NUTRITION CONTENTS

Introduction

Chapter 1: Energy Balance ......................................................................................................... 3

The energy balance equation. ............................................................................................... 4

Chapter 2: Digestion, Absorption & Excretion of Nutrients .......................................................... 8

The gastrointestinal tract (GIT): .................................................................................................. 8

Carbohydrates and Fibre ......................................................................................................... 10

Lipids ..................................................................................................................................... 12

Proteins ................................................................................................................................. 14

Chapter 3: Macronutrients ....................................................................................................... 18

Carbohydrates ........................................................................................................................ 18

Understanding the GI & GL ................................................................................................. 20

Protein & Amino Acids ............................................................................................................ 24

Fats & Lipids ........................................................................................................................... 27

Fluid ...................................................................................................................................... 30

Chapter 4: Micronutrients ........................................................................................................ 34

Vitamins ................................................................................................................................ 34

Minerals ................................................................................................................................ 37

Chapter 5: Nutrition through the Life Cycle ............................................................................... 43

Healthy eating for Infants and Toddlers .................................................................................... 43

Nutrition for Children & Adolescents ........................................................................................ 46

Nutrition in the Adult years ...................................................................................................... 48

Women’s Health Issues: ..................................................................................................... 48

Men’s Health Issues:........................................................................................................... 48

 Nutrition in the Elderly ............................................................................................................ 49

Chapter 6: Behaviour Modification ........................................................................................... 51

Chapter 7: Healthy Eating ......................................................................................................... 54

Chapter 8: Weight Management ............................................................................................... 60

Weight-loss medications.......................................................................................................... 62

Weight-loss surgery ................................................................................................................ 63

Chapter 9: Metabolic Syndrome ................................................................................................ 65

Chapter 10: Food Allergy, Intolerance & Sensitivity .................................................................. 69

Food allergy ........................................................................................................................... 70

Food intolerance and sensitivity ............................................................................................... 72

Chapter 11: Eating Disorders.................................................................................................... 75

Anorexia Nervosa ................................................................................................................... 75

Bulimia Nervosa...................................................................................................................... 75

Information Resources
 INTRODUCTION
NUTRITION

The ‘Essentials of Nutrition course’ is designed to lay the foundations for good nutrition,
optimal health and the prevention of disease through all stages of the life cycle.

On completion of the course you should be able to make general recommendations to clients
to optimise their health through nutrition. You should also be able to refute myths and identify
risks in clients, altering their behaviour to reduce the risk and prevent progression of disease.
Please note that this course does NOT qualify you to prescribe specific diets or treat nutrition
related illnesses such as Diabetes, Dyslipidemia (abnormal fat levels), heart disease or eating
disorders.

Chapters which will be covered in this course include:

1. Energy Balance
2. Digestion, Absorption, Transport & Excretion of Nutrients
3. Macronutrients
4. Micronutrients
5. Nutrition through the Life Cycle
6. Behaviour Modification
7. Healthy Eating
8. Weight Management
9. Metabolic Syndrome
10. Food Allergy, Intolerance and Sensitivity
11. Eating Disorders
 ESSENTIALS OF NUTRITION
CHAPTER 1: ENERGY BALANCE
NUTRITION ENERGY BALANCE
ENERGY BALANCE
Energy is defined as the “capacity to do work”.

The ultimate source of all energy in living organisms is the sun. Through the process of
photosynthesis, green plants intercept a portion of the sunlight reaching their leaves and
capture them with the chemical bonds of carbohydrate.

Proteins, fats and other carbohydrates are synthesised from this basic carbohydrate to meet
the nutritional needs of the plant. Animals and humans obtain these nutrients and energy by
consuming plants and the flesh of other animals.

The body has a unique ability to shift the fuel mixture of carbohydrates, proteins and fats to
accommodate energy needs. However, consuming too much or too little over time results in
body weight changes. Hence, body weight reflects adequacy of energy intake but is not a
reliable indicator of macronutrient or micronutrient adequacy.

The World Health Organisation (WHO) defines energy requirements as follows:

The energy requirement of an individual is the level of energy intake from food that will balance
energy expenditure when the individual has a body size, composition and level of physical
activity that is consistent with long term good health. And that will allow for the maintenance of
economically necessary and socially desirable physical activity. In children and lactating
women the energy requirements included the energy needs associated with the deposition of
tissues or the secretion of milk at rates consistent with good health. (WHO, 1985)
THE ENERGY BALANCE EQUATION

Energy balance: Ein= Eout (Eout = to BMR + PA+TEF)

Bodyweight is maintained

Energy In (Ein) › Energy Out (Eout) – bodyweight increases

Energy In (Ein) ‹ Energy Out (Eout) – bodyweight decreases

Energy In (Ein)

 Energy is available from the foods and liquids we consume.

 The energy we consume is represented by Energy In, or Ein.
 Energy derived from food is commonly described in Kilojoules or Calories.

A food calorie (1 kilocalorie/ 4.18 kilojoules) is defined as the amount of energy required to
raise the temperature of a litre of water by 1ºC at sea level.

1 Calorie = 4.184 kilojoules = 4184 joules.1 kilocalorie = 1000 calories

Foods contain various nutrients:

 Proteins, carbohydrates, and fats provide energy.
 Vitamins and minerals in foods, although essential for normal metabolic functions, do not
contribute energy to our diets.

Just how much energy we consume depends on the amount of carbohydrate, protein and fat
the food contains. Foods such as fruits, vegetables and legumes are low-energy (kilojoule)
dense foods. Fats and alcohol are by far the most energy-dense foods. This is why they
should only be consumed in moderation, particularly if you are overweight or obese.

Energy value per gram supplied by nutrients:

Nutrient Amount (g) Energy value Kj Energy value Cal
Protein 1 17 4
Carbohydrate 1 17 4
Fat 1 37 9
Alcohol 1 29 7
Dietary fibre 1 13 3
Water 1 0 0
Energy out (Eout): (Eout = to BMR + PA+TF)

Energy is expended by the human body in the form of:

 Resting metabolic rate (RMR)

 Thermic effect of food (TEF)
 Energy expended in physical activity (EEPA).

These three components make up the persons’ daily total energy expenditure (TEE).

Basal metabolic rates (BMR):

Definition: “The amount of calories (energy) required to fuel the involuntary activities of the
body at rest.”
 Involuntary activities include maintaining body temperature and muscle tone, producing
and releasing secretions, propelling the gastrointestinal tract, inflating the lungs and
beating the heart.

In summary, the basal metabolic rate is the rate at which the body burns calories to sustain
itself. With average amounts of physical activity, the BMR accounts for 60-70% of total energy
requirements in most people.

Basal metabolic rate is influence by numerous factors including:

1. Body Composition
Definition: What the body is made up of e.g. muscle, adipose tissue, bone, water etc.
 Lean body tissue (muscle mass) requires more calories for maintenance than fat tissue
does. People with more lean muscle mass have a higher metabolic rate than do people
with proportionally more adipose tissue.

2. Hormones
The function of the thyroid gland can directly affect metabolic rate. An overactive thyroid
can greatly increase metabolic rate but is associated with potentially fatal medical
complications e.g. anxiety, short attention span, high blood pressure, increased pulse rate,
increased perspiration etc. Additionally, an under active thyroid results in the body having a
reduced metabolism and medical concerns including fatigue, reduced body temperature,
lowered pulse rate, constipation, intolerance to cold etc.

3. Fever/ Body Temperature

Metabolism increases by 7% for every degree above or below normal body temperature.
When a person is sick and has a fever they have an increased BMR. Similarly in extreme
cold conditions, the BMR is increased to prevent the body temperature from dropping
below normal.
4. Body Size
When considering two people of the same gender and who weigh the same, the taller
person will have a higher metabolic rate than the shorter one because of the larger surface
area. (Greater service area to lose/ absorb heat)

5. Environmental Temperature
Very hot and very cold environmental temperatures increase the metabolic rate because
the body uses more energy to regulate its own temperature.

6. Starvation, Fasting and Malnutrition

Part of the decline in BMR that occurs with these conditions is a result of the loss of lean
body tissue. Hormonal changes may also contribute to the decrease in metabolic rate.

7. Stress
Stress hormones raise the metabolic rate however psychological stress resulting in
lethargy or depression can decrease your BMR.

8. Drugs
Certain drugs or medication can either decrease or increase the metabolic rate.

Thermic Effect of Food (TEF):

The thermic effect of food is an estimation of the amount of energy required to digest, absorb,
transport, metabolise and store nutrients. In a normal mixed diet, the ‘cost’ of processing food
is estimated to be about 10% of total caloric intake.
It is important to note that the actual thermic effect of food varies with the composition of food
eaten, the frequency of eating and the size of the meals consumed.

Physical Activity (PA):

Physical activity or voluntary muscular activity represents the second largest contributor to
total energy expenditure, usually accounting for 25% to 30% of total calories used. Compared
with the other contributing factors (BMR and TEF), physical activity is the biggest variable on
total calorie expenditure. The actual amount of energy used for physical activity depends on
the intensity and duration of the activity and the weight of the person performing the activity.

To estimate how much energy you use in a day for physical activity relative to BMR and TEF,
a rule-of-thumb would be:
 20% if you are sedentary (mainly sitting, lying down or standing)
 30% for light activity such as walking no more than 2 hours daily
 40% for moderate activity such as gardening, heavy housework, dancing etc.
 50% if you are an athlete
 ESSENTIALS OF NUTRITION
CHAPTER 2: DIGESTION, ABSORPTION &
EXCRETION OF NUTRIENTS
 DIGESTION, ABSORPTION & EXCRETION
NUTRITION

THE GASTROINTESTINAL
TRACT (GIT)
The primary role of the GIT is to:

 Extract macronutrients such as

protein, carbohydrates and lipids as
well as water from ingested food and
beverages.

 Absorb necessary micronutrients,

vitamins, minerals and trace
elements.

 Serve as a physical and immunological

barrier to microorganisms, foreign
material and potential antigens
consumed with food.

The GIT tract extends from the mouth to the

anus and includes the oesophagus,
stomach, liver, gallbladder, pancreas, small
and large intestine.

It is one of the largest organs in the body.

In addition to a large surface area, the GIT is extremely active in carrying out the important
functions of secretion, digestion, absorption and excretion.

THE DIGESTION PROCESS

Digestion begins the moment you put food into your mouth and continues until you eliminate
its waste a day or two later. Along the way, various organs play distinct roles in the processing
of food.

Mouth

In the mouth, chewing reduces the size of food particles which are mixed with secretions
that prepare them for swallowing. Salivary glands secrete saliva, releasing an enzyme called
salivary amylase which changes some starches into simple sugars and softens the food for
swallowing. The saliva also allows the taste buds of the tongue to sense the flavours of your
foods.

Oesophagus

The oesophagus transports food and liquid from the mouth to the stomach. The elasticity of
the oesophagus enables it to stretch to nearly two centimetres in diameter to accommodate
food masses of various sizes. As food moves down the oesophagus, the upper oesophageal
sphincter closes to keep it from backing up into the throat. Next, the lower oesophageal
sphincter opens to allow the food to exit, and then closes to prevent regurgitation back into the
oesophagus.

Stomach

In the stomach food is mixed with acidic fluid and enzymes. It takes about two hours for the
stomach to process a typical meal. During that time, hydrochloric acid and pepsin break down
proteins into their constituent amino acids, while the muscular walls of the stomach manually
churn the food, reducing its contents to a thick liquid called chyme.

Small intestine

When food reaches the appropriate consistency and concentration the stomach allows its
contents to pass into the small intestine where most digestion takes place. The chyme
arrives in the duodenum, the first section of the small intestine, through the pyloric valve. At
about the same time, bile and enzymes enter through ducts from the liver and pancreas. In the
next part of the small intestine, the jejunum, fats, starches, and proteins are further broken
down and absorbed by the body. In the final portion of the small intestine, the ileum, water,
vitamin B, and bile salts are absorbed.

The lining of the ileum (final portion of small intestine) also contains nodules called Peyer’s
patches—collections of immune cells that pick up signs of pathogens (disease causing
bacteria) in the digestive system and relay that information through the blood and lymph to
immune cells throughout the body.

The lining of the small intestine comprises folds that are covered with tiny finger like
projections called villi, which are in turn covered with microvilli. The folds, villi, and microvilli
greatly increase the surface area of the intestinal lining to expedite the process of absorption.
Nutrients diffuse across the villus membranes into the cells and blood vessels at the centre of
each villus, to be transported to other parts of the body. Most digestible molecules of food, as
well as water and minerals, are absorbed through the small intestine in a process that takes a
few hours.

Colon (large intestine)

Any undigested or indigestible matter that remains passes through the ileocecal valve into the
cecum, a pouch at the beginning of the colon. The intestinal wall soaks up most of the
remaining water. Bacteria that reside in the colon feed off whatever nutrients are left,
producing fatty acids as well as hydrogen, carbon dioxide and in some people, methane gas.
Some of these gases are consumed as nutrients by the cells of the colon, while others are
expelled as flatus. The little matter that is still undigested is propelled along by contractions of
the colon wall into the rectum and excreted through the anus.

DIGESTION AND ABSORPTION OF SPECIFIC TYPES OF

NUTRIENTS
CARBOHYDRATES AND FIBRE
Digestion (See Figure 1.1)

Dietary carbohydrates include:

 Monosaccharides- “single sugars”: glucose, fructose, and galactose

 Disaccharides-“double sugars”: maltose, sucrose, lactose
 Polysaccharides- “Many sugars” or complex carbohydrates: fibre, starch, dextrin

 Monosaccharides are the only form of carbohydrates that the body is able to absorb
intact. All other digestible carbohydrates must be broken down to monosaccharides
before they can be absorbed.
 For disaccharides, digestion is accomplished by simply splitting the double sugars into
single molecules.
 For polysaccharides, digestion proceeds step by step as the long glucose chains are
ultimately reduced to single glucose units.

 Cooked starch begins to undergo digestion in the mouth by the action of the salivary
amylase, but the overall effect is small because is not held in the mouth for long.

 The stomach serves to churn and mix its contents, but its acid medium halts any residual
effect of the swallowed amylase.

 Most carbohydrate digestion occurs in the small intestine, where pancreatic amylase
enzymes work to reduce complex carbohydrates into shorter chains and disaccharides.

 Disaccharides enzymes (maltase, sucrose, and lactase) on the surface of the cells of
the small intestine finish the process of digestion by splitting maltose, sucrose, and
lactose, respectively, into monosaccharides.

 Normally 95% of starch is digested, usually within 1 to 4 hours after eating.

  The human gastrointestinal tract lacks the enzymes needed to digest fibres. Fibres are
not digested but influence the speed of digestion. Soluble fibres delay gastric
emptying, which contributes to a feeling of satiety or fullness.

