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Understanding
normal and
Clinical nutrition
eleventh e d i t i o n
Rolfes pinna
whitney
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203
Understanding
Normal & Clinical
Nutrition
Understanding
Normal & Clinical
Nutrition
Eleventh Edition
Sharon Rady Rolfes

Kathryn Pinna
Ellie Whitney
Australia ● Brazil ● Mexico ● Singapore ● United Kingdom ● United States
Understanding Normal & Clinical Nutrition, © 2018, 2015 Cengage Learning
Eleventh Edition
ALL RIGHTS RESERVED. No part of this work covered by the copyright herein may
Sharon Rady Rolfes, Kathryn Pinna, be reproduced or distributed in any form or by any means, except as permitted
Ellie Whitney by U.S. copyright law, without the prior written permission of the copyright owner.
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Printed in Canada
Print Number: 01 Print Year: 2016
To Ellie Whitney, my mentor, partner, and friend, with much appreciation
for believing in me, sharing your wisdom, and giving me the opportunity
to pursue a career more challenging and rewarding than any I could have
imagined.
Sharon
To my parents, John and Tina Pinna, whose zest for learning inspired my own.
Kathryn
To the memory of Gary Woodruff, the editor who first encouraged me to write.
Ellie
About the Authors
Sharon Rady Rolfes received her MS in nutrition and food sci- Ellie Whitney grew up in New York City and received her BA
ence from Florida State University. She is a founding member and PhD degrees in English and Biology at Har vard and
of Nutrition and Health Associates, an information resource Washington Universities. She taught at both Florida State
center that maintains a research database on more than University and Florida A&M University, wrote newspaper col-
1000 nutrition-related topics. She has taught at Florida State umns on environmental matters for the Tallahassee Democrat,
University and coauthored several other college textbooks, and coauthored almost a dozen college textbooks on nutri-
including Understanding Nutrition. In addition to writing, she tion, health, and related topics, many of which repeatedly
serves as a consultant for various educational projects. Her reappear as new editions. She spent three decades exploring
volunteer work includes serving on the board of Working outdoor Florida and studying its ecology, and then cowrote
Well, a community initiative dedicated to creating a healthy Priceless Florida: Natural Ecosystems and Native Species (Pineap-
workforce. She maintains her registration as a dietitian nutri- ple Press, 2004). Now retired, and more concerned about cli-
tionist (RDN) and membership in the Academy of Nutrition mate change than any other issue, she volunteers full-time for
and Dietetics. the nonpartisan national nonprofit Citizens Climate Lobby.
Kathryn Pinna received her MS and PhD in nutrition from

the University of California at Berkeley. She taught nu-
trition, food science, and human biolog y courses in the
San Francisco Bay area for over 25 years and also worked
as an outpatient dietitian, Internet consultant, and free-
lance writer. Her other publications include the textbooks
Nutrition for Health and Health Care and Nutrition and Diet
Therapy. She is a registered dietitian and a member of the
American Society for Nutrition and the Academy of Nutri-
tion and Dietetics.
Brief Contents
ChaPtER 1 An Overview of Nutrition 3
highlight 1 > Nutrition Information and Misinformation 30
ChaPtER 2 Planning a Healthy Diet 37
highlight 2 > Vegetarian Diets 64
ChaPtER 3 Digestion, Absorption, and Transport 71
highlight 3 > Common Digestive Problems 90
ChaPtER 4 The Carbohydrates: Sugars, Starches, and Fibers 99
highlight 4 > Carbs, kCalories, and Controversies 128
ChaPtER 5 The Lipids: Triglycerides, Phospholipids, and Sterols 133
highlight 5 > High-Fat Foods—Friend or Foe? 164
ChaPtER 6 Protein: Amino Acids 171
highlight 6 > Nutritional Genomics 194
ChaPtER 7 Energy Metabolism 201
highlight 7 > Alcohol in the Body 222
ChaPtER 8 Energy Balance and Body Composition 235
highlight 8 > Eating Disorders 256
ChaPtER 9 Weight Management: Overweight, Obesity, and Underweight 265
highlight 9 > The Latest and Greatest Weight-Loss Diet—Again 296
ChaPtER 10 The Water-Soluble Vitamins: B Vitamins and Vitamin C 301
highlight > 10 > Vitamin and Mineral Supplements 335
ChaPtER 11 The Fat-Soluble Vitamins: A, D, E, and K 343
highlight 11 > Antioxidant Nutrients in Disease Prevention 364
ChaPtER 12 Water and the Major Minerals 371
highlight 12 > Osteoporosis and Calcium 400
ChaPtER 13 The Trace Minerals 407
highlight 13 > Phytochemicals and Functional Foods 433
ChaPtER 14 Life Cycle Nutrition: Pregnancy and Lactation 441
highlight > 14 > Fetal Alcohol Syndrome 473
ChaPtER 15 Life Cycle Nutrition: Infancy, Childhood, and Adolescence 477
highlight 15 > Childhood Obesity and the Early Development of Chronic Diseases 516
ChaPtER 16 Life Cycle Nutrition: Adulthood and the Later Years 523
highlight 16 > Hunger and Community Nutrition 547
ChaPtER 17 Nutrition Care and Assessment 555
highlight 17 > Nutrition and Immunity 574
vii
Chapter 18 Nutrition Intervention 581
highlight 18 > Food Allergies 595
Chapter 19 Medications, Diet-Drug Interactions, and Herbal Products 599
highlight 19 > Complementary and Alternative Medicine 613
Chapter 20 Enteral Nutrition Support 619
highlight 20 > Inborn Errors of Metabolism 638
Chapter 21 Parenteral Nutrition Support 643
highlight 21 > Ethical Issues in Nutrition Care 659
Chapter 22 Metabolic and Respiratory Stress 663
highlight 22 > Multiple Organ Dysfunction Syndrome 681
Chapter 23 Upper Gastrointestinal Disorders 685
highlight 23 > Oral Health and Chronic Illness 704
Chapter 24 Lower Gastrointestinal Disorders 709
highlight 24 > Probiotics and Intestinal Health 735
Chapter 25 Liver Disease and Gallstones 739
highlight 25 > Anemia in Illness 757
Chapter 26 Diabetes Mellitus 763
highlight 26 > The Metabolic Syndrome 788
Chapter 27 Cardiovascular Diseases 793
highlight 27 > Coping with Feeding Disabilities 820
Chapter 28 Kidney Diseases 825
highlight 28 > Dialysis 847
Chapter 29 Cancer and HIV Infection 851
highlight 29 > Foodborne Illness 871
appendix a Cells, Hormones, and Nerves
appendix B Basic Chemistry Concepts
appendix C Biochemical Structures and Pathways
appendix d Measures of Protein Quality
appendix e Nutrition Assessment: Supplemental Information
appendix F Estimated Energy Needs
appendix G Choose Your Foods: Food Lists for Diabetes and Weight Management
appendix h Table of Food Composition
appendix i WHO Nutrition Recommendations
appendix J Healthy People 2020
appendix K Aids to Calculation
appendix L Enteral Formulas
Glossary GL-1
Index IN-1
inside Covers
Dietary Reference Intakes (DRI) A
Daily Values (DV) for Food Labels Y
Body Mass Index (BMI) Z
viii Brief Contents
Table of Contents
Preface xvii 2-2 Diet-Planning Guides 42
Acknowledgments xxiii USDA Food Patterns 42
Reviewers xxiv Food Lists 49
Putting the Plan into Action 50
ChaPtER 1 From Guidelines to Groceries 51
an overview of nutrition 3 2-3 Food Labels 56
1-1 Food Choices 4 The Ingredient List 56
Nutrition Facts Panel 56
1-2 The Nutrients 6
Claims on Labels 60
Nutrients in Foods and in the Body 6 Consumer Education 60
The Energy-Yielding Nutrients: Carbohydrate, Fat,
highlight 2 > Vegetarian Diets 64
and Protein 8
The Vitamins 11
The Minerals 11 ChaPtER 3
Water 12 digestion, absorption, and transport 71
1-3 The Science of Nutrition 12 3-1 Digestion 72
Conducting Research 12 Anatomy of the Digestive Tract 72
Analyzing Research Findings 16 The Muscular Action of Digestion 75
Publishing Research 17 The Secretions of Digestion 76
1-4 Dietary Reference Intakes 18 The Final Stage 77
Establishing Nutrient Recommendations 18 3-2 Absorption 78
Establishing Energy Recommendations 20 Anatomy of the Absorptive System 79
Using Nutrient Recommendations 21 A Closer Look at the Intestinal Cells 80
Comparing Nutrient Recommendations 21 3-3 The Circulatory Systems 82
1-5 Nutrition Assessment 22 The Vascular System 82
Nutrition Assessment of Individuals 22 The Lymphatic System 84
Nutrition Assessment of Populations 24 3-4 The Health and Regulation of the GI Tract 85
1-6 Diet and Health 26 Gastrointestinal Microbiome 85
Chronic Diseases 26 Gastrointestinal Hormones and Nerve Pathways 85
Risk Factors for Chronic Diseases 27 The System at Its Best 87
highlight 1 > Nutrition Information and Misinformation 30 highlight 3 > Common Digestive Problems 90
ChaPtER 2 ChaPtER 4
Planning a healthy diet 37 the Carbohydrates: Sugars, Starches,
2-1 Principles and Guidelines 38 and Fibers 99
Diet-Planning Principles 38 4-1 The Chemist’s View of Carbohydrates 100
Dietary Guidelines for Americans 40 Monosaccharides 100
Disaccharides 102
Polysaccharides 103
4-2 Digestion and Absorption of Carbohydrates 105
HSNphotography/Shutterstock.com
Carbohydrate Digestion 105

Carbohydrate Absorption 107
Lactose Intolerance 107
4-3 Glucose in the Body 108
A Preview of Carbohydrate Metabolism 109
The Constancy of Blood Glucose 110
ix
4-4 Health Effects and Recommended Intakes of Sugars 113 Roles of Proteins 179
Health Effects of Sugars 114 A Preview of Protein Metabolism 182
Recommended Intakes of Sugars 117 6-4 Protein in Foods 185
Alternative Sweeteners 118 Protein Quality 185
4-5 Health Effects and Recommended Intakes of Starch Complementary Proteins 185
and Fibers 120 6-5 Health Effects and Recommended Intakes of Protein 186
Health Effects of Starch and Fibers 121 Health Effects of Protein 186
Recommended Intakes of Starch and Fibers 123 Recommended Intakes of Protein 188
From Guidelines to Groceries 124 From Guidelines to Groceries 189
highlight 4 > Carbs, kCalories, and Controversies 128 Read Food Labels 190
Protein and Amino Acid Supplements 190
ChaPtER 5 highlight 6 > Nutritional Genomics 194
the Lipids: triglycerides, Phospholipids,
and Sterols 133 ChaPtER 7
5-1 The Chemist’s View of Fatty Acids and Triglycerides 134 Energy Metabolism 201
Fatty Acids 134 7-1 Chemical Reactions in the Body 202
Triglycerides 136
7-2 Breaking Down Nutrients for Energy 205
Characteristics of Solid Fats and Oils 136
Glucose 206
5-2 The Chemist’s View of Phospholipids and Sterols 140 Glycerol and Fatty Acids 208
Phospholipids 140 Amino Acids 210
Sterols 140 The Final Steps of Energy Metabolism 211
5-3 Digestion, Absorption, and Transport of Lipids 142 7-3 Feasting and Fasting 216
Lipid Digestion 142 Feasting—Excess Energy 217
Lipid Absorption 144 The Transition from Feasting to Fasting 218
Lipid Transport 144 Fasting—Inadequate Energy 218
5-4 Lipids in the Body 148 Low-Carbohydrate Diets 220
Roles of Triglycerides 148 highlight 7 > Alcohol in the Body 222
Essential Fatty Acids 148
A Preview of Lipid Metabolism 150 ChaPtER 8
5-5 Health Effects and Recommended Intakes of Saturated Fats, Energy Balance and Body Composition 235
Trans Fats, and Cholesterol 150
8-1 Energy Balance 236
Health Effects of Saturated Fats, Trans Fats,
and Cholesterol 151 8-2 Energy In: The kCalories Foods Provide 236
Recommended Intakes of Saturated Fat, Trans Fat, Food Composition 236
and Cholesterol 152 Food Intake 237
5-6 Health Effects and Recommended Intakes of 8-3 Energy Out: The kCalories the Body Expends 240
Monounsaturated and Polyunsaturated Fats 153 Components of Energy Expenditure 240
Health Effects of Monounsaturated and Estimating Energy Requirements 244
Polyunsaturated Fats 153 8-4 Body Weight and Body Composition 245
Recommended Intakes of Monounsaturated Defining Healthy Body Weight 246
and Polyunsaturated Fats 154 Body Fat and Its Distribution 248
From Guidelines to Groceries 154 8-5 Health Risks Associated with Body Weight and Body Fat 251
highlight 5 > High-Fat Foods—Friend or Foe? 164 Health Risks of Underweight 252
Health Risks of Overweight 252
ChaPtER 6 Fit and Fat versus Sedentary and Slim 253
Protein: amino acids 171 highlight 8 > Eating Disorders 256
6-1 The Chemist’s View of Proteins 172
Amino Acids 172
Proteins 173
Nejron Photo/Shutterstock.com
6-2 Digestion and Absorption of Proteins 175

