SCHOOL OF NURSING

NUTDTH1
Nutrition and Diet
NUTDTL1 Therapy

Prepared by: A Self-regulated Learning Module

Cesaria A. Yalong, MAN, RN

Juvy E. Carame, PhD, MAN

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 TABLE OF CONTENTS
PAGE
CONTENTS
NO.
COVER PAGE . . . . . . . . . . . . . . 1
TABLE OF CONTENTS . . . . . . . . . . . 2
INTRODUCTION . . . . . . . . . . . . . 5
COURSE STUDY GUIDE . . . . . . . . . . . 6
UNIT I – INTRODUCTION TO NUTRITION 11
LESSON 1. Definition of terms . . . . . . . . . . 13
Nutrition Facts and Myths Activity . . . . . . 18
LESSON 2. Basic Nutrition Concepts . . . . . . . 19
1. Nutrition Facts and Myths Discussion . . . . 21
2. Crossword Puzzle Activity . . . . . . . . 23
3. Review of Anatomy and Physiology of 25
Digestive System . . . . . . . . . 28
4. Overview of digestion, absorption,
and Metabolism . . . . . . . . . . 30
UNIT II – BASIC TOOLS IN NUTRITION . . . . . .
LESSON 1. Basic Food Guides . . . . . . . . . 34
Dietary Guidelines . . . . . . . . . 36
Basic 3 Food Group . . . . . . . . . . 40
Basic 6 Food Group . . . . . . . . . . 43
LESSON 2. FNRI & USDA Food Guide Pyramid . . . . . 56
LESSON 3. RDA or RENI . . . . . . . . . . . 57
LESSON 4. FEL (Food Exchange List) . . . . . . . 66
LESSON 5. Food labelling . . . . . . . . . . . 73
UNIT III – SIX ESSENTIAL NUTRIENTS . . . . . . . 96
LESSON 1. Classification by predominant function . . . . 97

LESSON 2. Carbohydrates . . . . . . . . . . . 100

LESSON 3. Protein . . . . . . . . . . . . 126

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LESSON 4. Fats . . . . . . . . . . . . . 139

LESSON 5. Vitamins and Minerals . . . . . . 156

LESSON 6. Water . . . . . . . . . . . . . 221

UNIT IV – DIETARY COMPUTATIONS . . . . . . . 240

. 241
A. Determining the age in years/months . . . . . .
B. Determining Ideal Body Weight/ Desired Body Weight
1. Infants
a. 1-6 months
b. 7-12 months 243
2. Children(13-18y/o) 244
a. Gomez Classification . . . . . . .

3. Adults
a. Hamwi method . . . . . . . . . . 246
b. NDAP method . . . . . . . . . . 246
c. BMI 247
C. Dietary calculations
Total Energy Allowance (TEA) . . . . . . . 248
1. Energy Intake . . . . . . . . . . . . . 248
2. Basal Metabolic Rate (BMR) . . . . . . . . . 249
3. Factors affecting BMR . . . . . . . . . . 251
4. Total Energy Allowance for Infants / Children /
Adolescent / Adult . . . . . . . . 254
4. Calculating Nutrient Needs . . . . . . . . . 258
Meal Planning with Exchange List . . . . . . . . . 259

UNIT V – Nutritional Assessment (NUTRITION-FOCUSED NURSING

CARE PLAN) . . . . . . . . . . . . . . . 263
A. Assessment . . . . . . . . . . . . . 264
B. Nursing Diagnosis . . . . . . . . . . . 276

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 C. Planning . . . . . . . . . . . . . . 276
D. Implementation . . . . . . . . . . . . . 277
E. Evaluation . . . . . . . . . . . . . . 278
UNIT VI. NUTRITION THROUGHOUT THE LIFESPAN . . . 283
A. Pregnancy . . . . . . . . . . . . . . 284
B. Lactation . . . . . . . . . . . . . . 307
C. Infancy . . . . . . . . . . . . . . 337
D. Preschoolers & Schoolers / Childhood . . . . . . . 357
E. Adolescence . . . . . . . . . . . . . 383
F. Adulthood . . . . . . . . . . . . . . 400
UNIT VII.A. DIET THERAPY 415
A. General diets . . . . . . . . . . . . . 418
B. Diets modified in consistency . . . . . . . . . 420
C. Diets Modified in Composition . . . . . . . . . 425
UNIT VII.B. ENTERAL TUBE FEEDING . . . . . . . 433

UNIT VIII. DIETARY MANAGEMENT OF SOME COMMON

MEDICAL CONDITIONS . . . . . . . . . . 445

EVALUATION . . . . . . . . . . . . . . 460
REFERENCES . . . . . . . . . . . . . . 462
APPENDICES . . . . . . . . . . . . . . 464
Performance Checklist on NGT insertion, Irrigation,
Feeding, Lavage, and Removal . . . . . . . . . . 465
Recommended Energy Intake 469
Rubrics . . . . . . . . . . . . . . . . 475
Food Exchange List . . . . . . . . . . . . . 481
Syllabus . . . . . . . . . . . . . . . . 489

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 INTRODUCTION

Nutrition and Diet Therapy is a course offered to students enrolled in the

BSN Program. This course includes basic facts of nutrition and various aspects
of therapeutic nutrition needed by nurses in effectively dealing with their clients. It
also covers nutrients and other substances and their action, their interaction and
balance with health and diseases and the process by which human being
ingests, digests, absorbs, transports, utilizes and excretes food substances. It will
also focus in the therapeutic and food service aspects of the delivery of
nutritional services in hospitals and other healthcare institutions.

Although the nurse may not be the primary mover in nutrition, the
provision of service as a collaborator in effecting nutrition care is a significant role
of a nurse, since one of the major objectives of each nurse is to maintain
homeostasis and good health through sound nutrition.

At the end of the course, given relevant situation/condition, you will be

able to:

1. apply appropriate principles and techniques to assist clients in maintaining

nutritional health

2.utilize knowledge of diet therapy in assisting clients needing dietary

modifications

There are eight units/ chapters in this course. Each chapter corresponds
to the number of each module. The module includes all the topics to be learned
with their corresponding learning outcomes for you to achieve.

Unit I: Introduction to nutrition and diet therapy

Unit II: Basic tools in nutrition
Unit III: Six Essential Nutrients
Unit IV: Dietary computations
Unit V: Nutrition-focused Nursing Care Plan
Unit VI: Nutrition across the lifespan

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 Unit VII: Diet therapy
Unit VIII: Dietary management of some common medical
conditions

With the different activities provided in every module, may you find this
course material engaging and challenging as it develops your critical thinking and
problem-solving skills.

COURSE STUDY GUIDE

LET'S GET STARTED!

This module was prepared to provide all the information to cater to your
learning needs. This will deepen your understanding of Nutrition and its
application in the practice of nursing.

With proper assistance from parents/ guardians and my help as your

facilitator, may you realize its value and engage yourself in learning its contents
and be able to meet all the requirements contained within this module.

Please take some time to read the following tips and guidelines:

1. ORIENTATION - This is an offline course which requires

students to complete a variety of
activities.
- Course objectives may be met through
an individual study using suggested
resources, and formal as well as
informal exchanges of concept

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 understanding with classmates or
instructor regarding specific topics.
- Teaching methods will include but not
limited to audio-visual aids, and
independent study of text and resource
materials.
- The instructor may serve as a guide
and consultant while the student is
responsible for identifying their own
learning needs, self-direction, seeking
consultation, and demonstrating of the
course objectives.

2. SYLLABUS & - Explanation of the contents of the

GRADING SYSTEM syllabus and how the grading system
works for this semester will be done on
the first meeting during orientation. You
can find a copy of this on the
appendices of this module.

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3. SELF-DISCIPLINE AND - To be successful in distance learning,
MOTIVATION you should have self-discipline and
motivation. This characteristic is usually
seen in the learner's ability to stay
current with class assignments, and
develop and adhere to a schedule for
activities.
- You can do this by creating a place for
studying to work in peace, and prioritize
studying &/ reading over other activities
on your set time or schedule.
- Since all of your activities are
asynchronous/ provided offline, you can
complete your assignments at different
times throughout the day or week.
However, with this freedom and
flexibility comes greater responsibility. It
will be up to you to motivate yourself to
keep up with assigned tasks.

4. COMMUNICATION AND - Preferred communication methods are

SUPPORT individualized office hours, email, or via
cell phone.
- If a phone call is not answered, please
leave a message and/ or send an e-
mail using the direct e-mail link on the
course home page.
- You will be treated with collegial
respect and you are expected to

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 communicate likewise in a professional
manner.

For inquiries and other concerns, students,

parents, or guardians may directly contact the
following management personnel through the
contact details provided below:

Vice President for Academic

Affairs [email protected]
[email protected]
[email protected]
School of Nursing Facebook: Nursing UB
GUIDANCE SERVICES

Online consultation and counseling are offered by the Center for

Counseling and Student Development (CCSD). To avail of these services,
students are required to register online and provide their consent in compliance
with the Data Privacy Act.

5. POLICY ON - Intellectual property refers to anything

INTELLECTUAL created by someone, including but not
PROPERTY RIGHTS limited to, inventions, literary works,
AND PLAGIARISM items created by artists (e.g., artwork,
musical pieces), symbols, designs,
images, pictures and even names that
are used for commercial purposes.

- Plagiarism is defined as using or

copying words or ideas from someone
else’s work and claiming as one’s
own. Plagiarism also includes implicit

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 or explicit failure to cite sources of a
quotation and paraphrasing most of
the words or ideas of a source without
giving credit to the author. Any form of
activity that constitutes plagiarism
must be avoided by students,
teaching, and non-teaching
personnel.

- Cheating in one’s work constitutes

unethical and deceitful practice and
must never be committed.

- Academic honesty is encouraged at

all times.

- Violators shall be dealt with following

the stipulations in the appropriate
student, teaching or non-teaching
manual.

Reference: UB’s Flexible Learning Approach: A Primer for Higher Education

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 UNIT I
INTRODUCTION TO NUTRIRION

This chapter gives us an overview of what is the relationship between nutrition

and health. This module starts with a pretest that will not be graded; this will be used as
a tool to determine your pre-existing knowledge on the course. Through this, we will find
out where do you need more instruction on and what you may already know. In this way,
we will be able to learn about your interests and readiness for the content.

This chapter will include the different terms and concepts in nutrition, such as
nutrition myths and facts, views on a healthy diet or eating, and how a food/ nutrient is
digested inside the body. By reading and knowing these basic concepts in
nutrition, we will be able to deepen our understanding of the magnitude and
importance of nutrition in maintaining health and in the prevention and
correction of illness and disease.

As HIPPOCRATES believed, 'The body must be treated as a

whole and not just a series of parts'; He also quoted, 'let thy food be thy medicine and
the medicine be thy food.' Today Hippocrates is known as the "Father of Medicine."

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 PRETEST #1

Let us then test your Nutrition IQ!

WHAT IS YOUR NUTRITION IQ AS YOU BEGIN THE STUDY OF NUTRITION?

Some of the following statements are true and some are false. Read each
question and then write your answer in the blank.

_____ 1. A daily diet for weight reduction should have adequate amounts of protein,
carbohydrate fat, minerals, and vitamins but should furnish less than the daily
requirements for k calories.
_____ 2. Margarine and butter contain the same number of calories.
_____ 3. Food allergies and food intolerance are the same thing.
_____ 4. A well person who eats the right kinds and amount of foods everyday generally
does not need to take vitamin pills to meet the Daily Reference Intake.
_____ 5. Skipping meals is a good way to lose weight safely.
_____ 6. Children should have dessert unless they clean their plates.
_____ 7. Calcium supplements are the best way to increase calcium intake if the
individual does not like milk.
_____ 8. The risk of heart disease can be reduced by following a diet low in saturated
fat, cholesterol, and sodium.
_____ 9. White bread is the same as wheat bread.
_____ 10. Olives, olive oil, avocados, and most nuts are low saturated fat, and moderate
amounts are fine for a low-cholesterol diet.
_____ 11. People with diverticulosis should eat dried beans and peas because they are
high in fiber, depending on individual tolerance.
_____ 12. An obese woman should lose weight if she becomes pregnant.
_____ 13. Children should be forced to eat vegetables for their own good.
_____ 14. Baby teeth are not important, and therefore good dental care and oral hygiene
should wait until children are old enough to brush their own teeth.
_____ 15. It is possible for elderly people to develop muscle mass.
_____ 16. Not all food additives are harmful.

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_____ 17. If a survivor of cancer gains weight, it is always because of consumption of
too many k calories.
_____ 18. Natural sweets such as honey may be eaten freely by people with diabetes.
_____ 19. Drinking water at meal times may aid digestion if the water is not used to
wash down food.
_____ 20. A teenager needs more milk every day than does a preschooler.

LESSON 1
DEFINITION OF TERMS
WEEK
ACTIVITIES
1 TOPIC LEARNING OUTCOMES
Day 1 Syllabus Orientation
Expectations
Day 2 Upon completion of this lesson, you will be able to: 1. Pretest
2. Word search
1. define common terms used in the study of puzzle
nutrition. 3. Sorting myths
2. differentiate between food, nutrients and from facts
nutrition.
3. explain different myths and facts about
nutrition.

COMMON TERMS USED IN THE STUDY OF NUTRITION

1. NUTRITION: The study of how your body uses the food that you eat; It is the science
of food in relation to health of an individual, community, or society and the process
through which food is used to sustain life & growth.

2. MALNUTRITION: “Poor nutritional status”; A state in which a prolonged lack of one or

more nutrients retards physical development or causes the appearance of specific
clinical conditions (anemia, goiter, rickets, etc.)
- May occur because the diet is poor or because of a digestion and metabolism
problems which can lead to conditions such as obesity, heart disease, hypertension, &
hypercholesterolemia

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 - is the condition that develops when the body does not get the right amount of
the vitamins, minerals, and other nutrients it needs to maintain healthy tissues and organ
function.

3. DIET: all-inclusive term referring to food regularly eaten and liquids regularly
consumed; the sum of the food consumed by an organism or group

Dieting - the deliberate selection of food to control body weight or nutrient intake.

Diet food - foods that aid in dieting

Cuisine - the diet of a particular culture

4. BALANCED DIET - A diet in which foods are chosen to

provide kcalories, essential nutrients, and fiber in the right
proportions.

5.ENZYMES - a protein produced by cells to accelerate specific chemical reactions

Enzymes are generally named by adding the ending “-ase” to the name of the
substance on which the enzyme acts (for example, protease is an enzyme that acts on
proteins).
Most enzymes are recognized by the ending ase, like -maltase,
lipase and transaminase.

6. KILOCALORIES / CALORIES - The term used to

represent the amount of energy required to raise the
temperature of a liter of water one degree centigrade at sea
level.
• A bomb calorimeter is used to determine the
energy values of foods by placing a sample of food

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 in a chamber, surrounding it with water, and then
burning it.
• A calorie is the amount of heat needed to raise the
temperature of 1 kilogram of water 1 degree
Celsius.

7. EMPTY-KCALORIE FOODS - Foods that provide few nutrients for the number of
kilocalories they contain.

8. GOOD NUTRITIONAL STATUS

- Implies appropriate intake of the macronutrients – carbohydrates, proteins, and
fats and the various vitamins and minerals often referred to as “ Micronutrients” because
they are needed in small quantities.

- If there is good digestion, absorption, and cellular metabolism of these nutrients

in the diet, a person can generally achieve good nutritional status

9. MEDICAL NUTRITION THERAPY- “DIET THERAPY”

Is the treatment of disease through nutritional therapy by registered dietitians
(RDs).

10. FOOD- MATERIAL

- usually of plant or animal origin, that contains or consists of essential
body nutrients, such as carbohydrates, fats, proteins, vitamins, or
minerals, and is ingested and assimilated by an organism to produce
energy, stimulate growth, and maintain life.

QUALITIES OF A GOOD FOOD

1. Nourishing or nutritious
2. It has satiety value
3. Prepared under sanitary conditions, aesthetically and scientifically
4. Free from toxic agents
5. Palatability satisfies the consumers
6. Offers variety and planned within socio-economic context

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11. GOOD NUTRITION – means eating the right quantity, quality and diversity of foods
and getting the care we need to keep our bodies strong and healthy and prevent us from
getting sick.
1. When a person is undernourished, there are usually numerous reasons.
2. Often, these reasons are connected. If a child is malnourished, the father may
blame the mother for not feeding the child enough.
3. Yet the father may not be giving the mother the right variety of foods to cook.
4. Maybe he cannot afford it, or he does not have enough land.
5. It is important to do a proper analysis and not blame one person.
6. In many cases, the solution to one person’s malnutrition will involve the whole
community.

12. NUTRIENTS- consist of various chemical substances in the food that makes up each
person’s diet; (A nutrient is a chemical substance in food that helps maintain the body.)
Some provide energy.
- All help build cells and tissues, regulate bodily processes such as
breathing.
- No single food supplies all the nutrients the body needs to function.
- Deficiency Disease: failure to meet your nutrient needs.
Nutrients are the components of food which have a function in …
- Providing energy,
- Providing material for growth,
- repair,
- reproduction,
- starting and controlling various processes
- immune system; iron and red blood cells
13. NUTRIENT DENSITY – a measure of the nutrients provided in a food per kilocalorie
of that food.

14. ESSENTIAL NUTRIENTS - Nutrients that either cannot be made in the body or
cannot be made in the quantities needed by the body; therefore, we must obtain them
from food.

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15. HEALTH - is a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity.

16. HORMONES - A HORMONE is a chemical produced in one part of the body and
released into the blood to trigger or regulate particular functions of the body.
• For example, insulin is a hormone made in the pancreas that tells other cells
when to use glucose for energy.
• chemicals produced by cells of the body to stimulate or retard certain life
processes such as growth and reproduction.

17. NUTRITURE - The state of the nutrition of the body. Nutritional status, especially
with regard to a specific nutrient.

NUTRITION MYTHS AND FACTS

A myth is an advice that becomes popular without facts to back it up. When it
comes to nutrition, especially with weight loss, many popular beliefs are myths and
others are only partly true.

Nutrition Myths and Facts debunks many common misconceptions about

nutrition that are perpetuated by the media and offers solid facts instead. Students will
learn that they can eat a variety of foods and still maintain a healthy weight for their
gender, height and activity level. The video examines the special nutritional needs of
adolescents, whose growing bodies require additional calcium, iron and other minerals.
In addition, healthy eating tips are offered, including how to interpret nutritional labels
and measure portions.

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 UNIT 1: ACTIVITY 1
Ask some people in your community (your friends, neighbors or family) about their
common beliefs about food or nutrition and list ten (10) of the most relevant on the
spaces below.
(to be Processed in the next lesson)

MYTHS
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

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LESSON 2
BASIC NUTRITION CONCEPTS
1. Facts and Myths about nutrition
2. What is the importance of
nutrition?
3. Review of Anatomy and
Physiology of Digestive System
4. Overview of digestion, absorption,
and metabolism
WEEK
ACTIVITIES
2 TOPIC LEARNING OUTCOMES
Day 3
At the end of the lesson, you will be able to:
1. distinguish between nutrition myths and 1. Pretest
facts. 2. Sorting myths from
2. explain the terminology related to healthier facts about nutrition
living 3. Word search puzzle
3. explain why do we need to study nutrition. 4. Short answer
4. Describe how nutrition affects one’s health. questions
5. Explain the anatomy of the digestive system 5. Concept mapping
and the corresponding functions of its parts.
6. Describe the mechanical and chemical
processes of digestion, absorption, and
metabolism of foods.
7. Describe how nutrition affects one’s health
Describe the principles of a healthy diet.

Pretest: TRUE or FALSE

Write the word TRUE if the statement is correct and write FALSE if the statement is
incorrect.

_______ 1. Going without carbohydrates can make you feel tired and grumpy.
_______ 2. Simple carbohydrates have little nutritional value and are high in calories.
_______ 3. If you want to follow a healthy diet, you should avoid all fats.
_______ 4. High-protein/high-fat diets are a healthy way to lose weight.
_______ 5. Because diet drinks do not have sugar, they are as good for you as water.
_______ 6. If you take a vitamin supplement, you don’t need to worry about what you
eat the rest of the day.
_______ 7. Fat-free foods can have as many calories as their full-fat counterparts.

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_______ 8. Effective fat-burning creams have been developed that can be applied to the
skin.
_______ 9. Skipping meals is a good way to cut calories.
_______10. Exercise can increase your metabolism so you will burn calories more
quickly.

The Answer Key for this activity appears on APPENDIX __.

FOOD, NUTRITION AND HEALTH

The connections between our foods, the nutrients they provide and our health
are complex, but have far-reaching consequences for individuals and society. As
changing diets and dietary habits place an increasing burden on healthcare systems, it is
crucial that we develop new products, interventions and refined guidelines which will
improve health through diet. Achieving this will depend upon a complete understanding
of the biological processes which connect the foods we eat to our long-term health.

THE IMPORTANCE OF NUTRITION FOR HEALTH AND SOCIETY

Eating a well-balanced diet, with adequate nutrients and appropriate calories, is a

fundamental requirement for continued health. An appropriate diet contributes to healthy
development, healthy ageing and greater resilience against disease. Similarly, a poor or
inappropriate diet places people at greater risk of infection and a range of chronic
illnesses – including cancer, type 2 diabetes and cardiovascular disease.

NUTRITION: FACTS VS. MYTHS

It has never been easy to sort through the facts and fallacies about food; and
marketing ploys, clever phrases, wishful thinking, pseudo-science, media hype and
celebrity testimonials don’t help. Here are some common and enduring food myths:

Myth: Fresh fruits and vegetables are healthier than frozen or canned.

Fact: Research shows frozen and canned foods are as nutritious as fresh.
In fact, since lycopene is more easily absorbed in the body after it has been processed,
canned tomatoes, corn and carrots are sometimes better nutrition choices.

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Myth: Body weight is a reliable indicator of a healthful diet.

Fact: No two people have the same body composition. The measure of a

person’s diet and your overall health is a combination of factors, including weight.

Myth: Eating carbohydrates causes weight gain.

Fact: Calories cause weight gain. Excess carbohydrates are no more fattening than
calories from any source. Despite the claims of low-carb diet books, a high-carbohydrate
diet does not promote fat storage by enhancing insulin resistance.

Myth: Eating just before bedtime is fattening.

Fact: What you eat, not when, makes the difference; calories have the same effect on
the body no matter when they are consumed. Evidence does suggest that eating regular
meals, especially breakfast, helps promote weight loss by reducing fat intake and
minimizing impulsive snacking.

Myth: Eating sugar causes diabetes.

Fact: Diabetes is caused by a lack of insulin in the body. Since foods that are high in
sugar are often high in calories, overeating those foods can lead to weight gain.
Research shows people who are overweight and obese are at increased risk for
diabetes.

Myth: Occasionally following a fad diet is a safe way to quickly lose weight.

Fact: Many fad diets are developed by people with no science or health background so
some fad diets can even be considered harmful to people with certain health problems.
When trying to lose weight, consult a registered dietitian.

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Nutrition: It’s a Matter of Fact

National Nutrition Month® is a nutrition education and information campaign

created by the American Dietetic Association. The campaign is designed to focus
attention on the importance of making informed food choices and developing sound
eating and physical activity habits. National Nutrition Month also promotes ADA and its
members to the public and the media as the most valuable and credible source of timely,
scientifically based food and nutrition information.

UNIT 1: ACTIVITY 2

WORD SEARCH PUZZLE

Rules: Locate the given words in the grid, they may appear forward, backward or
diagonally.

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T Q A D F I O N M K L P R Y I D F V X Z A N M
S H A C W Q T Y E R Y U N T E C A B I O V R N
E B E V A L E C N G H I U E N D R F R L Y I A
P E S R A D F V U Q W E T I R T T U I O P T S
L Q W A A S D F G H J K R N L Z X C V B L I C
K A T N M P Q W E R T Y I U I O P L K J C V G
U G F D S A Y Z X C V B T N M L K J G H C B E
B H G F D S E N T R O L I O N M O K L A A N I
I A Q W E R S T Y U I O O P A S D F L G R B S
V A S D F B G H J K L M N I L O K O C H P P A
S V B N R M A S D F G H I B V C R S X J Q R I
X Q W A E R T Y U I O P S D A I B N M K W O B
T O C P O W E R T H U C T V E X Z V N L E T O
V B N R F C V G H U I O P S P O T E O M R E X
I A S R A Y C A L L E M H A I L C A F N T I U
M E Y K N U T R I T I O N A T E N T O B Y N E
B E J E N M I K A S W A C V B E I I O V U X A
E A T S E B U I O M L X S F E L M N D C I C T
A E S A P I Q U E J A C K I B Q M G I X O V V
L I N T B O G S A R B O N Q K I S T O Z P B C
M K U R D O A P O L M K I Y T T Y A C A L N A
V S C D I C L C U I N U T R N I T O N S K M E
B C A L N O T I E S U N O E T R E S G D J K I
W A T R U O C I S N C M I L E A O S D F H J V
Q E I S R S I E T M E R O T C H O E O G G H E
T Z X T S T R D E A T A S C B K N L S H F G I
Y V I A E S C N F U T M W R T I O P Q J D F P
U O M F C E T R N O X E Z M S K L K U K S D I
I C A V B N I Y O U P N B I B L A V R H A S A
N Q W E R T Y U I O P O U M E R S M R T Z A C
M P O I U Y T R E W Q C E S W Q U I B L A V R
F T S E B U R T O X I A A A E E N L I A S M L
O A X C N E N Z Y M E R S M R N T U Y E A V P
M C X G B U I O M L X S F U R I W O P H C M D
Q W C V I O P X D R G I A T E C H N T K L M I
A S C D I E T I T I A N Q P L E A D B N N M E
D E N A C Q W A X C B N M C U I O L M K I Y T
NUTRITION NUTRITIONIST FAT CALORIES NUTRIENTS NURSE
HEALTH METABOLISM DIET CUISINE THERAPY EATING
PROTEIN DIETITIAN CARBS FOOD ENZYMES MENU

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5. Pick four words from the list and define them using your own words.

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________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

24
 UNIT I: ACTIVITY 3

From the common beliefs that you have written before the lesson on Myths &
Beliefs, Categorize and write in the columns below which are MYTHS and which
are FACTS.
FACTS MYTHS

25
Food, nutrition and health

The connections between our foods, the nutrients they provide and our health
are complex, but have far-reaching consequences for individuals and society. As
changing diets and dietary habits place an increasing burden on healthcare systems, it is
crucial that we develop new products, interventions and refined guidelines which will
improve health through diet. Achieving this will depend upon a complete understanding
of the biological processes which connect the foods we eat to our long-term health.

The importance of nutrition for health and society

Eating a well-balanced diet, with adequate nutrients and appropriate calories, is a

fundamental requirement for continued health. An appropriate diet contributes to healthy
development, healthy ageing and greater resilience against disease. Similarly, a poor or
inappropriate diet places people at greater risk of infection and a range of chronic
illnesses – including cancer, type 2 diabetes and cardiovascular disease.

Despite the clear connections between nutrition and health, more than half of the
UK population are obese or overweight, consumption of fruit and vegetables is falling
and the calorie density of the average shopping basket is increasing. Meanwhile, around
three million people in the UK are malnourished, including 25% of those in hospital and
42% in long-term care.

This represents a serious economic and social challenge. High body mass index
is one of the leading risk factors for chronic disease in the UK, accounting for 9%
(£5.1Bn per year) of NHS spend. The cost to the wider economy is vast at around £16Bn
per year, rising to £50Bn by 2050 if action is not taken. As costs escalate, the need for
new products and interventions to promote health through our diets is becoming ever
more urgent.

26
Review of Anatomy and Physiology of Digestive System

THE DIGESTIVE SYSTEM

- The GI tract – is a 23 to 26 foot long pathway that extends from the mouth
through the esophagus, stomach, and intestines to the anus.

The small intestine – is the longest segment of the GI tract, accounting for about two thirds
of the total length.

3 anatomic parts; duodenum upper part, jejunum middle part, ileum lower part
- it folds back and forth on itself, providing approximately 7000cm of surface
area for secretion and absorption.

ABSORPTION – the process by which nutrients enter the bloodstream through the
intestinal walls.

Oxygen and Nutrients are supplied to the stomach by the gastric artery and to
the intestine by the mesenteric arteries.
Blood is drained from these organs by the veins that merge with others in the
abdomen to form a large vessel called the portal vein.

27
 Nutrient-rich blood is then carried to the liver.

The blood flow to the GI tract is about 20% of the total cardiac output and
increases significantly after eating.

FUNCTION OF THE DIGESTIVE SYSTEM

1. To breakdown food particles into the molecular form for digestion.

2. To absorb into the bloodstream the small molecules produced by digestion
3. To eliminate undigested and unabsorbed foodstuffs and other waste
products from the body.

After food is ingested, it is propelled through the GI tract, coming into contact with a wide
variety of secretions that aid in its digestion, absorption, or elimination from the GI tract.

The process of digestion begins with the act of chewing, in which food is broken down
into small particles that can be swallowed and mixed with digestive enzymes.

Eating – or even the sight, smell, or taste of food- can cause reflex salivation.
Saliva is the first secretion that comes in contact with food, it contains the enzyme
ptyalin, or salivary amylase, which begins the digestion of starches.

It also contains mucus and water, which help to lubricate the food as it is chewed,
thereby facilitating swallowing.

As food is swallowed, the epiglottis moves to cover the tracheal opening and prevent
aspiration of food into the lungs.

Swallowing, which propels the bolus of food into the upper esophagus, thus ends as a
reflex action.

The smooth muscle in the wall of the esophagus contracts in a rhythmic sequence from
the upper esophagus toward the stomach to propel the bolus of food along the tract.

28
During this process of esophageal peristalsis, the lower esophageal sphincter relaxes
and permits the bolus of food to enter the stomach

Subsequently, the lower esophageal sphincter closes tightly to prevent reflux of stomach
contents into the esophagus.

OVERVIEW OF DIGESTION AND ABSORPTION

As food is swallowed, the epiglottis moves to cover the tracheal opening and
prevent aspiration of food into the lungs.

2. Metabolism
a. METABOLISM – is the chemical process of transforming foods into
complex tissue elements and of transforming complex body substances
into simple ones, along with the production of heat and energy.

b. ANABOLISM – the constructive part of metabolism concerned especially

with macro molecular synthesis.

c. CATABOLISM – destructive metabolism involving the release of energy

and resulting in breaking down of complex materials with the organism.

29
 d. DIGESTION – phase of the digestive process that occurs when digestive
enzymes and secretions mix with ingested food and when proteins, fats,
and sugars are broken down into their component smaller molecules.

e. ABSORPTION- phase of the digestive process that occurs when small

molecules, vitamins, and minerals pass through the walls of the small and
large intestine and into the bloodstream.

f. TRANSPORT – transfer of completely digested food that can be used by

the different cells of the body.
g. EXCRETION – phase of digestive process that occurs after digestion and
absorption, when waste products are evacuated from the body.

ROLES OF ENZYMES AND HORMONES IN DIGESTION AND ABSORPTION

ENZYMES – are organic catalyst that are protein in nature and are produced by living
cells.

Gastric secretions contain the enzyme pepsin which is important for initiating protein
digestion.

The pancreas also secretes digestive enzymes, including trypsin which aids in digesting
protein; amylase aids in digesting starch; and lipase aids in digesting fats.

HORMONES – are organic substances produced by special cells of the body

which are discharged into the blood to be circulated and brought to specific
organs or tissues that are remote from the source or point of manufacture.
- most hormones are produced by endocrine or ductless glands, some are
protein in nature and others are related to lipids.

Motilin (small intestine) –regulates motility of intestines

Secretin (duodenum) – stimulates the pancreas to release acid neutralizing

bicarbonates into the small intestines.

30
 UNIT I: ACTIVITY 4

STUDY QUESTIONS: Answer briefly the following questions and try to incorporate them
in your concept map below.

1. How do enzymes help in the digestion of food?

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

2. What are the functions of hydrochloric acid?

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

3. List the factors which are needed for normal digestion.

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

4. What are the coenzymes and cofactors needed in the citric acid cycle?

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

31
 UNIT I: ACTIVITY 5
Make a concept map of the DIGESTIVE PROCESS, from food intake up to the
excretion of waste products. Include also the different roles of enzymes and
hormones in the process

32
 UNIT II
BASIC TOOLS IN NUTRITION
(Guidelines in Promoting Good Nutrition/ Tools for healthy eating)

Do you know what is in the plate of every person?

Although everyone needs the same nutrients, each individual requires different
amount of each nutrient depending on the age, gender, physiological make-up and
physical activity. Knowledge about good nutrition is important because the quality of
people’s lives and health depend on it.

This chapter focuses on evidence-based guidelines and principles that are

recommended for the prevention, management, and treatment of various diseases
caused by poor nutrition.

1. Food guides
2. Dietary guidelines
3. Basic food group
4. FNRI & USDA (United States Department of Agriculture) Food Guide Pyramid
o Different types of Food Pyramid (according to age brackets)
5. RDA VS. RENI
6. 10 Nutritional Guidelines for Filipinos (NGF)
/ Pinggang Pinoy by NNC vs. myplate
7. FEL (Food Exchange List)
8. Food Labeling

LESSON 1
BASIC FOOD GROUP

WEEK
ACTIVITIES
2 TOPIC LEARNING OUTCOMES
At the end of the lesson, you will be able to:
Day 4 1. Short
1. Discuss the principles of moderation, balance and answer
variety in the Food Guide Pyramid. question
Week 3. Describe the basic tools used in nutrition. quiz
3 4. State the significance of the food guide pyramid 2. Lesson
5. Differentiate and interpret the different food pyramid planning
for each age group based on FNRI.DOST description.

33
 Day 5 6. Compare and contrast RDA with the RENI for 3. Engaging
&6 Filipinos questions
7. Explain the 10 Nutritional guidelines for Filipinos and 4. Playing
the “Pinggang Pinoy”. favorites
8. Plan a balanced diet using the Food Exchange List 5. Study
as a guide. questions
9. Evaluate nutrition labels and choose nutrient-dense 6. Label the
over energy-dense food sources. pyramid
7. Reading
food label
8. Label
Detective

FOOD GUIDES

- are graphic representations of all or some of the messages of the dietary

guidelines.
- They typically represent the recommended food groups in the suggested
proportions for a good diet.
- Messages about lifestyle, such as recommendations of regular physical
activity and warnings related to alcohol consumption may also be
displayed.
- The most common example of food guides are in the shape of a food
pyramid and food plate.
- However, many countries choose a food guide that is culturally specific
for the population of each country and may become an important symbol
in a nation's nutrition communication and education strategy.
- Some countries have adapted their food guide for different population
groups.

DIETARY GUIDELINES

- are developed by interdisciplinary teams of experts, comprising

representatives of agriculture, health, education, nutrition and food
science, consumers, non-governmental organizations, the food industry,
communications and anthropology.

34
 The implementation of dietary guidelines should be monitored and evaluated
regularly. It would be useful to develop implementation and evaluation mechanisms in
parallel with the development of the guidelines themselves, in order to sensitize the
nation’s nutrition leaders and bring an action plan into play at the same time as the
guidelines are promulgated.

DIETARY GUIDELINES FOR AMERICANS

The Dietary Guidelines for Americans provides evidence-based nutrition

information and advice for people ages two and older to help Americans make healthy
choices about food and beverages in their daily lives. The Guidelines also serve as the
basis for federal food and nutrition education programs, like the new MyPlate, My Wins
campaign to help you find reSOLUTIONS that will help you meet your healthy eating
goals.

- The 2015-2020 Dietary Guidelines for Americans focuses on making small

shifts in your daily eating habits to improve your health over the long run.
- They also emphasize the importance of “eating patterns,” which refer to the
combination of ALL foods and beverages a person consumes regularly over
time, rather than focusing on individual nutrients or foods in isolation.
- Healthy eating patterns, along with regular physical activity, have been shown
in a large body of current science to help people reach and maintain good
health while reducing risks of chronic disease throughout their lives.
- Additionally, healthy eating patterns can be adapted to an individual’s budget,
taste preferences, traditions, and culture.
- The core recommendations for these healthy eating patterns are unchanged
from previous editions of the Guidelines, and continue to encourage
Americans to consume more healthy foods like vegetables, fruits, whole
grains, fat-free and low-fat dairy products, lean meats, seafood, other protein
foods, and oils. They also recommend limiting sodium, saturated and trans
fats, and added sugars.

35
NUTRITIONAL GUIDELINES FOR FILIPINOS: a prescription to good nutrition

- The Nutritional Guidelines for Filipinos (NGF) is a set of dietary guidelines

based on the eating pattern, lifestyle, and health status of Filipinos.
- The NGF contains all the nutrition messages to healthy living for all age
groups from infants to adults, pregnant and lactating women, and the elderly.
- The first NGF released in 1990 was composed of five messages called
“Dietary Guidelines for Filipinos.”
- In 2000, a revised nutritional guidelines composed of ten messages was
released and it was called the Nutritional Guidelines for Filipinos.
- In 2012, the Technical Working Group (TWG) for the revision of the NGF, led
by the Food and Nutrition Research Institute of the Department of Science
and Technology (FNRI-DOST) developed a new set of the NGF, based on
the 2000 edition.

The 2012 NGF now includes the basis and justification for each of the ten
nutritional and health message.

Below are the new messages of the 2012 NGF:

1 - Eat a variety of foods everyday to get the nutrients needed by the body.
2 - Breastfeed infants exclusively from birth up to six months and then give appropriate
complementary foods while continuing breastfeeding for two years and beyond for
optimum growth and development.
3 - Eat more vegetables and fruits to get the essential vitamins, minerals, and fiber for
regulation of body processes.
4 - Consume fish, lean meat, poultry, egg, dried beans or nuts daily for growth and repair
of body tissues.
5 - Consume milk, milk products, and other calcium-rich food such as small fish and
shellfish, everyday for healthy bones and teeth.
6 - Consume safe foods and water to prevent diarrhea and other food-and water-borne
diseases.
7 - Use iodized salt to prevent Iodine Deficiency Disorders.
8 - Limit intake of salty, fried, fatty, and sugar-rich foods to prevent cardiovascular
diseases.
9 - Attain normal body weight through proper diet and moderate physical activity to

36
maintain good health and help prevent obesity.
10 - Be physically active, make healthy food choices, manage stress, avoid alcoholic
beverage, and do not smoke to help prevent lifestyle-related non-communicable
disease.

• The revisions were made based on the results of the 2008 National Nutrition
Survey (NNS) conducted by FNRI-DOST.
• Based on the said survey, the Filipino household diet fell below the
recommended levels except for niacin, which is above the recommended.
• Furthermore, all nutrients and energy were below the 100 percent adequacy
levels. This was the basis of NGF messages no. 1, 3, and 4.

o There is no single food that contains all the nutrients that our body needs so
eating a variety of food ensures that daily nutritional needs are met.
o There was also a decrease in consumption of fruits from 77 grams in 205 to 54
grams in 2008 and also a decrease in milk consumption from 44 grams to 42
grams. These results were the basis of message no. 3 and 5, respectively.
Vegetables and fruits are the main sources of vitamins, minerals, and fiber, while
milk is a good source of calcium.
o Low urinary iodine excretion is still a prevalent problem among pregnant and
lactating mothers, indicating to low iodine intake. Iodine is important during
pregnancy because it is needed for the brain development of the infant while
lactating mothers must have adequate supply of iodine in their breastmilk. This is
the message of NGF no. 7.
o The total cholesterol level among Filipino adults increased from 8.5 (mg/dL) in
2003 to 10.2 (mg/dL) in 2008.
- High cholesterol level may be attributed to the high consumption of sodium rich
foods by Filipinos.
o Salt and soy sauce were among the top 10 widely used miscellaneous food items
used by Filipinos.
o In addition, heart diseases ranked first among the causes of death based on the
2005 Department of Health survey. This is the reason behind no. 8 of NGF.

37
 o Excessive intake of salt and soy sauce can result to high blood pressure
especially to salt-sensitive individuals. Persistent high blood pressure can result
to cardiovascular diseases.
o There is also a decreasing trend of physical inactivity among Filipinos and also a
large percentage of Filipino smokers at 31.0% and drinkers at 26.9%. These
situations were the basis of messages no. 9 and 10 of the NGF.
o People are always encouraged to exercise at least thirty minutes a day, three to
five times a week.
o Limit alcohol drinking to one drink per day for women and two drinks for men is
also advised.
One alcoholic drink is equivalent to one and half ounce distilled beverage such
as gin or 12 ounces or a bottle of beer or four ounces wine or half glass wine or
an ounce of 100 proof whiskey.
Let’s practice the ten nutritional guidelines to achieve good health and optimal
nutritional status.

For more information on food and nutrition, contact: Dr. Mario V. Capanzana,
Director, Food and Nutrition Research Institute, Department of Science and Technology,
General Santos Avenue, Bicutan, Taguig City; Tel/Fax Num: 8372934 and 8373164;
email: [email protected], [email protected]; FNRI-DOST website:
http://www.fnri.dost.gov.ph.; FNRI Facebook page: facebook.com/FNRI-DOST; FNRI
Twitter account: twitter.com/FNRI-DOST (DOST-FNRI S & T Media Service: Press
Release – CELINA ANN Z. JAVIER) )

https://www.fnri.dost.gov.ph/index.php/publications/writers-pool-corner/57-food-and-nutrition/204-nutritional-
guidelines-for-filipinos-a-prescription-to
goodnutrition#:~:text=%2D%20Eat%20more%20vegetables%20and%20fruits,and%20repair%20of%20bod
y%20tissues.-June 2020

38
3 FOOD GROUPS

Different foods can be grouped into different groups depending on the major nutrients
they provide.

❖ According to this classification there are:

Energy giving foods/GO foods

Body building foods/GROW foods

Protective foods/GLOW foods

Water (sits outside of the classification but is mentioned here as it is also

essential for the human body to function properly)

Most foods provide more than one nutrient. Many energy giving foods are also sources
of proteins and micronutrients, while many body building foods also provide energy and
micronutrients.

1. Energy giving foods provide the energy needed by our bodies to:
Perform activities such as walking, digging, working
Maintain normal physiological processes such as breathing and all other processes
within our bodies

- Energy giving foods are mainly rich in the food nutrients carbohydrates or fats.
- We obtain carbohydrates through eating plant-based foods. The main examples
of carbohydrate containing foods include: millet, Irish potatoes, sweet potatoes,
cassava, posho (made from maize or other flour), sorghum, yams, rice, plantain
(matooke) and bread.
- Fats and oils are usually solid, semi-solids or liquid depending on their chemical
composition and environmental temperatures. Examples of fats and oils
commonly consumed in our diets include liquid oils (sunflower oil, mukwano oil),
ghee, suet (fat normally found on kidney and meat of cattle and sheep). Apart
from being good sources of energy, fats and oils also add flavour and taste to
food.

39
 - They further insulate the body, cushion vital organs and are essential for the
absorption and utilization of fat-soluble vitamins A, D, E and K. Thus, a very
low consumption of fats and oils may lead to a deficiency of these vitamins
predisposing our bodies to diseases and/or symptoms associated with a lack of
these vitamins. (This will be discussed in detail under the Classification of
nutrients)

2. BODY BUILDING FOODS OR GROW FOODS

- Body building foods or GROW foods are those rich in the food nutrients called
proteins.
- They are essential for growth, boosting body immunity against infections and
diseases, the formation of all tissues, including muscles, bones, teeth, skin and
nails and for wound repair.

Bodybuilding foods come from two major sources:

1. Animal-based foods and related products: fish, meat, poultry, eggs, milk and
yoghurt.
2. Plant-based foods and related products: mainly beans (incl soy beans) and peas

Animal-based foods provide a richer source of proteins that are more easily utilised by
the body than those supplied by plant-based foods. We can increase household intake
of animal-based proteins by domesticating certain animals and birds. The birds (hens,
ducks) can be eaten but also lay eggs, which are a rich source of proteins. Animals like
rabbits are also relatively easy to rear: they do not require much space to be kept, are
not too demanding in as far as feeding is concerned and have high multiplication rates.
- The quality of proteins from plant-based foods can be improved by eating a
combination of different such foods, e.g. rice and beans. The proteins missing in
beans are present in rice so when these are eaten in combination one can also
obtain a good supply of proteins for the body. It is therefore important to eat a
mixture of plant-based foods in our diets and even more so if access to
animal-based foods is limited.

