NCM105 NUTRITION AND DIET THERAPY LECTURE
SEPTEMBER 8, 2021
MODULE 1
 Many children and adolescents in the
Philippines are not growing up healthy
 One in three Filipino children are too thin for
their height
 A tenth of Filipino adolescents are now
overweight
 Increased vulnerability to disease due to poor
health-seeking, behavior, incomplete
immunization, poor hygiene and care practices,
and inadequate diet
FOODS
 Is anything edible
 Includes all foods and drinks acceptable for that
particular society, culture or religion
 Gives us a feeling of comfort and satisfaction
 Establishes our identity
 Most of our food habits are learned in the home
from our parents. As we grow up, our
experience and learning help us to change some
of these food habits. You are learning about
food and nutrition in order to be able to teach
and help mothers to change their food habits
for the better
DIET
 Is the sequence and balance of meals in a day
 Is concerned with the eating patterns of
individuals or a group
 Some people may eat twice in a day (breakfast
and dinner); others may eat four times
(breakfast, lunch, snack and dinner); still others
may seem to be chewing all day long
NUTRITION
 Is the interaction between food and the body
 Is about the nutrients contained in food, and
their action, interaction and balance in relation
to health and disease
 Is the process by which people can ingest,
digest, absorb, transport, utilize and excrete
food substances
 Is concerned with social, cultural and
physiological implications of food and eating
 The science of nutrition is the science of
showing how food nourishes the body
NUTRIENT
 Is an active chemical component in food that
plays a specific structural or functional role in
the body’s activity
 Is an active chemical component in food that
plays a specific structural or functional role in
the body’s activity
 Vitamins and minerals are needed in very small
amounts and they are called micronutrients
How food keeps us healthy?
 Food is needed for energy and nutrients to
exist, it provides energy for work, and warmth
for the body
 Everybody also needs food to build, maintain
and repair their body
 It is also required for control of body processes
and for protection against disease and
infections
 Food helps us to keep healthy, warm, well-
nourished, free of infections and alive
The importance of nutrients
 The nutrients we get from the food we eat will
affect the size and shape of our body. The use
of nutrients to build tissues and supply energy
at various stages of our life is explained here
Using nutrients to build tissue
Example:
A person who weighs 50 kg consists of 31 kg of
water, 9 kg of protein, 7 kg of fat and 3 kg of minerals.
 Therefore, besides water, the most important
building nutrient is protein.
 Fat is also important to build cells and energy
stores.
 Some minerals are important, for example
calcium, which is necessary to build bones and
teeth, and;
 Iron which helps to build haemoglobin in the
blood.
Using nutrients to build the body
For growth:
 A child starts to grow as a single cell inside its
mother. The cell absorbs nutrients; it grows and
divides into two cells. The cell uses nutrients as
building materials for the new cell and other
nutrients for energy to do the work of building.
Each cell then absorbs more nutrients to grow
larger and divide again. The cells continue to
absorb nutrients and to grow and divide until
there are millions of cells which form different
 tissues such as skin, muscle and bone. The
child’s body also makes fluids such as blood, How the body uses nutrients in food we eat
which nourishes and protects the cells. Nutrients Use
Carbohydrates (starches
For energy
For pregnancy: and sugars)
During pregnancy, a woman needs body To keep gut healthy
FIbre
building nutrients to: To help digestion
 provide the baby and placenta with nutrients to For energy
grow To build cells
Fats
 increase the size of her uterus and breasts Stored for use as energy
 make more blood and stores of fat that can be when needed
mobilized during lactation, and other nutrients. To build cells
To make Fluids
For chemical processes
To secrete fluids: Proteins
For energy
 The body has to keep making fluids such as To protect against
saliva, digestive juices, tears and breastmilk infection
because they are continually used up. To build cells
Minerals To make fluids
For chemical processes
To replace cells: For chemical processes
 Most cells live only a short time. The body must To build cells
Vitamins
build new cells to replace those that die. The To protect against
need to replace cells continues throughout life. infection
For chemical processes
Skin is a good example. The outside layer of the Water To build cells
skin is already dead. All the time new cells are To make fluids
growing under the dead cells to replace them.
When you wash and dry yourself, you remove MODULE 2: NUTRIENTS AND THEIR SOURCES
SEPTEMBER 8, 2021
the dead cells.
 If you wear shoes for a long time you get holes
CLASSIFICATION OF ESSENTIAL NUTRIENTS
in the soles. But if you walk without shoes, you MACRONUTRIENTS
do not get holes in your feet, because new skin  MACRO means large; as their name suggest
cells grow under the old cells to replace them. these are nutrients which people need to eat
regularly and in a fairly large amount. They
include carbohydrates, fats, proteins, fibre and
To repair tissues: water. These substances are needed for the
 After injury or illness, the body makes new cells supply of energy and growth,
to repair the damaged tissues. for metabolism and other body functions.
 Metabolism means the process involved in the
generation of energy and all the ‘building
Using nutrients to produce energy
blocks’ required to maintain the body and its
 When you turn on the engine of a car, the
functions.
petrol combines with oxygen and ‘burns’ to
make energy. The energy makes the car move,
NUTRIENT TYPES AND THEIR NAMES
and it also makes the engine warm. Similarly,
 Food that contains a lot of protein are called
the body ‘burns’ nutrients to make energy.
body-building foods or growing foods
 Foods that contain a lot of fat or carbohydrates
and perhaps only a little protein are called
energy-giving foods
 Foods in which the most important nutrients
are vitamins or minerals are called protective
foods
CARBOHYDRATES
 Carbohydrates are referred to as energy-giving
foods. They provide energy in the form of
calories that the body needs to be able to work,
and to support other functions.
 Carbohydrates are needed in large amounts by
the body. Indeed, up to 65% of our energy
comes from carbohydrates. They are the body’s
main source of fuel because they are easily
converted into energy. This energy is usually in
the form of glucose, which all tissues and cells
in our bodies readily use.
 For the brain, kidneys, central nervous system
and muscles to function properly, they need
carbohydrates. These carbohydrates are usually
stored in the muscles and the liver, where they
are later used for energy.
 The main sources of carbohydrates are bread,
wheat, potatoes of all kinds, maize, rice,
cassava, pasta, macaroni, banana, sweets, sugar
cane, sweet fruits, and honey. Other foods like
vegetables, beans, nuts and seeds contain
carbohydrates, but in lesser amounts.
CLASSIFICATIONS OF CARBOHYDRATES
 Monosaccharides and disaccharides are
referred to as simple sugars or simple
carbohydrates that our body can easily utilize.
For this reason, people with diabetes mellitus
shouldn’t eat too many of these carbohydrates.
Examples include sugar, honey, sweet fruits and
sugar cane.
 Polysaccharides are called complex
carbohydrates and they need to be broken
down into simple sugars to be used by our
body. They can be consumed by diabetic
patients without restriction. Examples include
starch and cellulose.
PROTEINS
 About 10–35% of calories should come from
protein. Proteins are needed in our diets for
growth (especially important for children, teens
and pregnant women) and to improve immune
functions. They also play an important role in
making essential hormones and enzymes, in
tissue repair, preserving lean muscle mass, and
supplying energy in times when carbohydrates
are not available.
 Pregnant women need protein to build their
bodies and that of the babies and placentas, to
make extra blood and for fat storage.
Breastfeeding mothers need protein to make
breastmilk.
SOURCES OF PROTEIN
 The main sources of proteins are meats,
chicken, eggs, breastmilk, beans, ground nuts,
lentils, fish, cheese and milk.
 All animal foods contain more protein than
plants and are therefore usually better sources
of body building foods. However, even though
plant protein is usually not as good for body-
building as animal proteins, they can become
more effective nutritionally when both are
mixed with each other.
FATS AND OILS
 Fats and oils are concentrated sources of energy
and so are important nutrients for young
children who need a lot of energy-rich food.
Fats can also make meals tastier and satisfying.
Fat is found in meat, chicken, milk products,
butters, creams, avocado, cooking oils and fats,
cheese, fish and ground nuts.
CLASSIFICATION OF FATS
 Fats are classified into saturated and
unsaturated fats. The classification is important
to enable you to advise your community about
which fats can be consumed with less risk to
people’s health. Saturated fats are not good for
a person’s health.
 Saturated fats are usually solid at cool
temperatures. Eating too much saturated fat is
not good for a person’s health, as it can cause
heart and blood vessel problems.
Examples: butter, ghee, suet, lard, coconut oil and palm
oil, cakes, biscuits, fatty cuts of meat, sausages, bacon,
cured meats like salami, chorizo and pancetta, cheese
 Unsaturated fats are usually liquid at room
temperature. These types of fats are healthy
fats. Examples include fats from fish, oil seeds
(sesame and sunflower), maize oil and ground
nut oil and breastmilk. As a general rule, plant
sources of fats are better for a person’s health
than the animal sources, because animal fats
contain more saturated fats.
WATER
 A 50 kg adult contains about 31 litres of water
and a one-year-old, 10 kg child contains nearly 8
litres of water. Almost every part of the body
contains large amounts of water.
 People can live without solid food for a few
weeks, but we cannot live without water for
more than a few days. An adult need about 2–3
litres of water each day. That is why giving
drinks are so important when people lose a lot
of water, such as when they have diarrhea.
 Water is essential for life. We need water for a
number of reasons:
 For the body to make cells and fluids such
as tears, digestive juices and breastmilk
 For the body to make sweat for cooling
itself
 For essential body processes — most take
place in water
 For keeping the lining of the mouth,
intestine, eyelids and lungs wet and
healthy
 For the production of urine, which carries
waste from the body.
FIBRE
 Fibre is a mixture of different carbohydrates
which are not digested like other nutrients but
pass through the gut nearly unchanged.
 Foods’s rich in fibre are ‘kocho’; vegetables like
cabbage, ‘kosta’, carrots, cassava; fruits like
banana and avocado; peas and beans; whole-
grain cereals like wheat flour and refined maize.
Including fibre in the diet
Fibre should be included in the diet for the
following reasons:
 Fibre makes food bulky or bigger — this can
help a person who is overweight to eat less food
 Fibre makes the faeces soft and bulky; this can
help prevent constipation
 Fibre slows the absorption of nutrients, so it
helps nutrients to enter the blood stream
slowly. This is important for patients with
diabetes mellitus.
MICRONUTRIENT
VITAMINS
 Vitamins are groups of related substances
present in small amounts in foodstuffs and are
necessary for the body to function normally.
Vitamins are also called protective foods. They
are grouped together because, as their name
implies, they are a vital factor in the diet.
CLASSIFICATIONS OF VITAMINS
Vitamins are classified into two groups:
 Fat soluble vitamins (vitamins A, D, E and K) are
soluble in fats and fat solvents. They are
insoluble in water. So, these are utilized only if
there is enough fat in the body.
 Water soluble vitamins (vitamins B and C, and
folic acid) are soluble in water and so they
cannot be stored in the body.
 The best sources of micronutrients in our diets
are fruits and vegetables. These two food
groups contain essential vitamins and minerals.
Animal sources of foods are also both good
sources of micronutrients. However, an
adequate micronutrient intake can only be
achieved through sufficient intake of a balanced
diet that includes plenty of fruits and
vegetables.
VITAMINS FUNCTION FOOD
SOURCES
Vitamin A Night vision Breastmilk,
Healing epithelial cell tomatoes,
s cabbage,
Normal development lettuce,
of teeth and bones pumpkins
Mangoes,
 papaya, carrots MINERALS
 Minerals are the substances that people need
Liver, kidney,
to ensure the health and correct working of
egg yolk, milk, their soft tissues, fluids and their skeleton.
butter, cheese Examples of minerals include calcium, iron,
cream iodine, fluorine, phosphorus, potassium, zinc,
Vitamin D Needed for Ultra violet selenium, and sodium.
absorption of calcium light from the
from small intestines sun