Protein Digestion 175
Protein Absorption 175
6-3 Proteins in the Body 177
Protein Synthesis 177
x table of Contents
Nonvitamins 323
Interactions among the B Vitamins 323
10-3 Vitamin C 327
Blacknote/Shutterstock.com
Vitamin C Roles 327
Vitamin C Recommendations 329
Vitamin C Deficiency 329
Vitamin C Toxicity 330
Vitamin C Food Sources 330
highlight 10 > Vitamin and Mineral Supplements 335
ChaPtER 9
Weight Management: overweight, obesity, ChaPtER 11
and Underweight 265 the Fat-Soluble vitamins: a, d, E, and K 343
9-1 Overweight and Obesity 266 11-1 Vitamin A and Beta-Carotene 344
Fat Cell Development 266 Roles in the Body 344
Fat Cell Metabolism 267 Vitamin A Deficiency 346
Set-Point Theory 267 Vitamin A Toxicity 347
9-2 Causes of Overweight and Obesity 268 Vitamin A Recommendations 348
Genetics and Epigenetics 268 Vitamin A in Foods 349
Environment 270 11-2 Vitamin D 351
9-3 Problems of Overweight and Obesity 272 Roles in the Body 351
Health Risks 272 Vitamin D Deficiency 353
Perceptions and Prejudices 273 Vitamin D Toxicity 354
Dangerous Interventions 273 Vitamin D Recommendations and Sources 354
9-4 Aggressive Treatments for Obesity 274 11-3 Vitamin E 357
Drugs 275 Vitamin E as an Antioxidant 357
Surgery 275 Vitamin E Deficiency 357
9-5 Weight-Loss Strategies 276 Vitamin E Toxicity 357
Changes, Losses, and Goals 277 Vitamin E Recommendations 358
Eating Patterns 277 Vitamin E in Foods 358
Physical Activity 281 11-4 Vitamin K 358
Environmental Influences 284 Roles in the Body 358
Behavior and Attitude 285 Vitamin K Deficiency 359
Weight Maintenance 287 Vitamin K Toxicity 359
Prevention 288 Vitamin K Recommendations and Sources 360
Community Programs 289 highlight 11 > Antioxidant Nutrients in Disease Prevention 364
9-6 Underweight 289
Problems of Underweight 289 ChaPtER 12
Weight-Gain Strategies 290 Water and the Major Minerals 371
highlight 9 > The Latest and Greatest Weight-Loss
12-1 Water and the Body Fluids 372
Diet—Again 296
Water Balance and Recommended Intakes 372
Blood Volume and Blood Pressure 374
ChaPtER 10
Fluid and Electrolyte Balance 376
the Water-Soluble vitamins: B vitamins Fluid and Electrolyte Imbalance 379
and vitamin C 301 Acid-Base Balance 379
10-1 The Vitamins—An Overview 302 12-2 The Minerals—An Overview 381
10-2 The B Vitamins 304 12-3 The Major Minerals 382
Thiamin 305 Sodium 382
Riboflavin 308 Chloride 386
Niacin 309 Potassium 387
Biotin 312 Calcium 388
Pantothenic Acid 313 Phosphorus 394
Vitamin B6 313 Magnesium 395
Folate 315 Sulfate 397
Vitamin B12 320 highlight 12 > Osteoporosis and Calcium 400
Choline 322
table of Contents xi
CHAPTER 13 Infant Formula 483
The Trace Minerals 407 Special Needs of Preterm Infants 484
Introducing Cow’s Milk 484
13-1 The Trace Minerals—An Overview 408 Introducing Solid Foods 485
13-2 The Trace Minerals 410 Mealtimes with Toddlers 488
Iron 410 15-2 Nutrition during Childhood 488
Zinc 419 Energy and Nutrient Needs 488
Iodine 422 Hunger and Malnutrition in Children 491
Selenium 424 The Malnutrition-Lead Connection 492
Copper 425 Hyperactivity and “Hyper” Behavior 494
Manganese 426 Food Allergy and Intolerance 495
Fluoride 426 Childhood Obesity 496
Chromium 427 Mealtimes at Home 502
Molybdenum 428 Nutrition at School 504
13-3 Contaminant Minerals 429 15-3 Nutrition during Adolescence 507
Highlight 13 > Phytochemicals and Functional Foods 433 Growth and Development 507
Energy and Nutrient Needs 507
CHAPTER 14 Food Choices and Health Habits 509
Life Cycle Nutrition: Pregnancy and Lactation 441 Highlight 15 > Childhood Obesity and the Early Development
14-1 Nutrition prior to Pregnancy 442
of Chronic Diseases 516
14-2 Growth and Development during Pregnancy 443
CHAPTER 16
Placental Development 443
Fetal Growth and Development 443
Life Cycle Nutrition: Adulthood and the Later
Critical Periods 444 Years 523
14-3 Maternal Weight 448 16-1 Nutrition and Longevity 524
Weight prior to Conception 448 Observation of Older Adults 525
Weight Gain during Pregnancy 448 Manipulation of Diet 526
Exercise during Pregnancy 450 16-2 The Aging Process 528
14-4 Nutrition during Pregnancy 451 Physiological Changes 529
Energy and Nutrient Needs during Pregnancy 452 Other Changes 531
Vegetarian Diets during Pregnancy and Lactation 455 16-3 Energy and Nutrient Needs
Common Nutrition-Related Concerns of Pregnancy 455 of Older Adults 532
14-5 High-Risk Pregnancies 456 Water 532
The Infant’s Birthweight 457 Energy and Energy Nutrients 533
Malnutrition and Pregnancy 457 Vitamins and Minerals 533
Food Assistance Programs 458 Dietary Supplements 534
Maternal Health 458 16-4 Nutrition-Related Concerns
The Mother’s Age 460 of Older Adults 535
Practices Incompatible with Pregnancy 461 Vision 535
14-6 Nutrition during Lactation 464 Arthritis 536
Lactation: A Physiological Process 464 The Aging Brain 537
Breastfeeding: A Learned Behavior 465 Alcohol 539
Maternal Energy and Nutrient Needs during 16-5 Food Choices and Eating Habits of Older Adults 540
Lactation 465 Malnutrition 541
Maternal Health 467 Food Assistance Programs 541
Practices Incompatible with Lactation 468 Meals for Singles 542
Highlight 14 > Fetal Alcohol Syndrome 473 Highlight 16 > Hunger and Community Nutrition 547
CHAPTER 15
Life Cycle Nutrition: Infancy, Childhood,
Aydindurdu/ Dreamstime.com
and Adolescence 477

15-1 Nutrition during Infancy 478
Energy and Nutrient Needs 478
Breast Milk 480
xii Table of Contents
19-2 Diet-Drug Interactions 602
Drug Effects on Food Intake 604
Drug Effects on Nutrient Absorption 604
Dietary Effects on Drug Absorption 604
Drug Effects on Nutrient Metabolism 605
Dietary Effects on Drug Metabolism 606
Drug Effects on Nutrient Excretion 607
Rob Lewine/Getty Images

Dietary Effects on Drug Excretion 607
Diet-Drug Interactions and Toxicity 607
19-3 Herbal Supplements 608
Effectiveness and Safety of Herbal Products 609
Use of Herbal Products in Illness 611
ChaPtER 17 highlight 19 > Complementary and Alternative
nutrition Care and assessment 555 Medicine 613
17-1 Nutrition in Health Care 555

ChaPtER 20
Effects of Illness on Nutrition Status 556
Responsibility for Nutrition Care 556
Enteral nutrition Support 619
Nutrition Screening 557 20-1 Oral Supplements 620
The Nutrition Care Process 558 20-2 Tube Feedings in Medical Care 621
17-2 Nutrition Assessment 561 Candidates for Tube Feedings 621
Historical Information 561 Tube-Feeding Routes 621
Food Intake Data 562 20-3 Enteral Formulas 624
Anthropometric Data 565 Types of Enteral Formulas 624
Biochemical Data 569 Formula Characteristics 625
Physical Examination 571 Formula Selection 626
highlight 17 > Nutrition and Immunity 574 20-4 Administration of Tube Feedings 627
Safe Handling 627
ChaPtER 18 Initiating and Advancing a Tube Feeding 628
nutrition intervention 581 Meeting Water Needs 631
Medication Delivery during Tube Feedings 632
18-1 Implementing Nutrition Care 581
Tube-Feeding Complications 632
Approaches to Nutrition Care 582
Transition to Table Foods 634
Documenting Nutrition Care 584
highlight 20 > Inborn Errors of Metabolism 638
18-2 Energy Intakes in Hospital Patients 585
Indirect Calorimetry 586
Predictive Equations 586
ChaPtER 21
18-3 Dietary Modifications 588
Parenteral nutrition Support 643
Modified Diets 588 21-1 Indications for Parenteral Nutrition 643
Alternative Feeding Routes 591 Peripheral Parenteral Nutrition 644
Nothing by Mouth (NPO) 592 Total Parenteral Nutrition 645
18-4 Foodservice 592 21-2 Parenteral Solutions 646
Menu Planning 592 Parenteral Nutrients 646
Food Selection 592 Solution Preparation 648
Food Safety 592 21-3 Administering Parenteral Nutrition 650
Improving Food Intake 593 Insertion and Care of Intravenous Catheters 650
highlight 18 > Food Allergies 595 Administration of Parenteral Solutions 651
Discontinuing Parenteral Nutrition 652
ChaPtER 19 Managing Metabolic Complications 653
Medications, diet-drug interactions, 21-4 Nutrition Support at Home 655
and herbal Products 599 Candidates for Home Nutrition Support 655
Planning Home Nutrition Care 655
19-1 Medications in Disease Treatment 599
Quality-of-Life Issues 656
Medication Administration 600
Risks from Medications 600
highlight 21 > Ethical Issues in Nutrition Care 659
Patients at High Risk of Adverse Effects 602
table of Contents xiii
ChaPtER 22 ChaPtER 25
Metabolic and Respiratory Stress 663 Liver disease and Gallstones 739
22-1 The Body’s Responses to Stress and Injury 664 25-1 Fatty Liver and Hepatitis 740
Hormonal Responses to Stress 664 Fatty Liver 740
The Inflammatory Response 665 Hepatitis 741
22-2 Nutrition Treatment of Acute Stress 666 25-2 Cirrhosis 742
Determining Nutritional Requirements 667 Consequences of Cirrhosis 743
Approaches to Nutrition Care in Acute Stress 670 Treatment of Cirrhosis 746
Patients with Burn Injuries 670 Nutrition Therapy for Cirrhosis 746
22-3 Respiratory Stress 672 25-3 Liver Transplantation 750
Chronic Obstructive Pulmonary Disease 673 25-4 Gallstone Disease 751
Respiratory Failure 676 Types of Gallstones 751
highlight 22 > Multiple Organ Dysfunction Syndrome 681 Consequences of Gallstones 752
Risk Factors for Cholesterol Gallstones 752
ChaPtER 23 Treatment of Gallstones 753
Upper Gastrointestinal disorders 685 highlight 25 > Anemia in Illness 757
23-1 Conditions Affecting the Esophagus 686
Dysphagia 686 ChaPtER 26
Gastroesophageal Reflux Disease 689 diabetes Mellitus 763
23-2 Conditions Affecting the Stomach 692 26-1 Overview of Diabetes Mellitus 763
Dyspepsia 692 Symptoms of Diabetes Mellitus 765
Nausea and Vomiting 693 Diagnosis of Diabetes Mellitus 765
Gastroparesis 693 Types of Diabetes Mellitus 765
Gastritis 694 Prevention of Type 2 Diabetes Mellitus 767
Peptic Ulcer Disease 694 Acute Complications of Diabetes Mellitus 767
23-3 Gastric Surgery 696 Chronic Complications of Diabetes Mellitus 769
Gastrectomy 696 26-2 Treatment of Diabetes Mellitus 771
Bariatric Surgery 699 Treatment Goals 771
highlight 23 > Oral Health and Chronic Illness 704 Evaluating Diabetes Treatment 772
Nutrition Therapy: Dietary Recommendations 773
ChaPtER 24 Nutrition Therapy: Meal-Planning Strategies 775
Insulin Therapy 778
Lower Gastrointestinal disorders 709
Antidiabetic Drugs 781
24-1 Common Intestinal Problems 709 Physical Activity and Diabetes Management 781
Constipation 710 Sick-Day Management 783
Intestinal Gas 712 26-3 Diabetes Management in Pregnancy 784
Diarrhea 712 Pregnancy in Type 1 or Type 2 Diabetes 784
24-2 Malabsorption 714 Gestational Diabetes 784
Fat Malabsorption 714 highlight 26 > The Metabolic Syndrome 788
Bacterial Overgrowth 715
24-3 Conditions Affecting the Pancreas 717
Pancreatitis 717
Cystic Fibrosis 719
24.4 Conditions Affecting the Small Intestine 721
Celiac Disease 721
Inflammatory Bowel Diseases 723
Dmitry Lobanov/Shutterstock.com
Short Bowel Syndrome 726

