day; by 6 months: 4 times a day
o Correct techniques include the following:
 The nipple holes should be large enough for milk to drip out on its
own without shaking the bottle.
 The nipple should always be filled with milk to prevent the infant
from swallowing air while feeding.
 Daily formula intake for an infant should be 1.5 to 2 ounces per
pound of body weight, but growth is a better measure of health than
the amount of formula swallowed.
 A single feeding should not exceed 8 ounces
o Propping an infant with a bottle is never acceptable because choking is
a real hazard.
 Special Formulas
o Soy protein formula - free of cow’s milk protein and lactose and are
iron-fortified.
 Recommended for:
 Galactosemia and hereditary lactase deficiency
 Those whose parents desire a vegetarian diet
 Secondary lactose intolerance following acute
gastroenteritis
o Hypoallergenic formula - should be well tolerated by at least 90% of
individuals who are allergic to the parent protein from which that
formula has been derived.
 Hazards of Formula Feeding
o The wrong strength
o Prepared with contaminated water, equipment, or hands
o Kept at feeding temperature too long. Body temperature is “just right”
for bacteria to multiply, whether in the body or in a formula bottle.

Introduction of Semisolid Foods to Infants

 Exclusive breastfeeding for 6 months is recommended
 Solid foods introduced too early may cause development of allergies because of
the permeability of the intestine.
 Complementary foods can be given at age 4-6 months, when the infant is able
to control his or her head and trunk
 Waiting too long to introduce solid foods may delay the infant’s acquiring the
skill to manipulate the tongue and mouth appropriately.
 New foods should be introduced one at a time and a week apart so that if a
problem develops, the responsible food can be readily identified.
 A food should be tried for 3 to 5 days before the infant is permitted to reject
it.

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SUGGESTED PROGRESSION FOR OFFERING FOODS TO INFANT AT LOW RISK OF

ALLERGIES
AGE OF INFANT FOOD RATIONALE/PRECAUTIONS
4 Months Infant cereal mixed Because of risk of allergies, rice offered
with formula first; wheat after age 12 months. Read
labels: some mixed infant cereals contain
wheat.
5–6 Months Strained vegetables Less sweet than fruits; thought less likely
to be rejected if offered before fruit
6–7 Months Strained fruits Will be well accepted; humans have strong
preference for sweets.
6–8 Months Finger foods Encourages self-feeding. Different textures
(bananas, crackers) may aid speech development.
7–8 Months Strained meats May be introduced earlier to add iron and
zinc to the diet. Offer variety
10 Months Strained or mashed Start with 1 /2 tsp. Due to possible
egg yolk allergy, delay egg white until 1 year old.
10 Months Bite-sized cooked Select appropriate foods
foods
12 Months Foods from adult Select suitable foods, prepared according
table to baby’s abilities.

Weaning the Infant

 Weaning - the process of gradually acclimating a young child to food other than
the mother’s milk or breast milk substitute as the child’s natural need to suckle
wanes.
 At 4-6 months, infant will show interest in the cup; if infant is not exclusively
breastfed, water can be offered.
 It is best to substitute the cup for the bottle for one feeding period at a time.
 Solid foods may be introduced at approximately 6 months of age, after the
extrusion reflex (x the normal infant reflex to protrude the tongue outward
when it is touched.) of early infancy disappears and the ability to swallow solid
food is established.
 If the mother decides to wean the child from breast or bottle before its first
birthday, the replacement should be infant formula, not unmodified cow’s
milk.

NUTRITIONAL PROBLEMS IN INFANCY

1. Allergies
 Allergen - a substance that provokes an abnormal individual hypersensitivity
or allergy
 Proteins that are not broken down into amino acids and small peptides can
enter the blood stream intact and in their most allergenic form
a. IgE-Mediated Allergies (Food Allergies)
 The following eight protein families account for the majority of food
allergies:
o Milk o Fish
o Egg o Crustacean shellfish
o Peanut o Soy
o Tree nuts o Wheat
 Symptoms of anaphylactic reaction to food
o Difficulty swallowing/breathing
o Cough and wheezing, shortness of breath
o Hoarse voice and/or stridor
o Edema of face and hands
o Paleness and clamminess
o Tachycardia
o Loss of consciousness

Module IV
 b. Nonfood Transfers of Allergens
 Allergens can be transferred by modes other than ingestion:
 Kissing
 Inhalation
 Organ transplantation
 Treatment
o Avoidance of the allergen
o Pharmacologic treatment:
 Antihistamines that block histamine receptors in the tissues for
mild to moderate symptoms
 Epinephrine (adrenalin) with bronchodilator and vasopressor
actions for severe reactions; self-administered epinephrine can
be lifesaving.
2. Colic
 Infantile colic occurs in 10% to 25% of infants.
 Spasms of the muscles of the colon occurs, makes the abdomen tense, and
the infant flex his or her legs up to the belly and may appear flushed.
 The classic definition of colic is the “Rule of Threes,” crying for more than:
o 3 hours a day
o 3 days per week
o 3 weeks
 May be caused by:
o Abdominal distention resulting from swallowing air
o Carbohydrate metabolism may be immature, producing transient
lactose intolerance.
 Treatment:
o Holding the baby o Offering cold formula
upright o Swaddling
o Burping o Carrying the infant
o Providing warm o Rocking
water to drink o Making soft repetitive sound
o Diluting the formula
3. Diarrhea
 WHO defines diarrhea as the passage of more than three loose, watery
stools a day.
 common cause of mortality among children younger than 5 years old
 common causes: overfeeding and food intolerances
 Inflamed intestines caused by diarrhea causes temporary lactose
intolerance
 Rotavirus: most common cause of infectious enteritis in human infants
o Gastroenteritis caused by rotavirus results in about 20 to 60 deaths
in the United States annually in children younger than 5 years old,
but 500,000 deaths in the same ages worldwide
o Treatment and prevention: rotavirus vaccine
 Parents/caregiver of infants experiencing diarrhea should watch out for:
o Young or small infant
 < 6 months of age
 <17.6 pounds in weight

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o History of premature birth, chronic medical conditions, or

concurrent illness
o Fever
 38°C (100.4°F) for infants ages < 3 months
 39°C (102.2°F) for children ages 3 to 36 months
o Visible blood in stool
o High output, including frequent and substantial volumes of diarrhea
o Persistent vomiting
o Signs of dehydration
 Sunken eyes
 Decreased tears
 Dry mucous membranes
 Decreased urine output
o Change in mental status (e.g., irritability, apathy, or lethargy)
o Suboptimal response to oral rehydration therapy (ORT) already
administered or inability of the caregiver to administer ORT.
 Treatment
o Oral rehydration solutions (ORS) should be used for rehydration,
which should be accomplished in 3 to 4 hours.
o An age-appropriate, unrestricted diet should be given as soon as
dehydration is corrected.
o For breastfed infants, nursing should be continued.
o For formula-fed infants, diluted formula is not recommended, and
special formula is not necessary.
o Additional ORS should be administered for ongoing losses through
diarrhea.
o No unnecessary laboratory tests or medications should be
administered.

NUTRITION OF THE TODDLER (Ages 1 to 3 Years)

Psychosocial Development
 autonomy versus shame and doubt
 One way parents can assist a toddler achieve autonomy is to encourage choices
from acceptable food alternatives.
 If parents insist that a child eat certain items or amounts, the child may learn
to use food rejection as a means of gaining attention.

Physical Growth and Development

 weight gain in the second year : 4 to 6 pounds
 Height increase: 4 inches
 Growth slows
 the child’s muscles of the back, buttocks, and thighs are enlarging
 bones are becoming more mineralized, and “baby fat” is disappearing
 fine motor control improves

Nutrient Needs and Intake

 Energy: 80 – 120 kcal/kg/day

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 need for many nutrients increases proportionately with body size throughout
the growth years
 Food: prefers finger foods
 Mealtimes
o Toddlers appreciate company
o A 1-year-old’s stomach holds just 1 cup: necessitates small servings
 New Foods
o Offer brightly colored foods
o Tough meat or very fibrous vegetables are not for the toddler
o Daily intake should include:
 One serving of a vitamin C-rich fruit or vegetable
 One serving of a green leafy or yellow vegetable
 Limited sugar
 Grams of fiber equal to child’s age +5 beginning at age 2

Nutritional Concerns
1. Iron-Deficiency Anemia
 Milk anemia - iron deficiency anemia caused by overconsumption of milk
and underconsumption of iron-rich foods
2. Milk intake

NUTRITION OF THE PRESCHOOL CHILD (Ages 3 to 6 Years)

Psychosocial Development
 Initiative versus Guilt
 Children can participate in planning and preparation of meals, and they should
help in the kitchen, not just with cleanup.

Physical Growth and Development

 child continues to gain 4 to 5 pounds per year
 gain in height of about 2 inches per year; length doubles at age 5
 Half the adult height is attained by approximately age 2 years

Nutrient Needs and Intake

 Energy (kcal): 90 kcal/kg/day
 New Foods: offer new foods one at a time in small amounts.

Nutritional Concerns
 Dental Health
o Fluorosis- overuse of supplements and the ingestion of fluoridated
toothpaste
o Dental caries - a study showed that preschool children from ages 1 to 5
years who consumed sugar-containing drinks, especially at night, and
daily sugar intake were independent risk factors in the development of
early childhood caries

NUTRITION OF THE SCHOOL-AGE CHILD (Ages 6 to 12 Years)

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Psychosocial Development
 Industry versus Inferiority
 School-age children can participate in planning menus, shopping for food,
preparing the meals, as well as cleaning up afterward

Physical Growth and Development

 average yearly growth during the school years is7 pounds and 2.5 inches
 Exercise can help the school-age child’s growth and development by
stimulating osteoblasts and expending energy to control weight.

Nutritional Needs and Concerns

 Energy (kcal):70 kcal/kg/day
 Meal Patterns and Behaviors
 breakfast is essential and should contain one-fourth to one-third of the
day’s nutrients
 study shows that eating with family decreases incidence of food
insecurity, purging, binge eating and frequent dieting
 Nutritional at School
 Interactions with other children and school experiences expose a child
to new foods and different cultures.
 School-based feeding programs for undernourished public school
children implemented by DedEd aims to supply at least one fortified
meal for 120 days in a year
 Fortified meals consist of increased content of essential
micronutrients, calories and protein

NUTRITION IN ADOLESCENSE (Ages 12-20)

Adolescence
 Adolescence is the period that extends from the onset of puberty until full
growth is reached.
 Adolescence is second only to infancy in the nutritional requirements necessary
for growth and development.

Psychosocial Development
 Identity versus Role Confusion
 Task is to achieve own identity and capabilities

Physical Growth and Development

 Growth spurt period
 During the peak of the adolescent growth spurt, the mineral and protein
content of the body is increased.

Nutritional Needs and Concerns

 Energy (kcal): 60-80 kcal/kg/day
 Calcium and iron
o adolescent diets are lacking in calcium and iron

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o Long term deficiencies of those minerals may be manifested in

osteoporosis or anemia.
o Teens should strive to consume three to four servings of iron-rich foods
and four to five servings of calcium-rich foods daily.
 Overenthusiastic weight control
o Anorexia nervosa affects 0.5% to1% of 14- to 18-year-old girls
 Acne and diet
o Acne is triggered by sex hormones stimulating the sebaceous glands
o Recent evidence has identified that reactive oxygen species, free
radicals, and oxidative stress play a role in initiating acne, and
antioxidant vitamins like A and E are lower in clients who have acne
 Smoking, Alcohol, and Drugs
o Experiments with these substances often begin in the early teens.
o They affect the nutritional status in different ways: they can lessen the
sense of taste and smell, decrease appetite, and reduce vitamin C level
in the body.
 Poor choices of food
o Fond of eating fast foods which are excessively high in fat and sodium,
as well as calories, and contain only limited amounts of vitamins and
minerals (other than sodium) and little fiber.

Overweight in Children and Adolescents

Strategies to Prevent Childhood Overweight

1. Infants: Promote and support breastfeeding
2. Toddler and Preschooler:
a. Implement MyPlate at home and in day care/preschool
b. Limit sweetened drinks
c. Begin 1% or fat-free dairy
d. Encourage daily physical activity
3. School Age and Adolescent:
a. Health curriculum
b. Active, appealing physical education for all
c. Offering healthy food and beverages in school
4. All ages:
a. Limit TV/computer game time to 2 hours/day
b. Encourage at least 1 hour of physical activity daily
c. Encourage 5 servings of fruits and vegetables daily
d. Eat a healthy breakfast daily
e. Encourage family meals
f. Serve recommended portion sizes
g. Calculate and plot BMIs yearly
h. Advocate for healthful food choices in restaurants
i. Discourage consumption of empty kilocalories
j. Expand access to supermarkets with reasonably priced produce
k. Provide safe environments for physical activity

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Lesson 3

 Nutrition for Adults: The

Early, Middle, and Later Years

NUTRITION IN YOUNG (EARLY) ADULTHOOD (Ages 18-39)

Psychosocial Development
 Intimacy versus Isolation

Nutrition in the Young Adult

 Energy (kcal): men- 3000; women- 2400
 Protein: men- 56 grams/day; women- 46 grams/day
 Minerals: Calcium, iron and potassium increase
 Advise:
o Eat a variety of foods
o Maintain ideal weight
o Avoid too much fat, sugar, and sodium
o Drink alcohol moderately
o Eat foods with adequate starch and fiber

Nutritional Concerns
 Unwanted weight gains
 Chronic Diseases
o Risky behaviors such as smoking, low physical activity, and alcohol
abuse are not uncommon in this age group
o Metabolic syndrome - a constellation of factors including elevated BMI
and waist circumference, elevated blood pressure, inappropriate blood
lipid levels, and elevated blood glucose or insulin levels that contributes
to chronic disease

NUTRITION IN MIDDLE ADULTHOOD (Ages 40 – 65)

Psychosocial Development
 Generativity versus Stagnation
 Task of generativity involves serving as a mentor to the next generation
Nutrition in the Middle Adulthood
 Energy (kcal): men – 2900; women - 2300
 Consumes slightly higher than middle adults
 Similar with young adults, middle adults do not meet the RDAs
 Calcium: 1200 mg (to prevent fracture especially in women)

Nutritional Concerns

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 23

 Middle-age adults are also consumers of sugar-sweetened beverages

 Chronic Disease risk
o cardiovascular disease, diabetes, and cancer increase in prevalence

NUTRITION IN OLDER ADULTHOOD (Ages 65 - 85)

Psychosocial Development
 Integrity versus Despair
 Integrity in the sense of being whole or complete

Nutrition in Older Adult

 Energy (kcal):71 years and older – 1564-2238
 Carbohydrates: 130 grams/day
 Nutritional component is one of the factors that contribute to adult morbidity
and mortality
 Energy needs decrease with age
 20 minutes of aerobic exercise is beneficial
 High CHON prompts calcium loss in urine
 Iron absorption is impaired in aging
 Dehydration in elderly: confusion
o Fluid intake: about 1.5 liters/day
 Common deficiencies: Vitamin A, D, C, Niacin, B12
o High Vitamin A= increased bone loss
 Advise:
o Eat vegetables rich in beta-carotene
o Low fat and low calorie diet
o Take vitamin supplements daily
o Drink plenty of water
 Avoid:
o red meat
o smoking
o sugars, fats, and oils
o alcohol, black tea and caffeinated drinks
o preserved foods

Common Problems in Old Adults

1. Anxiety, insecurity, loneliness
 Loneliness may lead to alcoholism
2. Difficulty sleeping
 drink warm milk before bed
 Avoid tea and coffee
3. Low protein intake
 Main cause is lack of money
 Sarcopenia – loss of muscle mass
4. Nutrient Deficiencies

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 Recent studies have shown that the elderly are often deficient in protein,
iron, calcium, and vitamins A and C. This increases the incidence of iron-
deficiency anemia and osteoporosis, decreases resistance to infections, and
lowers overall health status.
5. Osteoporosis
 An adequate calcium intake throughout life helps protect against
osteoporosis
6. Constipation, Diverticulosis and Cancer
 Appropriate fiber intakes may help prevent disorders of the digestive tract
such as constipation, diverticulosis, and possibly colon cancer
 Variety in food intake, as well as ample intakes of certain fruits and
7. Atherosclerosis, Diabetes. Obesity, Hypertension
 Appropriate energy intake helps prevent obesity, diabetes, and related
cardiovascular diseases such as atherosclerosis and hypertension
 Moderate sodium intake and adequate intakes of potassium, calcium, and
other minerals help prevent hypertension
8. Anemia

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 25

 MODULE SUMMARY

This module has 2 lessons that discussed clinical nutrition and diet therapy.
Lesson 1 tackled the nutrition care process as the foundation of nutrition
therapy.
Lesson 2 discussed diet therapy that comprised different diet modifications and
routes.
Congratulations! You have just studied Module V. Now you are ready to
evaluate how much you have benefited from your reading by answering the summative
test. Good Luck!!!

 SUMMATIVE TEST
Multiple Choice

1. The fastest-growing age group 4. A disease of the immune system

is:
a. under 21 years of age.
b. 30 to 45 years of age.
c. 50 to 70 years of age.
d. over 85 years of age.
2. Which of the following lifestyle
habits can enhance the length
and quality of people’s lives?
a. Moderate smoking
b. Six hours of sleep daily
c. Regular physical activity
d. Skipping breakfast
3. Which of the following is among
the better-known relationships
between nutrition and disease
prevention?
a. Appropriate fiber intake helps
prevent goiter.
b. Moderate sodium intake helps
prevent obesity.
c. Moderate sugar intake helps
prevent hypertension.
d. Appropriate energy intake
helps prevent diabetes and
cardiovascular disease.
that involves painful
inflammation of the joints is:
a. sarcopenia.
b. osteoarthritis.
c. senile dementia.
d. rheumatoid arthritis
5. Examples of low-kcalorie, high-
quality protein foods include: a.
cottage cheese, sour cream, and
eggs. b. green and yellow
vegetables and citrus fruits. c.
potatoes, rice, pasta, and
whole-grain breads. d. lean
meats, poultry, fish, legumes,
fat-free milk, and eggs.
6. For malnourished and
underweight people, protein-
and energy-dense snacks
include:
a. fresh fruits and vegetables.
b. yogurt and cottage cheese.
c. whole grains and high-fiber
legumes.
d. scrambled eggs and peanut
butter on wheat toast.

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 26

7. Which of the following does not a. loneliness and multiple

contribute to dehydration risk in
older adults?
a. They do not seem to feel
thirsty.
b. Total body water increases
with age.
c. They may find it difficult to
get a drink.
d. They may have difficulty
swallowing liquids.
8. Inadequate milk intake and
limited exposure to sunlight
contribute to older adults’ risk
of:
a. vitamin A deficiency.
b. vitamin D deficiency.
c. riboflavin deficiency.
d. vitamin B12 deficiency.
9. Two risk factors for malnutrition
in older adults are:
medication use.
b. increased energy needs and
lack of fiber.
c. decreased mineral absorption
and antioxidant intake.
d. high carbohydrate intake and
lack of physical activity.
10. Strategies to improve nutrition
status when growing old
include:
a. increasing vitamin A intake
and exercising 30 minutes daily.
b. choosing nutrient-dense foods
and maintaining appropriate
weight.
c. avoiding high-fiber foods and
taking a daily vitamin-mineral
supplement.
d. eating at least one big meal
per day and drinking at least 10
glasses of water daily

Laboratory Activity

1. List six nutrients that are required in larger amounts during pregnancy.
Describe their special role during this period. Identify four food sources of
each.
2. Identify two common problems associated with pregnancy, and describe the
dietary management of each.
3. What are the benefits of breastfeeding in infants and their mother?
4. Identify two common problems and their remedies in old adults.
5. Describe how healthy diet and physical activity increase longevity or life
expectancy.