Calcification of the Eggs, butter,

skeleton fish

Fortified oils,
fats and cereals
Vitamin K For blood clotting Green leafy
vegetables

Fruits, cereals,
meat, dairy A BALANCED DIET
products  Eating a balanced diet means choosing a wide
variety of foods and drinks from all the food
groups. It also means eating certain things in
B Metabolism of Milk, egg yolk,
small amounts, namely saturated fat,
complex carbohydrates,
liver, kidney cholesterol, simple sugar, salt and alcohol. The
proteins and fats
and heart goal is to take in all of the nutrients you need
for health at the recommended levels and
perhaps restrict those things that are not good
Whole grain
for the body.
cereals, meat,
whole bread, FOOD PYRAMID
fish, bananas  It helps us identify the food groups people
should combine in order to make a balanced
Vitamin C Prevention of scurvy Fresh fruits diet. The food groups at the top of the pyramid
should be eaten in moderation (small amount)
(oranges,
but food groups at the bottom of the pyramid
Aiding wound healing banana, should be eaten in larger amounts.
mango,
Assisting absorption grapefruits,
of iron lemons,
potatoes) and
vegetables
(cabbage,
carrots, pepper,
tomatoes)

Breastmilk
 NUTRITION DURING PREGNANCY AND LACTATION
 An unborn child needs a healthy and well-
nourished mother to grow properly. Therefore,
a mother needs to gain weight during
MODULE 3: NUTRITIONAL REQUIREMENTS pregnancy to help nourish her growing baby.
THROUGHOUT THE LIFECYCLE
Women who do not gain enough weight often
SEPTEMBER 15, 2021
have babies that weigh too little (low birth
weight). A baby weighing less than 2.5 kg has an
Why it is important to know nutritional
increased chance of both physical and mental
requirements?
health problems. It may also suffer more from
 You need to know nutritional requirements of
infection and malnutrition compared with
an individual or group for two major reasons: babies of normal weight
1. Prescriptive reasons: that is, to provide or dispense  Women should gain at least 11 kg during
food supplies; for example: pregnancy. If the mother gains less than this,
 to procure food for national consumption the baby’s chances of survival and health
 to secure food for institutional declines. If a mother is overweight, she still
consumption needs to gain for her baby’s health. She should
 to run nutritional supplementation not try to lose weight while she is pregnant.
programmes.
2. Diagnostic reasons: mainly to identify whether a
group or an individual is suffering from malnutrition of
any kind; for example:
 to evaluate nutritional intervention
programmes
 to determine whether the food available
in the stock is adequate to feed the
household or nation for a certain duration
of time.
 In order to estimate nutritional requirements of
individuals or groups, we need to consider the
following factors:
 Physical activity — whether a person is
engaged in heavy physical activity
 The age and sex of the individual or group
 Body size and composition — what the
general build is of a person or group GAINING WEIGHT IN PREGNANCY
 Climate — whether a person or group is  A pregnant mother should gain weight
living in hot or cold climate
 Physiological states, such as pregnancy
smoothly and steadily. If weight gain occurs
and lactation. suddenly, she should see a health professional.
 Based on these factors, nutritional  During the first three months, she should
requirements in the different segments of the expect to gain a total of 1–2 kg.
population can be classified into four groups.  During the last six months, she needs to gain
These correspond to different parts of the about 0.5 kg each week.
lifespan, namely (a) pregnancy and lactation, (b)  If she has already gained 11 kg after six–seven
infancy and childhood (c) adolescence and months, she should continue to gain
adulthood, and (d) old age. You are now going moderately until delivery.
to look at each of these in turn.
  The baby puts most of its weight during the last
few months.
EATING DURING PREGNANCY
 Women’s nutrition during pregnancy and
lactation should focus on the three
micronutrients (vitamin A, iron and iodine) and
extra energy intake/reduction of energy
expenditure. Therefore, the following are
essential nutrition actions related to maternal
nutrition:
 A pregnant or breastfeeding woman needs
extra foods, especially those that are good
sources of iron.
 Pregnant women need at least one additional
meal (200 Kcal) per day during the pregnancy.
 A pregnant woman needs to cut down her
energy expenditure. She should reduce her
involvement in strenuous household tasks that
lead to higher energy expenditure.
 Pregnant women should eat iodised salt in their
diet.
 Pregnant women should take vitamin A rich
foods (such as papaya, mango, tomato, carrot,
and green leafy vegetable) and animal foods
(such as fish and liver).
 In the malarious areas, pregnant women should
sleep under an insecticide-treated bed net.
 Pregnant women during the third trimester of
pregnancy should be de-wormed using
mebendazole or albendazole.
 Pregnant women need a well-balanced diet
containing mixture of foods. This should include
as far as possible food from the different food
groups (animal products, fruits, vegetables,
cereals and legumes).
NUTRITION DURING LACTATION (BREASTFEEDING)
 If all babies are to be healthy and grow well,
they must be fed breastmilk. When a baby sucks
at the nipple, this causes the milk to come into
the breast and continue to flow. Breastmilk is
food produced by the mother’s body especially
for the baby, and it contains all the nutrients
(nourishment) a healthy baby need.
 A lactating woman needs at least two extra
meals (550 Kcal) of whatever is available at
home. In addition, a dose of vitamin A
(200,000IU) should be given once between
delivery and six weeks after delivery. This will
enable the baby to get an adequate supply of
vitamin A for the first six months. During the
first six months the best way of feeding the
baby is for the mother to breastfeed exclusively.
NUTRITIONAL REQUIREMENTS IN INFANCY,
CHILDHOOD AND ADOLESCENCE
 The common feature of infancy, childhood and
adolescence is that all these age groups are
undergoing rapid growth and development. This
in turn poses a heavy demand on their
nutritional requirements. Small children and
infants do not have a well-developed body
nutrient store, and therefore are more
vulnerable to infection. In addition, they have a
larger surface area compared to their body size.
All these factors increase their basal metabolic
rate (BMR), resulting in an increased
requirement for nutrients.
ADOLESCENT GROWTH SPURT
 Adolescents also undergo a very rapid growth
during their puberty (called the pubertal
growth spurt). During the pubertal growth
spurt, they increase rapidly both in weight and
height. Therefore, they need a nutrient intake
that is proportional with their rate of growth.
The growth rate is very high right after birth
(infancy). Then the growth rate slows down
until the age of 12–14 years. At about 15–16
years (the pubertal period) there is a sharp rise
in growth rate/velocity. After that, the growth
rate slows down again.
 Requirements for macronutrients (proteins,
carbohydrates and fats) and micronutrients are
higher on a per kilogram basis during infancy
and childhood than at any other developmental
stage. These needs are influenced by the rapid
 cell division occurring during growth, which
requires protein, energy and fat. Increased
needs for these nutrients are reflected in daily
requirements for these age groups.
INCREASE NEED FOR NUTRIENTS
ENERGY
 While most adults require 25–30 calories per kg,
a 4 kg infant requires more than 100 kilocalories
per kg (430 calories/day). Infants of four to six
months who weigh 6 kg require roughly 82
kilocalories per kg (490 calories/day). Energy
needs remain high through the early formative
years. Children of one to three years require
approximately 83 kilocalories per kg (990
calories/day). Energy requirements decline
thereafter and are based on weight, height, and
physical activity.
 As an energy source, breastmilk offers
significant advantages over manufactured
formula milk. Breastfeeding is associated with
reduced risk for obesity, a wide range of
allergies, hypertension, and type 1 diabetes. It is
also linked with improved cognitive
development; and with decreased incidence
and severity of infections. It is also less costly
than formula feeding. The list below outlines
the nutrients and other constituents of