Polysaccharides Disaccharides Monosaccharides

Fibre Starch Dextrin Maltose Sucrose Lactose Glucose Fructose Galactose

Salivary
Mouth some most
amylase

Stomach
Dextrin
Small amounts
of sucrose –
Small fructose + glucose
Pancreatic
intestine
Amylase

Maltase Sucrase Lactose

Maltose
Intestinal
brush
border

Glucose Glucose Glucose

Large
Bacteria
Intestine
+ + +
Short
chain
Glucose Fructose Galactose Glucose Fructose Galactose
fatty
acids
absorbed
Excreted
through Absorbed through the intestinal mucosa
undigested
colon

Figure 1.1: Carbohydrate digestion

Absorption

 Glucose, fructose, and galactose are absorbed through the intestinal mucosa cells and
travel to the liver via the portal vein.
 Small amounts of starch that have not been fully digested pass into the colon with fibre
and are excreted in the stools.
 Fibres may impair the absorption of some minerals – namely calcium, zinc, and iron – by
binding with them in the small intestine. Soluble fibre slows the absorption of glucose,
thereby delaying the rise in blood sugar that occurs after eating.

Metabolism

Glucose, fructose, and galactose arrive at the liver via the portal vein.
Fructose and galactose are converted to glucose. The liver releases glucose into the
bloodstream, where its level is held fairly constant by the action of hormones.
A rise in blood glucose concentration after eating causes the pancreas to secrete insulin,
which moves glucose out of the bloodstream and into the cells.
Most cells take only as much glucose as they need for immediate energy needs.
Muscle and liver cells take extra glucose to store as glycogen. The release of insulin lowers
blood glucose to normal levels.
After a while, as the body uses up the energy from the last meal, the blood glucose
concentrations begin to drop. Even a slight fall in blood glucose stimulates the pancreas to
release glucagon, which causes the liver to release glucose from its supply of glycogen. The
result is that blood glucose levels increase to normal.

Insulin and glucagon are the major hormones responsible for the regulation of blood glucose
levels. When the blood glucose concentration rises after eating, the pancreas secretes insulin,
which enables glucose to move from the bloodstream into cells. When blood glucose levels
begin to drop, Glucagon is secreted by the pancreas in response to low blood glucose levels.
It stimulates the breakdown of glycogen to release glucose into the blood.

LIPIDS

Digestion (See Figure 1.2)

 A minimal amount of chemical digestion of fat occurs in the mouth and stomach through
the action of lingual (mouth) lipase and gastric (stomach) lipases.

 As fat enters the duodenum, it stimulates the release of the hormone cholecystokinin,
which in turn stimulates the gallbladder to release bile.

 Bile is an emulsifier produced in the liver from bile salts, cholesterol, phospholipids,
bilirubin and electrolytes.
  Bile prepares fat for digestion by suspending the hydrophobic (‘afraid of water’) molecules
in the watery intestinal fluid.

 Emulsified fat particles have enlarged surface areas on which digestive enzymes can
work.

 Most fat digestion occurs in the small intestine.

 Pancreatic lipase, the most important and powerful lipase, splits off one fatty acid at a
time from the triglyceride molecule, working from the outside in until two free fatty
acids and monoglyceride remain.

 Usually the process stops at this point, but sometimes digestion continues and the
monoglyceride splits into a free fatty acid and a glyceride molecule.

 The end products of fat digestion, mostly monoglycerides with free fatty acid and little
glycerol, are absorbed into intestinal cells.

 It is normal for a small amount of fat (4-5 g) to escape digestion and be excreted in the
faeces. Cholesterol does not undergo digestion; it is absorbed as is.

Ingested fat- triglyceride

Mouth
Lingual lipase
Stomach Gastric lipase

Bile
Small intestine Gall bladder
Intestinal and pancreatic
Emulsified fat (triglycerides)
lipases

Lipases
End products for absorption Monoglycerides, fatty acids and glycerol

Figure 1.2: Fat digestion

Absorption

 About 95% of consumed fat is absorbed, mostly in the duodenum and jejunum.

 Small fat particles, such as short-and medium-chain fatty acids and glycerol, are
absorbed directly through the mucosal cells into capillaries leading to the portal vein
and liver.
  The absorption of larger fat particles, namely monoglycerides and long-chain fatty
acids, is more complex. Although they are insoluble in water, monoglycerides and long-
chain fatty acids dissolve into micelles, compounds created by bile salts that encircle fat
particles to facilitate their diffusion into intestinal cells.

 After achieving their goal of delivering fat to the intestinal cells, most of the released bile
salts are reabsorbed in the terminal ileum, transported back to the liver, and recycled.

 Once inside the intestinal cells, the monoglycerides and long-chained fatty acids combine
to form triglycerides.

 The reformed triglycerides, along with phospholipids and cholesterol, become encased
in protein to form chylomicrons.

 Chylomicrons transport absorbed lipids from intestinal cells through the lymph and
eventually into the bloodstream for the distribution throughout the body.

Metabolism

 In the bloodstream, triglycerides in the chylomicrons are broken down into glycerol
and fatty acids by lipoprotein lipase, a fat-digesting enzyme located on the surface of
adipose cells and other body cells.

 These fatty acids and glycerol enter cells, where they can be catabolised (broken down)
for energy or rebuilt into triglycerides for storage.

PROTEINS

Digestion (See Figure 1.3)

 Chemical digestion of protein begins in the stomach.

 Hydrochloric acid converts pepsinogen to the active enzyme pepsin, which begins the
process of breaking down proteins into small polypeptides and some amino acids.

 The majority of protein digestion occurs in the small intestine, where pancreatic
proteases reduce polypeptides into shorter chains, tripeptides, dipeptides, and
amino acids.
  Enzymes located on the surface of the cells that line the small intestine complete the
digestion.

 Aminopeptidase splits amino acids from the amino ends of short peptides, and
dipeptidase reduces dipeptides to amino acids.

Absorption

 Amino acids, and sometimes a few dipeptides or larger peptides, are absorbed through
the mucosa of the small intestine by active transport with the aid of vitamin B6.

 Intestinal cells release amino acids into the bloodstream for transport to the liver via the
portal vein.
Dietary Protein

Pepsin
Stomach
Polypeptides
Small intestine:
Pancreatic proteases
Trypsin, chymotrypsin, carboxypeptidase

Intestinal wall Tripeptides, dipeptides, amino acids

secretions
Aminopeptidase

Dipeptides, amino acids

Dipeptides
End products for
absorption Amino Acids

Figure 1.3: Protein digestion

Metabolism

The liver acts as a clearing house for the amino acids it receives. It uses the amino acids it
needs, releases those that are not needed elsewhere and handles the extra.
For instance, the liver retains amino acids to make the liver cells, non-essential amino
acids and plasma proteins.

The pathways available to amino acids are either:

 Anabolic (building up)
Primarily, the amino acids are used by all body cells to synthesise proteins that are either
lost through normal wear and tear or are needed to build new tissue, such as during
pregnancy or adolescent growth. Amino acids can also be used to make other molecules
(eg, non-essential amino acids, other nitrogen-containing compounds and fat) when protein
is consumed in excess of need.
 Catabolic (breaking down)
Catabolically, amino acids stripped of their nitrogen can be broken down for energy. Some
amino acids can be converted to glucose. It is important to note that an excess of amino acids
(protein) is converted either to fat for storage or it is excreted. It is not stored as protein.
 ESSENTIALS OF NUTRITION
CHAPTER 3: MACRONUTRIENTS
 MACRONUTRIENTS
NUTRITION
MACRONUTRIENTS
CARBOHYDRATES
Carbohydrates encompass a broad range of foods, including table sugar, fruits and
vegetables, and grains such as rice and wheat. The Daily Recommended Intake (DRI) for
carbohydrates is 45% to 65% of your daily calories. Most of these carbohydrates should come
from whole-grain foods, vegetables and fruits. If most of the carbohydrates you eat are refined
carbohydrates such as; white bread, white potatoes, white rice and other refined starches or
sugars, you could end up gaining weight and putting yourself at risk for disease.

Carbohydrates are found in all starchy and/or sweet foods. Rice, pasta, potatoes, cereals,
legumes, breads, cakes, biscuits and puddings are all starchy foods. Cold drinks, beer, dried
fruits, fresh fruits, vegetables, sweets, sugars and desserts all contain a high percentage of
simple sugars. Milk and other dairy products (e.g. custard, yoghurt, and cheese) contain
lactose, which is also a carbohydrate.

Function of Carbohydrates
• Important for energy production
• Stored in the muscles and liver as glycogen
• The brain requires a constant supply of glucose as its primary fuel source.
• Can be converted into fats and protein if the need arises
• Only non-essential amino acids may be produced from glucose (the essential AAs need
to be ingested/eaten)

Classification and Sources

1. Monosaccharides are single simple sugars.

Examples include:
• Glucose – found in table sugar and fruits
• Fructose – found in fruits and vegetables
• Galactose – found in milk

2. Disaccharides are formed when two monosaccharides are chemically bonded

together.
Examples include:
• Sucrose (glucose + fructose) is common table sugar, brown sugar, syrup and
molasses
 • Lactose (glucose + galactose), is the main sugar found in milk.
• Maltose (glucose + glucose) is found in cereals and beer.

 Polysaccharides are long chains of many monosaccharide units.

They are often referred to as “complex carbohydrates” in contrast to the simple sugars (the
mono and disaccharides).
Most polysaccharides are of plant origin and are commonly known as starches and fibre.
The most abundant polysaccharide is cellulose, which the human body cannot digest and is
more commonly referred to as fibre.

Fibre
Fibre is defined as the non-digestible remnants of plant origin. Cellulose is the most abundant
form. The main benefit of fibre lies in its ability to absorb large amounts of water.

Types of fibre and their role in the body.

There are 2 types of fibre; soluble and insoluble fibres, which have different functions within
the body, but are both beneficial for your health.

Soluble Fibre(gel fibre)

 Includes pectins, gums and some hemicelluloses.
 Pectins are found in fruit and vegetables, while gums are found in oat bran, barley and
legumes, e.g. dried beans, peas and legumes.
 It slows down the movement of food through the stomach and therefore helps with blood
sugar control in diabetics.
 As part of a low-fat diet, soluble fibre also reduces the blood cholesterol levels and acts as
a stool softener.

Insoluble fibre (sponge fibre)

 Consists of cellulose and some hemicelluloses. It includes whole-wheat flour, bran,
vegetables and fruit with edible skins and seeds, e.g. Guavas.
 This type of fibre helps with the retention of water, which promotes more frequent bowel
movements and softer stools.
 Acts as a bulking agent and as Nature’s pot scourers – keeping you regular and preventing
digestive problems.

Benefits of the High Fibre Diet

 The water binding properties contribute weight, bulk, softness and ease of peristaltic
movements.
 Fibre can improve digestion by speeding up the passage of food through the digestive
system.
 Fibre enables more water to be absorbed in the gut resulting in a softer, but formed
stool. This aids in the prevention of constipation, haemorrhoids and bloating.
  Slightly reduces “bad” Low Density Lipoproteins (LDL) cholesterol & is linked to a lower
rate of heart disease
 Soluble fibre in particular appears to improve both blood sugar and insulin sensitivity,
and high-fibre diets may even lower the need for insulin.
 By increasing the bulk of foods and creating a feeling of fullness, fibre may also help
you avoid overeating and becoming overweight.
 Fibre slows digestion and therefore lowers a food’s Glycemic load, which likely helps to
prevent Diabetes.

CLIENT ADVICE - General Guidelines to ensure adequate fibre intake:

 To reap the benefits of fibre, try to consume 20 to 35 grams a day

 Do not skip meals; rather eat 3 regular, balanced meals a day
 All refined products (e.g. white bread) should be replaced with unrefined products (e.g.
whole-wheat bread or brown bread)
 Try adding digestive bran to porridge, soup or stews. Start with 2 teaspoons a day and
gradually increase to amount to 2 tablespoons a day to the family meal
 Raw fruits and vegetables with the skin, should replace canned, peeled or cooked items
 Dried fruit may be eaten regularly in moderation
 Have a fruit as a snack
 Enjoy a healthy green, raw salad with lunch and supper
 Limit the amount of sugar, sweetened food items and fried foods eaten as they do not
contain any fibre
 Drink at least 8 glasses of water per day. Start by increasing the amount slowly
 Exercise should be part of your daily routine

 Some practical advice: If you currently eat only modest amounts of fibre, increase your
consumption slowly over several weeks and drink plenty of fluids with your meals. In this
way, you can allow your digestive tract time to adjust, and lessen gas and other types of
gastrointestinal distress that may occur. Drinking fluids is also important in order to avoid
constipation.Insoluble fibre absorbs fluid as it is digested, so you need to drink enough to
compensate and keep things moving.

UNDERSTANDING THE GI & GL

Glycemic INDEX

The glycemic index (GI) assigns a numeric score to a standard size (50 grams) of hundreds
of carbohydrate foods based on the rise in blood glucose that they cause. Items in the index
are compared to a reference food—either glucose itself or white bread—which has been set at
the arbitrary glycemic value of 100.
The Glycemic Index (GI) factor is simply a ranking of foods on a scale from 0-100 based on
their immediate actual effect on blood glucose levels. It is a physiological measure of how fast,
and to what extent, a carbohydrate food affects blood glucose levels. On the index, glucose is
taken as 100 since it causes the greatest and most rapid rise in blood glucose - all other foods
are rated in comparison to glucose.

Values near 100 are absorbed

“faster” and below 55 “slower”

Low Glycemic Index:

less than 55

Intermediate Glycemic Index:

between 55 -70

High Glycemic Index:

more than 70

Glycemic LOAD

A new concept, called the Glycaemic load (GL), “fine tunes” the Glycaemic Index (GI)
concept. In practical application, the GI tells only part of the story, by indicating how rapidly a
particular carbohydrate raises blood sugar. What it doesn’t tell you is how much carbohydrate
is in a serving of a particular food. To understand a food’s effect on blood sugar, you need
both things—which is where glycemic load comes in. Glycemic load is based on the amount of
carbohydrate in the serving and the food’s GI and therefore gives a more accurate picture of a
food’s real-life impact on blood sugar level. This is often a more useful term because it
describes both the amount of carbohydrate in a serving of food and how fast that amount will
raise your blood sugar level. The glycemic load is simply the food’s Glycemic index times the
amount of carbohydrate in a serving.