24.5 Conditions Affecting the Large Intestine 728
Irritable Bowel Syndrome 728
Diverticular Disease of the Colon 729
Colostomies and Ileostomies 730
highlight 24 > Probiotics and Intestinal Health 735
xiv table of Contents
CHAPTER 27 CHAPTER 29
Cardiovascular Diseases 793 Cancer and HIV Infection 851
27-1 Atherosclerosis 794 29-1 Cancer 851
Consequences of Atherosclerosis 794 How Cancer Develops 852
Development of Atherosclerosis 795 Nutrition and Cancer Risk 852
Causes of Atherosclerosis 796 Consequences of Cancer 854
27-2 Coronary Heart Disease (CHD) 797 Treatments for Cancer 856
Symptoms of Coronary Heart Disease 797 Nutrition Therapy for Cancer 858
Evaluating Risk for Coronary Heart Disease 797 29-2 HIV Infection 862
Lifestyle Management to Reduce CHD Risk 799 Prevention of HIV Infection 862
Vitamin Supplementation and CHD Risk 803 Consequences of HIV Infection 863
Lifestyle Changes for Hypertriglyceridemia 803 Treatments for HIV Infection 865
Drug Therapies for CHD Prevention 805 Nutrition Therapy for HIV Infection 866
Treatment of Heart Attack 805 Highlight 29 > Foodborne Illness 871
27-3 Stroke 807
Stroke Prevention 807
Stroke Management 807
APPEnDIx A
Cells, Hormones, and Nerves
27-4 Hypertension 808
Factors That Influence Blood Pressure 808 APPEnDIx B
Factors That Contribute to Hypertension 809 Basic Chemistry Concepts
Treatment of Hypertension 810 APPEnDIx C
27-5 Heart Failure 814 Biochemical Structures and Pathways
Consequences of Heart Failure 814
Medical Management of Heart Failure 815
APPEnDIx D
Measures of Protein Quality
Highlight 27 > Coping with Feeding Disabilities 820
APPEnDIx E
CHAPTER 28 Nutrition Assessment: Supplemental Information
Kidney Diseases 825 APPEnDIx F
28-1 Functions of the Kidneys 825 Estimated Energy Needs
28-2 The Nephrotic Syndrome 827 APPEnDIx G
Consequences of the Nephrotic Syndrome 827 Choose Your Foods: Food Lists for Diabetes and Weight
Treatment of the Nephrotic Syndrome 827 Management
28-3 Acute Kidney Injury 830 APPEnDIx H
Causes of Acute Kidney Injury 830 Table of Food Composition
Consequences of Acute Kidney Injury 830
Treatment of Acute Kidney Injury 831 APPEnDIx I
WHO Nutrition Recommendations
28-4 Chronic Kidney Disease 833
Consequences of Chronic Kidney Disease 833 APPEnDIx J
Treatment of Chronic Kidney Disease 834 Healthy People 2020
Kidney Transplants 838
APPEnDIx K
28-5 Kidney Stones 841 Aids to Calculation
Formation of Kidney Stones 841
Consequences of Kidney Stones 842 APPEnDIx L
Prevention and Treatment of Kidney Stones 842 Enteral Formulas
Highlight 28 > Dialysis 847 Glossary GL-1
Index IN-1
InsIDE CoVERs
AJPhoto/Science Source
Dietary Reference Intakes (DRI) A

Daily Values (DV) for Food Labels Y
Body Mass Index (BMI) Z
Table of Contents xv
>how to
t
Think Metric 9 Help Hospital Patients Improve Their Food Intakes 593
Calculate the Energy Available from Foods 10 Reduce the Risks of Adverse Effects from Medications 602
Determine Whether a Website Is Reliable 31 Prevent Diet-Drug Interactions 608
Compare Foods Based on Nutrient Density 39 Help Patients Improve Intakes with Oral Supplements 620
Calculate Personal Daily Values 59 Help Patients Cope with Tube Feedings 629
Reduce the Intake of Added Sugars 118 Plan a Tube-Feeding Schedule 630
Make Heart-Healthy Choices—by Food Group 157 Administer Medications to Patients Receiving Tube Feedings 632
Calculate a Personal Daily Value for Fat 160 Express the Osmolar Concentration of a Solution 645
Understand “% Daily Value” and “% kCalories from Fat” 161 Calculate the Macronutrient and Energy Content of a
Calculate Recommended Protein Intakes 189 Parenteral Solution 649
Estimate Energy Requirements 245 Estimate the Osmolarity of a Parenteral Solution 650
Determine BMI 249 Estimate Energy Needs Using Disease-Specific Stress Factors 668
Compare Foods Based on Energy Density 280 Improve Acceptance of Mechanically Altered Foods 689
Identify a Fad Diet or Weight-Loss Scam 299 Manage Gastroesophageal Reflux Disease 691
Evaluate Foods for Their Nutrient Contributions 306 Alter the Diet to Reduce Symptoms of Dumping Syndrome 698
Estimate Niacin Equivalents 310 Alter Dietary Habits to Achieve and Maintain Weight Loss after
Estimate Dietary Folate Equivalents 317 Bariatric Surgery 701
Cut Salt (and Sodium) Intake 384 Follow a Fat-Restricted Diet 717
Estimate Your Calcium Intake 392 Help the Cirrhosis Patient Eat Enough Food 748
Estimate the Recommended Daily Intake for Iron 416 Use Carbohydrate Counting in Clinical Practice 776
Plot Measures on a Growth Chart 479 Treat High Blood Cholesterol to Reduce Atherosclerotic CVD Risk 799
Protect against Lead Toxicity 494 Implement a Heart-Healthy Diet 804
Stretch Food Dollars and Reduce Waste 550 Reduce Sodium Intake 813
Measure Length and Height 566 Help Patients Comply with a Renal Diet 839
Measure Weight 567 Increase kCalories and Protein in Meals 859
Estimate and Evaluate Changes in Body Weight 568 Help Patients Handle Food-Related Problems 860
Estimate Appropriate Energy Intakes for Hospital Patients 587 Prevent Foodborne Illnesses 875
CaSE
StUdY
Nutrition Screening and Assessment 572 Patient with Short Bowel Syndrome 728
Implementing Nutrition Care 594 Young Adult with Irritable Bowel Syndrome 729
Injured Hiker Requiring Enteral Nutrition Support 635 Man with Cirrhosis 749
Patient with Intestinal Disease Requiring Parenteral Child with Type 1 Diabetes 783
Nutrition 654 Woman with Type 2 Diabetes 785
Patient with a Severe Burn 672 Patient with Cardiovascular Disease 813
Elderly Man with Emphysema 676 Woman with Acute Kidney Injury 832
Woman with GERD 692 Man with Chronic Kidney Disease 840
Nutrition Care after Gastric Surgery 699 Woman with Cancer 862
Child with Cystic Fibrosis 720 Man with HIV Infection 868
xvi table of Contents
Preface
As we launch this eleventh edition of Understanding Normal through 13 describe the vitamins, the minerals, and water—
and Clinical Nutrition, nutrition research continues to un- their roles in the body, deficiency and toxicity symptoms, and
cover the many complex relationships between nutrition and sources. Chapters 14 through 16 complete the “normal” chap-
health. Our goals for this edition are to incorporate these ters by presenting the special nutrient needs of people through
current research findings into the core information neces- the life cycle—pregnancy and lactation; infancy, childhood,
sary for an introductory course in nutrition. As with previous adolescence; and adulthood and the later years.
editions, each chapter has been substantially updated and The remaining “clinical” chapters of the book focus on the
revised to include new topics as well as expand on existing nutrition care of individuals with health problems. Chapter
topics. The chapters include practical information and valu- 17 explains how illnesses and their treatments influence nu-
able resources to help readers apply nutrition knowledge and trient needs and describes the process of nutrition assessment.
skills to their daily lives and the clinical setting. Chapter 18 discusses how nutrition care is implemented and
A main objective in writing this book has always been to introduces the different types of therapeutic diets used in
share our enthusiasm about nutrition in a manner that mo- patient care. Chapter 19 explores the potential interactions
tivates students to study and learn. Moreover, we seek to pro- between nutrients and medications and examines the ben-
vide accurate information that is meaningful to the student or efits and risks associated with herbal products. Chapters 20
health professional. Students of nutrition often find the subject and 21 describe specialized methods for providing nutrients
to be both fascinating and overwhelming; there are so many to people who are unable to consume a regular diet. Chapter
details to learn—new terms, new chemical structures, and new 22 describes the inflammatory process and shows how meta-
biological concepts. Taken one step at a time, however, the sci- bolic and respiratory stress influence nutrient needs. Chap-
ence of nutrition may seem less daunting and the facts more ters 23 through 29 explore the pathology, medical treatment,
memorable. We hope that this book serves you well. and nutrition therapy for specific diseases, including gastro-
intestinal disorders, liver disease, diabetes mellitus, cardio-
vascular diseases, renal diseases, cancer, and HIV infection.
a Book tour of this Edition the highlights Every chapter is followed by a highlight
Understanding Normal and Clinical Nutrition presents updated, that provides readers with an in-depth look at a current, and of-
comprehensive coverage of the fundamentals of nutrition and ten controversial, topic that may relate to its companion chap-
nutrition therapy for an introductory nutrition course. The early ter. For example, Highlight 4 examines the scientific evidence
chapters introduce the nutrients and their work in the body as behind some of the current controversies surrounding carbohy-
well as recommendations about nutrition that are essential for drates and their role in weight gain and weight loss. New to this
maintaining health and preventing disease. The later chapters edition are Critical Thinking Questions designed to encourage
provide instruction in clinical nutrition—the pathophysiology readers to develop clear, rational, open-minded, and informed
and nutrition care for a wide range of medical conditions. thoughts based on the evidence presented in the highlight.
the Chapters Chapter 1 begins by exploring why we eat Special Features The art and layout in this edition have
the foods we do and continues with a brief overview of the nu-
been carefully designed to be inviting while enhancing stu-
trients, the science of nutrition, recommended nutrient intakes,
dent learning. For example, numbered steps have been added
and important relationships between diet and health. Chapter
to several figures to clarify sequences and processes. In addi-
2 describes the menu-planning principles and food guides used
tion, special features help readers identify key concepts and
to create diets that support good health and includes instruc-
apply nutrition knowledge. For example, when a new term
tions on how to read a food label. In Chapter 3, readers follow
is introduced, it is printed in bold type, and a definition is
the journey of digestion and absorption as the body breaks
provided. These definitions often include pronunciations and
down foods into absorbable nutrients. Chapters 4 through 6
derivations to facilitate understanding. The glossary at the
describe carbohydrates, fats, and proteins—their chemistry,
end of the text includes all defined terms.
roles in the body, and places in the diet. Chapter 7 shows how
the body derives energy from these three nutrients. Chapters definition (DEF-eh-NISH-en): the meaning of a word.
8 and 9 continue the story with a look at energy balance, the ● de = from
factors associated with overweight and underweight, and the ● finis = boundary
benefits and risks of weight loss and weight gain. Chapters 10