breastmilk:
 Water = 87–89%
 Vitamins (particularly vitamin A)
 Fat = 3–5%
 Energy = 60–70 kcal/100 ml
 Carbohydrate (lactose) = 6.9–7.2%
 Mineral = 0.2%
 Protein = 0.8–0.9%
 Higher intakes of protein and energy for growth
are recommended for adolescents. For most
micronutrients, recommendations are the same
as for adults. Exceptions are made for certain
minerals needed for bone growth (e.g., calcium
and phosphorus). Evidence is clear that bone
calcium accretion increases as a result of
exercise rather than from increases in calcium
intake. Since weight gain often begins during
adolescence and young adulthood, young
people must establish healthy eating and
lifestyle habits that reduce the risk for chronic
disease later in life.
WATER
 Infants and children need plenty of water to
drink, particularly when ill, or exposed to
extreme temperatures.
 Total water requirements (from beverages and
foods) are also higher in infants and children
than for adults. Children have a larger body
surface area per unit of body weight and a
reduced capacity for sweating when compared
with adults, and therefore are at greater risk of
morbidity and mortality from dehydration.
Parents may underestimate these fluid needs,
especially if infants and children are
experiencing fever, diarrhea or exposure to very
cold or very hot temperatures
ESSENTIAL FATTY ACIDS
 Requirements for fatty acids or fats on a per
kilogram basis are higher in infants than adults.
Some fatty acids play a key role in the central
nervous system. However, infants and children
should not ingest large amounts of foods that
contain predominantly fats, so it is important to
get the balance right.
INFANCY AND CHILDHOOD
 Increased requirements of energy, protein,
essential fatty acids, calcium and phosphorus.
ADOLESCENCE
 Increased requirements of energy, protein,
calcium, phosphorus and zinc.
NUTRITIONAL REQUIREMENTS DURING
ADULTHOOD
 The nutritional needs in adults of 19–50 years of
age differ slightly according to gender. Males
require more of vitamins C, K, B1, B2 and B3,
and zinc. Females require more iron, compared
with males of similar age.
 NUTRITIONAL REQUIREMENTS DURING LATER
YEARS
 Elderly people are especially vulnerable to
nutritional problems due to age related changes
in their body (impaired physiological and
anatomical capacity). Box 3.5 overleaf sets out
some of the problems an older person might
experience which could impact on their diet.
POSSIBLE NUTRITIONAL ISSUES IN OLD AGE
 Problems of procuring and preparing foods
 Psychosocial problems
 Digestion problems
 Nutrient absorption problems
 Renal changes
 Memory loss (senile dementia), which may
include forgetting to eat
 Sensory changes
 Physical problems like weakness, gouty arthritis
and painful joints.
MODULE 4: THE DIGESTION AND ABSORPTION
PROCESS
SEPTEMBER 15, 2021
THE DIGESTIVE SYSTEM
 Is one of the eleven organ systems of the
human body and it is composed of several
hollow tube-shaped organs including the
mouth, pharynx, esophagus, stomach, small
intestine, large intestine (or colon), rectum,
and anus.
 It is lined with mucosal tissue that secretes
digestive juices (which aid in the breakdown of
food) and mucus (which facilitates the
propulsion of food through the tract).
 Smooth muscle tissue surrounds the digestive
tract and its contraction produces waves,
known as peristalsis, that propel food down
the tract.
 Nutrients as well as some non-nutrients are
absorbed.
 Substances such as fiber get left behind and are
appropriately excreted.
FROM THE MOUTH TO THE STOMACH
There are four steps in the digestion process.
1. The first step is ingestion, which is the collection
of food into the digestive tract. It may seem a
simple process, but ingestion involves smelling
food, thinking about food, and the involuntary
release of saliva, in the mouth to prepare for
food entry.
2. In the mouth, where the second step of
digestion occurs, the mechanical and chemical
breakdown of food begins. The chemical
breakdown of food involves enzymes, which
break apart the components in food. In the
mouth, the enzyme amylase is secreted to
begin breaking down complex
carbohydrate. Mechanical breakdown starts
with mastication (chewing) in the mouth. Teeth
crush and grind large food particles, while saliva
initiates the chemical breakdown of food and
enables its movement downward.
3. The slippery mass of partially broken-down food
is called bolus, which moves down the digestive
tract as you swallow. Swallowing may seem
voluntary at first because it requires conscious
effort to push the food with the tongue back
toward the throat, but after this, swallowing
proceeds involuntarily, meaning it cannot be
stopped once it begins.
As you swallow, the bolus is pushed from the
mouth through the pharynx and into a muscular
tube called the esophagus. As it travels through
the pharynx, a small flap called the epiglottis
closes, to prevent choking by keeping food from
going into the trachea. Peristaltic contractions
in the esophagus propel the food down to the
stomach.
4. At the junction between the esophagus and
stomach, there is a sphincter muscle that
remains closed until the food bolus approaches.
The pressure of the food bolus stimulates the
lower esophageal sphincter to relax and open
and food then moves from the esophagus into
the stomach. The mechanical breakdown of
food is accentuated by the muscular
contractions of the stomach and small intestine
that mash, mix, slosh, and propel food down
the alimentary canal. Solid food takes between
four and eight seconds to travel down the
esophagus, and liquids take about one second.
FROM THE STOMACH TO THE SMALL INTESTINE
 When food enters the stomach, a highly
muscular organ, powerful peristaltic
contractions help mash, pulverize, and churn
food into chyme. Chyme is a semiliquid mass of
partially digested food that also contains gastric
juices secreted by cells in the stomach. Cells in
the stomach also secrete hydrochloric acid and
 the enzyme pepsin, that chemically breaks
down protein into smaller molecules. A thick
mucus coat lines the stomach to protect it from
digesting itself.
 The stomach has three basic tasks:
 To store food
 To mechanically and chemically break down
food
 To empty partially broken-down food into
the small intestine
The length of time food spends in the stomach
varies by the macronutrient composition of the meal. A
high-fat or high-protein meal takes longer to break
down than one rich in carbohydrates. It usually takes a
few hours after a meal to empty the stomach contents
completely. The sphincter that allows chyme to pass
into the small intestine is known as the pyloric
sphincter.
The small intestine is divided into three structural
parts: the duodenum, the jejunum, and the ileum. Once
the chyme enters the duodenum (the first segment of
the small intestine), three accessory (or helper) organs:
liver, pancreas, and gallbladder are stimulated to
release juices that aid in digestion. The pancreas
secretes up to 1.5 liters of pancreatic juice through a
duct into the duodenum per day. This fluid consists
mostly of water, but it also contains bicarbonate ions
that neutralize the acidity of the stomach-derived
chyme and enzymes that further break down proteins,
carbohydrates, and lipids. The gallbladder secretes a
much smaller amount of bile to help digest fats, also
through a duct that leads to the duodenum. Bile is
made in the liver and stored in the gallbladder. Bile’s
components act like detergents by surrounding fats
similar to the way dish soap removes grease from a
frying pan. This allows for the movement of fats in the
watery environment of the small intestine. Two
different types of muscular contractions, called
peristalsis and segmentation, move and mix the food in
various stages of digestion through the small intestine.
Similar to what occurs in the esophagus and stomach,
peristalsis is circular waves of smooth muscle
contraction that propel food forward. Segmentation
sloshes food back and forth in both directions
promoting further mixing of the chyme. Almost all the
components of food are completely broken down to
their simplest unit within the first 25 centimeters of the
small intestine. Instead of proteins, carbohydrates, and
lipids, the chyme now consists of amino acids,
monosaccharides, and emulsified fatty acids.
The next step of digestion (nutrient absorption)
takes place in the remaining length of the small
intestine, or ileum (>5 meters).
The small intestine is perfectly structured for