GL= CHO content per portion x GI

100

Low Glycemic Load: Less than 10

Intermediate Glycemic Load: Between 10-20
High Glycemic Load: More than 20

For example, a big slice of white bread will spike the blood sugar more than a little slice of the
same white bread. The glycemic index is the same for both pieces, but the glycemic load is
higher for the large piece. For menu-planning purposes, the glycemic load is more meaningful
than the glycemic index because it’s based on the portion size of a particular food eaten.
It is thus a measure that incorporates both the quantity and quality of the dietary carbohydrates
consumed. Some fruits and vegetables, for example, have higher GI values and might be
perceived as “bad”. Considering the quantity of carbohydrate per portion, however, the GL is
low. This means that their effect on blood glucose levels would be minimal. For example:

To calculate: 1 cup watermelon has 10g of carbs

GL= grams of carbs as a % x GI (Glycemic Index)
GL = 10g x 72/100 = 7.2 (GI = 72 - high)
GL = 7 – low

“Good carbs, bad carbs”: Factors which influence Glycemic Index

The high-carbohydrate foods that are good for you can help protect against health problems in
part because they have a relatively low glycemic load. They’re digested slowly, which means
they cause a gradual rise in blood sugar. How can you tell the difference?
You can gauge whether a carbohydrate is good or bad based on these characteristics:

How heavily processed is the food?

Some scientists think that the glycemic load of the average western diet has increased
because people are eating greater amounts of prepared foods that contain heavily processed
carbohydrates. One factor influencing glycemic load is its degree of refinement of that
particular grain. In general, the smaller the pieces, the faster they’re digested. This is one
reason finely ground white wheat flour is digested faster than coarsely ground (sometimes
called “stone-ground”) wheat flour. It’s the same with whole oats compared with instant or
“quick” oatmeal.

Processing also removes the fibrous casing from grains. This casing is good for you because it
slows digestion and contains a host of nutrients that may lower the risk of some diseases.
Studies show that whole-grain foods such as brown rice and barley, which have their fibrous
casing intact, are healthier than the more heavily processed refined grains. In results from two
large on-going studies, the Nurses’ Health Study and the Health Professionals Follow-up
Study, people who ate the most whole grains (four slices of whole-wheat bread daily) were
less likely to develop type 2 diabetes, heart disease, and several types of cancer (including
cancer of the mouth, stomach, colon, gallbladder, and ovary) than other people.

Is it really whole grain?

Not all foods in the grocery store that claim to be “whole grain” really are. “Whole-wheat” bread
may include a lot of refined white flour. Look for labels that say “100% whole wheat” (or oats or
rye or another grain). Read the ingredients list to make sure that the first ingredient is a whole
grain. Some whole-grain foods can be easily spotted by their colour. Brown rice is a whole
grain (it’s brown because its casing is intact), but white rice isn’t. But colour isn’t always a good
indicator because some whole-grain products don’t look the part. As you’ll notice in restaurants
advertising “whole-wheat pizza crust” and on grocery store shelves, some whole-grain breads
and other items are now white. To make whole-grain bread white, manufacturers use an albino
variety of whole-wheat flour that’s lower in gluten and softer in texture. Because the flour isn’t
refined, it’s technically a whole grain. However, it’s so new to the market that its glycemic index
is still unknown.

How much fibre is in the food?

Fibre is the indigestible part of grains, vegetables, and fruits. Its delays the time it takes for the
food to be digested. Whole-grain foods have more fibre than refined foods.

How much fat is in a meal or snack?

You’ll reduce the spike in blood sugar from carbohydrates by combining the food with protein
or fats. Because fats take longer to digest than carbohydrates, the more fat a meal or snack
has, the more slowly it will be digested and, possibly, the less detrimental an effect it will have
on your blood sugar. Just make sure that the fat or protein is a healthy one. A handful of
cashews or other nuts is a better snack than a biscuit made with butter or trans fats.

CLIENT ADVICE - Principles of low-glycemic eating

 Eat a lot of non-starchy vegetables, beans and fruits such as apples, pears, peaches, and
berries. Even tropical fruits like bananas, mangoes, and papayas tend to have a lower
glycemic index than typical desserts.
 Eat grains in the least-processed state possible such as whole-kernel bread, brown rice,
and whole barley, millet, and wheat berries; or traditionally processed grains, such as
stone-ground bread, steel-cut oats, and natural granola or muesli breakfast cereals.
 Limit white potatoes and refined grain products such as white breads and white pasta to
small side dishes.
 Limit concentrated sweets—including high-calorie foods with a low glycemic index, such as
ice cream—to occasional treats. Reduce fruit juice to no more than one-half cup a day.
 Completely eliminate sugar-sweetened drinks.
 Eat a healthful type of protein, such as beans, fish, or skinless chicken, at most meals.
 Choose foods with healthful fats, such as olive oil, nuts (almonds, walnuts, pecans), and
avocados, but stick to moderate amounts. Limit saturated fats from dairy and other animal
products.
 Have three meals and one or two snacks each day, and don’t skip breakfast.
 Eat slowly and stop when full

Hypoglycaemia

Hypoglycaemia occurs when blood sugar levels fall below normal levels. The most common
form of hypoglycaemia occurs after a meal or snack is eaten. This is known as reactive
hypoglycaemia. High GI foods (except when eaten during or after exercise) result in a sharp
increase in blood glucose levels within a short period of time. The body responds by releasing
insulin to lower the blood glucose levels and counteract the effect. In those susceptible, the
insulin removes the glucose from the bloodstream too effectively, resulting in a rapid fall in blood
glucose levels and the onset of symptoms: tremors, heart palpitations, sweating, anxiety,
irritability, sleepiness, weakness, poor concentration and fatigue.

When your blood sugar is too low, you feel hungry; if it’s low soon after a meal, you’re inclined
to overeat and possibly gain weight. Another problem with a steady diet of high-glycemic
meals is that over many years, your body’s system of responding to insulin could become
impaired. This is called insulin resistance. When your cells are less responsive to insulin, the
resulting overload of sugar in your bloodstream forces the pancreas to produce more insulin in
an effort to move the sugar (glucose) from the blood into the cells. As this situation worsens,
blood sugar rises chronically to an abnormal level defined as type 2 diabetes. If the pancreas
is forced into overdrive for a sustained period, it may wear down and eventually lose some of
its ability to produce insulin, leading to insulin deficiency and worsening of type 2 diabetes.

To avoid hypoglycaemia:

• Eat regular meals and snacks, preferably every 3 to 4 hours.

• Include low GI foods at every meal or snack to keep blood glucose levels steady.
• Avoid eating high GI foods on their own unless during or after exercise.
• Preferably avoid eating high GI foods but if you have to eat a high GI carbohydrates, then
combine it with a low GI carbohydrate or some protein. This will lower the overall GI of the
meal.

PROTEIN & AMINO ACIDS

How much protein do you need?

That question has been the subject of debate for decades, and the range set by the DRIs is
wide: 10% to 35% of your daily calories can come from protein. For most men and women,
protein provides about 15% of their total daily calories.

What kind of protein is best? When it comes to foods that prevent or promote disease, experts
know less about dietary protein than they do about fats and carbohydrates. Still, large, ongoing
studies have revealed some connections between the type of protein people eat and their risk
for particular illnesses.

Evidence suggests that substituting vegetable protein for animal protein may lower the risk for
heart disease. Shifting to protein-rich foods other than red meat could play an important role in
lowering the risk of heart disease. Processed meats may be the real culprit.
There are plenty of reasons to favour plant protein such as protein-rich vegetables and beans
over red and processed meats. These plant proteins come in healthier packages than meat
protein. And not only are these plant-based foods a good source of healthy polyunsaturated
and monounsaturated fat, they also provide fibre as well as vitamins and minerals.

The greatest benefit in choosing proteins from foods like fish, skinless chicken, beans, soy,
nuts, and whole grains is because they’re relatively low in saturated fat. Fish and chicken are
good options but should still be considered accessories to your diet, filling just one quarter of
your plate, while filling the remaining three quarters with whole grains, vegetables, beans, and
other produce. If you eat red meat, make it only an occasional part of your diet and stick to
small portions and choose lean cuts. Also, avoid processed meats, such as ham, bacon,
pastrami, salami, sausage, bratwurst, hotdogs, and pepperoni.

Essential Functions of Proteins

 Structural proteins for cartilage, muscles, tendons, ligaments, organs, bones, hair, skin
and all other tissues; provide building blocks to build new cells and repair old ones
 Producing Anti bodies or immunological substances
 Enzymes which catalyze body processes , aid in the digestion and absorption of food
 A source of fuel when muscle glycogen is low
 Hormones which regulate body processes
 Contractile proteins which make up the skeletal muscles
 Blood proteins which make up hemoglobin and albumin

Ideally, the body needs a daily supply of amino acids to make new proteins. This supply comes
from the protein in food. A lack of protein in the diet can slow growth, reduce muscle mass, lower
immunity, weaken the heart and respiratory system, and even cause death.
Burning protein as an energy source is wasteful but protein is used as an energy source if
inadequate amounts of carbohydrate are consumed. At risk are: endurance athletes and others
doing intense exercise whose carbohydrates needs are high, dieters on strict diets and body
builders who consume protein at the expense of carbohydrate under the mistaken belief that the
extra protein will result in muscle gain.

Classification and Structure

Proteins are complex molecules made up of smaller sub-units called amino acids.
About 20 amino acids supply the raw material for the body’s proteins. Following genetic
instructions, the body strings these amino acids together into chains to make the specific
proteins it needs. If those amino acids aren’t available, your body scavenges protein from its
tissues to get them.

From a functional classification:

 Amino acids that are synthesised in the human body in adequate amounts are termed non-
essential.

 Those that cannot be synthesised at all in the body, or that are synthesised in inadequate
amounts, are termed essential because they must be supplied by food sources.

 Of more than 20 amino acids that have been identified, 9 are considered essential. (8 in
adults)
 Nine Essential Amino Acids Non-Essential Amino Acids
Histidine (BCAA *) - babies Alanine
Isoleucine (BCAA*) Arginine
Luecine (BCAA*) Aspartic Acid
Lysine Cystine
Methionine Glutamic Acid
Phenylalanine Glutamine
Theronine Glycine
Tryptophan Proline
Valine Serine
Tyrosine

* BCAA= Branched Chain Amino Acids

Protein Requirements:

The body’s needs for essential amino acids and Nitrogen require dietary protein of optimal
quality and adequate quantity. The RDA for sedentary people is 0.8g/kg. Active people have
higher protein requirements than this.

Keeping in mind that 100g (regular chicken breast) of protein-rich food contains ± 30g of protein,
thus it becomes obvious that one’s protein needs can easily be met by 150-300gm of protein
foods daily (plant and animal proteins).

Additionally, cereals, fruit and vegetables, and milk products also contain protein, so in actual
fact the average adult male only needs 180-210gm of protein food per day. The dairy products,
cereals, fruit and vegetables that he consumes per day will supply the rest of the protein. Equally
females only require 120-180gm protein foods per day.

Vegetarianism

Types of Vegetarians:
 Vegans (NO animal products) Food of plant origin only
 Lacto vegetarians (lacto = milk). Plant-based diet with milk
 Ovo-vegetarians (ovo = eggs) Plant-based diet with eggs, no dairy
 Lacto-ovo-vegetarians (eggs + milk) Plant-based diet with eggs, no dairy
 Pesco vegetarians (Pesco = fish) Lacto-ovo vegetarian diet with the addition of fish.
Excludes chicken and red meat.
 Polo vegetarians (polo = eat chicken) Lacto-ovo vegetarian diet with the addition of
chicken. Excludes fish and red meat.
Food combining rules for VEGTARIANS
The “food combining rules” try and ensure that all amino acids are consumed adequately.
Good ideas for putting together an AA balanced meal include mixing…

 Legumes (beans, split peas or lentils) or peanuts & grain products.

 Samp & beans
 Rice & Beans
 Peanut Butter & brown bread

 Legumes or peanuts with seeds and nuts.

 Hummus (chickpeas and sesame seeds)

 Grain products and dairy products.

 Macaroni & cheese
 Whole grain cereal & milk
 Cheese & crackers

 Nuts and seeds with dairy products

 Yoghurt with sunflower & pumpkin seeds

Animal foods are good sources of many important vitamins and minerals, thus nutrients most
likely to be lacking in strict vegetarian diets include: Iron, Calcium and Riboflavin, Zinc, and
Vitamin B12.

A well-balanced vegetarian diet can provide the body with essential amino acids and adequate
amounts of vitamins and minerals needed for good health provided there is a large enough range
of grains and vegetables eaten and in the correct combination.

FATS & LIPIDS

The DRI for fat gives considerable leeway: 20% to 35% of your daily calories can come from
fat. This means you can get up to 35% of your calories from fat and still have a diet that’s good
for your heart, helps reduce your risk of hypertension, and lets you maintain your weight or
even lose weight. Even more may be fine, so long as it’s mostly healthy fats from fish and
plant sources .It is the type of fat you eat, not the total amount that counts. The body needs
fat. It’s a major energy source and also helps you absorb certain vitamins and nutrients.

Fat is a critically important macronutrient as it is a concentrated form of energy with 1g of fat

supplying more than double the amount of energy than glucose (9kCal vs 4kcal/ gram).
Functions of Dietary fat

 Responsible for satisfied feeling after eating (Satiety)

 Reduced rate of Gastric emptying i.e. leaves the stomach more slowly than
carbohydrates or proteins
 Primary function of lipids is to provide a concentrated source of energy
 Transport of fat soluble vitamins (A,D,E,K)
 Insulation & cushioning of organs
 Forms part of membranes
 Insulation of nerve cells – myelin sheath
 Maintenance of menstrual cycle or oestrogen which is essential in activating osteoblasts

Classification and structure

• Basic structural unit is the fatty acid molecule

• Fatty acids are either saturated or unsaturated

 Saturated fats are those in which all chemical bonding sites are filled
 Unsaturated fats have some unfilled bonding sites

• Can have 1,2 or more bonding sites – mono-unsaturated and poly-unsaturated fats

Unsaturated fats are liquid or

soft at room temperature (oil
and tub margarine)
 Veggie fats are high in
unsaturated fat

Saturated fats are solid at room

temp (lard, butter)
 Animal products are high in
saturated fat

What’s the difference between a good fat and a bad fat?

All fats have a similar chemical structure: a chain of carbon atoms bonded to hydrogen
atoms. What differs is the length and shape of their carbon chains and the number of
hydrogen atoms connected to the carbon atoms.
Seemingly slight differences in structure translate into crucial differences in the body.
“Bad fat”
The two forms of unhealthy fat; trans-fats and saturated fats, share a physical trait: they’re
solid at room temperature. Think of butter, margarine, shortening, or the marbled fat in a
steak. Bad fats are found in some liquids too, including whole milk and cream. These fats drive
up your total cholesterol, tipping the balance toward LDL cholesterol, the destructive type that
prompts blockages to form in the coronary arteries.