xvii
how to
LEaRninG GPS Many of the chapters include To” in Chapter 1 presents the
The opening page of each chapter provides a Learning GPS that “How To” features that guide steps in calculating energy in-
serves as an outline and directs readers to the main headings (and readers through problem-solv- take from the grams of carbohy-
subheadings) within the chapter. Each main heading is followed ing tasks. For example, a “How drate, fat, and protein in a food.
by a Learn It—a learning objective for the content covered in that
section. The Learn It also appears within the text at the start of
❯ tRY it Each “How To” feature ends with a “Try It” activ-
each main section as well as at the start of each Review It. After
ity that gives readers an opportunity to practice these new
reading and studying the chapter, students should be able to
lessons.
demonstrate competency in the Learn It objectives.
Nutrition in Your Life/Nutrition CaSE

in the Clinical Setting StUdY
Chapters 1 through 16 open with a paragraph called Nutri- The clinical chapters include case studies that present prob-
tion in Your Life that introduces the chapter’s content in a lems and pose questions that allow readers to apply chapter
friendly and familiar way. This short paragraph closes with material to hypothetical situations. Readers who successfully
a preview of how readers might apply that content to their master these exercises will be better prepared to face real-
daily lives by inviting them to use the Nutrition Portfolio life challenges that arise in the clinical setting.
section at the end of those chapters. Similarly, Chapters 17
through 29 open with a Nutrition in the Clinical Setting
paragraph, which introduces real-life concerns associated
with diseases or their treatments. Nutrition Assessment Checklist
The clinical chapters close with Nutrition Assessment Check-
lists that help readers evaluate how various disorders impair
Nutrition Por tfolio/Clinical nutrition status. These sections highlight the medical, di-
etary, anthropometric, biochemical, and physical findings
Portfolio most relevant to patients with specific diseases.
At the end of Chapters 1 through 16, a Nutrition Portfolio

prompts readers to consider whether their personal choices are Diet-
meeting the dietary goals presented in the chapter. Chapters 17 Drug interactions
through 29 finish with a Clinical Portfolio section, which
enables readers to practice their clinical skills by addressing Most of the clinical chapters also include a section on Diet-
hypothetical clinical situations. Many of these assignments in- Drug Interactions that presents the nutrition-related concerns
clude instructions that use the Diet & Wellness Plus program. associated with the medications commonly used to treat the
Such tools help students assess their current choices and make disorders described in the chapter.
informed decisions about healthy options.
❯ REVIEW IT Each major section within a chapter concludes the appendixes The appendixes are valuable references
with a Review It paragraph that summarizes key concepts. Simi- for a number of purposes. Appendix A summarizes back-
larly, Review It tables cue readers to important summaries. ground information on the hormonal and nervous systems,
complementing Appendixes B and C on basic chemistry, the
Also featured in this edition are the 2015–2020 Dietary chemical structures of nutrients, and major metabolic path-
Guidelines for Americans, which are introduced in Chapter 2 ways. Appendix D describes measures of protein quality.
and presented throughout the text whenever their subjects Appendix E provides supplemental coverage of nutrition assess-
are discussed. Look for the following design. ment, and Appendix F presents the estimated energy require-
ments for men and women at various levels of physical activity.
Appendix G presents the 2014 Choose Your Foods: Food Lists for
> diE ta RY GUidEL inE S F oR a MERiC a nS 2 0 15 – 2 0 2 0
Diabetes and Weight Management. Appendix H is a 4000-item
These guidelines provide science-based advice to promote health and
food composition table. Appendix I presents nutrition recom-
to reduce the risk of chronic disease through diet and physical activity.
mendations from the World Health Organization (WHO).
xviii Preface
Appendix J presents the Healthy People 2020 nutrition- Chapter 3
related objectives. Appendix K features aids to calculations, ● Introduced microbiome and revised section on gastroin-
a short tutorial on converting metric measures and handling
testinal bacteria
basic math problems commonly found in the world of nu-
trition. Appendix L provides examples of commercial enteral
formulas commonly used in tube feedings or to supplement
Chapter 4
oral diets. ● Revised table showing nutrients in sugars and other
foods to include potassium and vitamin D
the inside Covers The inside covers put commonly ● Created tables to define glucose for normal and diabetes;
used information at your fingertips. The inside front covers to show the glycemic index of a few common foods; to
(pp. A–C) present the current nutrient recommendations, list the functions of sugars in foods; and to present ways
and the inside back covers feature the Daily Values used on to prevent dental caries
food labels and a glossary of nutrient measures (p. Y on the ● Included fructose metabolism in the highlight
left) as well as suggested weight ranges for various heights
(p. Z on the right). Chapter 5
● Created tables to define blood lipids for heart health; to
notable Changes in this Edition list fat choices among protein foods and among milk
products; to show omega-3 fatty acid quantities in a vari-
Because nutrition is an active science, staying current is para- ety of fish and seafood
mount. Just as nutrition research continuously adds to and ● Created new figure on how to read fish oil supplement
revises the accepted body of knowledge, this edition builds
labels
on the science of previous editions with the latest in nutrition
research. Much has changed in the world of nutrition and in
● Added definitions for resistin and adiponectin
our daily lives since the first edition. The number of foods has
increased dramatically—even as we spend less time than ever Chapter 6
in the kitchen preparing meals. The connections between ● Expanded discussion on the association between dietary
diet and disease have become more apparent—and consumer protein and body weight
interest in making smart health choices has followed. More
people are living longer and healthier lives. The science of Chapter 7
nutrition has grown rapidly, with new facts emerging daily. ● Created new figure illustrating labels on beer, wine, and
In this edition, as with all previous editions, every chapter liquor
has been revised to enhance learning by presenting current
information accurately and attractively. For all chapters and Chapter 8
highlights we have:
● Discussed “3500 kcalorie rule” and its limitations
● Reviewed and updated content
● Created new tables for estimating energy expended on
● Created several new figures and tables and revised others basal metabolism and on thermic effect of foods and for
to enhance learning percent body fat at various BMI
● Included 2015-2020 Dietary Guidelines for Americans ● Revised section on female athlete triad to include
new expanded term—Relative Energy Deficiency in
Chapter 1 Sports (RED-S)—and created new table of its adverse
● Created table to summarize ways to describe six classes consequences
of nutrients ● Added discussion of food addiction to section on binge
● Introduced registered dietitian nutritionist (RDN), another eating disorder
term to describe an RD
Chapter 9
Chapter 2 ● Added discussion of brite adipocytes to section on brown
● Revised section on Dietary Guidelines to reflect 2015– adipocyte tissue and uncoupling proteins
2020 recommendations
● Updated table on FDA-approved weight loss drugs
● Revised figure comparing nutrient density of two break-
● Revised figure on gastric surgery used to treat obesity
fasts to include potassium and vitamin D
● Deleted discussion and figure on unrealistic expectations
● Introduced proposed food labels and revised figure to il-
lustrate differences ● Created new table of national strategies to prevent
obesity
● Introduced front-of-package labeling and added figure to
illustrate ● Updated table on popular weight loss diets
Preface xix
Chapter 11 Chapter 20
● Added a paragraph on “golden rice,” a genetically modi- ● Refined the terms related to nutrition support: intro-
fied rice used in the worldwide fight against vitamin A duced the terms specialized nutrition support and oral
deficiency nutrition support
● Added details on vitamin D’s non-bone-related roles ● Shortened the section on oral supplements
● Rewrote the introduction to vitamin E ● Updated the feeding tube photo
● Rewrote the food sources of vitamin K paragraph to ● Modified the sections on initiating and advancing tube
include the terms phylloquinone (vitamin K 1) and feedings and meeting water needs
menaquinone (vitamin K2)
Chapter 21
Chapter 12 ● Added additional details in the table on patient moni-
● Revised calcium balance figure toring during parenteral nutrition
● Revised the section on discontinuing parenteral nutrition
Chapter 13 ● Revised the glossary definitions in the highlight on ethi-
● Created table of factors influencing iron absorption cal issues
Chapter 14 Chapter 22
● Created several new tables: benefits of WIC, risk factors ● Added glossary definitions for complement, indirect calo-
for gestational diabetes, signs and symptoms of pre- rimetry, and minute ventilation
eclampsia, complications from smoking during preg- ● Revised the sections on estimating energy needs during
nancy, tips to prevent listeriosis
acute stress, use of glutamine or arginine during acute
● Reorganized sections on fetal programming and fetal de- illness, and micronutrient needs in acute stress
velopment of chronic diseases ● Modified the How To feature for estimating energy needs
using stress factors
Chapter 15
● In the table on predictive equations used in ventilator-
● Created several new tables: protective factors in breast
dependent patients, updated the Ireton-Jones and Penn
milk, tips for picky eaters, examples of foods and non-
State equations, and used the Penn State equation in the
food items children can choke on, iron recommenda-
example
tions for adolescents
● Shortened the section on causes of chronic obstructive
● Added information about fluoride and formula
pulmonary disease, and modified some sections on nu-
preparation
trition therapy for respiratory failure
● Added brief discussion about new AAP guidelines for re-
duced, low-fat, and fat-free milk for toddlers Chapter 23
● Added discussion of new school meal initiatives ● Added a discussion about gastroparesis
Modified some material in the sections on gastritis, gas-
Chapter 16
●
troesophageal reflux disease, and bariatric surgery; added

● Created new figure comparing healthy lens with cataract lens glossary definitions for bloating and bacterial overgrowth
In the section on bariatric surgery, added a figure show-
Chapter 17
●
ing the sleeve gastrectomy surgery

● Added a table showing the relationship between the rate
of involuntary weight loss and nutritional risk Chapter 24
● Updated the laboratory values in the table on routine ● Revised some of the material in the sections on constipa-
laboratory tests tion, intestinal gas, acute and chronic pancreatitis, cystic
● Added a paragraph about C-reactive protein in the sec- fibrosis, celiac disease, irritable bowel syndrome, and di-
tion on biochemical analyses verticular disease of the colon
● Revised the discussion on fluid retention ● Added calcium channel activators to the table of laxa-
tives and bulk-forming agents
Chapter 19 ● Revised the table of foods that increase intestinal gas
● Reorganized the beginning paragraphs of the highlight ● Introduced the concept of FODMAPs and added a defini-
on complementary and alternative medicine tion for bacterial translocation
xx Preface
Chapter 25 ● In the section on kidney stones, introduced hypocitratu-
ria as a risk factor and reformatted the table on food
● Shortened the paragraph on nutrition treatment for
sources of oxalates
hepatitis
● Modified some sections about cirrhosis complications, Chapter 29
including the table listing the clinical features of hepatic
● Updated the tables on factors that influence cancer risk
encephalopathy
● Revised the section on biological therapies for cancer to
● Revised the section on the medical treatment for cirrhosis
include more examples of cancer immunotherapy; in-
cluded new definitions for monoclonal antibodies and im-
Chapter 26 mune checkpoint inhibitors
● Updated statistics throughout the chapter
● Revised the section about food safety concerns for im-
● Added a margin table comparing glycated hemoglobin munosuppressed cancer patients
(HbA1c) and plasma glucose levels
● Expanded the section on the prevention of HIV infection
● In the section on diabetic neuropathy, distinguished be- to include a discussion about prophylactic medications
tween peripheral and autonomic neuropathy and added used in persons at risk of HIV exposure
glossary definitions for these two different forms of
● Updated the definition of AIDS-wasting syndrome to re-
neuropathy
flect current guidelines
● Revised various sections on nutrition therapy to reflect
the updated clinical guidelines
● Revised the discussion on exchange lists to reflect the Student and instructor Resources
food lists released in 2014 (Appendix G was also up-
dated to show the 2014 food lists) nutrition Mindtap for Understanding normal
● Added inhaled insulin and sodium-glucose cotrans- and Clinical nutrition
porter 2 (SGLT2) inhibitors to the tables listing the dif- MindTap is well beyond an eBook, a homework solution or
ferent types of insulin and antidiabetic drugs digital supplement, a resource center website, a course deliv-
ery platform, or a Learning Management System. More than
● Revised the discussion on insulin use in type 2 diabetes 70 percent of students surveyed said that it was unlike any-
● Updated several sections in the Nutrition in Practice on thing they have ever seen before. MindTap is a new personal
metabolic syndrome learning experience that combines all of your digital assets—
● Added a figure showing how metabolic syndrome varies readings, multimedia, activities, and assessments—into a
among ethnic groups and removed the figure showing singular learning path to improve student outcomes.
how it varies with age
diet & Wellness Plus
Chapter 27 Diet & Wellness Plus helps you gain a better understanding
● Revised various paragraphs in the sections on atheroscle- of how nutrition relates to your personal health goals. It en-
rosis, cardiovascular disease (CVD) risk assessment, CVD ables you to track your diet and activity, generate reports,
lifestyle management, hypertension, and heart failure and analyze the nutritional value of the food you eat! It in-
cludes over 55,000 foods in the database, custom food and
● Revised the How To feature about identifying and treat- recipe features, the latest Dietary References, as well as your
ing high blood cholesterol goal and actual percentages of essential nutrients, vitamins,
● Eliminated the box on assessing risk of heart disease and minerals. It also helps you to identify a problem behav-
● Updated the section on hypertension treatment ior and make a positive change. After completing a Wellness
● In the highlight on feeding disabilities, revised the sec- Profile questionnaire, Diet & Wellness Plus will rate the level
tion related to altered energy requirements of concern for eight different areas of wellness, helping you
determine the areas where you are most at risk. It then helps
Chapter 28 you put together a plan for positive change by helping you
select a goal to work toward, complete with a reward for all
● Modified the table on causes of acute kidney injury, and your hard work. Diet & Wellness Plus is also available as an
revised the discussion about the evaluation of acute kid- App that can accessed from the App dock in MindTap and
ney injury can be used throughout the course for students to track their
● Updated the section on the evaluation of chronic kidney diet, activity, and behavior change.
disease to reflect new clinical practice guidelines
● Clarified and updated some sections related to nutri- Global health Watch
tion therapy for chronic kidney disease to reflect current Updated with today’s current headlines, Global Health
recommendations Watch is your one-stop resource for classroom discussion
and research projects. This resource center provides access to
Preface xxi
thousands of trusted health sources, including academic
journals, magazines, newspapers, videos, podcasts, and more.
Closing Comments
It is updated daily to offer the most current news about topics We have taken great care to provide accurate information
related to your health course. and have included many references at the end of each chap-
ter and highlight. To keep the number of references man-
Cognero test Bank ageable over the decades, however, many statements that
Cengage Learning Testing Powered by Cognero is a flexible, appeared in previous editions with references now appear
online system that allows you to: without them. All statements reflect current nutrition knowl-
● Author, edit, and manage test bank content from mul- edge, and the authors will supply references upon request.
tiple Cengage Learning solutions In addition to supporting text statements, the end-of-chapter
references provide readers with resources for finding a good
● Create multiple test versions in an instant
overview or more details on the subject. Nutrition is a fas-
● Deliver tests from your learning management system cinating subject, and we hope our enthusiasm for it comes
(LMS), your classroom, or wherever you want through on every page.
instructor’s Companion Site Sharon Rady Rolfes