maximizing nutrient absorption. Its surface area is
greater than 200 square meters, which is about the size
of a tennis court. The surface area of the small intestine
increases by multiple levels of folding. The internal
tissue of the small intestine is covered in villi, which are
tiny finger-like projections that are covered with even
smaller projections, called microvilli. The digested
nutrients pass through the absorptive cells of the
intestine via diffusion or special transport proteins.
Amino acids, minerals, alcohol, water soluble vitamins,
and monosaccharides (sugars like glucose) are
transported from the intestinal cells into capillaries, but
the much larger emulsified fatty acids, fat-soluble
vitamins, and other lipids are transported first through
lymphatic vessels, which soon meet up with blood
vessels.
FROM THE SMALL INTESTINE TO THE LARGE
INTESTINE
The process of digestion is fairly efficient. Any
food that is still incompletely broken down (usually less
than ten percent of food consumed) and the food’s
indigestible fiber content moves from the small
intestine to the large intestine (colon) through a
connecting valve, ileoceceal sphincter. The main task of
the large intestine is to reabsorb water. Remember,
water is present not only in solid foods but also the
stomach releases a few hundred milliliters of gastric
juice and the pancreas adds approximately another 500
milliliters during the digestion of the meal. For the body
to conserve water, it is important that the water is
reabsorbed. In the large intestine, no further chemical
or mechanical breakdown of food takes place, unless it
is accomplished by the bacteria that inhabit this portion
of the digestive tract. The number of bacteria residing in
the large intestine is estimated to be greater than
10(14), which is more than the total number of cells in
the human body (10(13)). This may seem rather
unpleasant, but the great majority of bacteria in the
large intestine are harmless and some are even
beneficial. The bacteria synthesize the essential
nutrient, vitamin K, short chain fatty acids, which are
essential for our health, from the undigested fiber. Also,
minerals, such as sodium and potassium, are absorbed.
FROM THE LARGE INTESTINE TO THE ANUS
After a few hours in the stomach, plus three to
six hours in the small intestine, and about sixteen hours
in the large intestine, the digestion process enters step
four, which is the elimination of indigestible food as
feces. Feces contain indigestible food and gut bacteria
(almost 50 percent of content). It is stored in the rectum
until it is expelled through the anus via defecation.
PROCESS OF DIGESTION
 Digestion involves two processes - physical and
chemical. During the physical process, the food
is mixed and moved throughout the
gastrointestinal tract. This process is also
referred to as motility and the partially digested
food is propelled by the wave-like action called
peristalsis. Ring-like muscular valves called
sphincters prevent the back flow of partially
digested food and digestive juices. There are
sphincters between the esophagus and stomach
(esophageal sphincter), between the stomach
and small intestine (pyloric sphincter) and small
intestine and colon (ileocecal sphincter).
 The chemical process of digestion involves the
release of water, acid, bicarbonate and enzymes
to be mixed with the food to further break it
down into smaller subunits. Chemical
breakdown starts in the mouth where enzymes
break down complex carbohydrate. In the
stomach, water and acid are released to begin
the breakdown of protein. A mucus lining
protects the stomach from the corrosive acid.
The mixture, also known as chyme, enters the
small intestine where bicarbonate is introduced
to neutralize the acid and enzymes are added to
break chemical bonds. Most small intestine
digestive enzymes are produced in the pancreas
and small intestine.
REGULATION OF DIGESTION
 Our nervous system and hormones control
digestion. The nervous system consists of the
central nervous system, and the peripheral
nervous system. Our brain and spinal cord make
up the central nervous system while the
peripheral system lies outside the skull and
vertebral column. There are two components to
the peripheral system: the somatic system that
supplies the skin and muscle, and the
autonomic system which supplies smooth
muscle, cardiac muscle, and glands. The
autonomic system has two divisions: the
parasympathetic (PSNS or PNS) and sympathetic
system (SNS). The PSNS supplies signals to
maintain normal function and conserve body
processes. The SNS provides signals to
accelerate the process. Our gastrointestinal
tract receives signals from the central and
autonomic systems as well as sends signals to
these systems.
MODULE 5: NUTRITIONAL ASSESSMENT
SEPTEMBER 22, 2021
As a nurse/healthcare provider you will frequently be
dealing with your patient’s nutritional problems. Using
different nutritional assessment methods discussed
today, you will learn how to assess the nutritional status
of children, mothers and other adult patients.
Nutritional assessment is the interpretation of
anthropometric, biochemical (laboratory), clinical and
dietary data to determine whether a person or groups
of people are well nourished or malnourished (over-
nourished or under-nourished).
Nutritional assessment can be done using the ABCD
methods. These refer to the following:
A. Anthropometry
B. Biochemical/biophysical methods
C. Clinical methods (Nutrition-Focused Physical
Findings)
D. Dietary methods.
ANTHROPOMETRIC MEASUREMENTS USED TO
ASSESS GROWTH
To assess growth in children you can use several
different measurements including length, height, weight
and head circumference.
Length
A wooden measuring board (also called sliding board) is
used for measuring the length of children under two
years old to the nearest mm. Measuring the child lying
down always gives readings greater than the child’s
actual height by 1-2 cm.
Procedure
To measure the length of a child under two years, you
need one assistant and a sliding board.
1. Both assistant and measurer are on their knees.
2. The assistant holds the child’s head with both
hands and makes sure that the head touches
the base of the board.
3. The assistant’s arms should be comfortably
straight.
4. The line of sight of the child should be
perpendicular to the base of the board (looking
straight upwards).
5. The child should lie flat on the board.
6. The measurer should place their hands on the
child’s knees or shins.
7. The child’s foot should be flat against the
footpiece.
8. Read the length from the tape attached to the
board.
9. Record the measurement on the questionnaire.
Height
This is measured with the child or adult in a standing
position (usually children who are two years old or
more). The head should be in the Frankfurt position (a
position where the line passing from the external ear
hole to the lower eye lid is parallel to the floor) during
measurement, and the shoulders, buttocks and the
heels should touch the vertical stand. Either a
stadiometer or a portable anthropometer can be used
for measuring. Measurements are recorded to the
nearest mm.
Procedure
As with measuring a child’s length, to measure a child’s
height, you need to have another person helping you.
1. Both the assistant and measurer should be on
their knees.
2. The right hand of the assistant should be on the
shins of the child against the base of the board.
3. The left hand of the assistant should be on the
knees of the child to keep them close to the
board.
4. The heel, the calf, buttocks, shoulder
and occipital prominence (prominent area on
the back of the head) should be flat against the
board.
5. The child should be looking straight ahead
6. The hands of the child should be by their side
7. The measurer’s left hand should be on the
child’s chin
8. The child’s shoulders should be levelled
9. The head piece should be placed firmly on the
child’s head
10. The measurement should be recorded on the
questionnaire
Weight
A weighing sling (spring balance), also called the ‘Salter
Scale’ is used for measuring the weight of children
under two years old, to the nearest 0.1 kg. In adults and
children over two years a beam balance is used and the
measurement is also to the nearest 0.1 kg. In both cases
a digital electronic scale can be used if you have one
available. Do not forget to re-adjust the scale to zero
before each weighing. You also need to check whether
your scale is measuring correctly by weighing an object
of known weight.