40
 - We have different protein requirements at different ages: children require more
protein-rich foods than adults because they are growing. Pregnant women should
also eat plenty of protein-rich foods because they need to feed themselves as
well as their growing baby. The same is true for lactating / breastfeeding mothers
whose bodies need to be able to produce breast milk.

3. PROTECTIVE FOODS OR GLOW FOODS

- Protective or GLOW foods include vegetables and fruits.

- These foods are rich in vitamins and minerals which are required by the body for
physiological functions such as the strengthening of the immune/defense system
and to prevent conditions such as anemia (resulting from iron deficiency), night
blindness (resulting from Vitamin A deficiency), goiter (resulting from iodine
deficiency) and rickets (resulting from a lack of Vitamin D and calcium).
- Some vitamins and minerals are also essential for the production of energy by
the body and maintaining water balance in the body.

Vegetables are a rich source of several vitamins and minerals. In addition,

vegetables add taste, flavour and colour to our meals. Common vegetables
include: amaranthus (dodo), spinach, kale (sukumawiki), pumpkin leaves,
cowpea leaves, carrots, cassava leaves, green pepper, nnakati,
malakwang,eboo.

Fruits - A variety of fruits are grown and are accessible in the markets of
Western Uganda, including avocados, mangoes, pawpaws, pumpkin, passion
fruit, pineapple, jackfruit, oranges, lemons and other citrus fruits. The deep yellow
or orange coloured fruits are richer in vitamins, particularly vitamin A.

6 FOOD GROUP
- These are the 6 essential nutrients ( to be discussed in Unit III)

41
 LESSON 2
FNRI & USDA FOOD GUIDE PYRAMID

How does one know what and how much food to eat? A helpful tool in choosing the
foods and the amounts needed for healthy diet is the Food Guide Pyramid.

- The Food Guide Pyramid (FGP) is a simple graphic presentation of foods

grouped according to nutrient contribution.
- The FGP was developed to help individuals select a well-balanced diet to
promote good health.
- It shows the five food groups arranged in a pyramid.
- The pyramidal shape indicates the relative amounts or proportions of each food
group that should be eaten every day.
- Foods at the base should be eaten most of, and those at the tip should be eaten
the least. Foods at the middle levels should be eaten in moderation.
- At the base of the pyramid are carbohydrate-rich foods such as rice and other
cereals, bread and root crops. These foods provide the bulk of the Filipino diet.
- Vegetables and fruits provide not only vitamins and minerals but also fiber and
should be eaten more of. Meat, fish, poultry and dairy products provide good
quality protein but are also sources of fat and therefore should be eaten in
moderation.
- Sugar and fat which provide calories mainly are recommended to be eaten the
least.

The Pyramid also points to exercise, personal and environmental hygiene as essential
for the child’s health and suggests for physical activity to substitute television watching
or playing computer games.

The Food Guide Pyramid shows how the principles of variety, moderation and balance
can be applied in the selection and consumption of foods. A picture of the Food Guide
Pyramid and the recommended number of servings for healthy adults is shown.

42
DAILY NUTRITIONAL GUIDE PYRAMID FOR FILIPINO LACTATING WOMEN

DAILY NUTRITIONAL GUIDE PYRAMID FOR FILIPINO PREGNANT WOMEN

43
DAILY NUTRITIONAL GUIDE PYRAMID FOR FILIPINO CHILDREN (1-6 YEARS OLD)

DAILY NUTRITIONAL GUIDE PYRAMID FOR FILIPINO CHILDREN (7-12 YEARS

OLD)

44
DAILY NUTRITIONAL GUIDE PYRAMID FOR FILIPINO TEENAGERS (13-19 YEARS
OLD)

DAILY NUTRITIONAL GUIDE PYRAMID FOR FILIPINO ADULTS

45
DAILY NUTRITIONAL GUIDE PYRAMID FOR FILIPINO ELDERLY

FOOD PYRAMID BY FNRI-DOST.PH

46
DIETARY GUIDELINES (The Food Guide Pyramid) – by USDA

Dietary Guidelines (Foods In Each Group)

On the pyramid, each color represents a different food group:

• Orange: The grains group, which includes foods like bread, cereal, rice, and
pasta)
• Green: Vegetables provide many of the vitamins and minerals kids need for
good health, and they provide fiber to aid digestion.
• Red: Fruits are especially good sources of important vitamins like A and C. This
food group also adds minerals such as potassium and fiber, which help digestion.
• Blue: Dairy: This food group, which includes milk and other foods like milk,
yogurt, and cheese, is an important source of vitamin A, vitamin D, calcium, and
protein.
• Purple: Proteins (meats, beans, and fish) Foods in this group also provide
vitamin B-complex and iron, which helps build strong bones and teeth and
support muscles.
• Yellow: Fats and oils: Fats and oils are essential nutrients to maintain body
function but should be used sparingly. Fats help the body absorb vitamins A, D,

47
 E, K, and beta-carotene. Even though fats may be needed to maintain good
health, it may be a good idea to limit them.

Dietary Guidelines (Daily recommended amounts) (*All based on high school aged
students ages 14-18*)

Orange (Grain Group) 6-7 ounces per day

Green (Vegetables) 21/2-3 cups per day

Red (Fruits) 11/2-2 cups per day

Blue (Dairy) 3 cups per day

Purple (Protein) 5-6 ounces per day

Yellow (Fats and Oils) 5-6 teaspoons per day

Dietary Guidelines (What is a serving size or portion?) ( I will have samples of

serving sizes too!) So What’s a Portion Anyway?
This is where the food label can come in handy. For portion size on items like canned
soup, yogurt, snack foods, sauces, etc., you can discover what is considered one
serving by checking the top of the food label.

Orange (Grain Group 6-7 oz per day): What is an ounce? 1 slice of bread, ½ cup of
cooked rice or pasta, ½ cup of oatmeal, 1 mini bagel, 3 cups popcorn, 1 cup of ready to
eat cereal

Green (Vegetable Group 2 ½ -3 cups per day): Most veggie servings are 1 cup
(brocolli, corn, carrots, celery, cuccumbers) Leafy veggies such as lettuce or spinach (2
cups raw is 1 serving)

Red (Fruits Group 1 ½ -2 cups per day): 1 cup of fruit equals to: ½ large apple or 1
small apple, 1 large orange or bananna, 8 large strawberries, and ½ dried fruits= 1 cup

48
 UNIT II: ACTIVITY 1

DUE: _______________________

Objective: The objective of this activity is to utilize and understand the new
Food Guide Pyramid to complete an assessment using yourself as the subject.

Assignment: Determine the recommended amounts of servings and nutrients needed in

our daily diet based on your age, sex, and daily exercise using Daily Nutritional Guide
Pyramid using the images above.

Track your eating and exercise habits for 3 days recording your results on the food
tracking worksheets provided. Develop a reflection paper where you analyze and reflect
your eating and exercise habits over a three-day period.

Use these steps to help complete your assignment:

Assignment #1:

• Go to https://ufdc.ufl.edu/IR00003814/00001
• On the table, Find the calorie level that is right for your gender, activity level, and
age.**

1. First, choose the column for your gender.

2. Next, choose your activity level.
3. Then, find your age and the calorie level that matches your physical activity.

49
 *Calorie levels are based on the Estimated Energy Requirements (EER) and activity levels
from the Institute of Medicine Dietary Reference Intakes Macronutrients Report, 2002.
SEDENTARY = less than 30 minutes a day of moderate physical activity, in addition to
daily activities. MOD. ACTIVE = at least 30 minutes and up to 60 minutes a day of
moderate physical activity, in addition to daily activities. ACTIVE = 60 or minutes a day of
moderate physical activity, in addition to daily activities.
**You can also find calorie levels for your family members.

• 1. AGE =
• 2. GENDER =
• 3. ACTIVITY LEVEL =
• CALORIE LEVEL: _________________

50
 • 4. Then, find your age and the calorie level that matches your physical activity.
• Your individualized daily requirements/daily servings will BE COMPUTED in the
following lessons
• Turn in your data from nos. 1- 4 and Keep your data for future use. (this will be
compiled along with other work for your final project).
Assignment #2

STUDY QUESTIONS:

1. What is the difference between food pyramid and MyPlate?

2. Why did they change the food pyramid to MyPlate?
3. What is the USDA food pyramid?
4. Why the USDA food pyramid is wrong?

UNIT II: ACTIVITY 2

PLAYING FAVORITES
Name: _____________________________________

The MyPyramid food guidance system is designed to help us eat a variety of healthy
foods.
Think of at least 20 of your favorite foods—the foods you eat most often as snacks
and at mealtimes. Write each of these foods under their appropriate category in the
MyPyramid diagram on the next page. After you’ve finished, answer the questions
below.

51
 1. From which category did most of your favorite foods come? Explain why this is
your favorite category.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

2. From which category did the least of your favorite foods come? Explain why this
is your least favorite category.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

3. What changes could you make to make the foods you eat more often healthier?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

52
NAME: _________________________________________ SECTION: ________

file:///D:/nutrition_myths_and_facts.pdf

53
 UNIT II: ACTIVITY 3

Design a Health Promotional Plan to be taught to Grade one (1) children about the Basic
Food groups or the food pyramid. It should focus on the following:

- What are the materials that will be used?

- What are your objectives?
- Content of the lesson

54
 LESSON 3
RDA or RENI

THE RECOMMENDED DIETARY ALLOWANCES FOR NUTRIENTS

Introduction
Each day we need a number of nutrients to enable our body to carry out its
activities efficiently. To determine what nutrients, we need each day and how much, to
keep us in good health, a lot of research has been done. The results of these studies
have been used to work out the nutritional requirements of Indian people.

Why were the Recommendations Set-up?

In a number of studies the harmful effects of nutrient deficiencies on the human
body and its functions were observed. These were so revealing that the League of
Nations thought it necessary to set-up a committee to review available experimental data
and recommend daily dietary allowances for each of the nutrients that were known at
that time.

The Recommended Dietary Allowances for Nutrients 27

During the Second World War (1939–45), the military recruiting officers had to
reject a number of young men, who wanted to enlist, because they were underweight.
Naturally the governments in various countries were anxious to rectify this situation.
Another related problem was the need to estimate the amount of food to be sent to
various army units. This led to the setting up of Recommended

Dietary Allowances (RDA) in number of countries between, 1940 and 1944. India
was one of the first countries to set-up Recommended Dietary Allowances in 1944. The
desirable dietary intakes of energy, protein, calcium, iron, vitamin A, thiamin, ascorbic
acid and vitamin D were suggested in the RDAs set-up in 1944.

55
 On the basis of newer research findings, these recommendations have been
revised four times and fifth revision is expected in the near future. In 1958, the
recommendations for energy were revised. In 1968 and again in 1978 allowances of all
nutrients except energy were revised. In 1968, additional recommendations were made
for four B vitamins, namely riboflavin, nicotinic acid, folic acid and vitamin B12. In 1978,
the requirements for a one more B vitamin, pyridoxine (B6) were included.

In making these recommendations, the ICMR committee was guided by the

dietary allowances suggested by Expert group of FAO and WHO and also by the results
of studies carried out in India on nutrient requirements.

In the 1978 revision, the unit of energy joule, adopted by International Union of
Sciences and IUNS (International Union of Nutritional Sciences) has also been included.
The 1978 revision was entitled Recommended Dietary Intake (RDI), to emphasise the
intake of nutrients. The word ‘recommended’ is used to emphasise that these values
need to be revised periodically
on the basis of newer research data.

The last revision was made in 1988. The important features of the 1988 revision are:
• the revision of body weight standards for Indians
• complete revision of energy requirements
• definition of quantum and type of fat intakes
• modification of RDAs of vitamin A and D
• inclusion of several nutrients and dietary factors not considered earlier, such as fibre,
electrolytes (sodium, potassium), magnesium, phosphorus, vitamin E and K, and
• for the first time a provisional recommendation on trace elements was made.
No substantial changes were made in the RDAs for protein, B-complex vitamins, iron
and calcium.

General Principles of Deriving RDA

A number of general principles are used to arrive at nutritional requirements of an
individual or the RDA for a population. These are:

56
• Dietary intakes: This approach has been used to arrive at the energy needs of
children.
Energy intakes of normally growing children is used as the basis for RDA.
• Growth: To define requirements in early infancy, the breast milk intake of healthy
infants, or the requirement of any particular nutrient for satisfactory growth has been
utilised.

• Nutrient balance: As for a number of other nutrients, to arrive at the protein

requirements, the minimum intake of nutrient for equilibrium (intake = output) in adults,
and nutrient retention consistent with satisfactory growth in children, have been used
widely.

• Obligatory loss of nutrients: is the minimal loss of the nutrient or its metabolic
product through normal routes of elimination (viz., urine, faeces and sweat). It is
determined on a diet devoid of or very low in the nutrient. For example, a protein-free
diet in case of proteins.
This information is used to determine the amount of nutrient to be consumed
daily through the diet to replace the obligatory loss. In infants and children, growth
requirements are added to the above maintenance requirements.

• Factorial method: In this method, the needs for various functions are assessed
separately and added up to assess the total daily requirements. This is the method used
to arrive at total energy requirements.

• Nutrient turnover: Data collected by studying turnover of certain nutrients in healthy

persons, using isotopically labelled nutrients has been used to determine their
requirements. Vitamin A, vitamin C, iron and vitamin B12 requirement have been
measured in this manner.

• Depletion and repletion studies: These have been used to determine the
requirements of water-soluble vitamins. The vitamin status is measured by recording the
levels of vitamin or its coenzyme in serum or tissue (e.g., erythrocytes, leucocytes). The
of ascorbic acid (vitamin C), thiamin, riboflavin, niacin and pyridoxine have been
established using this approach. The subjects are first fed a diet very low in the nutrient

57
being studied until the biochemical parameters reach a low level. After that feeding
graded doses of the nutrient is studied. The level at which response increases rapidly
indicates the level of requirement of
the nutrient.

The RENI is used to denote recommendations for energy and 21 nutrients including
protein, folate, calcium, and zinc for the maintenance of health and well-being of nearly all
healthy persons in the population.

- For example, women need more iron than men, while a pregnant woman needs
more of the essential nutrients than a non-pregnant woman. Moreover, some
nutrients should be consumed more frequently, such as water-soluble vitamins like
vitamin C. Other nutrients, on the other hand, can be harmful if more than what is
recommended is taken, like vitamin A.
- Remember, RENI is a guide to good nutrition that can help in food choices.

The Food and Nutrition Research Institute of the Department of Science and
Technology (FNRI-DOST) launches the PDRI 2015 during the opening ceremony of the
41st FNRI Seminar Series on July 1, 2015 at the FNRI Auditorium. The 2015 PDRI adopts
the multi-level approach for setting nutrient reference values to meet the needs of various
stakeholders for appropriate nutrient reference values.

This is for planning and assessing diets of healthy groups and individuals. PDRI is the
collective term comprising reference value for energy and nutrient levels of intakes. The
components of PDRI are:

• Estimated Average Requirement (EAR): daily nutrient intake level that meets the
median or average requirement of healthy individuals in particular life stage and
sex group, corrected for incomplete utilization or dietary nutrient bioavailability.
• Recommended Energy/Nutrient Intake (REI/RNI): level of intake of energy or
nutrient which is considered adequate for the maintenance of health and well-being
of healthy persons in the population.
• Adequate Intake (AI): daily nutrient intake level that is based on observed or
experimentally-determined approximation of the average nutrient intake by a group

58
 (groups) of apparently healthy people that are assumed to sustain a defined
nutritional state.
• Tolerable Upper Intake Level or Upper Limit (UL): highest average daily nutrient
intake level likely to pose no adverse health effects to almost all individuals in the
general population.

Refer to PDRI Tables for details. (See Appendices)

An article taken from the DOST-FNRI FB page – a sample promotional items for
nutrition

𝐖o𝐫𝐫𝐢𝐞𝐝 𝐚𝐛𝐨𝐮𝐭 𝐲𝐨𝐮𝐫 𝐩𝐫𝐞𝐠𝐧𝐚𝐧𝐜𝐲? 𝐀𝐬𝐤 𝐃𝐎𝐒𝐓-𝐅𝐍𝐑𝐈!

“ Ang bilis ng panahon…nasa unang trimester na ng pagbubuntis si misis”,

uttered by an expectant father in one of the mother’s classes I conducted.

This was followed by the question: Ano kaya ang mga dapat kainin ni misis habang
nagbubuntis”?

59
 These are frequently asked questions (FAQs) from expectant parents on
pregnancy.

Do not worry! The Department of Science and Technology-Food and Nutrition

Research Institute (DOST-FNRI) is at your service to give healthy advice on pregnancy
with the Pinggang Pinoy.

As the name suggests, Pinggang Pinoy is especially designed for Filipinos that
features the GO, GROW and GLOW foods represented by food items commonly
consumed by the population.

The GO foods are represented by a bowl of rice, a staple food of Filipinos, and
fish like tilapia for GROW foods, as well as banana and malunggay leaves for GLOW
foods.

Included in Pinggang Pinoy’s simple and graphic design is also a glass of water,
which stresses the importance of sufficient water and fluid intake, and a figure jogging to
represent regular physical activity.

Recognizing the different nutrient requirements of the different age groups, the
FNRI developed the Pinggang Pinoy plates for children, adolescents, pregnant women
and lactating mothers and the elderly.

For pregnant mothers, here are some tips on healthy eating:

• Have a healthy diet. It should have the right balance of carbohydrates, proteins, and
healthy fats as well as vitamins and minerals. Follow the Pinggang Pinoy developed by
the DOST-FNRI. The Pinggang Pinoy shows the approximate relative proportions, on a
per meal basis, the three food groups as follows:

• -Half of the plate is comprised of vegetables and fruits or Glow foods, with the
vegetables portion being a bit bigger.

• The other half is comprised of rice or Go food, and fish or Grow Food, with more rice
than fish.

60
Below is a sample one-day meal plan for a pregnant mother:

• Include milk in your daily diet, as shown in the sample meal plan. Milk offers essential
nutrients, like calcium, protein, and vitamin D.

• Calcium is important in developing the baby’s bones and teeth.

• Vitamin D helps the body absorb calcium more effectively.

• Protein is necessary for repairing body tissues and preserving or increasing lean
muscle mass.

• Ensure that half of your plate is comprised of vegetables and fruits or Glow foods.
Vegetables and fruits are also rich in dietary fiber that can help prevent constipation that
is common to pregnant women.

• Stay hydrated. Drink 9 or more glasses of water daily.

• Have enough rest and sleep.

• Stay active during pregnancy. Regular and moderate exercise, such as walking can
help keep you feeling healthy and comfortable. But make sure you consult your doctor
before starting an exercise routine.

The DOST-FNRI’s vision is to provide innovative and timely food and nutrition
tools that will ensure a healthy and well-nourished Filipino population, especially among
pregnant and lactating mothers who are the bearers of the country’s next generation.

DOST-FNRI, kasama ninyo sa iba't ibang yugto ng buhay at kabuhayan.

For more information on food and nutrition, contact: Dr. Mario V. Capanzana, Director,
Food and Nutrition Research Institute, Department of Science and Technology, General Santos
Avenue, Bicutan, Taguig City. E-mail: [email protected], Telefax: 8837-2934 and 8827-3164,
or call: 88372071 local 2296 or visit our website: http://www.fnri.dost.gov.ph and like our
Facebook page and follow us on Twitter and Instagram.
-with Fortunato de la Peña Rowena Cristina Guevara Mario Capanzana

61
 UNIT II: ACTIVITY 4

ANSWER the following questions:

1. How would you describe your diet?

______________________________________________________________________
______________________________________________________________________

______________________________________________________________________
2. What does a healthy diet look like to you?
______________________________________________________________________
______________________________________________________________________

______________________________________________________________________

3. Why is good nutrition important?

______________________________________________________________________
______________________________________________________________________

______________________________________________________________________

62
 4. What can nurses do to promote sound nutrition? Explain your answer
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

5. What can be some factors that affect food selection?

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

6. What is healthy eating to you?

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

7. How can one be assured of obtaining nutrient adequacy?

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

63
LESSON 4
FEL (Food Exchange List)

*FEL TABLE PROVIDED IN Separate sheet*

In 1950, the US Food Exchange list was developed by the American Dietetic
Association, the American Diabetes Association and the US Public Health Service to
target meal planning problems.

The aim of this concept was to provide people with diabetes with the tools to
incorporate consistency in their meal planning and include a wider variety of foods.
Carbohydrate exchanges are 15g per portio, which is different to the United Kingdom
carbohydrate portions of one per 10g.

You should not change to another method of counting food values if you use the
US Food Exchange as this may require changing your medication if you have diabetes.

WHAT IS FOOD EXCHANGE?

The word exchange refers to the food items on each list which may be
substituted with any other food item on the same list.

One exchange is approximately equal to another in carbohydrate, calories,

protein and fat within each food list.

The last published version of the Exchange Lists for Meal Planning was
published by the American Diabetes Association and the American Dietetic Association
in January 2013. These food exchange lists can be used to assess serving sizes for
each food group.

THE FOOD EXCHANGE LISTS are groups of foods that will help you choose the right
kind and amount of foods.
The Exchange Lists is basic tool in nutrition and it is used in meal planning, diet
instruction and estimating the energy and macronutrient content of normal and

64
therapeutic diets. This tool was developed by the Food and Nutrition Research Institute,
DOST.

- The Exchange Lists allow variety in your diet and will give you almost unlimited
choices of foods.
- Foods are listed under six main groups, namely: rice, meat, milk, vegetable, fruit
and fat. This consist of common foods grouped in terms of equivalent amounts of
Carbohydrates, protein, fats and calories.
- EXCHANGES - a food item may be replaced or substituted with, or “exchanges”
for another food item belonging in the same list since food in the same amounts
of energy and energy-giving nutrients.
- One portion of a particular food, called an exchange, is approximately equal
in calories and in the amount of protein, fat and carbohydrates to foods in the
same group.

- They also contain more or less similar amounts of vitamins and minerals.
- Foods in any one group can be substituted or exchanged with other foods in the
same group although the sizes of the serving portion may not be the same.
- Foods in one group, however, cannot be traded for foods in another group.
- For example, one piece of galunggong may be substituted for one slice of
tenderloin because they are both in the meat group, but one piece of galunggong
cannot be substituted for two slices of bread because galunggong is in the meat
group and the bread is in the rice group.
- Always refer to the Food Exchange Lists at the end of this handbook (Appendix )
when planning your meals.

Measuring and Weighing Foods

- The measures and weights of food in the Exchange Lists are for the edible
portion or E.P. (raw or cooked) or the portion that is customarily eaten. It is
important to eat the right serving sizes of foods in your meal plan.
- Each portion of food should be measured accurately until you become familiar
with size of portions. Use a standard measuring cup and set of measuring
spoons.
- All measurements should be level.

65
 - In this revised edition, as purchased or A.P. weights have been included for the
rice and fruit exchanges.
- A.P. refers to the form of the food as purchased from the market that still
includes the peel or skin, seeds, etc. (refuse) or the parts that are not usually
eaten.
- It will be useful to have a small scale for weighing some foods. However, it is not
entirely necessary as the lists give the measures of food equivalent to one
exchange.

Processed Food

- When using processed food not listed in the Exchange Lists – canned food,
cured or processed food, ask your dietitian about them. READ LABELS and
avoid those with added sugar, or with too much fat or salt.

DIABETIC EXCHANGE

A diabetic exchange diet is designed to allow you easy control over the amount
of sugar and cholesterol you allow into your body. A successful diabetic exchange diet
will help to control your weight, BMI (Body Mass Index) and your sugar levels.

It is necessary to carefully measure food in a diabetic exchange diet, and it is

generally recommended to eat three meals and one snack per day.

The diabetic exchange divides foods into six specific groups, and measures food
per serving size. (See Lists on the appendices)

A balanced diet will take the correct proportion from each food group, and your
dietician will tell you the number of servings that should be eaten from each food group
per day.

Food in the same group may be exchanged to give variety. Be sure to carefully
measure or weigh each food and drink item.

66
HOW DOES THE DIABETIC EXCHANGE WORK?

The diabetic exchange system is flexible and centred around selecting foods
based around your calorie intake.

To work out your calorie level and how many servings of each food group you
can have per day, you will need to calculate your BMI (Body Mass Index).

If you in the normal BMI range, you are generally allowed between 1,800 and
2,000 calories per day. For those in the overweight BMI range, this is reduced to roughly
1,600 and then between 1,200 and 1,400 for people in the obese range.

Upon working out your BMI and calorie allowances, you should then assess how
much carbohydrate you can have in your daily diet.

This can be done by multiplying your daily calorie intake by .43 and then dividing
that number by four.

Exchange = ([Daily Calorie Intake] * .43)/4.

An example of this would be 1600 x .43 = 688 / 4 = 172 grams of carbohydrate,

which would be your daily allowance.

DIABETIC EXCHANGE FOOD GROUPS

This list is certainly not comprehensive, but it does contain a wide variety of
foods that conform to the diabetic exchange diet. Some foods may not be included that
are perfectly alright to eat, but patients on a diabetic exchange diet should avoid eating
foods in the ‘ Prohibited List ’.

However, because a food does not appear in the prohibited list, it is not
necessarily alright to eat.

BREAD AND STARCH

Each serving from this list contains 15 grams of carbohydrate, 0-3 grams protein, 0-1
gram fat and 80 calories.

67
▪ 1/2 cup of cooked lima beans ▪ 1/2 3-inch bagel
▪ 1/2 cup of cooked pasta ▪ 1 slice of bread (not oversized)
▪ 1/2 a 6-inch piece of pita bread ▪ 1/2 cup of cooked cereal
▪ 1/2 cup of mashed potatoes or a small ▪ 1/2 cup of corn or 1 medium corn on the
jacket potato cob
▪ 1/3 cup of cooked rice ▪ 6 saltine crackers / three 2-1/2-inch
▪ 1/2 cup of cooked green peas square crackers
▪ 1/2 a hamburger or hot dog bun ▪ 1 small dinner roll
▪ 2 rice cakes ▪ 1/2 cup cooked dried beans (I.E; kidney,
▪ One 6-inch round small tortilla pinto, lentils, chick peas, white, navy)
▪ 1/2 cup of cooked winter squash ▪ 1/2 an English muffin

FRUIT

Each serving from this list contains 15 grams of carbohydrate, no grams of fat or protein
and 60 calories.

▪ 1 small apple (c. 3 inch) ▪ 1/2 large pear (c. 4 inch)

▪ 1 small (c. 5 inch) banana or 1/2 a 9-inch ▪ 1/2 cup of tinned pineapple
banana ▪ 2 plums
▪ 17 small or 12 large red or white grapes ▪ 3 dried prunes
▪ 1 kiwi fruit ▪ 2 tbs. of raisins
▪ 1 cup of melon (cantaloupe, honeydew, ▪ 1-1/4 cup of whole strawberries
etc.) ▪ 1-1/4 cup of cubed watermelon
▪ 1 small orange (c. 3 inch)
▪ 1 medium peach (c. 3 inch)

VEGETABLES

To conform with the diabetic exchange it is possible to have one cup of raw or 1/2 cup
cooked portion of most vegetables.

▪ Asparagus ▪ Mixed vegetables (less corn and peas)

▪ Green beans ▪ Mushrooms
▪ Broccoli ▪ Onions (Red, white)
▪ Cabbage ▪ Pea pods
▪ Carrots ▪ Peppers (Red, yellow, green)
▪ Cauliflower ▪ Radishes
▪ Celery ▪ Salad greens (lettuce, watercress,
▪ Collard greens spinach)
▪ Cucumber ▪ Summer squash
▪ Eggplant ▪ Tomatoes (fresh or tinned)
▪ Green beans ▪ Turnip greens
▪ Kale ▪ Turnips
▪ Zucchini squash

DAIRY

▪ 1 cup of skimmed, 1-percent, or 2- ▪ 1/3 cup of dry non-fat milk

percent milk ▪ 1 cup of skimmed or low-fat buttermilk
▪ 1 cup of non-fat plain or sugar-free
yogurt

70
MEAT OR MEAT SUBSTITUTES

▪ 1/4 cup of canned tuna, salmon ▪ 1/4 cup of low-fat cottage cheese
▪ 1 ounce of chicken (less skin) ▪ One 1-inch cube or 1 ounce of low-fat
▪ 1 large egg or 1/4 cup of egg substitute solid cheese
(Keep under 3 per week) ▪ 1/2 cup of tofu
▪ 1 ounce of fish (not breaded, fried) ▪ 1 ounce of turkey (less skin)
▪ 1 ounce of lean beef or pork

FATS

▪ 1/8 portion of a medium avocado

▪ 1 Tablespoon of regular cream cheese or 2 tablespoons of low-fat cream cheese
▪ 1 Tablespoon of regular margarine or 2 tsp. low-fat margarine
▪ 1 Tablespoon of regular mayonnaise or 1 Tablespoon of low-fat mayonnaise
▪ 6 almonds or cashew nuts, 10 peanuts, or 4 halves of pecan nuts
▪ 1 Tablespoon of oil, such as canola, corn, or olive oil
▪ 2 Tablespoons of peanut butter
▪ 1 Tablespoon of regular salad dressing or 2 Tablespoons of low-fat salad dressing

PROHIBITED LIST

These are the foods it is best to try and avoid.

▪ Cakes ▪ Pastries
▪ Candy ▪ Pie
▪ Cookies ▪ Regular fizzy drinks
▪ Ice cream ▪ Sugar-coated cereals
▪ Jelly and jam ▪ Sweet rolls

FOODS AND BEVERAGES CONTAINING:

▪ Corn syrup
▪ Dextrose
▪ Fructose
▪ Glucose
▪ High fructose corn syrup
▪ Honey
▪ Maltose
▪ Molasses
▪ Sucrose
▪ Sugar (brow, corn, powdered)
▪ Syrup

73
MEAL PLAN

- Your meal plan below is a guide which shows the number of exchanges (food
choices) you can eat at each meal and snack.
• The Food Exchange Lists help you plan your meals so that you can keep your
diabetes under control. You can avoid monotony in your diet by varying the
choice of foods within a particular food group.
• Your meal plan has been computed especially for you.
• It can be adjusted if it is not working out for you. Consult your dietitian regularly to
review your meal plan and adjust it according to your varying needs.

YOUR MEAL PLAN

Total _____ Rice Exchanges _____ Calories
_____ Meat Exchanges _____ grams Carbohydrate
_____ Lean Meat _____ grams Protein
_____ Medium fat meat _____ grams Fat
_____ High-Fat meat _____ Milk Exchanges
_____ Vegetable Exchanges
_____ Group A Vegetables
_____ Group B Vegetables
_____ Fruit Exchanges
_____ Fat Exchanges

References:
FOOD AND NUTRITION RESEARCH INSTITUTE Nutritional Handbook for Persons with Diabetes(2008)
https://logreport.thefilipinodoctor.com/cpm_pdf/CPM14th%20DIABETES%20food%20guide.pdf

72
LESSON 5
UNDERSTANDING FOOD LABELS

ENGAGING QUESTIONS: Please provide your answers below each question.

1. When you shop for your favorite food items, do you take time to read the label?
______________________________

2. Have you ever used food labels to decide what food to buy?
________________________________________________________________
________________________________________________________________

3. What information do you look at? Why?

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

4. Have you ever felt frustrated or turned off by food labels? WHY?
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

73
 Why Labeling?
- New food labels tell a lot about food.
- They don’t suggest what foods to eat—that’s
your decision.
- But labels can help you make your “personal
best” food choices—choices that benefit you
now and, in the future too.

The good news is: Nutrition labeling can help you

make food choices that
meet these Dietary Guidelines and promote a lifetime of
good health.

With today’s labels, you can:

- Compare one food with another.

- Choose foods that help provide the balance of nutrients your body needs.
- Plan meals and your whole diet so they are moderate, varied and balanced.

FOOD LABELS
- It is a description intended to inform the consumer of nutritional properties so that
they can make healthier food choices.
- It give information about the product’s content, ingredients' & nutritional value.

FUNCTION

- The serving size on the label is based on an average portion size.

- Similar food products have similar serving sizes to make comparing products
easier.
- The serving size on the label does not always correlate with a healthy serving
size.
- Most of the time, it does not match the serving size on the diabetic exchange list.

74
 - The United States Food and Drug Administration (FDA) has proposed making
changes to the food labels that may correct these problems.

Understanding Nutrition Labelling to Make Informed Food Choices

- The different kinds of nutrition information found on food labels are the Nutrition
Facts, the ingredient list, nutrition claims and health claims.

Each country has their own Government regulations about nutrition labelling.

Example:

1. Only Nutrition Facts and the ingredient list are mandatory in Canada.

2. An example of a regulated health claim is: “ A healthy diet rich in vegetables and
fruit may help reduce the risk of some types of cancer.”
3. In the USA, the Nutrition Labeling and Education Act of 1990 (NLEA) requires
nutrition labeling for most food and authorizes the use of nutrient content claims
and approved health claims.
- The nutrition label should indicate approved health claims to clear up confusion.
- Proper nutrition label helps consumers choose more healthful diets and offers an
incentive to food companies to improve the nutritional qualities of their products.
4. In the Philippines and other countries in the Southeast Asian Region, there is no
mandatory nutrition-labeling requirement for foods.
- However, several food manufacturers, especially the multinationals voluntarily,
include nutrition information on their food products.

LABELLING LAW

􀂄 REPUBLIC ACT 3720 (FOOD, DRUG AND COSMETIC ACT)

􀂄 Prescribes rules and regulations for the packaging and labeling of foods
distributed in the Philippines

􀂄 Bureau of Food and Drug (BFAD) interprets regulations and details of RA 3720

􀂄 Provides lists of substances permitted for use in food and food packaging
materials

75
NUTRITION LABELING

- Nutrition facts shall be presented in tabular form

- All nutrient quantities shall be declared in relation to the average or
usual serving in terms of slices, pieces or a specified weight or volume.
- Declaration of nutrients can be expressed in unit per serving or %
Recommended Energy and Nutrient (RENI) Intake or both.
- Locally manufactured food products intended for local consumption
shall also indicate the corresponding RENI values in actual percentage
expressed in whole numbers.
- Nutrients present in amounts less than 2% of the RENI shall be
indicated by the statement “contains less (or symbol “<“) 2% or by an
asterisk referring to this statement.

LABELLING

􀂄 Means provision of adequate information and accurate identification of the

pre-packaged foods on the package

76
 􀂄 Means by which product communicates with the consumers, traders,
regulatory agency

􀂄 It must be correct, not misleading, accurate and legible

PARTS OF A LABEL

􀂄 Principal Display Panel (PDP) or Alternate Principal Display Panel

􀂄 Portion of the package label that is most likely to be seen by the consumer.

- Sometimes, a food package may also have an alternate principal display panel,
which refers to the other surface of the package that is also suitable for display
as PDP.

􀂄 Required information:

􀂄 Product Identity Name

􀂄 Net Content Declaration

MANDATORY LABELLING REQUIREMENTS

1. Product Identity or Name of Product

􀂄 the name should distinguish the product from other products of the same type
􀂄 A sufficient precise description of the food and of its nature
􀂄 Product name should not be misleading
􀂄 The name prescribed by law

77
 2. Net Content Declaration

Expression of the weight, measure or numerical count or a combination of numerical

count and weight of the product inside the package.

- helps consumer compare product fairly.

Examples:

- NET WEIGHT 227 g

- NET CONTENTS 355 mL
- NET WT. 397 g
- 24 pieces
- NET WT. 2.95 kg
- NET CONTENTS 9.463 L

3. Ingredients

- Are defined in Article to mean “any substance, including additives, used in the
manufacture or preparation of a foodstuff and still present in the finished
product.”
- Listing of all the ingredients or components of the product in descending order
of predominance by weight

Examples:

- Snails in Coconut Milk

- Ingredients: Snail, coconut milk, salt, garlic, spices

• Benzoic acid (preservative)

• Sodium slfate (antioxidant)

• FD & C Blue No. 1

78
LET’S TAKE A REVIEW 😊

The list of ingredients, which is mandatory, can also help you make informed food
choices.
- It is important to know that the ingredients are always listed in descending
order by weight with the item in the greatest amount listed first.
- This can help you choose between products.
- Another example shown below, whole grain rolled oats is the ingredient in the
greatest amount since it is listed first.

The list of ingredients is:

• a source of certain nutrient information; and
• a source of information for people with food allergies or health concerns or for
people who avoid certain ingredients based on their beliefs.
• For example, the ingredient list will show if the food contains added sugars such
as corn syrup, dextrose, fructose, glucose, golden syrup, malt syrup, invert
sugar and concentrated fruit juice.

4. Name and Address of Manufacturer, Packer or Distributor

–shown for any complaints or suggestions.

􀂋 Examples:

• Manufactured by:________________________________
• Distributed by:__________________________________
• Packed by: ____________________________________

5. Country of Origin

- Example: Product of the Philippines

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 - Lot identification code
- The lot identification code/ production code shall be embossed or otherwise
permanently marked on immediate individual packages or containers.
- some products may appear misleading if their place of origin is not stated.

6. Open-Date Marking for specific food

- means legibly indicating a date on food labels/packages for the purpose of

informing the consumer about the expected quality of product at a given period of
time provided that it has been properly stored.

EXAMPLE: 􀂄 “Consume before”

􀂄 “Best before”
􀂄 “expiration date”
- All foods should be date marked apart from very long life products.
- Indicates the end of a period after the certain qualities to the product must be
expected to deteriorate.
- After such date, the product may still be satisfactory for human consumption &
may remain marketable, but the makers presumably no longer guarantee its best
quality.

7. Preparation Instructions – this should be shown specially on high risk food so

all bacteria are killed during cooking.

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 8. Storage Instructions – should be given so that the date mark should be valid.
9. Information Panel

- Required information:

1. All other mandatory information which include the name and address of the
manufacturer, packer, or distributor; the ingredient list and the country of
origin

2. The nutrition facts (when present) may appear on the information panel
➢ Are you aware of the nutritional information the label provides you?
➢ If not, it is about time you learn about the nutritional qualities of all the
products you buy and plan a healthy diet.

INFORMATION PROVIDED ON FOOD LABELS?

A. NUTRITION FACTS

NUTRITION FACTS

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What food products have Nutrition Facts?
Almost all prepackaged foods have Nutrition Facts.
Some exceptions are:
• fresh fruit and vegetables;
• raw meat, poultry, fish and seafood;
• foods prepared or processed at the store: bakery items, sausage, salads;
• foods that contain very few nutrients: coffee beans, tea leaves, spices;
• alcoholic beverages.

How do you use the Nutrition Facts table?

The Nutrition Facts table has information that will enable you to:
a. compare foods that are similar to determine which one may be a better choice for
you;
b. find foods that have more of a nutrient that you might want, like fibre, vitamin A,
calcium or iron;
c. find foods that have less of a nutrient that you might want less of, such as fat,
saturated fat, trans fat, sugars or sodium; and select foods for special diets; for
example, some individuals who manage their diabetes may want to use the
Nutrition Facts table to keep track of the amount of carbohydrate they are
consuming.

Nutrition Facts are based on a specific amount of food - compare this to the
amount you eat.

❖ The first thing you should do when you read the Nutrition Facts table is to:
• look at the specific amount of food listed; and
• compare it to how much you actually eat.

If you eat more or less than specified in the Nutrition Facts table, the amount of each
nutrient consumed will be different than what’s shown in the table.

This specific amount will be given in measures you may be familiar with, such as 1 cup
or 1 slice of bread and in a metric unit such as millilitres or grams.

It is important to refer to this amount when comparing products.

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The specific amount of food is not necessarily a suggested quantity of food to consume.

1. SERVING & SERVING SIZE – amount per serving

- This gives you the size and total number of servings in the container.
- This reflects the amount that people customarily consume.
- Uses standard serving sizes.
- Influences the amount of nutrients a consumer will receive depending upon how
much he has consumed in relation to a serving.

Example. ½ cup (114 g)

Servings per container 4

2. AMOUNTS PER SERVING

- The total calories and the calories from fat are listed.
- These numbers help consumers make decisions about fat intake.
- The list of nutrients includes total fat, trans fat, saturated fat, cholesterol, sodium,
total carbohydrate, dietary fiber, sugars, and protein.
- These nutrients are important to our health.
- Their amounts are given in grams (g) or milligrams (mg) per serving to the right
of the nutrient.

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 - This example shows that the amount you consume may be different than the
specific amount listed in the Nutrition Facts table.

- You should therefore refer to the Nutrition Facts table to determine the specific
amount of food listed and compare it to the amount of food that you consume.

- For packages that are consumed as one portion (e.g., small containers of yogurt,
individual-size packs of peanuts, juice-boxes), the nutrient information in the
Nutrition Facts table applies to the whole package so that it is easier for people to
know the amount of calories and nutrients they are consuming.

3. PERCENT DAILY VALUE

Now let’s look at another component of the Nutrition Facts table – the % Daily
Value.

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 PERCENTAGE DAILY VALUE (%)
- The amounts of vitamins and minerals are listed
as a Percent Daily Value on the nutrition label.
- The Percent Daily Value for vitamins and minerals
gives a general idea of how much of a vitamin or
mineral 1 serving of the food contributes to the
total daily requirement.
- The % Daily Value is used to determine whether
there is a little or a lot of a nutrient in a specific
amount of food;
• a benchmark for evaluating the nutrient content of
foods quickly and easily; and
• based on recommendations for a healthy diet.

For example, if the Percent Daily Value for vitamin C of all the foods you eat in a day
adds up to 100%, you are getting the recommended amount of vitamin C.

How can you use the % Daily Value?

Follow these three steps to choose healthier food products:

Step 1: Look at the amount of food

- Nutrition Facts are based on a specific amount of food. Compare this to the
amount you eat.

Step 2: Read the % Daily Value.

- The % DV helps you see if a specific amount of food has a little or a lot of a
nutrient.
- As a rule of thumb, remember the following numbers:
• 5% DV or less is a little.
• 15% DV or more is a lot.
- This applies to all nutrients in the Nutrition Facts table.

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Step 3: Choose.

- Make a better choice for you.

- You may want to look for food products with higher % DVs for fibre, vitamin A,
calcium and iron.

- You may also want to look for foods with lower % DVs for fat, saturated and trans
fats, and sodium.

- Remember to compare similar amounts of food.

- There is no mention of vitamin C in the nutrients to increase list, but for some
individuals, it could be a nutrient to increase.

- Vegetables and fruit are the best food sources of vitamin C.

Now let’s see how we can use what we have just learned to choose a cereal that
would provide more fibre.

- Here are 2 Nutrition Facts tables for cereals A and B.

- You can compare these 2 products since their weights in grams, 28 g and 30
g, are similar.
- Cereal A provides 28% of the Daily Value for fibre, whereas cereal B provides
4 % DV.
- Cereal A would be a better choice for you as part of a healthy lifestyle.
- Remember: 5% DV or less is a little and 15% DV or more is a lot.

- When comparing similar food products, such as these two cereals, you should
compare the amount of food by weight or volume (usually given in g or mL).

- This way, you are certain that you are comparing similar amounts of food.

- You may also be able to compare products that don’t have similar amounts of
food.

- For example, you could compare the % DVs of a bagel (90 g) to the % DVs of
2 slices of bread (70 g) because you would most likely eat either amount of
food at one meal.