Module IV
 MODULE V
Clinical Nutrition and Diet Therapy
Lesson 1: Nutrition Care Process

Lesson 2: Diet Modification and Diet Therapy

Module V Page 163

 MODULE V
CLINICAL NUTRITION AND DIET THERAPY

 INTRODUCTION

This module will introduce the process used for providing nutrition care
and the implementation of nutrition care in clinical practice, and the principles
and objectives of diet therapy.

LEARNING OUTCOMES
After studying the module, you should be able to:

1. Assess the nutritional status of a given client using relevant

parameters and appropriate nutritional assessment tools
2. Formulate relevant nutrition diagnosis.
3. Implement safe and quality interventions with the client to address
the nutritional needs, problems, and issues.
4. Provide health education in nutrition and diet therapy to targeted
clientele.
5. Document nutritional status accurately and comprehensively.
6. Identify the most common therapeutic diets used in clinical care.

 DIRECTIONS/ MODULE ORGANIZER

There are three lessons in the module. Read each lesson carefully then
answer the exercises/activities to find out how much you have benefited from
it. Work on these exercises carefully and submit your output to your instructor
or to the CCHAMS Office.

In case you encounter difficulty, discuss this with your instructor during
the face-to-face meeting. If not contact your instructor at the CCHAMS office.

Good luck and happy reading!!!

Module V Page 164

Lesson 1

 Nutrition Care Process

NUTRITION CARE PROCESS

 A systematic problem-solving method that dietetics professionals use to
critically think and make decisions to address nutrition-related problems and
provide safe and effective quality nutrition care.
 Composed of Assessment, Diagnosis, Intervention, and Monitoring and
Evaluation (ADIME)
 It provides a consistent structure and framework for nutrition professionals to
use to provide individualized care for patients.
 Nurses are intimately involved in the care process and often identify nutrition
needs within the nursing diagnosis.

Health Care Team

 In the area of nutrition care, the following are involved:
o Registered Dietician
 carries the major responsibility of medical nutrition therapy
 The dietitian determines nutrition needs, plans and manages
nutrition therapy, evaluates the plan of care, and documents
results
o Physician and support staff
 Physician prescribes diet orders (or nutrition prescriptions)
 The team may include some or all of the following members:
nurse, dietitian, physical therapist, occupational therapist,
speech therapist, respiratory therapist, radiologist, physician
assistant, kinesiotherapist, pharmacist, and social worker
o Nurse
 Nurses are in a unique position to provide additional nutrition
support by referring patients to the dietitian when necessary
 They are in the closest continuous contact with hospitalized
patients and their families, which is important to ensure the
most beneficial health care approach.
 Nurse helps to develop, support, and carry out the plan of care
determined by the dietician.
 Successful nutrition care depends on the close collaboration of the dietitian
and the nurse.

Nutrition Screening
 A brief assessment of health-related variables to identify patients who are
malnourished or at risk for malnutrition.

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  The information collected in a nutrition screening may include the admitting
diagnosis, physical measurements and test results obtained during the
admission process, relevant signs and symptoms, and information about
nutrition and health status provided by the patient or caregiver
 Subjective Global Assessment
o evaluates a person’s risk of malnutrition by ranking key variables of the
medical history and physical examination
o These variables are each given an A, B, or C rating:
 A: Well nourished: if no significant loss of weight, fat, or muscle
tissue and no dietary difficulties, functional impairments, or GI
symptoms; also applies to patients with recent weight gain and
improved appetite, functioning, or medical prognosis
 B: Moderate malnutrition: if 5 to 10 percent weight loss, mild
loss of muscle or fat tissue, decreased food intake, and digestive
or functional difficulties that impair food intake; the B
classification usually applies to patients with an even mix of A,
B, and C ratings
 C: Severe malnutrition: if more than 10 percent weight loss,
severe loss of muscle or fat tissue, edema, multiple GI
symptoms, and functional impairments
 Other nutrition screening tools:
o Malnutrition Screening Tool (MST)
o Malnutrition Universal Screening Tool (MUST)

PHASES OF THE NUTRITION CARE PROCESS

I. NUTRITION ASSESSMENT
 involves the collection and analysis of health-related information in order to
identify specific nutrition problems and their underlying causes
 includes ABCDE of assessment, which stands for A – anthropometric, B –
biochemical, C – clinical, D – dietary, and E – energy needs
 At the conclusion of the gathering of nutrition assessment data, health care
providers must distinguish relevant from irrelevant data, validate the data, and
then determine whether there is a need to obtain additional information.

A. Anthropometric Assessment
 Height
 Desirable Body Weight (DBW) or Ideal Body Weight (IBW)
o Hamwi Formula – short cut to determining ideal body weight
for adults
 IBW for males: 106 pounds for 5 feet plus 6 pounds
per inch over 5 feet
 IBW for females: 100 pounds for 5 feet plus 5 pounds
per inch over 5 feet
 Add 10% for large frame. Subtract 10% for small frame
 Percent IBW = current weight/ideal weight x 100
 Interpretation:
 A weight of 20% or more above ideal body
weight due to accumulation of body fat, is an
indication of obesity

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  A weight of 20% or less below ideal weight is
an indication of possible nutritional risk
 Percent of Weight Loss = Usual weight – present
weight/ usual weight x 100
 Unplanned and/or recent weight loss of 10% in
a period of 30 days is a risk factor for
malnutrition, while weight loss exceeding 20%
is a high risk factor for surgical patients.
 BMI
A healthy body weight typically falls within a BMI range of
o
18.5 to 25
o (BMI is further discussed in Module 3)
 Head Circumference
o helps to assess brain growth and malnutrition in children up
to 3 years of age
o Head circumference values can also track brain development
in premature and small-for-gestational-age infants
o To measure, the tape is placed just above the eyebrows and
ears and around the occipital prominence at the back of the
head.
 Body Composition
o The dietitian may measure various aspects of body size and
composition to determine relative levels of lean tissue
compared to fat mass.
 Fat-fold or Skin-fold Thickness – measured with
caliper
 Waist Circumference
o Waist circumference assessment and waist-to-height ratio
are important considerations for both overweight and
normal-weight individuals, because they indicate the risk for
chronic diseases (e.g., type 2 diabetes, cardiovascular
disease, hypertension, cancer, overall mortality), even
among individuals of normal weight.
o waist circumference should be < 102 cm for men and < 88 cm
for women
 Mid-arm Circumference (MAC)
o gives an indication of body protein reserves and helps to
detect protein malnutrition
B. Biochemical (Laboratory) Assessment
 Advantage
o Can detect early sub clinical status of nutrient deficiency
o Can identify specific nutrient deficiency
o Objective tests, independent of the emotional and subjective
factors that usually affect the investigator or reliability of
the patient’s recollection
 Disadvantage
o Expensive and time-consuming
o Standards could vary with wide range
o There may be problems with interpreting results

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  Examples of biochemical tests pertinent to nutrition include, but are
not limited to, the following:
o Plasma proteins: serum albumin and prealbumin evaluate for
protein status
o Liver enzymes: evaluate liver function
o Blood urea nitrogen and serum electrolytes: evaluate renal
function
o Urinary urea nitrogen excretion: estimate nitrogen balance
o Creatinine height index: evaluate protein tissue breakdown
o Complete blood count: evaluate for anemia
o Fasting glucose: evaluate for hyper- and hypoglycemia
o Total lymphocyte count: evaluate immune function
C. Clinical Assessment
 nutritional physical examinations to assess patients for signs and
symptoms consistent with malnutrition or specific nutrient
deficiency
o Techniques in physical examination:
 Inspection- Systematic visual inspection
 Auscultation- Using a stethoscope and naked ear to
identify deviations from standard sounds
 Palpation- Examination of the body using touch
 Percussion- Use of sound to distinguish deviations
from standard sounds created by presence of body
organs and cavities
 also includes medical history like past surgeries, previous diagnoses,
disorders of the family members
 Advantages
o Can be performed in a large no. of individuals in a short
period of time
o Less expensive
o Other staff may perform PE, given the proper training
 Disadvantages
o Deficiencies may not be clearly manifested
o Overlapping of deficiency states
o Bias of the observer
o Reliability of patients recollection

CLINICAL SIGNS THAT SUGGEST NUTRIENT IMBALANCE

Area of Concern Possible Deficiency Possible Excess
HAIR
Dull, dry, and brittle Protein
Easily plucked, with no pain Protein
Hair loss Protein, zinc, biotin Vitamin A
Flag sign (i.e., loss of hair pigment in Protein, copper
strips around the head)
HEAD AND NECK
Bulging fontanel (in infants) Vitamin A
Headache Vitamin A, D
Epistaxis (i.e., nosebleed) Vitamin K

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Thyroid enlargement Iodine
EYES
Conjunctival and corneal xerosis (i.e., Vitamin A
dryness)
Pale conjunctivae Iron
Blue sclerae Iron
Corneal vascularization Vitamin B2
MOUTH
Cheilosis or angular stomatitis (i.e., Vitamin B2
lesions at the corners of the mouth)
Glossitis (i.e., red, sore tongue) Niacin, folate, vit B12,
and other B vit
Gingivitis (i.e., inflamed gums) Vitamin C
Hypogeusia or dysgeusia (i.e., poor sense Zinc
of taste or distorted taste)
Dental caries Fluoride
Mottling of teeth Fluoride
Atrophy of papillae on tongue Iron, B Vitamins
SKIN
Dry or scaly Vit. A, Zinc, Essential Vit. A
fatty acids (EFAs)
Follicular hyperkeratosis (resembles Vit. A, EFAs, B Vit.
gooseflesh)
Eczematous lesions Zinc
Petechiae or ecchymoses Vitamin C and K
Nasolabial seborrhea (i.e., greasy, scaly Niacin, vit B12, B6
areas between the nose and lip)
Darkening and peeling of skin in areas Niacin
exposed to sun
Poor wound healing Protein, Zinc, vit C
NAILS
Spoon shaped (Koilonychia) Iron
Brittle and fragile Protein
HEART
Enlargement, tachycardia, or failure B1
Small heart Energy
Sudden failure or death Selenium
Arrhythmia Magnesium, Potassium,
Selenium
Hypertension Calcium, Potassium Sodium
ABDOMEN
Hepatomegaly Protein Vitamin A
Ascites Protein
MUSCULOSKELETAL EXTREMETIES
Muscle wasting (especially in the temporal Energy
area)
Edema Pro, vit B
Calf tenderness Vit B1 or C, biotin, Se
Beading of ribs or “rachitic rosary” in a Vit C, D

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child
Bone and joint tenderness Vit C, D, Ca, P
Knock knees, bowed legs, or fragile bones Vit D, Ca, P, Cu
NEUROLOGIC
Paresthesias (i.e., pain and tingling or Vit B1, B6, B12, biotin
altered sensation in the extremities)
Weakness Vit C, B1, B6, B12,
energy
Ataxia and decreased position and Vit B1, B12
vibratory senses
Tremor Magnesium
Decreased tendon reflexes Vit B1
Confabulation or disorientation Vit B1, B12
Drowsiness and lethargy Vit B1 Vit A, D
Depression Vit B1, biotin, B12

D. Dietary Assessment
 Food intake data
 Methods commonly used as well as each method’s advantages and
disadvantages are discussed in the table below.

Method Description Advantages Disadvantages

24-hour Guided interview  Results are not  Process relies on
dietary in which the dependent on literacy memory.
recall foods and or educational level  Underestimation and
beverages of respondent. overestimation of food
consumed in a  Interview occurs after intakes are common.
24-hour period food is consumed, so  Food items that cause
are described in method does not embarrassment
detail. influence dietary (alcohol, desserts) may
choices. be omitted.
 Results are obtained  Data from a single day
quickly; method is cannot accurately
relatively easy to represent the
conduct. respondent’s usual
 Method does not intake.
require reading or  Seasonal variations may
writing ability. not be addressed.
 Skill of interviewer
affects outcome.
Food Written survey of  Process examines long-  Process relies on
frequency food consumption term food intake, so memory.
questionnair during a specific day-to-day and  Food lists often include
e period of time, seasonal variability common foods only.
often a 1-year should not affect  Serving sizes are often
period. results. difficult for
 Questionnaire is respondents to
completed after food evaluate without
is consumed, so assistance.

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 method does not  Calculated nutrient
influence food choices. intakes may not be
 Method is inexpensive accurate.
to administer.  Food lists for the
general population are
of limited value in
special populations.
 Method is not effective
for monitoring short-
term changes in food
intake.
Food record Written account  Process does not rely  Recording process itself
of food consumed on memory. influences food intake.
during a specified  Recording foods as  Underreporting and
period, usually they are consumed portion size errors are
several may improve accuracy common.
consecutive days. of food intake data.  Process is time-
Accuracy is  Process is useful for consuming and
improved by controlling intake burdensome for
including weights because keeping respondent; requires
or measures of records increases high degree of
foods. awareness of food motivation.
choices.  Method requires
literacy and the
physical ability to
write.
 Seasonal changes in
diet are not taken into
account.
Direct Observation of  Process does not rely  Process is possible only
observation meal trays or on memory. in residential
shelf inventories  Method does not situations.
before and after influence food intake.  Method is labor
eating; possible  Method can be used intensive.
only in to evaluate the
residential acceptability of a
facilities. prescribed diet.

E. Energy Needs Assessment

 The prediction equations most commonly used in clinical practice
are as follows:
1. Mifflin-St. Jeor
 most accurate in estimating basal metabolic rate (BMR)
 Men: RMR = (9.99 × wt in kg) + (6.25 × ht in cm) − (4.92
× age in yr) + 5
 Women: RMR = (9.99 × wt in kg) + (6.25 × ht in cm) −
(4.92 × age in yr) − 161
1. Harris-Benedict

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 was found to systematically overestimate basal energy
expenditure (BEE) by at least 5%
 Men: RMR = 66.47 + (13.75 × wt in kg) + (5.0 × ht in cm)
− (6.75 × age in yr)
 Women: RMR = 665.09 + (9.56 × wt in kg) + (1.84 × ht in
cm) − (4.67 × age in yr)
2. Owen
 underestimates RMR about 21% of the time and
overestimates RMR 6% of the time
 Men: RMR = 879 + (10.2 × wt in kg)
 Women: RMR = 795 + (7.18 × wt in kg)

II. NUTRITION DIAGNOSIS AND PLAN OF CARE

 involves the identification and labeling of an existing nutrition problem that
the food and nutrition professional is responsible for treating independently
 Nutrition diagnoses are organized into the following three categories:
o Intake: Too much or too little of a food or nutrient compared with
actual or estimated needs; inadequate, excessive, or inappropriate are
used to describe the specific nutrient or substance that is altered
o Clinical: Nutrition problems that relate to medical or physical
conditions like problems in swallowing, chewing, digestion, absorption,
and maintaining appropriate weight
o Behavioral and environmental: Knowledge, attitudes, beliefs, physical
environment, access to food, and food safety
 A nutrition diagnosis statement will have three distinct and concise elements:
Problem, Etiology, and the Signs/symptoms (PES)
o Problem: may include nutrient deficiencies (e.g., iron-deficiency
anemia) or underlying disease that requires a modified diet (e.g., renal
disease, liver disease)
o Etiology: causes or contributing risk factors are identifiable factors that
are directly leading to the stated problem
o Sign/Symptoms: accumulation of subjective and objective changes in
the patient’s health status that indicate a nutrition problem and that
are the results of the identified etiology
 Within a nutrition diagnostic PES statement, the signs and
symptoms should be preceded by the words as evidenced by
 Examples:
o Excessive caloric intake (problem) related to frequent consumption of
large portions of high-fat meals (etiology) as evidenced by average
daily intake of calories exceeding recommended amount by 500 kcal
and 12-pound weight gain during the past 18 months (signs).
o “Inadequate energy intake (P) related to changes in taste and appetite
(E) as evidenced by average daily kcal intake 50% less than estimated
recommendations (S)”

III. NUTRITION INTERVENTION

 Nutrition interventions are “purposefully planned actions designed with the
intent of changing a nutrition-related behavior, risk factor, environmental
condition, or aspect of health status for an individual, target group, or the
community at large.”

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  Objectives of the care plan are client-driven, thus focusing attention on
personal needs and goals as well as on the identified requirements of medical
care for the patient.
 The nutrition intervention strategies are organized into four categories:
o Food and/or Nutrient Delivery
 Personalized/individualized needs can be achieved through
exploring the following areas with the family:
1. Personal needs: What personal desires, concerns, goals,
or life situation needs must be met?
2. Disease: How does the patient’s disease or condition
affect the body and its normal metabolic functions?
3. Nutrition therapy: Prioritize diagnoses on the basis of
urgency, impact, and resources. How and why must the
diet change to meet the needs created by the patient’s
particular disease or condition?
4. Food plan: How do these necessary nutritional
modifications affect daily food choices? Write a nutrition
prescription that is focused on the etiology to meet these
needs.
 Mode of Feeding:
1. Oral Nutrition
2. Enteral Nutrition
o a mode of feeding that makes use of the
gastrointestinal tract through oral or tube feeding
o When a patient’s gastrointestinal tract is
functioning but he or she cannot consume food
orally, enteral feeding is an option
3. Parenteral Nutrition
o a mode of feeding that does not make use of the
gastrointestinal tract but that instead provides
nutrition support via the intravenous delivery of
nutrient solutions
o If patients are unable to tolerate any nutrient
delivery into the gastrointestinal tract, parenteral
nutrition therapy is considered

(Further discussion of the modes of feeding will be in Lesson 2 of this

module.)

o Nutrition Education
 A formal process to instruct or train a patient/client in a skill
 Impart knowledge to help patients/clients voluntarily manage or
modify food, nutrition and physical activity choices, and
behavior to maintain or improve health
o Nutrition Counseling
 A supportive process that is characterized by a collaborative
counselor-patient relationship to promote health
 Sets priorities, establishes goals, and creates individualized
action plans that acknowledge and foster responsibility for self-
care to treat an existing condition

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 o Coordination of Nutrition Care
 Consultation with, referral to, or coordination of nutrition care
with other health care providers, institutions, or agencies that
can assist with the treatment or management of nutrition-
related problems.

IV. NUTRITION MONITORING AND EVALUATION

 identifies patient outcomes relevant to the nutrition diagnosis and the
intervention plan
 The three components of this process are as follows:
1. monitor progress,
2. measure outcomes, and
3. evaluate outcomes
 Outcome measures include the following categories:
1. Food-/nutrition-related history outcomes
 Food and nutrient intake
 Food and nutrient administration
 Medication, complementary/alternative medicine use
 Knowledge and beliefs
 Availability of food and supplies
 Physical activity, nutrition quality of life
2. Anthropometric measurement outcomes
 Height
 Weight
 Body mass index
 Growth pattern indices and percentile ranks
 Weight history
3. Biochemical data, medical tests, and procedure outcomes
 Lab data (e.g., electrolytes, glucose) and tests (e.g., gastric
emptying time, resting metabolic rate)
4. Nutrition-focused physical finding outcomes
 Physical appearance  Appetite
 Muscle and fat wasting  Affect
 Swallow function
 Efficacy of the care plan is assessed, and changes are made, if necessary.
 If changes are not necessary and the patient’s goals have been satisfied, the
dietitian may discharge the patient from nutrition services at this point.

DOCUMENTING NUTRITION CARE

 Each step of the nutrition care process must be documented in the patient’s
medical record
 ADIME format
o Using this format, the nutrition care plan is recorded as follows:
 Assessment. The assessment section summarizes relevant
assessment results, such as the medical problem, historical
information, height, weight, BMI, laboratory test results, and
relevant symptoms.
 Diagnosis. The diagnosis section lists and prioritizes the nutrition
diagnoses.