Weighing a child using a harness and spring balance.

BIOCHEMICAL DATA, MEDICAL TESTS, AND
1. Adjust the pointer of the scale to zero level. PROCEDURES
2. Take off the child’s heavy clothes and shoes.  Lab data (e.g., electrolytes, glucose) and tests
3. Hold the child’s legs through the leg holes (e.g., gastric emptying time, resting metabolic
4. Hold the child’s feet rate)
5. Hang the child on the Salter Scale
6. Read the scale at eye level to the nearest 0.1 kg NUTRITION-FOCUSED PHYSICAL FINDINGS
7. Remove the child slowly and safely.  Physical appearance, muscle and fat wasting,
swallow function, appetite, and effect.
 Muscle or grip strength
 Scalp, hair, mouth, skin and nail health
 Appearance and feeling of different body parts,
including the arms, legs, chest, back and face
 Signs of fluid retention or dehydration
DIET HISTORY
Is a detailed retrospective dietary assessment
which obtains details of individual foods and
comprehensive information about foods eaten less
regularly. It is used to describe usual food and/or
nutrient intakes over months or a year

MODULE 6: NUTRITION SUPPORT

SEPTEMBER 22, 2021

UNDERNUTRITION
Undernutrition can occur for multiple reasons.
Food resources may be unavailable, or you may have a
condition that makes it difficult to eat, absorb nutrition,
or prepare food. Drinking too much alcohol can also
lead to undernutrition.
The symptoms of undernutrition include:
 fatigue
 difficulty staying warm
HEIGHT-FOR AGE CHART PHILIPPINES  a lower body temperature
 diarrhea
 reduced appetite
 a lack of emotion
 irritability
 weakness
 slower breathing
 numbness or tingling of the hands and feet
 dry skin
 hair loss
 bruises