Everything you need for your course in one place! This col- Kathryn Pinna
lection of book-specific lecture and class tools is available Ellie Whitney
online via www.cengage.com/login. Access and download
PowerPoint presentations, images, the instructor’s manual,
videos, and more.
xxii Preface
Acknowledgments
To produce a book requires the coordinated effort of a team thoughtful suggestions and efficient analysis of reviews, Carol
of people—and, no doubt, each team member has another Samet for her management of this project, Tom Ziolkowski
team of support people as well. We salute, with a big round for his energetic efforts in marketing, Miriam Myers for her
of applause, everyone who has worked so diligently to en- dedication in developing online animations and study tools,
sure the quality of this book. and Christine Myaskovsky for her assistance in obtaining
We thank our partners and friends, Linda DeBruyne and permissions.
Fran Webb, for their valuable consultations and contribu- We also thank Gary Hespenheide for creatively designing
tions; working together over the past 30-plus years has been these pages, Mathangi Anantharaman at Lumina Datamatics
a most wonderful experience. We especially appreciate Linda’s Limited for selecting photographs that deliver nutrition messages
research assistance on several chapters. Special thanks to Da- attractively, Debbie Stone for copyediting, and MPS Limited for
vid Stone for his help in critiquing and proofreading various proofreading close to 1000 final text pages. We would also like
sections in the clinical chapters. Thanks also to Chelsea Mack- to extend our gratitude to Edward Dionne, our project manager,
enzie for her work on manuscript preparation and to Taylor and the talented team at MPS Limited for their assistance with
Newman for her assistance in creating informative tables and layout, production, and indexing. To the hundreds of others in-
descriptive figures. volved in production and sales, we tip our hats in appreciation.
Our heartfelt thanks to our editorial team for their efforts We are especially grateful to our friends and families for
in creating an outstanding nutrition textbook—Krista Mastroi- their continued encouragement and support. We also thank
anni for her leadership and support, Lauren Oliveira for her our many reviewers for their comments and contributions.
xxiii
Reviewers of Understanding
Normal & Clinical Nutrition
Becky Alejandre Sue Fredstrom Rebecca A. Kleinschmidt
American River College Minnesota State University, Mankato University of Alaska Southeast
Janet B. Anderson Trish Froehlich Vicki Kloosterhouse
Utah State University Palm Beach Community College Oakland Community College
Sandra D. Baker Stephen P. Gagnon Donna M. Kopas
University of Delaware Hillsborough Community College Pennsylvania State University
Angelina Boyce Leonard E. Gerber Susan M. Krueger
Hillsborough Community College University of Rhode Island University of Wisconsin, Eau Claire
Lynn S. Brann Jill Golden Barbara Lange
Syracuse University Orange Coast College College of Central Florida
Shalon Bull Barbara J. Goldman Melissa Langone
Palm Beach Community College Palm Beach State College Pasco-Hernando Community College
Dorothy A. Byrne Debra Goodwin Grace Lasker
University of Texas, San Antonio Jacksonville State University Lake Washington Institute of Technology
Angela Caldwell Kathleen Gould Darlene M. Levinson
Black River Technical College Towson University Oakland Community College, Orchard
John R. Capeheart Margaret Gunther Ridge
University of Houston, Downtown Palomar College Kimberly Lower
Leah Carter Charlene Hamilton Collin County Community College
Bakersfield College University of Delaware Mary Marian
James F. Collins Debra Head University of Arizona
University of Florida University of Central Arkansas Melissa B. McGuire
Cathy Cunningham D. J. Hennager Maple Woods Community College
Texas Tech University Kirkwood Community College Diane L. McKay
Diane Curis Catherine Hagen Howard Tufts University
Los Rios Community College District Texarkana College Anne Miller
De Anza College
Lisa K. Diewald Samantha Hutson
Montgomery County Community College Tennessee Technological University Anahita M. Mistry
Eastern Michigan University
Kelly K. Eichmann Jasminka Z. Ilich
Fresno City College Florida State University Lisa Morse
Arizona State University
Shannon Fenster Ernest B. Izevbigie
Bellevue College Jackson State University Mithia Mukutmoni
Sierra College
Shawn Flanagan Craig Kasper
Steven Nizielski
University of Iowa Hillsborough Community College
Grand Valley State University
Mary Flynn Shawnee Kelly
Carmen L. Nochera
Brown University Pennsylvania State University
Grand Valley State University
Betty J. Forbes Younghee Kim
Yvonne Ortega
West Virginia University Bowling Green State University
Santa Monica College
xxiv
Jane M. Osowski Juanita G. Sanchez Kenneth Strothkamp
University of Southern Mississippi Southwest Texas Junior College Lewis & Clark College
Sarah Panarello Kathy L. Sedlet Robin Sytsma
Yakima Valley Community College Collin County Community College Solano Community College
Ryan Paruch Vidya Sharma Alanna M. Tynes
Tulsa Community College San Antonio College Lone Star College—Tomball
Jill Patterson Melissa Shock Andrea Villarreal
Pennsylvania State University University of Central Arkansas Phoenix College
Gina Pazzaglia Tiffany Shurtz Terry Weideman
West Chester University University of Central Oklahoma Oakland Community College, Highland
Julie Priday Lake
Krista M. Simonetti
Centralia College
Maricopa County College H. Garrison Wilkes
Barbara F. Rabsatt University of Massachusetts, Boston
Helenkay Smith
Brevard Community College
Community College of Allegheny Lauri Wright
Kelsey Rami County University of South Florida
South Dakota State University
LuAnn Soliah Lynne C. Zeman
Teresa Rittenbach Baylor University Kirkwood Community College
University of Jamestown
Bernice Gales Spurlock Maureen Zimmerman
Jennifer Rogers Hinds Community College Mesa Community College
University of Iowa
xxv
Bildagentur Zoonar GmbH/Shutterstock.com
1 Learning gPS
1-1 Food Choices 4
An Overview
Learn iT Describe how various factors
influence personal food choices.
1-2 The nutrients 6
Learn iT Name the six major classes of
of Nutrition
nutrients and identify which are organic and
which yield energy.
nutrients in Foods and in the Body 6
The energy-Yielding nutrients:
Carbohydrate, Fat, and Protein 8
The Vitamins 11
The Minerals 11
Water 12
1-3 The Science of nutrition 12
Nutrition in Your Life Learn iT Explain the scientific method and how
scientists use various types of research studies
Believe it or not, you have probably eaten at least 20,000 meals in your life. and methods to acquire nutrition information.
Without any conscious effort on your part, your body uses the nutrients from Conducting research 12
those foods to make all its components, fuel all its activities, and defend itself analyzing research Findings 16
against diseases. How successfully your body handles these tasks depends, in Publishing research 17
part, on your food choices. Nutritious food choices support healthy bodies. In 1-4 Dietary reference intakes 18
the Nutrition Portfolio at the end of this chapter, you can see how your current Learn iT Define the four categories of the
food choices are influencing your health and risk of chronic diseases. DRI and explain their purposes.
establishing nutrient recommendations 18
establishing energy recommendations 20
Using nutrient recommendations 21
Comparing nutrient recommendations 21
nutrition has always played a significant role in your life. Every day, several 1-5 nutrition assessment 22
Learn iT Explain how the four assessment
times a day, you select foods that influence your body’s health. Each day’s
methods are used to detect energy and
food choices may benefit or harm health only a little, but over time, the con- nutrient deficiencies and excesses.
sequences of these choices become major. That being the case, paying close nutrition assessment of individuals 22
nutrition assessment of Populations 24
attention to good eating habits now supports health benefits later. Conversely,
1-6 Diet and Health 26
carelessness about food choices can contribute to chronic diseases. Of Learn iT Identify several risk factors and
course, some people will become ill or die young no matter what choices they explain their relationships to chronic diseases.
Chronic Diseases 26
make, and others will live long lives despite making poor choices. For most
risk Factors for Chronic Diseases 27
of us, however, the food choices we make will benefit or impair our health in
Highlight 1 Nutrition Information and
proportion to the wisdom of those choices. Misinformation 30
Although most people realize food habits affect health, they often choose Learn iT Recognize misinformation and describe
how to identify reliable nutrition information.
foods for other reasons. After all, foods bring pleasures, traditions, and as-
sociations as well as nourishment. The challenge, then, is to combine favor-
nutrition: the science of the nutrients in foods and their
ite foods and fun times with a nutritionally balanced diet. Take a moment actions within the body. A broader definition includes the
to review the definition and note that diet does not mean a restrictive food study of human behaviors related to food and eating.
foods: products derived from plants or animals that can
plan designed for weight loss. It simply refers to the foods and beverages a be taken into the body to yield energy and nutrients for the
maintenance of life and the growth and repair of tissues.
person consumes. Whether it’s a vegetarian diet, a weight-loss diet, or any chronic diseases: diseases characterized by slow progression
other kind of diet depends on the types of foods and beverages a person and long duration. Examples include heart disease, diabetes, and
some cancers.
chooses. chronos 5 time
diet: the foods and beverages a person eats and drinks.
3
1-1 Food Choices
❯ LEARN IT Describe how various factors influence personal food choices.
People decide what to eat, when to eat, how much to eat, and even whether to eat
in highly personal ways based on a complex interaction of genetic, behavioral, or
social factors rather than on an awareness of nutrition’s importance to health.1
A variety of food choices can support good health, and an understanding of hu-
man nutrition helps you make sensible selections more often.
Preferences As you might expect, the number one reason most people choose
certain foods is taste—they like the flavor. Two widely shared preferences are for
the sweetness of sugar and the savoriness of salt.2 High-fat foods also appear to
be a universally common preference. Other preferences might be for the hot pep-
pers common in Mexican cooking or the curry spices of Indian cuisine. Research
suggests that genetics may influence taste perceptions and therefore food likes
and dislikes.3 Similarly, the hormones of pregnancy seem to influence food crav-
ings and aversions (see Chapter 14).
Habit People sometimes select foods out of habit. They eat cereal every morning,
for example, simply because they have always eaten cereal for breakfast. Eating a
familiar food and not having to make any decisions can be comforting.
ethnic Heritage and regional Cuisines Among the strongest influences on food
choices are ethnic heritage and regional cuisines. People tend to prefer the foods
Corbis Premium RF/Alamy Stock Photo
they grew up eating. Every country, and in fact every region of a country, has its
own typical foods and ways of combining them into meals. These cuisines reflect
a unique combination of local ingredients and cooking styles. Chowder in New
England is made with clams, but in the Florida Keys conch is the featured ingre-
dient. The Pacific Northwest is as famous for its marionberry pie as Georgia is
for its peach cobbler. Philly has its cheesesteaks and New Orleans has its oyster
po’boys. The “American diet” includes many ethnic foods and regional styles, all
PHoTo 1-1 An enjoyable way to learn about a culture adding variety to the diet.
is to taste the ethnic foods. Enjoying traditional ethnic foods provides an opportunity to celebrate a per-
son’s heritage (see Photo 1-1). People offering ethnic foods share a part of their
culture with others, and those accepting the foods learn about another’s way of
life. Developing cultural competence honors individual preferences and is par-
ticularly important for professionals who help others plan healthy diets.
Social interactions Most people enjoy companionship while eating. It’s fun to
go out with friends for a meal or share a snack when watching a movie together.
Meals are often social events, and sharing food is part of hospitality. Social
customs invite people to accept food or drink offered by a host or shared by a
group—regardless of hunger signals. Chapter 9 describes how people tend to eat
more food when socializing with others.
availability, Convenience, and economy People often eat foods that are accessible,
quick and easy to prepare, and within their financial means. Consumers who
value convenience frequently eat out, bring home ready-to-eat meals, or have food
delivered. Even when they venture into the kitchen, they want to prepare a meal
in 15 to 20 minutes, using less than a half dozen ingredients—and those “ingredi-
ents” are often semiprepared foods, such as canned soups and frozen foods.
Consumer emphasis on convenience limits food choices to the selections of-
fered on menus and products designed for quick preparation. Whether decisions
based on convenience meet a person’s nutrition needs depends on the choices
ethnic foods: foods associated with particular cultural made. Eating a banana or a candy bar may be equally convenient, but the fruit
groups.
provides more vitamins and minerals and less sugar and fat.
cultural competence: having an awareness and acceptance
of cultures and the ability to interact effectively with people Rising food costs have shifted some consumers’ priorities and changed their
of diverse cultures. shopping habits.4 They are less likely to buy higher-priced convenience foods and
4 Chapter 1
more likely to buy less-expensive store brand items and prepare home-cooked
meals. In fact, more than 70 percent of meals are prepared in the home. 5 Those
who frequently prepare their own meals report more positive emotions and
healthier food choices.6 They tend to eat fast food less often and are more likely
to meet dietary guidelines for fat, calcium, fruits, vegetables, and whole grains.
Not surprisingly, when eating out, consumers choose low-cost fast-food outlets
over more expensive fine-dining restaurants. Foods eaten away from home, es-
pecially fast-food meals, tend to be high in kcalories, total fat, saturated fat, and
trans fat—which can contribute to a variety of health problems.7
Unfortunately, healthful diets that include plenty of fruits and vegetables tend
to be more costly than less healthful diets featuring foods containing solid fats
and added sugars.8 These low-cost foods are often high in kcalories and low in
nutrients.9 Consumers can improve the quality of their diets without increasing
their spending by choosing more plant-based foods, such as nuts, legumes, and
whole grains, and fewer refined grains, red and processed meats, and high-fat
milk products.10
Positive and negative associations People tend to like particular foods associ-
ated with happy occasions—such as hot dogs at ball games or cake and ice cream
at birthday parties. By the same token, people can develop aversions and dislike
foods that they ate when they felt sick or that they were forced to eat in negative
situations. Similarly, children learn to like and dislike certain foods when their
parents use foods as rewards or punishments. Negative experiences can have long-
lasting influences on food preferences. More than 50 years after World War II,
veterans who had experienced intense combat in the Pacific dislike Chinese and
Japanese food significantly more than their peers who were not engaged in battle
or those who fought elsewhere.
emotions Emotions guide food choices and eating behaviors.11 Some people can-
not eat when they are emotionally upset. Others may eat in response to a variety
of emotional stimuli—for example, to relieve boredom or depression or to calm
anxiety. A depressed person may choose to eat rather than to call a friend. A per-
son who has returned home from an exciting evening out may unwind with a late-
night snack. These people may find emotional comfort, in part, because foods
can influence the brain’s chemistry and the mind’s response. Carbohydrates and
alcohol, for example, tend to calm, whereas proteins and caffeine are more likely
to stimulate. Eating in response to emotions and stress can easily lead to overeat-
ing and obesity, but it may be helpful at times. For example, sharing food at times
of bereavement serves both the giver’s need to provide comfort and the receiver’s
need to be cared for and to interact with others as well as to take nourishment.
Values Food choices may reflect people’s religious beliefs, political views, or
environmental concerns. For example, some Christians forgo meat on Fridays
during Lent (the period prior to Easter), Jewish law includes an extensive set of
dietary rules that govern the use of foods derived from animals, and Muslims
fast between sunrise and sunset during Ramadan (the ninth month of the Islamic
calendar). Some vegetarians select foods based on their concern for animal rights.
A concerned consumer may boycott fruit picked by migrant workers who have
been exploited. People may buy vegetables from local farmers to save the fuel and
environmental costs of foods shipped from far away. They may also select foods
packaged in containers that can be reused or recycled. Some consumers accept or
reject foods that have been irradiated, grown organically, or genetically modified,
depending on their approval of these processes.
Body Weight and image Sometimes people select certain foods and supplements
that they believe will improve their physical appearance and avoid those they
believe might be detrimental. Such decisions can be beneficial when based on
sound nutrition and fitness knowledge, but decisions based on fads or carried to
an overview of nutrition 5
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CHAPTER II.
REMOVAL FROM GRANDMOTHER’S.
Author’s early home—Its charms—Author’s ignorance of “old master”—His