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  Intervention. The intervention section describes treatment goals
and expected outcomes, specific interventions, and the patient’s
responses to nutrition care.
 Monitoring and Evaluation. The monitoring and evaluation section
records the patient’s progress, changes in the patient’s condition,
and adjustments in the care plan.
 SOAP Format
o The letters represent the types of information included in each section:
Subjective, Objective, Assessment, and the Plan for care.
 Subjective information is obtained in an interview with the patient
or caregiver and includes the chief medical problem and relevant
symptoms.
 Objective information includes nutrition screening or assessment
data, such as the results of anthropometric and laboratory tests and
the physical examination.
 Assessment section contains a brief evaluation of the subjective and
objective data and provides concise diagnoses of the nutrition
problems.
 Plan includes recommendations that can help solve the problem,
including the nutrition prescription, plan for nutrition education and
counseling, and referrals to other professionals or agencies.

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Lesson 2

 Diet Modification and Diet

Therapy

CLINICAL NUTRITION
 focuses on the nutritional management of individuals or group of individuals
with established disease condition
 deals with issues such as altered nutritional requirements associated with the
disease, disease severity and malnutrition and many such issues

DIETETICS
 The branch of medicine concerned with how food and nutrition affects human
health comprising the rules to be followed for preventing, relieving or curing
disease by diet.
 deals with feeding individuals based on the principles of nutrition
 the science and art of human nutritional care

CLINICAL DIETETICS
 the application of dietetics in a hospital or health care institutional setting

DIET THERAPY
 a branch of dietetics concerned with the use of food for therapeutic purpose
 The purpose of diet therapy is to restore or maintain an acceptable nutritional
status of a patient. This is accomplished by modifying one or more of the
following aspects of the diet:
o Basic nutrient(s) o Texture or consistency
o Caloric contribution o Seasoning

Principles and Objectives of Diet Therapy

1. To increase or decrease body weight
2. To maintain a state of positive health and good nutritional status
3. To ensure adequate nutrition for all age groups and physical conditions
4. To correct nutrient deficiency that may occur
5. To prevent chronic degenerative processes and diseases
6. To adjust food intake to the body’s ability to metabolize the nutrient e.g.
carbohydrate modification in diabetes mellitus

THERAPEUTIC DIET
 a qualitative/quantitative modified version of a normal regular diet which has
been tailored to suit the changing nutritional needs of patient/individual and
are used to improve specific health/disease condition
 Some common examples of therapeutic diets 3 include clear liquid diet,
diabetic diet, renal diet, gluten free diet, low fat diet, high fiber diet

Normal/ General Diet

 a balanced diet which meets the nutritional needs of an individual/patient

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 o Balanced diet is defined as one which contains a variety of foods in such
quantities and proportions that the need for energy, proteins, vitamins,
minerals, fats and other nutrients is adequately met for maintaining
health and well being.
 given when the individual's medical condition does not warrant any specific
modification
 provides approximately 1600 to 2200Kcal, and contain around 180 to 300g
carbohydrates, 60 to 80g of fat and 40 to 70 g of protein

Modification of Normal Diet

The reasons for modifying the diets may include:

 For essential or lifesaving treatment: For example in celiac disease, providing
gluten free diet
 To replete patients who are malnourished because of disease such as cancer
and intestinal diseases by providing a greater amount of a nutrient such as
protein
 To correct deficiencies and maintain or restore optimum nutritional status
 To provide rest or relieve an affected organ such as in gastritis
 To adjust to the body's ability to digest, absorb, metabolize or excrete: For
example a low fat diet provided in fat malabsorption
 To adjust to tolerance of food intake. For example in case of patients with
cancer of esophagus tube feeding is recommended when patients cannot
tolerate food by mouth
 To exclude foods due to food allergies or food intolerance
 To adjust to mechanical difficulties, for example for elderly patients with
denture problems, changing the texture/consistency of food recommended due
to problems with chewing and/or swallowing
 To increase or decrease body weight/body composition when required, for
example as in the case of obesity or underweight
 As helpful treatment, alternative or complementary to drugs, as in diabetes or
in hypertension
Significance of Modified/Therapeutic Diet
 it is useful in managing the disease condition
 it promotes resistance to disease condition
 is preventive or supplemental treatment

Types of Modified/Therapeutic Diet

A. Diets of Altered Consistency
a. Liquid Diet
 consists of foods that can be served in liquid or strained form in
room temperature
 usually prescribed in febrile states, postoperatively i.e. after
surgery when the patient is unable to tolerate solid foods
 used for individuals with acute infections or digestive problems,
to replace fluids lost by vomiting, diarrhea
 Clear Liquid Diet
o provides foods and fluids that are clear and liquid at
room temperature

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 o purpose is to provide fluids and electrolytes to prevent
dehydration
o provides some amount of energy but very little amount of
other nutrients; is nutritionally inadequate and should be
used only for short periods i.e. 1-2 days
o contains 600 to 900Kcal, 120 to 200g carbohydrate,
minimal fat 5 to 10g protein and small amount of sodium
and potassium (electrolytes)
o useful in situations when the gastrointestinal tract has to
be kept functionally at rest
o Examples of clear liquid diet: Water, strained fruit juices,
coconut water, lime juice, whey water, barley/arrowroot
water, rice kanji, clear dal soup, strained vegetable or
meat soup, tea or coffee without milk or cream,
carbonated beverages, ice pops, plain gelatin
 Full Liquid Diet
o provides food and fluids that are liquid or semi liquid at
room temperature
o used as a step between a clear liquid diet and a regular
diet
o purpose of the full liquid diet is to provide an oral (by
mouth) source of fluid for individuals who are incapable
of chewing, swallowing or digesting solid food
o provides more calories than the clear liquid diet and gives
adequate nourishment, except that it is deficient in fiber
o An average full liquid diet can provide approximately
1000 to 1800 calories and 50 to 65g of protein and
adequate minerals and vitamins
o Examples of full liquid diet: Foods allowed or included in
a full liquid diet include beverages, cream soups,
vegetable soups, strained food juices, lassi/butter milk,
yogurt, hot cocoa, coffee/tea with milk, carbonated
beverages, cereal porridges (refined cereals) custard,
sherbet, gelatin, puddings, ice cream, eggnog,
margarine, butter, cream (added to foods), poached, half
boiled egg
b. Soft Diet
 provides soft whole food that is lightly seasoned and are similar
to the regular diet
 does not contain harsh fiber or strong flavors
 provides a transition between a liquid and a normal diet i.e.
during the period when a patient has to give up a full liquid diet
but is yet not able to tolerate a normal diet
 given during acute infections, certain gastrointestinal disorders
and at the post-operative stage to individuals who are in the
early phase of recovery following a surgery
 can be nutritionally adequate (providing approximately 1800-
2000 calories, 55-65g protein) provided the patient is able to
consume adequate amount of food

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  Examples of soft diet: A soft diet freely permits the use of
cooked vegetables, soft raw fruits without seeds, broths and all
soups, washed pulses in the form of soups and in combination of
cereals and vegetables, breads and ready-to-eat cereals (most
preferable refined such as pasta, noodles etc.), milk and milk
beverages, yogurt, light desserts (custard, jelly, ice cream), egg,
tender and minced, ground, stewed meat and meat products, fat
like butter, cream, vegetable oil and salt and sugar in
moderation
 Foods to be best avoided in the soft diet include coarse cereals,
spicy highly seasoned and fried foods, dry fruits and nuts, rich
desserts.
 Mechanically Soft Diet
o a normal diet that is modified only in texture for ease of
mastication i.e. chewing
o for individuals who cannot chew or use facial muscles for
a variety of dental, medical or surgical conditions and
elderly persons who have dental problems
o The food in mechanical soft diet is similar to the soft diet
and may be full liquid, chopped, pureed or regular food
with soft consistency
c. Bland Diet
 made of foods that are soft, not very spicy and low in fiber
 consists of foods which are mechanically, chemically and
thermally non-irritating i.e. are least likely to irritate the
gastrointestinal tract
 for individuals suffering from gastric or duodenal ulcers, gastritis
or ulcerative colitis
 Foods Included: Milk and milk products low in fat or fat free;
Bread, pasta made from refined cereals, rice; cooked fruits and
vegetables without peel and seeds; Eggs and lean tender meat
such as fish, poultry that are steamed, baked or grilled; Cream,
butter; Puddings and custards, clear soups.
 Foods Avoided: Fried, fatty foods; Strong flavored foods; Strong
tea, coffee, alcoholic beverages, condiments and spices; High
fiber foods; hot soups and beverages; whole grains rich in fiber;
strong cheeses.
B. Modification in Quantity
a. Restriction Diet
 Sodium restricted diet – for patients with high blood pressure
 Purine restricted diet – for patients with gout
 Low residue diet - prescribed and/or before abdominal surgery
b. Elimination Diet - recommended when there is food intolerances or
complete insensitivity to a particular food
 gluten free diet
 dairy free diet
 nut free diet
c. increase in the amount of a specific dietary constituent
 high potassium diet – for high blood pressure

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  high fiber diet – for constipation
 iron rich diet – for anemia
C. Modification in Nutrient (Proteins, Fat, Carbohydrate) Content
a. diabetic diet
 for patients with high blood sugar
 Refined carbohydrates are avoided; complex carbohydrates are
recommended
b. fat controlled low cholesterol diet
 for patients with heart disease
c. low protein diet
 for patients with renal failure and advanced liver disease
d. high protein, high calorie diet
 for HIV, cancer, and malnourished patients
e. weight reduction diet
 for overweight and obese patients
D. Changes in Meal Frequency
a. Small but frequent meals
 For individuals suffering with gastro-esophageal reflux disease
(GERD)
 Pregnant women experiencing nausea and vomiting
E. Changes in Method of Cooking
a. Leaching (soaking in water)
 indicated for cooking vegetables for people with chronic kidney
diseases because the kidney's no longer maintain the ideal 12
level of potassium necessary for optimum health
 drains out excessive potassium and phosphorous from the
vegetables
b. In elderly people food may be modified by mechanical processing such
as mashing, blendrizing or chopping
c. For patients on bland diet foods steamed, baked or grilled are
recommended.
F. Modification in the Method of Feeding
a. Enteral Feeding
 provision of nutrients using the gastrointestinal (GI) tract,
usually refers to the use of tube feedings, which deliver
nutrient-dense formulas directly to the stomach or small
intestine via a thin, flexible tube
 used only for patients with functional GI tract
 Candidates for Tube Feedings:
o Severe swallowing disorders
o Impaired motility in the upper GI tract
o GI obstructions and fistulas that can be bypassed with a
feeding tube
o Certain types of intestinal surgeries
o Little or no appetite for extended periods, especially if
the patient is malnourished
o Extremely high nutrient requirements
o Mechanical ventilation

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 o Mental incapacitation due to confusion, neurological
disorders, or coma
 Contraindications
o severe GI bleeding
o high-output fistulas
o intractable (not easily managed/controlled) vomiting or
diarrhea
o severe malabsorption
 Routes (Defined and compared in the table below.)
o Orogastric - tube is inserted into the stomach through
the mouth. This method is often used to feed infants
because a nasogastric tube may hinder the infant’s
breathing.

TUBE FEEDING ROUTES

Insertion Method or Advantages
Feeding Site
Transnasal Does not require surgery or
(a transnasal feeding incisions for placement;
tube is one that is tubes can be placed by a
inserted through the nurse or trained dietitian.
nose)
1. Nasogastric Easiest to insert and confirm
(tube is placed into the placement; least expensive
stomach via the nose) method; feedings can often
be given intermittently and
without an infusion pump.
2. Nasoduodenal and Lower risk of aspiration in
nasojejunal compromised patients;
(tube is placed into the allows for earlier tube
duodenum or jejunum feedings than gastric
via the nose) feedings during acute stress;
may allow enteral feedings
even when obstructions,
fistulas, or other medical
conditions prevent gastric
feedings.
Tube enterostomies Allow the lower esophageal
(an opening into the GI sphincter to remain closed,
tract through the reducing the risk of
abdominal wall) aspiration; more comfortable
than transnasal insertion for
long-term use; site is not
visible under clothing.
1. Gastrostomy Allow the lower esophageal
[An opening into the sphincter to remain closed,
stomach through which reducing the risk of
a feeding tube can be aspiration; more comfortable
Disadvantages
Easy to remove by
disoriented patients; long
term use may irritate the
nasal passages, throat, and
esophagus.
Highest risk of aspiration in
compromised patients; risk
of tube migration to the
small intestine.
More difficult to insert and
confirm placement; risk of
tube migration to the
stomach; feedings require
an infusion pump for
administration.
Tubes must be placed by a
physician or surgeon;
general anesthesia may be
required for surgically
placed tubes; risk of
complications from the
insertion procedure; risk of
infection at the insertion
site.
Tubes must be placed by a
physician or surgeon;
general anesthesia may be
required for surgically

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passed. A nonsurgical than transnasal insertion for placed tubes; risk of
technique for creating a long-term use; site is not complications from the
gastrostomy under local visible under clothing. insertion procedure; risk of
anesthesia is called infection at the insertion
percutaneous site.
endoscopic gastrostomy
(PEG)]
2. Jejunostomy Lowest risk of aspiration; Most difficult insertion
[An opening into the allows for earlier tube procedure; most costly
jejunum through which feedings than gastrostomy method; feedings require an
a feeding tube can be during critical illness; may infusion pump for
passed. A nonsurgical allow enteral feedings even administration.
technique for creating a when obstructions, fistulas,
jejunostomy is called or medical conditions
percutaneous prevent gastric feedings.
endoscopic jejunostomy
(PEJ). The tube can
either be guided into
the jejunum via a
gastrostomy or passed
directly into the
jejunum (direct PEJ)]

 Types of Enteral Formulas

o Standard formulas
 enteral formulas that contain mostly intact
proteins and polysaccharides
 Also called polymeric formulas
 Blenderized formulas
- enteral formulas that are prepared by
using a food blender to mix and puree
whole foods
o Elemental formulas/Hydrolyzed/Chemically
Defined/Monomeric Formulas
 1-3 kcal/ml; enteral formulas that contain
proteins and carbohydrates that are partially or
fully hydrolyzed
o Specialized formulas
 1-2 kcal/ml; enteral formulas for patients with
specific illnesses
 Also called disease-specific or specialty formulas
o Modular formulas
 3-8 kcal/ml; enteral formulas prepared in the
hospital from modules that contain single
macronutrients; used for people with unique
nutrient needs
 Selection of Formula
o factors considered when choosing a formula are shown in
the image on the next page
 Feeding tubes

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 o Feeding tubes are made from soft, flexible materials
(such as silicone or polyurethane) and come in a variety
of lengths and diameters
o The outer diameter of a feeding tube is measured in
French units, in which each unit equals 1/3 millimeter;
thus, a “12 French” feeding tube has a 4-millimeter
diameter (12* 1/3 mm =4 mm)
o Double-lumen tubes allow a single tube to be used for
both intestinal feedings and gastric decompression, a
procedure in which the stomach contents of patients with
motility problems or obstructions are removed by suction.

Selection of Formula

 Methods of Delivery
o intermittent: delivery of about 250 to 400 milliliters of
formula over 30 to 45 minutes

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 o continuous: slow delivery of formula at a constant rate
over an 8- to 24-hour period
o bolus: delivery of about 250 to 500 milliliters of formula
over a 5- to 15-minute period
 Tube Feeding Complications
o Insertion: nasal damage, variceal bleeding
o PEG/PEJ Insertion: bleeding; intestinal /colonic
perforation
o Post-insertion trauma: discomfort, erosions, fistula,
strictures
o Displacement: tube falls out, bronchial administration of
feed
o Reflux: esophagitis, aspiration
o GI Intolerance: nausea, pain, bloating, diarrhea
o Metabolic: refeeding syndrome, hyperglycemia, fluid
overload, electrolyte disturbance
 Nursing Considerations
o When beginning enteral feedings:
 protocols should be reviewed carefully before
working with patients
 patient tolerance must be considered when
adjusting formula delivery rates
 Assess the abdomen by auscultating for bowel
sounds and palpating for rigidity, distension, and
tenderness.
o On an ongoing basis:
 monitor patient for gastric distension, nausea,
bloating, and vomiting
 Stop the infusion and notify the provider if the
patient experiences acute abdominal pain,
abdominal rigidity, or vomiting.
o After feeding:
 measure the gastric residual volume, or the
volume of formula and GI secretions remaining in
the stomach after feeding
 experts recommend that feedings be withheld and
an evaluation be conducted if the gastric residual
volume exceeds 500 milliliters
b. Parenteral Feeding
 provides nutrients intravenously to patients who do not have
sufficient GI function to handle enteral feedings
 Usually used for severely malnourished patients undergoing
chemotherapy and major surgery
 The primary purpose of the method is to maintain a positive
nitrogen balance.
 TPN also aims at:
o Keeping the patient’s nutrition at a healthy state.
o Preserving muscle mass; thus, lessening body fat.
o Managing proper metabolism.

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 o Sustaining continuous circulation inside the body.
Candidates for Parenteral Nutrition (conditions)
o Intractable vomiting or diarrhea
o Severe GI bleeding
o Intestinal obstructions or fistulas
o Paralytic ileus (intestinal paralysis)
o Short bowel syndrome (a substantial portion of the small
intestine has been removed)
o Bone marrow transplants
o Severe malnutrition and intolerance to enteral nutrition
 Access sites:
o Peripheral veins – Peripheral Parenteral Nutrition (PPN)
 smaller, peripheral vein is used
 used most often in patients who require short-
term nutrition support (less than 2 weeks) and
who do not have high nutrient needs or fluid
restrictions
 limited to 900 milliosmoles per liter because
peripheral veins are sensitive to high nutrient
concentrations
o Central veins – Central/Total Parenteral Nutrition (TPN)
 Use of superior vena cava or subclavian vein
 PICC – Peripherally Inserted Central Catheter
- less invasive and lower in cost
- a less invasive and low-cost central line
access that is inserted in the basilic vein,
with the tip in the superior vena cava or
right atrium
 Components of Parenteral Solutions
o Amino acids
 amino acid concentrations in commercial solutions
To convert range from 3 to 20 percent
nutrient o Carbohydrates
concentrations to  provided in the form dextrose monohydrate which
grams per gives 3.4 kcalories per gram
milliliter:  concentrations greater than 10 percent are usually
 10% amino acid used only in TPN solutions
solution = 10 g o Lipids
amino acids/100  supply essential fatty acids
 available in 10, 20, and 30 percent solutions,
mL
containing 1.1, 2.0, and 3.0 kcalories per
 10% dextrose milliliter, respectively
solution = 10 g  may supply 20 to 30 percent of total kcalories
dextrose o Fluids and electrolytes
monohydrate/100  include sodium, potassium, chloride, calcium,
mL magnesium, and phosphate
o Vitamins and Trace Minerals
 All vitamins are usually included in parenteral
solutions, although a preparation without vitamin
K is available for patients using warfarin therapy

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  trace minerals typically added to parenteral
solutions include chromium, copper, manganese,
selenium, and zinc
 Iron is often excluded because it can destabilize
parenteral solutions that contain lipid emulsions;
therefore, special forms of iron may need to be
injected separately.
 Parenteral formulations
o total nutrient admixture (TNA)/ 3-in-1 solution/an all-in-
one solution
 contains dextrose, amino acids, and lipids
o 2-in-1 solution
 Excludes lipids
 Methods of Administering Parenteral Nutrition
o Continuous Parenteral Nutrition
 infused continuously over 24 hours
o Cyclic Parenteral Nutrition
 For long-term parenteral nutrition, infusions are
given 10- to 14-hour periods per day
 Potential Complications
o Catheter-Related
 Air embolism
 Blood clotting at catheter tip
 Clogging of catheter
 Dislodgment of catheter
 Improper placement
 Infection, sepsis
 Phlebitis
 Tissue injury
o Metabolic
 Electrolyte imbalances
 Gallbladder disease
 Hyperglycemia, hypoglycemia
 Hypertriglyceridemia
 Liver disease
 Metabolic bone disease
 Nutrient deficiencies
 Refeeding syndrome
- a condition that sometimes develops when
a severely malnourished person is
aggressively fed; characterized by
electrolyte and fluid imbalances and
hyperglycemia.
 Nursing Considerations:
o Discard all unused, cloudy, or sedimented fluids.
o Do not add drugs and other mixtures to a solution
containing protein.
o Refrigerate solutions until they are used.
o Be aware that dates should be on tube feedings, and that
they should not be given past 24 hours of date.