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 - It is also appropriate to compare the % DV listed for calcium in two single
servings of yogurt, one containing 125 g of yogurt and the other containing 175
g, as they are both sizes that you would eat at one sitting.
- ≥ 20% → high or excellent source
- 10 – 19 % → good source
- ≤ 5% → low
- Cholesterol (mg & %DV)
- Sodium ( mg & %DV)

4. VITAMINS AND MINERALS

Only 2 vitamins (A and C) and 2 minerals (calcium and iron) are required on the food
label. But, when vitamins or minerals are added to the food, or when a vitamin or mineral
claim is made, those nutrients must be listed on the nutrition label. Food companies can
voluntarily list other vitamins and minerals in the food.

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 B. NUTRITION CLAIMS

- Are regulated statements made when a food meets certain criteria

- They are optional, and may be found only on some food products

- Nutrition claims are also referred to as nutrient content claims.

- It can also help you make informed food choices by highlighting a feature of
interest in the food, such as “Good source of vitamin C.”
- Here are examples of nutrition claims that can help you choose foods to
decrease your intake of certain nutrients, such as fat or sodium.
- To be able to use these nutrition claims, the food product must meet specific
criteria (according to government regulations and guidelines to ensure that they
are consistent and not misleading.)

- For example:
• for “sodium free”, the product must have less than 5 mg of sodium per specific
amount of food and per a pre-set amount of food specified in the regulations,
the reference amount;
• in order to be able to say the product is “low in fat”, the product must have 3 g or
less of fat per specific amount of food and per reference amount.

EXAMPLES of nutrition claims that indicate a food has more of certain nutrients which
you may want to increase, such as iron, calcium or fibre.
- Because nutrition claims are optional and only highlight one nutrient, you may
still need to refer to the Nutrition Facts table to make informed food choices.
- To be able to use these nutrition claims, the food must meet specific criteria. For
example:

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 • the claim “source of fibre” indicates that the product must have 2 g or more of
fibre per specific amount of food and per reference amount;
• to be able to say the product is “high in fibre”, the product must have 4 g or
more of fibre per specific amount of food and per reference amount;
• for a product to have the claim “very high in fibre”, the product must have at
least 6 g of fibre per specific amount of food and per reference amount; and
• for most vitamins and minerals, a “source” indicates that a serving of the food
contains at least 5% of the Daily value, as indicated in the Nutrition Facts
table.

C. HEALTH CLAIMS --- “ A healthy diet…”

- tells about the relationship between a nutrient/food and the risk of a disease or
health-related condition may also show up on the front of the package.
There are also five health claims on how diet affects health and the reduction of the risk
of disease.

- AN EXAMPLE of one of the four claims that start with the wording “A healthy
diet...”.
1. “A healthy diet low in saturated and trans fats may reduce the risk of heart
disease. (Naming the food) is free of saturated and trans fats.”

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 - Government regulations specify the criteria a food must meet before a claim can
be made, and the wording of the claim to ensure that they are consistent and not
misleading.
- Because health claims are optional and only highlight a few key nutrients or
foods, you may still need to refer to the Nutrition Facts table to make food
choices that are better for you.

The other disease risk reduction claims are:

2. a healthy diet with adequate calcium and vitamin D, and regular physical
activity, help to achieve strong bones and may reduce the risk of
osteoporosis;
3. a healthy diet rich in vegetables and fruit may help reduce the risk of some
types of cancer; and
4. a healthy diet containing foods high in potassium and low in sodium may
reduce the risk of high blood pressure, a risk factor for stroke and heart
disease.
5. "[serving size from Nutrition Facts table in metric and common household
measures] of [naming the product] provides X% of the daily amount of plant
sterols shown to help reduce/lower cholesterol in adults."
- Calcium & osteoporosis- must contain 20% (200mg) or more of the RDI, for
calcium per serving.
http://www.inspection.gc.ca/english/fssa/labeti/guide/tab8e.shtml

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 NUTRITION LABELLING SUMMARY:

✓ Use Nutrition Facts, the ingredient list, nutrition claims and health claims to
make informed food choices.
✓ Nutrition Facts are based on a specific amount of food – compare this to the
amount you eat.
✓ Use the % Daily Value to see if a food has a little or a lot of a nutrient.
✓ REMEMBER: 5%DV or less is little, 15% DV or more is a lot.

1. Serving Size

2. Total Fat

3. Saturated Fat

4. Trans Fat

5. Cholesterol

6. Calories from Fat

7. % Daily Value

8. Sodium %

9. Dietary Fiber %
• We have just reviewed how the Nutrition Facts table can help you make
informed decisions.

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 UNIT II: ACTIVITY 5

Betty Crocker Quaker Granola Raisins Cereal

CHOICE A CHOICE B

Using the food labels ABOVE answer the following questions: CHOICE CHOICE
A B
1. How many grams are in one serving?
2. How many calories are in one serving?
3. How many calories are from fat in one serving?
4. Find the percent of calories from fat

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 5. Which of these two foods is a healthier choice? Why?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

LABEL DETECTIVE

Directions: Compare 2 (two) food labels you can find at home. Then answer the
questions. Attach the labels to this sheet when you are done.

1. What two foods are you comparing?

1. __________________________ 2. _________________________
2. What are the serving sizes?

1. Food Label #1 __________________ 2. Food Label #2 _______________

3. which food has:

1. Food Label #1 2. Food Label #2

Fewer calories per
serving?
Fewer calories from fat?
Less sodium (salt)?
Less sugar?
More protein?
More Vitamin A?
More Vitamin C?
More calcium?
More Iron?

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4. Which food would be the healthier choice?
______________________________________

WHY?
______________________________________________________________________

______________________________________________________________________

5. How can food labels help improve your eating habits? Give examples.

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Self-Check: Check the 1st column if you have accomplished the given tasks

I found and compared all the information from the 2 food labels.
I compared the nutritional values of the 2 foods and decided which is healthier.
I explained how food labels can improve eating habits and give 2 specific
examples.

https://www.etr.org/healthsmart/assets/File/sample-lessons/MS-NutritionAndPhysicalActivityLesson.pdf

94
 READING A FOOD LABEL

LABEL DETECTIVE ACTIVITY SHEET

OBJECTIVE 4 3 2 1

1. How food Correctly & clearly Clearly explains how States that food Does not state
labels help explains how food food labels can help labels can help that food labels
improve labels can help improve eating improve eating can help improve
eating habits. improve eating habits and offers 1 habits but does not eating habits or
habits Using 2 specific and correct offer specific and offer correct
specific and correct example. correct example. examples.
examples.
2. Using Correctly finds and Correctly finds and Correctly finds and Does not find or
nutritional compares all 10 compares all 8 facts compares all 6-8 compare
information to facts from the 2 from the 2 sample facts from the 2 Most of the facts
compare sample Food labels, Food labels, and sample Food from the 2
products. and gives specific gives correct labels, and gives sample Food
and correct responses to most correct responses labels, and/ or
responses to all questions. to some questions. does not answer
questions. most of the
questions.
3. Using food Correctly identifies Correctly identifies identifies which Does not identify
labels to which food is which food is food is healthier which food is
make healthy healthier based on healthier based on without healthier.
food choices. nutrition facts, and nutrition facts, and explaining why
clearly explains why gives a general based on the
it is healthier. explanation of why it nutrition facts.
is healthier.

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 UNIT III
SIX ESSENTIAL NUTRIENTS

A person’s body cannot produce everything that it needs to function. There are
six essential nutrients that people need to consume through dietary sources to maintain
optimal health.

The World Health Organization (WHO) note that essential nutrients are crucial in
supporting a person’s reproduction, good health, and growth. The WHO divide these
essential nutrients into two categories: micronutrients and macronutrients.

Micronutrients are nutrients that a person needs in small doses. Micronutrients

consist of vitamins and minerals. Although the body only needs small amounts of them,
a deficiency can cause ill health.

Macronutrients are nutrients that a person needs in larger amounts.

Macronutrients include water, protein, carbohydrates, and fats.

CONTENTS
Classification of Nutrients
1. Classification by predominant
function
2. According to essentiality
3. According to chemical nature or
property
4. According to concentration
5. According to digestibility

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 LESSON 1
Classification of Nutrients

WEEK
ACTIVITIES
4 TOPIC LEARNING OUTCOMES
1. Study
Day 7 At the end of the lesson, you will be able to: questions
2. Laboratory
______ 1. Classify nutrients appropriately. activities
Day 8
2. Describe the micronutrient/ macronutrient
_______ content of various foods and meal items.
3. Identify the essential nutrients, its
Week 5 importance and food sources.
Day 9 4. Understand the classification of food into
different food groups.
_______ 5. Name the nutrients and discuss their
importance in the body.
Day 10 List the primary food sources for each of the
nutrients.

1. Classification by PREDOMINANT FUNCTION

Nutrient – is a chemical component needed by the body .
- chemical substances found in food
- some are manufactured in the body (a process called “biosynthesis”)
- while some are made in the laboratory ( manmade nutrients useful for research or
therapeutic purposes

a. Body-building- they form tissues or are structural components of the body.

Water – is most abundant in the body, accounting for about 2/3 of body weight
Protein - 1/5th or 20%
Minerals - 4%
Carbohydrates – less than one pound about 1/3 kilogram or 1%
Vitamins – are not considered structural nutrients since the total concentration in the body
is not even an ounce (less 28 gms

b. Regulatory – they maintain normal

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 physiologic processes.
- include all the six groups of
nutrients.
- they maintain homeostasis of body
fluids and expedite metabolic processes.
c. Furnish energy – are carbohydrate, fat
and protein.
- sometimes referred to as the “fuel
nutrients”

2. According to CHEMICAL NATURE/ STRUCTURE – nutrients are either organic

or inorganic.

a. Organic nutrients are those that come from anything food-based that
contains carbon in its genetic makeup. This includes carbohydrates,
lipids, vitamins, and protein.
b. Inorganic Nutrients
- Inorganic nutrients are different from organic nutrients in one key way:
they do not contain carbon.

- There are only two groups of inorganic foods that you need to be
concerned about: minerals and water.

3. According to ESSENTIALITY

- the six major nutrients are group of individual nutrients each of which has important
physiological role in the body.
- all nutrients are physiologically essential to the body, but some are dietary essentials
(these should be supplied from food because the body does not synthesize them).

There are six major nutrients: Carbohydrates (CHO), Lipids (fats), Proteins, Vitamins,
Minerals, Water.

1. Proteins: meat, dairy, legumes, nuts, seafood and eggs

2. Carbohydrates
o Glucose dietary fiber

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 3. Lipids (most commonly called fats)
o linoleic acid linolenic acid
4. Vitamins
o water soluble B group vitamins and vitamin C
o fat soluble vitamins A, D, E and K
5. Minerals
There are 16 essential minerals:

• Calcium Phosphorus Potassium

• Sulfur Sodium Chloride
• Magnesium Iron Zinc
• Copper Manganese Iodine
• Selenium Molybdenum Chromium
• Fluoride

6. Water: As a beverage and a component of many foods, especially vegetables

and fruits.

4. According to CONCENTRATION – some nutrients are needed in large amounts than

others.

– nutrients may be termed macronutrients or micronutrients.

Macronutrients – water, protein, fat and carbohydrates (present in the body in large
amounts)

Micronutrients – all vitamins and the trace minerals, which are measured in milligrams
or fractions.

5. According to DIGESTIBILITY, carbohydrates are simply grouped into:

- Digestible –sugars, starches, dextrin and glycogen
- Partially digestible – galactogens, mannosans, inulin and pentosans
- Indigestible carbohydrates – cellulose and Hemicellulose
Only the digestible carbohydrates – sugars and starches, supply energy, upon complete
hydrolysis- 1 gram yields 4 kcal.

Indigestible carbohydrates – like the dietary fibers (cellulose, hemicellulose) not broken
down by the human beings in the intestine into glucose units due to lack of specific
enzymes so they do not yield energy

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 LESSON 2
CARBOHYDRATES

CONTENT
A. Carbohydrates

1. Functions 4. Recommended intake

2. Nature 5. Deficiencies/toxicity
3. Types 6. Food sources

WEEK ACTIVITIES
6 TOPIC LEARNING OUTCOMES (ASSESSMENT)
Day 11 At the end of the lesson, you will be able to: • Study
Questions
1. Describe the functions and general • Laboratory
recommendations for carbohydrate, protein, activity
and fat in health prevention and disease
management.
2. Classify the type(s) of carbohydrate found in
various foods.
3. Describe the functions of carbohydrates.
4. Modify a menu to ensure that the adequate
intake for fiber is provided.
5. Calculate the calorie content of a food that
contains only carbohydrates.
6. Suggest ways to limit sugar intake.

In this lesson, we begin our study of the macronutrients— carbohydrates, fats,

and proteins. These three nutrients share a unique characteristic: the ability to supply
energy.

Carbohydrates are of prime importance in the human diet. Over the ages they
have nurtured cultures throughout the world as the major source of energy for work
and growth. In recent years researchers have focused attention on digestible and
indigestible carbohydrates and their various effects on health. Indigestible
carbohydrates, usually referred to as fiber, have specific functions in maintaining
gastrointestinal health. Plant foods identified as functional foods have distinct
characteristics that positively influence health.

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 We will first review the different types of carbohydrate and then examine their
functions.

A. CARBOHYDRATES
- Originally called saccharides, a Greek word, meaning “sugars”
- Organic compounds abundant in plants and widespread in nature.
- About 50-60 percent of energy needs come from carbohydrates.
- It contains or is made up of molecules carbon(C), hydrogen(H), and
oxygen(O). Carbohydrates are the most widespread organic substances and
play a vital role in all life.
- The ratio of hydrogen to oxygen is 2:1 as in water molecule, hence the word
carbo-hydrate referring to “a hydrated carbon”

Dietary Importance

Carbohydrates make up a major portion of the food of people all over the world.
Fruits, vegetables, cereals, grains, and dairy foods supply carbohydrate; in some
countries fruits, vegetables, and grains make up 85% of the diet.1 Rice is one of the
world’s most important sources of carbohydrate, feeding 3 billion people in the
developing world.2 In the typical American diet, about one half of total kilocalories
(kcalories or kcal) come from carbohydrates. Carbohydrate foods are readily available,
relatively low in cost, and easily stored.

Compared with food items that require refrigeration or have a short shelf life,
many carbohydrate foods can be held in dry storage for fairly long periods without
spoiling. Modern processing and packaging methods have extended the shelf life of
carbohydrate products almost indefinitely.

FUNCTIONS OF CARBOHYDRATES
1. Energy
The primary function of starch and sugars is to supply energy to cells, especially
brain cells that depend on glucose. When carbohydrate is lacking, fats can be used as
an energy source by most organ systems; however, body tissues require a constant

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supply of glucose to function most efficiently.
Body stores of carbohydrate are relatively small but still serve as an important
energy reserve. An adult man has about 300 to 350 g of carbohydrate stored in his liver
and muscle in the form of glycogen, and another 10 g of glucose circulates in his blood.
Together, this glycogen and glucose will supply the energy for only a half day of
moderate activity. To meet the body’s constant demand, carbohydrate
foods must be eaten regularly and at reasonably frequent intervals.

2. Special Functions
Carbohydrates have other specialized roles in overall body metabolism.

3. Glycogen–Carbohydrate Storage
Liver and muscle glycogen are in constant interchange with the body’s overall
energy system. These energy reserves protect cells, especially brain cells, from
depressed metabolic function and injury and support urgent muscle responses.

4. Protein-Sparing Action
Carbohydrates help regulate protein metabolism. An adequate supply of
carbohydrate to satisfy ongoing energy demands prevents the channeling of protein for
energy. This protein-sparing action of carbohydrate allows protein to be reserved for
tissue building and repair.

5. Antiketogenic Effect
Carbohydrates influence fat metabolism. The supply of carbohydrate determines
how much fat must be broken down to meet energy needs, thereby controlling the
formation of ketones. Ketones are intermediate products of fat metabolism that normally
are produced in very small amounts.

However, when carbohydrate is inadequate to meet cell energy needs, as in

starvation or uncontrolled diabetes or very lowcarbohydrate
diets, fat is oxidized at extreme rates. Sufficient amounts of dietary carbohydrates
prevent any damaging excess of ketones.

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6. Heart Action
Heart action is a life-sustaining muscle activity. Although fatty acids are the
preferred fuel for the heart, the glycogen stored in cardiac muscle is an important
emergency source of contractile energy.

7. Central Nervous System

The brain and central nervous system (CNS) depend on carbohydrate for energy
but have very low carbohydrate reserves—enough to last only 10 to 15 minutes. This
makes them especially dependent on a minute-to-minute supply of
glucose from the blood.

Sustained hypoglycemic shock causes irreversible brain damage. Providing an

adequate morning supply of glucose for brain function may help to explain why
individuals who eat breakfast do better in school than those who skip breakfast.19
Glucose increases the synthesis of acetylcholine, a neurotransmitter that acts on areas
of the brain responsible for memory and cognitive function.

TYPES/CLASSIFICATION ACCORDING TO COMPLEXITY

1. COMPLEX CARBOHYDRATES contain many more nutrients than simple

carbohydrates.

• These complex carbohydrates, such as whole wheat bread, potatoes and rice
have a high nutrient density and are a good source of dietary fibre, and sh0uld
be a major ingredient in any persons diet. Between 55% and 75% of calories
should come from carbohydrates.
• They have a low fat content, but are usually consumed with meat, cheese, oil or
butter, all of which are very fattening. It is a good idea to try and limit the amount
of fatty foods and protein rich foods combined with carbohydrates.
• For instance a pasta dish with a garlic, chili or tomato sauce is far healthier than
a similar pasta covered in a cream, cheese or meat topping.

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2. SIMPLE CARBOHYDRATES - are usually refined foods such as white sugar, white
bread or cola. These foods contain little else besides energy (ie. empty calories).
- Any food that does not have a large variety of nutrients is considered to have
a low nutrient density. Foods that have low nutrient densities should be
limited to small portions and only eaten as a special treat if the bulk of your
diet consists of nutrient dense, natural, wholefoods (eg. bananas, fruit juice,
nuts, granola, beans and green vegetables).

c. Monosaccharides
- Monosaccharides are simple sugars (glucose, fructose, and galactose) that
do not need to be further digested to be absorbed.
- The most important dietary monosaccharide is glucose, also called dextrose.
It constitutes about 0.1 % of the blood of mammals and is essential to life.
o c.1. Glucose, either free or combined with other molecules, is
probably the most abundant organic compound. It is the ultimate
hydrolysis product of starch and cellulose.
o c.2. Fructose, also known as fruit sugar, occurs free, along with
glucose and sucrose, in many fruits, vegetables, and honey.

o c.3. Galactose is a simple sugar, which belongs to

simple carbohydrates. Galactose is composed of the same elements
as glucose, but has a different arrangement of atoms.
Galactose is not an essential nutrient, which means you do not need to get it from food
to be healthy; galactose can be synthesized in the human body from glucose.

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In the human body, most of the ingested galactose is converted to glucose, which can
provide 4.1 kilocalories per gram of energy, which is about the same as sucrose.

Galactose can bind to glucose to make lactose (in breast milk), to lipids to make
glycolipids (for example, molecules that constitute blood groups A, B and AB), or to
proteins to make glycoproteins (for example, in cell membranes).

The main dietary source of galactose is lactose from milk and yogurt, which is digested
to galactose and glucose.

Foods containing small amounts of free galactose include low-lactose or lactose-free

milk, certain yogurts, cheeses, creams, ice creams and other foods artificially sweetened
with galactose. Plain natural foods (fruits, vegetables, nuts, grains, fresh meats, eggs,
milk) usually contain less than 0.3 g galactose per serving.

Certain medications may contain galactose as a filler.

d. Disaccharides
- Are sugars formed from two monosaccharides.
- Ordinary cane sugar (sucrose) is a disaccharide composed of glucose and
fructose monosaccharide units.
o d.1. Sucrose is the most important disaccharide, it occurs in all
photosynthetic plants where it appears to serve as an easily
transported energy source. Its two main commercial sources are
sugar beets and sugar cane.
- The juices, which contain about 20% sucrose, are put through a rather
extensive purification process to remove impurities.
o d.2. Maltose is a disaccharide of two glucose molecules and is
found in beer and cereals. It is formed by the action of an enzyme
from malt on starch, further hydrolysis of maltose, catalyzed by the
enzyme maltase (from yeast) gives only glucose.
o b.3. Lactose is the sugar present in milk, human milk contains five
to eight percent and cow's milk, four to six percent. It is composed
of one molecule of glucose and one of galactose.

e. Polysaccharides
- Starch, glycogen, cellulose and most types of fiber are polysaccharides.

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 - Starch is the reserve carbohydrate in many plants and comprises large
percentages of cereals, potatoes, corn, and rice.
- Under the microscope, the appearance of the granules of starch from these
different sources varies both in shape and size. Chemically, however, they
are similar.
- Complete hydrolysis of starch yields glucose but partial hydrolysis gives
maltose as well.
- Partial hydrolysis of starch transforms it into dextrins, polysaccharides of
smaller molecular weight than starch.
- They are more readily digested than starch and are used, mixed with
maltose, in infant foods.

1. Glycogen, the reserve carbohydrate of animals, is found mainly in the liver and
muscles.

- Glycogen helps maintain the proper amount of glucose in the blood by

removing and storing excess glucose derived from ingested food or by
supplying it to the blood when it is needed by the body cells for energy.
2. Cellulose is the main structural material of plant life, being the chief ingredient of cell
walls of cotton, wood pulp, straw, com cobs, and many other materials.

3. Fiber includes a variety of carbohydrates and other components.

The chemical linkages in starch and glycogen can be split by the human
intestinal enzymes, but those of polysaccharides found in fiber are indigestible, although
some fiber components can be broken down by enzymes released by intestinal bacteria
to short-chain fatty acids that can be reabsorbed.

e. Oligosaccharides

o Oligosaccharides contain less than ten monomer units to make up the molecule.
- They are present in a number of plant foods including leeks, garlic, onions,
Jerusalem artichokes, lentils and beans.
o Generally, these sugars are considered to be of minor nutritional significance.
However, both the galactosyl-sucroses (raffinose, stachyose and verbascose)
contained in legume seeds and the fructosyl-sucroses in onions, leeks and
artichokes are resistant to digestion in the upper gastrointestinal tract.

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 o Consequently, they pass largely unchanged into the colon, where fermentation
occurs, resulting in the production of volatile fatty acids and gases and causing
flatulence.
- This can be uncomfortable and may discourage the consumption of these
foods.
- Nevertheless, there are health benefits from this fermentation, and
oligosaccharides have been studied and developed as possible components
of prebiotics or functional foods, which provide a food source for colonic
bacteria.

DIGESTION AND ABSORPTION OF CARBOHYDRATES

Digestion
- The conversion of starch and sugars to glucose begins in the mouth where
salivary amylase (ptyalin) from the parotid gland acts on starch to begin its
breakdown into dextrins and maltose.
- No specific enzyme in the stomach acts on carbohydrate; however, by the time
the food mass is completely mixed with gastric acid, as much as 20% to 30% of
the starch has been broken down to maltose.
- Enzymes that complete the chemical digestion of carbohydrate come from two
sources: the pancreas and the small intestine, as follows:
• Pancreatic secretions: Pancreatic amylase entering the duodenum through the
common bile duct completes the breakdown of starch to maltose.
• Intestinal secretions: Cells within the brush border of the small intestine secrete three
disaccharidases, sucrase, lactase, and maltase, which act on their respective
disaccharides to release the monosaccharides, glucose, galactose, and fructose.

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Absorption and Metabolism
- Glucose is absorbed by an active pumping system using sodium as a carrier. Of
the total carbohydrate absorbed, 80% is in the form of glucose, and the
remaining 20% is galactose and fructose.
- Via the capillaries in the villi, the products of carbohydrate digestion enter the
portal blood circulation en route to the liver.
- Here, fructose and galactose are converted to glucose. Glucose not needed for
immediate energy is converted to glycogen or adipose tissue for storage.

KEY TERMS
Energy density … The relative number of kcalories per unit weight of food; foods high in fat and added sugar have
high energy density; vegetables that contain large amounts ofwater and fiber have low energy density.
Amylase … A digestive enzyme that breaks down starch; salivaryamylase begins the digestion of starch in the mouth;
pancreatic amylase enters the small intestine as part of the pancreatic secretions to continue starch breakdown in the
duodenum.
Sucrase … Enzyme that splits the disaccharide sucrose, releasing the monosaccharides glucose and fructose.
Lactase … Enzyme that splits the disaccharide lactose, releasing the monosaccharides glucose and galactose.
Maltase … Enzyme that splits the disaccharide maltose, releasing two units of the monosaccharide glucose.
Portal … An entryway, usually referring to the portal circulation of blood that delivers nutrients absorbed from the small
intestine to the liver.

RECOMMENDED DIETARY INTAKE

While there is no (RDA) for carbohydrate, a level of 50 to 60% of total caloric
requirement should be provided by carbohydrates

DIETARY REFERENCE INTAKES

The Recommended Dietary Allowance (RDA) for carbohydrate is the same for all
persons older than 1 year. Children, adolescents, and adults need a minimum of
130g/day, the amount required to supply the energy demands of the CNS
for 1 day. Most people consume more than this minimum amount to meet their overall
energy requirement and keep fat and protein intakes at acceptable levels.

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Acceptable Macronutrient Distribution Range
A diet rich in plant-based foods supplies important nutrients and fiber, but it is
unwise to take in excessive amounts of carbohydrate, just as it is not prudent to severely
limit carbohydrate.
To provide guidance for developing dietary patterns, nutrition experts established the
Acceptable Macronutrient Distribution Ranges (AMDRs) for allocating macronutrient
intakes in proportion to total kcalories. The adult AMDR for carbohydrate is 45% to 65%
of total energy intake. The AMDRs enable us to individualize diets to meet
specific health situations and personal food preferences yet encourage sound nutrition
habits.

ACCEPTABLE MACRONUTRIENT DISTRIBUTION RANGES

Carbohydrate: 45% to 65% of total kcalories
Fat: 20% to 35% of total kcalories
Protein: 10% to 35% of total kcalories

DEFICIENCY AND EXCESS

In severe deficiencies, in case of famine and prolonged starvation, the ill effects of a
limited total food intake result in multiple nutrient deficiencies, particularly protein energy
malnutrition (PEM).

The first clinical signs are decreased blood sugar level, loss of weight, and retarded
growth for infants and children.

In excessive intake of calories, whether from carbohydrates, fats or proteins, obesity or

adiposity becomes the problem. If the intake of fat and protein is normal, but the
carbohydrates intake is lower than the recommended level to supply caloric
requirements, ketosis or acidosis occurs.

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FOOD SOURCES OF SUGAR
Sources of Naturally Occurring Sugars*
Orange juice Peaches Strawberries
Grape juice Apples Grapes
Fluid milk Powdered milk Bananas
Some cheeses (cheeses vary in the amount of lactose they
contain, depending on method of manufacture)

SOURCES OF ADDED SUGARS

Pancake syrup Fruit drinks Soft drinks
Candy Sports drinks Cookies
Cake Ice cream Frozen desserts

DIETARY FIBER
- Dietary fiber includes the nondigestible carbohydrates and lignin found intact in
plant foods.
- Several dietary fibers important in human nutrition are described below:

• Cellulose: Cellulose is the material in plant cell walls that provides structure. We find it
in the stems and leaves of vegetables, in the coverings of seeds and grains, and in skins
and hulls. Because humans are unable to break down cellulose, it remains in the
digestive tract and contributes bulk to the food mass.

• Hemicellulose: This polysaccharide is found in plant cell walls and often surrounds
cellulose. Some hemicelluloses help regulate colon pressure by providing bulk for
normal muscle action, whereas others are fermented by colonic bacteria.

• Lignin: Lignin is the only dietary fiber that is not a carbohydrate.

It is a large molecule that forms the woody part of plants and in the intestine combines
with bile acids and prevents their reabsorption. Lignin contributes the sandy texture to
pears and lima beans.

• Pectin: This fiber is found in plant cell walls. It forms a viscous, sticky gel that binds
cholesterol and prevents its absorption. Pectin also helps to slow gastric emptying and
extend feelings of satiety.

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• Gums: Plants secrete gums in response to plant injury. In the intestine gums bind
cholesterol and prevent its absorption.
Bacteria in the colon ferment gums to form short chain fatty acids that nourish colonic
cells (this action is also true of resistant starch).

• β-Glucans: These water-soluble fibers are found in oats and oat bran, foods that carry
a health claim on the label indicating they can reduce the risk of heart disease.
(β-glucans interfere with the absorption of cholesterol.) Box 3-5 gives examples of foods
that provide specific varieties of fiber.

FUNCTIONAL FIBER
- Functional fibers are nondigestible polysaccharides that have been added to a
food to increase its fiber content. The term functional fiber is used to distinguish
those fibers that are added to foods from those that are intact in plants and eaten
in that form.
- Functional fibers can be isolated from plant foods or manufactured, and they are
used as dietary supplements or added to processed foods.
- A particular fiber can be either a dietary fiber or a functional fiber depending on
how it is eaten or used.
- The pectin in the apple you ate at lunch is considered a dietary fiber. On the
other hand, pectin that was isolated from fruit sources and added to homemade
or commercial jellies or used as a fiber ingredient in patient tube feedings is
classified as a functional fiber.
- Functional fibers added in food processing must be listed on the food label.
- Flaxseed and psyllium are two common functional fibers.
- Flaxseed is a common ingredient in breads and cereals marketed as high fiber.

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 - Psyllium, an ingredient in bulk laxatives, is also available as a dietary
supplement.
- A person’s total fiber intake includes both dietary and functional fiber. Selected
food sources of dietary fiber and their energy content are listed in Table 3-6. Note
that foods high in fiber tend to be low to moderate in kcalories.

HEALTH PROMOTION
Health Benefits of Fiber
- Dietary fiber influences the food mix in the gastrointestinal tract and
gastrointestinal function.
- Individuals who follow dietary patterns that include higher amounts of dietary
fiber are less likely to develop chronic conditions such as type 2 diabetes,
cardiovascular disease, or metabolic syndrome, and they have lower mortality
rates.
- We outline below the effect of fiber on specific risk factors associated with
chronic conditions.
• Increases fecal mass and promotes laxation:
- The capacity of dietary fiber to hold water and bacteria creates its bulk forming
and laxative effects. The added mass helps the food bolus move more rapidly
through the small intestine, promoting normal bowel action and preventing or
alleviating constipation.
- A larger food mass in the colon averts the development of diverticula, small
pouches that protrude outward through the lining of the colon. When the food
residue entering the colon is low in bulk, the muscles must contract more
forcefully to move it forward, which over time contributes to the formation of
diverticula with risk of inflammation and infection.
- Dietary fiber has been effective in treating diarrhea and may be useful in treating
other gastrointestinal conditions.

• Promotes growth of beneficial colonic microflora:

- Bacteria living in the colon ferment dietary fiber along with resistant starch. This
action produces short-chain fatty acids that nourish the cells lining the colon and
stimulate their growth.

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 - Fiber encourages the proliferation of health promoting bacteria in the colon and
has been used to treat irritable bowel syndrome.
• Binds bile acids and cholesterol:
- Fiber binds cholesterol and bile acids in the lower section of the small intestine
and prevents their absorption. Bound to fiber, cholesterol and bile acids are
eliminated in the feces.
- When bile acids are lost, cholesterol must be removed from circulating blood
lipoproteins to synthesize their replacements, with a resulting decrease in blood
cholesterol. Ready-to-eat whole-grain oat cereal has been used to reduce LDL
cholesterol levels.
• Slows rise in blood glucose and insulin levels:
- Foods rich in fiber have a low GI, with their glucose content released slowly into
the blood. This slow release prevents a rapid spike in blood glucose after eating.
- The blunting of blood glucose levels lessens the amount of insulin needed to
move glucose into muscle and fat cells, thereby reducing the work of the
pancreas. Fiber intake at recommended levels may assist in the prevention and
management of diabetes.
• Assists in weight management:
- Fiber lowers the energy density of the diet by displacing carbohydrate, fat, or
protein in a food, thereby reducing its energy content. A diet containing
recommended levels of fiber requires more chewing and promotes satiety,
helping to lower food intake.
- The 2010 Dietary Guidelines Advisory Committee quoted strong and consistent
evidence that in adults, diets lower in energy density support weight loss and
weight maintenance. Diets lower in energy density include more fruits,
vegetables, whole grains, and legumes, and fewer kcalories from fat, baked
desserts, and fried foods.
Water also lowers the energy density of meals and particular foods, such as soups. In a
national survey, individuals who consumed more fiber in the form of beans had lower
body weights and lower waist circumferences.

Although dietary fiber performs many actions that support health, much remains to be
learned as to its effect on specific chronic conditions. Total fiber intake does not seem to

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defend against colorectal cancer, although greater use of whole-grain cereals is
associated with lower risk. It may be that other dietary components associated with
fiber— particular nutrients or phytochemicals—rather than the fiber itself confer
resistance to chronic disease (see our later discussion in the section “Functional
Foods”).

RECOMMENDED FIBER INTAKE

The Adequate Intake (AI) for total fiber is based on the amount expected to lower the
risk of coronary heart disease and type 2 diabetes.
- Men age 50 and younger should consume 38g/day
- those age 51 and older need 30g/day.
- AIs for younger women = 25g/day
- older women = 21g/day
- Unfortunately, consumer directives are inconsistent, as the current nutrition label
recommends a fiber intake of 25g in a 2000-kcal diet, considerably lower than the
AI for men.
- Fiber intake in the United States is barely half the AI. Mean daily intake is 18.7
g/day for men and 15.5 g/day for women.
- Women consume more fiber than men based on kcalories (8.1 g/1000 kcal
versus 7.0 g/1000 kcal).
- Whole grains account for nearly half of fiber intake (44%) among U.S. adults,
followed by vegetables (21%), fruit (13%), and legumes (10%).
- The MyPlate (ChooseMyPlate.gov) goal of 4 1 2 cups of fruits and vegetables
and three whole-grain servings per day within a 2000-kcal diet provides about 30
g of fiber.

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 https://www.benefiber.com/fiber-in-your-life/daily-fiber-intake/top-10-high-fiber-foods/

1. Beans Lentils and other beans are an

easy way to sneak fiber into your diet in soups, stews and salads. A bonus? All of these
provide a great source of protein, too. Some bakers have even started including beans
or bean flours in their baked goods, which research proves can still make quality cakes.

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2. Broccoli This veggie can get pigeonholed as the
fiber vegetable. Its cruciferous nature—meaning it’s from the Brassica genus of plants
along with cauliflower, cabbage and kale—makes it rich in many nutrients in addition to
fiber.

Studies have shown that broccoli’s 5 grams of fiber per cup can positively support the
bacteria in the gut, which may help your gut stay healthy and balanced.

3. Berries Berries get a lot of attention for

their antioxidants, but they’re full of fiber, too. Just a cup of fresh blueberries can give
you almost 4 grams of fiber, and there is nearly the same amount of fiber in a cup of
frozen unsweetened blueberries. Blackberries, strawberries and raspberries are also
great sources of fiber. Of course, one of the biggest benefits of berries is that they’re
naturally low in calories, too.

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4. Avocados Avocados pretty much go
with everything—toast, salads, entrees, eggs—and while they’re often recognized for
their hefty dose of healthy fats, there are 10 grams of fiber in one cup of avocado (so just
imagine how much is in your guacamole).

5. Popcorn There’s one gram of fiber in one

cup of popcorn, and the snack (when natural and not covered in butter, like at the
movies) is a whole grain that can satiate cravings with a hit of fiber. It’s even been called
the King of Snack Foods.

6. Whole Grains Good news for bread lovers:

Real whole grains, found in 100% whole wheat bread, whole wheat pasta, brown rice,
and oats, have fiber. One tip to watch out for: as required by The Food and Drug

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Administration, whole grains should be the first ingredient on a food package in order for
it to be considered a real whole grain.

7. Apples That old saying that “an apple a

day keeps the doctor away isn’t necessarily true, according to research, but the fruit can
boost your fiber intake. There are about 4 grams of fiber in an apple, depending on its
size, but this serving amount can help protect arteries and lower cholesterol. And, of
course, they’re a nice and crunchy snack.

8. Dried Fruits Dried fruits like figs,

prunes and dates can boost your fiber intake dramatically and are recommended for
those struggling with constipation. The sugar called sorbitol, which naturally occurs in
these fruits, can help your bowels and lead to more comfort.

However, eating too many can lead to cramping or diarrhea, so try a small serving and
see how you feel once you’ve digested them, before noshing on too many more.

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9. Potatoes Sweet potatoes, red potatoes,
purple potatoes and even the plain old white potato are all good sources of fiber; one
small potato with skin can provide close to 3 grams of fiber. The veggie has a bad
reputation for running in the wrong crowds—fries and chips, to name a few.

However, when not fried in oil and slathered in salt, potatoes can provide many benefits.
Plus, the fiber in potatoes can help protect the intestinal wall from potentially harmful
chemicals found in some foods and drinks.

10. Nuts Nuts aren’t just a great source of

protein and healthy fats—sunflower seeds and almonds each have more than 3 grams
of fiber in a serving. They can help you reach the 25-gram intake of fiber recommended
by the FDA for women and 38-gram recommendation for men.

Raw or dry-roasted nuts are preferred over the pre-packaged variety (which are usually
cooked in oils that can add extra, unnecessary calories.) Even nut butters can pack a
punch of fiber.

*According to the Institute of Medicine, it is recommended that, in adults 50 or younger,

women should consume 25 grams of fiber daily and men 38 grams. In adults 51 or older,
women should consume 21 grams of fiber daily and men 30 grams.

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 UNIT III: ACTIVITY 1

STUDY QUESTIONS:

1.Is it advisable to derive energy from alcohol? Why?

2.What is the principle behind losing or gaining weight?

3. Comment on the following statement: “The larger the number of meals into which a
day’s food intake is divided, the less likely the person is to store fat”.

4. True or False. Explain your answer.

a. Water is fattening

b. Drinking kalamansi juice in large amounts will cause a person to lose weight

c. Obesity is due to heredity

d. Physical activity or exercise constitutes a major portion of the individual’s total

energy need.

ACTIVITY 2

Quiz:

1. How will eating excessive amounts of added sugars affect health?

2. List the benefits of eating more fiber. What are the consequences of eating too
much? Too little?

3. What are phytochemicals, and how do they benefit plants and humans?

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 UNIT III: LABORATORY ACTIVITY

MACRONUTRIENTS-Carbohydrates

Name: _________________________________ Date Due: _______________

Year and Section: ______________ Date Submitted: ___________

Professor’s Signature:__________ Score: ___________________

When planning diets, one should consider the amount of carbohydrates in the
food to be prepared and the contributions of other nutrients in a given food. Bread, rice,
corn, sweet potatoes and white potatoes are important contributors from the vegetable-
fruit group to the carbohydrate intake. Bananas, dried fruits, beans are also relatively
high in carbohydrates.

Most people consider carbohydrates as fattening and avoid them if they want to
lose weight. However, it would be wise to cut down on sugars and not totally avoid them,
while eating more of the complex form of carbohydrates.

I. OBJECTIVES
There are certain conditions where the body cannot metabolize some forms of
carbohydrates. From the lecture, you learned the different sources of carbohydrates and
their importance to one’s health. In this exercise, you will be assigned to plan a meal for
a specific carbohydrate disorder.

At the end of 3 hours, you should be able to:

1. Plan and prepare a meal for an individual requiring a carbohydrate intake

modification, and
2. Discuss the diet and its implication to the disease condition.

II. PROCEDURES
Case #1. A child suffering from underweight/ under nutrition.

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 Using a 1500 caloric requirement, calculate and plan a high CHO diet allowing 70
to 80% of total caloric requirement for carbohydrates. Prepare sample menu plan
for lunch.

Table 1. Meal Plan for HIGH Carbohydrate Diet

No. of CHO PRO FAT Meal Distribution

Food Ex- ENERGY
Exchanges changes g g g kcal B L D Sn

I. Veg A

Veg B

II. Fruits

I. Milk

IV. Rice

V. Meat

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VI. Sugar

VII. Fat

Total

Table 1-1. Sample Lunch Menu

Menu Household Measure

1. Discuss the following and write the answers in Table 1-2.

1.1 Symptoms
1.2 Causes
1.3 Prevalence
1.4 Dietary Changes

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 Table 1-2. Worksheet for Carbohydrate-related Diseases

Disease Symptoms Causes Prevalence Dietary Changes

Case #2. A teenager who is obese.

Using a 1500 caloric requirement, calculate and plan a LOW CHO diet allowing
50% of total caloric requirement for carbohydrates. Prepare sample menu plan
for lunch.

Table 2. Meal Plan for LOW Carbohydrate Diet

No. of CHO PRO FAT Meal Distribution

Food Ex- ENERGY
Exchanges changes g g g kcal B L D Sn

I. Veg A

Veg B

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II. Fruits

III. Milk

IV. Rice

V. Meat

VI. Sugar

VII. Fat

Total

III. EVALUATION

1. Present in class (when possible) the dietary plan for Case #1 and discuss
answers to question #2.
2. You will be evaluated using the following criteria: (Refer to table below)
2.1 Accuracy in Diet Computation
2.2 Suitability of the food served to disease condition, and
2.3 How the diet can promote good health.
3. Submit individual worksheets at the end of the laboratory activity.

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Evaluation of presentation:

10 - Outstanding 8 - Very Satisfactory 7-Satisfactory 6- fair 5- Poor

Accuracy in Suitability of the How the diet Overall Score

Diet food served to can promote
Computation disease good health
condition 10 points (perfect score 30 points)
10 points 10 points

IV. QUESTIONS FOR DISCUSSION

1. What is the importance of the following to the body?

a. Insoluble fibers
b. Soluble fibers
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

2. What is ketosis?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

3. What are harmful effects of excessive fiber intake?

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
4. How does the body make glucose from protein?
Activity Taken from:

Caudal, Ma. Lourdes. (2008) Basic Nutrition and Diet Therapy Textbook for Nursing
Students Revised Ed.,C & E Publishing Inc.

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 LESSON 3
PROTEIN

1. Functions 3. Deficiencies/toxicity
2. Types 4. Food sources
Week 6 TOPIC LEARNING OUTCOME ACTIVITY
At the end of the lesson, you will be able to:
Day 12 1. Discuss the functions of protein. 1. Laboratory
2. Select the foods which are primary sources of activity
protein. 2. Nutrient hunt
3. Explain the effects of inadequate or excess
protein intakes.
4. Recognize the importance of protein in the diet.
5. Compare complete and incomplete proteins.
6. Explain protein “sparing.”
7. Calculate an individual’s protein requirement.
8. Select appropriate sources of nutrients that are
most likely to be defi cient in a vegetarian diet.
9. Describe nitrogen balance and how it is
determined.

PROTEINS AND AMINO ACIDS

Protein came from the Greek word “protos”/proteios meaning “primary” or

“holding first place”/ “is of prime importance” since it is the first substance recognized as
a vital part of a living tissue. It contains nitrogen in addition to the basic carbon,
hydrogen and oxygen.

They are more complex compounds of high molecular weights, structured in specific
arrangement and numbers of their simpler building units, amino acids.

They are organic substances that on digestion yield their constituent unit building block-
amino acids.

b. There are 22 amino acids

c. All amino acids exist in nature as alpha-amino carboxylic acids
d. Glycine is the simplest amino acid identified in 1820.
e. Threonine was the last to be identified in 1935

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MULDER: a Dutch chemist proposed the name in 1840 and until now the word is used
due to its unique function of building and repairing cells and other specialized roles in
metabolism that cannot be accomplished or performed by other nutrients

Virtually every life process depends on proteins (enzymes, hormones,

muscle cells, blood cells, antibodies)
FUNCTIONS OF PROTEINS AND AMINO ACIDS

Proteins accomplish all three functions of a nutrient: body-building, regulating

processes and supplying energy. It’s unique function of tissue building and repairing
cannot be taken over by other nutrients.