Nutritional Deficiencies: Macronutrient deficiencies

 Macronutrient deficiencies include deficiencies
in protein, fat, and/or calories and can lead to stunting,
pronounced wasting (marasmus) or a affects their babies.
disproportionately large abdomen (a sign of
kwashiorkor). Marasmus is a disease of severe wasting
due to a prolonged inadequate intake of protein,
carbohydrate, and fat. Kwashiorkor is a disease that
results from a prolonged inadequate intake of protein.
MARASMUS
Marasmus occurs more often in young children and
babies. It leads to dehydration and weight loss.
Starvation is a form of this disorder. The symptoms of
marasmus include:
 weight loss
 dehydration
 chronic diarrhea
 stomach shrinkage
The main symptom of marasmus is being underweight.
Children with this condition have lost a lot of muscle
mass and subcutaneous fat. Subcutaneous fat is the
layer of fat just under the skin. Dry skin and brittle hair
are also symptoms of marasmus.
In children with marasmus, the following can also occur:
 chronic diarrhea
 respiratory infections
 intellectual disability
 stunted growth
Seriously malnourished children may look older and
have little to no energy or enthusiasm for anything.
Marasmus can also make children short-tempered and
irritable, but this is usually a more common symptom of
kwashiorkor.
CAUSES
Nutrient deficiency is the main cause of
marasmus. It occurs in children that don’t ingest enough
protein, calories, carbohydrates, and other important
nutrients. This is usually due to poverty and a scarcity of
food.
RISK FACTORS FOR MARASMUS
Growing up in a developing country is a risk
factor for marasmus. Areas that have famines or high
rates of poverty have higher percentages of children
with marasmus. Nursing mothers may be unable to
produce enough breast milk due to malnutrition. This
Viral, bacterial, and parasitic infections can
cause children to take in too few nutrients. Regions with
high disease rates and insufficient medical care may also
have other factors that reduce the chances of people
having enough food to eat.
DIAGNOSIS
A healthcare provider can often make a
preliminary diagnosis of marasmus through a physical
exam. Measurements, such as height and weight, can
help determine whether a child has marasmus. When
those measurements are well below the measurements
that a healthy child of a particular age should have,
marasmus may be the cause.
A lack of motion in a malnourished child may
also help confirm a diagnosis of marasmus. Children
with the condition tend to lack the energy or will to do
anything.
Marasmus is difficult to diagnose using blood
tests. This is because many children with marasmus also
have infections that can affect blood test results.
TREATMENT
Initial treatment of marasmus often includes
dried skim milk powder mixed with boiled water. Later,
the mixture can also include a vegetable oil such as
sesame, casein, and sugar. Casein is milk protein. The oil
increases the energy content and density of the
mixture.
Once a child starts to recover, they should have
a more balanced diet that meets their nutritional needs.
If dehydration is a problem because of diarrhea,
rehydration should also be a priority. A child may not
necessarily need fluids delivered intravenously. Oral
hydration may be sufficient.
Infections are common among children with
marasmus, so treatment with antibiotics or other
medications is standard. Treating infections and any
other health issues can help give them the best chance
of recovery.
KWASHIORKOR
Kwashiorkor, also known as “edematous
malnutrition” because of its association
with edema (fluid retention), is a nutritional disorder Foods must be introduced and calories should be
most often seen in regions experiencing famine. It is a increased slowly because you have been without proper
form of malnutrition caused by a lack of protein in the nutrition for a long period. Your body may need to
diet. People who have kwashiorkor typically have an adjust to the increased intake.
extremely emaciated appearance in all body parts
Your doctor will also recommend long-term
except their ankles, feet, and belly, which swell with
vitamin and mineral supplementation to your diet.
fluid.
MARASMUS SYMPTOMS KWASHIORKOR
SYMPTOMS
SYMPTOMS
The symptoms of kwashiorkor include: Weight loss inability to grow or gain
 change in skin and hair color (to a rust color) weight
and texture Dehydration Edema, swelling of the
 fatigue hands and feet
 diarrhea Stomach shrinkage Stomach bulging
diarrhea
 loss of muscle mass
 failure to grow or gain weight
 edema (swelling) of the ankles, feet, and belly NUTRITIONAL DEFICIENCIES: MICRONUTRIENT
 damaged immune system, which can lead to DEFICIENCIES
more frequent and severe infections
Micronutrient deficiencies would include deficiencies in
 irritability
vitamins and minerals in the body.
DIAGNOSIS  Scurvy
 Beriberi
If kwashiorkor is suspected, your doctor will first
 Pellagra
examine you to check for an enlarged liver
(hepatomegaly) and swelling. Next, blood and urine  Rickets
tests may be ordered to measure the level of protein  Goiter
and sugar in your blood.  Iron deficiency Anemia

Other tests may be performed on your blood and SCURVY

urine to measure signs of malnutrition and lack of
protein. These tests may look for muscle breakdown
and assess kidney function, overall health, and growth.
These tests include:
 arterial blood gas
 blood urea nitrogen (BUN)
 blood levels of creatinine
 blood levels of potassium
 urinalysis
 complete blood count (CBC)
HOW IS KWASHIORKOR TREATED?
Kwashiorkor can be corrected by eating more
protein and more calories overall, especially if
treatment is started early.
You may first be given more calories in the form
of carbohydrates, sugars, and fats. Once these calories
provide energy, you will be given foods with proteins.
 Severe vitamin C deficiency
 Is one of the oldest vitamin deficiency diseases
recorded and the first one to be cured by
adding a vitamin to the diet.
 Is rare as most people get enough vitamin C in
their diet. It’s usually easy to treat.
RISK FACTORS
 Have no fresh fruits or vegetables in your diet
for a while
 Eat very little food at all – possible reasons
include treatments that make you feel very sick
all the time (such as chemotherapy) or an eating
disorder such as anorexia
 Smoke, as smoking reduces how much vitamin
C your body gets from food
 Have a long-term dependency on drugs or
alcohol that affects your diet
  Have a poor diet while pregnant or
breastfeeding, because the body needs more
vitamin C at these times
 Babies, children and older people who find it
hard to have a healthy diet may also be more at
risk of scurvy
SIGNS
 Adult acne, easy bruising, sore gums,
hemorrhages around bones
TREATMENT
 Scurvy is easily treated by adding some vitamin
C to your diet such as fresh fruit and vegetables
 Most people treated for scurvy feel better
within 48 hours and make a full recovery within
2 weeks.
Who is at risk?
 Alcohol abuse, which can make it hard for your
body to absorb and store thiamine
 Genetic beriberi, a rare condition that prevents
the body from absorbing thiamine
 Hyperthyroidism (overactive thyroid gland)
 Extreme nausea and vomiting in pregnancy
 Bariatric surgery
 AIDS
 Prolonged diarrhea or use of diuretics
(medication that makes you urinate more)
 Undergoing kidney dialysis
Thiamine-rich foods:
Fortified breakfast cereals, pork, fish, beans, lentils,
green peas, enriched cereals, breads, noodles, rice,
sunflower seeds, yogurt

Vitamin C-rich foods PELLAGRA

Citrus fruit, such as oranges and orange juice; peppers; Pellagra is a disease caused by low levels of
strawberries; broccoli; guavas and potatoes niacin, also known as vitamin B-3.
It’s marked by three D’s:
BERIBERI - Dementia, Diarrhea, Dermatitis
Is a disease caused by a vitamin B-1 deficiency, Pellagra is a vitamin deficiency disease associated with
also known as thiamine deficiency. poverty.
Types of the disease:
1. Wet Beriberi – affects the heart and circulatory Dermatitis related to pellagra usually causes a rash on
system. In extreme cases, wet beriberi can the face, lips, feet or hands. In some people, dermatitis
cause heart failure. forms around the neck, a symptom known as Casal
2. Dry Beriberi – damages the nerves and can lead necklace.
to decreased muscle strength and eventually,
muscle paralysis. Additional dermatitis symptoms include:
SYMPTOMS  Red, flaky skin
Wet Beriberi  Areas of discoloration, ranging from red to
- Shortness of breath during physical brown
activity  Thick, crusty, scaly or cracked skin
- Waking up short of breath  Itchy, burning patches of skin
- Rapid heart rate In some cases, the neurological signs of pellagra appear
- Swollen lower legs early on, but they are often hard to identify. As the
Dry beriberi disease progresses, possible dementia symptoms
- Decreased muscle function, particularly include:
in the lower legs  Apathy
- Tingling or loss of feeling in the feet and
 Depression
hands
 Confusion, irritability, or mood changes
- Mental confusion
 Headaches
- Difficulty speaking
 Restlessness or anxiety
- Vomiting
 Disorientation or delusions
- Involuntary eye movement
- Paralysis
TREATMENT
Pellagra us treated with dietary changes and a niacin or
nicotinamide supplement. It may also need to be given
intravenously. Nicotinamide is another form of vitamin
B-3. With early treatment, many people make a full
recovery and start feeling better within a few days of
starting treatment. Skin improvement may take several
months. However, if left untreated, primary pellagra
usually causes death after four or five years.
hormones: thyroxine and triiodinethyronine. Without a
sufficient amount of iodine in the diet the gland begins
to enlarge its cells in its efforts to produce the hormone,
thus producing a goiter, which is a swelling around the
neck. Certain regions lack iodine in the soil which leads
to cretinism, the physical and mental development of
an infant passed on from the lack of iodine in the
mother’s diet.