Saturated fat
The word “saturated” here refers to the number of hydrogen atoms in this type of fat. In
saturated fat, the chain of carbon atoms holds as many hydrogen atoms as possible, making it
literally saturated with hydrogen atoms. Each carbon atom in the chain is connected to the
next by a single bond, leaving the maximum number of bonding points available to hold
hydrogen. By contrast, in unsaturated fats, the carbon atoms have fewer than the maximum
number of hydrogens. If you are trying to reduce saturated fat, your best choice is to replace it
with polyunsaturated oils, like canola oil. In regards to cholesterol, a diet high in saturated fats
boosts total cholesterol by elevating harmful LDL.

Trans- fats (partially hydrogenated oils).

Trans- fats are rapidly fading from the scene, thanks to the government requirement that they
be listed on food labels. Trans- fats were created in the laboratory to provide cheap
alternatives to butter. Food chemists learned how to solidify vegetable oil by heating it in the
presence of hydrogen and a heavy-metal catalyst such as palladium. The process, called
hydrogenation, gives the carbon atoms more hydrogen atoms to hold, making polyunsaturated
fat (a good fat) more like saturated fat in structure. That’s how solid vegetable fats such as
shortening and margarine came into being. On food label ingredient lists, this manufactured
substance is typically listed as “partially hydrogenated oil.” Trans- fats are even worse for you
than saturated fats. Not only do they increase your LDL cholesterol, but they also reduce your
beneficial HDL cholesterol.

“Good fat”
Good fats come mainly from vegetable, nut, and fish products. They differ from bad fats by
having fewer hydrogen atoms bonded to their carbon chains. They are liquid, not solid, at room
temperature. There are two broad categories of beneficial fats: polyunsaturated
and monounsaturated.

Polyunsaturated fats
When you pour liquid cooking oil into a pan, there’s a good chance you’re using
polyunsaturated fat. Corn oil, sunflower oil, and safflower oil are common examples. (The
exceptions are sunflower and safflower oils labelled “high-oleic,” which come from crops
intentionally bred to produce mostly monounsaturated fats.) Polyunsaturated fats are essential
fats. That means they’re required for normal body functions, but your body can’t manufactured
them and so you must get them from food. Polyunsaturated fats help build cell membranes,
the exterior casing of each cell, and the sheaths surrounding nerves. They are vital for blood
clotting, muscle movement, and inflammation. They reduce LDL more than other types of fats,
improving your cholesterol profile .Even better, they also lower triglycerides. A polyunsaturated
fat has two or more double bonds in its carbon chain. There are two types of polyunsaturated
fats: omega-3 (n-3) fatty acids and omega-6 (n-6) fatty acids. (The numbers refer to the
distance between the end of a carbon chain and the first double bond) Both types offer health
benefits.

Research has shown that omega-3s in dietary fish and fish oil supplements help prevent and
even treat heart disease and stroke. The reasons are several: these fats help reduce blood
pressure, raise HDL and lower triglycerides. Evidence also suggests they may help reduce the
need for corticosteroid medication in people with rheumatoid arthritis.

Omega-3s come mainly from fish, but you can also find them in flaxseeds, walnuts, canola oil
and un-hydrogenated soybean oil. Fatty fish such as salmon, mackerel, and sardines are
especially good sources of omega-3s.Omega-6 fatty acids are even more protective against
heart disease. High levels of linoleic acid, an omega-6, can be found in vegetable oils such as;
safflower, soybean, sunflower, walnut, and corn oils.

Monounsaturated fats
When you dip your bread in olive oil at an Italian restaurant you’re getting mostly
monounsaturated fat. Unlike a polyunsaturated fat, which has two or more double bonds of
carbon atoms, a monounsaturated fat has just one. The result is that it has more hydrogen
atoms than a polyunsaturated fat, but fewer than a saturated fat. Good sources of
monounsaturated fats are olive oil, peanut oil, canola oil, avocados, and most nuts, as well as
high-oleic safflower and sunflower oils.

FLUID
Functions of Water
Water occupies essentially every space within and between body cells and is involved in
virtually every body function. Some of the functions of water include:

1. Provides shape and structure to cells. Approximately two thirds of the body’s water is
located within cells (intracellular fluid). Muscle cells have a higher concentration of
water (73%) than fat, which is only about 25% water. Men generally have a higher body
muscle percentage than women and therefore a higher body water percentage.

2. Regulates Body Temperature. Because water absorbs heat slowly, the large amount
of water contained in the body helps maintain body temperature homeostasis, despite
fluctuations in environmental temperatures. Evaporation of water (sweat) from the skin
cools the body.

3. Aids in absorption of nutrients. Approximately 7 to 9 litres of water is secreted in the

gastrointestinal tract daily to aid in digestion and absorption. Except for approximately
100ml of water excreted through the faeces, all of the water contained in the
 gastrointestinal secretions (saliva, gastric secretion, bile, pancreatic secretions and
intestinal mucosal secretions) is reabsorbed in the ileum and colon.

4. Transports nutrients and oxygen to cells. By moistening the air sacs in the lungs,
water allows oxygen to dissolve and move into the blood for distribution throughout the
body. Approximately 92% of blood plasma is water.

5. Serves as a solvent for vitamins, minerals, glucose and amino acids. The solvating
property of water is vital for health and survival.

6. Participates in chemical reactions. For instance, water is used in the synthesis of

hormones and enzymes.

7. Eliminates waste products. Water helps excrete body wastes through urine, faeces
and expirations.

8. Is a major component of mucus and other lubricating fluids. As such, it reduces

friction in joints, where bones, ligaments and tendons come into contact with each
other.

Water Requirement
Water is an essential nutrient because the body cannot produce as much water as it needs on
a daily basis. To maintain water balance, intake should be approximately the same as output.
On average, adults lose approximately 1450-2800ml of water daily. Water is lost through the
skin and expirations (skin loss) accounts for approximately half of the total water lost daily.
Water is also lost from urine and faeces to make up the remaining water loss.

Source of water loss Average amount Lost (ml/d)

Perspiration 450-900
Exhalations 350
Urine 500-1400
Faeces 150
Total 1450-2800

Another way to calculate water requirements is to allow 1- 1.5ml of water per calorie
consumed:
 For instance, someone consuming 2000 calories daily needs 2000-3000ml fluid.

Actual requirements can be highly variable. Factors affecting water requirements include
extreme environmental temperatures (very hot or very cold), high altitude, low humidity,
and strenuous exercise increase losses. Water evaporation from the skin is also increased
by prolonged exposure to heated or recirculated air, such as during long airplane flights.
Vomiting and diarrhoea and fever increase water losses. Water requirements increase
during pregnancy and lactation. People who eat a high- fibre diet need to consume more
water because fibre works by absorbing water into the gastrointestinal tract.
Amongst healthy adults, thirst is usually a reliable indicator of when water needed. However,
thirst is blunted in the elderly, in children and during hot weather and strenuous exercise.
For these people and conditions, drinking fluids should not be delayed until the sensation of
thirst occurs because then the fluid loss is significant. Because the body cannot store water, it
should be consumed throughout the day.

CLIENT ADVICE - Tips to encourage adequate fluid intake:

 Drink before you become thirsty

 Choose liquids with appealing taste
 Keep a water bottle at your desk
 Make water part of your meals
 Drink a glass of water before each meal, especially if weight control is a concern
 Buy bottled sparkling water in place of carbonated beverages
 Pack bottled water in your lunch
 Drink sufficient low fat or fat-free milk
 Try sparkling water with a wedge of lemon/ lime, cut strawberries or fresh mint for a little
variety
 Eat enough fruit and vegetables
 Drink extra fluids before, during or after exercise, especially in hot weather
 Try use herbal tea, decaffeinated tea or decaffeinated coffee in place of some or all
caffeinated beverages
 ESSENTIALS OF NUTRITION
CHAPTER 4: MICRONUTRIENTS
 MICRONUTRIENTS
NUTRITION
MICRONUTRIENTS
Micronutrients are nutrients required in relatively small amounts by the body. These nutrients
are essential for optimal health and functioning of the body. They enable the body to produce
enzymes, hormones and other substances essential for growth and development. Deficiencies
can have severe health consequences.

Micronutrients are divided in to two groups – Vitamins & Minerals

VITAMINS
There are two categories of vitamins – water soluble and fat soluble vitamins.

Water Soluble Vitamins Fat Soluble Vitamins

Vitamin C ,B1, B2, B3, B5, B6, B12, folic

Vitamin A, E, D, E, K
acid, biotin

Are absorbed with fat in chylomicrons which

Are absorbed directly into the bloodstream
enters the lymphatic system before circulating
in the bloodstream

Move freely through the watery environment of Attach to protein carriers to be transported in
blood with cells the bloodstream

Are excreted in urine when consumed in excess Are stored, not excreted when consumed in
amounts excess of need. The liver and adipose tissue
are the primary storage sites

Are generally nontoxic because the body can

Can be toxic when consumed in large doses
protect itself from large doses by increasing
over a prolonged period of time
excretion

Must be consumed daily as there is no reserve Do not have to be eaten every day because the
in storage body can retrieve them from stores as needed

Are found in the watery portion of foods Are found in the fat and oil portion of foods

SA NRV’s = The South African National Reference Intake (also referred to as Recommended
dietary allowance) for individuals 4yrs and older. * = SA NRV not established

Please note that the NRV levels for vitamins and minerals are the amounts required to
prevent a deficiency state in a healthy population. The NRV’s do not take into account
individual biochemical requirements and do not cover ill or stressed individual’s requirements.
Fat soluble Vitamins
SA NRV’s Functions Best food sources
Vitamin A Essential role in good vision, growth and development, Liver, margarine, butter,
900υg RE /
the development and maintenance of body, immune cheese, egg yolk and full
2970IU
functions and reproduction. cream milk.
Deficiency signs: poor night vision, dry skin,
OR
increased risk of infections.

Beta carotene Converts into vitamin A in the body thus has the same Carrots, sweet potatoes,
6000υgRE/
functions as pre-formed vitamin A as well as an pumpkins, spinach,
19980IU
antioxidant function. broccoli, endive,
Deficiency signs: as for vitamin A asparagus, apricots,
spanspek, pawpaw,
mangoes, nectarines and
peaches.

Vitamin D Essential for normal growth and development. Fish liver oil, fatty fish
15υg/ 600IU
Important role in maintaining the calcium/ phosphorus such as; kippers,
balance in the soft body tissue and bones. mackerel, salmon,
Deficiency signs: softening of the bones sardines and tuna, eggs
(osteomalacia), rickets in children, bone pain, and full cream milk.
muscular weakness, brittle bones.

Vitamin E The most important fat soluble antioxidant nutrient. Wheat germ oil, soya
15mg/ 22IU
Protects the body's tissues against damaging bodies bean oil, maize oil,
(known as free radicals). Also has a role in hormone safflower oil, sunflower oil
production. and peanut oil.
Deficiency signs are rare: haemolyticanaemia,
tiredness, irritability, reduced libido, muscle weakness.
Vitamin E deficiency may be associated with increased
risk of rheumatoid arthritis, pre-eclampsia
Water Soluble Vitamins
SA NRV’s Functions Best food sources
Thiamine(B1) Essential for growth, normal appetite and Food of plant and animal
1.2mg
digestion. Plays an essential role in carbohydrate origin including:
metabolism and nervous system function. Dried brewer’s yeast, yeast
Deficiency signs: easily fatigued, muscle extract and brown rice.
weakness, loss of appetite, irritability, depression,
poor concentration, tingling of hands and feet.
Riboflavin (B2) Essential for growth, the breakdown of Food of plant and animal
1.3mg
carbohydrates, proteins and fats in the body. Also origin including: Yeast
supports antioxidant functions. extract, dried brewer’s
Deficiency signs: blood shot eyes, sensitivity to yeast, liver, wheat germ,
light, cataracts, sickle cell anaemia, cracks and cheese and eggs.
sores around the mouth and nose, hair loss.
Niacin (B3) Important for the breakdown of carbohydrates and Food of plant and animal
16mg
proteins in the body. origin including: Yeast
Deficiency signs: Pellagra (rare) extract, dried brewer’s
Symptoms include: loss of appetite, skin rash, yeast, wheat bran, nuts,
diarrhoea, swollen tongue diarrhoea, mental liver, chicken and red meat.
changes, and digestive and emotional
disturbance.
Calcium-D- Essential roles in the breakdown of fats, proteins Food of plant and animal
Pantothenate
and carbohydrates in the body. origin including: nuts, wheat
5mg
Deficiency signs are rare: loss of appetite, bran, wheat germ, soya flour
indigestion, fatigue and headaches. and eggs.
Vitamin B6 Performs a wide variety of functions in the body Food of plant and animal
1,7mg
and is extremely versatile, involved in more than origin including: chickpeas,
100 enzyme reactions, mostly concerned with liver, fatty fish, poultry,
protein metabolism potatoes and bananas.
Isolated vitamin B6 deficiency is uncommon;
inadequate vitamin B6 status is usually associated
with low concentrations of B12 and folic acid
Water Soluble Vitamins
Functions Best food sources
Cyanocobalam Essential role for normal function of all cells Food animal origin including:
in (B12)
especially those of the gut, bone marrow and liver, kidney, fish, red meat,
2,4 υg
nervous system. pork, eggs and cheese.
Deficiency signs: numbness, fatigue, anaemia,
muscle weakness, if prolonged - nerve
deterioration.

Folic acid Essential for red blood cells development to Dried brewer’s yeast, Soya
400υg
prevent anaemia. flour, wheat germ, wheat
Important in early foetal development. bran, nuts, liver and green
Important to prevent elevated levels of leafy vegetables.
homocysteine.
Deficiency signs: Elevated levels of
homocysteine - an indicator for heart disease,
neural tube defects in foetus, weakness, fatigue
and anaemia.

Biotin Essential part of enzymes. Involved in the Cherries blackcurrants,

30υg
breakdown of fats and proteins in the body. guavas, horseradish,
Deficiency signs: skin inflammation, hair loss, broccoli, green peppers and
anaemia, nausea and tiredness. citrus fruits.

Vitamin C Has many functions including: a protective Kiwi fruit, cherries,

100mg
antioxidant, in immune system, wound healing, blackcurrants, guavas,
formation of collagen (the major protein involved horseradish, broccoli, green
in tissue and bone formation) and increases peppers and citrus fruits.
absorption of iron.
Deficiency signs: tiredness, easy bruising,
scurvy, bleeding gums, loosening of teeth, poor
wound healing.
MINERALS
Although minerals only account for approximately 4% of the body’s total weight, they are
found in all body fluids and tissues.