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 o Be alert for signs of gas, regurgitation, cramping, and
diarrhea, and be prepared to intervene.
o Take necessary precautions when using nutrient solutions
because they are excellent sources for bacterial growth.
o Be especially alert for signs of hypo- or hyperglycemia
when TPN is used and intervene if necessary.
o Assist the patient in adjusting to an alternate feeding
method. Many patients experience stress due to fear and
concern of unfamiliar feeding methods.
o Encourage and practice good oral hygiene measures with
the patient, even though he or she is not eating by
mouth.
o Encourage early ambulation, which makes use of the
muscles and increases the use of calcium and protein.
Physical activity also raises morale.

Selecting a Feeding Route

Module V Page 187

 MODULE SUMMARY

This module has 2 lessons which discussed clinical nutrition and diet therapy.
Lesson 1 tackled nutrition care process as the foundation of nutrition therapy.
Lesson 2 discussed diet therapy which consisted
Congratulations! You have just studied Module V. Now you are ready to
evaluate how much you have benefited from your reading by answering the summative
test. Good Luck!!!

 SUMMATIVE TEST
Multiple Choices

1. For a patient who is at high risk of 4. A difference between continuous and

aspiration and is not expected to be intermittent feedings is that
able to eat table foods for several continuous feedings:
months, an appropriate placement a. require an infusion pump.
of a feeding tube might be: b. allow greater freedom of movement.
a. nasogastric. c. are more similar to normal patterns
b. nasoenteric. of eating.
c. gastrostomy. d. are associated with more GI side
d. jejunostomy. effects.

2. In selecting an appropriate enteral 5. A patient needs 1800 milliliters of

formula for a patient, the primary
consideration is:
a. formula osmolality.
b. the patient’s nutrient needs.
c. availability of infusion pumps.
d. formula cost.
3. An important measure that may
prevent bacterial contamination in
tube feeding formulas is:
a. nonstop feeding of formula.
b. using the same feeding bag and
tubing each day.
c. discarding opened containers of
formula not used within 24 hours.
d. adding formula to the feeding
container before it empties
completely.
formula a day. If the patient is to
receive formula intermittently
every four hours, how many
milliliters of formula will she need
at each feeding?
a. 225
b. 300
c. 400
d. 425
Enumeration
1. What are the steps in nutrition care
process? Define each step.
2. What are the different therapeutic
diets used in clinical care? Which
patients benefit from these types of
therapeutic diet?

Module V Page 188

 Laboratory Activity
I. Suppose a patient is receiving 1.25 liters (1250 milliliters) of a parenteral solution
that contains 5 percent amino acids and 30 percent dextrose, supplemented with
250 milliliters of a 20 percent lipid emulsion daily. How many grams of protein and
carbohydrate is the person receiving, and what is the total energy intake for the
day?

II. Using the following assessment data, develop a nutrition care plan. (Use NANDA or
other NCP reference books)
Subjective:
Patient reports excessive snacking at work, little exercise, recent weight gain
of 10 lb in past year; willing to attempt 5% weight loss and dietary/lifestyle changes to
reduce LDL-C before trying statin medication

Objective:
Height: 6’1”
Weight: 268 lb
BMI: 35.4, obesity II
Total cholesterol: 288 mg/dL
Waist circumference: 45”
LDL-C: 214 mg/dL;
HDL-C: 48 mg/dL
EER: 2725 kcal
Triglycerides: 132 mg/dL
Diet order: Weight reduction; heart-healthy diet

Assessment:
Abdominal obesity; dietary recall indicates ~3700 kcal intake per day and diet
high in fat, saturated fat, trans fat

Nutrition Diagnosis/Plan:
Nutrition Intervention:

Module V Page 189

 1

MODULE VI
Nutrition for Health, Fitness, and
Illnesses
Lesson 1: Nutrition in Weight Management

Lesson 2: Nutrition and Physical Fitness

Lesson 3: Nutrition for Certain Illnesses

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 2

MODULE VI

NUTRITION FOR HEALTH AND FITNESS

 INTRODUCTION

This module will introduce the specific dietary treatments for certain illnesses
as well as for physical fitness.

LEARNING OBJECTIVES
After studying the module, you should be able to:

1. Recognize the effects of weight loss on the body.

2. Explain the benefits of physical activity and nutrition for health, wellness,
and quantity and quality of life.
3. Incorporate knowledge and understanding of the principles of nutrition to
the prevention and treatment of specific diseases.

 DIRECTIONS/ MODULE ORGANIZER

There are three lessons in the module. Read each lesson carefully then answer
the exercises/activities to find out how much you have benefited from it. Work on
these exercises carefully and submit your output to your instructor or to the CCHAMS
Office.

In case you encounter difficulty, discuss this with your instructor during the
face-to-face meeting. If not contact your instructor at the CCHAMS office.

Good luck and happy reading!!!

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Lesson 1

 Nutrition in Weight Management

WEIGHT MANAGEMENT
Weight management is a concern not only from a personal viewpoint but also
from a societal perspective. Consequences of excessive body weight cause many
individuals to suffer economically, socially, mentally, and physically.

OVERWEIGHT

Prevalence and Incidence of Overweight and Obesity

 Prevalence means the total number of cases of a specific disease divided by
the number of individuals in the population at a certain time.
 Incidence is defined as the frequency of occurrence of any event or condition
over time and in relation to the population in which it occurs. Asian American
children have the lowest incidence of obesity.
 According to the report released by Asia Roundtable on Food Innovation for
Improved Nutrition, Philippines faces an obesity and overweight prevalence of
5.1 percent and 23.6 percent. Despite low prevalence rates. Obesity has a
strong impact in our country due to large number of obese persons in the
country – 18 million Filipinos ar obese and overweight.

Consequences of Obesity
1. Social
a. Cultural Expectations
 Some studies have demonstrated that culture can affect
attitudes toward thinness
 Some perceive leanness as being attractive and desirable and
fatness as being unattractive and undesirable
b. Documented Prejudice
 Research has documented health-care professionals, including
both physicians and nurses, often have biases toward obese
clients as they view obese clients as noncompliant, lazy, and
unattractive
 Health-care providers should treat obese clients with respect,
kindness, and patience.
2. Psychological
a. Body Image Disturbances
 Body image is the mental picture a person has of himself or
herself.
 A disturbed body image can manifest itself in two ways”
a. People with distorted body images are usually dissatisfied
with their bodies.
e.g. Chronic complaints, demands for extra attention,
and frequent negative statements made by clients about
the way they look may be signs of an underlying body
image disturbance.
b. Persons with distorted body images frequently do not
view their bodies realistically
e.g. people may view themselves as having certain body
parts larger than they actually are
3. Medical
a. People who are overweight or obese are more likely to develop health
problems such as:

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 Hypertension
 Dyslipidemia (e.g., high total The Five-Hundred Rule
cholesterol or high levels of  To lose 1 pound of body
triglycerides) fat per week, an
 Type 2 diabetes individual must eat 500
 Coronary heart disease kilocalories fewer per
 Stroke day than his or her body
 Gallbladder and liver disease expends for 7 days.
 Osteoarthritis  To gain 1 pound of body
 Sleep apnea and respiratory problems fat per week, the
b. Gynecological problems (abnormal menses individual must eat 500
and infertility) (CDC, 2012) kilocalories more per day
c. Abdominal obesity for 7 days than his or her
 excess weight is between the body expends.
client’s chest and pelvis
 Clients with abdominal obesity are said to be shaped like an
apple and are especially vulnerable to chronic disease risks
associated with excessive body weight
d. Gluteal-femoral obesity
 excess weight is around the client’s buttocks, hips, and thighs
 Clients with gluteal-femoral obesity are said to be pear-shaped
and are not as susceptible to chronic disease risks associated
with excessive body fat.

Advantages of Weight Loss

 Weight loss to lower blood pressure in overweight and obese persons with high
blood pressure
 Weight loss to lower elevated levels of cholesterol, low-density lipoprotein
cholesterol, and triglycerides and to raise low levels of high-density lipoprotein
cholesterol in overweight and obese persons with dyslipidemia
 Some weight loss to lower elevated blood glucose levels in overweight and
obese persons with type 2 diabetes

Treatment of Energy Imbalances

 Goals for Weight Loss
o The initial goal of weight loss should be to reduce body weight by 10%
from the baseline (current weight).
o Safe weight loss occurs at about 1 to 2 pounds per week for a period of
6 months
 Achieving Weight Loss
o Behavior Modification
 Behavior-oriented therapies are designed to help change
patterns that contribute to excessive weight and that can help
empower individuals to plan constructive actions to meet
personal health goals.
 Basic Strategies and Actions:
1. the control of eating behavior (e.g., a food diary that
includes when, where, why, how, and how much); and

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2. the promotion of physical activity to increase energy

output
3. the pursuit of emotional (stress), social, and psychologic
health
 Three progressive actions for individual strategies:
1. Defining problem behavior
- define the problem behavior, potential barriers to
the new behavior, and the desired behavior
outcome
2. Recording and analyzing baseline behavior
- Record eating and exercise behavior, and carefully
analyze it in terms of physical setting and people
involved
3. Planning a behavior management strategy
- Set up controls of the external environment that
involves the situational forces related to each of
the three behavior areas involved: (1) the stimulus
that occurs before the behavior; (2) the response
to the behavior; and (3) the results of the
behavior.
o Dietary Modification
 Basic Principles
1. Realistic goals: Goals must be realistic in terms of overall
weight loss and rate of loss, averaging 1 2 to 1 lb per
week (or no more than 2 lb per week for clinically severe
obese patients)
2. Negative energy balance: The most important factor that
affects weight loss is the establishment of a negative
energy balance with a reduction of 500 to 1000 kcal/day.
3. Nutritional adequacy: the ratio of macronutrients should
have an appropriate balance that is based on a wide
variety of food sources
4. Cultural appeal: The food plan must be similar enough to
an individual’s cultural eating patterns to form the basis
for a permanent alteration of eating habits.
5. Energy readjustment to maintain weight: When the
desired weight level is reached, the kilocalorie level is
adjusted in accordance with maintenance needs.
 Dietary therapy (also called medical nutrition therapy)
1. Diets must maintain adequate amounts of all nutrients
and should provide at least:
- 45% of kilocalories from carbohydrate
- 20% of kilocalories from fat
- 10% of the kilocalories from protein or 0.8
gram/kg, whichever is higher
- Remaining 25% of kilocalories open to negotiation
with the client
- 25 to 35 grams of fiber
- All essential vitamins and minerals

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UNDERWEIGHT

Dietary Treatment
 The dietary goal, in accordance with each person’s tolerance, is to increase
energy and nutrient intake, with adherence to the following needs:
o High-caloric diet: above the standard requirement for that individual
o High protein: to rebuild tissues
o High carbohydrate: to provide the primary energy source in an easily
digested form
o Moderate fat: to provide essential fatty acids and add energy without
exceeding tolerance limits
o Good sources of vitamins and minerals: provided by a variety of
nutrient-dense foods and dietary supplements when individual
deficiencies require them

EATING DISORDERS
 Anorexia nervosa
 Bulimia
 Binge-Eating Disorder
(Eating disorders are discussed in Module II, Lesson 4.)
Treating Eating Disorders
 The treatment of eating disorders requires a multidisciplinary approach
including:
o Hospitalization
 Indicated for severe malnutrition, suicidal ideation, electrolyte
disturbances, dehydration, abnormal vital signs, cardiac
arrhythmias, and failure of outpatient treatment
o Vitamin and mineral supplementation
o Psychotherapy
 Mainstay treatment for certain eating disorders
o Medical therapy to correct complications related to the illnesses
 Nutritional Considerations
o Refeeding
o Emotional support
o Nonrestrictive vegetarian or vegan diets can be adequate
 Anorexia Nervosa
o Hospital Feeding
 Most practitioners start with a diet containing 1000–3000 kcal
and progressively increase the intake by 200 kcal every three or
four days until the daily intake is adequate for an acceptable
weight gain
 Nurses should monitor the patient’s eating behavior and pay full
attention to the following feeding routines:
1. Check that the foods served comply with the meal plan.
2. Pay attention to the patient’s hands constantly.

Module VI
 7

3. Assume a friendly and supportive attitude so that the

patient will not feel spied on.
4. Leave the room only in an emergency, since the patient
may try to get rid of some foods.
5. Prevent food disposal by keeping any container (such as a
facial tissue box, a wastebasket, or a flower pot) away
from the patient during the meal and checking the meal
tray after the patient has finished eating. The patient
may hide food under napkins or smear it under the bed,
on the window sill, and so forth.
6. Permit a maximum of one hour for eating a meal.
7. If feasible, arrange for the patient to eat alone and be
monitored by the same nurse.
8. If possible, the patient should wear a pocketless hospital
gown while eating.
9. Insist that the patient rest for 1 ⁄2 to one hour after a
meal and does not leave the bed, since she may induce
vomiting.
 Nursing Considerations:
1. All team members must be consistent and caring in their
handling of the feeding routines.
2. Patients may not manipulate or dictate food intake.
3. Feeding periods must be closely supervised.
4. Bathroom privileges must be denied for at least 30
minutes after a meal to prevent self-induced vomiting.
5. Major sleep disturbances that occur early in treatment
cease as the patient gains weight.
6. Avoid all conversation related to food or weight gain
while the patient is hospitalized, except as it relates to
an agreed-upon contract (“You have complied with diet
goals this week so you may [have] [get] [do] the
reward.”).
7. Nutrition education for patient and family can begin
when the patient is discharged.
8. Psychological counseling takes precedence over
nutritional counseling.
9. During nutritional repletion, serum electrolytes should be
closely monitored for signs of refeeding syndrome, which
is characterized by serum electrolyte depletion, fluid
shifts, cardiac arrhythmias, and glucose derangements
occurring in severely malnourished patients when they
receive nutritional repletion either orally, enterally, or
parenterally.
 Bulimia
o Managed on an outpatient basis
o Clients may receive antidepressant drug therapy along with counseling.
o The client should keep a journal or log of the food eaten and the things
that he or she believes trigger the eating frenzies

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o The client should keep a journal or log of the food eaten and the things
that he or she believes trigger the eating frenzies
o Foods such as fruits, vegetables, and cereal grains that are high in fiber
are emphasized.
o Clients are advised to use only those foods that are preportioned and
only those that are eaten with utensils (not finger foods).

Clinical Application

Situation: You have a friend whose 14-year-old daughter is causing her

concern. She confides to you the following: Jenny is so different lately; she has
become quite secretive. She has dark circles under her eyes, and her neck looks
swollen. I’ve asked her several times if she’s OK, and she says yes, she’s just tired. I
suppose she is, she eats pretty well and hasn’t lost weight, but I think she must have
trouble digesting her food. I hear her in the bathroom after meals, and it sounds like
she is throwing up, but she says I’m mistaken. Do you think I should force her to go to
the doctor, or is this just a phase she’s going through?
Based on your present knowledge of eating disorders, and cognizant of
the behaviors of adolescents, how will you answer your friend?

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Lesson 2

 Nutrition and Physical Fitness

Physical Activity
 bodily movement produced by the contraction of skeletal muscles that
substantially increases energy expenditure above the basal level
 Examples of physical activity would be walking or riding a bike as a form of
transportation, using the stairs instead of the escalator, or manual labor such
as carpentry work, gardening, or farming

Exercise
 a subcategory of physical activity that is planned, structured, repetitive, and
with the purpose of improving or maintaining one or more component of
physical fitness
 Examples of exercise include aerobic classes, jogging, running, swimming,
cycling, weight training, tennis, and other such bouts of planned activities with
the intension of improving overall physical fitness.

Physical Fitness
 the ability to carry out daily tasks with vigor and alertness, without undue
fatigue, and with ample energy to enjoy leisure-time pursuits and respond to
emergencies
 Physical fitness includes a number of components consisting of
cardiorespiratory endurance (aerobic power), skeletal muscle endurance,
skeletal muscle strength, skeletal muscle power, flexibility, balance, speed of
movement, reaction time, and body composition.
 Components of fitness:
o Flexibility
 the capacity of the joints to move through a full range of
motion; the ability to bend and recover without injury.
o Cardiorespiratory endurance
 the ability to perform large-muscle dynamic exercise of
moderate-to-high intensity for prolonged periods.
 supports the ongoing activity of the heart and lungs
o Muscle strength
 the ability of muscles to work against resistance
o Muscle endurance
 the ability of a muscle to contract repeatedly within a given
time without becoming exhausted

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Health Benefits Associated with Regular Physical Activity

CHILDREN AND ADOLESCENTS

Strong Evidence
 Improved cardiorespiratory and muscular fitness
 Improved bone health
 Improved cardiovascular and metabolic health biomarkers
 Favorable body composition
Moderate Evidence
 Reduced symptoms of depression

ADULTS AND OLDER ADULTS

Strong Evidence
 Lower risk of early death
 Lower risk of coronary heart
disease
 Lower risk of stroke
 Lower risk of high blood pressure
 Lower risk of adverse blood lipid
profile
 Lower risk of type 2 diabetes
 Lower risk of metabolic syndrome
 Lower risk of colon cancer
 Lower risk of breast cancer
Moderate to Strong Evidence
 Better functional health (for older adults)
 Reduced abdominal obesity
Moderate Evidence
 Lower risk of hip fracture
 Lower risk of lung cancer
 Lower risk of endometrial cancer
 Prevention of weight gain
 Weight loss, particularly when
combined with reduced calorie
intake
 Improved cardiorespiratory and
muscular fitness
 Prevention of falls
 Reduced depression
 Better cognitive function (for older
adults)
 Improved weight maintenance
after weight loss
 Increased bone density
 Improved sleep quality

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Physical Activity
Pyramid

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 12

Types of Physical Activity How to Choose an

1. Resistance Training Exercise Program?
 creates and maintains muscle and bone 1. Choose an exercise you
strength, improves blood pressure in like so that you will
prehypertensive/hypertensive individuals, enjoy doing it.
and increases insulin sensitivity 2. Choose one that can be
 includes 8 to 10 separate exercises (with 8 done in all seasons.
to 12 repetitions of each) focusing on all 3. Choose one that can be
major muscle groups and that are done preferably near
performed 2 to 3 days per week your residence.
2. Aerobic Exercise 4. Choose one for which you
 include activities such as walking, have facilities.
swimming, running, jogging, bicycling, and 5. Choose one that can be
aerobic dancing routines and similar done regularly.
workouts 6. Choose an exercise that
 walking can be an excellent form of involves the large
aerobic exercise if the pace is fast enough muscles in the body.
to elevate the pulse rate and if it is
maintained for at least 20 minutes
 To build aerobic capacity, the level of exercise must raise the pulse
rate to within 60% to 90% of an individual’s maximal heart rate
o to estimate the maximal heart rate is to subtract the person’s
age from 220
3. Weight-Bearing Exercise
 aerobic and resistance-type exercises
 Weight-bearing exercises such as walking, jogging, aerobic dancing, and
jumping rope are important for bone structure and strength
4. Activities of Daily Living
 Many activities of daily living do not reach aerobic levels
 e.g., walking to work or to the store, walking the dog, playing catch
with children
 enjoyable ADLs may benefit the individual by doing it often

Requirements for Moderate Exercise

Fluids and Oxygen
 Fluids
o through skin and sweat
 Electrolytes
o Though sweat contains electrolytes, chloride, magnesium and
potassium, performance is not disturbed by electrolyte losses.
o In hot months, during training, a dilute salt solution (1/2 teaspoon salt
per liter) may be used as a rehydration drink to correct excessive sweat
losses
 Oxygen
o The need for oxygen increases with exercise, as more oxygen is needed
to release extra body energy
o Body Fitness
 Measured in terms of aerobic capacity.