gradual perception of the truth concerning him—His relations to Col.
Edward Lloyd—Author’s removal to “old master’s” home—His journey
thence—His separation from his grandmother—His grief.
LIVING thus with my grandmother, whose kindness and love stood in

place of my mother’s, it was some time before I knew myself to be a
slave. I knew many other things before I knew that. Her little cabin
had to me the attractions of a palace. Its fence-railed floor—which
was equally floor and bedstead—up stairs, and its clay floor down
stairs, its dirt and straw chimney, and windowless sides, and that
most curious piece of workmanship, the ladder stairway, and the
hole so strangely dug in front of the fire-place, beneath which
grandmamma placed her sweet potatoes, to keep them from frost in
winter, were full of interest to my childish observation. The squirrels,
as they skipped the fences, climbed the trees, or gathered their nuts,
were an unceasing delight to me. There, too, right at the side of the
hut, stood the old well, with its stately and skyward-pointing beam,
so aptly placed between the limbs of what had once been a tree, and
so nicely balanced, that I could move it up and down with only one
hand, and could get a drink myself without calling for help. Nor were
these all the attractions of the place. At a little distance stood Mr.
Lee’s mill, where the people came in large numbers to get their corn
ground. I can never tell the many things thought and felt, as I sat on
the bank and watched that mill, and the turning of its ponderous
wheel. The mill-pond, too, had its charms; and with my pin-hook and
thread line I could get amusing nibbles if I could catch no fish.
It was not long, however, before I began to learn the sad fact that
this house of my childhood belonged not to my dear old
grandmother, but to some one I had never seen, and who lived a
great distance off. I learned, too, the sadder fact, that not only the
home and lot, but that grandmother herself and all the little children
around her belonged to a mysterious personage, called by
grandmother, with every mark of reverence, “Old Master.” Thus early
did clouds and shadows begin to fall upon my path.
I learned that this old master, whose name seemed ever to be
mentioned with fear and shuddering, only allowed the little children
to live with grandmother for a limited time, and that as soon as they
were big enough they were promptly taken away to live with the said
old master. These were distressing revelations indeed. My
grandmother was all the world to me, and the thought of being
separated from her was a most unwelcome suggestion to my
affections and hopes. This mysterious old master was really a man
of some consequence. He owned several farms in Tuckahoe, was
the chief clerk and butler on the home plantation of Colonel Lloyd,
had overseers as well as slaves on his own farms, and gave
directions to the overseers on the farms owned by Colonel Lloyd.
Captain Aaron Anthony, for such is the name and title of my old
master, lived on Colonel Lloyd’s plantation, which was situated on
the Wye river, and which was one of the largest, most fertile, and
best appointed in the State.
About this plantation and this old master I was most eager to
know everything which could be known; and, unhappily for me, all
the information I could get concerning him increased my dread of
being separated from my grandmother and grandfather. I wished it
was possible I could remain small all my life, knowing that the sooner
I grew large the shorter would be my time to remain with them.
Everything about the cabin became doubly dear, and I was sure
there could be no other spot equal to it on earth. But the time came
when I must go, and my grandmother, knowing my fears, in pity for
them, kindly kept me ignorant of the dreaded moment up to the
morning (a beautiful summer morning) when we were to start, and,
indeed, during the whole journey, which, child as I was, I remember
as well as if it were yesterday, she kept the unwelcome truth hidden
from me. The distance from Tuckahoe to Colonel Lloyd’s, where my
old master lived, was full twelve miles, and the walk was quite a
severe test of the endurance of my young legs. The journey would
have proved too severe for me, but that my dear old grandmother
(blessings on her memory) afforded occasional relief by “toteing” me
on her shoulder. Advanced in years as she was, as was evident from
the more than one gray hair which peeped from between the ample
and graceful folds of her newly and smoothly ironed bandana turban,
grandmother was yet a woman of power and spirit. She was
remarkably straight in figure, elastic and muscular in movement. I
seemed hardly to be a burden to her. She would have “toted” me
farther, but I felt myself too much of a man to allow it. Yet while I
walked I was not independent of her. She often found me holding her
skirts lest something should come out of the woods and eat me up.
Several old logs and stumps imposed upon me, and got themselves
taken for enormous animals. I could plainly see their legs, eyes,
ears, and teeth, till I got close enough to see that the eyes were
knots, washed white with rain, and the legs were broken limbs, and
the ears and teeth only such because of the point from which they
were seen.
As the day advanced the heat increased, and it was not until the
afternoon that we reached the much dreaded end of the journey.
Here I found myself in the midst of a group of children of all sizes
and of many colors, black, brown, copper colored, and nearly white. I
had not seen so many children before. As a new comer I was an
object of special interest. After laughing and yelling around me and
playing all sorts of wild tricks they asked me to go out and play with
them. This I refused to do. Grandmamma looked sad, and I could not
help feeling that our being there boded no good to me. She was
soon to lose another object of affection, as she had lost many
before. Affectionately patting me on the head she told me to be a
good boy and go out to play with the children. They are “kin to you,”
she said, “go and play with them.” She pointed out to me my brother
Perry, my sisters, Sarah and Eliza. I had never seen them before,
and though I had sometimes heard of them and felt a curious interest
in them, I really did not understand what they were to me or I to
them. Brothers and sisters we were by blood, but slavery had made
us strangers. They were already initiated into the mysteries of old
master’s domicile, and they seemed to look upon me with a certain
degree of compassion. I really wanted to play with them, but they
were strangers to me, and I was full of fear that my grandmother
might leave for home without taking me with her. Entreated to do so,
however, and that, too, by my dear grandmother, I went to the back
part of the house to play with them and the other children. Play,
however, I did not, but stood with my back against the wall
witnessing the playing of the others. At last, while standing there,
one of the children, who had been in the kitchen, ran up to me in a
sort of roguish glee, exclaiming, “Fed, Fed, grandmamma gone!” I
could not believe it. Yet, fearing the worst, I ran into the kitchen to
see for myself, and lo! she was indeed gone, and was now far away
and “clean” out of sight. I need not tell all that happened now. Almost
heart-broken at the discovery, I fell upon the ground and wept a
boy’s bitter tears, refusing to be comforted. My brother gave me
peaches and pears to quiet me, but I promptly threw them on the
ground. I had never been deceived before, and something of
resentment at this, mingled with my grief at parting with my
grandmother.
It was now late in the afternoon. The day had been an exciting
and wearisome one, and, I know not where, but I suppose I sobbed
myself to sleep, and its balm was never more welcome to any
wounded soul than to mine. The reader may be surprised that I
relate so minutely an incident apparently so trivial and which must
have occurred when I was less than seven years old, but as I wish to
give a faithful history of my experience in slavery, I cannot withhold a
circumstance which at the time affected me so deeply, and which I
still remember so vividly. Besides, this was my first introduction to
the realities of the slave system.
CHAPTER III.
TROUBLES OF CHILDHOOD.
Col. Lloyd’s plantation—Aunt Katy—Her cruelty and ill-nature—Capt.