1. BODY_BUILDING OR STRUCTURAL ROLE

Twenty percent (20%) or one-fifth of an adult body weight is protein. Based on

dry weight 50% or half of an adult body is protein. Of this, one-third is in the muscle, one
fifth in bones and cartilages, one tenth is in the skin and the rest in body fluids and other
body tissues. In its broadcast coverage, “body-building” includes all living cells and
tissues:

1. Protein is an integral part of cell nuclei and protoplasm.

2. The solid mass of soft tissue like muscles, vital organs, glands and blood cells is
made up of basically of protein.

3. Protein is the supporting organic matrix for bones, teeth, hair and nails.

4. All enzymes are protein in nature

5. Most hormones are derived from protein

6. other bodily secretions and fluids are produced with the help of proteins. The only
fluids that should not contain protein are: bile, sweat and urine

7. Antibodies contain protein (as gamma globulin), thus aiding in bodily resistance to
infections.

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2. SOURCE OF ENERGY

Protein supply 4 cal per gram although it is more expensive source of energy
compared to fat and carbohydrate. Since protein is the sole nutrient that supplies amino
acids for body building and repairing, it’s role of energy-giving is secondary. Protein
should be spared or saved for it’s more important function of building and repairing by
adequate fat and carbohydrate intakes. Based on energy intake, protein allowance is
expressed as 10 to 15% of total caloric supply. To illustrate: 10% of a 2,200 caloric
allowance is 220 Cal. This is equivalent to 55 grams protein (220 divided by 4 Cal/gm
protein), which is the recommended daily allowance of protein for an adult Filipina.

3. REGULATOR OF BODILY PROCESSES

Protein regulates osmotic pressure, hence water balance and acid-base balance.
It helps in the exchange of nutrients and other metabolites which pass between cells and
the intercellular fluids or between tissues and the blood or lymph (extracellular fluids).

When a person has low plasma proteins, fluid balance is disturbed and
accumulate in-between tissues resulting in swelling or edema. Nutritional edema is one
clinical sign of hypoproteinemia (low protein level in the blood).

SOURCES OF ESSENTIAL AMINO ACIDS

Only protein can supply the 8-10 essential amino acids that play distinctive distinctive
physiological functions which cannot be accomplished by another essential amino acid.
To cite a few:

METHIONINE is a methylating agent(supplies the methyl radical-CH3) which is

needed for important substances in the body, like choline, heme portion of
hemoglobin, etc.

PHENYLALANINE is the precursor for the amino acid tyrosine; both are
important in the production of the hormones; thyroxine and epinephrine.

TRYPTOPHAN is the precursor of niacin (a B-vitamin) as well as for serotonin, a

vasoconstrictor.

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 GLYCINE, the simplest amino acid, combines with any toxic substance rendering
them harmless.

TYPES OF PROTEIN

Complete proteins: These foods contain all the essential amino acids. They mostly
occur in animal foods, such as meat, dairy, and eggs.

Incomplete proteins: These foods contain at least one essential amino acid, so there is
a lack of balance in the proteins. Plant foods, such as peas, beans, and grains mostly
contain incomplete protein.

Complementary proteins: These refer to two or more foods containing incomplete

proteins that people can combine to supply complete protein. Examples include rice and
beans or bread with peanut butter.

DIGESTION OF PROTEIN

a. In the stomach, enzyme pepsin, produced first as inactive precursor to pepsinogen,

then activated by the hydrochloric acid and converts protein to proteases and peptones.

In infants, enzyme rennin converts casein to coagulated curd.

b. Small intestines (alkaline)

Pancreas – trypsin (produced first as inactive precursor trypsinogen and then activated
by enterokinase) converts proteins, proteases and peptones to polypeptides and
peptides

Chrymotrypsin (produced first as inactive precursor chrymotrypsigen and then activated

by active trypsin) converts proteases and peptones to polypeptides and dipeptides; also
coagulates milk.

Carboxypeptidase converts polypeptides to simpler peptides, dipeptides and amino

acids.

INTESTINE – aminopeptidase converts polypeptides to peptides and amino acids

- dipeptidase converts dipeptides to amino acids

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ABSORPTION OF PROTEIN

Amino acids are absorbed from the gastrointestinal tract mainly by carrier
transport. Vitamin B6 is believed to be intimately involved with this mechanism.

After absorption into the intestinal mucosa, the amino acids are taken directly to
the portal blood system through the fine network of capillaries. Competition for the
absorption of amino acids seems to exist so that an amino acid, which is predominant,
may retard the absorption of the other amino acids.

Dipeptides and tripeptides are absorbed much faster than equivalent amino acid
mixtures. The peak level of absorption of proteins is intermediate between
carbohydrates and fats.

Occasionally, whole proteins or larger fragments of short-chain peptides are

absorbed and this gives rise to a hypersensitivity reaction (allergy) Colostrum (first
breastmilk) is passed by the mother to the infant during the first days of life, for the infant
to obtain immunity and is absorbed by the infant by means of pinocytosis.

RECOMMENDED INTAKE

The minimum amino acid requirement is 0.35 to 0.525 gm per kilogram desirable
body weight (Nitrogen x 6.35). The daily allowance for protein includes a margin of
safety to account for individual differences, variations in NPU (net protein utilization),
protein quality.

Daily Allowances (RDA) have an added safety factor by increasing the minimum
requirement 1.5 to 2 times. The simplest and easiest guide is to use 1gm/kg desirable
body weight for normal adults.

In the Philippines, protein allowance for adult man and woman is computed at
1.14gm/kg body weight based on the consumption of rice-based diets. In the USA where
protein sources are of better quality, a level of 0.9 gm/kg is recommended.

In Oriental countries where cereal and other vegetable proteins supply significant
amounts of protein, a higher level is suggested. Another method of expressing protein
intake is based on total caloric requirement.

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Example: 10% of a 2,200 Kcalorie need of an adult Filipina is equivalent to 55gm
protein(220Kcal divided by 4Kcal/gm protein.)

GENERAL DAILY RECOMMENDATION OF FOOD AND NUTRITION BOARD

ADULT – 0-9 gm/kgBW

CHILDREN –growth needs vary according to age and growth patterns

PREGNANCY – rapid growth requires an increase of 30 gms over that of the non-
pregnant woman

LACTATION - requires an increase of 20 gms

In Oriental countries where cereal and other vegetable proteins supply significant
amounts of protein, a higher level is suggested.

Another method of expressing protein intake is based on total caloric requirement.

Example: 10% of a 2,200 Kcalorie need of an adult Filipina is equivalent to 55gm

protein(220Kcal divided by 4Kcal/gm protein.)

GENERAL DAILY RECOMMENDATION OF FOOD AND NUTRITION BOARD

ADULT – 0-9 gm/kgBW

CHILDREN – growth needs vary according to age and growth patterns

PREGNANCY – rapid growth requires an increase of 30 gms over that of the non-
pregnant woman

LACTATION - requires an increase of 20 gms

DEFICIENCY AND EXCESS OF PROTEIN INTAKE

Protein deficiency is when people do not get adequate amounts of protein from
their diet. Kwashiorkor, its most severe form, is most commonly seen in children in
developing countries.

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1. Edema

Edema, which is characterized by swollen and puffy skin, is a classic symptom of

kwashiorkor. Scientists believe it is caused by low amounts of human serum albumin,
which is the most abundant protein in the liquid part of blood, or blood plasma.

One of albumin’s main functions is to maintain oncotic pressure — a force that

draws fluid into the blood circulation. In this way, albumin prevents excessive amounts of
fluid from accumulating in tissues or other body compartments. Because of reduced
human serum albumin levels, severe protein deficiency leads to lower oncotic pressure.
As a result, fluid accumulates in tissues, causing swelling.

For the same reason, protein deficiency may lead to fluid buildup inside the
abdominal cavity. A bloated belly is a characteristic sign of kwashiorkor.

Keep in mind that edema is a symptom of severe protein deficiency, which is

unlikely to happen in developed countries.

2. Fatty Liver

Another common symptom of kwashiorkor is a fatty liver, or fat accumulation in

liver cells
Left untreated, the condition may develop into fatty liver disease, causing inflammation,
liver scarring and potentially liver failure.

Fatty liver is a common condition in obese people, as well as those who

consume a lot of alcohol. Why it occurs in cases of protein deficiency is unclear, but
studies suggest that an impaired synthesis of fat-transporting proteins, known as
lipoproteins, may contribute to the condition

SUMMARY: Fatty liver is one of the symptoms of kwashiorkor in children. In worst case
scenarios, it may lead to liver failure.

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3. Skin, Hair and Nail Problems

Protein deficiency often leaves its mark on the skin, hair and nails, which are
largely made of protein. For instance, kwashiorkor in children is distinguished by flaky or
splitting skin, redness and patches of depigmented skin

Hair thinning, faded hair color, hair loss (alopecia) and brittle nails are also
common symptoms. However, these symptoms are unlikely to appear unless you have a
severe protein deficiency.
4. Loss of Muscle Mass

Your muscles are your body’s largest reservoir of protein. When dietary protein is
in short supply, the body tends to take protein from skeletal muscles to preserve more
important tissues and body functions. As a result, lack of protein leads to muscle wasting
over time.

Even moderate protein insufficiency may cause muscle wasting, especially in

elderly people. One study in elderly men and women found that muscle loss was greater
among those who consumed the lowest amounts of protein.

This has been confirmed by other studies that show that an increased protein intake may
slow the muscle degeneration that comes with old age.

5. Greater Risk of Bone Fractures

Muscles are not the only tissues affected by low protein intake. Your bones are
also at risk. Not consuming enough protein may weaken your bones and increase the
risk of fractures.

One study in postmenopausal women found that a higher protein intake was
associated with a lower risk of hip fractures. The highest intake was linked to a 69%
reduced risk, and animal-source protein appeared to have the greatest benefits.

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 Another study in postmenopausal women with recent hip fractures showed that
taking 20 grams of protein supplements per day for half a year slowed bone loss by
2.3%.

6. Stunted Growth in Children

Protein not only helps maintain muscle and bone mass, but it’s also essential for
body growth. Thus, deficiency or insufficiency is especially harmful to children whose
growing bodies require a steady supply.

In fact, stunting is the most common sign of childhood malnutrition. In 2013, an

estimated 161 million children suffered from stunted growth

Observational studies show a strong association between low protein intake and
impaired growth. Stunted growth is also one of the main characteristics of kwashiorkor in
children

7. Increased Severity of Infections

A protein deficit can also take its toll on the immune system. Impaired immune
function may increase the risk or severity of infections, a common symptom of severe
protein deficiency

For instance, one study in mice showed that following a diet consisting of only
2% protein was associated with a more severe influenza infection, compared to a diet
providing 18% protein

Even marginally low protein intake may impair immune function. One small study
in older women showed following a low-protein diet for nine weeks significantly reduced
their immune response

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8. Greater Appetite and Calorie Intake

Although poor appetite is one of the symptoms of severe protein deficiency, the
opposite seems to be true for milder forms of deficiency.
When your protein intake is inadequate, your body attempts to restore your protein
status by increasing your appetite, encouraging you to find something to eat.

But a protein deficit doesn’t aimlessly drive the urge to eat, at least not for
everyone. It may selectively increase people’s appetite for savory foods, which tend to
be high in protein. While this may certainly help in times of food shortage, the problem is
that modern society offers unlimited access to savory, high-calorie foods.

Many of these convenience foods contain some protein. However, the amount of
protein in these foods is often considerably low compared to the number of calories they
provide. As a result, poor protein intake may lead to weight gain and obesity, an idea
known as the protein leverage hypothesis

Not all studies support the hypothesis, but protein is clearly more satiating than
carbs and fat. This is part of the reason why increased protein intake can reduce overall
calorie intake and promote weight loss.

If you are feeling hungry all the time and have difficulties keeping your calorie
intake in check, try adding some lean protein to every meal.

TOXICITY OR TOO MUCH PROTEIN INTAKE

You’re probably familiar with high-protein diets, which have seen a recent
resurgence since diets like Atkins and the Zone gained popularity in the 1990s. Diets
such as the Caveman or Paleo diet can vary in terms of macronutrient ratios, but are
typically high in protein.

While the standard ketogenic (or “keto”) diet emphasizes fat, it can also be high
in protein. Even mostly or entirely plant-based diets can be high in protein.

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Protein is an essential part of a healthy diet. It helps to build and repair muscle, organs,
and bones. High-protein diets have also been shown to be helpful with reducing fat,
losing weight, increasing satiety, or a feeling of fullness, and retaining muscle.

However, high-protein diets have also been associated with several risks that are
important to be aware of and understand. Nutritional experts don’t advocate
consumption to exceed the recommended daily amount.

When calculating how much total protein you currently eat or should eat, factor in
protein from your diet (e.g., food and drink sources). You should also factor in
supplements, if the supplements you use contain substantial amounts of protein, such
as protein powder.

Weight gain

High-protein diets may tout weight loss, but this type of weight loss may only be
short-term. Excess protein consumed is usually stored as fat, while the surplus of amino
acids is excreted. This can lead to weight gain over time, especially if you consume too
many calories while trying to increase your protein intake. A 2016 study found that
weight gain was significantly associated with diets where protein replaced
carbohydrates, but not when it replaced fat.

Bad breath
Eating large amounts of protein can lead to bad breath, especially if you restrict
your carbohydrate intake.

In an older registry, 40 percent of participants reported bad breath. This could be

in part because your body goes into a metabolic state called ketosis, which produces
chemicals that give off an unpleasant fruity smell. Brushing and flossing won’t get rid of
the smell. You can double your water intake, brush your teeth more often, and chew
gum to counter some of this effect.

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Constipation

In the same study, 44 percent of participants reported constipation. High-protein

diets that restrict carbohydrates are typically low in fiber. Increasing your water and fiber
intake can help prevent constipation.

Diarrhea

Eating too much dairy or processed food, coupled with a lack of fiber, can cause
diarrhea. This is especially true if you’re lactose-intolerant or consume protein sources
such as fried meat, fish, and poultry. Eat heart-healthy proteins instead.
To avoid diarrhea, drink plenty of water, avoid caffeinated beverages, limit fried foods
and excess fat consumption, and increase your fiber intake.

Dehydration

Your body flushes out excess nitrogen with fluids and water. This can leave you
dehydrated even though you may not feel more thirsty than usual.

A small 2002 study involving athletes found that as protein intake increased,
hydration levels decreased. However, a 2006 study concluded that consuming more
protein had a minimal impact on hydration.

This risk or effect can be minimized by increasing your water intake, especially if
you’re an active person. Regardless of protein consumption, it’s always important
to drink plenty of water throughout the day.

Kidney damage

While no major studies Trusted Source link high protein intake to kidney damage
in healthy individuals, excess protein can cause damage in people with preexisting
kidney disease.

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 This is because of the excess nitrogen found in the amino acids that make up
proteins. Damaged kidneys have to work harder to get rid of the extra nitrogen and
waste products of protein metabolism.

Increased cancer risk

Studies have shown that certain high-protein diets that are particularly high in red
meat-based protein are linked to an increased risk of various health issues, including
cancer. Eating more red and/or processed meat is associated with colorectal, breast,
and prostate cancer.

Conversely, eating protein from other sources has been associated with a
decreased risk of cancer. Scientists believe this could be due, in part, to hormones,
carcinogenic compounds, and fats found in meat.
Heart disease

Eating lots of red meat and full-fat dairy foods as part of a high-protein diet may
lead to heart disease. This could be related to higher intakes of saturated fat and
cholesterol.

According to a 2010 study, eating large amounts of red meat and high-fat dairy
was shown to increase the risk of coronary heart disease in women. Eating poultry, fish,
and nuts lowered the risk.

A 2018 study also showed that long-term consumption of red meat can increase
trimethylamine N-oxide (TMAO), a gut-generated chemical that is linked to heart
disease. Findings also showed that reducing or eliminating dietary red meat reversed the
effects.

Calcium loss

Diets that are high in protein and meat may cause calcium loss. This is
sometimes associated with osteoporosis and poor bone health.
A 2013 review of studies found an association between high levels of protein
consumption and poor bone health. However, another 2013 review found that the effect

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of protein on bone health is inconclusive. Further research is needed to expand and
conclude upon these findings.

Best sources of protein

When you’re choosing high-protein foods, be sure to select healthier options.

This can help lower your risk for some of the negative effects of a high-protein diet.
Healthy sources of protein include:
- grass-fed lean meats, pasture-raised poultry, and organic dairy
- wild fish
- eggs from pastured hens
- legumes, nuts, and whole grains

Try to avoid high-fat meats and dairy products as well as fried or processed protein
sources. Eat heart-healthy proteins instead.

UNIT III: ACTIVITY 2

STUDY QUESTIONS

1. Distinguish between protein anabolism and protein catabolism.

Describe a clinical situation in which protein anabolism exceeds protein catabolism and
one in which the opposite is true.

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

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2. Explain the term protein-sparing effect. What happens to protein requirements in
poorly planned weight-loss diets that are inappropriately low in carbohydrate?

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

3. Describe the factors that influence dietary protein needs.

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

4. A pediatrician told a vegan couple that their 2-year-old daughter was falling behind in
her growth rate. What dietary factors are likely related to her poor growth? Using the
various tools for developing vegetarian food plans presented in this chapter, plan 1 day
of meals for this child, indicating food amounts that would meet her protein and energy
needs and respect the vegan food pattern.

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

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______________________________________________________________________
______________________________________________________________________

5. How does poor gastric acid secretion influence protein nutrition?

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
__________________________________________________________________

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 LABORATORY ACTIVITY
MACRONUTRIENTS-Proteins

Name: Date Due:

Year and Section: Date Submitted:

Professor’s Signature: Score:

Most people think of meat, fish and poultry as good source of protein. While they
provide most protein per serving portion in the daily diet, it is a mistake to assume that
these are the only good source of protein. Legumes are also rich in protein, as are nuts
of many kinds. Breads and cereals contain relatively small amounts or protein.

IV. OBJECTIVES
Protein is indispensable to life and its deficiency can bring about damaging
effects to one’s health. Its excess, however, can also be harmful. Two groups will be
required to plan meals for people with protein malabsorption, and the planned diet will
play an important role in the recovery from this deficiency.

At the end of 3 hours, you should be able to:

1. Recognize the importance of protein in the Filipino diet, and

2. Plan and prepare meals for individuals requiring protein intake modification.

V. PROCEDURES

Case: An individual suffering from Gouty Arthritis.

1. Calculate and plan a 1800 kcal purine diet. Prepare sample menu plan for
dinner.

a. Research for Purine content of different food items.

Example:
List of foods that are high in Low purine foods
purine

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 Table 3. Meal Plan for Low Protein Diet

No. of CHO PRO FAT Meal Distribution

Food Ex- ENERGY
Exchanges changes g g g kcal B L D Sn

I. Veg A

Veg B

II. Fruits

VI. Milk

V. Meat

VI. Sugar

VII. Fat

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Total

• LEGEND: B = Breakfast
▪ L = lunch
▪ D = Dinner
▪ Sn = Snack

Table 2-1. Sample Dinner Menu

Menu Household Measure

2. Discuss the following and write the answers in Table 2-3.

a. Symptoms
______________________________________________________________________
______________________________________________________________________
b. Causes
______________________________________________________________________
______________________________________________________________________
c. Prevalence
______________________________________________________________________
______________________________________________________________________
d. Dietary Changes
______________________________________________________________________
______________________________________________________________________

Table 2-6. Worksheet for Protein-related Diseases

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 Disease Symptoms Causes Prevalence Dietary Changes

VII. EVALUATION
4. Present in class (when possible) the dietary plan for Case #1 and discuss
answers to questions.
5. You will be evaluated using the following criteria: (Refer to table below)
5.1 Accuracy in Diet Computation
5.2 Suitability of the food served to disease condition, and
5.3 How the diet can promote good health.
6. Submit individual worksheets at the end of the laboratory activity.

Evaluation of presentation:

10 - Outstanding 8 - Very Satisfactory 7-Satisfactory 6- fair 5- Poor

Accuracy in Suitability of the Overall Score

Diet food served to How the diet
Computation disease can promote
condition good health
10 points 10 points 10 points (perfect score 30 points)

VIII. QUESTIONS FOR DISCUSSION

1. What are the health effects of proteins?

❖ Taken from: Caudal, Ma. Lourdes. (2008) Basic Nutrition and Diet Therapy
Textbook for Nursing Students Revised Ed.,C & E Publishing Inc.

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 LESSON 4
FATS/ CHOLESTEROL

Fats and waters

1. Functions
2. Types 4. Food sources
3. Deficiencies/toxicity 5. Cholesterol

WEEK
TOPIC LEARNING OUTCOMES ACTIVITIES
7
Upon completion of this lesson, you will be able to: 1. Study Questions
1 Compare saturated, monounsaturated, and
polyunsaturated fatty acids.
2 Propose ways to improve the type of fat present in a
sample meal plan.

DAY 3 Explain the functions of fat in the body.

13 4 Discuss the digestion and absorption of fat.
5. Give examples of foods that provide omega-3 fatty
acids.
6. Calculate the number of calories from fat in various
foods.
7. Identify sources of saturated, polyunsaturated and
monounsaturated fatty acids.
8. Explain the importance of these fatty acids in one’s
diet.
9. Explain the effects of excess fat intakes to the
body

FATS/LIPIDS

Fat is one of the three main macronutrients, along with the other two:
carbohydrate and protein. Fats molecules consist of primarily carbon and hydrogen
atoms, thus they are all hydrocarbon molecules. Examples include cholesterol,
phospholipids and triglycerides.

A fat molecule is made up of two components: A glycerol which is the "backbone"

of the molecule. Fatty acids which are attached to the backbone.

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HERE ARE THE TOP FIVE FUNCTIONS OF FAT IN OUR BODIES:

1. Promotes Absorption of Fat-Soluble Vitamins

• Vitamins A, D, E, and K are considered fat-soluble because they are meant to
dissolve in fat. These vitamins play vital roles in maintaining our health but
require the presence of fat for the body to absorb them properly.
• The body needs vitamin A for healthy bones and teeth, to moisturize the eyes, to
maintain mucous membrane and skin health, and to assist in cell division.
• It also needs vitamin D for the optimal absorption and utilization of calcium to
promote bone health, vitamin E to act as a powerful antioxidant, and vitamin K to
promote bone health and blood clotting.
• All of these functions could likely be impaired with an absence of fat in the diet as
the body will not be able to absorb these specific vitamins effectively.

2. Supports Optimal Health

• Omega-3 essential fatty acids protect the body through a wide range of
mechanisms.
• They promote relaxation and contraction of artery walls, which can help prevent
heart disease and stroke.
• Omega-3s also play a critical role in the synthesis of hormones that control blood
clotting, and they enhance metabolic and immune system functions.
• Sources of omega-3 fats include olive oil, walnuts, flaxseed, eggs, salmon, tuna,
and other fatty fish.

3. Boosts Brain Function

• Fats are important for brain health and development. 60 percent of the brain is
made up of fat, making it a critical macronutrient for mental growth and
development.
• Pregnant women are encouraged to consume high amounts of omega-3 fatty
acids to enhance their baby’s brain and eye development.
• Fat also enhances the synthesis of many neurotransmitters — the chemical
messengers of the brain!

4. Provides Energy

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 • Fat is a very effective source of energy for the body — it provides twice as much
energy production of carbs!
• However, your body will not use fat as its primary source of energy if it has
access to carbs.
• But, when your body’s carbohydrate supply has diminished, it will break down
your fat reserves and convert fat to energy that powers metabolic activities.

5. Insulates the Body

• Your body uses its subcutaneous fat reserves as an insulator against extreme
cold and heat, helping to maintain body temperature and protect nerves from
damage so that they may work at optimal levels.
• It also protects organs by cushioning them.
• While excess body fat is considered a health risk, this point is highlighted to show
that the body is extremely efficient in using and storing energy!
• We should feel confident in our ability to find our nutritional “happy place” that
provides nutrients for optimal fuel and protection by observing how our body is
responding to the quantity and quality of our food choices.

Contrary to the contentious views about fat in the media and among certain
fitness circles, fats are a cornerstone of any healthy and balanced diet. Apart from
providing several health-enhancing benefits, fats also improve the palatability of food
and increase satiety, helping to keep you full longer with less food — especially if you
have cut back on carbohydrates. By balancing this macronutrient effectively with
carbohydrates and protein, you will quickly see how fat supports a sustainable and
successful nutrition plan.

TYPES OF FAT

1. Unsaturated fats
Unsaturated fats, which are liquid at room temperature, are considered beneficial
fats because they can improve blood cholesterol levels, ease inflammation, stabilize
heart rhythms, and play a number of other beneficial roles. Unsaturated fats are
predominantly found in foods from plants, such as vegetable oils, nuts, and seeds.
There are two types of “good” unsaturated fats:

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 a. Monounsaturated fats
- are found in high concentrations in:
Olive, peanut, and canola oils
Avocados
Nuts such as almonds, hazelnuts, and pecans
Seeds such as pumpkin and sesame seeds

b. Polyunsaturated fats
- are found in high concentrations in
Sunflower, corn, soybean, and flaxseed oils
Walnuts
Flax seeds
Fish
Canola oil – though higher in monounsaturated fat, it’s also a good source of
polyunsaturated fat.

Omega-3 fats are an important type of polyunsaturated fat. The body can’t make these,
so they must come from food.
An excellent way to get omega-3 fats is by eating fish 2-3 times a week.
Good plant sources of omega-3 fats include flax seeds, walnuts, and canola or soybean
oil.
Higher blood omega-3 fats are associated with lower risk of premature death among
older adults, according to a study by HSPH faculty.

Most people don’t eat enough healthful unsaturated fats. The American Heart
Association suggests that 8-10 percent of daily calories should come from
polyunsaturated fats, and there is evidence that eating more polyunsaturated fat—up to
15 percent of daily calories—in place of saturated fat can lower heart disease risk.
• Dutch researchers conducted an analysis of 60 trials that examined the effects of
carbohydrates and various fats on blood lipid levels. In trials in which polyunsaturated
and monounsaturated fats were eaten in place of carbohydrates, these good fats
decreased levels of harmful LDL and increased protective HDL.

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• More recently, a randomized trial known as the Optimal Macronutrient Intake Trial for
Heart Health (OmniHeart) showed that replacing a carbohydrate-rich diet with one rich in
unsaturated fat, predominantly monounsaturated fats, lowers blood pressure, improves
lipid levels, and reduces the estimated cardiovascular risk.

2. Saturated Fats
All foods containing fat have a mix of specific types of fats. Even healthy foods
like chicken and nuts have small amounts of saturated fat, though much less than the
amounts found in beef, cheese, and ice cream. Saturated fat is mainly found in animal
foods, but a few plant foods are also high in saturated fats, such as coconut, coconut oil,
palm oil, and palm kernel oil.
• The Dietary Guidelines for Americans recommends getting less than 10 percent of
calories each day from saturated fat. (10)
• The American Heart Association goes even further, recommending limiting saturated
fat to no more than 7 percent of calories. (11)
Though decades of dietary advice suggested saturated fat was harmful, in recent
years that idea has begun to evolve. Several studies suggest that eating diets high in
saturated fat do not raise the risk of heart disease, with one report analyzing the findings
of 21 studies that followed 350,000 people for up to 23 years.

• Investigators looked at the relationship between saturated fat intake and coronary heart
disease (CHD), stroke, and cardiovascular disease (CVD). Their controversial
conclusion: “There is insufficient evidence from prospective epidemiologic studies to
conclude that dietary saturated fat is associated with an increased risk of CHD, stroke,
or CVD.”
• A well-publicized 2014 study questioned the link between saturated fat and heart
disease, but HSPH nutrition experts determined the paper to be seriously misleading. In
order to set the record straight, Harvard School of Public Health convened a panel of
nutrition experts and held a teach-in, “Saturated or not: Does type of fat matter?“
The overarching message is that cutting back on saturated fat can be good for
health if people replace saturated fat with good fats, especially, polyunsaturated fats.
Eating good fats in place of saturated fat lowers the “bad” LDL cholesterol, and it
improves the ratio of total cholesterol to “good” HDL cholesterol, lowering the risk of
heart disease.

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 Eating good fats in place of saturated fat can also help prevent insulin resistance,
a precursor to diabetes. So while saturated fat may not be as harmful as once thought,
evidence clearly shows that unsaturated fat remains the healthiest type of fat.3.

3.Trans Fats
Trans fatty acids, more commonly called trans fats, are made by heating liquid
vegetable oils in the presence of hydrogen gas and a catalyst, a process called
hydrogenation.
• Partially hydrogenating vegetable oils makes them more stable and less likely to
become rancid. This process also converts the oil into a solid, which makes them
function as margarine or shortening.
• Partially hydrogenated oils can withstand repeated heating without breaking down,
making them ideal for frying fast foods.
• For these reasons, partially hydrogenated oils became a mainstay in restaurants and
the food industry – for frying, baked goods, and processed snack foods and margarine.
Partially hydrogenated oil is not the only source of trans fats in our diets. Trans fats are
also naturally found in beef fat and dairy fat in small amounts.
Trans fats are the worst type of fat for the heart, blood vessels, and rest of the body
because they:
➢ Raise bad LDL and lower good HDL
➢ Create inflammation, – a reaction related to immunity – which has been
implicated in heart disease, stroke, diabetes, and other chronic
conditions
➢ Contribute to insulin resistance
➢ Can have harmful health effects even in small amounts – for each
additional 2 percent of calories from trans fat consumed daily, the risk of
coronary heart disease increases by 23 percent.

DIGESTION AND ABSORPTION

In the stomach, simple emulsified fat is digested to free fatty acids and glycerol
by the action of gastric lipase.

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 Non-emulsified fat is acted upon by bile salts in the small intestines and the
resulting emulsified fat is hydrolyzed by pancreatic lipase to fatty acids and glycerol.
Almost all fats are absorbed into the lymphatic system from the intestinal mucosa
as chylomicrons. The glycerol portion and short chained free fatty acids are absorbed
directly into the portal circulation via the liver.
The circulating fat and other lipids find their way in almost all tissues.
The major site of fat metabolism is in the liver, but practically all tissues can utilize fat for
energy, classified as:
1. The element VARIABLE , which is also called the depot fat. This is reversibly stored
or withdrawn and is in dynamic state.
2. The element CONSTANT , which is also called the protoplasmic fat. It is an integral
component of cell (e.g., glycolipid in brain, nerves). The fat cannot be used for energy
even under prolonged starvation, hence is held constant.

Oxidation of fatty acids to release energy is accomplished by the betaoxidation

process: a long carbon chain in the fatty acid is cleaved off stepwise removing an
acetate radical.
The active acetate enters the Krebs Cycle, which is the common pathway for energy
release with the by-products: water and carbon dioxide.

ABSORPTION
The main products of fat digestion are fatty acids, glycerol and the glycerides.
The peak of fat absorption is reached within 4 to 6 hours.
Majority of the dietary fat is in the form of triglycerides.
Mono and diglycerides together with cholesterol and phospolipids are also ingested.

The way the body handles the absorption of fat is related to the length of the
carbon chain. Longer chained fatty acids are more difficult to absorb especially if they
are saturated type than those with a high content of polyunsaturated fatty acids or short-
chained fatty acids.

Long chain triglycerides absorbed into the epithelial cell as monoglycerides, fatty
acids and glycerol. The fats and unesterified fatty acids bound with small amounts of
protein to form lipoproteins called chylomicrons.

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They pass into the lymphatics with the aid of bile salts.
Medium and short chain triglycerides are absorbed mainly by diffusion and
carried by the portal vein to the liver

The glycerol portion of the fat molecule is converted to glucose to provide

energy. Cholesterol ingested as such in the diet or from body synthesis is absorbed in
the intestine with the aid of bile salts as free unesterified cholesterol.
Others are esterified with fatty acids and are absorbed as cholesterol esters via the
lymphatics.

The amount of cholesterol absorbed is generally dependent upon intake

Phospholipids – lecithin are found in foods and some are endogenously produced.
- They are water soluble and may be absorbed directly by passive diffusion.

FOOD SOURCES
- Visible fats and oils such as butter, margarine, lard, cooking oils, fish-liver
oils, pork fat, chicken fat.
- Very good sources found in nuts, such as oil seeds and some legumes.

- Cream cheese, whole milk, olives, chocolate, peanut butter, and fatty fish like
sardines, avocado, pastries and fried foods contribute significant amounts in
the diet.

- Plant sources for unsaturated fatty acids are corn, cotton seed, sesame,
sunflower and soybean oils, products utilizing vegetable oils and fatty fish like
tuna, salmon, sardine and mackerel.
- Coconut oil is low in EFA and has more saturated fatty acids compared to
other vegetable oils.
- Foods high in saturated fatty acids are: butterfat, whole milk, ice cream
made from whole milk, egg yolk, bacon, lard hydrogenated shortenings; fatty
meats like pork, ham, certain beef cuts, poultry fat, sausages; chocolates,
rich pastry and puddings made with the animal fat.

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RECOMMENDED DAILY ALLOWANCES

- In the Philippines, it is suggested that at least 20% of total caloric allowance

be supplied by dietary fat.
- A higher level is recommended for children, adolescents and active adults.
- Planning the daily diet following the “Guide to Good Nutrition” satisfies the
20% minimum level

DEFICIENCY AND EXCESS

• Deficiency of fats reduce caloric supply in the body and cause protein
catabolism.
- Deficiency of essential fatty acids- causes retarded growth and an
eczematous skin in infants.
Signs of inadequate fat intake include:

• Dry and scaly skin

• Dry eyes
• Feeling constantly cold
• Dry hair and/or hair loss
• Hormonal problems, including loss of menstrual cycle
• Inability to feel full/always feeling hungry
• Issues concentrating and/or mental fatigue
• Deficiencies in fat-soluble vitamins
- Constant fatigue

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 • Excessive intake above the normal levels resulting in extra caloric supply leads
to obesity.

CHOLESTEROL is a waxy, fat-like substance that's found in all the cells in your body.
Your body needs some cholesterol to make hormones, vitamin D, and substances that
help you digest foods.

148
 Cholesterol levels for adults. Total cholesterol levels less than 200 milligrams per
deciliter (mg/dL) are considered desirable for adults. A reading between 200 and 239
mg/dL is considered borderline high and a reading of 240 mg/dL and above is
considered high. LDL cholesterol levels should be less than 100 mg/dL.

With high cholesterol, you can develop fatty deposits in your blood vessels.
Eventually, these deposits grow, making it difficult for enough blood to flow through your
arteries. Sometimes, those deposits can break suddenly and form a clot that causes a
heart attack or stroke.

High cholesterol can be inherited, but it's often the result of unhealthy lifestyle
choices, which make it preventable and treatable. A healthy diet, regular exercise and
sometimes medication can help reduce high cholesterol.

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When to see a doctor

Ask your doctor if you should have a cholesterol test. Children and young adults
with no risk factors for heart disease are usually tested once between the ages of 9 and
11 and again between the ages of 17 and 19. Retesting for adults with no risk factors for
heart disease is usually done every five years.

If your test results aren't within desirable ranges, your doctor might recommend
more-frequent measurements. Your doctor might also suggest more-frequent tests if you
have a family history of high cholesterol, heart disease or other risk factors, such as
smoking, diabetes or high blood pressure.

CAUSES

Cholesterol is carried through your blood, attached to proteins. This combination of

proteins and cholesterol is called a lipoprotein. There are different types of cholesterol,
based on what the lipoprotein carries. They are:

• Low-density lipoprotein (LDL). LDL, or "bad" cholesterol, transports cholesterol

particles throughout your body. LDL cholesterol builds up in the walls of your
arteries, making them hard and narrow.

• High-density lipoprotein (HDL). HDL, or "good" cholesterol, picks up excess

cholesterol and takes it back to your liver.

A lipid profile also typically measures triglycerides, a type of fat in the blood.
Having a high triglyceride level can also increase your risk of heart disease.

Factors you can control — such as inactivity, obesity and an unhealthy diet —
contribute to high cholesterol and low HDL cholesterol. Factors beyond your control
might play a role, too. For example, your genetic makeup might keep cells from
removing LDL cholesterol from your blood efficiently or cause your liver to produce too
much cholesterol.

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 RISK FACTORS

Factors that can increase your risk of bad cholesterol include:

• Poor diet. Eating saturated fat, found in animal products, and trans fats, found in
some commercially baked cookies and crackers and microwave popcorn, can raise
your cholesterol level. Foods that are high in cholesterol, such as red meat and full-
fat dairy products, will also increase your cholesterol.

• Obesity. Having a body mass index (BMI) of 30 or greater puts you at risk of high
cholesterol.

• Lack of exercise. Exercise helps boost your body's HDL, or "good," cholesterol
while increasing the size of the particles that make up your LDL, or "bad,"
cholesterol, which makes it less harmful.

• Smoking. Cigarette smoking damages the walls of your blood vessels, making
them more prone to accumulate fatty deposits. Smoking might also lower your level
of HDL, or "good," cholesterol.

• Age. Because your body's chemistry changes as you age, your risk of high
cholesterol climbs. For instance, as you age, your liver becomes less able to
remove LDL cholesterol.

• Diabetes. High blood sugar contributes to higher levels of a dangerous cholesterol

called very-low-density lipoprotein (VLDL) and lower HDL cholesterol. High blood
sugar also damages the lining of your arteries.

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COMPLICATIONS

Development of atherosclerosisOpen pop-up dialog box

High cholesterol can cause a dangerous accumulation of cholesterol and other

deposits on the walls of your arteries (atherosclerosis). These deposits (plaques) can
reduce blood flow through your arteries, which can cause complications, such as:

• Chest pain. If the arteries that supply your heart with blood (coronary arteries) are
affected, you might have chest pain (angina) and other symptoms of coronary
artery disease.

• Heart attack. If plaques tear or rupture, a blood clot can form at the plaque-rupture
site — blocking the flow of blood or breaking free and plugging an artery
downstream. If blood flow to part of your heart stops, you'll have a heart attack.

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 • Stroke. Similar to a heart attack, a stroke occurs when a blood clot blocks blood
flow to part of your brain.

PREVENTION

The same heart-healthy lifestyle changes that can lower your cholesterol can help
prevent you from having high cholesterol in the first place. To help prevent high
cholesterol, you can:

• Eat a low-salt diet that emphasizes fruits, vegetables and whole grains

• Limit the amount of animal fats and use good fats in moderation

• Lose extra pounds and maintain a healthy weight

• Quit smoking

• Exercise on most days of the week for at least 30 minutes

• Drink alcohol in moderation, if at all

• Manage stress

LIPIDS
- lipids the chemical group name for organic substances of a fatty nature; the
lipids include fats, oils, waxes, and other fat-related compounds such as
cholesterol.
- Although the term "lipid" is sometimes used as a synonym for fats, fats are
a subgroup of lipids called triglycerides. Lipids also encompass molecules
such as fatty acids and their derivatives (including tri-, di-, monoglycerides,
and phospholipids), as well as other sterol-containing metabolites
such as cholesterol.
- The chemical term lipid includes fats, oils, and related compounds that are
insoluble in water and greasy to the touch.
- Some food lipids—butter, margarine, or cooking oil—are easily recognized as
fats. Other foods that appear to be carbohydrates, such as bakery items or
potato chips, often contain significant amounts of fat.

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 UNIT III: ACTIVITY 3

STUDY QUESTIONS:

1. How is fat stored in the body?

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

2. What hormones control fat metabolism?

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

3. What is the role of lipid in fat metabolism?

4. Name the vitamins useful in the utilization of fats.

5. Distinguish between:

A. fat vs. oil

B. saturated vs. unsaturated fat

C. fat vs. lipid

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 Quiz: (3 points each)

1. What does the hardness or softness of a fat typically signify?

2. Which foods contain cholesterol?

3. Describe the difference between LDL and HDL in terms of cholesterol and protein
composition.

4. List the recommendations for intake of total fat, saturated fat, and cholesterol.

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 LESSON 5
VITAMINS AND MINERALS
Characteristics
Functions
- Classifications
Sources
Recommended intake
Deficiency/ Excess

WEEK TOPIC LEARNING OUTCOMES ACTIVITIES

7
1. Study
Upon completion of this chapter, you will be able to questions
Day 14 1. Compare and contrast fat- and water-soluble vitamins.
2. Describe general functions and uses of vitamins.
3. Judge when vitamin supplements may be necessary.
4. Identify the physiologic functions of each vitamin and
mineral.
5. Recognize the best food sources of each mineral.

HISTORICAL BACKGROUND

Vitamins were formerly called “accessory food factors” because their presence in
minute quantities is easily overlooked. They are the last group of organic compounds
vital to life maintenance and growth to be discovered. Animals fed pure mixture s of
carbohydrate, protein, fat, minerals and water showed poor growth and deficiency signs.
The missing factors proved to be nutrients we know as vitamins.

The word “vitamin” was originated by Casimir Funk in 1912 when he was
searching for a constituent in rice bran which could cure beriberi. The missing substance
he called “vitamin” was coined from “vita” meaning necessary for life and “amine’
denoting that the anti-factor contained nitrogen. He hypothesized that nutritional
deficiencies which are observed in the past such as scurvy, pellagra, and rickets,
resulted from lack of “vitamins.” Researchers later showed that not all these dietary
factors were amines or nitrogen-containing, hence the final letter e was dropped and we
now have the word VITAMIN.

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DEFINITION:

As each vitamin was discovered, the following two characteristics that define a vitamin
clearly emerged:

1. It must be a vital organic substance that is not a carbohydrate, fat, or protein;

and it must be necessary to perform a specific metabolic function or to
prevent a deficiency disease.

2. It cannot be manufactured by the body in sufficient quantities to sustain life, so

it must be supplied by the diet.

Because the body only needs vitamins in small amounts, they are considered
micronutrients. The total volume of vitamins that a healthy person normally
requires each day would barely fill a teaspoon. Thus, the units of measure for
vitamins—milligrams or micrograms—are exceedingly small and difficult to
visualize (see the For Further Focus box, “Small
Measures for Small Needs”). Nonetheless, all vitamins are essential to life.

VITAMINS: FAT-SOLUBLE VITAMINS

1. VITAMIN A

The old names of viatamin A are: axeropthol; antixeropthalmic vitamin; anti-

infective vitamin; and opthalmin. The current nomenclature is based on it’s
physiologically active chemical forms. This are: retinol(vitamin A1,); dehydrotinol (vitamin
A2) Retinaldehyde (vitamin A1 aldehyde) and retinoic acid (vitamin A1 acid). Retinal has
90% and retinoic acid 60% of the potency of retinol. Retinol and retinal can be reversibly
oxidized and reduced; retinoic acid once formed cannot be converted back to retinal.

Precursors of provitamin A are alpha-beta-, and gamma-carotene and

cryptoxanthin. The presence of this provitamins is related to green and yellow pigments
in fruits and vegetables. From these carotenoid compounds in plants, animals are able
to form vitamin A.

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Vitamin is measured in International Unit (I.U) which was originallt defined as the amount
required daily by a white rat to promote normal growth. An IU is equivalent to one U.S.P.
unit (United Staes Pharmacopenia)

FUNCTIONS

1. Vitamin a maintains the integrity of epithelial tissues, especially mucus linings.

➢ When Vitamin A is lacking, there is keratinization (hardening and sloughing) of

the mucus membranes lining the respiratory tract, urinary system, eyes and the
skin.
➢ Keratinization of the eye epithelium is the stigma of xerophthalia.

2. Since Vitamin a is a constituent of the visual purple of the retina, it is needed for
normal night vision.

➢ The rods and cones in the retina cannot adjust to light changes resulting in night
blindness when there is Vitamin A deficiency.

3. Vitamin A is needed for normal bone and skeletal growth.

➢ It catalyzes the release of protein-splitting enzymes that act on the cartilage of

bone tissue.
➢ Excessive vitamin A causes complete-disintegration of bone matrix.
➢ The nervous and reproductive systems need Vitamin A for the stability of cell
membranes. Excessive amounts of retinol make the membranes abnormally
susceptible to rupture as observed in hypervitaminosis A.