Macrominerals

o Are present in the body in amounts greater than 5g and are needed in relatively
large quantities (›100mg/day)
o Calcium, magnesium, phosphorus, potassium, iron

Microminerals / trace elements

o Are present in the body in amounts less than 5g and are needed in relatively small
quantities (‹15mg/day)
o Copper, zinc, manganese, iodine, chromium iodine, molybdenum, selenium

General functions of Minerals

 Structure
Minerals provide structure to bones and teeth. Soft tissue gains structural support from
minerals and they are a fundamental constituent of skin, hair and nails.

 Fluid balance
The volume of water in the body and how it is distributed among body compartments are
determined largely by concentrations of mineral solutes in solutions.

 Acid-base balance
The term refers to the maintenance of the body’s concentrations of hydrogen ions. Minerals
are also involved in regulating pH functioning as a buffer system.

 Nerve cell transmission and muscle contraction

The exchange of minerals across nerve cell membranes causes transmission of nerve
impulses. Calcium stimulates muscles to contract and sodium, potassium and magnesium
are involved in muscle relaxation.

 Vitamin, enzyme and hormone activity

Minerals help to regulate body processes through their role in the activation of vitamins,
enzymes and hormones.
Macromineral Chart
Minerals Functions Best food sources
Calcium Essential for bone health development. Helps Hard cheeses, soft
1300mg
prevent osteoporosis developing later in life cheeses, canned fish,
Also involved in cell functions, nerve and muscle nuts, beans, cow’s milk,
function. eggs and cereals.
Deficiency signs: Rickets in children,
Osteomalacia in adults, poor muscle tone, bone
pain, muscle weakness, delayed healing of
fractures, osteoporosis developed later in life.

Phosphorus Provides phosphates in the body. Needed as part Yeast extract, dried
1250mg
of bones and teeth, as well as many other body brewer’s yeast, dried skim
functions. milk, wheat germ, soya
Deficiency signs: Virtually unknown, except in flour, hard cheeses,
some disease states. canned fish, nuts, cereals,
Weakness, bone pain, joint stiffness, general eggs, red meat, poultry
tiredness, Osteomalacia, tremors, mental and fish.
confusion.
Magnesium Important for many body functions such as energy Soya beans, nuts, dried
420mg
production, cell formation and nerve transmission brewer’s yeast, brown rice,
Deficiency signs: Rare. Sometimes seen in whole wheat flour, peas,
diabetics. seafood and dried fruit.
Symptoms include muscle weakness, tiredness,
irritability, convulsions, muscle cramps and
tremors, irregular heart beat, low blood sugar.

Iron Carries oxygen in red blood cells. Important for Dried brewers yeast,
18mg
good immune function. wheat bran, liver, kidney,
Deficiency signs: Tiredness, weakness, anaemia cocoa powder, Soya flour,
learning problems in children, headaches, dried fruit and sardines.
shortness of breath, reduced physical performance.
Micromineral / Trace element Chart
Minerals Functions Best food sources
Zinc Trace mineral involved in the many enzyme Oysters, liver, dried
11mg
functions. Important for all cells in the body. brewer’s yeast, shell fish,
Important for growth in children. red meat, hard cheeses,
Essential for wound healing and supports good canned fish and eggs.
immune function.
Deficiency signs: poor wound healing, white spots
on nails, increased susceptibility to infections, loss
of sense of taste and smell, impaired mental and
physical development, reduced fertility.
Iodine Trace mineral important for thyroid hormones, Dried kelp, salt, haddock,
150υg
which normalise the metabolism. herring, cottage cheese,
Deficiency signs: poor thyroid function, tiredness, shrimp, eggs and hard
weight gain, mood swings. cheeses.
Manganese Trace mineral needed for healthy skin, bone, and Cereals, whole wheat
2,3mg cartilage formation, as well as glucose tolerance. bread, nuts, fruit, liver,
Deficiency signs: not known, but low blood levels green leafy vegetables and
have been found. root vegetables.
Selenium Trace mineral needed in small amounts to help Organ meats, fish, shell
55υg protect the body's tissues against damage from fish, meat and cereals.
harmful bodies called (free radicals).
Supports thyroid function.
Important role in immune function.
Deficiency signs: muscle weakness.
A deficiency may increase the risk for rheumatoid
arthritis, heart disease.
Copper Trace mineral needed to absorb and use iron in the Liver, shell fish, dried
0,9mg body. brewer’s yeast, olives, nuts,
Needed to make enzymes in the body, cereals, red meat, pork fish
Needed to make the skin pigment melanin. and poultry.
Involved in the formation of body tissue.
Supports a healthy immune system.
 Deficiency signs: in adults: microcitic,
haemochromic anaemia, hair and skin de-
pigmentation, brittle bones, irritability. In children:
failure to thrive, pale skin, de-pigmentation of hair
and skin.
Molybdenum Important component of the enzymes involved in Food of plant and animal
45υg brain function. origin including: Buckwheat,
Deficiency signs: unknown in humans wheat germ, liver, Soya
beans, whole grain cereals
and organ meats.
Chromium Involved in insulin activity Food of plant and animal
35υg Influences carbohydrate, protein and fat origin including: Egg yolk,
metabolism. molasses, dried brewers
Deficiency signs: impaired glucose tolerance, yeast, beef, hard cheeses,
impaired growth. liver, fruit juices and
cereals.
Fluoride Essential protective effect on tooth enamel, to help Water
prevent teeth decay.
Deficiency signs: Teeth decay
 ESSENTIALS OF NUTRITION
CHAPTER 5: LIFE CYCLE NUTRITION
 LIFE CYCLE NUTRITION
NUTRITION

NUTRITION THROUGH THE LIFE CYCLE

HEALTHY EATING FOR INFANTS AND TODDLERS
Breastfeeding
“Breastfeeding is an unequalled way of providing ideal food for the healthy growth and
development of infants. It is also an integral part of the reproductive process with important
implications for the health of mothers. As a global public health recommendation, infants
should be exclusively breastfed for the first six months of life to achieve optimal growth,
development and health.” – WHO, 2002.

Some of the advantages of breastfeeding are:

• Breast milk is the best natural food for babies
• Breast milk is always clean
• Breast milk protects the baby from diseases as it contains antibodies passed from
mother to child via breast milk
• Breast milk can improve cognitive/brain function
• Breast milk is available 24 hours a day and requires no special preparation
• Breast milk is nature’s gift to the infant and does not need to be purchased
• Breastfeeding develops a special bonding relationship between mother and baby
• Breastfeeding helps parents to space their children, (since during breastfeeding a
woman does not usually menstruate), thereby improving family planning.

The process of lactation is nutritionally demanding and so a healthy diet is very important. The
recommended calorie increase is an extra 500kcal per day above the levels for non-pregnant
women. Maternal fat stores accumulated during pregnancy provide about 400 – 600 kJ per
day during the early months of lactation.

The more often the woman breast-feeds, the more milk her body will produce and the more
energy she will expend and the quicker she will lose the weight gained during pregnancy. But
be careful: lactation is not the time for highly restrictive weight-loss diets. Dieting during this
time can mean that mothers produce less milk.
Once lactation is well established, a moderate reduction in kj intake (to increase the rate of fat
utilisation) can usually be initiated without any detrimental effects. A healthy, sensible eating
and exercise programme should be your primary focus.
What to avoid during breastfeeding:
Many chemicals and substances pass from the mother into breast milk. Mothers should avoid
all medications and over-the-counter products, including herbs and diet pills, when they are
breastfeeding, unless medications have been specifically prescribed by the doctor. Mothers
should also avoid alcohol as this can pass into breast milk.

If their baby is colicky (i.e. has an immature digestive system), they may have to cut out all
spicy foods (pickles, curry etc.), and some vegetables which may lead to gas production.
These include the cabbage family, raw onions, garlic, cucumber, sweet peppers, and legumes
(dry cooked beans, peas and lentils).

Avoid caffeinated drinks and if coffee is consumed it should be limited to a maximum of 2

cups a day and choose the de-caffeinated variety. More than this might affect the baby’s
sleeping patterns as caffeine can be passed on to the baby in the breast milk.

Birth to 6 months
It is too early to introduce solids if the baby:
 Is less than 4-6 months old
 Cannot hold his/ her head up
 Is still satisfied by their milk feed (a milk feed should satisfy for 3-4 hours)

The early introduction of solids does not help a baby sleep through the night. Dropping the
night feed is more likely a developmental milestone and has little to do with feeding.
The introduction of solids is a phase of childhood nutrition which entails the transitions from
milk to soft foods, finger foods and finally to family foods.

Reducing the risk of allergy

There is an increased risk of allergies when solids are introduced too early, i.e. before 4-6
months. A baby’s immune system may react to proteins in foods other than breast milk. These
reactions may trigger allergic responses in the baby, which may present as eczema, diarrhoea
or vomiting. When one or both parent has a family history of allergy, there is a higher risk of
their baby developing an allergy. It is best to delay the introduction of solids to as close to 6
months as possible.
Solids should be introduced one food at a time. Current literature indicates that foods should
only be withheld in the case of a known allergy and that delaying the introduction of allergen
foods may in fact increase the risk of developing allergies as opposed to decreasing the risk as
was once thought.

Stage 1: 6 months
Introduce solids when the baby can
 Sit with support
 Has good head and neck control
 Can push up with his/her arms when placed on their stomach
At this stage the diet remains mainly milk. Milk will remain a major part of the babies’ diet for
the full first year. Milk however is no longer adequate to meet the baby’s energy needs and
iron stored are being depleted. Mothers should give the normal milk feed and then offer the
semi-solid food as the “top-up” to the milk diet.
At each feeding, small sized servings of 1-2 teaspoons should be offered, increasing slowly to
portions of 2-4 dessert spoons after the milk feeds. It is recommended that babies are
introduced to solids with vegetables or iron-fortified cereals at 6 months.

Stage 2: from 7 months - “Meal” first then milk

The baby is ready to move to the next stage when:
 Their sucking pattern has changed, so they are less likely to drool and spit out food.
 They show a desire for food by opening their mouth and leaning forward, and display
disinterest or fullness by leaning back and turning away.
 Hand-to-mouth co-ordination is good, so they able to grasp food and move it to their
mouth.

Mashed or chopped foods are suitable for “gumming” but with the appearance of the front
incisor teeth, babies are generally ready for soft “finger foods” – cooked vegetables and fruit
cut into small cubes, or pasta that can be picked up by small hands. Encourage chewing.
Introduce meat (poultry etc.) and meat substitutes (dried beans, lentils etc) finely ground and
one variety at a time – again waiting about a week between a new food.

Foods to avoid for fear of choking:

Round, hard foods such as nuts, sweets, grapes, popcorn, raw carrots, raw green pepper
chunks, hard cheese, sausages or hot dogs, may cause a child to choke and should be
avoided until the child is at least 2 years old.

Stage 3: From 9 months

At the beginning of stage 3, the confident eater:
 Can sit alone easily
 Self-feeds with hands and drinks from a lidded cup
 Has one or two teeth
 Begins to chew

It is important that from 6-12 months the baby receives approximately 750ml milk per day.
After one year he should continue to drink approximately 500ml of milk per day.

It is NOT necessary or recommended to give a child:

o Baby desserts
o Concentrated fruit juice
o Chips, biscuits or sweets
o Salt, stock cubes, seasonings, aromat
o Sugary foods / added sugar
NUTRITION FOR CHILDREN & ADOLESCENTS

The relationship that a child develops with food can have lifelong implications. Parents need to
remember that for children or adolescents, food is not purely a means of consuming nutrition
and acquiring energy. The relationship with food is a complex one. Food and eating provides
more than nutrition for growth and development. The development of feeding skills, food
habits, and nutrition parallels cognitive development through the different stages of childhood
and teen development.

Age Cognitive Characteristics Relationship to feeding and nutrition

 Form automatic reflexes to  Self-feeding skills emerge

Birth – 2
intentional interaction, and use of  Food is used to satisfy hunger,
years
symbols exploring and fine motor skills

 Eating is less important than social,

 Thought processes are
unsystematic and intuitive
2- 7 years  Use of symbols
 Reasoning based on appearance
 Child’s view is egocentric
language and cognitive growth
 Food is described by colour, shape
and quantity – not “groups”, also as
“like” and “don’t like”
 Foods can be described and “good
for you” but without logic reason

 Realise nutrition has positive effect

 Child can focus on several
aspects simultaneously
7-11 years  Reasoning becomes systematic
and rational
 Decreased egocentric view
on health and growth, but not on how
and why
 Meal times take on social
significance
 Opportunities for selection of food
increase (peer influence rises)

 Food functions at physiological level

are understood
 Conflicts in making food choices
(knowledge of nutritious food vs.
preferences)
 Hypothetical and abstract thought  Awareness of body shape and
expands opinion of body image increases.
11 years +
 Understanding of scientific  The influence of food intake or
processes deepens restriction can be a challenging one
for pre-teens to manage.
 Behaviour is largely governed by
peers and societal norms and
expectations and there is reduced
parental influence.
Some of the most important factors influencing food intake or children and teenagers include:

 Family environment – This is the primary influence that will determine food intake. Food
attitudes of parents will almost certainly determine the likes and dislikes of children later on
in life. The atmosphere around food and mealtimes will influence the child’s’ attitude
towards food. The positive environment that allows enough time to eat, is tolerant of
occasional spills, and encourages conversations that include all family members. A
mother’s relationship with food has a particularly powerful impact on her daughter’s own
relationship towards foods which develops from a young age.

 Media messages – Children can often not distinguish between commercial messages and
regular programmes. Almost ½ of all commercials are for food. Most of them that are
targeting children are high in fat, sugar or salt.

 Peer influence – The older a child gets, the more important peer influences become.
Parents need to set limits for undesirable influences, but also to be realistic.

 Illness or Disease – Sick children often require a different nutritional regime and often
some sort of rebellion is seen against the prescribed diet.

The most common nutritional problems seen in children school children (age 6 – 12 years):

 Mostly favourite foods are often offered to them resulting in reduced variety.
 There are limitations to options set by foods that travel well in lunch or snack packs.
 Children frequently skip meals and compensate with poor snack choices.
 There are readily available soft drinks and less nutritional foods offered at schools in the
tuck shop etc.
NUTRITION IN THE ADULT YEARS
Women’s Health Issues:

The term “women’s health issues” refers to the prevention, diagnosis and management of
health concerns that:
 Are unique to women such as menstruation, pregnancy and reproductive diseases
 Are more common in women than men
 Manifest differently in women than men

The most common women’s health issues include:

Heart Disease: After 50, women die of heart disease at the same rate as men but women
tend to have poorer outcomes to heart disease.

Cancer: Lung cancer, breast cancer and colorectal cancer are the leading cause of
cancer deaths in women.

Diabetes: Diabetes increases the risk of heart disease more in women than in men.
Obesity is implicated in the majority of cases of type 2 diabetes.