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- Aerobic capacity is the ability of the body to provide the

increased demands for oxygen and use it during exercise
o Body Composition
 determined by lean body mass and body fat
 The aerobic capacity is dependent on the percentage of lean
body mass and body fat

Nutritional Needs for Exercise

Nutrient Reserves
 It is important to have nutrient reserves to meet the demands during periods of
exercise
 Carbohydrate is the major nutrient to provide energy for exercise
 Total fat should not exceed 20 to 25 per cent of the total dietary calories
 No additional protein is needed, as it is not meant to serve as an energy
source.
 Vitamins and minerals are essential only in the process of energy release as co-
factors
 The athletes, who need more energy, take larger amounts of good food, which
increases their intake of vitamins and minerals
o The only groups that need to focus special attention in this respect are
adolescent and female athletes, who may need iron supplements, if
their blood iron levels are very low.

Exercise and Energy

 The amount of energy used in exercise varies with:
1. the intensity of the exercise
2. the duration of the exercise
3. the sex, age, weight of the individual
4. the state of the individual
5. the level of training
 Exercise is the only way to regulate the person’s body system and to regulate
the body fat content.

Athletic Performance
 Preparation for Athletics/Sports
o Carbohydrate loading: the need to increase muscle glycogen stores
prior to the competition
 The carbohydrate intake (mainly starch from grains) is increased
slowly in the week before the event, beginning with 350g and
increasing it to 450 to 500g in four days
 Intake is reduced to normal the day before the event
 used only by persons engaged in endurance activities such as
marathons, long distance running, cycling, walking, swimming
and cross-country skiing
o Precontest/Pregame Meal: light meal of about 300 kcal, two to four
hours before the game/contest
 should be mainly cereal preparation, which is high in complex
carbohydrate, low in protein, with little fat or fiber in it

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 During performance:
o athlete should drink 400 to 500 ml cool water two hours before the
competition, another 400 to 500 ml 15 minutes before the event
o Plain cold water is normally the fluid of choice to ensure rehydration,
except for endurance competitions or training round.
 Recovery Meal
o high-carbohydrate foods plus protein after physical activity to enhance
glycogen storage
o carbohydrate-containing beverages such as sports drinks or fruit juices
may be preferred if the individual is not hungry after physical acivity
 Ergogenic aids
o Work producing aids
o substances or treatments that purportedly improve athletic
performance above and beyond what is possible through training
o For practical purposes, most ergogenic aids can be categorized as
follows:
 those that perform as claimed
 those that may perform as claimed but for which there is
insufficient evidence at this time
 those that do not perform as claimed
 those that are dangerous, banned, or illegal, and therefore
should not be used
o Commonly used ergogenic aids: Female Athlete Triad:
 Anabolic steroids - used to increase The female athlete triad is
muscle size, strength and performance a medical condition
 It is illegal to use steroids and comprised of three
those who use these are interrelated components
disqualified from participating in
faced by women who are
Olympic games.
 Caffeine - enhances endurance and, to very physically active:
some extent, enhances short-term, (1) Low energy availability
high-intensity exercise performance. with or without disordered
 Creatine - enhance stores of the high- eating;
energy compound creatine phosphate (2) Menstrual dysfunction;
(CP) in muscles; improve performance and
by increasing muscle strength and size, (3) Low bone mineral
cell hydration, or glycogen loading density.
capacity
 Sodium bicarbonate - ingested prior to
high-intensity sports performance buffers the acid and
neutralizes the carbon dioxide, thereby maintaining muscle pH
levels closer to normal and enhancing exercise capacity

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Lesson 3

 Nutrition for Certain Illnesses

NUTRITION THERAPY FOR DIABETES MELLITUS

Diabetes Mellitus
 Defined as a group of disorders with measurable persistent hyperglycemia,
which results from defects in insulin production, insulin action, or both.
 Symptoms - excessive urine production (polyuria), thirst (polydipsia),
excessive hunger (polyphagia), blurred vision, and, in some cases, weight loss
 Hyperglycemia - elevated level of glucose in the blood
 Types:
o Diabetes Mellitus Type I /insulin-dependent diabetes mellitus (IDDM)/
, juvenile-onset diabetes
 results from a cellular-mediated autoimmune destruction of the -
cells of the pancreas, which produce insulin
o Diabetes Mellitus Type II / non–insulin dependent diabetes mellitus
(NIDDM)/ adult-onset diabetes
 results from an insulin resistance or insulin defect: either the body is
not producing enough insulin or the insulin that it is being produced
cannot be used
o Gestational Diabetes
 defined as carbohydrate intolerance of variable severity with onset
or first recognition during pregnancy
 Management Goals:
o Maintain optimal nutrition
o Prevent hypoglycemia or hyperglycemia
o Prevent complications
 Diet Therapy
o Nutrient balance: 50%-55% Carb, 15%-20% Proteins, 30% Fat
o Caloric requirement
 Overweight – 1200 – 1500 cal/day
 Thin, young, and male – up to 4000 cal/day
o Protein: 1.5 g/kg body weight
o Carbohydrate and Fats: after subtracting calories from protein,
remainder calories is divided equally between CHO and fats
o What to avoid:
 Extra flour, bread crumbs, and butter
 Frozen, canned fruits with sugar
 Concentrated sweets and desserts like sugar, candies, jellies, jams,
marmalades, syrup, honey, molasses, soft drinks, cakes, cookies,
pies, pastries, sweet rolls
o Planning measured diet:

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 Include the basic foods to ensure adequate levels of minerals and

vitamins
 2 cups milk (3 or more for children)
 5 oz milk
 2 servings vegetables
 2 servings fruit
 Breads and cereals
 List carbohydrate, protein, and fat values for milk, vegetables, and
fruit.
 Subtract the carbohydrate values of these foods from the
carbohydrate level prescribed. Divide the difference by 15 to
determine the number of bread exchanges.
 Subtract the total protein values of milk and meat from the total fat
prescribed. Divide the difference by 7 to determine the number of
meat exchanges.
 Subtract the total fat values for milk and meat frim the fat
prescribed. Divide the difference by 5 to determine the number of
fat exchanges.
 Sample calculation of Diet:
 Carb: 150, Protein: 70, Fats:70
Exchange Lists No. of Carbohydrate Protein Fat (g)
Exchanges (g) (g)
Milk 2 24 16 20
Veg A 1-2
Veg B 1 7 2
Fruit 3 30
61*
Bread 6 90 12
30**
Meat 6 42 30
50***
Fat 4 20
Totals for the day 151 72 70
 *150–6 = 89 g CHO to be supplied from bread exchanges
1 bread exchange = 15 g CHO
89 divided by 15 = 6 bread exchanges
 **70-30=40 g protein to be supplied from meat exchanges
1 exchange meat = 7 g protein
40 divided by 7 = 6 meat exchanges
 ***70-50=20 g fat to be supplied from fat exchanges
1 fat exchange = 5 g fat
20 divided by 5 = 4 fat exchanges
 Sample Menu:
Breakfast: Milk (1 exchange) = 1 cup milk
Fruit (1 exchange) = ¼ medium papaya
Bread (2 exchanges) = 1 cup rice

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Meat (1 exchange) 1 egg (1 tsp butter)

Fat (1 exchange)
Lunch: Milk (1 exchange) = 1 cup milk
Veg Group A
Fruit (1 exchange) = 1 banana
Bread (2 exchanges) = 1 cup rice
Meat (2 exchanges) pork sinigang
Fat (1 exchange)
Dinner: Veg Group V: 1 exchange = pinakbet
Fruit (1 exchange) = 1 pineapple
Bread (2 exchanges) = 1 cup rice
Meat (3 exchanges) fried bangus
Fat (1 exchange)
NUTRITION THERAPY FOR DISEASES OF THE GASTROINTESTINAL TRACT
 Peptic Ulcer
o An ulceration in the protective inside layer of the lower esophagus,
stomach, or duodenum
o Dietary Treatment:
 Bland Diet – a nutritionally adequate diet that includes food that has
bland flavor and soft consistency, and mechanically and chemically non-
stimulating
 Sufficient protein and ascorbic acid are important for ulcer healing
 Fats from cream, milk, butter and eggs are easily digested and helps
inhibit acid secretion
 Avoid: Caffeine and tannins in coffee, tea, cola beverages, some spices,
alcohol, tobacco
 Diverticular Disease
o Diverticulosis indicates the presence of diverticula (pouch) in the colon
which can lead to swelling (diverticulitis) of small pouches in the colon wall
and lining
o Dietary Treatment:
 A well-balanced diet with variety of foods and adequate protein
 For acute episodes: liquids and low-residue foods, excluding roughage
 As swelling decreases: high-fiber diet to lessen straining
 Malabsorption syndrome (celiac sprue)
o A condition in which the mucosa of the small intestine is damaged by gluten
which results to malabsorption of nutrients.
o Non-tropical Sprue – a diarrheal condition in which excessive fat is
excreted in the stool (steatorrhoea); nitrogen, minerals and vitamins are
also excreted in significant amounts that the individual becomes severely
malnourished.
o Dietary Treatment:
 High-protein diet (100 g or more)
 Vitamin and mineral supplements
 Low-fat fiber diet

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 Avoid: wheat, rye, oats, thickened soups, cooked salad dressings, cold
cuts, breaded meats, meat loaf, corn, rice cereals
 Ulcerative colitis
o An inflammatory bowel disease of the large intestine limited to the rectum
and the colon which causes profuse and bloody diarrhea.
o Signs and symptoms: severe diarrhea, rectal bleeding, cramping, abdominal
pain, anorexia, weight loss
o Dietary Treatment:
 High protein (120-150 g/day) – egg, cheese, meat. Milk in cooked form
 High calories (2500-3000 cal/day)
 Increased vitamins and minerals
 Low-residue diet
 Other treatment: rest, sulfonamides
 Lactose Intolerance
o Caused by deficiency of lactase which hydrolyzes lactose
o Undigested lactose remains in the small intestine and may serve as a
substrate for bacterial fermentation
o Dietary Treatment:
 Lactose-restricted diet
 Avoid: milk, milk products, lactose, whey, casein
 Cottage cheese, aged cheddar, and fermented milk like yogurt may be
given depending on the tolerance of the individual
 Diarrhea
o frequent loose or liquid bowel movement
o Acute - less than 2 weeks; caused by viral or bacterial, or protozoan
infections, medication side effects or altered dietary intake
o Chronic – more than 2 weeks; results from malabsorption disorder or PEM or
medical treatments
o Dietary treatment:
 Nil per os (NPO) or “nothing by mouth” for 12 hours with IV fluids and
electrolytes
 Oral fluids as condition improves
 Liberal fluids to prevent dehydration
 Broth and electrolyte solutions to replace Na and K losses
 Pectin to help control diarrhea
 Oral rehydration (3/4 tsp salt, 1 tsp baking soda, 1 cup orange juice, 4
tbsp sugar, and 1 liter water)
 Constipation
o A condition in which a person experiences hard feces that are difficult to
egest
o Symptoms: lack of appetite, lethargy, bad breath, distended stomach,
caked tongue
o Types:

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 Atonic constipation – experienced by older people, obese individuals,

before surgery and during pregnancy; caused by inadequate diet,
irregular meals, lack of liquids and fiber in diet and irregular defecation
 Spastic Constipation – caused by over stimulation of the intestinal
nerve endings resulting in asymmetrical contractions of the bowel;
caused by extreme use of cathartics, laxatives, tobacco, tea, coffee,
alcohol, stress, poor hygiene, lack of fluids, and irregular defecation
 Obstructive Constipation – passage of feces is impeded or a
compression by surrounding tissues happens causing the drying and
enlargement of fecal mass
o Dietary Treatment:
 High-fiber diet – 20-35 g/day
 Liberal fluid intake – prunes and prune juice contain laxatives
 In acute attacks or spastic constipation: low-fiber diet
 Intestinal Gas
o Increased occurrence of passage of gas or cramping pain associated with
the build-up of gas in the GIT, gas swallowed, or gas exchange in the GIT
and blood or produced during digestion
o Dietary treatment:
 Exclude gas-producing food
 Small frequent meals and chewing food thoroughly
 Hemorrhoids
o Enlarged veins which occur in the lower part of the rectum at the anal
opening; caused by constipation, prolonged use of cathartics, childbearing
and enema
o Dietary Treatment:
 High-fiber diet – 25-35 g/day to relieve constipation
 Liberal fluids – 8-10 glasses of water/day
 Low-fiber diet for flare ups
 Avoid: highly-seasoned foods and relishes
 Gastroesophageal reflux disease (GERD), hiatal hernia, esophagitis or
heartburn
o Dietary Treatment:
 Maintain ideal body weight
 Limit foods that relax the lower esophageal sphincter like alcohol, mint,
chocolates
 Increase intake of foods that do not affect the lower esophageal
sphincter like protein and carbohydrate foods with low-fat content
 Avoid: foods high in fat, large meals, soft drinks, citrus fruits and
juices, coffee, herbs, spices, tomato products, very hot/cold foods
 Short bowel syndrome
o A malabsorption disorder caused by resection of portions of the small
intestine due to an illness or injury
o Dietary Treatment:

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 Parenteral nutrition support to be indicated if enteral nutrition

exacerbates symptoms
 Frequent monitoring of fluids and electrolyte balance
 Dietary fat restriction
NUTRITION FOR SPECIAL GASTROINTESTINAL SURGERY
 Mouth, throat, or neck surgery
o Oral liquid feeding or tube feedings (Blenderized or special formula
preparations such as Sustagen)
 Gastric resection
o Immediate post-operative period – gradual build-up of foods a few at a time
until tolerance is established
o “Later-dumping syndrome” may develop, rapid food passage draws water
from surrounding blood volume causing shock symptoms; relief achieved by
diet: 5 or 6 small meals low in carbohydrate, mainly protein and fat with
liquids only between meals
 Cholecystectomy
o Low fat following surgery avoids pain from constriction at wound site
 Ileostomy and colostomy
o Initial period of reduced residue diet to be indicated, but return to regular
full diet as soon as possible for both nutritional and psychological reasons
 Rectal Surgery
o Non-residue diet given immediately; the low-residue diet given as needed
with return to full diet as soon as possible

NUTRITIONTHERAPY FOR DISEASES OF THE LIVER, GALLBLADDER, AND PANCREAS

LIVER
 Hepatitis
o Inflammation of the liver
o Hepatitis A – caused by virus transmitted by the fecal-oral route
o Hepatitis B – caused by virus that can cause both acute and chronic
hepatitis; transmitted through blood transfusion, tattoo application, sexual
intercourse, contact with blood or body fluids, breastfeeding
o Hepatitis C – caused by virus with RNA genome that is a member of the
Flaviviridae family; transmitted through blood contact or sexual contact
and can also cross the placenta; may lead to chronic hepatitis and cirrhosis
o Hepatitis D – caused by hepatitis delta agent, similar to a viroid; can only
propagate in the presence of hepatitis B virus; transmitted through blood
contact and sexual contact
o Hepatitis E – has symptoms similar to hepatitis A; transmitted by drinking
water infected with virus or oral anal contact
o Dietary Treatment:
 Protein – 1 – 2 g/kg body weight; protein from animal source is
recommended

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 Energy – bed patients without fever: 2000-2500 cal; with fever, loos of
body protein or poor absorption of food from the intestinal tract: 2500-
4000 cal
 Minerals and Vitamins – supplements are required for patients with
faulty absorption
 Moderate fat – 80-100 g/day
 Example: high protein milk shake: 16 g protein; 585 calories
- 1 cup milk
- 5 tbsp non-fat dry milk
- 2 tbsp chocolate syrup
 Cirrhosis
o A chronic degenerative disease in which the build-up of fibrous connective
tissue replaces the liver cells following fatty degeneration of long standing
o Dietary Treatment
 Cirrhosis with ascites: sodium restriction to 250 mg to control edema
 Protein intake of 100 g at a sodium level of 250 mg
 Fat restriction is not necessary
 Others: rest, supportive care
 Avoid: alcohol
 Hepatic coma
o Happens when there is too much ammonia in blood circulation
o Dietary Treatment:
 High calories (1500-2000) to prevent tissue catabolism and the
liberation of additional nitrogen’
GALLBLADDER
 Cholecystitis
o Inflammation of the gallbladder which might result from either formation of
gallstones blocking the cystic duct or infection of the gallbladder;
symptoms are nausea and vomiting, chills and fever, indigestion and
heartburn
o Choledolithiasis – stones fall into the common bile duct
o Dietary treatment:
 Low fat diet
 Plain and simple foods
 Avoid: rich pastries, whole milk, cream, ice cream, chocolates, nuts,
fatty, fried and gas forming foods, spices and high-residue foods
 Limit: lean meat, egg yolk, butter, margarine, salad dressings
PANCREAS
 Pancreatitis
o Inflammation of the pancreas due to decreased production of the digestive
enzymes; may also result from biliary tract disease and surgery, alcohol
abuse, and gallbladder disease
o Acute pancreatitis – caused by excessive alcohol intake and gallbladder
disease; symptoms are nausea and vomiting, pain, and diarrhea

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o Chronic pancreatitis – results in permanent pancreas damage; may cause

chronic pain and abdominal distention
o Dietary treatment
 Acute attacks – NPO for 48 hours to avoid organ stimulation
 Low-fat, low-elemental formulas when enteral feeding is appropriate
 Chronic cases – low to moderate fat, high CHO, moderate protein diet
 Fluids and electrolytes given intravenously
 Six feeding daily to facilitate adequate nutritional intake
 Cystic fibrosis
o A hereditary disease in which the levels of sodium and chloride in tears and
saliva, electrolyte in sweat, and viscous secretion in the small intestine,
pancreas, bile ducts and bronchi become high; mainly affected organs are
lungs and digestive system
o Dietary treatment:
 Calories high enough to supply demands for growth
 High protein diet to compensate for fecal losses
 Liberal fat intake since fat is an important source of calories
 Vitamins and minerals
 Liberal fluid intake
NUTRITION THERAPY FOR CARDIOVASCULAR DISEASES
 Atherosclerosis
o Refers to the thickening of the inside walls of the blood vessels
o Caused by the accumulation of fatty materials including high proportion of
cholesterol as well as other substances
o Most common cause of heart attacks
o Dietary treatment:
 Low-fat diet, low in saturated fat and cholesterol
 Increase in monounsaturated fatty acids to lower plasma total
cholesterol and LDL cholesterol levels
 Increase in polyunsaturated fats, omega-6 and omega-3 fatty acids
 300 mg cholesterol intake per day
 Increase in complex carbohydrates and restriction of simple sugars
 Calories: 1200-1600 for women, 2000-2500 for men
 Congestive heart failure (CHF)/Cardiac failure
o A circulatory congestion resulting in the heart’s inability to maintain
adequate bloody supply to meet oxygen demands
o Symptoms: shortness of breath (dyspnea), edema of the feet and legs
o Dietary treatment
 Sodium-restricted diet
- Mild restriction – 2-3 g Na
- Moderate – 1000 mg
- Strict restriction – 500 mg
- Severe restriction – 250 mg
 Calorie control to reduce the work of the heart
 Texture control to aid in digestion