FOOD SOURCES

• Preformed vitamin A is found in animal like liver, egg yolk, milk, cream, butter
and cheese. Fortified margarine or skim milk fortified with vitamin A are common
foods that are ideal carriers of Vitamin a. Among fishes, “dilis” is excellent,
followed by clams, “tahong” and other shellfish. Fish liver oils are the richest
natural sources although they are not customarilytaken in as food. They are
useful pharmaceutical preparations for therapy.

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 • Precursors or provitamin A are found in green and yellow vegetables.
- The dark green leaves of “malunggay”, “kamote”, “kangkong”, “pechay”,
“kalabas”, “patola”, “mustasa”, “sili” or pepper leaves, “kulitis” or “spinaka”,
“alugbati”, “gabi” “saluyot” and “ampalaya” are among the Philippine favorites.
- Yellow fruits and vegetables include:carrot, squash, tomato, mango,
cantaloupe, “tiesa”, papaya, yellow “kamote” and yellow corn.
- Yellow fruits of foreign origin rich in vitamin A are apricots, peaches and
nectarines.
- These are expensive in the Philippines, nevertheless available ion canned
forms and are used occasionally.

In general, the deeper the yellow and the darker the green, the more potential
vitamin A present. In planning the diet, the use of the GUIDE TO GOOD EATING
assures one of adequate vitamin A intake.

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REQUIREMENT OR ALLOWANCE

Minimum requirement for vitamin A is related to body weight, expressed as 20

I.U. beta-carotence per kg body weight.

The RDA (recommended daily allowance) is based on the assumption that in a

mixed average diet, 2/3 is contributed by precursors and 1/3 from preformed vitamin A.
The Phiippine RDA for Vitamin a is 5,000 I.U. for normal adults and pregnant
mothers.

Additional 2,000 I.U. is provided for lactation. The principle of vitamin

requirement based on body weight is applied from infancy to adolescence.

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VITAMIN A DEFICIENCY

- signs are manifestations of interference with the normal functions of Vitamin A just
discussed. These include

-poor adaptation or night blindness

-eye lesions
-retarded growth
--lower resistance to infection
-faulty skeletal and dental development
-keratiization of epithelial linings
-disturbances in the respiratory, gastrointestinal and genitourinary tracts

Skin lesions in vitamin a deficiency are characterized as “toad skin”. Clinically known as
phrynodema, the skin is dry and rough with popular eruptions occurring around the hair
follicles. The site of dermal changes are usually in the thighs, abdomen, upper arms and
back.

Eye lesions are the most critical in avitaminosis A. The cornea of the eyeis affected
early, the lachrymal gland fails to function, followed by keratinization and rupture of the
corneal tissues. Infection sets in, pus develops and the eye hemorrhages.This set of
symptoms is known as Bitot’s spots in it’s mild form and xeropthalmia in it’s severe form.
In some cases, total blindness results.

• Vitamin A deficiency is a public health problems in the Philippines.

Hypervitaminosis A is characterized by violent headache, nausea and vomiting,

thickening of the skin with peeling off, swollen painful long bones, coarse sparse hair
and enlargement of the spleen and liver. In young girls and women, there is cessation of
menstrautaion.

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VITAMIN A TOXICITY

Vitamin A toxicity rarely occurs unless by accident and only from the preformed
vitamin. For example: others unknowingly give massive doses of Vitamin A to their
babies or overanxious adolescents try to treat acne with excessive vitamin A
supplements. Toxic effects occur when daily doses of 50,000 I.U. continue for several
months (clinical cases showed a range from 6 to 15 months beteween the start of
massive intake of Vitamin A to the onset of toxic symptoms).

2. VITAMIN D

• Vitamin D is a group of related sterols with anti-rachitic or “ricket-preventive”

properties, hence it’s other name, anti-rachitic vitamin.
• About 16 forms are known but only two are important in human nutrition.
• Vitamin D2 is ergocalciferl or irrdiated 7-dehydrocholesterol.
• The former is found in the lipid portions of plats while the latter is the substance
formed in the skin upon exposure to ultraviolet rays of sunlight, giving it’s other
name for vitamin D as the “sunshine vitamin”.
• At this point, it is erroneos to say that a source of Vitamin D is the sun.
• One milligram of vitamin d contains 40,000 I.U.

FUNCTIONS

o Vitamin D promotes normal bone development because it facilitates the

absorption of calcium and phospohorus.
o The role of vitamin d in calcification is obvious because lack of vitamin D results
in:
- reduced intestinal absorption of calcium and phospohorus,
- hypocalcemia (low blood calcium levels),
- reduced resorption of phosphate
- and amino acids from the kidney and increased enzyme alkaline phosphates
in the blood.
- The latter is a biochemical test in rickets.

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FOOD SOURCES

▪ Animal sources are fortified margarine, butter, milk and cheese; liver and other
glandular organs; sardines and salmon; egg yolk.
▪ Fish liver oils are the most concentrated sources but are usually for pharmaceutic
or therapeutic purpose.
▪ Plant sources are not significant compared to animal sources.
▪ Minimum requirement for vitamin d is easily met by an ordinary mixed diet and by
normal exposure to sunlight.

REQUIREMENTS OR ALLOAWANCE

o Evaluation of Vitamin D requirement is difficult since there is some biosynthesis

that cannot be measured exactly.
o However, the allowance of 100 to 400 I.U. is sufficient for a man.
o Levels above these are recommended for people who are not exposed directly to
the sun or in cases when fat and fat-soluble vitamin utilization is interfered with.

DEFICIENCY AND TOXICITY

o Deficiency in infants lead to TETANY (a syndrome characterized by abnormal

muscle twitchings, cramps and sharp bilateral spasms of joints in the wrist and
ankles).
o RICKETS in children is the severe form of manifested as defective bones and
retarded growth.
- Bones become soft, fragile and deformed, such as pigeon-breasted, knock-
kneed, bow-legged, malformed teeth and rachitic roasary-like chest.
- In the latter, the end of ribs is rounded or beaded.
- Also, spine and pelvic joints are enlarged. In infants, dentition and closing of
the fontanelles are delayed.

o In adults, the term used for deficiency is OSTEOMALACIA, meaning softening of

the bones.
o There are also skeletal deformities, easy fatigability of bones and rheumatic-like
pains of joints. Osteomalacia is sometimes called”adult rickets”.

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 VITAMIN D TOXICITY

▪ HYPERVITAMINOSIS D causes nausea, diarrhea, polyuria and weight loss in

the early stages.
▪ Later on, there is dimenarilization of bones and deposits of minerals to soft
tissues (calcification of soft tissues which is abnormal). Renal damage and
uremia have been observed in severe cases.
▪ The main consequence of vitamin D toxicity is a buildup of calcium in your blood
(hypercalcemia), which can cause nausea and vomiting, weakness, and frequent
urination.
▪ Vitamin D toxicity might progress to bone pain and kidney problems, such as the
formation of calcium stones.

3. VITAMIN E (TOCOPHEROL)

- Early vitamin studies identified a substance that was necessary for animal
reproduction.
- This substance was named tocopherol from two Greek words: tophos,
meaning “childbirth,” and phero, meaning “to bring,” with the -ol ending used
to indicate its alcohol functional group.
- Tocopherol became known as the antisterility vitamin, but it was soon
demonstrated to have this effect only in rats and a few other animals and not
in people.
- A number of related compounds have since been discovered.
- Tocopherol is the generic name for this entire group of homologous fat-
soluble nutrients, which are designated as α-, β-, γ-, and δ-tocopherol or
tocotrienol.
- Of these eight nutrients, α-tocopherol is the only one that is significant in
human nutrition and thus used to calculate dietary needs.

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FUNCTIONS

The most vital function of α-tocopherol is its antioxidant action in tissues. In

addition vitamin E has several other important functions, such as cell signalling that

drives gene expression and antiproliferative effects in the eye that are seemingly
protective against conditions such as glaucoma.22,23

1. Antioxidant Function

➢ α-Tocopherol is the body’s most abundant fat-soluble antioxidant.

➢ The polyunsaturated fatty acids in the phospholipids of cell and organelle
membranes are particularly susceptible to free radical oxidation.
➢ α-Tocopherol intercepts this oxidation process and protects the polyunsaturated
fatty acids from damage.

2. Relation to Selenium Metabolism

➢ Selenium is a trace mineral that, as part of the seleniumcontaining enzyme

glutathione peroxidase, works with α-tocopherol as an antioxidant.
➢ Glutathione peroxidase is the second line of defense for preventing free radical
damage to membranes.
➢ Glutathione peroxidase spares α-tocopherol from oxidation, thereby reducing the
dietary requirement for α-tocopherol.

Similarly, α-tocopherol spares glutathione peroxidase from oxidation, thus reducing the
dietary requirement for selenium.

❖ TOCOPHEROL the chemical name for vitamin E, which was named by early
investigators because their initial work with rats indicated a reproductive
function; in people, vitamin E functions as a strong antioxidant that preserves
structural membranes such as cell walls.

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FOOD SOURCES

o The richest sources of α-tocopherol are vegetable oils (e.g., wheat germ,
soybean, safflower).
o Note that vegetable oils are also the richest sources of polyunsaturated fatty
acids, which α-tocopherol protects.
o Other food sources of α-tocopherol include nuts, seeds, and fortified cereals.
Table 7-3 provides a list of food sources of vitamin E.
o α-Tocopherol is unstable to heat and alkalis.

RECOMMENDED INTAKE

▪ α-Tocopherol requirements are expressed in milligrams per day.

▪ The RDA is expressed in milligrams of α-tocopherol, the form of vitamin E with
high biologic activity.
▪ About 80% of the vitamin E from dietary sources (including fortified foods) is α-
tocopherol, and about 20% is other forms.
▪ The RDA is 15 mg for both males and females ages 14 and older, but actual
intake falls much below this level.
▪ In the United States adult men average 8.9 mg/day of α-tocopherol and adult
women average 7.1 mg/day24; nevertheless, only 5% of adults examined in
recent national surveys had blood vitamin E levels categorized as deficient.11
❖ One International Unit (I.U.) is equivalent to 1 milligram di-alpha-tocopherol

DEFICIENCY/TOXICITY

Deficiency of tocopherols in man is very rare and only under experimental conditions.
In induced vitamin E deficiencies, the following were observed:

-hemolysis of red blood cells

-low blood levels of tocopherols
-increased urinary secretion of creatinine and decreased excretion of
creatinine

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Other deficiency symptoms:

Muscle weakness: Vitamin E is essential to the central nervous system. It is among the
body’s main antioxidants, and a deficiency results in oxidative stress, which can lead to
muscle weakness.

Coordination and walking difficulties: A deficiency can cause certain neurons, called
the Purkinje neurons, to break down, harming their ability to transmit signals.
Numbness and tingling: Damage to nerve fibers can prevent the nerves from
transmitting signals correctly, resulting in these sensations, which are also called
peripheral neuropathy.

Vision deterioration: A vitamin E deficiency can weaken light receptors in the retina
and other cells in the eye. This can lead to loss of vision over time.

Immune system problems: Some research suggests that a lack of vitamin E can inhibit
the immune cells. Older adults may be particularly at risk.

Muscle weakness and difficulties with coordination are neurological symptoms that
indicate damage to the central and peripheral nervous systems.

CAUSES OF VITAMIN E DEFICIENCY

1. Genetics
Vitamin E deficiency often runs in families.
Learning about family history can make diagnosing certain rare, inherited diseases
easier. Two of these diseases, congenital abetalipoproteinemia and familial isolated
vitamin E deficiency, are chronic and result in extremely low vitamin E levels.

2. Medical conditions
Vitamin E deficiency can also result from diseases that severely reduce the absorption of
fat. This is because the body requires fat to absorb vitamin E correctly.

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 Some of these diseases include:
➢ chronic pancreatitis
➢ celiac disease
➢ cholestatic liver disease
➢ cystic fibrosis.

Deficiency is also common in newborns and babies born prematurely who have lower
birth weights and less fat.Premature infants are at particular risk because an immature
digestive tract can interfere with fat and vitamin E absorption.Vitamin E deficiencies in
these infants can also lead to hemolytic anemia, which destroys red blood cells.

TOXICITY
- α-Tocopherol from food sources has no known toxic effects in people.
- Supplemental α-tocopherol intakes that exceed the UL of 1000 mg/day may
interfere with vitamin K activity and blood clotting.
- Although the exact mechanism is unknown, this may be particularly
problematic for individuals who are deficient in vitamin K or for patients who
are receiving anticoagulation therapy.

Hypervitaminosis E has not been reported largely because it has not been
reported largely because it could not be stored to a large extent in the body. Also
it’s presence in food is not widespread.

4. VITAMIN K
• Also called the anti-hemorrhagic factor, vitamin K was first discovered by a
Danish scientist who demonstrated it’s role in blood coagulation.
• The Danish spelling is “koagulation”, hence the letter K designation.

There are synthetic water soluble vitamins for vitamin K administration and for clinical
when fat absorption is impaired.
• Vitamin K plays a key role in helping the blood clot, preventing excessive
bleeding. Unlike many other vitamins, vitamin K is not typically used as a
dietary supplement.

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 • Vitamin K is actually a group of compounds. The most important of these
compounds appears to be vitamin K1 and vitamin K2. Vitamin K1 is
obtained from leafy greens and some other vegetables. Vitamin K2 is a
group of compounds largely obtained from meats, cheeses, and eggs,
and synthesized by bacteria.

• Vitamin K1 is the main form of vitamin K supplement available in the U.S.

Recently, some people have looked to vitamin K2 to treat osteoporosis and

steroid-induced bone loss, but the research is conflicting. At this point there is not
enough data to recommend using vitamin K2 for osteoporosis.

FUNCTIONS:
The most important biological role of vitamin K is the maintenance of
prothrombin level in blood plasma. The coagulation of blood is a series of reactions that
depend on several factors. Prothrombin and pro-convertin are among this vitamin K is
needed in the synthesis of both.

FOOD SOURCES

The best way to get the daily requirement of vitamin K is by eating food sources. Vitamin
K is found in the following foods:

• Green leafy vegetables, such as kale, spinach, turnip greens, collards, Swiss
chard, mustard greens, parsley, romaine, and green leaf lettuce

• Vegetables such as Brussels sprouts, broccoli, cauliflower, and cabbage

• Fish, liver, meat, eggs, and cereals (contain smaller amounts)

Vitamin K is also made by the bacteria in the lower intestinal tract.

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HOW MUCH VITAMIN K SHOULD YOU TAKE?

The recommended adequate intake of vitamin K you take in, both from food and other
sources is below. Most people get enough vitamin K from their diets.

Group Adequate Intake

Children 0-6 months 2 micrograms/day

Children 7-12 months 2.5 micrograms/day

Children 1-3 30 micrograms/day

Children 4-8 55 micrograms/day

Children 9-13 60 micrograms/day

Girls 14-18 75 micrograms/day

Women 19 and up 90 micrograms/day

Women, pregnant or breastfeeding (19-50) 90 micrograms/day

Women, pregnant or breastfeeding (under 19) 75 micrograms/day

Boys 14-18 75 micrograms/day

Men 19 and up 120 micrograms/day

There have been no adverse effects of vitamin K seen with the levels found in food
or supplements. However, this does not rule out danger with high dose.

DEFICIENCY

Low levels of vitamin K can raise the risk of uncontrolled bleeding. While vitamin
K deficiencies are rare in adults, they are very common in newborn infants. A single
injection of vitamin K for newborns is standard. Vitamin K is also used to counteract an
overdose of the blood thinner Coumadin.

While vitamin K deficiencies are uncommon, you may be at higher risk if you:

-Have a disease that affects absorption in the digestive tract, such as Crohn's
disease or active celiac disease

170
 -Take drugs that interfere with vitamin K absorption
-Are severely malnourished
-Drink alcohol heavily

In these cases, a health care provider might suggest vitamin K supplements.

Uses of vitamin K for cancer, for the symptoms of morning sickness, for the removal of
spider veins, and for other conditions are unproven.

TOXICITY
Excessive vitamin k is not observed to an extent as hypervitaminosis A or D,
unless massive doses of the synthetic form have been administered. The toxic effects of
vitamin k are:
vomiting, hemolysis and albuminuria. Kernicterus is a condition resulting from the
accumulation of bile pigments in the gray matter of the central nervous system. This has
been observed for infants with uncontrolled synthetic vitamin K therapy.

Vitamin K toxicity is typically seen in formula-fed infants or those receiving

synthetic vitamin K-3 (menadione) injections. Because of its toxicity, menadione is no
longer used for treatment of vitamin K deficiency.

The effects of vitamin K toxicity can include jaundice in newborns, hemolytic

anemia, and hyperbilirubinemia. Toxicity also blocks the effects of oral anticoagulants

ACTIVITY

STUDY QUESTIONS:

1. Enumerate the different ways in which Vitamins can be preserved in food.

2. How are Vitamins destroyed?

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

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______________________________________________________________________
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_____________________________________________________________________

WATER SOLUBLE VITAMINS

VITAMINS

• A vitamin that can dissolve in water. Water-soluble vitamins are carried to the
body's tissues but are not stored in the body. They are found in plant and animal
foods or dietary supplements and must be taken in daily. Vitamin C and
members of the vitamin B complex are water-soluble.
• The water-soluble vitamins are vitamin c or ascorbic acid and the B-complex
vitamins. Vitamin C is the most easily destroyed of all the vitamins. It is the “fresh
food” vitamin since it occurs in growing parts of plants. All raw fresh fruits and
vegetables conatin ascorbic acid in varying amounts. Vitamin C is involved in a
number of biological roles as well as in foods as an antioxidant.
• The B-complex vitamins important in human nutrition are:
1. thiamine (B1)
2. riboflavin (B2)
3. niacin (B3)
4. pantothenic acid (B5)
5. pyridoxine (B6)
6. biotin (B7)
7. folate (B9)
8. cobalamin (B12)

1. VITAMIN C (ASCORBIC ACID)

• Vitamin C or ascorbic acid is also known as antiscorbutic vitamin because the

nutritional disease it prevents is scurvy.
• The most active biological forms are L-ascorbic acid and L-dehydroascorbic acid.
• It is one of the safest and most effective nutrients, experts say. It may not be the
cure for the common cold (though it's thought to help prevent more serious
complications).

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 • But the benefits of vitamin C may include protection against immune system
deficiencies, cardiovascular disease, prenatal health problems, eye disease, and
even skin wrinkling.
• The unit of measurement for Vitamin c is in terms of milligram (mg)

FUNCTIONS:

Vitamin C plays an important role in many physiological processes in humans. It

is needed for the repair of tissues in all parts of the body.

The important functions of vitamin C include the formation of protein used to

make skin, tendons, ligaments, and blood vessels for healing wounds and forming scar
tissue, for repairing and maintaining cartilage, bones, and teeth and aid in the absorption
of iron. It can also act as a reducing and capping agent for metal nanoparticles.

Vitamin C is necessary for the following reactions:

1. Conversion of folic acid to it’s active form, folinic acid.

2. Healing of wounds and bone fractures

3. Prevention of megaloblastic anemia and pinpoint hemorrhages also called

petechial hemorrhages.

4. Building of bodily resistance against infections

5. Production of steroid hormones, particularly adrenocortico-hormone under

severe stress.

6. Tyrosine and phenylalanine metabolism

7. Iron utilization: vitamin C improves iron absorption. It makes iron more

available for hemoglobin and red blood cell maturation.

❖ Antioxidant activity
- One of the important properties of vitamin C is its antioxidant activity.
- Antioxidant activity of vitamin C helps to prevent certain diseases such as
cancer, cardiovascular diseases, common cold, age-related muscular
degeneration and cataract.
❖ In cancer treatment

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 - Since 1970, it has been known that high dose of vitamin C has beneficial
effects on the survival time in patients with terminal cancer, which was
reported by Cameron, Campbell, and Pauling. Research is undergoing in
detail for using vitamin C in cancer treatment.
- One of the studies suggests that pharmacologic doses of vitamin C might
show promising effects on the treatment of tumours.
- Vitamin C can act as pro-oxidant and it can generate hydrogen peroxide.
- Administration of high dose of vitamin C gives long survival times for patients
with advanced cancers.

➢ The continuing attack of DNA by unquenched reactive oxygen species is

believed to cause cancer.
➢ As a physiological antioxidant, ascorbic acid plays a role in the prevention of
oxidative damage to DNA, which is elevated in cells at sites of chronic
inflammation and in many pre-neoplastic lesions.
➢ Most DNA damage is repaired metabolically; however, the frequency of elevated
steady-state levels of oxidized DNA bases is estimated to be sufficient to cause
mutational events.
➢ The base damage product 8-hydroxy-2′-deoxyguanosine has been found to be
elevated in individuals with severe vitamin C deficiency and to be reduced by
supplementation with vitamins C and E.
Oxidative stress, arising as a result of an imbalance between free radical production and
antioxidant defences, causes damage to a wide range of molecular species including
lipids, proteins and nucleic acids. Oxidative stress caused by free radicals is shown in
Figure 1. The best way to ensure adequate intake of the antioxidant nutrients, such as
vitamins C and E and various kinds of minerals, is through a balanced diet consisting of
5–8 servings of fruits and vegetables per day.

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 Figure 1

Oxidative stress by free radicals.

In cardiovascular diseases

- The antioxidant property of vitamin C helps for the treatment of

cardiovascular diseases.
- Vitamin C has the capability for reducing monocyte adherence to the
endothelium, improving endothelium-dependent nitric oxide production and
vasodilation and reducing vascular smooth-muscle-cell apoptosis, which
prevents plaque instability in atherosclerosis.
- The oxidative damage including the oxidative modification of low-density
lipoproteins is a major cause of cardiovascular disease.
- The antioxidant property of vitamin C helps to reduce this to a certain extent .

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IN COMMON COLD

- Pauling in 1970 suggested that vitamin C can be used for the treatment of
common cold.
- There are so many reports in Cochrane Database Syst. Review showing the
use of prophylactic vitamin C reduces the cold duration in adults and children.
- The use of vitamin C might reduce the duration of common cold due to its
anti-histamine effect of high dose of vitamin C.
- However, the results are inconsistent and still research is undergoing in this
field.
- There are Database Syst. Review showing the use of prophylactic vitamin C
reduces the cold duration in adults and children. The use of vitamin C might
reduce the duration of common cold due to its anti-histamine effect of high
dose of vitamin C.

In age-related macular degeneration (AMD) and cataract

Age-related macular degeneration (AMD) and cataracts are two of the main
causes of vision loss in older. Oxidative stress might contribute to the aetiology of both
conditions. Thus, researchers have taken interest in the role of vitamin C and other
antioxidants in the development and treatment of these diseases. There are many
reports to study the role of vitamin C in AMD and cataract. Results from two studies
indicate that vitamin C intakes greater than 300 mg/day reduce the risk of cataract
formation by 75%.

All the studies indicate that the vitamin C formulations might slow AMD
progression and reduce the high risk of developing advanced AMD. AMD is shown in
Figure 6.

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 Figure 6.

AGE-RELATED MACULAR DEGENERATION.

ANTIOXIDANT MECHANISM

Vitamins C can protect the body against the destructive effects of free radicals.
Antioxidants neutralize free radicals by donating one of their own electrons, ending the
electron-stealing reaction, as shown in Figure 7. The antioxidant nutrients themselves do
not become free radicals by donating an electron because they are stable in either form
or act as scavengers, helping to prevent cell and tissue damage that could lead to
cellular damage and disease.

Figure 7.

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Antioxidant mechanism.

Ascorbic acid reacts with free radicals undergoing single-electron oxidation to

produce a relatively poor reactive intermediate, the ascorbyl radical, which
disproportionates to ascorbate and dehydroascorbate. Thus, ascorbic acid can reduce
toxic, reactive oxygen species superoxide anion (O2•) and hydroxyl radical (OH•), as
well as organic (RO2) and nitrogen (NO2•) oxy radicals. Those reactions are likely to be
of fundamental importance in all aerobic cells. This reaction is the basis of most of the
biological functions of ascorbic acid. The mechanism of free radical action on DNA is
shown in the Figure below.

Mechanism of free radical action on DNA.

Vitamin C also has role in protecting other vitamins (vitamin A and vitamin E)
from the harmful effects of oxidation. Vitamin C helps in protecting gums and retards
ageing. It strengthens the general physical condition by removing toxic metals from the
body. Vitamin C reduces the formation of cataract and hence useful in the treatment of
glaucoma.

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Synthesis of protein

Another important function of vitamin C is its role in the synthesis of protein.

Vitamin C helps in the synthesis of collagen. Collagen protects our skin from wrinkling
and makes our skin firm and strong. Collagen also protects and supports organs and
other soft tissues. One of the amino acids used to build collagen—hydroxyproline—is
only synthesized when vitamin C is available. Functions of vitamin C on skin.

FUNCTIONS OF VITAMIN C ON SKIN

Photoprotection

- Vitamin C reduces the damage caused by UV-light exposure.

- It cannot act as a sunscreen since it cannot absorb UV light.
- But the antioxidant activity of vitamin C helps to protect UV damage caused
by free radicals.
- In response to UV light, vitamin C transport proteins are increased,
suggesting an increased need for vitamin C uptake for adequate protection .
- Addition of keratinocytes on vitamin C reduces damages caused by UV light
and lipid peroxidation, limits the release of pro-inflammatory cytokines and
protects against apoptosis.
- Many studies have suggested that vitamin C consumption alone will not
reduce the effect of UV exposure; however, a combination of vitamin C and E
effectively increases minimal erythemal dose (MED) (the lowest dose of
ultraviolet radiation (UVR) that will produce a detectable erythema 24 hours
after UVR exposure) and decreases erythema-induced blood flow to
damaged areas of skin .
- Thus, interactions between the two antioxidant vitamins may be necessary to
achieve UV protection.
- The topical application of vitamin C also reduces the effect of UV exposure
and skin wrinkling and skin tumour .
- Vitamin C reduced the number of sunburned cells, decreased erythema
response and reduced DNA damage induced by UV exposure.
- The combination of antioxidant vitamins decreased the immunosuppressive
effects of UV exposure, increased MED and decreased cell damage.

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Wound healing

Vitamin C plays a key role in healing wound by the formation of collagen,

connective tissue. The new tissue is rebuilt with the help of collagen framework. This
function is supported by its co-factor vitamin C. Besides this, vitamin C performs as a
strong antioxidant and immune system modulator.

Deficiency of vitamin C

- Deficiency of vitamin C in humans causes a major disease called scurvy.

- The major signs of the disease occur primarily in mesenchymal tissues.
- It leads to impaired wound healing; edema; hemorrhage (due to deficient
formation of intercellular substance) in the skin, mucous membranes, internal
organs, and muscles; and weakening of collagenous structures in bone,
cartilage, teeth and connective tissues.
- Those who suffer from scurvy have swollen, bleeding gums with tooth loss.
- They also show lethargy, fatigue, rheumatic pains in the legs, muscular
atrophy and skin lesions, massive sheet hematomas in the thighs, and
ecchymoses and hemorrhages in many organs, including the intestines, sub-
periosteal tissues and eyes.
- All these features are accompanied by psychological changes: hysteria,
hypochondria and depression.
- In children, the syndrome is called Moeller-Barlow disease; it is seen in non-
breastfed infants usually at about 6 months of age and is characterized by
widening of bone-cartilage boundaries, stressed epiphyseal cartilage of the
extremities, severe joint pain and frequently, anaemia and fever. Children
having this disease present with a limp or inability to walk, tenderness of the
lower limbs, bleeding of the gums and petechial haemorrhages.

Signs and Symptoms of Vitamin C Deficiency

- The most common risk factors for vitamin C deficiency are poor diet,
alcoholism, anorexia, severe mental illness, smoking and dialysis (2Trusted
Source, 3Trusted Source).

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 - While symptoms of severe vitamin C deficiency can take months to develop,
there are some subtle signs to watch out for.

Here are the 15 most common signs and symptoms of vitamin C deficiency.

1. Rough, Bumpy Skin

Vitamin C plays a key role in collagen production, a protein that is abundant in

connective tissues like skin, hair, joints, bones and blood vessels (4Trusted Source).
When vitamin C levels are low, a skin condition known as keratosis pilaris can develop.

In this condition, bumpy “chicken skin” forms on the back of the upper arms, thighs or
buttocks due to a buildup of keratin protein inside the pores (5Trusted Source).

Keratosis pilaris caused by vitamin C deficiency typically appears after three to five
months of inadequate intake and resolves with supplementation (6Trusted Source).

However, there are many other potential causes of keratosis pilaris, so its presence
alone is not enough to diagnose a deficiency.

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2. Corkscrew-Shaped Body Hair

Vitamin C deficiency can also cause hair to grow in bent or coiled shapes due to
defects that develop in the protein structure of hair as it grows. Corkscrew-shaped hair is
one of the hallmark signs of vitamin C deficiency but may not be obvious, as these
damaged hairs are more likely to break off or fall out. Hair abnormalities often resolve
within one month of treatment with adequate amounts of vitamin C.

3. Bright Red Hair Follicles

Hair follicles on the surface of the skin contain many tiny blood vessels that
supply blood and nutrients to the area. When the body is deficient in vitamin C, these
small blood vessels become fragile and break easily, causing small, bright red spots to
appear around the hair follicles.

This is known as perifollicular hemorrhage and a well-documented sign of severe vitamin

C deficiency. Taking vitamin C supplements typically resolves this symptom within two
weeks

4. Spoon-Shaped Fingernails With Red Spots or Lines

Spoon-shaped nails are characterized by their concave shape and often thin and
brittle. They are more commonly associated with iron deficiency anemia but have also
been linked to vitamin C deficiency .

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 Red spots or vertical lines in the nail bed, known as splinter hemorrhage, may
also appear during vitamin C deficiency due to weakened blood vessels that rupture
easily. While the visual appearance of fingernails and toenails may help determine the
likelihood of vitamin C deficiency, note that it’s not considered diagnostic.

5. Dry, Damaged Skin

Healthy skin contains large amounts of vitamin C, especially in the epidermis, or

outer layer of skin. Vitamin C keeps skin healthy by protecting it from oxidative damage
caused by the sun and exposure to pollutants like cigarette smoke or the ozone.

It also promotes collagen production, which keeps skin looking plump and
youthful. High intakes of vitamin C are associated with better skin quality, while lower
intakes are associated with a 10% increased risk of developing dry, wrinkled skin.

While dry, damaged skin can be linked to vitamin C deficiency, it can also be
caused by many other factors, so this symptom alone is not enough to diagnose a
deficiency.

6. Easy Bruising

Bruising occurs when blood vessels under the skin rupture, causing blood to leak
into the surrounding areas. Easy bruising is a common sign of vitamin C deficiency since
poor collagen production causes weak blood vessels

Deficiency-related bruises may cover large areas of the body or appear as small,
purple dots under the skin. Easy bruising is often one of the first obvious symptoms of a
deficiency and should warrant further investigation into vitamin C levels.

7. Slowly Healing Wounds

Since vitamin C deficiency slows the rate of collagen formation, it causes wounds
to heal more slowly. Research has shown that people with chronic, non-healing leg
ulcers are significantly more likely to be deficient in vitamin C than those without chronic
leg ulcers.

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 In severe cases of vitamin C deficiency, old wounds may even reopen,
increasing the risk of infection. Slow wound healing is one of the more advanced signs of
deficiency and typically not seen until someone has been deficient for many months.

8. Painful, Swollen Joints

Since joints contain a lot of collagen-rich connective tissue, they can also be
affected by vitamin C deficiency. There have been many reported cases of joint pain
associated with vitamin C deficiency, often severe enough to cause limping or difficulty
walking.

Bleeding within the joints can also occur in people who are deficient in vitamin C,
causing swelling and additional pain . Yet, both of these symptoms can be treated with
vitamin C supplements and commonly resolve within one week .

9. Weak Bones

Vitamin C deficiency can also affect bone health. In fact, low intake has been
linked to increased risk of fracture and osteoporosis. Research has found that vitamin C
plays a critical role in bone formation, so a deficiency can increase the rate of bone loss.

Children’s skeletons may be especially affected by vitamin C deficiency, as they

are still growing and developing.

10. Bleeding Gums and Tooth Loss

Red, swollen, bleeding gums are another common sign of vitamin C deficiency.
Without adequate vitamin C, gum tissue becomes weakened and inflamed and blood
vessels bleed more easily.

In advanced stages of vitamin C deficiency, gums may even appear purple and
rotten. Eventually, teeth can fall out due to unhealthy gums and weak dentin, the
calcified inner layer of teeth.

11. Poor Immunity

Studies show that vitamin C accumulates inside various types of immune cells to
help them combat infection and destroy disease-causing pathogens .

Vitamin C deficiency is associated with poor immunity and a higher risk of

infection, including serious illnesses like pneumonia .

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 In fact, many people with scurvy, a disease caused by vitamin C deficiency,
eventually die of infection due to their poorly functioning immune systems .

12. Persistent Iron Deficiency Anemia

Vitamin C and iron deficiency anemia often occur together. Signs of iron
deficiency anemia include paleness, fatigue, trouble breathing during exercise, dry skin
and hair, headache and spoon-shaped fingernails.

Low levels of vitamin C may contribute to iron deficiency anemia by reducing the
absorption of iron from plant-based foods and negatively affecting iron metabolism.
Vitamin C deficiency also increases the risk of excessive bleeding, which can contribute
to anemia.

If iron deficiency anemia persists for a long time with no obvious causes, it may
be wise to check your vitamin C levels.

13. Fatigue and Poor Mood

Two of the earliest signs of vitamin C deficiency are fatigue and poor mood .
These symptoms can even appear even before a full-blown deficiency develops.

While fatigue and irritability may be some of the first symptoms to appear, they typically
resolve after just a few days of adequate intake or within 24 hours of high-dose
supplementation.

14. Unexplained Weight Gain

Vitamin C may help protect against obesity by regulating the release of fat from
fat cells, reducing stress hormones and decreasing inflammation. Research has found a
consistent link between low intake of vitamin C and excess body fat, but it’s not clear
whether it is a cause and effect relationship.

Interestingly, low blood levels of vitamin C have been linked to higher amounts of
belly fat, even in normal-weight individuals. While excess body fat alone is not enough to
indicate a vitamin C deficiency, it may be worth examining after other factors have been
ruled out.

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15. Chronic Inflammation and Oxidative Stress

Vitamin C is one of the body’s most important water-soluble antioxidants. It helps

prevent cellular damage by neutralizing free radicals that can cause oxidative stress and
inflammation in the body.

Oxidative stress and inflammation have been linked to many chronic illnesses,
including heart disease and diabetes, so reducing levels is likely beneficial. Low intakes
of vitamin C have been linked to higher levels of inflammation and oxidative stress, as
well as an increased risk of heart disease .

TOXICITY SYMPTOMS

Vitamin C is a water-soluble vitamin, which means it dissolves in water.

- In contrast to fat-soluble vitamins, water-soluble vitamins do not get stored
within the body.
- Instead, the vitamin C that you consume gets transported to your tissues via
body fluids, and any extra gets excreted in urine .
- Since your body does not store vitamin C or produce it on its own, it’s
important to consume foods that are rich in vitamin C daily .
- However, supplementing with high amounts of vitamin C can lead to adverse
effects, such as digestive distress and kidney stones.

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 - That’s because if you overload your body with larger-than-normal doses of
this vitamin, it will start to accumulate, potentially leading to overdose
symptoms .
- It’s important to note that it’s unnecessary for most people to take vitamin C
supplements, as you can easily get enough by eating fresh foods, especially
fruits and vegetables .

1.Too much vitamin C may cause digestive symptoms

- The most common side effect of high vitamin C intake is digestive distress.

- In general, these side effects do not occur from eating foods that contain vitamin C, but
rather from taking the vitamin in supplement form.

You’re most likely to experience digestive symptoms if you consume more than 2,000
mg at once. Thus, a tolerable upper limit (TUL) of 2,000 mg per day has been
established .The most common digestive symptoms of excessive vitamin C intake are
diarrhea and nausea.

Excessive intake has also been reported to lead to acid reflux, although this is not
supported by evidence .If you’re experiencing digestive problems as a result of taking
too much vitamin C, simply cut back your supplement dose or avoid vitamin C
supplements altogether

2. Vitamin C may cause iron overload

Vitamin C is known to enhance iron absorption. It can bind to non-heme iron,

which is found in plant foods. Non-heme iron is not absorbed by your body as efficiently
as heme iron, the type of iron found in animal products. Vitamin C binds with non-heme
iron, making it much easier for your body to absorb. This is an important function,
especially for individuals who get most of their iron from plant-based foods.

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 One study in adults found that iron absorption increased by 67% when they took
100 mg of vitamin C with a meal. However, individuals with conditions that increase the
risk of iron accumulation in the body, such as hemochromatosis, should be cautious with
vitamin C supplements. Under these circumstances, taking vitamin C in excess may lead
to iron overload, which can cause serious damage to your heart, liver, pancreas, thyroid,
and central nervous system. That said, iron overload is highly unlikely if you don't have a
condition that increases iron absorption. Additionally, iron overload is more likely to
occur when excess iron is consumed in supplement form.

3. Taking supplements in high doses may lead to kidney stones

Excess vitamin C is excreted from the body as oxalate, a bodily waste product.
Oxalate typically exits the body via urine. However, under some circumstances, oxalate
may bind to minerals and form crystals that can lead to the formation of kidney stones
.Consuming too much vitamin C has the potential to increase the amount of oxalate in
your urine, thus increasing the risk of developing kidney stones .In one study that had
adults take a 1,000-mg vitamin C supplement twice daily for 6 days, the amount of
oxalate they excreted increased by 20% .

High vitamin C intake is not only associated with greater amounts of urinary
oxalate but also linked to the development of kidney stones, especially if you consume
amounts greater than 2,000 mg .Reports of kidney failure have also been reported in
people who have taken more than 2,000 mg in a day. However, this is extremely rare,
especially in healthy people

How much vitamin C is too much?

Since vitamin C is water-soluble and your body excretes excess amounts of it

within a few hours after you consume it, it’s quite difficult to consume too much.

- In fact, it is nearly impossible for you to get too much vitamin C from your diet
alone. In healthy people, any extra vitamin C consumed above the
recommended daily amount simply gets flushed out of the body.

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 - To put it in perspective, you would need to consume 29 oranges or 13 bell
peppers before your intake reached the tolerable upper limit.
- However, the risks of vitamin C overdose are higher when people take
supplements, and it is possible to consume too much of the vitamin in some
circumstances.
- For example, those with conditions that increase the risk of iron overload or
are prone to kidney stones should be cautious with their vitamin C intake.
- All the adverse effects of vitamin C, including digestive distress and kidney
stones, appear to occur when people take it in mega doses greater than
2,000 mg.
- If you choose to take a vitamin C supplement, it is best to choose one that
contains no more than 100% of your daily needs. That’s 90 mg per day for
men and 75 mg per day for women

HERE ARE THE TOP 20 FOODS THAT ARE HIGH IN VITAMIN C.

1. Kakadu Plums

The Kakadu plum (Terminalia ferdinandiana) is an Australian native superfood

containing 100 times more vitamin C than oranges. It has the highest known
concentration of vitamin C, containing up to 5,300 mg per 100 grams. Just one plum
packs 481 mg of vitamin C, which is 530% of the DV. It’s also rich in potassium, vitamin
E and the antioxidant lutein, which may benefit eye health.

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2.Acerola Cherries Just one-half cup (49 grams)
of red acerola cherries (Malpighia emarginata) delivers 822 mg of vitamin C, or 913% of
the DV .Animal studies using acerola extract have shown that it may have cancer-
fighting properties, help prevent UVB skin damage and even decrease DNA damage
caused by bad diet .Despite these promising results, no human-based studies on the
effects of acerola cherry consumption exist.

3. Rose Hips

The rose hip is a small, sweet, tangy fruit from the rose plant. It’s loaded with
vitamin C. Approximately six rose hips provide 119 mg of vitamin C, or 132% of the DV
.Vitamin C is needed for collagen synthesis, which supports skin integrity as you age.
Studies have found that vitamin C reduces sun damage to the skin, lessening wrinkling,
dryness and discoloration and improving its overall appearance. Vitamin C also helps
wound healing and inflammatory skin conditions like dermatitis.

4. Chili Peppers
One green chili pepper contains 109 mg of vitamin C, or 121% of the DV. In
comparison, one red chili pepper delivers 65 mg, or 72% of the DV .Moreover, chili
peppers are rich in capsaicin, the compound that is responsible for their hot taste.
Capsaicin may also reduce pain and inflammation .There is also evidence that
approximately one tablespoon (10 grams) of red chili powder may help increase fat
burning.

5. Guavas

This pink-fleshed tropical fruit is native to Mexico and South America.A

single guava contains 126 mg of vitamin C, or 140% of the DV. It’s particularly rich in the
antioxidant lycopene.A six-week study involving 45 young, healthy people found that

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eating 400 grams of peeled guava per day, or around 7 pieces of this fruit, significantly
lowered their blood pressure and total cholesterol levels .

6. Sweet Yellow Peppers

The vitamin C content of sweet or bell peppers increases as they mature.Just
one-half cup (75 grams) of yellow peppers provides 137 mg of vitamin C, or 152% of the
DV, which is double the amount found in green peppers .Consuming enough vitamin C
is important for your eye health and may help protect against cataract progression.A
study in over 300 women found that those with higher vitamin C intakes had a 33%
lower risk of cataract progression, compared to those with the lowest intakes .

7. Blackcurrants
One-half cup (56 grams) of blackcurrants (Ribes nigrum) contains 101 mg of
vitamin C, or 112% of the DV . Antioxidant flavonoids known as anthocyanins give them
their rich, dark color.
Studies have shown that diets high in antioxidants like vitamin C and
anthocyanins may reduce oxidative damage associated with chronic diseases, including
heart disease, cancer and neurodegenerative diseases .

8. Thyme

Gram for gram, fresh thyme has three times more vitamin C than oranges and
one of the highest vitamin C concentration of all culinary herbs. One ounce (28 grams) of
fresh thyme provides 45 mg of vitamin C, which is 50% of the DV.
Even just sprinkling 1–2 tablespoons (3–6 grams) of fresh thyme over your meal
adds 3.5–7 mg of vitamin C to your diet, which can strengthen your immunity and help
fight infections.
While thyme is a popular remedy for sore throats and respiratory conditions, it’s
also high in vitamin C, which helps improve immune health, make antibodies, destroy
viruses and bacteria and clear infected cells .

9. Parsley
Two tablespoons (8 grams) of fresh parsley contain 10 mg of vitamin C, providing
11% of the recommended DV. Along with other leafy greens, parsley is a significant

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source of plant-based, non-heme iron. Vitamin C increases the absorption of non-heme
iron. This helps prevent and treat iron-deficiency anemia.
One two-month study gave people on a vegetarian diet 500 mg of vitamin C
twice a day with their meals. At the end of the study, their iron levels had increased by
17%, hemoglobin by 8% and ferritin, which is the stored form of iron, by 12%.

10. Mustard Spinach

One cup of raw chopped mustard spinach provides 195 mg of vitamin C, or
217% of the DV. Even though heat from cooking lowers the vitamin C content in foods,
one cup of cooked mustard greens still provides 117 mg of vitamin C, or 130% of the DV
.
As with many dark, leafy greens, mustard spinach is also high in vitamin A, potassium,
calcium, manganese, fiber and folate.

11. Kale Kale is a cruciferous vegetable.

One cup of chopped raw kale provides 80 mg of vitamin C, or 89% of the DV. It also
supplies high quantities of vitamin K and the carotenoids lutein and zeaxanthin.

One cup of cooked kale provides 53 mg, or 59% of the DV for vitamin C .
While cooking this vegetable reduces its vitamin C content, one study found that boiling,
frying or steaming leafy greens helps release more of their antioxidants. These potent
antioxidants may help reduce chronic inflammatory diseases.

12. Kiwis
One medium kiwi packs 71 mg of vitamin C, or 79% of the DV.
Studies have shown that the vitamin-C-rich kiwifruit may help reduce oxidative stress,
lower cholesterol and improve immunity. A study in 30 healthy people aged 20–51 found

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that eating 2–3 kiwis every day for 28 days reduced blood platelet stickiness by 18% and
lowered triglycerides by 15%. This may reduce the risk of blood clots and stroke.