Osteoporosis: Between 30-35 years, peak bone mass is attained. Thereafter, bone mass
is gradually lost. During the first 5 years after menopause onset, women
experience rapid bone loss related to oestrogen deficiency. Because
prevention is better than treatment, efforts should focus on maximising
peak bone mass before 35 years of age. Emphasis on weight bearing
activity and sufficient calcium intake during teens and early adulthood is
essential.

Men’s Health Issues:

Men have shorter life spans than women, partly because men are greater risk takers. Rates of
accidental death and disability are greater amongst men, and such outcomes are associated
with both voluntary activities (e.g. driving) and involuntary activities (e.g. serving in the
military).

The most common men’s health issues include:

Heart Disease: Primary risk factors for heart disease amongst men include high blood
cholesterol, smoking, sedentary desk-based lifestyles, high blood
pressure and a high fat diet. Strokes are more common in men than in
women.

Cancer: After lung cancer, colon and prostate cancer are a frequent cause of
cancer deaths in men.
NUTRITION IN THE ELDERLY
Nutritional Implications of ageing: Predictable changes in physiology and function, income,
health and psychosocial well-being are associated with ageing, although the rate and timing
with which they occur varies amongst individuals.

Changes with a potential impact on diet and nutritional status include the following:

1. Changes in body compositions and Energy expenditure: Ageing is associated with a

loss of lean body mass and an increase in adipose tissue accounting for a reduction in
approximately 20% REE (Resting Energy Expenditure). With a loss of muscle comes a loss
of strength and decrease in aerobic capacity.

2. Oral and gastrointestinal Changes:

 Loss of teeth and jawbone deterioration may create difficulty in chewing
 Decrease in saliva (due to medication) may result in difficulty swallowing and altered taste.
 Constipation is five to six times more common in elderly
 Reduced production of digestive enzymes and digestive juices can result in decreased
nutrient absorption of elderly, increasing risk of nutrient deficiency

3. Central nervous system Changes: Tremors slow reaction time, short–term memory
deficits, personality changes and depression may impair the ability to eat or to purchase
and prepare food.

4. Sensory losses:
 Hearing loss often leads to reduced socialisation, thus reduces appetite and intake
 Vision changes may impair food purchasing and preparation
 Olfactory (smelling) impairments can result in taste changes and thus increased fat, sugar
or salt content of otherwise unpleasant or bland tasting foods

5. Economic Changes: Lack of income and insufficient pensions often result in an

inadequate diet, lacking variety and increasing risk of nutritional deficiency.

6. Reliance on prescription medication: Medication may affect nutritional status by altering

the appetite, ability to taste or smell, digestion, absorption, metabolism and excretion of
nutrients. Additionally, food intake can increase or decrease the effectiveness of some
drugs by altering the rate of absorption. Lastly, if a large percentage of fixed income is
spent on medication, less money is available for food.

7. Social Changes:
Social isolation may arise from death of a spouse or friends or from impaired mobility. Older
people often complain that they do not like to cook for only one person, or eat alone. Older
adults may lack interest in eating because of poor self-esteem related to a change in body-
image, lack or productivity or feelings of aimlessness. Additionally nutritional deficiency in
nursing homes is extremely common.
 ESSENTIALS OF NUTRITION
CHAPTER 6: BEHAVIOUR MODIFICATION
 BEHAVIOUR MODIFICATION
NUTRITION
BEHAVIOUR MODIFICATION
CLIENT CONSULTATION

The consultation with your ‘client’ will assist you in:

1. Building a rapport
It is important to remember that all the information gathered is confidential and discussion of
the client with other professionals is prohibited without prior permission of the client. The
information should be recorded and stored in a lockable filing cabinet.

2. Finding out about their lifestyle and providing insight into current health and fitness
levels

3. Identifying the client’s goals

 Goals need to be SMART:

 S pecific
 M easurable (to assess progress)
 A chievable
 R ealistic
 T ime framed (finite dates need to be attached to stated goals)

4. Identifying needs for medical clearance.

5. Assessing client’s readiness to change

The 5 Stages of Change include:

 Pre-contemplation: An individual is not intending to take action in the near future,

usually measured as the next six months.
 Contemplation: People are intending to change in the next six months. They are more
aware of the pros of changing but are also acutely aware of the cons.
 Preparation is the stage in which people are intending to take action in the immediate
future, usually measured as the next month.
 Action is the stage in which people have made specific overt modifications in their life-
styles within the past six months.
 Maintenance is the stage in which people are working to prevent relapse but they do
not apply change processes as frequently as do people in action do.
The Health Belief Model (HBM)
According to Rosenstock IM (1974), the basic components of the HBM are derived from
theories which hypothesise that behaviour depends mainly upon two variables:

1. The value placed by an individual on a particular goal

2. The individual’s estimate of the likelihood that a given action will achieve that goal.

Conceptualised in the context of health-related behaviour, the correspondences were:

1. The desire to avoid illness (or if ill, to get well)

2. The belief that a specific health action will prevent (or improve) illness

The Health Belief Model consists of the following dimensions:

Each component needs to be carefully considered and addressed in order to bring about
change. The benefits need to be sufficient and the barriers need to be overcome in order to
bring about change.

Perceived susceptibility
This dimension refers to one’s subjective perception of the risk of contracting a condition.
 An individual considers how sedentary behaviour may increase their risk of becoming
diabetic knowing that both parents have been diagnosed as diabetics.

Perceived severity
This dimension includes evaluations of both medical/clinical consequences (e.g. death,
disability, and pain) and possible social consequences (e.g. effects of the conditions on work,
family life, and social relations).
 The individual assesses the impact of a diagnosis of diabetes on his/ her lifestyle.

Perceived benefits
While acceptance of personal susceptibility to a condition that was believed to be serious was
held to produce a force leading to behaviour, it did not define the particular course of action
that was likely to be taken; this was hypothesised to depend upon beliefs regarding the
effectiveness of the various actions available in reducing the disease threat.
 The individual witnessed a parent losing 10 kg and improving glucose control by
improving their eating behaviours and exercising regularly.

Perceived barriers
The potential negative aspects of a particular health action may act as impediments to
undertaking the recommended behaviour. A kind of cost-benefit analysis is thought to occur
where the individual weighs the action’s effectiveness against perceptions that it may be
expensive, dangerous, unpleasant, inconvenient, time-consuming, and so forth.
Potential Barriers to living a healthier lifestyle may include money, time, family, motivation or a
lack of knowledge/ education.
 The parent of the individual had to pay for a monthly gym contract and discontinue
playing poker in order to find the time to incorporate physical activity into his lifestyle.
 ESSENTIALS OF NUTRITION
CHAPTER 7: HEALTHY EATING
 NUTRITION HEALTHY EATING
HEALTHY EATING
Not long ago, a healthy diet could be summed up in two simple concepts:
 Maintain a balanced diet of proteins, carbohydrates, and fats
 Get the recommended amounts of vitamins and minerals

The basic notions of a healthy diet remain the same, but science has expanded on them.
Everyone needs a mix of proteins, carbohydrates, and fats, plus enough vitamins and
minerals, but we now know that some of the choices within these categories are better than
others.

There are good fats, which promote health and bad fats, which increase ones risk of illness.
The same is true for carbohydrates and possibly for proteins. Regarding vitamins and
minerals, the latest thinking goes beyond diseases caused by deficiency and now includes a
knowledge of how these substances affect our health—from bone strength to birth defects,
and from heart health to hypertension.

General Healthy Eating Guidelines

An understanding of food groups is the building blocks of a healthy diet. Each group supplies
some of the nutrients your body needs. No one of these food groups is more important than
another, so for good health you need them all.

Protein
10% to 35% of daily calories should come from proteins
All foods made from meat, poultry, seafood, beans and peas, eggs, processed soy products,
nuts and seeds are considered part of the Protein Foods Group. Beans and peas are also part
of the Vegetable Group.
Tips for optimal healthy protein intake
o Choose lean or low-fat meat and poultry
o Where possible choose free-range eggs and chicken
 o Eat fish particularly that is rich in omega-3 fatty acids, such as salmon, trout,
sardines, anchovies, herring and mackerel at least 3 times a week
o Processed meats such as ham, sausage, frankfurters and luncheon or deli meats
that have added sodium and a high fat content should be limited
o Choose unsalted nuts and seeds to keep your sodium intake low
o Try to increase plant protein sources wherever possible e.g. combine beef mince
and lentils for bolognaise sauce

Carbohydrates
45% to 65% of daily calories (reduce consumption of added sugar)

Grains
Any food made from wheat, rice, oats, cornmeal, barley or another cereal grain is a grain
product. Bread, pasta, oatmeal, breakfast cereals, tortillas, and grits are examples of grain
products.
Grains are divided into 2 subgroups, Whole Grains and Refined Grains.
 Whole grains contain the entire grain kernel ― the bran, germ, and endosperm.
Examples include:
o whole-wheat flour
o bulgur (cracked wheat)
o oatmeal
o whole cornmeal
o brown rice

 Refined grains have been milled, a process that removes the bran and germ. This is done
to give grains a finer texture and improve their shelf life, but it also removes dietary fibre,
iron, and many B vitamins.
Examples include:
o white flour
o de-germed cornmeal
o white bread
o white rice

Fibre (indigestible carbohydrate): 14 grams per every 1,000 calories. That’s about 21 to 38
grams a day, based on age and gender.

Fats
Fat is a critically important macronutrient as it is a concentrated form of energy with 1g fat
supplying 2x amount of energy than glucose (9kCal vs 4kcal/ gram). Fats form part of all
membranes (lipoproteins), including skin, brain and nerve tissue and provide insulation.
Some benefits of consuming an adequate supply of healthy fats is that fats in the diet are
responsible for the satisfied feeling after eating (Satiety), they reduce the rate of gastric
emptying as they leave the stomach more slowly than carbohydrates or proteins contributing to
the sensation of satiety. Fats in the diet provide a concentrated source of energy and are the
transport and storage site of fat soluble vitamins (A,D,E,K).
There are many different types of fats, some of which are more beneficial to the body than
others.

Saturated fat can result in increased levels of LDL (low density lipoptotein) known as “bad
cholesterol. Sources include fatty beef, mutton, lamb, duck all with fat, processed meats,
chicken and turkey skin, full cream milk, yoghurt cheese, butter, cream, ghee, chocolates,
take-aways. These foods should be consumed rarely and in moderation.
Trans fat (TF), a source of “bad fat” can result in increased levels in total cholesterol as well as
increased LDL. Common sources of trans-fats may include biscuits, pies, pastries, cakes,
crisps, samoosas, sausage rolls, pretzels, hard brick margarines, deep fried and battered food.

On the other hand monounsaturated fats (MUF) can contribute to reduced insulin resistance,
reduced triglycerides and reduced LDL. Good sources of MUF include olive oil, peanut oil,
olive oil margarine, olives, avocado, peanuts, peanut butter, almonds, cashew nuts and pecan
nuts. Good Polyunsaturated fats (PUF) are comprised of omega 3 and omega 6 fatty acids.
Beneficial Omega 3 fatty acids (alpha-linolenic acid) found naturally in dark oily fish (salmon,
mackerel, pilchards, herring, sardines), oils, (flaxseed/ linseed, canola, wheat germ, soybean)
and their nuts and seeds. Omega 6 (linoleic acid) fatty acids are found in soft-tub margarines,
low fat spreads, mayonnaise, salad dressing, oils (sunflower, sesame, safflower, corn) and
their nuts and seeds.

Dairy
All fluid milk products and many foods made from milk are considered part of this food group.
Foods made from milk that retain their calcium content are part of this group.
Foods made from milk that have little to no calcium, such as cream cheese, cream and butter
are not. Calcium-fortified soymilk (soy beverage) is also part of the Dairy Group.
Ice cream, whole milk, and cheese contain a lot of saturated fat and some naturally occurring
trans-fat and therefore can increase the risk of the health problems related to bad fats, notably
heart disease. The healthiest milk and milk products are low-fat versions, such as skim milk,
milk with 1% fat and reduced-fat cheeses.

For those who are lactose intolerant, smaller portions (such as 120ml of milk) may be well
tolerated. Lactose-free and low-lactose products are available, these include lactose-reduced
or lactose-free milk, yogurt, cheese and calcium-fortified soymilk (soy beverage). Also, enzyme
preparations can be added to milk to lower the lactose content.

Fruit and vegetables

“Eating to the rainbow “

Increased consumption of fruits and vegetables is associated with reduced risk of many
chronic diseases. Living plants produce numerous types of phytonutrients that exhibit
important health benefits for humans.
We’ve known for decades that fruits and vegetables contain important vitamins, minerals and
other nutrients. Science has also established that a plant based diet that includes lots of fruits
and vegetables can lower your risk of some life-threatening diseases. Moreover, if you eat lots
of fruit and vegetables, there’s less room for the unhealthy foods.

Fruits and vegetables contain hundreds of components known as phytonutrients, where the
majority have yet to be identified. These phytonutrients appear in a vast number of
combinations in the plants found in nature. Fruits and vegetables are also high in fibre, which
serves many functions in the body. In particular, fibre keeps the digestive system running
smoothly and may reduce the risk of heart disease, diabetes, gastrointestinal problems and
obesity.

Colourful choices
The reasons for choosing foods with so many colours, is that the healthiest diet includes a
variety of foods. And when it comes to fresh produce, colour is the most outward sign of the
different nutrients in different plants. To increase the benefit, choose produce with deep, rich
colours like blueberries, carrots, broccoli and spinach. Fruits and vegetables with deep colours
contain the most powerful phytochemicals. No single type of fruit or vegetable can deliver all
the beneficial phytonutrients.

Phytonutrients &
Colour Foods
possible actions

Tomato, tomato products,

Lycopene: antioxidants help reduce
Red watermelon, pomegranate,
cancer risk
strawberries

Carrots, sweet potato, mango, Beta-Carotene; supports immune

Orange
pumpkin, butternut system. Powerful antioxidant

Citrus fruits – orange, lemon,

Vitamin C, Flavanoids: detoxify
Yellow-orange papaya, peach, nectarine,
harmful substances
peppers, squash

Spinach, kale, collard, lettuce, Folate: Builds healthy cells and

Green
basil, rocket and other greens genetic material

Isoflavones, Indoles, lutein:

Broccoli, brussel sprouts,
Green-white eliminate excess oestrogen and
cabbage, cauliflower
carcinogens

All sulfides: destroy cancer cells,

White-green Garlic, onion, chives, asparagus reduce cell division, support
immune function
 Blueberries, purple grapes, Anthocyanidins: destroy free
Blue
plums radicals

Reservatrol: may decrease

Red-Purple Grapes, berries, plums
oestrogen production

Brown Wholegrains, legumes Fibre: carcinogen removal

A Healthy snacking strategy

Even healthy snacks can be un-healthy if you eat too much. In general, try to keep snacks to
around 500kJ (female) and 750kJ (male). Eating more calories than you burn each day leads
to weight gain. Excess weight is a major risk factor for several life-threatening diseases.