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 Limit caffeine
 Hypertension
o High blood pressure, common in males 55 years and below
o Dietary treatment
 Sodium intake at 1000mg/day
 Weight reduction
 Low-fat diet
 Other: lifestyle modification
 Myocardial infarction (MI)
o Heart attack; results from atherosclerosis of the coronary artery
o Dietary treatment:
 Liquid diet on the initial stages and as the condition improves,
progresses to foods of regular consistency
 Small, frequent meals
 Restriction on caffeine containing beverages to avoid myocardial
stimulation
 Sodium, cholesterol, fat, and calorie restriction
 Consumption of omega-3 fatty acid-rich foods to reduce blood clots
NUTRITIONTHERAPY FOR DISEASES OF THE KIDNEYS
 Acute glomerulonephritis
o May be a deferred hypersensitivity reaction initiated by infectious agents
related with tonsillitis or scarlet fever or is a consequence when an antigen-
antibody complex reaction in which some of the complexes become
ensnared in the glomeruli leads to swelling
o Dietary treatment
 Adequate protein
 No sodium restriction unless edema is seen
 High-calorie diet from fat and carbohydrates to spare tissues from being
used as an energy consumption
 Nephrotic syndrome
o Results from injury to the capillary walls of the glomerulus; characterized
by massive loss of protein in the blood and edema
o Dietary treatment:
 High-protein diet: 100-150 g daily
 High calorie diet
 Sodium restriction: 500 mg
 Renal Failure
o Acute Renal Failure (ARF)- a sudden decline of kidney function or abrupt
loss of kidney function
o Chronic Renal failure (CRF) – decline of kidney function
o Dietary treatment:
 Low to moderate protein: 30 – 50 g
 High carbohydrate diet for energy: 300-400 g
 Moderate fats: 70-90 g

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 Calories: 2000-2500
 Sodium control: 1300-1900 mg
 Potassium control: 1300 – 1900 mg
 Water control 800-1000 ml (according to excretion)
 Renal calculi (Urolithiasis)
o Formation of renal or urinary calculi in the urine that precipitate as stones
in the urinary passages
o Dietary treatment
 Large fluid intake
 Diet according to type of stones:
1. Calcium oxalate stones
- low calcium, low phosphate or oxalate diet
- increase potassium-rich foods and water
- avoid dairy products, beets, chocolates, strawberries, tea,
wheat bran
2. Uric acid stones
- Low purine diet
- Control intake of organ meats, whole grains and legumes
- Limit protein to 58-67 g/day
- Decrease intake of bread products
3. Cystine stones
- Control protein foods with methionine like meat, milk, egg
and cheese
- High fluid intake
 Renal surgery
o Post-operative nutritional needs
 Increased protein
 Adequate calories
 Adequate fluid/water
 Replacement of mineral deficiencies
 Intake of vitamin C for tissue synthesis and wound healing
 B complex for energy production and tissue building
o Dietary treatment
 Initial IV therapy
 Hyperalimentation (parenteral nutrition) for major tissue trauma or
injury or extensive surgery
 Post-operative diet: liquid, soft, to full diet as soon as possible
NUTRITION THERAPY FOR CANCERS

Cancer
 A group of many dissimilar diseases categorized by unrestrained replication of
cells
 Carcinogen – any agent directly involved in the promotion of cancer

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 Carcinogenesis – formation of a tumor from initiation (activation of

carcinogen), promotion (growth of cancer cells) and progression (uncontrolled
growth) processes
 Kinds of Tumor:
o Benign – confined and does not spread to the rest of the body; not
cancerous
o Malignant – may invade and injure tissues and organs and may even enter
bloodstream
 Types of cancer
o Carcinoma – arises from the cells of the skin, glandular organs, and inner
linings of internal organs
o Sarcoma – develops in muscles, cartilages, connective tissues, and bones
o Glioma – originates in the central nervous system and supporting connective
tissues in the brain
o Lymphoma – cancerous growth in lymph nodes and other tissues of the
lymphatic system
 Dietary treatment
o Oral Nutrition
 High-calorie, high-protein beverages may be offered
 In case of lactase deficiency, Lactaid may be given
o Tube Feedings
 Complete products – meal replacements that require digestion and
absorption
 Chemically-defined products – minimal or no digestion; for pancreatic
cancer
 Modular products – used in combination with other tube feeding
products to enhance calorie or protein intake
 Specialty products – vary in terms of specific amino acid, carbohydrate,
and fat content; for patients with hepatic or renal failure
o Total Parenteral Nutrition
 Used when the digestive tract is not functioning
NUTRITION THERAPY FOR ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS)

AIDS
 Caused by human immunodeficiency virus or HIV; transmitted through/from
sexual intercourse, blood transfusion, sharing contaminated needles, mother to
child during pregnancy, childbirth or breastfeeding
 It cannot spread by mere kissing, coughing, sneezing, touching, and sharing
utensils.
 Dietary treatment
o Energy – 35-45 kcal/kg BW; Protein – 2-2.5 g/kg BW
o Fats – increase omega-3 sources and decrease saturated fats in the diet
o Vitamins and minerals – an increase to be recommended in case of altered
metabolism

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NUTRITION THERAPY FOR BURNS

 Immediate shock period – days 1-3
o Initial fluid and electrolyte problems, massive flooding edema at burn site
pulling water from other parts of the body, as well as protein loss and
electrolyte loss (sodium); potassium drawn from cells to replace sodium loss
with rising serum levels of potassium
o Immediate parenteral – protein through blood or plasma expander
(dextran), sodium and chloride replacement through lactated Ringer’s
solution, water (dextrose solution) to cover losses
 Recovery period – days 3-5
o As fluid and electrolytes are reabsorbed, pattern shifts and sudden diuresis
follows
o Oral liquid solutions, such as Holdrane’s solution (water, salt, baking soda),
may now be tolerated
 Secondary feeding period – days 6-15
o Critical nutrition stage, tissue regeneration, turning from initial catabolic
period of negative nitrogen balance to an active tissue rebuilding stage
o Diet therapy: high protein (150-400 g) with protein supplements, high
calorie (3500-5000), high vitamins especially for wound healing and B
complex vitamins for energy and protein metabolism; record keeping of
intake to ensure meeting high nutrient requirements
 Follow-up reconstruction period – from second week on
o Grafting and plastic surgery – continued optimum nutrition
o Rehabilitation period – rebuilding patient both physically and emotionally
ROLE OF NUTRITION ON SOFT AND HARD DENTAL TISSUES
 Healthy oral tissue is the best protection against microbe invasion.
 Optimal oral health depends on adequate quantities of Vitamin A, B complex,
C, D, E, K, proteins, calcium, phosphorus, magnesium, iron, zinc, copper, and
some lipids such as omega-3 fatty acids
 Fats – provides a protective layer on teeth and prevents biofilm adherence;
some fats have antibacterial properties
 Proteins – responsible for repair and maintenance of body tissues
o Protein deficiency can influence tissue synthesis and maintenance and
healing; Protein excess can decrease calcium retention
 Vitamin A – sustains integrity of sulcular epithelium (part of the oral cavity) and
keeps the salivary gland working efficiently
o Deficiency results in salivary gland atrophy, hyperkeratinization of some
oral structures, compromised periodontal tissue healing, or carotene
coloration
 Vitamin D – controls the presence of calcium, magnesium and phosphorus
o Vitamin D and calcium levels have been linked to periodontal problems like
tooth loss
 Vitamin E – excessive vitamin E may create vitamin K deficiency which may
lead to bleeding problems

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 MODULE SUMMARY

This module has 3 lessons discussing nutrition for health, fitness, and illnesses.

Lesson 1 tackled the effects of excessive energy intake and ways on how to
maintain an ideal weight.

Lesson 2 discussed the recommended nutrition intake for athletes and those who
engage in physical fitness activities.

Lesson 3 discussed the recommended diet for some common illnesses.

Congratulations! You have just studied Module VI. Now you are ready to evaluate
how much you have benefited from your reading by answering the summative test.
Good Luck!!!

 SUMMATIVE TEST
1. What are the advantages of maintaining ideal body weight or losing weight for
obese individuals?
2. Discuss the diet needed by athletes before, during and after an event.
3. What are the recommended dietary treatments for anorexia nervosa? Bulimia?

Laboratory Activity
Prepare a sample dinner meal for a client with atherosclerosis.
Meal pattern Menu Dietary Consideration (e.g Rationale of
method of cooking, foods Diet
avoided, etc.)
Soup
Meat
Vegetables
Rice
Fruit or dessert
Beverages

Module VI
 MODULE VII
Community Nutrition and Health
Promotion
Lesson 1: Nutrition Education and Counseling:
Behavioral Change

Lesson 2: Filipino Culture, Values, Practices,

and Beliefs applicable in Nutrition

Lesson 3: Food-Related Illness and Allergies

 2

MODULE VII

COMMUNITY NUTRITION AND HEALTH PROMOTION

 INTRODUCTION

This module will discuss the process of nutritional education and

counseling, the food practices and beliefs of Filipinos which may affect health
and food safety, along with food borne illnesses.

LEARNING OBJECTIVES
After studying the module, you should be able to:

1. Interpret and apply nutrition science concepts to improve the health of

individuals and communities.
2. Describe the appropriate methods for the safe handling, storage, and
preparation of food to prevent illness by:
a. recognizing agents that cause food-borne illness.
b. knowing ways to minimize contamination.
c. becoming familiar with regulations regarding the protection of food.
3. Discuss common pathogens that may invade food and cause food borne
illnesses and food allergies.
4. Discuss the effects of Filipino culture and beliefs in health.

 DIRECTIONS/ MODULE ORGANIZER

There are three lessons in the module. Read each lesson carefully then
answer the exercises/activities to find out how much you have benefited from
it. Work on these exercises carefully and submit your output to your instructor
or to the CCHAMS Office.

In case you encounter difficulty, discuss this with your instructor during
the face-to-face meeting. If not contact your instructor at the CCHAMS office.

Good luck and happy reading!!!

Module VII
 3

Lesson 1

 Nutrition Education and

Counseling: Behavioral Change

BEHAVIOR CHANGE COMMUNICATION (BCC)

• Aimed at influencing the actions of families and communities - it aims to
change behavior and practice
• An ongoing process that requires effective communication to persuade,
encourage and support change
• Considering individual health beliefs and practices, BCC can promote
nutritional improvements and address local traditions and household dynamics
(conditions)
• Segmentation
o refers to targeting key messages to the relevant audience at the
relevant time
o This helps prevent information overload for people, by ensuring they are
not given unnecessary information

HEALTH BEHAVIOR THEORY

• Models that focus on behavior change at the individual and interpersonal level:
1. Health Belief Model
▪ focuses on individual health beliefs
2. Social Cognitive Theory
▪ Emphasizes interactions between individuals and their
environment
3. PRECEDE (Predisposing, Reinforcing, and Enabling Constructs in
Educational Diagnosis and Evaluation)
▪ Takes a broad look at factors influencing health outcomes
▪ Provides a structure that supports the planning and
implementation of health promotion or disease prevention
programs
4. Stages of Change Model/ Transtheoretical Model
▪ Focuses on one’s stage of readiness for change
▪ Includes precontemplation, contemplation, preparation, action
and maintenance
5. Relapse Prevention
▪ Aimed at maintaining behavior changes

Stages of Behavior Change

1. Pre-awareness
• people are not even aware of the changes that they need to make
• Provide information for them to become aware
2. Awareness
• the person has heard about the need to change their behavior, but
needs extra help and persuasion to start to actually bring about the
changes
3. Contemplation
• The person is contemplating (thinking) about changing their behavior,
but needs more information and continued support and persuasion
about the advantages and disadvantages of changing their behavior
4. Intention
• the person has understood the advantages and disadvantages of
changing their behavior but is not sure how they can bring about the
new behavior for themselves
5. Trial

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•
The person has tried the behavior or action required, but has faced
difficulties.
6. Adoption
• the person is demonstrating the new behavior
7. Maintenance
• The person’s behavior by this stage has changed and they understand
the benefits of the change
8. Telling others
• The person has done the behavior for a considerable length of time, it
has become routine behavior and now leads to the person convincing
others about the benefits of their health related behavior

NUTRITION BEHAVIOR CHANGE COMMUNICATION

• a strategy used to change nutrition related behaviors in the community

NUTRITION BEHAVIOR CHANGE COMMUNICATION STRATEGIES

Stage of Behavior Action Needed Communication Strategies
Change
Pre-awareness Build awareness and • Drama, songs
provide information • Community groups
• Radio
• Individual counseling
• Young child feeding support groups
Awareness Give more • Group discussions or talks
information, discuss • Oral and printed word
benefits and • Counseling cards
persuade • Feeding support groups
Contemplation and Persuasion and • Group discussions or talks Individual
intention encouragement counseling
• Counseling cards
• Feeding support groups
Trial Negotiate the best • Home visits
ways of overcoming • Use of visuals aids
obstacles • Groups of activities for family and the
community
• Negotiate with the husband and
mother-in-law (or influential family
members) to support
Adoption Further discussion • Encouraging and praising
on the benefits to • Emphasizing the importance of the
ensure the behavior behavior
continues
Maintenance Discuss benefits, • Congratulate mother and other family
provide support at members as appropriate
all levels • Suggest support groups to visit or join
to provide encouragement
• Encourage community members to
provide support
Telling others Praise and reinforce • Reinforce the benefits
the benefits and • Praise
give support

NUTRITION COUNSELING
• A process of finding the solution to an individual’s nutritional problem together
with their family or caregiver.
• GALIDRA Approach to nutrition counseling
o An effective method in the community-based management of
undernutrition

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The Essential Nutrition Actions

1. Promotion of optimal nutrition for women

2. Promotion of adequate intake of iron and folic acid and prevention and control of
anemia for women and children
3. Promotion of adequate intake of iodine by all members of the household
4. Promotion of optimal breastfeeding during the first six months
5. Promotion of optimal complementary feeding starting at 6 months with continued
breastfeeding to 2 years of age and beyond
6. Promotion of optimal nutritional care of sick and severely malnourished children
7. Prevention of vitamin A deficiency in women and children

Essential Nutrition Actions Key Messages

Nutrition of Pregnant Women
Iron supplementation during pregnancy
MESSAGE
Husband, ensure that your pregnant wife
has one additional meal every day to
maintain her strength.
• Pregnant women need to eat a variety
of foods, particularly animal products
(meat, milk, eggs, etc), plus fruits &
vegetables.
• Ripe papaya & mango, orange-fleshed
sweet potatoes, carrot & pumpkin are
especially good.
• Pregnant women need to eat more food
than usual rather than decrease their
intake.
MESSAGE
Pregnant woman: When you discover that
you are pregnant, go to the health facility
to get iron/folic acid pills to maintain
your strength & health during the
pregnancy and prevent anemia.
• Ask the Health Worker for iron/folic
acid tablets to be given to your
pregnant wife.
• The six-month course of iron/ folic acid
tablets can be carried over even after
the birth of the baby.
• Pregnant women have increased needs
for iron.
• Iron/ folic acid pills are important to
prevent anemia and will help to keep
her and the new baby healthy.

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Prevention of Malaria and Anemia
Iodized Salt
Early Initiation of Breastfeeding
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6
• Liver is also a good food source of iron
for pregnant women.
MESSAGE
Husband: Make sure your pregnant wife
gets de-worming pills once in the second
or third trimester of pregnancy.
• Ask the Health Worker for de-worming
pills to be given once to your pregnant
wife in the second or third trimester of
pregnancy.
• Intestinal worms can cause anemia,
which leads to tiredness and poor
health.
MESSAGE
Husband: Make sure your pregnant wife
receives her tetanus shots by going to the
immunization site.
MESSAGE
Father, ensure that your family sleeps
under an insecticide treated net (ITN),
especially pregnant women and children,
to prevent malaria.
• Malaria also causes anemia, which will
make members of your family unwell
and very tired.
• Family members with fever need to be
taken to a health facility for immediate
treatment.
MESSAGE
Mother, when you know you are pregnant,
make sure you go to the ante-natal clinic
to get IPT (malaria medicine) to keep you
from getting malaria and keep your
unborn baby healthy. Husband, make sure
your pregnant wife attends antenatal
clinic to get IPT to keep her from getting
malaria and keep your unborn baby
healthy.
Mother/Caretaker, ensure that all family
food is cooked using iodized salt so that
family members remain healthy.
• Iodized salt is not available
everywhere, but should be used when
available.
• Pregnant women need to use iodized
salt to ensure the health of their new
baby.
• Add the iodized salt at the end of the
cooking.
• When you store iodized salt, make sure
that it is covered properly.
MESSAGE
Put your baby on the breast immediately
after birth, even before the placenta is
expelled, to stimulate your production of
milk.
• The first yellow milk (colostrum) helps
to protect the infant from illness.
• The first yellow milk (colostrum) is the
 7

mother’s natural butter and will help

Exclusive Breastfeeding to 6 Months of
Age
Frequency of Breastfeeding
to expel your baby’s first dark stool.
• Immediate breastfeeding within one
hour of birth will help to expel the
placenta and reduce post-partum
bleeding.
• Pre-lacteal feeds such as sugar water,
water, butter, are not necessary and
may interfere with establishing good
breastfeeding practices during the first
days of the baby’s life.
MESSAGE
Feed your baby only breast milk for the
first six months, not even giving water,
for the baby to grow healthy and strong.
• Breast milk provides the best
nourishment possible for the baby and
will protect the baby from diarrhea and
respiratory infections.
• Empty the first breast before you
switch to the other for the baby to
receive all nutrients and fat from the
breast milk. If the baby takes water or
other liquids, it sucks less on the breast
leading to poor growth.
• Even during very hot weather, breast
milk will satisfy the baby’s thirst during
the first six months. If the baby takes
water and other liquids, the baby will
get diarrhea.
• Never use a bottle to feed your baby,
as these are hard to keep clean and will
cause diarrhea.
MESSAGE
Breastfeed your baby on demand, at least
10 times day and night, to produce
enough milk and provide your baby
enough food to grow healthy.
• Frequent breastfeeding helps the milk
to flow and ensures your baby grows
well. If you think that you don’t have
enough milk, increase the
breastfeeding frequency and be sure to
empty the breast before switching to
the other.
• Exclusive breastfeeding until 6 months,
if menses are not back, protects the
mother from getting pregnant
(Lactation Amenorrhea Method – LAM).
• Ensure proper positioning and
attachment so baby gets adequate
breast milk and to avoid breast
problems such as sore and cracked
nipples.
• Advise mothers with nipple and breast
problems to seek immediate care from
a Health Worker.
• Breastfeeding increases bonding
between mother and child.