Another study in 14 men with vitamin C deficiency found that eating two kiwis
daily for four weeks increased white blood cell activity by 20%. Blood levels of vitamin C
normalized after just one week, having increased by 304%.

13. Broccoli
Broccoli is a cruciferous vegetable. One-half cup of cooked broccoli provides 51
mg of vitamin C, or 57% of the DV.
Numerous observational studies have shown a possible association between eating
plenty of vitamin-C-rich cruciferous vegetables and lowered oxidative stress, improved
immunity and a decreased risk of cancer and heart disease.
One randomized study gave 27 young men who were heavy smokers a 250-
gram serving of steamed broccoli containing 146 mg of vitamin C every day. After ten
days, their levels of the inflammatory marker C-reactive protein had decreased by 48%.

14. Brussels Sprouts One-half cup of

cooked Brussels sprouts provides 49 mg, or 54% of the DV of vitamin C. Like most
cruciferous vegetables, Brussels sprouts are also high in fiber, vitamin K, folate, vitamin
A, manganese and potassium. Both vitamins C and K are important for your bone
health. In particular, vitamin C aids the formation of collagen, which is the fibrous part
your bones.
A large 2018 review found that a high dietary intake of vitamin C was associated
with a 26% reduced risk of hip fractures and a 33% reduced risk of osteoporosis.

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15. Lemons
Lemons were given to sailors during the 1700s to prevent scurvy. One whole raw
lemon, including its peel, provides 83 mg of vitamin C, or 92% of the DV.
The vitamin C in lemon juice also acts as an antioxidant.
When fruits and vegetables are cut, the enzyme polyphenol oxidase is exposed to
oxygen. This triggers oxidation and turns the food brown. Applying lemon juice to the
exposed surfaces acts as a barrier, preventing the browning process.

16. Lychees
One lychee provides nearly 7 mg of vitamin C, or 7.5% of the DV, while a one-
cup serving provides 151%. Lychees also contain omega-3 and omega-6 fatty acids,
which benefit your brain, heart and blood vessels.
Studies specifically on lychee are unavailable. Nonetheless, this fruit provides
plenty of vitamin C, which is known for its role in collagen synthesis and blood vessel
health.
An observational study in 196,000 people found that those with the highest
vitamin C intakes had a 42% reduced risk of stroke. Each extra serving of fruits or
vegetables lowered the risk by an additional 17%.

17. Persimmons
An orange-colored fruit that resembles a tomato. There are many different
varieties. Though the Japanese persimmon is the most popular, the native American
persimmon (Diospyros virginiana) contains almost nine times more vitamin C.
One American persimmon contains 16.5 mg of vitamin C, or 18% of the DV .

18. Papayas
One cup (145 grams) of papaya provides 87 mg of vitamin C, or 97% of the DV .
Vitamin C also aids memory and has potent anti-inflammatory effects in your brain .
In one study, 20 people with mild Alzheimer’s were given a concentrated papaya extract
for six months. The results showed decreased inflammation and a 40% reduction in
oxidative stress .

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19. Strawberries
One cup of strawberry halves (152 grams) provides 89 mg of vitamin C, or 99%
of the DV. Strawberries contain a diverse and potent mix of vitamin C, manganese,
flavonoids, folate and other beneficial antioxidants.

Studies have shown that due to their high antioxidant content, strawberries may
help prevent cancer, vascular disease, dementia and diabetes. One study in 27 people
with metabolic syndrome found that eating freeze-dried strawberries daily — the
equivalent of 3 cups fresh — reduced heart disease risk factors. At the end of the eight-
week study, their “bad” LDL cholesterol levels had decreased by 11%, while their levels
of the blood vessel inflammation marker VCAM had decreased by 18% .

20. Oranges
One medium-sized orange provides 70 mg of vitamin C, which is 78% of the DV.
Widely eaten, oranges make up a significant portion of dietary vitamin C intake.
Other citrus fruits can also help you meet your vitamin C needs. For example, half a
grapefruit contains 44 mg or 73% of the DV, a mandarin 24 mg or 39% of the DV and
the juice of one lime 13 mg or 22% of the DV.

References
https://www.webmd.com/diet/features/the-benefits-of-vitamin-c#1
https://www.intechopen.com/books/vitamin-c/vitamin-c-sources-functions-sensing-and-analysis
https://www.healthline.com/nutrition/vitamin-c-deficiency-symptoms#section15
https://www.healthline.com/nutrition/side-effects-of-too-much-vitamin-c#dosage
https://www.healthline.com/nutrition/vitamin-c-foods#section21

2. VITAMIN B

1. Thiamine (B1)
2. Riboflavin (B2)
3. Niacin (B3)
4. Pantothenic acid (B5)
5. Pyridoxine (B6)
6. Biotin (B7)

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 7. Folate (B9)
8. Cobalamin (B12)

1. THIAMIN (B1)
- The search for the cause of beriberi was successfully concluded with the identification
of thiamin. Its nature and metabolic role were clarified in the early 1930s.

beriberi… A disease of the peripheral nerves caused by thiamin deficiency.

Chemical and Physical Nature

- Thiamin is a water-soluble and fairly stable vitamin, although it is destroyed in
alkaline solutions. Its name comes from its chemical ring-like structure.

Absorption, Transport, and Storage

- Thiamin is absorbed most efficiently in the acid environment of the upper
small intestine before the food mass is buffered by the alkaline fluids entering
from the pancreas.
- Thiamin is not stored in large amounts, so a continuous dietary supply is
needed.
- Tissue thiamin responds rapidly to increased metabolic demand such as
occurs in fever, high muscular activity, pregnancy, and lactation.
- Tissue stores depend on both thiamin intake and general diet composition.
Carbohydrate increases the need for thiamin, whereas fat and protein spare
thiamin. When the tissues are saturated, unused thiamin is excreted in the
urine.

FUNCTION OF THIAMIN

Coenzyme Role
Thiamin functions as a control agent in energy metabolism.
When combined with phosphorus to form thiamin pyrophosphate (TPP), it is involved
in several metabolic reactions that ultimately provide the body with energy in the form of
adenosine triphosphate (ATP). About 90% of body thiamin is in the coenzyme form.

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 Thiamin is especially necessary for the healthy function of systems that are in
constant action and in need of energy, such as the gastrointestinal tract, the nervous
system, and the cardiovascular system.

FOOD SOURCES AND STABILITY

▪ Although thiamin is widespread in most plant and animal tissues, the amount is
usually small. Thus, thiamin deficiency is a distinct possibility when food intake is
markedly curtailed (e.g., with alcoholism or highly inadequate diets).
▪ Good food sources of thiamin include yeast, pork, whole or enriched grains (e.g.,
flour, bread, cereals), and legumes (Table 7-7).
▪ Some raw fish contain a thiamin-degrading enzyme (i.e., thiaminase) and
consequently are not good sources.
▪ Lean pork and beef are also good sources.
▪ Thiamin is extremely water soluble and readily lost in cooking water.

▪ Neutral or alkaline environments will destroy thiamin. As with other water-soluble

vitamins, prepared foods retain more thiamin when the cooking water is
consumed with the dish rather than discarded.

THIAMIN REQUIREMENT
Dietary Reference Intake
▪ The thiamin requirement is based on energy intake with a minimum of 0.3 mg of
thiamin/1000 kcal. To provide a margin of safety the RDA is set at 1.2 mg for
men and 1.1 mg for women.

Additional thiamin is needed during pregnancy and lactation. Because the

kidneys excrete excess thiamin, there are no reports of toxicity arising from oral doses
up to
50 mg. No UL has been established.

Thiamin Deficiency and Clinical Applications

When thiamin levels are insufficient to support cellular
energy metabolism, clinical effects become apparent, as follows:

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• Gastrointestinal system:
Anorexia, constipation, gastric atony, and poor hydrochloric acid secretion
progress as the deficiency continues. When the cells of the smooth muscles and the
secretory glands do not receive enough energy from glucose, they cannot perform the
digestive work needed to supply still more glucose to meet body needs. This vicious
cycle accelerates as the deficiency continues.
• Nervous system:
The CNS depends on glucose to do its work. Without sufficient thiamin to provide
this constant fuel, nerve activity is impaired, alertness and reflex responses are
diminished, and general apathy and fatigue take over.

If the deficiency continues, then lipogenesis is hindered, followed by damage to

the myelin sheaths, which is the lipid tissue covering the nerve fibers. This causes
increasing nerve irritation, pain, and prickly or deadening sensations. If unchecked, then
paralysis will result as in the classic deficiency disease beriberi.

• Cardiovascular system:
The heart muscle weakens, leading to cardiac failure and edema of the lower
extremities.

• Musculoskeletal system:
Inadequate TPP in muscle tissue results in widespread chronic pain that
responds to thiamin therapy.
Thiamin status is evaluated by the activity of a TPP-dependent
enzyme transketolase found in red blood cells. This is a
common test to determine whether a clinical observation is
related to thiamin deficiency or another cause.

TOXICITY
The kidneys clear excess thiamin; therefore, there is no evidence of toxicity from
oral intake, and no UL exists.

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2. RIBOFLAVIN (also known as vitamin B2)
- is one of the B vitamins, which are all water soluble.
- Riboflavin is naturally present in some foods, added to some food products, and
available as a dietary supplement.
- This vitamin is an essential component of two major coenzymes, flavin
mononucleotide (FMN; also known as riboflavin-5’-phosphate) and flavin adenine
dinucleotide (FAD).
- These coenzymes play major roles in energy production; cellular function,
growth, and development; and metabolism of fats, drugs, and steroids .
- The conversion of the amino acid tryptophan to niacin (sometimes referred to
as vitamin B3) requires FAD. Similarly, the conversion of vitamin B6 to the coenzyme
pyridoxal 5’-phosphate needs FMN.
- In addition, riboflavin helps maintain normal levels of homocysteine, an amino
acid in the blood .

FUNCTIONS
▪ Riboflavin is a vitamin that is needed for growth and overall good health.
- It helps the body break down carbohydrates, proteins and fats to produce
energy, and it allows oxygen to be used by the body.
▪ Riboflavin is also used for the development and function of the skin, lining of the
digestive tract, blood cells and other vital organs,” Dr. Sherry Ross, women’s
health expert at Providence Saint John’s Health Center in Santa Monica,
California, told Live Science.
▪ It is also used for the conversion of tryptophan to niacin. It helps maintain healthy
skin, tongue and mouth, normal vision, proper growth and development.

DEFICIENCY
- Deficiency of riboflavin is rare in developed countries because it is a vitamin
found in many common foods. Some people are more prone to deficiency
than others.
- “This is more common in people on extreme diets who are underweight or
those with digestive problems such as celiac disease,” Dr. Kristine Arthur,
internist at Orange Coast Memorial Medical Center in Fountain Valley,
California, told Live Science.

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 - Teens, alcoholics and the elderly are also more susceptible to vitamin B2
deficiency because of poor diet.

- Deficiency can cause anemia, sore throat, mouth or lip sores, inflammation of
the skin and swelling of soft tissue in the mouth.

- These symptoms can show up after just a few days of deficiency, according
to the American Journal of Clinical Nutrition.

RIBOFLAVIN REQUIREMENT:
- The normal recommended daily allowance (RDA) of riboflavin is dependent
on age, gender and reproductive status.
- “RDA is 1.3 milligrams daily for men and 1.1 mg for women. A higher dose of
3 mg per day can help to prevent cataracts.
- Higher doses up to 400 mg can be used to treat migraine headaches,” said
Arthur.
- A cup of chopped kale has 0.1 mg, while a hard-boiled egg has 0.3 mg and a
glass of whole milk has 0.4 mg, according to the U.S. Department of
Agriculture.
- One cup of whole almonds has 1.4 mg of riboflavin, or 85 percent of the RDA.

o As a supplement, riboflavin is usually included in multivitamins and B-complex

vitamins.
o It also is available separately in doses of 25 mg, 50 mg and 100 mg. Relatively
nontoxic, riboflavin is considered safe at high doses because excess is disposed
of through the urinary tract.
o There may be some side effects from taking higher doses of B2, though. “Some
people notice their urine turning yellow-orange in color and having diarrhea when
taken in higher doses,” said Ross.

TOXICITY of riboflavin does not occur from oral doses but is possible when massive
doses are given by injection.
- However, it’s ill-defined effects are not serious as what is experienced in
hypervitaminoses A and D.

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FOOD SOURCES:
The best animal sources are cheese, milk, eggs, liver and other glandular
organs, and lean meats. Plant sources with highB2 values are whole grain, legumes,
leafy green vegetables and sea weeds. In the USA, riboflavin is added in flour
enrichment.
• https://www.livescience.com/51966-vitamin-b2-riboflavin.html
• https://ods.od.nih.gov/factsheets/Riboflavin-Consumer/
• https://ods.od.nih.gov/factsheets/Riboflavin-HealthProfessional/
• https://www.webmd.com/vitamins/ai/ingredientmono-957/riboflavin

3. NIACIN / NICOTINIC ACID (Vitamin B3)

• Vitamin B3, also called niacin, is one of the eight B-complex water-soluble
vitamins.
• Niacin, a name coined from nicotinic acid vitamin, comes in several forms,
including niacinamide (nicotinamide) and inositol hexanicotinate.
• Each of these forms has various uses as well.
• Niacin is the generic name for nicotinic acid (pyridine-3-carboxylic acid),
nicotinamide (niacinamide or pyridine-3-carboxamide), and related derivatives,
such as nicotinamide riboside [1-3].
• Niacin is naturally present in many foods, added to some food products, and
available as a dietary supplement.
• The obsolete names are antipellagra factor, pellagra-preventive factor (PP
factor), anti-black tongue factor.
• The unit of measurement is milligram
FUNCTIONS

• Niacin has a wide range of uses in the body, helping functions in the digestive
system, skin and nervous system.
• Niacin acts as hydrogen and electron acceptors, a biochemical reaction
important in energy metabolism (aerobic and anaerobic oxidation of glucose),
fatty acid synthesis/catabolism.
• The active coenzyme forms of niacin are nicotinamide adenine dinucletide (NAD
or Coenzyme l) and nicotinamide adenine dinucleotide phosphate (NADP or
Coenzyme ll).

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 • Niacin is also needed for photosynthesis in plants and carbon dioxide fixation in
animal cells.

DEFICIENCY/TOXICITY

o The deficiency signs and symptoms of niacin are closely parallel to those of
riboflavin since these two are interrelated with tissue metabolism.
o Early signs of niacin deficiency are anorexia, lassitude, indigestion and skin
changes.
o Pellagra is the classic deficiency disease characterized by 4 D’s namely:
dermatitis, dementia, diarrhea, and even death.
o The skin changes are different from other dermatitis because of it’s blackish or
dark, scaly patches that appear symmetrically in areas exposed to sunlight
called bilateral dermatitis.
o The tongue is beefy red and swollen (glossitis) and the corners of the mouth
cracked(angular stomatitis).
o In dogs, the tongue becomes black, hence the old name for niacin is anti-black
tongue factor.
The disorientation and confusion of a pellagrin could be accompanied by neuritis. The
fatal effects of pellagra are on the nervous system.

Toxicity has been observed when massive doses of niacin are given resulting in
hypermotility and acidity of the stomach and paralysis of the respiratory center.

FOOD SOURCES

- Excellent food sources for niacin are the same for protein sources:
outstanding are animal sources, namely liver and glandular organs, lean
meats, fish and poultry, milk and cheeses, eggs and legumes, nuts, whole
grains, enriched cereals and green vegetables.
- Corn is poor in both niacin and tryptophan; that is why pellagra is common in
population group subsisting on high-corn diets.
Supplying adequate niacin in the daily diet is easy as long as “Your guide to good
nutrition” is followed. Include liver and glandular organs once a week, using enriched

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breads and rice daily and eating the suggested daily servings for meats, fish, poultry,
legumes and nuts will insure sufficient niacin intake.

4. PANTOTHENIC ACID ( B5)

Pantothenic acid comes from the greek word, meaning “from everywhere or from
all sides” since it is present in all living things and is widespread in nature. It’s old names
are: chick antidermamtitis factor and filtrate factor.

- Pantothenic acid is measure in milligrams or micrograms.

Vitamin B5 is a water-soluble vitamin from the B group of vitamins. It helps

produce energy by breaking down fats and carbohydrates. It also promotes healthy skin,
hair, eyes, and liver. People need B5 to synthesize and metabolize fats, proteins, and
coenzyme A.B5 is one of the less known vitamins, possibly because deficiencies of it are
rare.
Vitamin B5 is also known as pantothenic acid, or Pantothenate. The word
pantothenic comes from the Greek “pantou,” meaning everywhere. Nearly all foods
contain small quantities of pantothenic acid.

FUNCTIONS

1. Digestive system
Vitamin B5 helps maintain a healthy digestive system and assists the body in
using other vitamins, especially vitamin B2. Vitamin B2 helps manage stress, but there
is no evidence that pantothenic acid reduces stress.

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Vitamin B5 has been shown to reduce the spread of acne as well as providing benefit to
many other areas of the body.

2. Skin care
Some studies have shown that vitamin B5 works as a moisturizer on the skin and
enhances the healing process of skin wounds.
One study showed that vitamin B5 helped facial acne and reduced the number of acne-
related facial blemishes when taken as a dietary supplement. Researchers noted a
“significant mean reduction in total lesion count” after 12 weeks of taking a B5 dietary
supplement. The authors call for more trials to confirm the results.

3. Cholesterol and triglycerides

Some studies suggest that vitamin B5 intake can help lower cholesterol and
levels of blood triglycerides, or fats. This course of management should only be pursued
under medical supervision.

4. Rheumatoid arthritis
Some researchers have found that people with rheumatoid arthritis have lower levels of
vitamin B5. However, more evidence is needed to confirm these results.

DEFICIENCY SYMPTOMS
Vitamin B5 deficiency is extremely rare in people as pantothenic acid is found in
nearly all foods. A healthy and varied diet should provide a person with enough.
Clinical trials have shown, however, that a deficiency may lead to:
- tiredness, Apathy, depression, irritability, sleep disorders, stomach pains
- Nausea, vomiting, numbness, muscle cramps, hypoglycemia, burning feet
- upper respiratory infections

- A deficiency of B5 can cause an increased sensitivity to insulin.

- In mice, a vitamin B5 deficiency led to skin irritation and graying of the fur, but
this was reversed when pantothenic acid was given.

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TOXICITY

- Toxicity of pantothenic acid is unlikely. In fact, no Tolerable Upper Level Intake

(UL) has been established for the vitamin.
- Large doses of the vitamin, when ingested, have no reported side effects and
massive doses (e.g., 10 g/day) may only yield mild intestinal distress, and
diarrhea at worst.
- has been suggested, however, that high doses of pantothenic acid might
worsen panic attacks in those with panic disorder by prolonging the duration
until adrenal exhaustion.
- Pantothenic acid, at a human equivalent dose within the range of common
supplementation, was shown to induce adrenal hyper-responsiveness to stress
stimulation.
- There are also no adverse reactions known following parenteral (injected) or
topical (skin) applications of the vitamin.

FOOD SOURCES OF VITAMIN B5

Vitamin B5 is widely found in both animals and plant products.

• Meat: Pork, chicken, turkey duck, beef, and especially animal organs such as
liver and kidney

• Fish: Salmon, lobster, and shellfish.

• Grains: Whole grain breads and cereals. Whole grains are a good source of
vitamin B5 but milling can remove up to 75 percent of the B5 content.

• Dairy products: Egg yolk, milk, yogurt, and milk products.

• Legumes: Lentils, split peas, and soybeans.

• Vegetables: Mushrooms, avocado, broccoli, sweet potatoes, corn,

cauliflower, kale, and tomatoes.

Other sources of vitamin B5 include brewer’s yeast, peanuts, sunflower seeds, wheat
germ, royal jelly, and oatmeal Pantothenic acid is widely available in food, but it is lost in

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processing, for example, in canning, freezing, and milling. To ensure an adequate
intake, foods should be eaten fresh rather than refined. As with all water-soluble
vitamins, vitamin B5 is lost when food is boiled.

https://www.medicalnewstoday.com/articles/219601#side_effects_and_interactions
https://med.libretexts.org/Courses/Dominican_University/DU_Bio_1550%3A_Nutrition_(LoPresto)/7%3A_Vitamins/7.3
%3A_Water_Soluble_Vitamins/Vitamin_B5_(Pantothenic_acid)

5. PYRIDOXINE (VITAMIN B6)

• Pyridoxine is the group name for three forms: pyridoxol (alcohol form), pyridoxal
(aldehyde form) and pryidoxamine(amine form).
Vitamin B6 group is measured in milligrams or micrograms.
• Vitamin B6 is one of the B vitamins that benefits the central nervous system. It is
involved in producing the neurotransmitters serotonin and norepinephrine, and in
forming myelin.
• Also known as pyridoxine, vitamin B6 is a water-soluble vitamin, which means it
dissolves in water. It is not stored by the body, and it is excreted in the urine, so
people need to take in Vitamin B6 every day. It is part of the family of B-complex
vitamins.
• Other functions of pyridoxine include protein and glucose metabolism, and the
manufacture of hemoglobin.
• Hemoglobin is a component of red blood cells. It carries oxygen. Vitamin B6 is
also involved in keeping the lymph nodes, thymus and spleen healthy.

FUNCTIONS:

All three forms are converted to the active co-enzyme factor pyridoxal phosphate
which is involved in amino acid metabolism. This includes: decarboxylation,
transamination, dehydration and other amino acid transformations. It catalyzes urea
production, synthesis of essential fatty acids, and the conversion of niacin to tryptophan.

Potential Side Effects of TOO MUCH Vitamin B6

Getting too much vitamin B6 from supplements can cause negative side effects.

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 - Vitamin B6 toxicity is not likely to occur from food sources of B6. It would be
nearly impossible to consume the amount in supplements from diet alone.
- Taking more than 1,000 mg of supplemental B6 a day may cause nerve
damage and pain or numbness in the hands or feet. Some of these side
effects have even been documented after just 100–300 mg of B6 per day .
- For these reasons, the tolerable upper limit of vitamin B6 is 100 mg per day
for adults .
- The amount of B6 used to manage certain health conditions rarely exceeds
this amount. If you’re interested in taking more than the tolerable upper limit,
consult your doctor.

VITAMIN B6 FOOD SOURCES AND SUPPLEMENTS

You can get vitamin B6 from food or supplements.

- The current recommended daily amount (RDA) for B6 is 1.3–1.7 mg for

adults over 19.
- Most healthy adults can get this amount through a balanced diet that includes
vitamin-B6-rich foods like turkey, chickpeas, tuna, salmon, potatoes
and bananas.
- Studies that highlight the use of vitamin B6 to prevent and treat health issues
focus on supplements rather than food sources.
- Doses of 30–250 mg of vitamin B6 per day have been used in research on
PMS, morning sickness and heart disease.
- These amounts of B6 are significantly higher than the RDA and sometimes
combined with other B vitamins. It’s difficult to assess if increasing intake of
B6 from dietary sources has the same benefits for certain conditions that
supplements may provide.
DEFICIENCY/TOXICITY

- No deficiency state has been observed in adult man by dietary depletion.

- Induce experimental deficiency by injecting an antagonist results in nausea
and vomiting, seborrheic or oily dermamtitis, glossitis, conjunctivitis and
depressive moods.

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 - In infants, deficiency state which resulted from feeding them milk formulae
lacking in pyridoxine for several weeks, caused irritability, poor growth,
anemia and convulsions.
- Deficiencies are rare, but they may occur if the individual has poor intestinal
absorption or is taking estrogens, corticosteroids, anticonvulsants, and some
other medications.

Long-term, excessive alcohol consumption may eventually result in a B6 deficiency, as

can hypothyroidism and diabetes.

Signs and symptoms of vitamin B6 deficiency include:

• Peripheral neuropathy with tingling, numbness, and pain in the hands and feet
• Anemia • Depression
• Seizures • Confusion
• Weakened immune system

It can lead to a pellagra-like syndrome, with seborrheic dermatitis, inflammation of the

tongue, or glossitis, and inflammation and cracking of the lips, known as cheilosis.

In infants, seizures may persist even after treatment with anticonvulsants. Other
deficiencies, like peripheral neuropathy, can be permanent.

TOXICITY FROM SUPPLEMENTS

- Vitamin B6 is available in multivitamins, in supplements combined with

other B vitamins (referred to as B-complex) and as an individual supplement,
commonly in the form of pyridoxine.
- Vitamin B6 supplements can be taken in an oral pill, liquid capsule or
chewable and sublingual forms. Absorption of vitamin B6 from the various
forms of supplements is similar and does not differ significantly
from absorption from food sources.
- Supplements taken orally are available without a prescription. Prescribed
doses and injectable forms of this medicine must be given by a healthcare
professional.

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 - Supplements typically range in dosage from 5 to 500 milligrams per tablet.
Although excess vitamin B6 is normally excreted in your urine, long-term
supplementation with amounts exceeding 50 milligrams per day for prolonged
duration may be harmful.
- Doses in excess of 1,000 milligrams per day of pyridoxine may lead to toxicity
that could result in painful neurological symptoms, known as sensory
neuropathy.
- The Linus Pauling Institute reports that some individuals have developed
sensory neuropathies at daily doses of less than 500 milligrams (taken
to treat carpal tunnel syndrome or premenstrual syndrome) over a period of
months. No evidence of sensory nerve damage has been reported with
intakes below 200 milligrams of pyridoxine daily.

SYMPTOMS OF B6 TOXICITY

Along with its needed effects, vitamin B6 supplements may cause some
unwanted outcomes. Even with small doses, some side effects may result. If any do
occur, you should seek medical attention, according to Drugs.com. These include:

• Nausea • Drowsiness
• Headache • Mild numbness or tingling

Prolonged high doses of vitamin B6, leading to toxicity, produce similar symptoms
to a vitamin B6 deficiency, according to a study published in Toxicology in Vitro in 2017.
Vitamin B6 deficiency and toxicity often involve changes in the blood, skin, heart,
gastrointestinal and, especially, neuronal cells.

The National Institutes of Health warns that taking 1 to 6 grams of vitamin B6 for an
extended period of 12 to 40 months can result in serious symptoms of:

• Nerve toxicity that causes lack of muscle control and coordination

• Burning pain, numbness, tingling and weakness of the hands and feet in a
stocking-glove distribution, according to the Merck Manual
• Painful, unsightly skin patches or disfiguring skin lesions
• Sensitivity to light
• Gastrointestinal problems, including nausea and heartburn

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 • Decreased sense of touch, inability to feel vibration, pain or extreme
temperatures
The severity of symptoms can be debilitating depending on the dosage_._ When
the B6 supplement is discontinued, a recent study has shown evidence that symptoms
are potentially reversible, as published in the journal Neurology in 2018.

Sources of Vitamin B6

Your body cannot store vitamin B6, so you must supply it daily from the food you
eat. You can usually get sufficient amounts of vitamin B6 from your diet. In the U.S.
many foods are fortified, including cereals and power bars.

Bioavailability of vitamin B6 from natural sources is estimated to be 75

percent from a varied diet. A paper published in StatPearls in 2019 reported that meat
sources have a higher bioavailability for B6 than plant-based sources. Foods naturally
rich in vitamin B6 provide about 0.25 to 1 milligram of B6 per serving,
according ConsumerLab.com. Some foods containing vitamin B6 include:

• Fish, including tuna and salmon

• Poultry, including chicken and turkey
• Meat, including organ meats
• Starchy vegetables such a potatoes
• Fruit, other than citrus

References:
https://ods.od.nih.gov/factsheets/Niacin-HealthProfessional/
https://www.medicalnewstoday.com/articles/219662
https://www.healthline.com/nutrition/vitamin-b6-benefits#section12
https://www.livestrong.com/article/317889-vitamin-b6-toxicity-symptoms/
https://www.sciencedirect.com/topics/medicine-and-dentistry/pyridoxine

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6. BIOTIN (B7)
Biotin is sometimes called the “anti-eggwhite injury factor”. Obsolete names for it
are: vitamin h, coenzyme r and Bios ll. It is measured in micrograms. It has been called
the “micromicronutrient”

- It is also known as vitamin H, in which case the H stands for “Haar und Haut,”
the German words for “hair and skin.”

BENEFITS AND FUNCTION

1. It helps the body convert food into energy and plays many other important roles in
health.

2. Biotin boosts the health of the hair and nails, supports a healthy pregnancy, and helps
manage blood sugar levels, among other benefits.

3. Biotin is necessary for the function of several enzymes known as carboxylases. These
are part of important metabolic processes, such as the production of glucose and fatty
acids.

Biotin plays a number of important roles in the body, including:

▪ Breaking down macronutrients

Biotin helps the body convert food into energy — it supports a number of enzymes
involved in the breakdown of carbs, fats, and proteins.

Specifically, biotin is involved in:

o Gluconeogenesis: This is the synthesis of glucose from sources other

than carbs, such as amino acids, and biotin-containing enzymes help
initiate this process.
o Fatty acid synthesis: Biotin assists enzymes that activate reactions that
are important for the production of fatty acids.

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 o Amino acid breakdown: Biotin-containing enzymes are involved in the
metabolism of several important amino acids, including leucine.
▪ Supporting nail health

Brittle nails are fragile and easily become split or cracked. A biotin deficiency can
lead to brittle nails.

For people with this deficiency, taking supplements that contain biotin could
improve the strength of their nails. Changing the diet and other lifestyle factors can help
improve nail health, as can some commercial products.

▪ Boosting hair health

The diet can play an important role in the health of the skin and hair. For
instance, some foods for healthy hair include eggs, Brazil nuts, and fatty fish.

Many hair products that claim to encourage healthier, stronger hair contain biotin.
Biotin deficiency can lead to hair loss, which indicates that the vitamin is involved in
keeping the hair healthy. However, little research has linked the vitamin with hair health
in people who do not have biotin deficiencies.

▪ Supporting pregnancy and breastfeeding

Biotin is very important for women who are pregnant or lactating. While symptomatic
biotin deficiency is rare, low biotin levels are common during pregnancy.

In fact, about 50% of pregnant women in the United States may have at least a mild
deficiency. This level of deficiency may affect a person’s health, but not enough to cause
noticeable symptoms.

Healthcare professionals believe that this deficiency is common among pregnant

women because the body breaks down the vitamin faster during pregnancy. As a result,
a pregnant woman may need more biotin — from the diet or from supplements — than a
woman who is not pregnant.

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 That said, it is important to consult a healthcare professional before taking
supplements during pregnancy or breastfeeding.

▪ Reducing blood sugar in people with diabetes

Type 2 diabetes is a metabolic condition characterized by high blood sugar levels

and impaired insulin function.

A biotin deficiency may disrupt blood sugar, or glucose, regulation.

Some evidence shows blood biotin levels may be lower in people with diabetes.
Studies in animals have suggested that supplements containing biotin and chromium
picolinate could prevent insulin resistance.

Researchers have also studied how biotin supplements affect blood sugar levels
in people with type 2 diabetes. The results have been mixed, but some studies have
shown that taking both biotin and chromium picolinate could help treat type 2 diabetes.

Overall, fully understanding the effects of biotin on diabetes and blood sugar
control will require more high-quality research.

▪ Boosting skin health

Scientists do not fully understand biotin’s role in maintaining healthy skin. However,
people with biotin deficiencies may experience skin problems, including red, scaly
rashes. Some people also believe that biotin may help improve psoriasis.

The vitamin’s influence on the skin may stem from its effect on fat metabolism. This
process is important for maintaining healthy skin, and it may be impaired in people with
low levels of biotin. It is important to note that no evidence shows that biotin improves
skin health in people who do not have a deficiency of the vitamin.

▪ Supporting MS treatment

Multiple sclerosis (MS) is an autoimmune disease. It damages the protective covering of

nerve fibers in the brain, spinal cord, and eyes. This protective covering is called myelin,
and biotin may play an important role in producing it.

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Studies have shown that people with MS respond positively to daily biotin doses of up to
300 milligrams (mg). This supplementation may reverse the progression of the disease
and reduce chronic disability.

SOURCES

Biotin exists in a wide variety of foods, which helps explain why a deficiency in the
vitamin is fairly rare.

Foods that are particularly high in biotin include:

• organ meats, such as liver and • legumes, such as soybeans and

kidney peanuts
• yeast • leafy greens
• egg yolks • cauliflower
• cheese • mushrooms
• nuts and nut butters
RECOMMENDED INTAKE

The Office of Dietary Supplements recommend the following biotin intake per day:

• 30 micrograms (mcg) for adults, including during pregnancy

• 35 mcg when lactating

BIOTIN DEFICIENCY is fairly rare. However, some people — such as pregnant women
and people who drink high amounts of alcohol — may develop mild deficiencies.

Also, eating raw eggs on a regular basis can cause biotin deficiency, because raw egg
whites contain a protein called avidin that binds to biotin, preventing the body from
absorbing it. Cooking the eggs deactivates their avidin.

7. FOLATE (B9)

FOLIC ACID, also called pteroylglutamic acid, folate, or folacin

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 - A water-soluble vitamin of the B complex that is essential in animals and
plants for the synthesis of nucleic acids.
- Folic acid is a synthetic, used in supplements and fortified foods.
- It’s a man-made version of folate, a naturally occurring B vitamin found in
many foods. Your body can’t make folate, so it must be obtained through
dietary intake.

Although the words folate and folic acid are often used interchangeably, these
vitamins are distinct. Synthesized folic acid differs structurally from folate and has slightly
different biological effects in the body. That said, both are considered to contribute to an
adequate dietary intake.

Folate is found in a number of plant and animal foods, including spinach, kale, broccoli,
avocado, citrus fruits, eggs, and beef liver.

Folic acid, on the other hand, is added to foods like flour, ready-to-eat breakfast cereals,
and bread. Folic acid is also sold in concentrated form in dietary supplements.

FUNCTIONS

Your body uses folate for a wide array of critical functions, including: the synthesis,
repair, and methylation — the addition of a methyl group — of DNA

• cellular division

• the conversion of homocysteine to methionine, an amino acid that’s used for

protein synthesis or converted into S-adenosylmethionine (SAMe), a compound
that acts as a primary methyl donor in your body and is necessary for numerous
cellular reactions

• the maturation of red blood cells

Folate is involved in a number of vital metabolic processes, and deficiency leads to

an array of negative health outcomes, including megaloblastic anemia, increased risk of

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heart disease and certain cancers, and birth defects in infants whose mothers were
deficient in folate

Prevention of birth defects and pregnancy complications

One of the most common uses of folic acid and folate supplements is the
prevention of birth defects, specifically neural tube defects, including spina bifida and
anencephaly — when a baby is born without parts of its brain or skull.

Maternal folate status is a predictor of neural tube defect risk, which has led to
national public health policies regarding folic acid supplementation for women who are or
may become pregnant.

For example, the U.S. Preventive Services Task Force, an independent panel of
national disease-prevention experts, recommends that all women who are planning to
become pregnant or capable of becoming pregnant supplement daily with 400–800 mcg
of folic acid starting at least 1 month before becoming pregnant and continuing through
the first 2–3 months of pregnancy. Folic acid supplements are prescribed to pregnant
women to prevent fetal birth defects and may also help prevent pregnancy-related
complications, including preeclampsia .

Treatment of folate deficiency

Folate deficiency can occur due to a variety of causes, including inadequate

dietary intake, surgery, pregnancy, alcoholism, and malabsorptive diseases (6Trusted
Source).

Deficiency can result in serious side effects, including megaloblastic anemia,

birth defects, mental impairment, impaired immune function, and depression. Both folic
acid and folate supplements are used to treat folate deficiency.

Promotion of brain health

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 Research has shown that low blood folate levels are associated with poor brain
function and an increased risk of dementia. Even normal but low folate levels are
associated with an increased risk of mental impairment in older adults. Studies have
demonstrated that folic acid supplements may improve brain function in those with
mental impairment and help treat Alzheimer’s disease.

A 2019 study in 180 adults with mild cognitive impairment (MCI) demonstrated
that supplementing with 400 mcg of folic acid per day for 2 years significantly improved
measures of brain function, including verbal IQ and reduced blood levels of certain
proteins involved in the development and progression of Alzheimer’s disease, compared
with a control group.

Another study in 121 people with newly diagnosed Alzheimer’s disease who were
being treated with the medication donepezil found that those who took 1,250 mcg of folic
acid per day for 6 months had improved cognition and reduced markers of inflammation,
compared with those who took donepezil alone.

Adjunctive treatment of mental health disorders

People with depression have been shown to have lower blood levels of folate
than people without depression.

Studies show that folic acid and folate supplements may reduce depressive
symptoms when used in conjunction with antidepressant medications. A systematic
review demonstrated that, when used alongside antidepressant medication, treatment
with folate-based supplements, including folic acid and methylfolate, were associated
with significantly greater reductions in depressive symptoms, compared with
antidepressant medication treatment alone.

What’s more, a review of 7 studies found that treatment with folate-based

supplements alongside antipsychotic medication resulted in reduced negative symptoms
in people with schizophrenia, compared with antipsychotic medication alone.

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Reduction of heart disease risk factors

Supplementing with folate-based supplements, including folic acid, may help

improve heart health and reduce your risk of heart disease risk factors. Having elevated
levels of the amino acid homocysteine is associated with an increased risk of
developing heart disease. Blood levels of homocysteine are determined by both
nutritional and genetic factors.

Folate plays a major role in the metabolism of homocysteine, and low folate
levels can contribute to high homocysteine levels, known as hyperhomocysteinemia.
Research has shown that supplementing with folic acid may reduce homocysteine levels
and heart disease risk.

For example, a review that included 30 studies and over 80,000 people
demonstrated that supplementing with folic acid led to a 4% reduction in overall heart
disease risk and a 10% reduction in stroke risk.

What’s more, folic acid supplements may help reduce high blood pressure, a
known heart disease risk factor. Additionally, folic acid supplements have been shown to
improve blood flow, which may help improve cardiovascular function.

Other potential benefits

Supplementing with folic acid has also been associated with the following benefits:

• Diabetes. Folate-based supplements may help improve blood sugar control,

reduce insulin resistance, and enhance cardiovascular function in those with
diabetes. These supplements may also help reduce diabetic complications,
including neuropathy.

• Fertility. Higher intake of supplemental folate (more than 800 mcg per day) is
associated with higher rates of live births in women undergoing assisted
reproductive technology. Adequate folate is also essential for oocyte (egg)
quality, implantation, and maturation.

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 • Inflammation. Folic acid and folate supplements have been shown to reduce
inflammatory markers, including C-reactive protein (CRP), in different
populations, including women with polycystic ovary syndrome (PCOS) and
children with epilepsy.

• Reduction of medication side effects. Folate-based supplements may help

reduce the incidence of side effects related to the use of certain medications,
including methotrexate, an immunosuppressant drug used to treat rheumatoid
arthritis, psoriasis, and certain cancers.

• Kidney disease. Due to impaired kidney function, hyperhomocysteinemia occurs

in over 80% of people with chronic kidney disease. Supplementing with folic acid
may help reduce homocysteine levels and heart disease risk in this population.

• This list is not exhaustive, and there are many other reasons why people use
folate-based supplements.

Folic acid for pregnancy

Folate plays essential roles in fetal growth and development. For example, it’s
needed for cellular division and tissue growth. This is why having optimal folate levels is
important both before and during pregnancy. Since the 1990s, flour and other food
staples have been fortified with folic acid based on study results linking low folate status
in women with a significantly increased risk of neural tube defects in their children.

It has been proven that both food fortification programs and folic acid
supplementation before and during pregnancy significantly reduces the risk of neural
tube defects, including spina bifida and anencephaly. Beyond its protective effect against
birth defects, supplementing with folic acid during pregnancy may improve
neurodevelopment and brain function in children, as well as protect against autism
spectrum disorders.

However, other studies have concluded that high folic acid intake and high levels
of unmetabolized folic acid in the bloodstream may have a negative effect on
neurocognitive development and increase autism risk, which will be discussed in the

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next section. Folate is also important for maternal health, and supplementing with folic
acid has been shown to reduce the risk of pregnancy-related complications, including
preeclampsia. Additionally, high maternal folate levels have been associated with a
significantly reduced risk of preterm birth.

DEFICIENCY

- In man, there is no naturally occurring deficiency from ordinary diets unless

secondary factors are present as in sprue and other-gastro-intestinal
disorders.
- Experimental deficiencies can be produced by administration of antagonists.
- The deficiency signs are glossitis, stomatitis, gastro-intestinal disturbances,
megaloblastic anemia of infancy and macrocytic anemia of pregnancy.
- Folic acid administration can improve the blood picture of pernicious anemia
but cannot remedy the nerve lesions and GIT symptoms which B12 alone
could cure.
- However, folic acid is needed to control macrocytic anemia of pregnancy,
sprue, and megaloblastic anemia of infancy.
- a massive dose of folic acid is quite toxic in lower animals resulting in kidney
lesions and uremia. in the usa, folic acid over 0.1 mg/day will not be sold
unless there is prescription.

TOXICITY

- Although there’s no set upper limit for food forms of folate, adverse
effects may occur when taking doses of synthetic folate over the set UL of
1,000 mcg.
- Your healthcare provider may recommend higher doses in certain
circumstances, such as in the case of folate deficiency, but you should not
take more than the UL without medical supervision.
- One study reported a fatality due to intentional excessive folic acid ingestion.
- However, toxicity is rare, as folate is water-soluble and readily excreted from
the body. Even so, high dose supplementation should be avoided unless
under medical supervision.

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FOOD SOURCES

- A wide variety of foods naturally contain folate, but the form that is added to
foods and supplements, folic acid, is better absorbed.
- In January 1998, the U.S. Food and Drug Administration required food
manufacturers to add folic acid to foods commonly eaten, including breads,
cereals, pasta, rice, and other grain products, to reduce the risk of neural
tube defects.
- This program has helped to increase the average folic acid intake by about
100 mcg/day. [38,39] Good sources of folate include:
• Dark green leafy vegetables (turnip • Fresh fruits, fruit juices
greens, spinach, romaine lettuce,
asparagus, Brussels sprouts, • Whole grains
broccoli)
• Liver
• Beans
• Seafood
• Peanuts
• Eggs
• Sunflower seeds
• Fortified foods and supplements

References:
https://www.healthline.com/nutrition/folic-acid#dosage
https://www.nhs.uk/conditions/vitamin-b12-or-folate-deficiency-anaemia/
https://www.britannica.com/science/folic-acid
https://www.hsph.harvard.edu/nutritionsource/folic-acid/

8. COBALAMIN (VITAMIN B12)

Vitamin B-12 is a crucial B vitamin. It is needed for nerve tissue health, brain
function, and the production of red blood cells. Cobalamin is another name for vitamin B-
12. Deficiency can result when levels of vitamin B-12 are too low. This can lead to
irreversible neurological symptoms. In the United States (U.S.), between 1.5 and 15
percent of the population are currently diagnosed with vitamin B-12 deficiency.

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 Vitamin B-12 is a water-soluble vitamin, like all other B-vitamins. This means it
can dissolve in water and travel through the bloodstream. The human body can store
vitamin B-12 for up to four years. Any excess or unwanted vitamin B-12 is excreted in
the urine.

Vitamin B-12 is the largest and most structurally complicated vitamin. It occurs
naturally in meat products and can only be industrially produced through bacterial
fermentation synthesis.

FUNCTIONS

Vitamin B-12 is crucial to the normal function of the brain and the nervous
system. It is also involved in the formation of red blood cells and helps to create and
regulate DNA.

The metabolism of every cell in the body depends on vitamin B-12, as it plays a
part in the synthesis of fatty acids and energy production. Vitamin B-12 enables the
release of energy by helping the human body absorb folic acid.

The human body produces millions of red blood cells every minute. These cells
cannot multiply properly without vitamin B-12. The production of red blood cells reduces
if vitamin B-12 levels are too low. Anemia can occur if the red blood cell count drops.