Niacin-rich foods Other risk factors for goiter include the following:
Liver, chicken breast, tuna, turkey, salmon, anchovies, - Hereditary (inherited from family)
pork, ground beef - Female gender
- Age over 40
RICKETS
Is a bone disease deficiency caused by a lack of The main symptoms of goiter include:
calcium and phosphate vitamin D, called the “sunshine”  A swelling in the front of the neck, just below
vitamin because it is the only vitamin that can be the Adam's apple
produced by the effects of sunlight on the skin.  A feeling of tightness in the throat area
It was a common disease of infants and children, but  Hoarseness (scratchy voice)
since all milk and infant formulas have vitamin D added  Neck vein swelling
to them, it is rarely seen today.  Dizziness when the arms are raised above the
head
SIGNS AND SYMPTOMS:  Other, less common symptoms include:
 Pain – the bones affected by rickets can be sore  Difficulty breathing (shortness of breath)
and painful, so the child may be reluctant to  Coughing
walk or may tire easily; the child’s walk may  Wheezing (due to squeezing of the windpipe)
look different (waddling)  Difficulty swallowing (due to squeezing of the
 Skeletal deformities – thickening of the ankles, esophagus, or “food tube”)
wrists and knees, bowed legs, soft skull bones
and, rarely, bending of the spine Some people who have a goiter may also
 Dental problems – including weak tooth have hyperthyroidism, or overactive thyroid. Symptoms
enamel, delay in teeth coming through and of hyperthyroidism can include:
increased risk of cavities.  An increased resting pulse rate
 Poor growth and development – if the skeleton  Rapid heartbeat
does not grow and develop properly, the child  Diarrhea, nausea, vomiting
will be shorter than average  Sweating without exercise or increased room
 Fragile bones – in severe cases, the bones temperature
become weaker and more prone to fractures  Shaking
 Agitation
CALCIUM AND PHOSPHATE-RICH FOODS:
Dairy products, including milk, yogurt and cheese; dark Some people with goiter may also
green, leafy vegetables, like broccoli and kale; fish, like have hypothyroidism, or underactive thyroid. Symptoms
sardines and salmon; calcium-fortified foods, like soy of hypothyroidism can include:
products, cereals, fruit juice, and milk alternatives.  Fatigue (feeling tired)
 Constipation
GOITER
 Dry skin
Iodine is necessary for the proper functioning of the
 Weight gain
thyroid gland which controls the body’s basal
 Menstrual irregularities
metabolism rate through its production of two
TREATMENT
 No treatment/"watchful waiting." If the goiter
is small and is not bothering you, your doctor
may decide that it doesn’t need to be treated.
However, the goiter will be closely watched for
any changes.
 Medications. Levothyroxine (Levothroid®,
Synthroid®) is a thyroid hormone replacement
therapy. It is prescribed if the cause of the
goiter is an underactive thyroid
(hypothyroidism). Other medications are
prescribed if the cause of the goiter is an
overactive thyroid (hyperthyroidism). These
drugs include methimazole (Tapazole®)
and propylthiouracil. The doctor might
prescribe aspirin or a corticosteroid
medication if goiter is caused by inflammation.
 Radioactive iodine treatment. This treatment,
used in cases of an overactive thyroid gland,
involves taking radioactive iodine orally. The
iodine goes to the thyroid gland and kills thyroid
cells, which shrinks the gland. After radioactive
iodine treatment, the patient usually has to take
thyroid hormone replacement therapy for the
rest of his or her life.
 Biopsy. A biopsy is the removal of a sample of
tissue or cells to be studied in a laboratory. A
biopsy may be needed if there are large nodules
in the thyroid gland. A biopsy is taken to rule
out cancer.
 Surgery. Surgery is performed to remove all or
part of the thyroid gland. Surgery may be
needed if the goiter is large and causes
problems with breathing and swallowing.
Surgery is also sometimes used to remove
nodules. Surgery must be done if cancer is
present. Depending on the amount of thyroid
gland removed, the patient may need to take
thyroid hormone replacement therapy for the
rest of his or her life.
IODINE-RICH FOODS:
Seaweeds, cold fish, dairy products, iodized salt,
shrimps, tuna, egg and prunes
IRON-DEFICIENCY ANEMIA
A condition in which blood lacks adequate healthy red
blood cells. Red blood cells carry oxygen to the body’s
tissues.
Risk factors
These groups of people may have an increased
in iron deficiency anemia:
 Women. Because women lose blood during
menstruation, women in general are at greater
risk of iron deficiency anemia.
 Infants and children. Infants, especially those
who were low birth weight or born
prematurely, who don’t get enough iron from
breast milk or formula may be at risk of iron
deficiency. Children need extra iron during
growth spurts. IF your child isn’t eating a
healthy, varied diet, he or she may be at risk of
anemia.
 Vegetarians. People who do not eat meat may
have a greater risk of iron deficiency anemia if
they do not eat other iron-rich foods.
 Frequent blood donors. People who routinely
donate blood may have an increased risk of iron
deficiency anemia since blood donation can
deplete iron stores. Low hemoglobin related to
blood donation may be a temporary problem
remedied by eating more iron-rich foods. IF you
are told that you cannot donate blood because
of low hemoglobin, ask your doctor whether
you should be concerned.
SYMPTOMS
Initially, iron deficiency anemia can be so mild
that it goes unnoticed. But as the body becomes more
deficient in iron and anemia worsen, the signs and
symptoms intensify. Iron deficiency anemia signs and
symptoms may include:
 Extreme fatigue
 Weakness
 Pale skin
 Chest pain, fast heartbeat or shortness of
breath
 Headache, dizziness or lightheadedness
 Cold hands and feet
 Inflammation or soreness of your tongue
 Brittle nails
 Unusual cravings for non-nutritive substances,
such as ice, dirt or starch
 Poor appetite, especially in infants and children
with iron deficiency anemia
Causes of iron deficiency anemia include:
  Blood loss. Blood contains iron within red blood
cells. So, if you lose blood, you lose some iron.
Women with heavy periods are at risk of iron
deficiency anemia because they lose blood
during menstruation. Slow, chronic blood loss
within the body — such as from a peptic ulcer, a
hiatal hernia, a colon polyp or colorectal cancer
— can cause iron deficiency anemia.
Gastrointestinal bleeding can result from
regular use of some over-the-counter pain
relievers, especially aspirin.
For casual events, one needs just a basic table
 A lack of iron in your diet. Your body regularly
setting: a placemat, cutlery (fork, knife and spoon), a
gets iron from the foods you eat. If you
dinner plate, a water glass, and a napkin.
consume too little iron, over time your body can
become iron deficient. Examples of iron-rich
Basic Table Setting Instructions
foods include meat, eggs, leafy green
vegetables and iron-fortified foods. For proper 1. Lay the placemat on the table.
growth and development, infants and children 2. Put the dinner plate in the middle of the
need iron from their diets, too. placemat.
 An inability to absorb iron. Iron from food is 3. Lay the napkin to the left of the plate.
absorbed into your bloodstream in your small 4. Place the fork on the napkin.
intestine. An intestinal disorder, such as celiac 5. To the right of the plate, place the knife closest
disease, which affects your intestine's ability to to the plate, blade pointing in. Place the spoon
absorb nutrients from digested food, can lead to the right of the knife. (Note: The bottoms of
to iron deficiency anemia. If part of your small the utensils and the plate should all be level.)
intestine has been bypassed or removed 6. Place the water glass slightly above the plate, in
surgically, that may affect your ability to absorb between the plate and the utensils, about
iron and other nutrients. where 1 p.m. would be on a clock face.
 Pregnancy. Without iron supplementation, iron 7. If you prefer, it is acceptable to set the napkin
deficiency anemia occurs in many pregnant on top of the plate in a basic table setting,
women because their iron stores need to serve though some think this can create a more
their own increased blood volume as well as be formal feeling.
a source of hemoglobin for the growing fetus.
CASUAL TABLE SETTING
Iron-rich foods:
Red meat, pork and poultry; seafood; beans; dark green
leafy vegetables such as spinach; dried fruit such as
raisins and apricots; iron-fortified cereals, breads and
pasta; peas