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PHILIPPINE NUTRITION PROGRAMS AND SERVICES
Government Nutrition Programs
Program Project/Component
Infant and young child Health systems support
feeding Community-based health
and nutrition support
Maternity Protection and
Improving Capacities of
Workplaces on
Breastfeeding
Establishment of
breastfeeding places in non-
health establishments
Enforcement of the Milk
Code
Integrated Management Enhancement of Facilities
of Acute Malnutrition (Including RUTF and RUSF)
and provision of services
Building of Capacity of Local
Implementers
National Dietary Supplementary feeding of
Supplementation pregnant women
Program Supplementary feeding of
children 6-23 months old
Supplementary feeding of
children 24-59 months old
Supplementary feeding of
school children
Food plants for producing
supplementary foods
National Nutrition In schools
Promotion Program for In communities
Behavior Change
In the workplace
Resource center
Micronutrient In health unit
supplementation In schools
(vitamin A, iron-folic Communication support
acid, multiple
micronutrient powder,
zinc)
Mandatory food Rice fortification with iron
fortification (technology
development, capacity Flour fortification with iron
building, regulation and and vitamin A
monitoring, promotion) Cooking oil fortification with
vitamin A
Sugar fortification with
vitamin A
Salt iodization
Nutrition in emergencies Capacity building for
mainstreaming nutrition
protection in emergencies
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8
Agencies involved
DOH, LGUs
DOH, NGOs, LGUs,
Development Partners (DPs)
DOLE, Employers,
Employees’ Unions, NGOs,
LGUs, DPs
All agencies, NGOs, LGUs,
DPs, CSC
DOH, LGUs
DOH, NGOs, LGUs, DP
DOH, NGOs, LGUs, DP
DOH, NGOs, LGUs, DP
DOH, NGOs, LGUs, DP
DSWD, NGOs, LGUs, DPs
DepEd, NGOs, LGUs, DPs
FNRI, LGUs, SUCs, NGOs
DepEd, NGOs, LGUs, DPs
DOH, DSWD, NGOs, LGUs,
DPs
DOH, DOLE, NGOs, LGUs,
DPs
NNC (coordinator)
DOH, NGOs, LGUs
DepEd, NGOs, LGUs
DOH, NGOs, LGUs
DOH, DSWD, DepED, NGOs,
LGUs, industry
DOH, DSWD, DepED, NGOs,
LGUs, industry
DOH, DSWD, DepED, NGOs,
LGUs, industry
DOH, DSWD, DepED, NGOs,
LGUs, industry
DOH, DSWD, DepED, NGOs,
LGUs, industry
DOH, DSWD, National/Local
Nutrition Cluster,
National/Local DRRMC,
NGOs, LGUs, DPs
 9

Overweight and Obesity Healthy Food Environment
Management and
Prevention Program Promotion of healthy
lifestyle
Weight Management
Intervention (for Overweight
and Obese Individuals)
DOH, DSWD, DOLE, NGOs,
LGUs, industry, CSC, DPs
DOH, DSWD, DOLE, NGOs,
LGUs, industry, CSC, DPs
DOH, DSWD, DOLE, NGOs,
LGUs, industry, CSC, DPs

Non-Government Organizations
1. Gawad Kalinga Community Development Foundation Inc. (GK)
• Implemented Kusina ng kalinga (KNK) in some parts of the country, an
anti-poverty campaign which aims to help end hunger among young Filipinos
by cooking delicious meals for children in public schools
• GK’s mission is to end poverty for 5 million families by 2024
2. Project PEARLS, Children’s Hour, and Reach Out and Feed Philippines
• Conducts daily feeding programs to battle school-age malnutrition and
supplement them with reading programs
3. Waves for Water
• Implemented Clean Water Couriers program which Provides clean water by
installing filtration systems and rainwater harvesting systems to
undeserved, remote communities
4. East-west Seed Foundation
• Builds and maintains garden in public schools through its Oh My Gulay!-
Tanim sa Kinabukasan program
5. Children’s Mission Philippines
• implements a Community Nutrition program where volunteers conduct
cooking classes with parents – teaching them lessons on how to make
affordable, nutritious, food and how to purify their drinking water
6. Advancement for Rural Kids (ARK)
• Builds kitchens for communities to complement school gardens
7. Feed the Children
• Implements Child-Focused Community Development (CFCD) to meet
immediate and long term needs of children, their families and communities
with their food and nutrition, health and water, education and livelihood
activities
8. Rise Against Hunger
• This organization has implementer several programs to combat hunger like
Meal Packaging Events, Good for Grocer, School Feeding Program, First 100
Days (in partnership with DOH), Farm to Fork program, Disaster Relief, Soap
for Hope, Bread for Bread, Good Food Farm, and Good Food Kitchen.

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Lesson 2


Filipino Culture, Values,
Practices, and Beliefs
applicable in Nutrition
FILIPINO FOOD AND CULTURE
• Traditional Food and Dishes
o food and culture of the Philippines are Tanghalian (lunch) and
largely influenced by Spanish, Chinese and hapunan (dinner) are
American traditions larger meals including
o White rice is the main food in the diet and rice, noodles, and
the primary source of protein is fish possibly an adobo
o Vinegar, soy sauce, salt, fish sauce and (stew) or sinigang (pork
fermented fish are traditional flavorings with fruit and
used in Filipino cuisine vegetables in a sour
• Holidays and Special Occasions broth). Fruit often
o More than 80 percent of Filipinos identify concludes the meal.
as Catholic, with almost 12 percent
identifying as another Christian denomination
o Food is often the center point of celebrations and the Philippines are
known for a long Christmas season
• Traditional Eating Patterns Agahan
o Fresh fish is often caught daily and many families (breakfast) is
have gardens often rice
o a clay pot is used for steaming rice and stewing other fried with
foods garlic and
o Because soups, stews and mixed dishes are common, eggs or
forks are spoons are frequently used, but knives may broiled fish
not be present on the table served with
• Current Food Practices coffee or hot
o Rice and fish are still the staple foods in the chocolate
Philippines
o Despite the availability of fortified rice and iodized
salt, micronutrient deficiencies persist.
o Anemia, hypothyroidism and osteoporosis are prevalent.
o In urban areas, more foods are available, including some American-style
fast food and convenience foods, like cereals, and obesity is on the rise.
o Most report enjoying American food just as well as traditional Filipino
food and consume them equally.
o While the use of butter as a spread is still uncommon, bakery foods,
cereals and waffles are commonly consumed, in addition to traditional
white rice.
o Merienda is the name of a midmorning and afternoon snack that was
introduced by the Spanish and was traditionally served around 3:00pm
after a siesta.
o Fast food consumption and increased portions of calorie dense foods are
associated with Filipino dietary acculturation.
TRADITIONAL HEALTH BELIEFS
• Flushing, heating and protection are the key elements to traditional health
beliefs.

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• Flushing rids the body of debris, heating regulates the internal temperature
and protection involves safeguarding the body from natural and supernatural
forces
• Being overweight is thought of as such protection and a layer of fat on the body
denotes resistance.
• Filipinos will use home remedies and herbal medicine first.
o drinking boiled ginger for a sore throat and boiling corn hair in water
and drinking it to promote urination
• A hilot, is a traditional practitioner sought for pain relief, and offers treatment
along the lines of chiropractic and massage
• Filipinos will seek the advice or a traditional healer or family elder prior to that
of a physician and usually only seek a doctor when the illness has advanced and
home remedies have failed.
Food and Religion
• Christianity (Roman Catholic)
o Generally no food restriction
o Meatless at the beginning of lent on ash Wednesday and on every
Lenten Friday
o Mormonism – refrains from alcohol or caffeine for physical and spiritual
health
• Islam
o Muslims must only eat halal (lawful) foods; haram (unlawful) foods
include pork (as it is considered unclean), alcohol, and food not
slaughtered in the name of Gdog
• Hinduism
o Cows are sacred and so beef is prohibited
• Buddhism
o Their belief in ahimsa (non-violence), refrains them from slaughtering
animals, makes them adopt a vegetarian diet
• Sikhism
o May choose to eat meat but are encourage to adopt lacto-vegetarian
diet as they put a premium on ahimsa, allowing them to eat vegetables
as well as dairy products
• Judaism
o Prohibits pork and shellfish
• Baha’i
o Refrains from drinking alcohol, but may consume it for medical purposes
• Jainism
o Prohibits meat, fish, eggs, honey, alcohol, root vegetables, garlic and
onions, and figs

Concept Check!
Clinical Application:
What are your thoughts on Filipinos seeking advice from a hilot? What do you think are
the disadvantages of seeking a traditional healer? How will you convince them to seek
a physician rather than a traditional healer?

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Lesson 3

 Food-Related Illness and

Allergies

FOOD SAFETY

Cross-contamination
• affects the transfer of food pathogens (such as bacteria, viruses, or fungi)
• eating food that has been contaminated with a pathogen results to being sick
Cross-contact
• refers to the transfer of food allergens
• Allergens only affect people who have sensitivities to them

Food Pathogens
• are microorganisms like bacteria, viruses, and to a lesser extent, fungi, that
cause disease when ingested
• causes foodborne illnesses
o Outbreak of food-borne illness - defined by the CDC as the occurrence
of two or more similar illnesses resulting from ingestion of a common
food.
• the top foodborne-illness-causing pathogens that require hospitalization are:
o Salmonella
o Norovirus (Norwalk virus)
o Campylobacter
o E. coli
o Listeria
o Clostridium perfringens
• A summary of each of these pathogens, their common food sources, and how
to minimize the risk of contamination for them is presented in the following
table:

Pathogen Food Sources Minimizing Risk

Salmonella Any raw food of animal origin
Infection: (e.g., meat, poultry, milk and
Salmonellosis dairy products, eggs, seafood)
results to symptoms and some fruits and vegetables
which include may carry salmonella bacteria.
diarrhea, fever, The bacteria can survive to cause
vomiting, and illness if meat, poultry, and egg
abdominal cramps products are not cooked to a safe
minimum internal temperature,
or if fruits and vegetables are
not thoroughly
washed. Salmonella can also
contaminate other food that
comes in contact with raw meat
Safe food handling
practices are necessary to
prevent bacteria on raw
food from causing illness.
This includes proper,
frequent handwashing;
avoiding cross-
contamination with other
foods during all parts of
the food-preparation
process; and cooking foods
to a safe minimum internal
temperature.

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and poultry.
Norovirus Any food served raw or handled
after being cooked can become
contaminated with norovirus.
Other sources include
contaminated foods, such as
oysters, fruits, or vegetables that
may have already been
contaminated during production.
Campylobacter Meat and poultry can
contain campylobacter. The
bacteria can be found in almost
all raw poultry because it lives in
the intestinal track of healthy
birds.
E. coli Contaminated foods (e.g.
Symptoms of undercooked ground beef,
Infection: unpasteurized milk and juice,
diarrhea, stomach soft cheeses made from
cramps, and low- unpasteurized milk, and raw
grade fevers that fruits and vegetables), untreated
start within 2 to 8 water, and any foods handled
days after ingestion with unclean hands can be
and that usually sources of E. coli.
resolve within 7
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13
Norovirus is the leading
cause of foodborne illness
in the U.S. Most outbreaks
occur in food service
settings; food handlers are
often the source of the
outbreaks. Safe food
handling practices (e.g.,
frequent handwashing
using proper techniques,
wearing clean disposable
gloves when handling food,
and changing gloves often)
can minimize most risk of
norovirus transmission.
Also, making sure to
properly wash fresh fruits
and vegetables and cooking
other foods to a safe
minimum internal
temperature can help
reduce the incidence of
norovirus.
Campylobacter bacteria
are extremely fragile and
are easily destroyed by
cooking to a safe minimum
internal temperature.
Freezing cannot be relied
on to destroy the bacteria.
Wash hands often,
especially after changing
diapers or any contact with
animals. Wash hands
before preparing or
touching food. Cook foods
to a safe minimum internal
temperature. Avoid eating
high-risk foods that are
sources of potential E.

days
Listeria Foods that are sources of
Infection: potential Listeria contamination
Listeriosis causing include ready-to-eat deli meats
diarrhea, flu-like and hot dogs, refrigerated meat
fever and headache, spreads, unpasteurized (raw)
pneumonia, sepsis, milk and dairy products, soft
meningitis, and cheese made with unpasteurized
endocarditis milk (queso fresco, feta, Brie,
Camembert), refrigerated
smoked seafood, or raw sprouts.
Foods processed in facilities
without adequate sanitation
practices in place can also
harbor Listeria.
Clostridium Beef, poultry, and gravy—and
perfringens any mixed dishes made with
Signs of infection: these foods—are the most
Nausea, vomiting, common food sources
weakness, blurred for Clostridium
vision, and slurred perfringens. Additionally, foods
speech are typical prepared in large batches and
initial symptoms. held or warmed for a long time
before serving can
cause Clostridium
perfringens infections.
Clostridium botulinum
causes a more serious but
less frequent type of food
poisoning
Staphylococcus The source of the food
aureus contamination could be
Signs of infection: something as minor as a small, or
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14
coli contamination.
The risk
of Listeria contamination
can be reduced through
proper washing of fresh
produce, storing raw
animal-based food
products separately from
other foods, washing hands
and cleaning and sanitizing
food preparation surfaces
and equipment after
handling uncooked foods,
eating perishable and
ready-to-eat foods as soon
as possible, avoiding
consuming unpasteurized
dairy products, and heating
hot dogs and deli meats
prior to consumption.
Clostridium perfringens is
one of the most common
causes of food poisoning in
the United States. Cooking
kills growing Clostridium
perfringens cells that
cause food poisoning, but
not necessarily the spores
that can grow into new
cells. If cooked food is not
promptly served or
refrigerated, the spores
can grow and produce new
cells. Thoroughly cooking
food and keeping food out
of the temperature danger
zone minimizes the risk of
contamination.
The toxin causes no
change in the normal
appearance, odor, or taste
 15

severe cramping even unnoticed, staphylococcal of the food, so the victim

and abdominal pain infection on the hand of a worker has no warning. A careful
with nausea, preparing the food. Foods that food history helps to
vomiting, and are particularly effective carriers determine the source of
diarrhea, usually of staphylococci and their toxins the poisoning, and portions
accompanied by include custard or cream-filled of the food are obtained
sweating, bakery goods, processed meats, for examination, if
headache, fever, ham, tongue, cheese, ice cream, possible. Bacteria may not
and sometimes potato salad, sauces, chicken be found, because heating
prostration and and ham salads, and combination kills the organisms but
shock. dishes such as spaghetti and does not destroy the toxins
casseroles. that have been produced.

Factors that Affect Bacterial Growth

• referred to by the acronym “FAT TOM”: food, acidity, time, temperature,
oxygen, and moisture
• Foods prone to bacterial contamination: meat, poultry, and seafood products;
dairy products like milk and cheese; fresh produce like fruits and vegetables;
soy products like tofu; and flavored oil immersions
• Cooking destroys bacteria and proper food handling avoids bacterial transfer

Preventing Cross-Contamination
During Storage
• Proper storage practices include storing food in designated areas only and not
with nonfood items, including chemicals
• All food (and nonfood) items should be stored at least 6 inches off the floor and
away from walls and ceilings.
• Food should be stored in wrapped or closed containers to prevent contaminants
from getting in
• Recommended storage practice:
o Top shelf (ready-to-eat foods): milk, fresh produce, cheese, salads,
yogurt
o 2nd shelf (cook to 140 F): reheated foods (precooked), such as ham or
breaded chicken
o 3rd shelf (cook to 145 F): fresh beef (not ground beef) or pork,
seafood
o 4th shelf (cook to 160 F): ground beef or pork, eggs
o Bottom shelf (cook to 165 F): raw chicken or turkey (including
ground), leftovers, casseroles

During Preparation
• Perform proper handwashing and wearing and changing disposable gloves as
needed
• Clean and sanitize food preparation area, including equipment before and after
use
• Prepare raw or uncooked meat, poultry, and seafood at a different time than
ready-to-eat foods
• Thoroughly wash all fresh produce (fruits and vegetables) under warm, running
water to remove any dirt or residue

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 16

Cross-Contamination from Chemicals

• Chemicals used in food service should be stored in their own area, away from
food and nonfood-related supplies and equipment.
• Chemicals should be stored in properly labeled containers.
• Do not reuse old food containers to store chemicals.
• Towels used to clean food spills should not be used for any other purpose.
• Cleaning agents and sanitizing solutions should be used in proper
concentrations and that residues should be rinsed or wiped clean.
Food Technology

Organic Farming
• The use of farming methods that employ natural means of pest control and that
meet the standards set by the National Organic Program of the U.S.
Department of Agriculture; organic foods are grown or produced without the
use of synthetic pesticides or fertilizers, sewage sludge, genetically modified
organisms, or ionizing radiation.
Food Additives
• are chemicals that are intentionally added to foods to prevent spoilage and
extend shelf-life
• Purposes of using food additives:
o Produce uniform qualities (e.g., color, flavor, aroma, texture, general
appearance)
o Standardize many functional factors (e.g., thickening, stabilization
[i.e., keeping parts from separating])
o Preserve foods by preventing oxidation
o Control acidity or alkalinity to improve flavor and texture of the cooked
product
o Enrich foods with added nutrients
• Examples are preservatives, sweeteners, color additives, flavors and spices,
flavor enhancers, nutrients, emulsifiers

Food Allergens
Food Intolerance
• only involve the digestive system and does not involve an immunological
response from the body
• Common food intolerances include gluten, milk and dairy, and monosodium
glutamate
• Does not cause life-threatening symptoms but can still be very uncomfortable
for the food-intolerant child
Food Allergies
• occur when certain foods are ingested, triggering an immune response by the
body
• exposure leads to production of a specific antibody, called immunoglobulin E,
that binds to a protein in the food that is responsible for the allergy, causing
allergic symptoms such as hives, rashes, and restricted breathing
• A child experiencing symptoms from an allergic response to a food might say
things like:
o My throat is itchy/scratchy/puffy/feels tight
o My tongue is hot/itchy/tingly
o There’s something stuck in my throat
o My mouth feels funny
o This food is spicy (especially when not eating a spicy food)
• Mild Symptoms:

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 17

ohives or rash, nausea or vomiting,

The 8 Major Food Allergens
stomach pain, nasal congestion, or
1. Milk
a runny nose
2. Eggs
• Severe allergic reaction
3. Fish
o swollen or puffy lips, tongue, or
4. Crustacean shellfish (e.g.
throat; shortness of breath;
crab, lobster, shrimp)
tightness in the chest; dizziness;
5. Tree nuts (e.g., almonds,
rapid heartbeat; a drop in blood
walnuts, pecans)
pressure; or anaphylaxis
6. Peanuts
o needs immediate action as death
7. Wheat
can occur if not treated promptly
8. Soybeans
o Anaphylaxis Management -
epinephrine injection and a trip to the emergency room.
Cross-contact
• refers to the unintentional transfer of an allergen from a food containing that
allergen to a food that does not contain the allergen
• Practices to reduce the incidence of cross-contact include:
o Clean and sanitize—with soap and water or all-purpose cleaning agents
and sanitizers that meet state and local food-safety regulations—all
surfaces that come into contact with food in kitchens, classrooms, and
other locations where food is prepared or eaten.
o Clean and sanitize food preparation equipment, such as food slicers,
and utensils before and after use to prevent cross-contact.
o Clean and sanitize trays and baking sheets after each use. (Oils can
seep through wax paper or other liners and cause cross-contact.)
o Use proper handwashing procedures that emphasize the use of soap
and water. Hand sanitizers are not effective in removing food
allergens, which are protein-based substances.
• Best practices that food service staff can use to reduce the incidence of
cross-contact when preparing food include:
o Prepare and store allergen-free foods separate from other foods.
o Label foods with stickers, color coding, or other methods to indicate
whether a food is allergen-free.
o Store allergen-containing foods away from other foods to prevent
cross-contact.
o Prepare allergen-free menu items first. These foods may need to be
prepared on a separate, clean pan to avoid cross-contact.
o Wear a new pair of disposable gloves when preparing and handling
allergen-free foods.
o Thoroughly wash any work surface with detergent solution using a
clean towel. Rinse with clean water. Sanitize surface and allow to air
dry
o Change your water and obtain a different cleaning towel before
cleaning any other area of the kitchen, serving, or dining area.
o Be certain that all utensils, knives, cutting boards, or other equipment
are cleaned and sanitized before use on next product. Change apron
as needed to prevent cross-contact.
o Familiarize yourself with the children who have food allergies.
o Train staff and other personnel to recognize symptoms and monitor
the area surrounding the child with allergies.
o Designate an allergy-free area and or table (note that children cannot
be required to use these designated allergen-free zones because of
privacy laws).
o Clean all tables and chairs thoroughly with soap and water and
sanitize with approved sanitizing agent. Use a dedicated bucket for
both cleaning and sanitizing a peanut-free area.

Module VII
 18

 MODULE SUMMARY

This module comprised 3 lessons on community nutrition and health promotion.

Lesson 1 discussed how nutrition education brings change to an individual.
Lesson 2 discussed the Filipino culture and values about health and nutrition.
Lesson 3 tackled food-related illnesses and allergies and how to prevent them.
Congratulations! You have just studied Module VII. Now you are ready to
evaluate how much you have benefited from your reading by answering the summative
test. Good Luck!!!

 1.
SUMMATIVE TEST
What are the common pathogens that may invade food and cause illnesses?
2. Differentiate nutrition education from nutrition counseling.
3. What is segmentation and why is it important?
4. Why is knowledge not enough to change behavior, action, or practice?

Laboratory Activity
1. What dietary restrictions do you or your family follows? What are the health
effects of the restrictions?
2. Research at least two (2) Filipino cultures and/or practices which are not listed
in the lesson and discuss the advantages and disadvantages of each with
regards to health.