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DEFICIENCY SYMPTOMS

Vitamin B-12 deficiency occurs when the body does not receive enough vitamin
B-12. It can result in irreversible and potentially severe damage, especially to the
nervous system and brain. Even slightly lower-than-normal levels of vitamin B-12 can
trigger deficiency symptoms, such as depression, confusion, memory problems,
and fatigue. However, these symptoms alone are not specific enough to diagnose
vitamin B-12 deficiency.

Other symptoms of vitamin B-12 deficiency include constipation, loss of appetite,

and weight loss. Once symptoms escalate, they can include neurological changes, such
as numbness and tingling in the hands and feet. Some people may have difficulty
maintaining balance.

Infants who lack vitamin B-12 may demonstrate unusual movements, such as
face tremors, as well as reflex problems, feeding difficulties, irritation, and eventual
growth problems if the deficiency is left untreated.

Vitamin B-12 deficiency carries a serious risk of permanent nerve and brain
damage. Some people with insufficient vitamin B-12 have a higher risk of
developing psychosis, mania, and dementia.

Insufficient vitamin B-12 can also lead to anemia. The most common symptoms
of anemia are fatigue, shortness of breath, and an irregular heartbeat. People with
anemia might also experience:

• a sore mouth or tongue • diarrhea

• weight loss • menstrual problem
• pale or yellowing skin

Vitamin B-12 deficiency also leaves people more susceptible to the effects of infections.

WHO IS AT RISK?

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 Vegans face a risk of vitamin B-12 deficiency, as their diet excludes animal-
sourced food products. Pregnancy and lactation can worsen deficiency in vegans. Plant-
sourced foods do not have enough cobalamin to guarantee long-term health. People
with pernicious anemia may lack vitamin B-12. Pernicious anemia is an autoimmune
disease that affects the blood. Patients with this disorder do not have enough intrinsic
factor (IF), a protein in the stomach that allows the body to absorb vitamin B-12.

Other at-risk groups include people with small intestine problems, for example,
an individual whose small intestine has been surgically shortened. They may not be able
to absorb cobalamin properly. People with Crohn’s disease are said to be at risk, but
researchers maintain that there is a lack of evidence to confirm this.

Gastritis, celiac disease, and inflammatory bowel disease may lead to a

deficiency because these conditions cause the absorption of nutrients to be reduced.
People with chronic alcoholism may lack vitamin B-12, as their bodies are also not able
to absorb nutrients efficiently.

Individuals treating diabetes with metformin are advised to monitor their levels of
vitamin B-12. Metformin might reduce the absorption of vitamin B-12. Treatment includes
vitamin B-12 injections. A vitamin B-12 injection must be administered to people that
have problems with nutrient absorption.

TOXICITY
Side effects

The side effects of taking vitamin B-12 are very limited. It is not considered to be
toxic in high quantities, and even 1000-mcg doses are not thought to be harmful.

There have been no reports of an adverse reaction to B-12 since 2001 when a
person in Germany reported rosacea as a result of a B-12 supplement. Cases of B-12-
triggered acne have also been reported.

Cyanocobalamin is an injectable form of the supplement that contains traces of

cyanide, a poisonous substance. As a result, some concerns have been raised about its

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possible effects. However, many fruits and vegetables contain these traces, and it is not
considered a significant health risk. This type of supplement is not, however,
recommended for people with kidney disease.

FOOD SOURCES
Vitamin B-12 can be found naturally in animal products, such as fish, meat, eggs,
and dairy products. It does not typically occur in plant foods.
Good dietary sources of vitamin B-12 include:

• beef • fish, especially haddock and tuna

• pork • dairy products, such as milk,
• ham cheese, and yogurt
• poultry • some nutritional yeast products
• lamb • eggs

Some types of soya milk and breakfast cereals are fortified with vitamin B-12.

It is always better to maintain a balanced diet and receive healthful amounts of nutrients
before active treatment is required. The symptoms of deficiency are easily avoided with
a healthful diet.

https://www.medicalnewstoday.com/articles/219822#foods

CHOLINE.

For over a hundred years, choline has been known to be a constituent of

important substances in the animal cells. It was first isolated from the bile in 1862. It
occurs in quantities larger than the usual minute levels for established vitamins in both
plant and animal cells. Choline biosynthesis is not yet proven in man. In lower animals, it
is synthesized with the amino acid serine as precursor and methionine as methyl donor
(CH3-radical supplier). Vitamin B12 and folic acid are needed as coenzymes in choline
biosynthesis. Adequate protein is therefore essential for the reactions.

The most important biological role of choline in several animal species including
man is a lipotropic agent, ex. It mobilizes fat and prevents fatty liver. Choline is needed

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for fat transport as a constituent of phospoholipids, namely: lecithin, cephalin and
sphingomyelin.

The richest food source for choline is eggyolk; other good sources are liver,
brain, kidney, heart, meats, legumes and nuts, yeast and wheat germ. The last two are
supplements or ingredients rather than common foods. There is no RDA for choline
although the average diet contains a range of 300-900 milligrams.

INOSITOL.

Known as chemical substance for many years, it was only in 1940 when some
investigators started to consider itas a vitamin. Inositol occurs in meat and meat
extractives, muscle and glandular organs, brain, legumes and nuts, fruits, vegetable and
grains. It is abundant in the diet and minimum requirements for inositol are not known.
It’s chemistry is closely similar to glucose, hence, the other name for it is “muscle sugar”.

LIPOIC ACID.

This is a sulfur-containing fatty acid that is not a true vitamin because it can be
synthesized in adequate amounts in the body. However, it is like the other vitamins as a
coenzyme factor. Together with TPP (thiamin-pyrophosphatase), lipoic acid is a
coenzyme for metabolism converting pyruvic acid to acetyl CoA. There is no set
requirement for lipoic as yet for human beings also it’s biological role is definitely known.
The concentrated source of lipoic acidare yeast and liver.

UBIQUINONE.

Also called coenzyme Q, this is lipid related to vitamin K. There are about 30
related quinones and only coenzyme Q has been observed in all cell nuclei and
microsomes. It acts as coenzyme factor in cellular respiration and enrgy metabolism.

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PARA-AMINOBENZOIC ACID (PABA): As a structural component of folic acid, PABA is
essential to humans. In certain microorganisms, PABA is a growth factor. It has been
found effective in the therapy of some rickettsial diseases (parasitic infections).

*More studies are needed to establish the essentiality of these vitamin-like factors in
human nutrition. It is not surprising if more vitamins will be added to our present list after
several decades.

CARNITINE

Carnitine is essential for the growth of mealworms. The role of carnitine in all
organisms is associated with the transfer of fatty acids from the bloodstream to active
sites of fatty acid oxidation within muscle cells. Carnitine, therefore, regulates the rate of
oxidation of these acids; this function may afford means by which a cell can rapidly shift
its metabolic patterns (e.g., from fat synthesis to fat breakdown). Synthesis of carnitine
occurs in insects and in higher animals; therefore, it is not considered a true vitamin.

ACTIVITY

STUDY QUESTIONS

1. Summarize your own information on all the vitamins categorized into water-soluble
and fat-soluble, using your own tabulation.

2. Why is there no hypervitaminosis of water-soluble vitamins. Explain your answer.

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

3. Explain each of the following-

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 a) vitamins as coenzyme factors

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

b) hematopoeies

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Referenceshttps://www.medicalnewstoday.com/articles/318724
https://www.medicalnewstoday.com/articles/318724#summary
https://www.britannica.com/science/vitamin/Vitamin-like-substances

MINERALS: THE TRACE ELEMENTS

These are group fof minerals which are needed by the body in ninute amounts to
perform certain vital functions. They are sometimes called trace minerals. Ordinarily
these kinerals can be supplied by an average mixed diet since the amounts needed are
very small. On the other hand, when the intake levels only slightly exceed the normal
functioning levels, toxicity results.

1. IRON

FUNCTIONS:
1. As a constituent of hemoglobin and myoglobin iron has an important role to play as a
carrier of oxygen needed for cellular respiration. It also is responsible for carrying carbon

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dioxide away from the lungs to the cells, where it is released as more oxygen is picked
up.

2. It is necessary for hemoglobin formation. The red blood cells or erythrocytes which
contain the hemoglobin are formed in the bone marrow, the process called
hemopoiesis. The red cells which have a lifespan of 120 days are continuously
undergoing destruction and replacement. In the course of their destruction, the hematin
of the hemoglobin is split into an iron compound, bilirubin and other pigments which are
carried to the liver and secreted by the bile. Iron released by normal blood cell
destruction can be reused again without loss.

FOOD SOURCES:

Iron is a nutrient needed for many functions of the body, such as making
haemoglobin in red blood cells, which transports oxygen from the lungs throughout the
body. While it can store iron, your body can't make it. The only way to get iron is from
food.

Iron-rich foods

There are 2 types of iron in food: haem and non-haem. Haem iron, found in
meat, poultry and seafood, is absorbed more effectively than non-haem iron, which is
found in eggs and plant foods.

Animal-based sources of iron

Top animal-based sources of iron include:

• liver (chicken, lamb) • lamb

• sardines • egg (chicken)
• kangaroo • duck
• beef • canned salmon

Plant-based sources of iron

Plant foods containing non-haem iron can still provide an adequate amount of iron for
the body. Good sources include:

• legumes (such as lentils, beans and chickpeas)

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 • firm tofu
• tempeh
• pumpkin seeds (pepitas) and sunflower seeds
• nuts, especially cashews and almonds
• wholegrain cereals such as oats or muesli, wholemeal bread, brown rice,
amaranth and quinoa
• dried apricots
• vegetables such as kale, broccoli, spinach and green peas
• dried apricots

How much iron do I need?

Your recommended daily intake (RDI) of iron depends on your age and sex:

• Children aged 1-3 years — 9 milligrams (mg)

• Children 4-8 — 10mg
• Boys 9-13 — 8mg
• Boys 14-18 — 11mg
• Girls 9-13 — 8mg
• Girls 14-18 — 15mg
• Men (adult) — 8mg
• Women aged 19-50 — 18mg
• Women 51+ — 8mg
• Pregnant women — 27mg
• Women breastfeeding exclusively — 9-10mg

Women need more iron to replace the amount lost in blood during menstruation. Until
menopause, women need about twice as much iron as men.

Iron deficiency occurs when your iron levels are too low, which can lead to anaemia. If
you are worried you have an iron deficiency, your doctor may order some blood
tests and may suggest iron supplements.

https://www.healthdirect.gov.au/foods-high-in-iron

DEFICIENCY SYMPTOMS OF IRON

Iron deficiency anemia is a common type of anemia — a condition in which blood
lacks adequate healthy red blood cells. Red blood cells carry oxygen to the body's
tissues.

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 As the name implies, iron deficiency anemia is due to insufficient iron. Without
enough iron, your body can't produce enough of a substance in red blood cells that
enables them to carry oxygen (hemoglobin). As a result, iron deficiency anemia may
leave you tired and short of breath.

You can usually correct iron deficiency anemia with iron supplementation.
Sometimes additional tests or treatments for iron deficiency anemia are necessary,
especially if your doctor suspects that you're bleeding internally.

SYMPTOMS

Initially, iron deficiency anemia can be so mild that it goes unnoticed. But as the
body becomes more deficient in iron and anemia worsens, the signs and symptoms
intensify.

IRON DEFICIENCY ANEMIA SIGNS AND SYMPTOMS MAY INCLUDE:

• Extreme fatigue
• Weakness
• Pale skin
• Chest pain, fast heartbeat or shortness of breath
• Headache, dizziness or lightheadedness
• Cold hands and feet
• Inflammation or soreness of your tongue
• Brittle nails
• Unusual cravings for non-nutritive substances, such as ice, dirt or starch
• Poor appetite, especially in infants and children with iron deficiency anemia

When to see a doctor

If you or your child develops signs and symptoms that suggest iron deficiency anemia,
see your doctor. Iron deficiency anemia isn't something to self-diagnose or treat. So see
your doctor for a diagnosis rather than taking iron supplements on your own.
Overloading the body with iron can be dangerous because excess iron accumulation can
damage your liver and cause other complications.

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https://www.mayoclinic.org/diseases-conditions/iron-deficiency-anemia/symptoms-
causes/syc-20355034

WHAT IS IRON POISONING?

Iron poisoning was once the leading cause of death from medication
overdose among children under age 6 in the United States. Iron poisoning is now on the
decline. However, it remains a serious health risk for children.

The problem isn’t usually too much iron in the diet. Instead, the culprits tend to be
iron supplements or multivitamins that look like candy. They can be very tempting to
small children.

A healthy amount of iron consumption is critical to the function of the brain,

muscles, and red blood cells. But the body can’t metabolize high doses of iron. Excess
iron can start to irritate the lining of your gastrointestinal tract. From there, some serious
complications will follow.

Symptoms of iron poisoning

Among the initial signs of iron poisoning are nausea and abdominal pain.
Vomiting blood can also occur. Iron poisoning can also lead to diarrhea and dehydration.
Sometimes, too much iron causes stools to turn black and bloody. These symptoms
usually develop within six hours. After that, symptoms may appear to improve for a day
or so.

After those early symptoms, other serious complications can develop within 48 hours
after the iron overdose, such as:

• dizziness
• low blood pressure and a fast or weak pulse
• headache
• fever

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 • shortness of breath and fluid in the lungs
• a grayish or bluish color in the skin
• jaundice (yellowing of the skin due to liver damage)
• seizures

https://www.healthline.com/health/iron-poisoning#outlook

2. ZINC is naturally found in a wide variety of both plant and animal foods.

Foods that don’t naturally contain this mineral, such as breakfast cereals, snack
bars and baking flour, are often fortified with synthetic forms of zinc.

You can also take zinc supplements or multi-nutrient supplements that provide
zinc. Because of its role in immune function, zinc is likewise added to some nasal
sprays, lozenges and other natural cold treatments.

Zinc is considered an essential nutrient, meaning that your body can’t produce or
store it. For this reason, you must get a constant supply through your diet.

Zinc is required for numerous processes in your body, including (1):

• Gene expression • Wound healing

• Enzymatic reactions • Growth and development
• Immune function
• Protein synthesis
• DNA synthesis
FUNCTIONS

1. Boosts Your Immune System

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 Zinc helps keep your immune system strong.Because it is necessary for immune
cell function and cell signaling, a deficiency can lead to a weakened immune
response.Zinc supplements stimulate particular immune cells and reduce oxidative
stress.For example, a review of seven studies demonstrated that 80–92 mg per day of
zinc may reduce the length of the common cold by up to 33% .What’s more, zinc
supplements significantly reduce the risk of infections and promote immune response in
older adults .

2. Accelerates Wound Healing

Zinc is commonly used in hospitals as a treatment for burns, certain ulcers and
other skin injuries .Because this mineral plays critical roles in collagen synthesis,
immune function and inflammatory response, it is necessary for proper healing. In fact,
your skin holds a relatively high amount — about 5% — of your body's zinc content.
While a zinc deficiency can slow wound healing, supplementing with zinc can speed
recovery in people with wounds.

For example, in a 12-week study in 60 people with diabetic foot ulcers, those
treated with 200 mg of zinc per day experienced significant reductions in ulcer size
compared to a placebo group.

3. May Reduce the Risk of Certain Age-Related Diseases

Zinc may significantly reduce your risk of age-related diseases, such as

pneumonia, infection and age-related macular degeneration (AMD).Zinc may relieve
oxidative stress and improve immune response by boosting the activity of T-cells and
natural killer cells, which help protect your body from infection .Older adults who
supplement with zinc experience improved influenza vaccination response, reduced risk
of pneumonia and boosted mental performance.

In fact, one study determined that 45 mg per day of zinc may decrease infection
rates in older adults by nearly 66%. Additionally, in a large study in over 4,200 people,
taking daily antioxidant supplements — vitamin E, vitamin C and beta-carotene — plus
80 mg of zinc decreased vision loss and significantly reduced the risk of advanced AMD.

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 4. May Help Treat Acne

Acne is a common skin disease that is estimated to affect up to 9.4% of the

global population.Acne is driven by obstruction of oil-producing glands, bacteria and
inflammation.Studies suggest that both topical and oral zinc treatments can effectively
treat acne by reducing inflammation, inhibiting the growth of P. acnes bacteria and
suppressing oily gland activity.People with acne tend to have lower levels of zinc.
Therefore, supplements may help reduce symptoms.

5. Decreases Inflammation

Zinc decreases oxidative stress and reduces levels of certain inflammatory

proteins in your body .

Oxidative stress leads to chronic inflammation, a contributing factor in a wide

array of chronic illnesses, such as heart disease, cancer and mental decline. In a study
in 40 older adults, those who took 45 mg of zinc per day experienced greater reductions
in inflammatory markers than a placebo group.

FOOD SOURCES

Many animal and plant foods are naturally rich in zinc, making it easy for most people to
consume adequate amounts.

Foods highest in zinc include :

• Shellfish: Oysters, crab, mussels, lobster and clams

• Meat: Beef, pork, lamb and bison
• Poultry: Turkey and chicken
• Fish: Flounder, sardines, salmon and sole
• Legumes: Chickpeas, lentils, black beans, kidney beans, etc.
• Nuts and seeds: Pumpkin seeds, cashews, hemp seeds, etc.
• Dairy products: Milk, yogurt and cheese
• Eggs
• Whole grains: Oats, quinoa, brown rice, etc.

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 • Certain vegetables: Mushrooms, kale, peas, asparagus and beet greens
Animal products, such as meat and shellfish, contain high amounts of zinc in a form that
your body easily absorbs.

Keep in mind that zinc found in plant-based sources like legumes and whole
grains is absorbed less efficiently because of other plant compounds that inhibit
absorption.

While many foods are naturally high in zinc, certain foods — such as ready-to-eat
breakfast cereals, snack bars and baking flours — are fortified with zinc (

DEFICIENCY SYMPTOMS

Although severe zinc deficiency is rare, it can occur in people with rare genetic
mutations, breastfeeding infants whose mothers don’t have enough zinc, people with
alcohol addictions and anyone taking certain immune-suppressing medications.

Symptoms of severe zinc deficiency include impaired growth and development,

delayed sexual maturity, skin rashes, chronic diarrhea, impaired wound healing and
behavioral issues.

Milder forms of zinc deficiency are more common, especially in children in

developing countries where diets are often lacking in important nutrients. It is estimated
that around 2 billion people worldwide are deficient in zinc due to inadequate dietary
intake. Since zinc deficiency impairs your immune system — increasing the chances of
infection — zinc deficiency is thought to cause over 450,000 deaths in children under 5
every year.

Those at risk of zinc deficiency include:

• People with gastrointestinal diseases like Crohn’s disease

• Vegetarians and vegans
• Pregnant and breastfeeding women
• Older infants who are exclusively breastfed
• People with sickle cell anemia

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 • People who are malnourished, including those with anorexia or bulimia
• People with chronic kidney disease
• Those who abuse alcohol
Symptoms of mild zinc deficiency include diarrhea, decreased immunity, thinning
hair, decreased appetite, mood disturbances, dry skin, fertility issues and impaired
wound healing.

Zinc deficiency is difficult to detect using laboratory tests due to your body’s tight
control over zinc levels. Thus, you may still be deficient even if tests indicate normal
levels.

Doctors consider other risk factors — such as poor dietary intake and genetics —
alongside blood results when determining whether you need supplements.

Toxicity and Dosage Recommendations

Just as a deficiency in zinc can cause health complications, excessive intake can
also lead to negative side effects.

The most common cause of zinc toxicity is too much supplemental zinc, which
can cause both acute and chronic symptoms.

Symptoms of toxicity include:

• Nausea and vomiting

• Loss of appetite
• Diarrhea
• Abdominal cramps
• Headaches
• Reduced immune function
• Decreased “good” HDL cholesterol levels
Ingesting too much zinc can also cause deficiencies in other nutrients.

For example, chronic high zinc ingestion can interfere with your absorption of
copper and iron.

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 Reductions in copper levels have even been reported in people consuming only
moderately high doses of zinc — 60 mg per day — for 10 weeks.

Recommended Dosages

In order to avoid overconsumption, stay away from high-dose zinc supplements

unless recommended by a doctor.

The recommended daily intake (RDI) is 11 mg for adult men and 8 mg for adult women.

Pregnant and breastfeeding women should consume 11 and 12 mg per day, respectively
.Unless a medical condition is hindering absorption, you should easily reach the RDI for
zinc through diet alone.

The tolerable upper level for zinc is 40 mg per day. However, this does not apply to
people with zinc deficiencies, who may need to take high-dose supplements.

If you take supplements, choose absorbable forms such as zinc citrate or zinc gluconate.
Stay away from zinc oxide, which is poorly absorbed.

https://www.healthline.com/nutrition/zinc#bottom-line

3. SELENIUM is an essential trace mineral that is important for many bodily processes,
including cognitive function, a healthy immune system, and fertility in both men and
women.

It contributes to thyroid hormone metabolism and DNA synthesis, and it helps protect
against oxidative damage and infection, according to the United States Office of Dietary
Supplements. It is present in human tissue, mostly in skeletal muscle.

Dietary sources are varied. They include Brazil nuts, seafood, and meats.

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The amount of selenium in food often depends on the selenium concentration of the soil
and water where farmers grew or raised the food.

FAST FACTS ON SELENIUM

Here are some key points about selenium. More detail is in the main article.

• Selenium is a mineral that plays a role in many bodily functions.

• It may protect against cancer, thyroid problems, cognitive decline, and asthma,
but more research is needed.

• Brazil nuts, some fish, brown rice, and eggs are good sources.

• The best source of nutrients is food. Any supplement use should first be
discussed with a doctor.

Possible health benefits

Selenium may help prevent cardiovascular disease, thyroid problems, cognitive decline,
which means disorders related to thinking, cancer, and others.

Cardiovascular disease: According to the Office for Dietary Supplements,

selenoproteins can protect against cardiovascular disease, because they prevent the
oxidative modification of lipids, or fats, in the body.

This reduces inflammation and prevents the buildup of platelets. However, clinical
evidence does not support the use of selenium supplements for this purpose.

Cognitive decline: Selenium’s antioxidant activity may help reduce the risk of cognitive,
or mental, decline, as people get older.

Evidence from studies is mixed, however, and selenium supplements are not yet
prescribed for people at risk of diseases such as Alzheimer’s, although it may have a
role in prevention that is still under investigation.

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Thyroid disorders: Selenium has an important role in producing and metabolizing
thyroid hormone.

There is some evidence that women with higher selenium levels have fewer thyroid
problems, but this has not been proven for men, and other studies have produced mixed
results.

More studies are under way to decide whether selenium supplements might support
thyroid health.

Cancer: The role played by selenium in DNA repair and other functions may mean that
is can help prevent cancer. However, studies have produced mixed results.

The U.S. Food and Drug Administration (FDA) concluded in 2003:

“Some scientific evidence suggests that consumption of selenium may reduce the risk of
certain forms of cancer.”

Studies have suggested that selenium may also help to:

• prevent HIV from progressing to AIDS

• reduce the risk of miscarriage

• protect against asthma

There has been some investigation into whether a woman’s selenium levels during
pregnancy might predict her child’s risk of asthma.

While selenium is clearly element for many aspects of human health, there is too little
evidence to indicate that supplements could be of use in preventing these conditions.

Selenium is an important mineral. It’s necessary for many processes, such as:
• thyroid hormone metabolism
• DNA synthesis

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 • reproduction
• protection from infection

Selenium deficiency refers to not having enough selenium in your system. This can
cause several health problems.

The amount of selenium in food sources is largely determined by the quality of the soil
used to grow them. Rainfall, evaporation, and pH levels all affect selenium concentration
in soil. This makes selenium deficiency more common in certain parts of the world. In the
United States, selenium deficiency is rare. However, an estimated 1 billion people
around the world are affected by selenium deficiency, according to a 2017 review.

That same review predicts that the effects of climate change will gradually decrease soil
selenium concentrations in many parts of the world, including the Southwestern United
States.

Selenium deficiency can produce a range of symptoms. The most common ones are:

• infertility in men and women

• muscle weakness
• fatigue
• mental fog
• hair loss
• weakened immune system

***The upper limit per day for selenium is 400 mcg for adults.

Selenium toxicity due to overdose is rare, especially from dietary sources, but an
overdose of highly concentrated supplements could have negative effects.

These may include:

a garlic-like smell on the breath and a metallic taste in the mouth

brittle nails
mottled or decaying teeth

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 gastrointestinal problems such as nausea
neurological abnormalities
fatigue and irritability
skins lesions and rashes
hair loss

In extreme cases, it could lead to kidney failure, heart failure, and death.

Selenium supplements can also interact with some medications, including cisplatin,
a chemotherapy drug. The use of this drug can reduce selenium levels in the body.

FOODS SOURCES

Selenium is most likely to be found in whole grains and animal produce, rather than
fresh fruit and vegetables.

The following foods are a good source:

Brazil nuts are rich in selenium.

• Brazil nuts: 1 ounce provides 544 micrograms (mcg), or 777 percent of the daily
recommended value (DV)

• Tuna: 3 ounces of yellowfin tuna, cooked dry, contains 92 mcg, or 131 percent of
DV

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 • Halibut, baked: 3 ounces, cooked dry, contains 47 mcg, or 68 percent of DV

• Brown rice, cooked: 1 cup contains 19 mcg

• Egg: One large egg contains 15 mcg

• Bread, white: 1 slice provides 10 mcg

The amount of selenium in grains and grain-based foods depends on the soil content
where the grains grew.

References:
https://www.medicalnewstoday.com/articles/287842#possible_health_risks
https://www.healthline.com/health/selenium-deficiency#diagnosis

4. MANGANESE
Only about 10 mg of manganese is present in the body. It is concentrated in the
liver and kidneys, with small amounts in other tissues such as the retina, bones and
salivary glands.

Manganese serves as an activator of a number of metabolic reactions. It acts as

a catalyst of a number of enzyme as necessary in glucose and fat metabolism, plays a
role in the formation of urea as part of the enzyme arginase and it increases the storage
of thiamin.

Absorption is through the intestine but amount absorbed is only minimal. Any
portion rejected by the intestine is excreted in the feces. The small quantity that is
absorbed in the small intestine is transported loosely bound with protein, to the tissues
for storage for utilization. The amount utilized by the tissues is ultimately carried to the
bile which returns it into the intestine where it is excreted with the other body wastes.

FOOD SOURCES AND REQUIREMENT

Of the food sources, nuts, whole grain cereals, dried legumes and tea are
considered to be rich sources. Moderate sources include green leafy vegetables, dried
fruits, fresh fruits, and non-leafy vegetables. Animal foods are poor sources. Although

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there is no requirement established yet, a diet with 4 mg manganese is aconsidered
adequate for this nutrient.

EFFECTS OF DEFICIENCY AND EXCESS

No incidence of manganese deficiency or toxicity caused by diet has yet been
observed in humans. However, in a study conducted by L. Hurley of University of
California, she raised the possibility that a lack ofmanganese might be related to the
malformation and stunted bones and ataxia noted in rats and mice when deprived with
manganese during pregnancy.

Diets containing 1000 to 2000 ppm of manganese had a depressing effect on

iron metabolism. Workers exposed to manganese dust manifested asthenia, apathy,
anorexia, headache, muscle cramps and speech disturnbances, similar to that of
Parkinsons disease.

5. COPPER
All tissues in the body vcontains traces of copper. Larger amounts are found in
the liver, brain, heart and kidney. In the serum, about 5% is bound with albumin, and
about 95% is bound with an a-globulin as the copper-binding protein ceruloplasmin.

FUNCTION
Copper is closely associated with iron in functions. It is essential in the formation
of hemoglobin. A copper-containing protein erythrucupein is present in the red blood
cells. Copper is valuable catalyst in oxidation-reduction mecahnisms of living cells as
well as a constituent of several of the oxidative enzymes for amino acids. Copper seems
to promote absorption of iron from the gastro intestinal tract and the transportation of
such from the tissues to the plasma.
Copper also helps to maintain the integrity of the myelin sheat surrounding the
nerve fibers, plays an unexplained role in bone formation and is part of tyrosinase which
is involved in the formation of melanin pigment of hair and skin through it’s role in
tyrosine metabolism. In conjunction with vitamin c, copper maintains the activity of the

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enzymes involved in the synthesis of the protein elastin in the wall of the aorta and is
possibly necessary for collagen metabolism.

FOOD SOURCES AND REQUIREMENT

Studies indicate that an adult will maintain copper balance on an intake of about
2 mg per day. A mixed diet provides about 2-5 mgso that copper will be amply supplied.
Food sources of copper provoding more than 8 ppm(parts per million or can be
expressed as milligram per liter mg/L) are organ meats, shellfish especially oysters,
nuts, cocoa, cherries, mushroom, and whole grain cereals. Moderate sources are leafy
vegetables, eggs, muscle meat, fish, poultry, beans, peas, fresh fruits and refined
cereals. Milk, cheese, butter, sugar, are poor sources.

6. IODINE

FUNCTION
- The most important of the iodine is the is it’s participation in the synthesis of thyroxine,
a hormone in the thyroid gland.
- Thyroxine regulates the rate of metabolism.
- It stimulates cell oxidation by increasing oxygen uptake and reaction rates of enzyme
systems handling glucose.
- If the secretion is deficient, the basal metabolism of the individual falls and the
circulation is reduced causing the slowing down of the activities.
- When energy needs increase, it is posiible that protein is used as source of calories
leading to increased loss of nitrogen.

REQUIREMENTS

To maintain desirable tissue levels of iodine, the adult body’s minimal

requirement is 50 to 75 mcg/day; therefore, to provide an extra margin of safety, the
RDA is 150 mcg/day for all people who are 14 years of age and older.
FOOD SOURCES
The iodine content of the plant and animals is determined to some extent by the
soil on which they are grown. As most soils contain very little iodine, most foodstuffs are
poor sources. The only rich sources of iodine are sea foods. If seafoods like oysters and

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shrimps are included in the diet at least three times a week, it might be sufficient to
prevent a deficiency. Seaweeds Are abundant in some regions in the Philippines contain
considerable amounts of iodine.
The Department of Health together with the other agencies instituted the
iodization of salt for prevention of goiter and for its treatment at least in the early stages.

DEFICIENCY
A deficiency of iodine is the primary cause of goiter. It may also be caused by
factors which interfere with the utlilization of iodine by the thyroid gland. In goiter, the
thyrioid gland enlarge to compensate for the lack of iodine needed for it’s normal
functioning.
The FNRI surveys revealed a deficient intake of iodine in the Filipino diet which
was even precipitated by a lack of Vitamin A in the diet. Observations reported in the
literature showed that vitamin A deficiency may induce goiter when the iodine intake is in
the lower normal range.

1. Goiter.
Goiter is characterized by an enlargement of the thyroid gland (Figure 8-7).
When the thyroid gland is starved for iodine, it cannot produce a normal amount of T4.
Because of a low blood T4 concentration, the pituitary gland continues to release more
TSH.
Large amounts of TSH overstimulate the nonproductive thyroid gland, thereby
causing its size to increase greatly. An iodine-starved thyroid gland may weigh 0.45 to
0.67 kg (1 to 1.5 lb) or more. Although the thyroid is one of the larger endocrine glands,
it normally only weighs 10 to 20 g in an adult.

2. Cretinism and congenital hypothyroidism.

Cretinism is a congenital disorder resulting from insufficient thyroid hormone to
the fetus during gestation. One reason for unavailable thyroid hormones is maternal
iodine deficiency throughout pregnancy. Cretinism is characterized by physical
deformity, dwarfism, mental retardation, and auditory disorders. During pregnancy, the
mother’s need for iodine takes precedence over the iodine needs of the developing
fetus.

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 Thus, the fetus suffers from iodine deficiency and continues to do so after birth.
The physical and mental development of these children is severely impeded and
irreversible.

3. Congenital hypothyroidism is a disorder resulting from insufficient thyroid hormone

during gestation attributable to genetic defects in the metabolic pathways
of the thyroid hormones. The severity of defectscan vary greatly but early treatment can
prevent further damage (see the Cultural Considerations box, “Hypermetabolism and
Hypometabolism: What are they and who is at risk?” in Chapter 6).

4. Impaired mental and physical development.

Studying long-term effects of nutrient deficiencies is difficult. When a person or a
population is deficient in one nutrient, they are likely deficient in other nutrients as well.
In addition, there are usually other contributing factors that influence the results of the
studies (e.g., sociodemographic, ethnic, lifestyle factors). That being said, there are
studies indicating that children born to women with even mild iodine deficiency during
pregnancy have a significant reduction in their intelligence quotient.27 Long-term severe
iodine deficiency during childhood and adolescence appears to delay growth and the
onset of puberty, both of which may be corrected with normalization of dietary iodine
levels.

5. Hypothyroidism.
Hypothyroidism occurs when a poorly functioning thyroid gland does not make
enough T4, thereby greatly reducing the basal metabolic rate. There are many causes of
hypothyroidism, including both iodine deficiency and iodine toxicity.
Iodine deficiency is the most common cause of hypothyroidism worldwide. Symptoms
include thin, coarse hair; dry skin; poor cold tolerance; weight gain; and a
low, husky voice.29 In severe and rare cases, hypothyroidism can advance to
myxedema coma and death.

TOXICITY

Excess iodine supplementation may lead to thyrotoxicosis or iodine-induced

hyperthyroidism. Individuals with underlying thyroid dysfunction are more

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susceptible to iodine toxicity from chronic or acute doses than are individuals without
existing thyroid dysfunction. Iodine toxicity may present as iodine excess goiter,
autoimmune thyroiditis, hypothyroidism, elevated TSH, and ocular damage.

Although the risk of iodine toxicity exists, the continued use of iodized salt is still
recommended and widely practiced in several countries, including the
United States. The risk for iodine deficiency far outweighs the small potential for iodine
toxicity. The UL of iodine in healthy adults is 1100 mcg/day.

ACTIVITY

1. Summarize your own information on all the MINERALS using your own tabulation.

MINERAL FUNCTION DEFICIENCY EXCESS SOURCES

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2. Why does prolonged diarrhea lead to potassium depletion and what are the
consequences?

3. In the early 1900s the mountainous regions of the Cordillera has an increase cases of
goiter. What was the cause of this? How can it be eliminated?

8. You are working with a 37-year-old man with gradually increasing blood pressure who
has been advised to increase his intakes of potassium and calcium and lower his intake
of sodium. When his work takes him on the road, he has lunch at a fast-food restaurant;
on other days he takes a sandwich from home to eat at his desk. Develop a menu for a
fast-food lunch and a packed lunch that will provide 33% of the DRI for potassium and
calcium and no more than 33% of the UL for sodium. (He has access to a refrigerator at
his worksite for storage of his packed lunch.)

LESSON 7
WATER
1. Chemical & physical properties of water
2. Distribution of water in the body
3. Functions of water
4. Recommended intake
5. Deficiency/ Dehydration
6. Toxicity/ Over hydration

WEEK TOPIC LEARNING OUTCOMES ACTIVITIES

8
1. Study
Upon completion of this chapter, you will be able to questions
1. Explain why water is important in the body. 2. Speech
Day 15
2. State the sources of water in the body and the routes of
water loss from the body.

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 Water is defined as an essential nutrient because it is required in amounts that
exceed the body's ability to produce it. All biochemical reactions occur in water. It fills the
spaces in and between cells and helps form structures of large molecules such as
protein and glycogen.

The atomic structure of a water molecule consists of two hydrogen (H) atoms
joined to one oxygen (O) atom. The unique way in which the hydrogen atoms are
attached to the oxygen atom causes one side of the molecule to have a negative charge
and the area in the opposite direction to have a positive charge. The resulting polarity of
charge causes molecules of water to be attracted to each other forming strong molecular
bonds.

Water has several other unique physical properties. These properties are:

• Water has a high specific heat. Specific heat is the amount of energy required to
change the temperature of a substance. Because water has a high specific heat,
it can absorb large amounts of heat energy before it begins to get hot. It also
means that water releases heat energy slowly when situations cause it to cool.
Water's high specific heat allows allows for the moderation of the Earth's climate
and helps organisms regulate their body temperature more effectively.
• Water in a pure state has a neutral pH. As a result, pure water is
neither acidic nor basic. Water changes its pH when substances are dissolved
in it. Rain has a naturally acidic pH of about 5.6 because it contains natural
derived carbon dioxide and sulfur dioxide.
• Water conducts heat more easily than any liquid except mercury. This fact
causes large bodies of liquid water like lakes and oceans to have essentially a
uniform vertical temperature profile.
• Water exists as a liquid over an important range of temperature from 0 - 100°
Celsius. This range allows water to remain as a liquid in most places on the
Earth.
• Liquid water is a universal solvent. It is able to dissolve a large number of
different chemical compounds. This feature also enables water to carry solvent
nutrients in runoff, infiltration, groundwater flow, and living organisms.

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 • Water has a high surface tension (Figure 4.3). In other words, water is
adhesive and elastic, and tends to aggregate in drops rather than spread out
over a surface as a thin film. This phenomenon also causes water to stick to the
sides of vertical structures despite gravity's downward pull. Water's high surface
tension allows for the formation of water droplets and waves, allows plants to
move water (and dissolved nutrients) from their roots to their leaves, and allows
the movement of blood through tiny vessels in the bodies of some animals.

• Water is the only substance on Earth that exists in all three physical states of
matter: solid, liquid, and gas. Incorporated in the changes of state are massive amounts
of heat exchange. This feature plays an important role in the redistribution of heat
energy in the Earth's atmosphere. In terms of heat being transferred into the
atmosphere, approximately 3/4's of this process is accomplished by the evaporation and
condensation of water.

• The freezing of water causes it to expand. When water freezes it expands rapidly
adding about 9 % by volume. Fresh water has a maximum density at around 4° Celsius.
Water is the only substance on this planet that does this.

Distribution of water in the body

It constitutes about 60-70% of the total body weight so that a body deprived of
water by as much as 10% will already result in illness and a 20% loss of body water may
cause death. It is next to oxygen in importance for the maintenance of life.

Water found in the body totals 45 liters in a normal adult. Two thirds of this (30
liters) is found inside or within the cells (intracellular fluids). One third (15 liters) is found
outside of the cells (ex. Extracellular fluids). These two compartments of the body are
separated by a semi permeable membrane.

Water outside the cell is found within the blood vessels and the lymphatic
(intravascular water). It is present in every tissue but the amounts vary considerably.

FUNCTIONS:

It’s common to hear that water is essential for your health.

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This substance makes up a majority of your body weight and is involved in many
important functions, including:

- flushing out waste from your body

- regulating body temperature
- helping your brain function
You get most of your water from drinking beverages, but food also contributes a small
amount to your daily water intake.

Read on to learn more ways water can help improve your well-being.

1. It helps create saliva

Water is a main component of saliva. Saliva also includes small amounts of
electrolytes, mucus, and enzymes. It’s essential for breaking down solid food and
keeping your mouth healthy.

Your body generally produces enough saliva with regular fluid intake. However,
your saliva production may decrease as a result of age or certain medications or
therapies.
If your mouth is drier than usual and increasing your water intake isn’t helping, see your
doctor.

2. It regulates your body temperature

Staying hydrated is crucial to maintaining your body temperature. Your body
loses water through sweat during physical activity and in hot environments.

Your sweat keeps your body cool, but your body temperature will rise if you don’t
replenish the water you lose. That’s because your body loses electrolytes and plasma
when it’s dehydrated.
If you’re sweating more than usual, make sure you drink plenty of water to avoid
dehydration.

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3. It protects your tissues, spinal cord, and joints
Water consumption helps lubricate and cushion your joints, spinal cord, and
tissues. This will help you enjoy physical activity and lessen discomfort caused by
conditions like arthritis.

4. It helps excrete waste through perspiration, urination, and defecation

Your body uses water to sweat, urinate, and have bowel movements.
Sweat regulates body temperature when you’re exercising or in warm temperatures. You
need water to replenish the lost fluid from sweat.

You also need enough water in your system to have healthy stool and avoid
constipation. Your kidneys are also important for filtering out waste through urination.
Adequate water intake helps your kidneys work more efficiently and helps to prevent
kidney stones.

5. It helps maximize physical performance

Drinking plenty of water during physical activity is essential. Athletes may
perspire up to 6 to 10 percent Trusted Source of body weight during physical activity.

Hydration also affects your strength, power, and endurance. You may be more
susceptible to the effects of dehydration if you’re participating in endurance training or
high-intensity sports such as basketball.

Negative effects of exercise in the heat without enough water can include serious
medical conditions, like decreased blood pressure and hyperthermia. Extreme
dehydration can cause seizures and even death.

6. It helps prevent constipation

Eating fiber isn’t the only way to prevent constipation. It’s also important to
maintain your water intake so your bowel movements contain enough water.
If you don’t consume enough water, magnesium, and fiber, you may be more likely to
experience constipation.
If you’re already constipated, you may find that drinking carbonated water Trusted
Source as well as plain water can help ease your symptoms.

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7. It aids in digestion
Contrary to what some believe, experts confirm drinking water before, during,
and after a meal will help your body break down the food you eat more easily. This will
help you digest food more effectively and get the most out of your meals.

Research shows Trusted Source the body adapts to changes in the consistency
of food and stomach contents, whether more solid or more liquid.
8. It helps with nutrient absorption
In addition to helping with food breakdown, water also helps dissolve vitamins,
minerals, and other nutrients from your food. It then delivers these vitamin components
to the rest of your body for use.

9. It helps you lose weight

Studies have linked body fat and weight loss with drinking water in both
overweight girlsTrusted Source and women. Drinking more water while dieting and
exercising may just help you lose extra pounds.

10. It improves blood oxygen circulation

Water carries helpful nutrients and oxygen to your entire body. Reaching your
daily water intake will improve your circulation and have a positive impact on your overall
health.

11. It helps fight off illness

Drinking enough water can help prevent certain medical conditions Trusted Source.
These include:
• constipation
• kidney stones
• exercise-induced asthma
• urinary tract infection
• hypertension
Water also helps you absorb important vitamins, minerals, and nutrients from your food,
which will increase your chances of staying healthy.

12. It helps boost energy

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 Drinking water may activate your metabolism. A boost in metabolism has been
associated with a positive impact on energy level.
One study found that drinking 500 milliliters of water boosted the metabolic rate by 30
percent in both men and women. These effects appeared to last over an hour.

13. It aids in cognitive function

Proper hydration is key to staying in tip-top cognitive shape. Research Trusted

Source indicates that not drinking enough water can negatively impact your focus,
alertness, and short-term memory.

14. It helps improve mood

Not getting enough water can also affect your mood. Dehydration may result in
fatigue and confusion as well as anxiety.

15. It helps keep skin bright

Adequate water intake will help keep your skin hydrated and may promote
collagen production. However, water intake alone isn’t enough to reduce the effects of
aging. This process is also connected to your genes and overall sun protection.

16. It prevents overall dehydration

Dehydration is the result of your body not having enough water. And because
water is imperative to so many bodily functions, dehydration can be very dangerous.

Severe dehydration can result in a number of severe complications, including:

• swelling in your brain
• kidney failure
• seizures

Make sure you drink enough water to make up for what’s lost through sweat, urination,
and bowel movements to avoid dehydration.

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Recommended intake

Being attentive to the amount of water you drink each day is important for optimal
health. Most people drink when they’re thirsty, which helps regulate daily water intake.

• about 15.5 cups of water (125 ounces) each day for men

• about 11.5 cups (91 ounces) daily for women

People get about 20 percent of their daily water intake from food. The rest is
dependent on drinking water and water-based beverages. So, ideally men would
consume about 100 ounces (3.0 liters) of water from beverages, and women, about 73
ounces (2.12 liters) from beverages.

You’ll have to increase your water intake if you’re exercising or living in a hotter
region to avoid dehydration. Other ways to assess hydration include your thirst and the
color of your urine. Feeling thirsty indicates your body is not receiving adequate
hydration. Urine that is dark or colored indicates dehydration. Pale or non-colored urine
typically indicates proper hydration.