CLIENT ADVICE - Tips for healthy snacking:

Snacking isn’t necessary for healthy eating, but if you know you are likely to snack between
meals, here are 10 ways to have your snack and eat it healthily.

1. Keep junk food out of the house

At home, you won’t eat what isn’t there. If someone in your household tends to have crisps or
ice cream around, keep them out of sight.

2. Stop and snack mindfully

Don’t eat your snack while doing something else like surfing the internet, watching TV or
working at your desk. Instead, stop what you’re doing for a few minutes and eat your snack
like you would a small meal.

3. You can take it with you

Think ahead and carry a small bag of healthful snacks in your pocket or handbag so you won’t
turn in desperation to the cookies at the coffee counter or the candy bars in the office vending
machine.

4. Go for the grain

Whole-grain snacks, such as whole-grain low salt pretzels or crackers and high-fibre, whole-
grain cereals, can give you some energy with staying power.

5. Mix and match

Try baby carrots or other raw veggies with yogurt. Dip high-fibre wheat crackers in guacamole.

6. Broaden the menu

Seek out some out-of-the-ordinary snacks or fruits like pomegranates, red or yellow peppers,
mangoes or roasted unsalted soya nuts.

7. Revisit breakfast
Many breakfast foods can be repurposed as a nutritious snack later in the day such as a slice
of whole-grain toast topped with low-fat cheese. Low-sugar granola also makes a quick snack.

8. Try a “hi-low” combination

Combine a small amount of something with healthy fat, like peanut butter, with a larger amount
of something very light, like apple slices or celery sticks.
 ESSENTIALS OF NUTRITION
CHAPTER 8: WEIGHT MANAGMENT
 WEIGHT MANAGEMENT
NUTRITION
WEIGHT MANAGEMENT
Some known factors that increase the risk of obesity include:
 Easy availability of high-calorie, heavily-processed foods
 Increased portion sizes
 Lack of regular exercise
 Long commutes to largely sedentary jobs
 Numerous genes that could contribute to obesity have been identified
 Increased stress
 Lack of adequate sleep
 Drug side effects e.g. cortisone and many psychiatric medications.
 Genetic disorders e.g. Down’s Syndrome

On a very simple level, weight depends on the number of calories consumed, how many of
those calories are stored, and how many are burnt burn up (see “Energy balance” chapter).
But each of these factors are influenced by a combination of genes and environment.

CLIENT ADVICE - General weight loss guidelines:

 Eat foods that are filling and low in calories: That means meals and snacks made with
whole grains, such as; brown rice, whole-wheat bread and oatmeal, as well as legumes,
such as lentils and other beans.
 When you eat meat, cut out fat and cut down portion sizes: Choose lean cuts of meat
and modest amounts—about 90-120gm per serving.
 Avoid fried foods: Frying foods adds fat and calories. For stovetop cooking, it’s better
either to stir-fry foods in non-stick pans lightly coated with a cooking oil spray or to braise
them in broth or wine. Baking, broiling and roasting add no extra fat to your meals.
 Use low-fat or non-fat dairy foods: Milk, yoghurt and cheese are good sources of protein
and calcium, but the full cream versions of these dairy products are very high in fat.
 Avoid fast foods: Hamburgers, chicken nuggets, fried chips and other fast-food meals and
snacks tend to promote weight gain for two reasons. They are high in fat and calories.
Additionally the supersize “value meals” are often excessively large and tempt you to
overeat.
 Avoid high-calorie, low-nutrient snacks: Chips and other deep-fried snacks are high in
fat and therefore calories. But even snacks labelled “low-fat” are often high in calories
because they contain large amounts of sugars and other carbohydrates.
 Watch what you drink. Regular sodas, fruit juices and especially, alcoholic beverages are
high in calories.
Physical activity: How much is enough?
If one person cuts back on calories without exercising and another person increases exercise
without cutting back on calories, the first person would probably find it easier to lose weight.
That’s because it’s easier to cut 500 calories a day from your diet than it is to burn 500 extra
calories through exercise.

You’d have to walk or run about 5 km a day—or 35 km a week—to lose 1 kg of fat. But if you
only cut back on calories, you’re more likely to regain the weight you lose. The body reacts to
weight loss as if it was starving and in response, the metabolism slows down. When your
metabolism slows, you burn fewer calories—even at rest.
The solution is to increase your physical activity because doing so will counteract the
metabolic slow down caused by reducing calories.

A regular schedule of exercise raises not only your energy expenditure while you are
exercising but also your resting energy expenditure(REE). Resting energy expenditure
remains elevated as long as you exercise at least three days a week on a regular basis.
Because it accounts for 60% to 75% of your daily energy expenditure, any increase in resting
energy expenditure is extremely important to weight-loss.

“Dieting”
Choosing the diet that fits you best
The answer to the recurrent question, “What’s the best diet for losing weight?” is any diet that
can be stuck with for a long time. It should be as good for overall health as it is for your
waistline. It should offer plenty of good-tasting and healthy choices, banish few foods, and not
require an extensive and expensive list of groceries or supplements.
Aim to keep the percentage of calories from major nutrients within the recommended
guidelines:
• Protein: 10% to 35%
• Carbohydrate: 45% to 65%
• Fat: 20% to 35%

Note that diets that are less than 45% carbohydrate or more than 35% protein are hard to
follow, and they’re no more effective than other diets. In addition to possibly increasing the risk
of heart disease, diets with very low carbohydrate levels may have a negative effect on mood.
Various factors could explain this observation, including the fact that carbohydrate-rich diets
boost the brain’s level of serotonin, a neurotransmitter that affects mood.

Identifying Fad Diets

 Some nutrition experts define a fad diet by a series of questions rather than assessing
popularity:
 Emphasis placed on increasing/ decreasing/ leaving out whole food groups or the
elimination of one or more of the five food groups
 Recommendations that promise a quick fix
 Lists of "good" and "bad" foods
 Recommendations of an energy intake of <1000kCal
 Promises of fast/ easy/ large weight losses and guaranteed successes without any effect.
 Emphasis placed on not combining certain foods/ food groups
  Includes injections with all sorts of wonderful effects
 Claims that sound too good to be true
 Simplistic conclusions drawn from a complex study or recommendations based on a
single study
 Dramatic statements that are refuted by reputable scientific organisations
 Recommendations made to help sell a product
 Recommendations based on studies published without review by other researchers
 Recommendations from studies that ignore differences among individuals or groups

WEIGHT-LOSS MEDICATIONS
Weight-loss drugs are not for the mildly overweight or those who just want to lose a few
kilograms to improve their appearance. For people whose health is at risk and who have failed
to reduce their weight through diet and exercise, drug therapy may increase the odds of
success. For many however, the health risks from these medications may not be worth the few
extra lost kilograms. Weight-loss medications have a history of serious safety concerns.

Major risks are associated with weight loss medication and OTC supplements, namely:
 being addictive
 causing paranoia
 pulmonary hypertension
 increased blood pressure and heart rate
 increased risk of having heart attack
 seizures
 serious muscle damage

Over-The-Counter (OTC) weight-loss supplements: Not worth the risk

Many people are tempted by the vast array of dietary supplements available without
prescription that promise to burn fat, curb your appetite, and help melt away the kilograms.
However, most popular weight-loss supplements are inadequately tested for safety.

Unlike the studies done on prescription drugs to gain approval by the FDA, studies on
supplements typically include small numbers of volunteers and don’t last very long.
Supplements are far less closely regulated than approved medications.
Dozens of supplements contain undisclosed prescription drugs, some of which are not
approved for use and many of which have serious, sometimes life-threatening side effects.
In 2009, the FDA’s Initiative against Contaminated Weight Loss Products identified more than
70 weight-loss supplements, each of which contained one or more of the following drugs:

 Sibutramine (Meridia), a weight-loss drug removed from the market in 2010. Many
products contained high levels of this drug which can increase the likelihood and severity of
the listed health risks.
 Fenproporex, a stimulant drug. It can cause arrhythmia (a disorder affecting your heart
rate or rhythm) and possible sudden death.
 Fluoxetine (Prozac), a prescription-only antidepressant.
 Bumetanide (Bumex) and furosemide (Lasix), prescription medications used to treat
swelling and fluid retention caused by heart, liver, or other diseases.
 Cetilistat, an experimental obesity drug, not approved, that is known to cause
gastrointestinal problems, including involuntary release of stool.
 Phenytoin (Dilantin, others), a prescription-only anti-seizure medication.
 Phenolphthalein. A solution used in chemical experiments and a suspected cancer-
causing agent that is not approved for marketing in the United States.

WEIGHT-LOSS SURGERY
If severely obese, diet and medications may have little effect on weight. The best chance for
long-term weight loss and better health may be surgery to promote weight loss, called bariatric
surgery. The results can be dramatic: within the first two years after surgery, people typically
achieve a maximum weight loss of around 20% to 35% of their initial body weight, depending
on the technique. Type 2 diabetes, high blood pressure, high cholesterol and sleep apnoea
can completely disappear in people who have bariatric surgery.

A range of other health problems also improve following surgery, including arthritis, asthma,
gastro-oesophageal reflux, infertility, sexual dysfunction and urinary incontinence.
The most common types of bariatric surgery are gastric bypass, gastric banding and sleeve
gastrectomy. A third procedure, sleeve gastrectomy, is emerging as an alternative technique,
as it combines the best features of bypass and banding.

 Gastric bypass surgery shrinks the size of your stomach by more than 90%, which
makes you feel full after eating very small amounts of food. Your body will absorb fewer
calories, because food bypasses most of the stomach and upper small intestine.

 Gastric banding, often called a “Lap-Band,” the name of the commercial system used
in the surgery, which is done laparoscopically. It also restricts the amount of food you
can eat by placing an adjustable band around the opening of the stomach.

 Sleeve gastrectomy transforms the stomach into a narrow tube by removing the
curved side of the organ instead of the lower part, as is done with gastric bypass.
 ESSENTIALS OF NUTRITION
CHAPTER 9: METABOLIC SYNDROME
 METABOLIC SYNDROME
NUTRITION

METABOLIC SYNDROME
Obesity related health conditions result in some of the world’s leading causes of death—heart
disease, stroke, diabetes and certain cancers—as well as less common ailments such as gout
and gallstones. Perhaps even more compelling is the strong link between excess weight and
depression, because this common mood disorder can have a profound, negative impact on a
person’s daily life and productivity.

Studies have shown that obesity increases the risk of diabetes and substantially boosts the
risk of developing high blood pressure, heart disease, stroke, and gallstones.
Among people who were overweight or obese, there was a direct relationship between BMI
and risk: the higher the BMI, the higher the likelihood of disease.
Some of the most common conditions associated with weight loss and obesity include:
Heart Disease and Stroke Cancer
Diabetes Depression
Sleep Apnoea

Metabolic Syndrome (mets) - previously known as Syndrome X or the Insulin Resistance

Syndrome - is a cluster of interrelated clinical symptoms that increase the risk for chronic
diseases including atherosclerosis and type 2 diabetes mellitus (T2DM). It is a complex
syndrome, characterised by the clustering of insulin resistance and hyperinsulinemia. It is also
associated with dyslipidemia (High levels of triglycerides and LDL and low levels of HDL),
hypertension, abdominal (visceral) obesity, glucose intolerance (diabetes) and an increased
risk of cardiovascular (heart) events.

Metabolic Syndrome is diagnosed when at least 3 of the following are present:

Characteristic Criteria for Diagnosis

over 102cm for men

Elevated Waist circumference
over 88cm for women

Elevated fasting blood glucose or use of medication over 6.1mmol/l

for hyperglycemia (5.6 mmol/L)

Hypertension (Elevated blood pressure ) > =130/85 mmHg

Reduced HDL (“good”) cholesterol levels men < 1.0 mmol/l

woman < 1.3 mmol/l

Elevated Triglyceride > 1.7mmol/l

Alone, each component of the cluster conveys increased CVD risk, but as a combination they
become much more powerful. This means that the management of persons with
hyperglycaemia and other features of the Metabolic Syndrome should focus not only on blood
glucose control but also include strategies for reduction of the other cardiovascular risk factors.
The Metabolic Syndrome with normal glucose tolerance identifies the subject as a member of
a group, with a very high risk of future diabetes. Thus, vigorous early management of the
syndrome may have a significant impact on the prevention of both diabetes and cardiovascular
disease.

The various risk factors are discussed individually in the section below, but it is also important
to understand the interaction of these factors.

Insulin resistance or Hyperinsulinemia

When the glucose levels in the blood rise (as they do after a meal), it stimulates the beta-cells
in the pancreas in order for them to produce insulin. Hyperinsulinemia is the condition when
the pancreas consistently produces too much insulin for a given glucose response. However,
in this period the body also gets used to having too much insulin available and becomes
ineffective at using it. Hyperinsulinemia eventually turns into insulin resistance. Insulin
resistance is a state in which a normal insulin concentration has a less than normal biological
response. This leads to impaired glucose tolerance and eventually diabetes mellitus.
Central obesity (apple shape) can also lead to insulin resistance due to the increased free fatty
acid (FFA) production that lowers glucose uptake (causing hyperglycemia or high blood
glucose levels) and in turn decreases insulin secretion.

Keep in mind whether a client is apple or pear shaped:

Dyslipidemia (abnormal lipid profile)

Dyslipidemia is characterised by increased levels of very low density lipoprotein (V-LDL) and
Triglycerides (TG) “bad cholesterol” as well as lower levels of High density lipoprotein (HDL) or
“good cholesterol”. Insulin resistance impairs the normal suppression of free fatty acid (FFA)
release from the fat cells. An increase in the release of FFAs in turn increases TG and V-LDL
levels. And the cycle perpetuates.

Hypertension (High Blood pressure)

High insulin concentrations are associated with hypertension. Multiple mechanisms have been
suggested to explain the relationship between hypertension and insulin resistance and
hyperinsulinemia. For example: Hyperinsulinemia increases the renal (kidney) sodium and
water re-absorption and this may lead to peripheral vasoconstriction and increase cardiac
output. It can also lead to increased plasma or adrenaline concentrations, which will increase
blood pressure. The relation between hypertension and hyperinsulinemia remains
controversial.

Impaired glucose tolerance (and Non-insulin dependent Diabetes Mellitus)

Increased insulin resistance and chronic over stimulation of the Beta-cells in the pancreas,
promotes hyperglycemia due to the impaired capacity to secrete insulin. This leads to constant
high blood glucose levels and eventually diabetes.