MODULE 7: TABLE SETTING

SEPTEMBER 27, 2021

BASIC TABLE SETTING

Essentially, the basic table setting, above, and the casual

table setting are nearly identical, but in a casual table
setting, there is the addition of a soup bowl and a
dinner plate.
As a general rule, only set out the glassware, tableware,
and flatware that you're going to be using. If you're not
having a salad course, all you need to set is a dinner
fork. If you're only serving white wine, a red wine glass
is not needed. And if there's no soup course, skip the
soup bowl and spoon.
Casual Table Setting Instructions
1. Lay the placemat on the table.
2. Put the dinner plate in the middle of the
placemat.
3. Place the salad plate on top of the dinner plate.
4. If you're starting with a soup course, place the
soup bowl on top of the salad plate.
5. Lay a napkin to the left of the charger.
6. To the left of the plate, place the fork on the
napkin.
7. On the right of the plate, place the knife closest
to the plate and then the spoon.
8. Directly above the knife, place the water glass.
9. To the right and slightly above the water glass,
place the wine glass or a glass for another
beverage.
If using individual salt and pepper shakers for each
guest, place them at the top of the placemat.
Otherwise, place them near the center of the table, or,
if using a long, rectangular table, place them in the
middle of each end.
FORMAL TABLE SETTING
If you're hosting an elegant dinner party, you might
want to know how to set a table for a three-course
meal. Real Simple home editor Stephanie Sisco says the
biggest difference between a casual table and a formal
table is the use of chargers, also known as presentation
plates. Traditionally, formal place settings also tend to
forgo placemats, but she says you can opt to use a
round placemat underneath a charger for an even more
formal look.
A formal table setting includes many pieces: a
tablecloth, chargers, dinner plates, soup bowls, salad
plates, bread plates, napkins, salad forks, dinner forks,
knives, soup spoons, butter knives, dessert spoons,
water glasses, red wine glasses, and white wine glasses.
Formal Dinner Table Setting Instructions
1. Lay an ironed tablecloth on the table.
2. Set a charger at each seat.
3. In the center of the charger, place a soup bowl.
4. Place the bread plate to the top left of the
charger (between 10 and 11 p.m. on a clock
face).
5. Lay a napkin to the left of the charger.
6. On the left of the charger, place the salad fork
on the outside, and the dinner fork on the
inside. You can put the forks on the napkin, or
for roomier settings, directly on the tablecloth
between the napkin and the charger.
7. On the right of the charger, place the knife
closest to the charger (blade facing in towards
the charger) and then the soup spoon. Note: All
vertical flatware (salad fork, dinner fork, knife,
and soup spoon) should be spaced evenly,
about half an inch away from each other, and
the bottoms of each utensil should be aligned
with the bottom of the charger.
8. Place a butter knife horizontally, blade facing
inwards on top of the bread plate with the
handle pointing to the right. (Note: In all place
settings the blade will face inwards towards the
plate.)
9. Directly above the charger, place a dessert
spoon (a teaspoon) with the handle pointing to
the right.
10. Directly above the knife, place a water glass. To
the right of the water glass and about three-
fourths of an inch downward, place the white
wine glass. The red wine glass goes to the right
of—and slightly above—the white wine glass.
(Note: Since people traditionally drink more
water than wine during dinner, the water is
kept closer to the diner.)
11. If using individual salt and pepper shakers for
each guest, place them above the dessert
spoon. Otherwise, place them near the center
of the table, or, if using a long,
 rectangular table, place them in the middle of
each end.
12. If using a place card, set it above the dessert
spoon.
After the soup course is complete and the bowls are
cleared, a salad plate will take the soup bowl's position.
Traditionally, a charger holds the spot for the dinner
plate, and is removed after the salad course so the place
is never bare. If you do not want to clear the table after
the soup course and bring out dinner plates, you can
place a dinner plate on top of the charger.
TABLE ETIQUETTE/DINNER ETIQUETTE
Proper etiquette is essential for making a
favorable impression at both lunch/dinner interviews as
well as in social business situations. 
Reception/Social Hour
Reception or social hours are typically for the
purpose of networking for jobs and entertaining clients.
Follow the lead of the majority of individuals in the
room and the following basic tips:
 Keep at least one hand free. If you are
standing, have only a drink or food in one hand,
never both.  Hold a drink in your left hand so
that you have a dry hand to offer a firm, not
crushing, hand shake.
 You can eat and drink while sitting, but it
is always better to stand and greet.
 Make good eye contact.  Don't forget to
introduce yourself to the host/hostess and
don't interrupt conversations.  
 Avoid approaching two people engaged in
deep conversation.  Wait until there is a break
so you can introduce yourself.  Look for visual
cues to join the conversation.
 Make eye contact.  Ask people questions about
themselves and the work they do.
 Always offer your contact information and
know when it is time to go.  Move on to the
next group or individual, follow up with
promising contacts, and assess how you can
improve your performance.
ARRIVAL/SITTING DOWN
 Arrive on time and call ahead if you know you
will be late.
 Do not place any bags, purses, sunglasses, cell
phones, or briefcases on the table.
 Have proper posture and keep elbows off the
table. 
TABLE SETTING
 When presented with a variety of eating
utensils, remember the guideline to "start at
the outside and work your way in".  For
example, if you have two forks, begin with the
fork on the outside.
 Do not talk with your utensils and never hold a
utensil in a fist.
 Set the utensils on your plate, not the table,
when you are not using them.
NAPKIN
 Typically, you want to put your napkin on your
lap (folded in half with the fold towards your
waist) soon after sitting down at the table, but
follow your host's lead.
 The napkin should remain on your lap
throughout the entire meal. Place your napkin
on your chair, or to the left of your plate, if you
leave the table as a signal to the server that you
will be returning.
 When the host places their napkin on the table,
this signifies the end of the meal. You should
then place your napkin on the table as well.
ORDERING AND BEING SERVED
Do not order the most expensive item from the
menu, appetizers, or dessert, unless your host
encourages you to do so. While it is best not to
order alcohol even if the interviewer does,
alcohol, if consumed, should be in moderation.
 Avoid ordering items that are messy or difficult
to eat (i.e. spaghetti, French onion soup).
 Wait for everyone to be served before
beginning to eat, unless the individual who has
not been served encourages you to begin
eating.
DURING THE MEAL
 Eat slowly and cut only a few small bites of your
meal at a time.
 Chew with your mouth closed and do not talk
with food in your mouth.
  Pass food items to the right (i.e. bread, salad
dressings). If you are the individual starting the
passing of the bread basket, first offer some to
the person on your left, then take some for
yourself, then pass to the right.
 Pass salt and pepper together, one in each
hand. If someone has asked you to pass these
items, you should not pause to use them.
 Taste your food before seasoning it.
 Do not use excessive amounts of sweeteners -
no more than two packets per meal is the rule
of thumb.
 Bread should be eaten by tearing it into small
pieces, buttering only a few bites at a time. Do
not cut bread with a knife or eat whole.
 Gently stir your soup to cool it instead of
blowing on it.  Spoon your soup away from you.
 You do not have to clean your plate. It is polite
to leave some food on your plate.

BE AWARE OF DIFFERENT EATING STYLES

 Continental or European Style: Cutting the food

with the right hand and using the left hand to
hold the food while cutting and when eating.
 American Style: Cutting the food with the right
hand and holding the food with the left, then
switching hands to eat with the right hand.

WHEN YOU HAVE FINISHED

 When you are finished, leave your plates in the

same position, do not push your plates aside or
stack them.
 Lay you fork and knife diagonally across the
plate, side by side, pointing at 10:00 and 4:00
on a clock face. This signifies to the wait staff
that you have finished.
 Always remember to thank your host.

-END OF MODULE-