Anthony’s partiality to Aunt Katy—Allowance of food—Author’s hunger—
Unexpected rescue by his mother—The reproof of Aunt Katy—Sleep—A
slave-mother’s love—Author’s inheritance—His mother’s acquirements—
Her death.
ONCE established on the home plantation of Col. Lloyd—I was with

the children there, left to the tender mercies of Aunt Katy, a slave
woman who was to my master what he was to Col. Lloyd. Disposing
of us in classes or sizes, he left to Aunt Katy all the minor details
concerning our management. She was a woman who never allowed
herself to act greatly within the limits of delegated power, no matter
how broad that authority might be. Ambitious of old master’s favor,
ill-tempered and cruel by nature, she found in her present position an
ample field for the exercise of her ill-omened qualities. She had a
strong hold upon old master, for she was a first-rate cook, and very
industrious. She was therefore greatly favored by him—and as one
mark of his favor she was the only mother who was permitted to
retain her children around her, and even to these, her own children,
she was often fiendish in her brutality. Cruel, however, as she
sometimes was to her own children, she was not destitute of
maternal feeling, and in her instinct to satisfy their demands for food,
she was often guilty of starving me and the other children. Want of
food was my chief trouble during my first summer here. Captain
Anthony, instead of allowing a given quantity of food to each slave,
committed the allowance for all to Aunt Katy, to be divided by her,
after cooking, amongst us. The allowance consisted of coarse corn
meal, not very abundant, and which by passing through Aunt Katy’s
hands, became more slender still for some of us. I have often been
so pinched with hunger, as to dispute with old “Nep,” the dog, for the
crumbs which fell from the kitchen table. Many times have I followed
with eager step, the waiting-girl when she shook the table-cloth, to
get the crumbs and small bones flung out for the dogs and cats. It
was a great thing to have the privilege of dipping a piece of bread
into the water in which meat had been boiled—and the skin taken
from the rusty bacon was a positive luxury. With this description of
the domestic arrangements of my new home, I may here recount a
circumstance which is deeply impressed on my memory, as affording
a bright gleam of a slave-mother’s love, and the earnestness of a
mother’s care. I had offended Aunt Katy. I do not remember in what
way, for my offences were numerous in that quarter, greatly
depending upon her moods as to their heinousness, and she had
adopted her usual mode of punishing me: namely, making me go all
day without food. For the first hour or two after dinner time, I
succeeded pretty well in keeping up my spirits; but as the day wore
away, I found it quite impossible to do so any longer. Sundown
came, but no bread; and in its stead came the threat from Aunt Katy,
with a scowl well suited to its terrible import, that she would starve
the life out of me. Brandishing her knife, she chopped off the heavy
slices of bread for the other children, and put the loaf away,
muttering all the while her savage designs upon myself. Against this
disappointment, for I was expecting that her heart would relent at
last, I made an extra effort to maintain my dignity, but when I saw the
other children around me with satisfied faces, I could stand it no
longer. I went out behind the kitchen wall and cried like a fine fellow.
When wearied with this, I returned to the kitchen, sat by the fire and
brooded over my hard lot. I was too hungry to sleep. While I sat in
the corner, I caught sight of an ear of Indian corn upon an upper
shelf. I watched my chance and got it; and shelling off a few grains, I
put it back again. These grains I quickly put into the hot ashes to
roast. I did this at the risk of getting a brutal thumping, for Aunt Katy
could beat as well as starve me. My corn was not long in roasting,
and I eagerly pulled it from the ashes, and placed it upon a stool in a
clever little pile. I began to help myself, when who but my own dear
mother should come in. The scene which followed is beyond my
power to describe. The friendless and hungry boy, in his extremest
need, found himself in the strong protecting arms of his mother. I
have before spoken of my mother’s dignified and impressive manner.
I shall never forget the indescribable expression of her countenance
when I told her that Aunt Katy had said she would starve the life out
of me. There was deep and tender pity in her glance at me, and a
fiery indignation at Aunt Katy at the same moment, and while she
took the corn from me, and gave in its stead a large ginger cake, she
read Aunt Katy a lecture which was never forgotten. That night I
learned as I had never learned before, that I was not only a child, but
somebody’s child. I was grander upon my mother’s knee than a king
upon his throne. But my triumph was short. I dropped off to sleep,
and waked in the morning to find my mother gone and myself at the
mercy again of the virago in my master’s kitchen, whose fiery wrath
was my constant dread.
The Last Time he saw his Mother.
My mother had walked twelve miles to see me, and had the
same distance to travel over again before the morning sunrise. I do
not remember ever seeing her again. Her death soon ended the little
communication that had existed between us, and with it, I believe, a
life full of weariness and heartfelt sorrow. To me it has ever been a
grief that I knew my mother so little, and have so few of her words
treasured in my remembrance. I have since learned that she was the
only one of all the colored people of Tuckahoe who could read. How
she acquired this knowledge I know not, for Tuckahoe was the last
place in the world where she would have been likely to find facilities
for learning. I can therefore fondly and proudly ascribe to her, an
earnest love of knowledge. That a field-hand should learn to read in
any slave State is remarkable, but the achievements of my mother,
considering the place and circumstances, was very extraordinary. In
view of this fact, I am happy to attribute any love of letters I may
have, not to my presumed Anglo-Saxon paternity, but to the native
genius of my sable, unprotected, and uncultivated mother—a woman
who belonged to a race whose mental endowments are still
disparaged and despised.
CHAPTER IV.
A GENERAL SURVEY OF THE SLAVE
PLANTATION.
Home Plantation of Colonel Lloyd—Its Isolation—Its Industries—The Slave

Rule—Power of Overseers—Author finds some Enjoyment—Natural
Scenery—Sloop “Sally Lloyd”—Wind Mill—Slave Quarter—“Old Master’s”
House—Stables, Store Houses, etc., etc.—The Great House—Its
Surroundings—Lloyd—Burial-Place—Superstition of Slaves—Colonel
Lloyd’s Wealth—Negro Politeness—Doctor Copper—Captain Anthony—
His Family—Master Daniel Lloyd—His Brothers—Social Etiquette.
IT was generally supposed that slavery in the State of Maryland