Obesity
Metabolic Syndrome occurs more frequently in people with central (visceral) fat distribution. The
fat tissue produces increased amounts of free fatty acid (FFA), which in turn lowers your glucose
uptake and also decreases pancreatic insulin secretion. This leaves the glucose unabsorbed in
the bloodstream, causing hyperglycemia. This can also decrease the body's sensitivity to insulin
and the person become insulin resistant.

Coronary artery disease (CAD) and Heart disease

The link between increased CAD risk and insulin resistance is multi-factorial. Both increased
insulin concentrations and decreased insulin sensitivity have been shown to be strong
independent risk factors in heart disease. The specific role of insulin in the development of
heart disease remains poorly understood. Insulin resistance and hyperinsulinemia are
common in NIDDM and are associated with hypertension, CAD and strokes.

Treatment
Goal: To prevent the progression or reverse the pathology of metabolic syndrome
 Diet
 Weight loss
 Exercise
 Medication - in the case of increased fasting glucose or impaired glucose tolerance and
dyslipidemia. It is critical to normalise cholesterols levels and blood pressure levels.

BMI- defined as the weight (kg)/sq. of height (m2), defined values are:
 Healthy weight 18.5–24.9
 Overweight 25–29.9
 Obesity I 30–34.9 (previously obese)
 Obesity II 35–39.9 (previously 'very obese')
 Obesity III 40 or more (previously 'morbidly obese')- NICE guideline 2006, CG043

Problems with BMI (Body mass Index)

1. BMI above is not applicable in children, elderly, pregnant women, major amputees etc.
2. BMI is particularly inaccurate for people who are fit or athletic, as the higher muscle mass
tends to put them in the "overweight" category by BMI, even though their body fat
percentages frequently fall in the 10-15% category, which is below that of a more sedentary
person of average build who has a "healthy" BMI number.
ESSENTIALS OF NUTRITION
CHAPTER 10: ALLERGIES &
INTOLERANCES
 ALLERGIES & INTOLERANCES
NUTRITION
FOOD ALLERGY, INTOLERANCE AND SENSITIVITY
Generally we ingest, digest, absorb and excrete food with no discomfort or unpleasant side
effects when all is well inside the gastrointestinal tract. If a poison or pathogen enters with your
food, if you lack the necessary enzymes to process the food you’ve eaten, or if your immune
system mistakes a food molecule for a dangerous invader, you get sick. You can become ill in
several different ways. The table below gives a small sample of what can happen.

6 common Foods and 4 ways they can make you sick

Allergic Sensitivity or Contamination or
Food Other
trigger intolerance innate poisons
Gluten sensitivity
Celiac disease
(causes gastric
Allergy to (autoimmune
distress and flulike Bacillus cereus
Wheat wheat reaction to gluten
symptoms) Bacillus contamination
protein that damages the
cereus
small intestine)
contamination
Allergy to Lactose intolerance Gastroenteritis
Milk milk (causes gastric from raw or
protein distress) unrefrigerated milk
Gastroenteritis
Allergy to
from raw or
Eggs egg
unrefrigerated
protein
cooked eggs
Scombroid
Poisoning from
poisoning
puffer
Allergy to (allergy-like reaction
Fish fish, which
fish protein from a histamine
contains a
released by spoiled
neurotoxin
fish)
Gastroenteritis
Allergy to
from
Peanuts peanut
contaminated
protein
peanut butter

Contaminated Food
Contamination is by far the leading cause of food related illness. The pathogens (agents of
disease) are most commonly bacteria, viruses or the toxins these microbes produce. Food can
also be contaminated by foreign substances such as pesticide residues or chemicals that
leach from containers. In some cases, the foods themselves naturally contain chemicals that
are poisonous to humans.

When microbes are swallowed, they work their way along the digestive system just as food
does, passing down the oesophagus and through the stomach. They typically don’t cause any
damage until they multiply in the small intestine. Some microbes stay in the intestine, where
they cause gas, cramping, and diarrhoea. Others, like Escherichia coli, excrete a toxin that is
absorbed into the blood and disseminated throughout the body. Still others, like certain strains
of Salmonella, Shigella, and Yersinia, can invade the intestinal walls, causing severe cramps
and bloody diarrhoea.

Some foods such as wild mushrooms, puffer fish, cassava, peach & apricot pips, bitter
almonds, potato stems, tomato leaves, raw cruciferous vegetables, raw or under-cooked
kidney beans or mercury- bearing fish can make you sick without any help from bacteria or
viruses—they contain natural toxins with a range of poisonous effects, ranging from nausea
and diarrhoea to neurologic damage or even irreversible kidney damage.

FOOD ALLERGY
Like many people, you could be uncertain whether your gastrointestinal symptoms reflect an
 Allergy (which requires eliminating all traces of the food from your diet) or an
 Intolerance (which can be managed with less drastic measures).

For various reasons, including improvements in diagnosis, the prevalence of diagnosed food
allergies has increased steadily over the past 10 to 20 years; an estimated 4% to 8% of
children and 4% of teens and adults are now affected.

Allergic reactions are overblown responses mounted by the body’s immune system against a
harmless substance—in this case, a food.
The eight foods responsible for 90% of food allergies:

 Eggs  Tree nuts

 Milk  Soy
 Peanuts  Fish
 Wheat  Shellfish

Food allergies are most prevalent in childhood. For example, milk allergy usually occurs before
the infant’s first birthday. Many children will outgrow allergies to milk, eggs, soy, and wheat by
the time they go to school. However, peanut, tree nut, fish, and shellfish allergies are more
persistent, often lasting throughout life. If you escaped a food allergy in childhood, you’re not
necessarily off the hook; you can develop allergies at any point in your life. Fish and shellfish
allergies are more likely than others to begin in adulthood, and women are more likely than
men to develop them.
Signs and Symptoms:

 There are more than 170 foods known to have triggered severe allergic reactions
 The signs and symptoms of a food allergic reaction may occur almost immediately after
eating or most often within 20 minutes to 2 hours after eating
 Rapid onset and development of potentially life threatening symptoms are characteristic
markers of anaphylaxis
 Allergic symptoms may initially appear mild or moderate but can progress very quickly
 The most dangerous allergic reactions (anaphylaxis) involve the respiratory system
(breathing) and/or cardiovascular system (heart and blood pressure).
 If left untreated, these symptoms can be fatal
 If you suspect a food has caused a reaction, avoid that food, talk with your doctor and have
it investigated. If you know you have a food allergy, then always avoid that specific food
trigger

Below is a table highlighting the spectrum of allergic reactions from mild to severe
anaphylaxis

Severe allergic reaction-

Mild to moderate allergic reaction
ANAPHYLAXIS
Hives, welts or body redness Difficult and/or noisy breathing

Swelling of the face, lips, eyes Swelling of the tongue

Tingling of the mouth Swelling or tightness in the throat

Vomiting, abdominal pain (these are signs of

Difficulty talking and/or hoarse voice
a severe allergic reaction/anaphylaxis in
someone with severe insect allergy)
Wheeze or persistent cough
Persistent dizziness or collapse in its
place

Pale and floppy (in young children)

77
FOOD INTOLERANCE AND SENSITIVITY
While food-borne illness can strike anyone, food intolerances, or sensitivities, are limited to
otherwise healthy people who have a certain biochemical makeup that makes them react
adversely to certain foods. That said, an estimated 20% to 45% of the population is intolerant
(or overly sensitive) to some food— a proportion that, for unknown reasons, is continuing to
grow. Lactose, a milk sugar, and gluten, a protein in grains, are the substances that people are
most likely to be intolerant or sensitive to.

It is easy to confuse food intolerance and food allergy.

Intolerances do not involve the body’s immune system unlike food allergy and Coeliac
Disease. After eating, some people complain of symptoms like headaches, bloating or mouth
ulcers but these are not caused by allergies. Some of these symptoms result from food
intolerance. Food intolerances are slower in onset and are not life threatening.

Natural chemicals are found in foods. These naturally occurring chemicals add flavour and
smell to food. The most common ones to upset sensitive people are glutamate, amines and
salicylates. Amines naturally occur in pineapples, bananas, vegetables, red wine, chocolate,
citrus fruits and mature cheeses. Salicylates are found in a wide variety of herbs, spices fruit
and vegetables. Glutamate occurs naturally in foods such as tomatoes, soy sauce,
mushrooms and some cheeses.

Other causes of intolerances

 Enzyme deficiencies – some people are born without enough of a certain enzyme.

 Lactose intolerance - is a person’s inability to digest lactase which is a sugar found in

milk. If you are lactose intolerant it may mean you have a deficiency of the enzyme lactase.
After consuming milk and milk products, people with lactose intolerance may experience
symptoms that range from mild to severe, based on the amount of lactose consumed and
the amount a person can tolerate. Common symptoms include bloating, wind, nausea and
diarrhoea.

Lactose intolerance is not the same as milk allergy:

Milk allergy means a person’s immune system has made anti-bodies to the milk protein. Each
time they eat or drink small amounts of milk or milk products like cheese or yoghurt it will
trigger an allergic reaction which could be mild or develop to be a potentially life threatening
allergic reaction.

 Food additives are chemicals added to foods to keep them fresh or to enhance their
colour, flavour or texture. For the majority of people, additives are not a problem but for
those with food intolerances they can cause adverse reactions like hives and or
diarrhoea.

78
The table below highlights some of the distinct differences between food allergies and food
intolerances:

Food Allergy Food Intolerance

Immune-mediated response Digestive system response

Cause: Sensitivity to a specific food protein Cause: Something “irritates’ the gut

Mild to severe symptoms: Nausea, cramps, May remain symptom free in controlled
diarrhoea, itchy skin, rash, SOB (Short of “doses “
breath) Bloating, Flatulence, heartburn, bloating,
Swelling, Respiratory distress cramps, vomiting

Gastrointestinal disturbances
Anaphylactic response
(Constipation/ Diarrhoea)

Antihistamines will NOT relieve any

Antihistamine treatment brings relief
symptoms.

Less than 2% of the population Up to 45% of the population

79
 ESSENTIALS OF NUTRITION
CHAPTER 11: EATING DISORDERS

80
 EATING DISORDERS
NUTRITION
EATING DISORDERS
Eating disorders can be caused by, and lead to, complicated physical and psychological
illnesses. Many people feel successful and in control when they become thin, but people with
eating disorders can become seriously ill and even die. They might start out dieting
successfully and be happy with their weight loss, but then they find they can't stop.

Eating Disorder Diagnostic Criteria from DSM IV-TR:

ANOREXIA NERVOSA

 Refusal to maintain body weight at or above a minimally normal weight for age and
height, for example, weight loss leading to maintenance of body weight less than 85%
of that expected or failure to make expected weight gain during period of growth,
leading to body weight less than 85% of that expected.
 Intense fear of gaining weight or becoming fat, even though underweight.
 Disturbance in the way one's body weight or shape is experienced, undue influence of
body weight or shape on self-evaluation, or denial of the seriousness of the current low
body weight.
 In postmenarcheal females, amenorrhea, i.e., the absence of at least 3 consecutive
menstrual cycles. A woman having periods only while on hormone medication (e.g.
estrogen) still qualifies as having amenorrhea.

Types
 Restricting Type: During the current episode of Anorexia Nervosa, the person has not
regularly engaged in binge-eating or purging behaviour (self-induced vomiting or misuse
of laxatives, diuretics, or enemas).

 Binge Eating/Purging Type: During the current episode of Anorexia Nervosa, the
person has regularly engaged in binge-eating or purging behaviour.

BULIMIA NERVOSA

 Recurrent episodes of binge eating characterised by both eating in a discrete period of

time (e.g., within any 2-hour period), an amount of food that is definitely larger than
most people would eat during a similar period of time and under similar circumstances.
 A sense of lack of control over eating during the episode, (such as a feeling that one
cannot stop eating or control what or how much one is eating).

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  Recurrent inappropriate compensatory behavior to prevent weight gain, such as self-
induced vomiting, misuse of laxatives, diuretics, enemas, or other medications, fasting,
or excessive exercise.
 The binge eating and inappropriate compensatory behavior both occur, on average, at
least twice a week for 3 months.
 Self-evaluation is unduly influenced by body shape and weight.

Types

 Purging Type: During the current episode of Bulimia Nervosa, the person has regularly
engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

 Non-purging Type: During the current episode of Bulimia Nervosa, the person has used
other inappropriate compensatory behaviour but has not regularly engaged in self-
induced vomiting or misused laxatives, diuretics, or enemas

Figure 11.1 Anorexia Nervosa: Distortion between real and perceived body shape and size

Eating Disorders Not Otherwise Specified

This diagnosis includes disorders of eating that do not meet the criteria for the above two
eating disorder diagnoses. Examples include:

 For female patients, all of the criteria for Anorexia Nervosa are met except that the patient
has regular menses.
 All of the criteria for Anorexia Nervosa are met except that, despite significant weight
loss, the patient's current weight is in the normal range.
 All of the criteria for Bulimia Nervosa are met except that the binge eating and
inappropriate compensatory mechanisms occur less than twice a week or for less than
3 months.

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  The patient has normal body weight and regularly uses inappropriate compensatory
behaviour after eating small amounts of food (e.g., self-induced vomiting after
consuming two cookies).
 The patient engages in repeatedly chewing and spitting out, but not swallowing, large
amounts of food.

Listed in the DSM IV-TR appendix as a diagnosis for further study:

 Binge Eating Disorder is defined as uncontrolled binge eating without emensis (not
menstruating) or laxative abuse. Absence of regular inappropriate compensatory
behaviour characteristic of Bulimia Nervosa. It is often, but not always, associated with
obesity symptoms.

 Night eating syndrome includes morning anorexia, increased appetite in the evening,
and insomnia. These patients can have complete or partial amnesia for eating during
the night.

CLIENT ADVICE - Practical signs of Eating Disorders in a client:

 Has an obsession with weight and food. It might seem like all your client thinks (and talks)
about is food, calories, fat grams, weight, and being thin
 Feels the need to exercise all the time, even when sick or exhausted, and might talk about
compensating for eating too much by exercising
 Avoids being in the company of other people during meals.
 Starts to wear big or baggy clothes as a way to hide his or her body and shape
 Goes on extreme or highly restrictive diets (for example, eating only clear soup or only raw
veggies), cuts food into tiny pieces, moves food around on the plate instead of eating it,
and is very precise about how food is arranged on the plate
 Goes to the bathroom a lot, especially right after meals, or you've heard reports or
witnessed that your client is vomiting after eating
 Appears to be gaining a lot of weight even though you never see him or her eat much.
 Is very defensive or sensitive about his or her weight loss or eating habits
 Buys or takes diet pills, laxatives, steroids or herbal supplements to lose weight
 Has a tendency to faint, bruises easily, is very pale, or starts complaining of being cold
more than usual (cold intolerance can be a symptom of being underweight)

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