Module VII
 MODULE VIII
Legal Mandates and Moral
Principles in Nutrition Care

Lesson 1: Legal Mandates Related to Nutrition

and Diet Therapy

Lesson 2: Ethico-Moral Principles Related to

Cultural and Spiritual Preferences

Lesson 3: Evidence-Based Guidelines (EBG) in

Nutrition Practice
 MODULE VIII
LEGAL MANDATES AND MORAL PRINCIPLES IN NUTRITION
CARE

 INTRODUCTION

This module will discuss the legal and moral aspect of nutrition care, ethical
considerations in end-of-life care and the evidence-based guidelines.

LEARNING OUTCOMES
After studying the module, you should be able to:

1. Adhere to existing legal, ethical, and moral principles related to nutrition

and diet therapy.
2. Use current information technologies to locate and apply evidence-based
guidelines and protocols.
3. Provide appropriate evidence-based nursing care using a participatory
approach based on clients’ preferences.

 DIRECTIONS/ MODULE ORGANIZER

There are three lessons in the module. Read each lesson carefully then answer
the exercises/activities to find out how much you have benefited from it. Work on
these exercises carefully and submit your output to your instructor or to the CCHAMS
Office.

In case you encounter difficulty, discuss this with your instructor during the
face-to-face meeting. If not contact your instructor at the CCHAMS office.

Good luck and happy reading!!!

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Lesson 1


FOOD AND DRUG ADMINISTRATION
Legal Mandates Related to
Nutrition and Diet Therapy

• Republic Act (RA) 3720 of the Republic of the Philippines was amended with
the passage of a new law, RA 9711 - “The Food and Drug Administration
(FDA) Act of 2009”.
• The FDA Act of 2009 created the Food and Drug Administration (FDA) in the
Department of Health (DOH) to be headed by a Director General with the rank
of Undersecretary of Health.
• The FDA Act affected two existing DOH agencies
o Bureau of Food and Drugs (BFAD) with regulatory functions over food,
drugs, medical devices, cosmetics and household hazardous substances
o Bureau of Health Devices and Technology (BHDT) with regulatory
functions over radiation devices and radiation facilities
• The FDA Act created 4 centers
o Center for Drug Regulation and Research (to include veterinary
medicine, vaccines and biologiocals)
o Center for Food and Regulation Research
o Center for Cosmetics Regulation and Research (to include household
hazardous/urban substances)
o Center for Device Regulation, Radiation health and Research

Major Aims of the FDA Act

1. To protect and promote the right to health of the Filipino people
2. To establish and maintain an effective health products regulatory system

Important Definitions in the FDA Act

• “Health products” means food, drugs, cosmetics, devices, biologicals, vaccines,
in-vitro diagnostic reagents and household/ urban hazardous substances and/or
a combination of and/or a derivative thereof. It shall also refer to products
that may have an effect on health which require regulations as determined by
the FDA.
• “Device” means medical devices, radiation devices and health-related devices.

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)

• Developed in 1996 and became part of the social security act.
• Primary purpose is to protect health care coverage for individuals who lose or
change their jobs
• Adopted in the Philippines as the Data Privacy Act (DPA) or RA 10173, in 2012.

Data Privacy Act

• Protects the individual from unauthorized processing of personal information
that is:
1. Private, not publicly available
2. Identifiable, where the identity of the individual is apparent either
through direct attribution or when put together the available
information

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 • DPA Compliance is continuously enacted and monitored as it is not a one-time
registration procedure and the law mandates:
1. The appointment of a Data Protection Officer
2. Conducting a privacy knowledge management program
3. Creating a privacy knowledge management program
4. Implementing a privacy and data protection policy
5. Exercising a breach reporting procedure

NATIONAL NUTRITION COUNCIL OF THE PHILIPPINES

• History of Composition and Legal Bases
o 1947 Creation of the Philippine Institute of Nutrition (PIN) as a first
attempt to institutionalize a national nutrition program
o 1960 Organization of the National Coordinating Council on Food and
Nutrition (NCCFN), a loose organization of government and non-
government agencies and organizations involved in nutrition and
related projects.
o 1974 Promulgation of Presidential Decree No. 491 (Nutrition Act of the
Philippines, 25 June 1974), which created the National Nutrition Council
(NNC) as the highest policy-making and coordinating body on nutrition.
o 2005 Executive Order No. 472 named the Department of Health (DOH)
as the chair of the NNC, with the Department of Agriculture (DA) and
the Interior of Local Government (DILG) as vice-chairs. In addition to its
policy and coordinating functions, NNC was also tasked to focus on
hunger-mitigation and authorized to generate and mobilize resources
for nutrition and hunger mitigation programs.
o 2007 Executive Order No. 616 designated the NNC as oversight of the
Accelerated Hunger-Mitigation Program to ensure that hunger-
mitigation measures are in place, and are reported to the President.

NNC Core Functions

1. Formulate national food and nutrition policies and strategies and serve as the
policy, coordinating and advisory body of food, nutrition and health concerns;
2. Coordinate planning, monitoring, and evaluation of the national nutrition
program;
3. Coordinate the hunger mitigation and malnutrition prevention program to
achieve relevant Millennium Development Goals;
4. Strengthen competencies and capabilities of stakeholders through public
education, capacity building and skills development;
5. Coordinate the release of funds, loans, and grants from government
organizations (GOs) and nongovernment organizations (NGOs); and . Call on any
department, bureau, office, agency and other instrumentalities of the
government for assistance in the form of personnel, facilities and resources as
the need arises

(Nutrition-based programs of the NNC are briefly discussed in Module 7, Lesson 1)

Concept Check!
What agencies in the country are involved in nutrition care?

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Lesson 2

 Ethico-Moral Principles Related to

Cultural and Spiritual Preferences

NUTRITIONAL GENOMICS

Human Genome
• refers to an organism’s complete set of genetic instructions providing all of the
information for organism to grow and develop
Genetics versus Genomics
• Genetics is a branch of science that studies the heritable characteristics and
traits that are passed down from parent to offspring
• Genomics is a term that refers to the study of a person’s entire set of genes
and include the interactions of these genes with each other and the person’s
environment
Nutritional genomics
• the study of interaction between nutrients and genes
• two fields of study:
o Nutrigenetics investigates the differences at a genetic level that
determine an individual’s response to what they eat.
o Nutrigenomics is the study of how food affects a person’s genes, and
how a person’s genes affects the way the body responds to food at a
molecular level, to understand how a specialized diet can be used to
prevent, regulate, or cure non-communicable diseases.
Diseases Related to Nutrigenetics
1. Methyltetrahydrofolate reductase (MTHFR) deficiency
• A genetic condition where folate cycle is interrupted due to deficiency
of Methyltetrahydrofolate reductase
2. Homocystinuria
• A genetic condition characterized by poor metabolism of folate due to a
possible mutation in a number of genes
3. Irritable bowel disease
• Occurs in genetically predisposed individuals who have impairment of
the mechanism of intestinal mucosal immune system, which is
exacerbated by environmental factors
4. Phenylketonuria
• Results from deficiency of hepatic phenylalanine hydroxylase (PAH)
enzyme
5. Celiac disease
• An autoimmune disease of the small intestines that develops in response
to the ingestion of dietary gluten

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Diseases Related to Nutrigenomics
1. Obesity
• Most obesity appears to be multifactorial, which means that it can
results from complex interactions between many genes including the
FTO, MC4R, TMEM18, GNPDA2, BDNF, NEGR1, SH2B1, ETV5, MTCH2, LEP,
LEPR and KCTD15 genes, lifestyle and environment
2. Diabetes mellitus
• The gene TCF7L2 has been linked to diabetes type 2; this gene affects
insulin secretion and glucose production
3. Cancer
• Occurs from gene mutation which changes cell functions, and can occur
during an individual’s lifetime through exposure to cancer causing
environmental factors, such as tobacco, sun rays, air pollution, and
even the food and water consumed, or it can be inherited from the
individual’s parents
4. Coronary Heart Disease
• density lipoprotein receptor (LDLR) gene demonstrates mutation
Current Genetic Practices

Genetic Testing
• an approach that allows health professionals as well as consumers to receive
information about their genes and chromosomes, including changes or
mutations in genes that may lead to or increase an individuals’ risk to develop
a disease
• Some tests done are the following:
1. newborn screening tests
2. diagnostic tests
3. carrier tests
4. prenatal tests
• Ethical Concerns
o Handling genetic data
o Discrimination by health insurance companies

NUTRITIONAL SUPPORT AND END-OF-LIFE DECISION MAKING

Artificial Nutrition
• includes oral nutritional supplements (ONS), enteral nutrition (EN) or
parenteral nutrition (PN)

Artificial Hydration
• provision of water or electrolyte solutions by any other route than the mouth
• can be achieved by tubes, intravenous and subcutaneous (dermoclysis)
administration

Ethical Principles
1. Autonomy

Module VIII Page 233

 • Autonomy does not mean that a patient has the right to obtain every
treatment him or her wishes or requests, if this particular treatment
would not be medically indicated
• A competent patient has the right to refuse a treatment after adequate
information even when this refusal would lead to his or her death
2. Beneficence and non-maleficence
• If the risks and burdens of a given therapy for a specific patient
outweigh the potential benefits, then the physician has the obligation of
not providing (withholding) the therapy
• Even when artificial nutrition and hydration will be stopped, standard
care to maintain a best possible quality of life to the patient has to be
maintained.
• Artificial nutrition is used in accordance with a realistic goal of
individual treatment, and the wishes of the patient himself/herself, and
based on assessment of the situation by the doctor and other healthcare
professionals.
3. Justice
• Every individual is entitled to obtain the best care available. Resources
have to be distributed fairly without any discrimination. On the other
hand treatments which are futile and do only prolong the suffering or
the dying phase, have to be avoided. In regard to limited resources
there has to be proper use of ethically appropriate and transparent
criteria.

WILL, INFORMATION AND CONSENT OF THE PATIENT

1. Patient’s Right
• The will of the adult patient who is capable to provide consent and
make judgments has to be respected in any case
2. Patient’s capacity to consent
• Even if the patient is not legally competent in accordance with civil
law, he/she might be still capable of expressing his/her wishes and
participating in the decision-making process.
3. patient's incapacity to consent
• In case a patient is unable to give consent and make judgments, the
representative (authorized according to different rules depending on
the countries law and practice) takes the decision
4. Advance directives
• Patients are authorized/encouraged to establish an advance directive or
a living will according to the specific laws in their countries
5. Presumed consent
• In the absence of an effective statement of the patient's will in a
specific situation, one should proceed in accordance with the patient's
presumed will
6. Quality of life
• Quality of life must always be taken into account in any type of medical
treatment including artificial nutrition.

Ethical Dilemmas in End-of-Life Decision Making

• Disagreement and tensions among decision makers

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 o To achieve a mutually acceptable solution or a compromise, one should
utilize all options. These include obtaining a second opinion, a case
discussion in ethics, clinical ethics counseling, or obtaining the
recommendations of a clinical ethics committee
o In the absence of an indication and lack of achieving a treatment goal
or in the absence of consent, nutritional therapy should be
discontinued.
• Withholding and withdrawing nutrition and hydration support therapy
o A medical treatment, which does not provide any benefit or has become
disproportionate can be withdrawn or withheld. Limitation of treatment
may imply progressively withdrawing it or reducing the dose
administered to limit side effects.
o In end of life situations, the purpose of treatment and care is to
improve the patient's quality of life.
o Withholding or withdrawing artificial nutrition and hydration is
legitimate under the following conditions:
1. the procedures are highly unlikely to improve nutritional and
fluid levels
2. the procedures will improve nutritional and fluid levels but the
patient will not benefit
3. the procedure will improve nutritional and fluid levels and the
patient will benefit, but the burdens of artificial nutrition and
hydration will outweigh the benefits (e.g. artificial nutrition and
hydration can be provided only with essential physical restraints
etc.)
• Voluntary refusal of nutrition and fluids
o Voluntary cessation of nutrition and hydration is a legally and medically
acceptable decision of a competent patient, when chosen in disease
conditions with frustrating prognosis and at the end life.
• Culture and religion
o There should be awareness and obligatory education for medical
personnel to enable them to treat patients appropriately to their
spiritual needs. Respect for religious, ethnic and cultural background of
patients and their families have to be granted.
• Forced feeding
o Providing nutrition against the will of the patient who is able to give
his/her consent or make judgments (enforced feeding) is generally
prohibited.

SOCIAL, POLITICAL AND ECONOMIC ISSUES AND CONCERNS AFFECTING NUTRITION

CARE

1. Lack of Access: Food Not Available

• Natural Disasters: Crop Failure/Crop Destruction from
1. Drought
2. Infestations
3. Floods
• No Food Transport/Inadequate Food transport due to
1. Poor Roads/No Roads
2. Inadequate Distribution System: lack of vehicles

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 3. Food Transport blocked by war, rebellion, revolution
2. Lack of Resources: Insufficient to obtain food
• No money to buy sufficient food due to
1. Unemployment - can't find/keep a job due to economic recession,
lack of skills/education
2. Inadequate wages
• Inadequate Food Production due to
1. Lack of seeds and equipment
2. Lack of fertile land
3. Lack of knowledge regarding successful crop production
4. Total crop needed to pay back loans for seeds and equipment with
nothing left to eat
3. Ignorance and/or Ill Will prevent equal access to/resources for food
• Political inequalities leading to poverty
• Cultural practices of unequal family distribution of food
• Lack of awareness of other's need
• Lack of concern for other's need

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Lesson 3


Evidence-Based Nutrition
Evidence-Based Guidelines (EBG)
in Nutrition Practice

• Involves using the best available nutrition evidence, together with clinical
experience, to conscientiously work with patients’ values and preferences to
help them prevent, resolve, or cope with problems related to their physical,
mental, and social health.

Fundamental Principles of Evidence-Based Practice

1. Optimal clinical decision making requires awareness of the best available
evidence, which ideally will come from unbiased systematic summaries of that
evidence.
2. Evidenced-based nutrition provides guidance on how to decide which evidence
is more or less trustworthy – that is, how certain can we be of our patients’
prognosis, diagnosis, or of our therapeutic options.
3. Evidence alone is never sufficient to make a clinical decision.

Evidence-Based Nutrition Practice Guidelines

• A series of guiding statements and treatment algorithms which are
developed using a systematic process for identifying, analyzing and
synthesizing scientific evidence.
• They are designed to assist practitioner and patient decisions about
appropriate nutrition care for specific disease states or conditions in
typical settings.
• Key elements:
o Scope
o interventions and practices considered
o major recommendations and corresponding rating of evidence
strength
o areas of agreement and disagreement
Steps in Adopting an Evidence-Based Practice
1. Express the information needed in an “answerable” format
• Using the PICO format will help develop answerable clinical questions:
o Patient/Population (or problem): middle-aged, African American
woman with type 2 diabetes
o Intervention: clinic attendance
o Comparison: no clinic attendance
o Outcome: hemoglobin A1c levels
2. Search for and retrieve the best evidence
• In the above PICO-formatted statement, the following four search terms
are identified: type 2 diabetes, clinic attendance, African American,
and hemoglobin A1c.
o To locate the best evidence, consider limiting the search to the
following three characteristics:
o Publication type: Limit the search to publication types with higher
levels of evidence, such as systematic reviews, meta-analyses,
randomized controlled trials, and practice guidelines.

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 o Date: Since medical information can quickly become outdated, limit
your search to the most recent evidence available.
o Population characteristics: Use the available limits features to
match the patient or problem, such as age and gender.
• When searching for the best evidence, consider the following three
characteristics to evaluate the clinical information resources you want
to select:
o Filtered sources - High-quality filtered resources, such as those
found in the Academy’s Evidence Analysis Library (EAL) and in well-
done current practice guidelines, are valuable for busy clinicians
who do not always have time to search for the best evidence.
o Unfiltered sources - (randomized controlled trials, cohort studies,
and case studies as those found in PubMed and the CINAHL
o Levels of evidence - Systematic reviews, meta-analyses, and
randomized controlled trials generally provide higher levels of
evidence.
▪ The evidence-based practice glossary below provides definitions
for various types of research studies.

Available Clinical Information Resources:

• Systematic reviews: The Cochrane Library includes Cochrane Reviews
and the Database of Abstracts of Reviews of Effects. PubMed Clinical
Queries
• Evidence Analysis Library (EAL)
• Evidenced-Based Journals:
o Evidence-Based Medicine (published by BMJ)
o Evidence-Based Complementary and Alternative Medicine (free
access)
o The Annals of Internal Medicine
• Research databases:

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 o PubMed (free access)
o CINAHL
o PsycINFO
• Other databases:
o Natural Medicines Comprehensive Database
o SPORTDiscus
3. Critically appraise the evidence
• According to a 2004 article in the Journal of the American Dietetic
Association, “Evidence (research data) is graded on the basis of the type
of research design, the rigor of the intervention used, and the strength
of evidence (data) collected.”
• Academy’s EAL grading system:
o Grade I: Good—these are high-quality studies that have
consistent findings with generalizability of results.
o Grade II: Fair—these studies have a strong research design but
may have minor methodological problems or inconsistencies in
study results. There can be minor doubts about the
generalizability of results.
o Grade III: Limited—these studies are weakly designed and have
inconsistent results. There are serious doubts about the
generalizability of the studies.
o Grade IV: Expert opinion only—Conclusions in these studies are
based on expert opinion and have not been substantiated by
research studies.
4. Apply the evidence to the clinical situation
• Questions to consider while utilizing the evidence:
o How closely do the findings resemble my patient and his or her
problems?
o Is the intervention feasible for this patient?
o Is the intervention aligned with my patient’s values and wishes?
5. Improve evidence-based practice via self-reflection
• Questions to consider:
o Were my clinical questions well formulated? (Were they in an
answerable format?)
o Did I select the best sources for the type of clinical questions?
o Am I searching efficiently and are my searches improving?
o Am I critically appraising the evidence, and am I integrating that
evidence into my practice?
o Do I have a system for becoming aware of “newly emerging
evidence”? Consider using automatic alerting systems by setting
up searches on the My NCBI feature of PubMed, monitoring the
Table of Contents in relevant journals, and subscribing to RSS
feeds such as those on Health Topics from MedlinePlus

Concept Check!
?
How important is evidence-based practice in nutrition care?

Module VIII Page 239

 MODULE SUMMARY
This module has 3 lessons on legal mandates and moral principles in nutrition
care.
Lesson 1 discussed the legal mandates related to nutrition and enumerated the
agencies related to the implementation of nutrition care policies.
Lesson 2 tackled moral principles considered in determining care for critically
ill patients with regard to culture and religion.
Lesson 3 discussed the evidence-based guidelines in nutrition practice. It also
included the sources for evidence-based researches which can be used as a basis for
nutrition care.
Congratulations! You have just studied Module VIII. Now you are ready to evaluate
how much you have benefited from your reading by answering the summative test.
Good Luck!!!

 SUMMATIVE TEST
1. What are the nutrition-based projects of NNC?
2. What is nutritional genomics?
3. What are the ethical considerations in end-of-life nutrition care?

Laboratory Activity
Final Activity (Group of 8): Considering all the lessons you have learned in this
whole module, plan for a meal for any one of the following population group:
a. Elderly patients
b. Pregnant woman in the first trimester
c. School-age child
Guidelines:
1. The course should consist of the following:
a. Appetizer
b. Vegetable course
c. Main course: fish or meat
d. Dessert
e. Drink
2. Consider the nutrient intake and other problems related to food intake of your
chosen population group.
3. Anticipate the amount of expenses while planning for the meal.
4. Since you are studying from home, cooking will be done at home. A video
presentation on the preparation, cooking and table setting should be submitted
along with the discussion of the benefits or the reasons why you chose that
particular course and the cost of the meals.
5. Submission of the output will be discussed during the virtual face to face
meeting.

Module VIII Page 240