existed in its mildest form, and that it was totally divested of those
harsh and terrible peculiarities which characterized the slave system
in the Southern and South Western States of the American Union.
The ground of this opinion was the contiguity of the free States, and
the influence of their moral, religious, and humane sentiments.
Public opinion was, indeed, a measurable restraint upon the cruelty
and barbarity of masters, overseers, and slave-drivers, whenever
and wherever it could reach them; but there were certain secluded
and out of the way places, even in the State of Maryland, fifty years
ago, seldom visited by a single ray of healthy public sentiment,
where slavery, wrapt in its own congenial darkness, could and did
develop all its malign and shocking characteristics, where it could be
indecent without shame, cruel without shuddering, and murderous
without apprehension or fear of exposure, or punishment. Just such
a secluded, dark, and out of the way place, was the home plantation
of Colonel Edward Lloyd, in Talbot county, eastern shore of
Maryland. It was far away from all the great thoroughfares of travel
and commerce, and proximate to no town or village. There was
neither school-house nor town-house in its neighborhood. The
school-house was unnecessary, for there were no children to go to
school. The children and grandchildren of Col. Lloyd were taught in
the house by a private tutor (a Mr. Page from Greenfield,
Massachusetts, a tall, gaunt, sapling of a man, remarkably dignified,
thoughtful, and reticent, and who did not speak a dozen words to a
slave in a whole year). The overseer’s children went off somewhere
in the State to school, and therefore could bring no foreign or
dangerous influence from abroad to embarrass the natural operation
of the slave system of the place. Not even the commonest
mechanics, from whom there might have been an occasional
outburst of honest and telling indignation at cruelty and wrong on
other plantations, were white men here. Its whole public was made
up of and divided into three classes, slaveholders, slaves, and
overseers. Its blacksmiths, wheelwrights, shoemakers, weavers, and
coopers, were slaves. Not even commerce, selfish and indifferent to
moral considerations as it usually is, was permitted within its
secluded precincts. Whether with a view of guarding against the
escape of its secrets, I know not, but it is a fact, that every leaf and
grain of the products of this plantation and those of the neighboring
farms, belonging to Col. Lloyd, were transported to Baltimore in his
own vessels, every man and boy on board of which, except the
captain, were owned by him as his property. In return, everything
brought to the plantation came through the same channel. To make
this isolation more apparent it may be stated that the adjoining
estates to Col. Lloyd’s were owned and occupied by friends of his,
who were as deeply interested as himself in maintaining the slave
system in all its rigor. These were the Tilgmans, the Goldboroughs,
the Lockermans, the Pacas, the Skinners, Gibsons, and others of
lesser affluence and standing.
The fact is, public opinion in such a quarter, the reader must see,
was not likely to be very efficient in protecting the slave from cruelty.
To be a restraint upon abuses of this nature, opinion must emanate
from humane and virtuous communities, and to no such opinion or
influence was Col. Lloyd’s plantation exposed. It was a little nation
by itself, having its own language, its own rules, regulations, and
customs. The troubles and controversies arising here were not
settled by the civil power of the State. The overseer was the
important dignitary. He was generally accuser, judge, jury, advocate,
and executioner. The criminal was always dumb—and no slave was
allowed to testify, other than against his brother slave.
There were, of course, no conflicting rights of property, for all the
people were the property of one man, and they could themselves
own no property. Religion and politics were largely excluded. One
class of the population was too high to be reached by the common
preacher, and the other class was too low in condition and ignorance
to be much cared for by religious teachers, and yet some religious
ideas did enter this dark corner.
This, however, is not the only view which the place presented.
Though civilization was in many respects shut out, nature could not
be. Though separated from the rest of the world, though public
opinion, as I have said, could seldom penetrate its dark domain,
though the whole place was stamped with its own peculiar iron-like
individuality, and though crimes, high-handed and atrocious, could
be committed there with strange and shocking impunity, it was to
outward seeming a most strikingly interesting place, full of life,
activity, and spirit, and presented a very favorable contrast to the
indolent monotony and languor of Tuckahoe. It resembled in some
respects descriptions I have since read of the old baronial domains
of Europe. Keen as was my regret, and great as was my sorrow, at
leaving my old home, I was not long in adapting myself to this my
new one. A man’s troubles are always half disposed of when he
finds endurance the only alternative. I found myself here; there was
no getting away; and naught remained for me but to make the best
of it. Here were plenty of children to play with, and plenty of pleasant
resorts for boys of my age and older. The little tendrils of affection so
rudely broken from the darling objects in and around my
grandmother’s home, gradually began to extend and twine
themselves around the new surroundings. Here for the first time I
saw a large wind-mill, with its wide-sweeping white wings, a
commanding object to a child’s eye. This was situated on what was
called Long Point—a tract of land dividing Miles river from the Wye. I
spent many hours here watching the wings of this wondrous mill. In
the river, or what was called the “Swash,” at a short distance from
the shore, quietly lying at anchor, with her small row boat dancing at
her stern, was a large sloop, the Sally Lloyd, called by that name in
honor of the favorite daughter of the Colonel. These two objects, the
sloop and mill, as I remember, awakened thoughts, ideas, and
wondering. Then here were a great many houses, human habitations
full of the mysteries of life at every stage of it. There was the little red
house up the road, occupied by Mr. Seveir, the overseer; a little
nearer to my old master’s stood a long, low, rough building literally
alive with slaves of all ages, sexes, conditions, sizes, and colors.
This was called the long quarter. Perched upon a hill east of our
house, was a tall dilapidated old brick building, the architectural
dimensions of which proclaimed its creation for a different purpose,
now occupied by slaves, in a similar manner to the long quarters.
Besides these, there were numerous other slave houses and huts,
scattered around in the neighborhood, every nook and corner of
which, were completely occupied.
Old master’s house, a long brick building, plain but substantial,
was centrally located, and was an independent establishment.
Besides these houses there were barns, stables, store houses,
tobacco-houses, blacksmith shops, wheelwright shops, cooper
shops; but above all there stood the grandest building my young
eyes had ever beheld, called by everyone on the plantation the great
house. This was occupied by Col. Lloyd and his family. It was
surrounded by numerous and variously shaped out-buildings. There
were kitchens, wash-houses, dairies, summer-houses, green-
houses, hen-houses, turkey-houses, pigeon-houses, and arbors of
many sizes and devices, all neatly painted or whitewashed—
interspersed with grand old trees, ornamental and primitive, which
afforded delightful shade in summer and imparted to the scene a
high degree of stately beauty. The great house itself was a large
white wooden building with wings on three sides of it. In front a broad
portico extended the entire length of the building, supported by a
long range of columns, which gave to the Colonel’s home an air of
great dignity and grandeur. It was a treat to my young and gradually
opening mind to behold this elaborate exhibition of wealth, power,
and beauty.
The carriage entrance to the house was by a large gate, more
than a quarter of a mile distant. The intermediate space was a
beautiful lawn, very neatly kept and cared for. It was dotted thickly
over with trees and flowers. The road or lane from the gate to the
great house was richly paved with white pebbles from the beach,
and in its course formed a complete circle around the lawn. Outside
this select enclosure were parks, as about the residences of the
English nobility, where rabbits, deer, and other wild game might be
seen peering and playing about, with “none to molest them or make
them afraid.” The tops of the stately poplars were often covered with
red-winged blackbirds, making all nature vocal with the joyous life
and beauty of their wild, warbling notes. These all belonged to me as
well as to Col. Edward Lloyd, and, whether they did or not, I greatly
enjoyed them. Not far from the great house were the stately
mansions of the dead Lloyds—a place of somber aspect. Vast
tombs, embowered beneath the weeping willow and the fir tree, told
of the generations of the family, as well as their wealth. Superstition
was rife among the slaves about this family burying-ground. Strange
sights had been seen there by some of the older slaves, and I was
often compelled to hear stories of shrouded ghosts, riding on great
black horses, and of balls of fire which had been seen to fly there at
midnight, and of startling and dreadful sounds that had been
repeatedly heard. Slaves knew enough of the Orthodox theology at
the time, to consign all bad slaveholders to hell, and they often
fancied such persons wishing themselves back again to wield the
lash. Tales of sights and sounds strange and terrible, connected with
the huge black tombs, were a great security to the grounds about
them, for few of the slaves had the courage to approach them during
the day time. It was a dark, gloomy and forbidding place, and it was
difficult to feel that the spirits of the sleeping dust there deposited
reigned with the blest in the realms of eternal peace.
Here was transacted the business of twenty or thirty different
farms, which, with the slaves upon them, numbering, in all, not less
than a thousand, all belonged to Col. Lloyd. Each farm was under
the management of an overseer, whose word was law.
Mr. Lloyd at this time was very rich. His slaves alone, numbering
as I have said not less than a thousand, were an immense fortune,
and though scarcely a month passed without the sale of one or more
lots to the Georgia traders, there was no apparent diminution in the
number of his human stock. The selling of any to the State of
Georgia was a sore and mournful event to those left behind, as well
as to the victims themselves.
The reader has already been informed of the handicrafts carried
on here by the slaves. “Uncle” Toney was the blacksmith, “Uncle”
Harry the Cartwright, and “Uncle” Abel was the shoemaker, and
these had assistants in their several departments. These mechanics
were called “Uncles” by all the younger slaves, not because they
really sustained that relationship to any, but according to plantation
etiquette as a mark of respect, due from the younger to the older
slaves. Strange and even ridiculous as it may seem, among a people
so uncultivated and with so many stern trials to look in the face,
there is not to be found among any people a more rigid enforcement
of the law of respect to elders than is maintained among them. I set
this down as partly constitutional with the colored race and partly
conventional. There is no better material in the world for making a
gentleman than is furnished in the African.
Among other slave notabilities, I found here one called by
everybody, white and colored, “Uncle” Isaac Copper. It was seldom
that a slave, however venerable, was honored with a surname in
Maryland, and so completely has the south shaped the manners of
the north in this respect that their right to such honor is tardily
admitted even now. It goes sadly against the grain to address and
treat a negro as one would address and treat a white man. But once
in a while, even in a slave state, a negro had a surname fastened to
him by common consent. This was the case with “Uncle” Isaac
Copper. When the “Uncle” was dropped, he was called Doctor
Copper. He was both our Doctor of Medicine and our Doctor of
Divinity. Where he took his degree I am unable to say, but he was
too well established in his profession to permit question as to his
native skill, or attainments. One qualification he certainly had. He
was a confirmed cripple, wholly unable to work, and was worth
nothing for sale in the market. Though lame, he was no sluggard. He
made his crutches do him good service, and was always on the alert
looking up the sick, and such as were supposed to need his aid and
counsel. His remedial prescriptions embraced four articles. For
diseases of the body, epsom salts and castor oil; for those of the
soul, the “Lord’s prayer,” and a few stout hickory switches.
I was early sent to Doctor Isaac Copper, with twenty or thirty
other children, to learn the Lord’s prayer. The old man was seated on
a huge three-legged oaken stool, armed with several large hickory
switches, and from the point where he sat, lame as he was, he could
reach every boy in the room. After standing a while to learn what was
expected of us, he commanded us to kneel down. This done, he told
us to say everything he said. “Our Father”—this we repeated after
him with promptness and uniformity—“who art in Heaven,” was less
promptly and uniformly repeated, and the old gentleman paused in
the prayer to give us a short lecture, and to use his switches on our
backs.
Everybody in the South seemed to want the privilege of whipping
somebody else. Uncle Isaac, though a good old man, shared the
common passion of his time and country. I cannot say I was much
edified by attendance upon his ministry. There was even at that time
something a little inconsistent and laughable, in my mind, in the
blending of prayer with punishment. I was not long in my new home
before I found that the dread I had conceived of Captain Anthony
was in a measure groundless. Instead of leaping out from some
hiding place and destroying me, he hardly seemed to notice my
presence. He probably thought as little of my arrival there, as of an
additional pig to his stock. He was the chief agent of his employer.
The overseers of all the farms composing the Lloyd estate, were in
some sort under him. The Colonel himself seldom addressed an
overseer, or allowed himself to be addressed by one. To Captain
Anthony, therefore, was committed the headship of all the farms. He
carried the keys of all the storehouses, weighed and measured the
allowances of each slave, at the end of each month; superintended
the storing of all goods brought to the store-house; dealt out the raw
material to the different handicraftsmen, shipped the grain, tobacco,
and all other saleable produce of the numerous farms to Baltimore,
and had a general oversight of all the workshops of the place. In
addition to all this he was frequently called abroad to Easton and
elsewhere in the discharge of his numerous duties as chief agent of
the estate.
The family of Captain Anthony consisted of two sons—Andrew
and Richard, his daughter Lucretia and her newly married husband,
Captain Thomas Auld. In the kitchen were Aunt Katy, Aunt Esther,
and ten or a dozen children, most of them older than myself. Capt.
Anthony was not considered a rich slaveholder, though he was pretty
well off in the world. He owned about thirty slaves and three farms in
the Tuckahoe district. The more valuable part of his property was in
slaves, of whom he sold one every year, which brought him in seven
or eight hundred dollars, besides his yearly salary and other revenue
from his lands.
I have been often asked during the earlier part of my free life at
the north, how I happened to have so little of the slave accent in my
speech. The mystery is in some measure explained by my
association with Daniel Lloyd, the youngest son of Col. Edward
Lloyd. The law of compensation holds here as well as elsewhere.
While this lad could not associate with ignorance without sharing its
shade, he could not give his black playmates his company without
giving them his superior intelligence as well. Without knowing this, or
caring about it at the time, I, for some cause or other, was attracted
to him and was much his companion.
I had little to do with the older brothers of Daniel—Edward and
Murray. They were grown up and were fine looking men. Edward
was especially esteemed by the slave children and by me among the
rest, not that he ever said anything to us or for us which could be
called particularly kind. It was enough for us that he never looked or
acted scornfully toward us. The idea of rank and station was rigidly
maintained on this estate. The family of Captain Anthony never
visited the great house, and the Lloyds never came to our house.
Equal non-intercourse was observed between Captain Anthony’s
family and the family of Mr. Seveir, the overseer.
Such, kind readers, was the community and such the place in
which my earliest and most lasting impressions of the workings of
slavery were received—of which impressions you will learn more in
the after coming chapters of this book.
CHAPTER V.
A SLAVEHOLDER’S CHARACTER.
Increasing acquaintance with old Master—Evils of unresisted passion—

Apparent tenderness—A man of trouble—Custom of muttering to himself
—Brutal outrage—A drunken overseer—Slaveholder’s impatience—
Wisdom of appeal—A base and selfish attempt to break up a courtship.
ALTHOUGH my old master, Captain Anthony, gave me, at the first of

my coming to him from my grandmother’s, very little attention, and
although that little was of a remarkably mild and gentle description, a
few months only were sufficient to convince me that mildness and
gentleness were not the prevailing or governing traits of his
character. These excellent qualities were displayed only
occasionally. He could, when it suited him, appear to be literally
insensible to the claims of humanity. He could not only be deaf to the
appeals of the helpless against the aggressor, but he could himself
commit outrages deep, dark, and nameless. Yet he was not by
nature worse than other men. Had he been brought up in a free
state, surrounded by the full restraints of civilized society—restraints
which are necessary to the freedom of all its members, alike and
equally, Capt. Anthony might have been as humane a man as are
members of such society generally. A man’s character always takes
its hue, more or less, from the form and color of things about him.
The slaveholder, as well as the slave, was the victim of the slave
system. Under the whole heavens there could be no relation more
unfavorable to the development of honorable character than that
sustained by the slaveholder to the slave. Reason is imprisoned here
and passions run wild. Could the reader have seen Captain Anthony
gently leading me by the hand, as he sometimes did, patting me on
the head, speaking to me in soft, caressing tones and calling me his
little Indian boy, he would have deemed him a kind-hearted old man,
and really almost fatherly to the slave boy. But the pleasant moods of
a slaveholder are transient and fitful. They neither come often nor
remain long. The temper of the old man was subject to special trials,
but since these trials were never borne patiently, they added little to
his natural stock of patience. Aside from his troubles with his slaves
and those of Mr. Lloyd’s, he made the impression upon me of being
an unhappy man. Even to my child’s eye he wore a troubled and at
times a haggard aspect. His strange movements excited my curiosity
and awakened my compassion. He seldom walked alone without
muttering to himself, and he occasionally stormed about as if defying
an army of invisible foes. Most of his leisure was spent in walking
around, cursing and gesticulating as if possessed by a demon. He
was evidently a wretched man, at war with his own soul and all the
world around him. To be overheard by the children disturbed him
very little. He made no more of our presence than that of the ducks
and geese he met on the green. But when his gestures were most
violent, ending with a threatening shake of the head and a sharp
snap of his middle finger and thumb, I deemed it wise to keep at a
safe distance from him.
One of the first circumstances that opened my eyes, to the
cruelties and wickedness of slavery and its hardening influences
upon my old master, was his refusal to interpose his authority to
protect and shield a young woman, a cousin of mine, who had been
most cruelly abused and beaten by his overseer in Tuckahoe. This
overseer, a Mr. Plummer, was like most of his class, little less than a
human brute; and in addition to his general profligacy and repulsive
coarseness, he was a miserable drunkard, a man not fit to have the
management of a drove of mules. In one of his moments of drunken
madness he committed the outrage which brought the young woman
in question down to my old master’s for protection. The poor girl, on
her arrival at our house, presented a most pitiable appearance. She
had left in haste and without preparation, and probably without the
knowledge of Mr. Plummer. She had traveled twelve miles, bare-
footed, bare-necked, and bare-headed. Her neck and shoulders
were covered with scars newly made, and not content with marring
her neck and shoulders with the cowhide, the cowardly wretch had

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Carbohydrate Digestion 105

6-2 Digestion and Absorption of Proteins 175

and Adolescence 477

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17-1 Nutrition in Health Care 555

table of Contents xiii

Short Bowel Syndrome 726

xiv table of Contents

Dietary Reference Intakes (DRI) A

xvi table of Contents

benefits and risks of weight loss and weight gain. Chapters 10

Nutrition in Your Life/Nutrition CaSE

At the end of Chapters 1 through 16, a Nutrition Portfolio

troesophageal reflux disease, and bariatric surgery; added

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instructor’s Companion Site Sharon Rady Rolfes

Author’s early home—Its charms—Author’s ignorance of “old master”—His

LIVING thus with my grandmother, whose kindness and love stood in

Col. Lloyd’s plantation—Aunt Katy—Her cruelty and ill-nature—Capt.

ONCE established on the home plantation of Col. Lloyd—I was with

Home Plantation of Colonel Lloyd—Its Isolation—Its Industries—The Slave

IT was generally supposed that slavery in the State of Maryland

Increasing acquaintance with old Master—Evils of unresisted passion—

ALTHOUGH my old master, Captain Anthony, gave me, at the first of

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