FUNCTION
Water makes up more than two-thirds of the weight of the human body. Without
water, humans would die in a few days. All the cells and organs need water to function.

Water serves as a lubricant. It makes up saliva and the fluids surrounding the
joints. Water regulates the body temperature through perspiration. It also helps prevent
and relieve constipation by moving food through the intestines.

Deficiency/ Dehydration

Dehydration may be serious if the loss is about 10% of the total body body water
and fatal if the loss is from 20-22%. This is especially critical in babies. Electrolytes are
also lost with the water. In this condition, the skin becomes loose and elastic.

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 A. Toxicity/ Over hydration
Overhydration or water intoxication results when there is excessive intake of
fluids without the corresponding increase in the intake of salt. This may arise if too much
water is given intravenously or by mouth. If the cells and tissues become water-logged
due to the entrance of the accumulated water, symptoms which may include anorexia,
vomiting, convulsions, coma and even death result. Excess fluid also becomes apparent
as edema. Edema is defined as the accumulation of water in the interstitial fluids.

References:
www.kidshealth.org www.webmd.com
www.eatwell.gov.uk www.feinberg.northwestern.edu
www.transfatfree.com www.mayoclinic.com

ACTIVITY

You are asked to give a 10-minute talk on water at a meal site for older adults. Prepare
an outline of your major points and justify your choice of information to be presented.
Develop a handout or flyer (brochure) with suggestions for increasing fluid intake.

238
 NUTRITION HUNT

Name: _____________________________________

Fill in the blanks with words from the word bank. Check your answers by referring to the
“What a Body Needs” fact sheet or by doing your own research. You will find useful
information on the following websites:

ANSWER BANK

Calcium folic acid protein calories fatty acids

trans fats high-fructose corn syrup electrolytes iron

omega-3 omega-6

1. The average teenage boy should consume anywhere from 2,200 to 2,700

____________________________ each day.

2. ________________________________ is found in dairy products, fish with edible

bones and dark green vegetables.

3. ________________________________ is a mineral that helps provide oxygen to our

blood to give us more energy and muscle growth.

4. ________________________________ is found in leafy greens, fruit, cheese and

fortified cereals.

5. When used in appropriate quantities, certain healthy __________________________

can contribute to the prevention and treatment of diseases such as diabetes, heart
disease, cancer, obesity, musculo-skeletal pain or inflammatory conditions.

6. Healthy fats, including polyunsaturated fatty acids like _______________________

,are necessary for proper brain development and growth.

7. High consumption of ________________________________ is linked to obesity and

diabetes in addition to severe liver problems.

239
8. ________________________________ are proven to raise the “lousy” or “bad”
cholesterol and lower the “healthy” or “good” cholesterol in our bodies.

9. ________________________________ is used by the body to build and repair

muscle, bones, cartilage, skin and bones.

10. ________________________________ are minerals that help keep our body’s fluid
levels balanced and are necessary to help the muscles, heart and other organs work
properly.

UNIT IV
CALCULATION OF DESIRABLE BODY WEIGHT AND ENERGY NEEDS

We learned in the previous units that a calorie is the amount of energy required
to raise the temperature of 1 kg of water by 1°C. In nutrition, calories are the measure of
the amount of energy in a food or used by the body to fuel activity. Energy balance is a
function of calorie intake versus calorie output (Fig. 1).
This chapter addresses the dynamics of energy balance and how total calorie
requirements are estimated. Methods to determine healthy body weight and standards
for evaluating body weight are presented.
In preparation for computation of different therapeutic diets, it is imperative that
you as nursing students first acquire knowledge in calculating Ideal Body Weight/ DBW.
This helps you determine your nutritional needs, BMI, body fat, plan a meal, and activity
calorie assessments.

240
Figure 1: Energy Balance: Calorie intake = Calorie output

WEEK TOPIC LEARNING OUTCOME ACTIVITY

8
• Ideal Body Weight
At the end of the lesson, you will be able to: Computations
• Basal Metabolic
1. Employ the steps in calculating the nutrient rate calculation
needs of individuals and come up with a • Total Energy
menu plan based on the client’s needs. Allowance (TEA)
2. Estimate an individual’s total calorie calculation
requirements. • Review questions

Day
16

• Body mass index and classification

• Determining Ideal Body Weight/ Desired Body Weight
- Infants
➢ 1-6months

241
 ➢ 7-12months

- Children(13-18y/o)

➢ Gomez Classification

EVALUATING WEIGHT STATUS

From a health perspective, “healthy” or “desirable” weight is that which is

statistically correlated to good health. But the relationship between body weight and
good health is more complicated than simply the number on the scale. The amount of
body fat a person has and where a person’s weight is distributed also infl uence health
risks, as does the presence of certain diseases or conditions, such as type 2 diabetes
and cardiovascular disease. Table 1 summarizes the standards for evaluating ideal body
weight, body mass index, and waist circumference.

These values are relatively arbitrary because risk exists on a continuum without
absolute cutoffs.

Table 1. Evaluating weight

CALCULATION OF IDEAL BODY WEIGHT (IBW)

Determining the age in years/months

- This is used for under 5 children in monitoring their weight to be compared

with the standards. E.g. the weight / height graph for children.

• Remember: 1 month= 30 day 1 year= 12 months

242
 STEPS:

Sample A

a.) Write the date of weighing this way

Ex: Date of weighing is December 6, 2008

Year Month Date

2006 12 06

b.) Write the birthdate of the child in the same way

Ex: Birthdate is March 2, 2006

Year Month Date

2006 03 02

c.) Subtract the birthdate from the date of weighing

2008 - 12 - 06

minus 2006 – 03 - 02

2 – 09 - 04 The child is 2 years, 9 months and 4 days

d.) Multiply “years by 12”. Add this to the number of months. Disregard the
“days” column.

2-9-4: 2 year x 12 = 24 months

+ 9 months

33 months

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Sample B (Date of Weighing is smaller / lesser than Date of Birth )

Date of Weighing is smaller than birthdate

2008 11 06

- 2005 - 12 - 24

a.) Borrow 30 days (1month) from “months” column. Add to “days” column.

2008 10 36

- 2005 - 12 - 24

b.) Borrow 12 months (1year) from “years” column. Add to “months”

2007 22 36 2 years x 12= 24 months

- 2005 - 12 - 24 +10 months

2 10 12 34 months

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 UNIT IV. ACTIVITY 1

GIVEN THE EXAMPLES ABOVE, TRY WORKING ON THE FOLLOWING:

1. A female child came for weight monitoring. She said her birthday is November
05, 2010. Today is August 10, 2020. How many months is she at present?

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

2. A male baby, carried by his mother.

Date of weighing: August 10, 2020
His birthday: December 25, 2019

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

A. Determining Ideal/Desirable Body Weight (IBW/DBW)

1. INFANTS

FORMULA in computing for ideal body weight for infants

a.) 1st 6 months

DBW gm = Birthweightgm + (Age mos x 600)

b.) 7-12 months

DBW gm = Birthweightgm + (Age mos x 500)

Infant’s weight doubles at 5-6 months

Triples at 12 months

Quadruples at 24 months

3. CHILDREN

245
 a.) DBW kg = (Age in years x 2) +8

Note: at least +2 kg every year

4. ADULTS
a.) Hamwi Method

The Hamwi method is a quick and easy way to compute “ideal” body weight (IBW)
based on an adult’s height and gender. The formula is as follows:
• For women: Allow 100 pounds for the fi rst 5 ft of height
➢ Add 5 pounds for each additional inch of height
• For men: Allow 106 pounds for the fi rst 5 ft of height
➢ Add 6 pounds for each additional inch of height.

Using this formula, a 5 ft 6 in tall women would have an “ideal” weight of 130 pounds and
a man of the same height would have an “ideal” weight of 142 pounds. IBW can be
adjusted upward or downward by 10% based on estimation of a person’s frame size.
Likewise, for people who are less than 5 ft tall, 2½ pounds are subtracted for each inch
under 5 ft. Although this formula is simple to use, it does not take into account body
composition or distribution of body fat, both of which impact health risk.

b.) NDAP Formula

Males: For the 1st 5 ft, allow 112 lbs; + 4 lbs every inch above or below 5ft

Females: For the 1st 5ft, allow 106 lbs; + 4 lbs every inch above or below 5 ft

c.) Tanhausser’s Method or Brocca Index

DBW kg = Height cm – 100

*For Filipinos, deduct 10% of the difference

d.) Adopt Method – For 5ft, use 105 lbs. Plus/minus 5ft for every inch
Increase/decrease

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 e) BMI

In the clinical setting, body mass index (BMI) has replaced traditional height–
weight calculations of “ideal” or “desirable” body weight. In 2003, the U.S. Preventive
Services Task Force (USPSTF) concluded that BMI is an acceptable measure for
identifying adults with excess weight (USPSTF, 2003). Although the USPSTF recently
updated the 2003 statement on screening for obesity and overweight in adults,
screening tests were not part of its review (Moyer, 2012).

The formula to calculate BMI is weight in kilograms divided by height in meters

squared or weight in pounds divided by height in inches squared multiplied by 703.
Nomograms and tables that plot height and weight to determine BMI eliminate
complicated mathematical calculations (Table 2). Despite its widespread use as a
screening tool, BMI is not without controversy. For instance, the BMI levels that defi ne
overweight and obesity are somewhat arbitrary because the relationship between
increasing weight and risk of disease is continuous. Also, BMI does not take body
composition into account; a lean athlete may have well-developed muscle mass and little
fat tissue, yet if his BMI is high, he would fall under the designation of overweight or
obese. Conversely, an elderly person may have a normal BMI and be deemed “healthy”
despite a high amount of body fat masked by a low percentage of muscle mass.
Last, ethnic differences exist in the relationship between BMI and health risks. For
instance, because of genetic differences in body composition, the health risks of obesity
occur at a BMI lower than 30 for Asian Americans and higher than 30 for Black
Americans.
BMI = Weight kg

Height m2

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 Table 2. Body Mass Index

B. DIETARY CALCULATIONS

Total Energy Allowance (TEA) or Total Energy Requirement (TER)

- Some refer it to TEE or Total Energy Expenditure
- Estimated Energy Requirement (EER)

The principle of calculating energy requirements from total energy expenditure

(TEE) plus the energy needs for growth applies to infants and children of all ages.

ENERGY INTAKE

Calories come from carbohydrates, protein, fat, and alcohol. The total number of
calories in a food or diet can be estimated by multiplying total grams of these nutrients
by the appropriate calories per gram—namely, 4 cal/g for carbohydrates and protein, 9
cal/g for fat, and 7 cal/g for alcohol.

A less accurate but easier way to estimate calorie intake is to estimate or count
the number of servings from each food group a person consumes. Multiply the number

248
of servings by the average amount of calories in a serving and then add the calories
from each group to get an approximation of the total calories consumed. Be aware that
representative foods within each of the Exchange Lists for Diabetics food groups are
generally free of added fat or sugar (Refer to Food Exchange List on the appendix). For
instance, items like pringles, brownies, and Krispy kreme donut are not part of those
food groups. As with “counting calories,” the accuracy of “counting servings” depends on
the quality of foods consumed and accuracy of portion size estimation.

ESTIMATED ENERGY REQUIREMENTS

Similar to the EAR, the EERs are defi ned as the dietary energy intake predicted
to maintain energy balance in healthy, normal-weight individuals of a defi ned age,
gender, weight, height, and level of physical activity consistent with good health.
Exceeding the EER may produce weight gain. See Chapter 7 for more on determining
energy needs.

BMR or BASAL METABOLIC RATE (metabolism)

- is the energy (measured in calories) expended by the body at rest to maintain

normal bodily functions; or calories required to keep your body functioning at rest.

BMR is also known as your body’s metabolism; therefore, any increase to your
metabolic weight, such as exercise, will increase your BMR.

To get your BMR, simply input your height, gender, age and weight below.

Once you’ve determined your BMR, you can begin to monitor how many calories a day
you need to maintain or lose weight.

- This continual work makes up about 60-70% of the calories we use ("burn" or expend)
and includes the beating of our heart, respiration, and the maintenance of body
temperature.

- Your BMR is influenced by a number of factors, including age, weight, height, gender,
environmental temperature, dieting, and exercise habits.

249
According to several sources, the average BMR or resting metabolic rate for women is
around 1400 calories per day.

The average BMR for men is just over 1600 calories.

But just because your number is above or below the average is not an indicator of
whether or not your RMR is normal.

• Basal Metabolic Rate is the number of calories required to keep your body
functioning at rest.
- This continual work makes up about 60-70% of the calories we use ("burn" or
expend) and includes the beating of our heart, respiration, and the maintenance
of body temperature.
- Your BMR is influenced by a number of factors, including age, weight, height,
gender, environmental temperature, dieting, and exercise habits.

• BMR is also known as your body’s metabolism; therefore, any increase to your
metabolic weight, such as exercise, will increase your BMR.
• To get your BMR, simply input your height, gender, age and weight below.
• Once you’ve determined your BMR, you can begin to monitor how many calories
a day you need to maintain or lose weight.
• According to several sources, the average BMR or resting metabolic rate for
women is around 1400 calories per day.
• The average RMR for men is just over 1600 calories.
• But just because your number is above or below the average is not an indicator
of whether or not your RMR is normal.

Conditions necessary for BMR Test

To ensure accuracy:
1. the subject must be in fasting or post-absorptive state, at least 12 hours after the
meal. (The test is usually taken in the morning.)
2. the subject must be awake, lying quietly, free from physical fatigue, nervousness or
tension as this causes an increase in heat production.

250
3. the environmental temperature should be between 20-25°C so that the subject can
maintain his body temperature.

Values obtained in this test which are within the plus or minus 10% are still considered
normal.

I. A simple method for the calculation of the BMR is to use the rule of thumb 1 kcal per
kg per hour for adult male and 0.9 kcal per kg per hour for adult female. So an individual
whose IBW is 50 kg has a basal metabolic energy need of 1200 kcal per day (50 x 1 kcal
x 24 hrs). This value however may not be applicable for obese or lean individuals.

Ex. Male 75 kg
= 1 kcal x 75 x 24
= 1800 kcal

Female 65 kg
= .9 kcal x 65 x 24
= 1404 kcal

Factors that affect the Basal Metabolic Rate (BMR)

1. Surface area -The greater the body surface area or skin area, the greater the amount
of heat loss will be, and in turn, the greater the necessary heat produced by the body.
Muscle tissue requires more O2, than does adipose tissue.

2 Sex -Women, in general, have a metabolism of about 5 to 10% lower than men even
when they are of the same weight and height. Women have a little more fat and less
muscular development than men.

3. Age - The metabolic rate is highest during the periods of rapid growth, chiefly during
the first and second years and reaches a lesser peak through the ages of puberty and
adolescence in both sexes. The BMR declines slowly with increasing age to lower
muscle tone from lessened activity.

251
4. Body composition - A large proportion of inactive adipose tissue lowers the BMR.
Athletes with great muscular development show about 5% increase in basal metabolism
over non-athletic individuals.

5. State of nutrition - A decrease in mass of active tissue like in undernourishment or

starvation causes a metabolism often as much as 50% below normal.

6. Sleep -During sleep, the metabolic rate falls approximately 10 to 15% below that of
waking levels. This is due to muscular relaxation and decreased activity of the
sympathetic nervous system.

7. Endocrine glands - The secretion of the endocrine glands are the principal regulators
of the metabolic rate. The male sex hormones increase the BMR about 10 to 15% and
the female sex hormones a little less.

8. Fever - It increases the BMR about 7% for each degree rise in the body temperature
above 98.6°F.

ENERGY BALANCE IN HEALTH PROMOTION

The state of energy balance is the relationship between the amount of calories
consumed and the amount of calories expended. As illustrated in Figure 7.3, when
calorie intake and output are approximately the same over time, body weight is stable. A
“positive” energy balance occurs when calorie intake exceeds calorie output, whether
the imbalance is caused by overeating, low activity, or both. Over time, the calories
consumed in excess of need contribute to weight gain. Because a pound of body fat is
equivalent to 3500 calories, an “extra” 500 cal/day for a whole week can result in a 1-
pound weight gain. Conversely, a “negative” calorie balance occurs when calorie output
exceeds intake, whether the imbalance is from decreasing calorie intake, increasing PA,
or (preferably) both. In 2009–2010, 68.8% of Americans 20 years of age and older were
overweight or obese, and 35.7% of American adults were obese (National Center for

252
 Health Statistics, 2012). Excess weight, the outcome of a positive energy
balance, also increases the risk of cardiovascular disease, hypertension, type 2
diabetes, and certain cancers (U.S. Department of Agriculture [USDA], U.S. Department
of Health and Human Services [ USDHHS], 2010).

Poor food choices and physical inactivity contribute to the current state of energy
imbalance in the United States. For instance, MyPlate recommends Americans limit their
intake of solid fats and added sugars to no more than 15% of total calories; yet on
average, Americans consume approximately 35% of their total calories in the form of
empty calories (ChooseMyPlate.gov). Likewise, fewer than 5% of adults participate in 30
minutes of PA each day (USDA, USDHHS, 2010).

ADEQUATE INTAKE

An Adequate Intake (AI) is set when an RDA cannot be determined due to lack of
sufficient data on requirements. It is a recommended average daily intake level thought
to meet or exceed the needs of virtually all members of a life stage or gender group
based on observed or experimentally determined estimates of nutrient intake by groups
of healthy people. The primary purpose of the AI is as a goal for the nutrient intake of
individuals.

This is similar to the use of the RDA except that the RDA is expected to meet the
needs of almost all healthy people, while in the case of an AI, it is not known what
percentage of people are covered.

Tolerable Upper Intake Level

The Tolerable Upper Intake Level (UL) is the highest level of average daily
nutrient intake that is likely to pose no risk of adverse health effects to almost all
individuals in the general population. It is not intended to be a recommended level of
intake; there is no benefit in consuming amounts greater than the RDA or AI.

253
A. TOTAL ENERGY ALLOWANCE FOR INFANTS

0 – 6 months: TER = DBW kg x 120 kcal

7 – 12 mos.: TER = DBW kg x 110 kcal

B. CHILDREN

Method I – Narins & Weil Formula

TER = 1000 + ( age in years x 100 )

Method II – Based on Age & DBW

TER = DBW x KCAL/ DBW/ day

Age (yrs.) Kcal/ DBW/ day

1–3 105

4–6 90

7–9 75

10 - 12 65 (boys) 55 (girls)

C. ADOLESCENTS

TER = DBW x kcal/ DBW/ day

Age (yrs.) Kcal/ DBW/ day

13 – 15 55 ( boys) 45 ( girls )

16 – 19 45 ( boys ) 40 ( girls )

Average for all ages, both sexes: 45

254
 D. Calculating TEA for ADULTS using the different methods.

1. Krause Method:

TER = DBW (kg) x Physical Activity Factor

ACTIVITY Kcal/ kg DBW/ day

Bedrest ( mobile ) 27. 5

Sedentary/ Very Light – mostly sitting down 30.

Light – student, nurse, teacher, engineer, housewife w/ 35

maid, restaurant trades, childcare, table tennis, golf
Moderate – wife w/o maid, vendors running on the streets, 40
jeepney drivers, dancing
Heavy – walking activities w/ load, heavy manual activities, 45
other heavy manual work

Acceptable Macronutrient Distribution Ranges

The Acceptable Macronutrient Distribution Ranges (AMDRs) are broad ranges

for each energy nutrient, expressed as a percentage of total calories consumed. These
ranges are associated with reduced risk of chronic disease and are such that an
adequate intake of all nutrients can be obtained. Over time, intakes above or below this
range may increase the risk of chronic disease or defi ciency, respectively. The AMDRs
for adults are as follows:

2. COOPER et al. Method

CALCULATE TEA = ____kcal (Basal needs)+ _________( % PA ) = ___________kcal

255
= round off to the nearest 50

Distribute TEA among CHO, CHON, & FAT

CHO = 50 – 70 %

CHON = 10 – 15 %

FAT = 20 – 30 %

Cooper et. Al Method: TER = BMR + PA + SDA

BMR = 1 kcal/kg DBW/ hour Note: 1 day = 24 hours

PA = % above basal or BMR

Bedrest = 10% Sedentary = 30%

Light = 50% Moderate = 75% Heavy = 100%

SDA = 10% (BMR)

Computing TER in certain disease or physiological conditions

Example 1: During fever and infection, BMR increases by 13%

For every degree Centigrade rise in body temperature,

Hence the initial BMR should be adjusted accordingly.

Example 2: During the 2nd & 3rd Trimester of Pregnancy, an additional

300 kcal allowance is added to the TER. During lactation,

Add 500 kcal to pre-pregnancy TER

Example 3: Surgery: TER =BMR x Activity Factor x Injury Factor

Example 4: A high Calorie diet will require additional 50-100% of TER

METHOD 1

Normal Distribution: CHO: 50 – 70% average of 60 % of TER

256
 PRO: 10 – 20

Fats: 20 - 25 (normal adults)

35 – 35 (children, adolescents, very active)

METHOD II

a.) Compute for Protein Requirement in grams

Normal Adults: PRO = 1.12g x kgDBW

b.) Get caloric equivalent

PRO kcal = PROg x 4 kcal/g

c.) Deduct from TER

d.) Distribute remaining TER into CHO (70%) and Fats (30%)

e.) Compute for the CHO and Fats in grams

Therapeutic Diets: Nutrient allowances vary according to disease Condition

Example 1: In a High Carb diet, the CHO allowance may be as high as 80-90% of the
TER

Example 2: A High Protein diet for an adult may require as high 1.5g/kgDBW or the
protein allowance is increased by 50-100% above normal

Example 3: A Low Fat Diet will provide fat not more than 15% of TER

Specific nutrients are given attention in certain disease conditions

Example 1: Sodium level is given attention in CVD. Level of NA restriction may vary
from very strict to “no added salt”

Example 2: In the step 2 of the modified NCEP Diet for CVD, cholesterol should be
limited to 200mg or less and the SFA, PUFA and MUFA are computed.

257
CALCULATING NUTRIENT NEEDS

EXAMPLE: A 20 year old male patient is hospitalized due to dengue fever. He is

5’4” in height and he weighs 100 lbs. Compute for his Total Energy Allowance (TEA) and
make a diet plan for him.

1. Determine DBW

- we will use here Hamwi’s method of DBW

- DBW = Male = 1st 5’ = 106; +/ - 6 per inch above 5’

- DBW = 106 + (6 X 4”) = 130 lbs.

2. Determine TEA

- using Krause Method, TEA = DBW (kg) X PA

- convert 1st the weight in lbs to kg = 100lbs / 2.2lbs/kg = 45.45 kg = round off to nearest
whole number = 45 kg

- TEA = 45 X 30 (for sedentary activity) = 1350 kcal

❖ During fever and infection, BMR increases by 13%; For every degree Centigrade
rise in body temperature, Hence the initial BMR should be adjusted accordingly.

- we can add additional kcal since the patient has fever = (13%) 0.13 X 1350 = 175

- TEA = 1350 + 175 = 1525 kcal

3. Distribute TEA into the macronutrients convert to grams

Normal Distribution: CHO: 60% = .60 X 1525 = 915 kcal / 4 229g

PRO: 20% = .20 X 1525 = 305 kcal / 4 76g

Fats: 20% = . 20 X 1525 = 305 kcal / 9 34g

100% 1525kcal

258
 4. MEAL PLANNING WITH EXCHANGE LISTS

Composition of Food Exchanges

List Food Measure CHO PRO FAT ENERGY

(g) (g) (g) (kcal) (kj)
I.A. Veg.A 1 cup raw - - - -
½ cup, cooked
I.A. Veg.A 2 cups raw 3 1 - 16
1 cup cooked
or
I.B. Veg.B ½ cup, raw 3 1 - 16
½ cup cooked
II. Fruit varies 10 - - 40
III. Milk
Whole varies 12 8 10 170
Low Fat 4 tablespoons 12 8 5
125
Skimmed varies 12 8 tr 80
IV. Rice varies 23 2 - 100
V. Meat
Low Fat varies - 8 1
41
Med. Fat varies - 8 6 86
High Fat varies - 8 10 122
VI. Fat 1 teaspoon - - 5 45
VII. Sugar 1 teaspoon 5 - - 20

5. Write a Sample Menu

Websites: Students’ Resources for additional reading.

American College of Sports Medicine at www.acsm.org

American Council on Exercise at www.acefitness.org
Calculate your own BEE at http://www-users.med.cornell.edu/~spon/picu/calc/beecalc.htm
National Institute of Diabetes and Digestive and Kidney Diseases, Physical Activity and Weight
Control at www.niddk.nih.gov/health/nutrit/pubs/physact.htm
President’s Council on Physical Fitness and Sports at www.fitness.gov

259
 ACTIVITY
CALCULATING DIETS

Diets for normal individuals and planning regular menu using the Food Exchange
List. The Food Exchange List is one of the basic tools in nutrition and diet therapy. It is
used in meal planning and estimating the energy and macronutrients of normal and
therapeutic diets.

I. ОBJЕCTIVES

This laboratory session helps the practical nursing students to compute their own

calorie requirements and plan their meals.

At the end of 3 hours, you should be able to:

1. assess your nutritional status and compute for your calorie requirement, and

2. plan a one-day menu based from your requirement.

II. PROCEDURES

A. Following the steps in estimating desirable body weight (DBW) discussed in the
lecture portion, calculate your Total Energy Allowance (TEA),

Compute for your calorie requirement

1. Determine your height = _______ Actual body weight = ________

2. Calculate DBW = ________ (specify formula used)

3. Calculate your basal needs

MALE = 1 kcal/ kg DBW / hour

260
 FEMALE = 0.9 kcal/ kg DBW / hour

BASAL NEEDS = _______ x ______ kg (DBW) x 24 (this is constant, 24 hrs./day)

= _______________ kcal

❖ Note again that the basal caloric needs here means it is the number
of calories required to keep your body functioning at rest or your BMR.

4. Estimate physical activities (PA) = (Basal needs (BMR) _______ X _____% PA)
= _____________________ kcal

Physical Needs – approximate percentage increase above basal

needs (use lower factor for women)
Bed rest 10-20 %
Sedentary 30%
Light activity 50-60%
Moderately active 60-70%
Severely active 90-110&

5. Add values from no. 3 & 4 to get TEA

TEA = _______________ kcal + __________ = kcal

❖ Multiply your answer in number 3 with % PA

❖ For example, your computed BMR is 1200kcal X 0.30 if the PA is sedentary, this
gives you a result of 360
❖ add this amount again with your computed BMR = 1200 + 360 = 1560 kcal)

CALCULATING NUTRIENT NEEDS

1. Determine DBW

2. Determine TER

3. Distribute TER into the macronutrients

Method I

261
 Normal distribution:

CHO :50 – 70% or average of 60% of TER

CHON : 10 – 20 % for ADULTS –ave.15% TER

FATS : 20 -25% (normal adults)

: 30 -35 (children, adolescents, very active)

100%

Method II

A. compute for protein requirement in grams

B. get caloric equivalent

CHON kcal = CHONg X 4kcal/g

C. deduct from TER

D. Distribute remaining TER into CHO (70%) and fats (30%)

E. Compute for the CHO and FATS in grams

THERAPEUTIC DIETS: Nutrient

262
 UNIT V
NUTRITION-FOCUSED NURSING CARE PLANNING

Nutrition assessment is the first step in nursing or nutrition care process. This is
the stage when we identify characteristics known to be associated with nutrition
problems. Only after determining that a problem exist can the health care practitioners
effectively plan and implement managements to help a person suffering from nutrition-
related problems.

WEEK TOPIC LEARNING OUTCOME ACTIVITY

9
At the end of the lesson, you will be able to: • Comprehensive
nutritional
1. Comprehensively assess a client`s assessment
Day 17 & nutritional status. • Nursing Care Plan
18 2. Discuss essential components and purposes • Review questions
of nutritional assessment and nutritional Food diary
screening.
3. Identify risk factors for and clinical signs of
malnutrition.
4. Develop a nursing care plan appropriate for
the client.

5. Describe nursing interventions to promote

optimal nutrition.
6. Discuss nursing interventions to manage
clients with nutritional problems.
Plan, implement, and evaluate nursing care
associated with nursing diagnoses related to
nutritional problems.

LESSON 1

NUTRITION-FOCUSED NURSING CARE PLAN

- Applying the nutrition care process will vary to a degree depending on the health care
setting

- EX: school setting; community, hospital, clinic

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A. NUTRITIONAL ASSESSMENT

- Data gathering with use of some TOOLS like:

• Interview
• medical charts, or
• simple assessment is – determining if the person is overweight or underweight or
has had a change in wt. that may be indicative of a change in health status.
• lab. Values – hemoglobin (to determine Iron status)

- Albumin – protein status

- Cholesterol & other blood fats such as triglycerides, BG

• physical signs of nutritional status may be evident

- also involves the psychological issues – contributing to physical health

concerns & may need to be addressed before realistic changes can take place

- EX: social events or poor self-esteem – may cause negative food choices

- this part of assessment – requires excellent communication skills – to promote

disclosure of potentially sensitive & personal lifestyle issues.

• Develop rapport & trust

- comprehensive nutritional assessment – conducted to determine goals &

interventions to correct actual or potential imbalances

1. HISTORY

- Dietary history
- no one approach can provide complete information because food habits change for
most persons
- used in conjunction w/ physical parameters of health
- current & past health history
EXAMPLE:

• Chewing & swallowing problems 2° ill-fitting dentures or missing teeth or from

mechanical problems (obstruction, inflammation, edema)

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 • neurological problem (dysphagia, Parkinson’s disease, stroke, traumatic brain
injury)
• anorexia or loss of appetite
• cognitive impairments
• paralysis or physical disabilities that may impair the ability to feed oneself
• excessive nutrient intake – bulimia nervosa/ obesity
• GI disorders – lactose intolerance; cystic fibrosis; pancreatic disorders;
inflammatory bowel disease; liver disorders
• altered metabolism – pregnancy; fever; sepsis; thermal injury
• Pressure ulcers; cancer; AIDS; major surgery; trauma; burns

a. DIET EVALUATION

a.1. DIET HISTORY

- through interview
- food preferences & intolerances
- taste, appetite, recent wt. changes
- desired wt. & usual wt.
- estimation of typical kilocalorie & nutrient intake

TOOLS:

a.2. 24-HOUR food RECALL

- quick & easy of evaluating intake

- person must be able to recount all the types & amounts of foods & beverages
consumed during a 24-hour period

a.3. FOOD FREQUENCY checklists

- a checklist of particular foods that helps determine what’s consumed & how often

- may list the foods in one column, & the person marks off how often they are eaten

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- periods of time

- how often the food is consumed (per day/ per week, or per m0nthe)

- if the food is eaten frequently, seldom, never

- typically does not include the serving size, & it may only include specific foods or
nutrients suspected of being deficient or excessive in the diet.

a.4. CALORIE COUNT

The ENERGY (CALORIE) value of food is the amount of energy produced in the body as
a result of food metabolism.

Calorie – the most common term to express energy

a unit measure of heat

a.5. FOOD DIARY

2. PHYSICAL EXAMINATION/ findings - clinical

- provide a clue to the presence of malnutrition

- indicators of malnutrition
- appearance of hair, skin, oral cavity, fingernails
- presence of edema

a. ANTHROPOMETRY

Anthropometry is the study of the measurement of the human body.

Anthropometric measurements include metrics such as height, weight, or head
circumference. Height is assessed using a stadiometer. Length refers to the
measurement of infants and children who are 2 years or younger or those 24–36 months
who are not able to stand without assistance, or who measure less than 30 inches while

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lying down.27 Growth charts used for children age 0–36 months use recumbent length,
whereas stature is used for those age 2–20 years.

Common Anthropometric Measurements

a.1. WEIGHT (wt.)

- this measurement needs to be undertaken at the very 1 st encounter w/ a patient & must
be regularly monitored

- usual BW should be noted

- taken on the same scale at the same time of day (typically before breakfast & after
voiding ), in the same amount of clothing, w/o shoes

- can be misleading – w/ an individual who is retaining fluid or is dehydrated

- wt. loss reflected of malnutrition is an unplanned wt. loss of 5% or more in 30 days or

10% or more in 6 mos.

- wt. loss is best expressed in term of percentage of wt. change

❖ Amount of wt. loss /usual or last recorded wt. * 100

Weight (for Age)

Indicates current nutritional status

Use International R Standard (IRS)/ World Health Organization (WHO)

standards

May be compared to ideal weight and interpreted as follows:

Types of Weighing scale:

1. Bar Scale

2. Salter Scale

3. Platform Scale

ACTUAL & IDEAL BODY WEIGHT & HEIGHT

- weight is the measure people use to judge their “fitness”

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 HEALTHY WEIGHT - defined by 3 criteria:

1. A weight that is within the suggested range for height

2. A fat distribution pattern that is associated w/ a low risk of illness & premature
death.

3. A medical history that reflects an absence of risk factors associated w/ obesity,

such as elevated blood cholesterol, blood glucose, or blood pressure.

Wt. Gain - Loss

1 lb/ wk (1/2 kg) = add 500 kcal./ day - less 500 cal

2 lbs/ wk ( 1 kg ) = add 1000 kcal./ day - less 1000 cal.

➢ Consume 10 kcal/ lb of BW – for wt. maintenance

➢ Most adults – 12 kcal/ lb
➢ Active adults – 15 kcal/ lb

➢ Bec. 35000 kcal equates to approximately 1 lb of body fat.

➢ Safe & permanent wt. loss --- should lose a maximum of 1 – 2 lb/ wk.
➢ Rapid wt. loss --- compel the body to use protein (muscle) instead of fat →
↓muscle mass --- body fat percentage increases

BODY MASS INDEX

- uses a pt’s wt. & ht. to help classify a person as underwt., normal, or obese

- measures weight in relation to height

- measure of adiposity or overfat, not simply overweight

- should not be applied to children, adolescents, adults over 65 y/o, pregnant & lactating
women, & highly muscular individuals.

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- determined by dividing weight (kg) by the square of height (meter – 1m = 39.37in)

FORMULA:

BMI = weight (kg)

Height(m²)

• >18.5 – underwt..
• 18.5 – 24.9 – normal
• 25.0 – 29.9 – overwt.
• 30.0 – 34.0 – obese – class 1
• 35 – 39.9 – class 2
• 40 or greater – morbid obesity

a.2. HEIGHT (for Age)

- should be measured w/ the individual standing as straight as possible, w/o shoes,

against the wall using a fixed measuring stick

Indicates stunting

Compare actual height with standard height for various ages

Using IRS or WHO Tables

Stunted if <90% of standard height

For infants, length at birth is about 50cm (48-52), + 24 cam at age 1

year; + 12cm at age 2; +8cm at age 3 ; +6cm/year from 4—8 years

a.3. SKINFOLD THICKNESS

Determine fatness or leanness

Compare with standards

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 Triceps, Biceps, Subscapular, Suprailiac, Abdomen, Upper thigh

a.4. TRICEPS SKIN FOLD (TSF)

- an index of the body’s fat or energy stores

Low skin fold measurement --- may indicate malnutrition

Used for both men & women

Measure the skinfold thickness --- in the posterior side of the nondominant upper arm at
the midpoint

a.5. BODY CIRCUMFERENCES

1. Head-Chest Ratio = Head circumference/ Chest circumference

0-5/6 months = >1

6 months =1

7-12 months = < 1

2. Mild-upper arm circumference (MAC)

– refer to standards

- upper arm

- indicates the level of the body’s protein stores which are found mainly in
the muscles

- Non-dominant arm is flexed at a 90-degree angle and the circumference

is measured w/ a non-stretchable measuring tape after the midpoint of the upper
arm is determined.

3. Waist circumference – 1 inch loss -> in 3 months = Normal

Waist Circumference
Recent evidence indicates that waist circumference may be an acceptable
alternative to BMI measurement in some subpopulations (Moyer, 2012). In fact,
the location of excess body fat may be a more important and reliable indicator of

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disease risk than the degree of total body fatness. Storing a disproportionate
amount of total body fat in the abdomen increases risks for type 2 diabetes and
cardiovascular disease.

Generally, men and postmenopausal women tend to store excess fat in

the upper body, particularly in the abdominal area, whereas premenopausal
women tend to store excess fat in the lower body, particularly in the hips and
thighs. Regardless of gender, people with a high distribution of abdominal fat
(i.e., “apples”) have a greater relative health risk than people with excess fat in
the hips and thighs (i.e., “pears”) (Fig. 7.2). The current waist circumference
recognized as abdominal obesity in the United States is 40 in or more for men
and 35 in or more for women (Alberti et al., 2009). As with BM ethnic groups
differ in regard to where risk begins in relation to waist circumference.
Values above standards indicate central body fat adiposity

Pear shape versus Apple shape

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 4. Waist/Hip Ratio

- Waist circumference is measured at the level of the umbilicus to the nearest

0.5 cm.
- The subject stands erect with relaxed abdominal muscles, arms at the side, and
feet together.
The measurement should be taken at the end of a normal expiration.

• Waist circumference

- Waist circumference predicts mortality better than any other anthropometric

measurement.

- It has been proposed that waist measurement alone can be used to assess
obesity, and two levels of risk have been identified

MALE FEMALE

LEVEL 1 > 94cm > 80cm

LEVEL2 > 102cm > 88cm

Waist circumference/2
Level 1 is the maximum acceptable waist circumference irrespective of the adult
age and there should be no further weight gain.

Level 2 denotes obesity and requires weight management to reduce the risk of
type 2 diabetes & CVS complications.

• Hip Circumference

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 - Is measured at the point of greatest circumference around hips & buttocks to the
nearest 0.5 cm.
- The subject should be standing and the measurer should squat beside him.
- Both measurement should taken with a flexible, non-stretchable tape in close
contact with the skin, but without indenting the soft tissue.

TO COMPUTE:
WHR = Waist in/cm / Hips in/cm

Interpretation of WHR

High risk WHR = >0.80 for females & >0.95 for males
- i.e. waist measurement >80% of hip measurement for women and >95% for men
indicates central (upper body) obesity and is considered high risk for diabetes &
CVS disorders.
- A WHR below these cut-off levels is considered low risk.

b. CLINICAL FEATURES OF

b.1. MALNUTRITION

- or poor nutritional status – a state in which a prolonged lack of one or more nutrients
retards physical development or causes the appearance of specific clinical conditions
(anemia, goiter, rickets, etc. – micronutrient deficiencies)

- this may occur because the diet is poor or because of a digestion & metabolism
problem.

- excess nutrient intake creates another form of malnutrition when it leads to conditions
such as obesity, heart disease, hypertension, & hypercholesterolemia.

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PHYSICAL SIGNS INDICATIVE OR SUGGESTIVE OF MALNUTRITION

NORMAL SIGNS POSSIBLE POSSIBLE

APPEARANCE ASSOCIATED W/ DISORDER NONNUTRITIONAL
MALNUTRITION OR NUTRIENT PROBLEM
DEFICIENCY
HAIR Shiny, firm, not easily Lack or natural shine; Kwashiorkor; Excessive bleaching of
plucked dull & dry; Less commonly hair;
Thin & sparse; Marasmus Alopecia
dyspigmented; flag
sign; easily plucked
(no pain)
FACE Skin color uniform; Nasolabial seborrhea Riboflavin Acne vulgaris
smooth, healthy (scaling of skin around kwashiorkor
appearance; not swollen nostrils);
Swollen face;
paleness
EYES Bright, clear, shiny; no Pale conjunctiva; Bloodshot eyes from
sores at corners of Bitot`s spot, exposure to weather.
eyelids; membranes are conjunctival xerosis Lack of sleep, smoke, or
healthy pink & moist; no (dryness) alcohol
prominent blood vessels Corneal xerosis
or mound of tissue or (dullness)
sclera.
LIPS Smooth, not chapped or Angular cheilosis Riboflavin Excessive salivation from
swollen (white or pink lesions improper fitting dentures
at corners of mouth)
TONGUE Deep red in Magenta tongue Riboflavin Leukopenia
appearance; not swollen (purplish) Folic acid
Filiform papillae Niacin
atrophy or hypertrophy
– red tongue
TEETH No cavities; no pain; Mottled enamel Fluorosis Malocclusion
bright Caries (cavities) Excessive sugar Periodontal disease
Missing teeth Health habits

GUMS Healthy; red; do not Spongy, bleeding Vitamin C Periodontal disease

bleed; not swollen Receding gums
GLANDS Face not swollen Thyroid enlargement Bulimia Allergic or inflammatory
Parotid enlargement Iodine enlargement of thyroid
(cheeks become Starvation
swollen)
NERVOUS Psychological stability; Psychomotor changes Kwashiorkor
SYSTEM normal reflexes Mental confusion
Sensory loss
Motor weakness
Loss of position sense
Loss of vibration
Loss of ankle &
knee jerks Thiamin
Burning & tingling of
hands & feet
(paresthesia) Niacin, Vitamin
Dementia B12

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MARASMUS & KWASHIORKOR

b.2. OBESITY

OVERWEIGHT – refers to an excess of body weight 10% greater than the standard

OBESITY – excess of body wt. 20% or more than the standard

What are the known causes and theories of OBESITY?

- causes are numerous, complex, and not thoroughly understood.

- it occurs when caloric intake exceeds expenditure over an extended period

- reduced physical activity

- genetic susceptibility – however, the environment is generally what allows the genetic
predisposition to be realized

- increase use of high-fructose corn syrup

- Hyperinsulinemia – family history of diabetes

--- insulin – lipogenic (inhibits lipolysis – breakdown of fat)

- Hormonal imbalance

❖ Prevention strategies for obesity

❖ Some treatment strategies for obesity

b.3. CERTAIN VITAMIN DEFICIENCIES

4. LABORATORY EXAMINATIONS –biochemical

- tests blood & urine

- composition of blood to compare w/ normal ranges for hemoglobin, albumin,

transferrin, total plasma protein, nitrogen content in 24-hour urinary output

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5. NUTRITIONAL ASSESSMENT OF SPECIFIC DISEASES

B. NURSING DIAGNOSIS

- please refer to NANDA – these are a examples of Nutrition-related Nursing Diagnosis:

• Imbalanced Nutrition: More Than Body Requirements

• Imbalanced Nutrition: Less Than Body Requirements
• Readiness for Enhanced Nutrition
• Risk for Imbalanced Nutrition: More Than Body Requirements

• Diagnostic label used as etiology

▪ Activity Intolerance
▪ Constipation
▪ Low Self-Esteem
▪ Risk for Infection

C. PLANNING

- this stage of the nursing process brings together all the findings of the assessment
phase

Identifying priority health concerns, long- term health goals, & STO

Specified health outcomes is important for facilitating behavioral change

- (measurable action verbs) – identify, state, demonstrate ( used in educational

objectives)

- expected time frame for achievement of the objectives

- EX: ( Educational/ Intervention objective )

- List food quantities needed to meet the goal of 25g of fiber

- Determine insulin-to-carbohydrate ratio for the goal of normalized glucose

- Increase protein intake to 1.2 – 1.5g/ kg of BW for the goal of albumin > 3.5mg/ dL

- Encourage at least 1500 ml of fluids

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- Describe serving sizes to meet a meal goal < 800 mg of Sodium using food labels

--- evaluated or measured through:

➢ Follow-up counseling sessions

➢ Observation
➢ Improved laboratory values
- planning – increases the effectiveness of the intervention

- communicates the care plan to other members of the health care team

• Evaluation PLAN - determined before the intervention phase

• Evaluation, ultimately means – changes in laboratory values or other clinical
health outcomes
• Documented positive health outcomes

• Planning for home care

▪ Provide aid with eating, purchasing food, and preparing meals

▪ Instruct about nutrition therapy

▪ Assess client and family's abilities for self-care, financial resources, and
need for referrals

D. IMPLEMENTATION/ intervention

- often begin w/ simple, brief, reinforcing messages

- verbal reinforcement of written educational material

- review food labels and have the pt. describe the amount of Sodium, sugar, or fat in the
food product

- putting plan into action

- based on the information gathered in the comprehensive nutritional assessment, 0 the

t. may require restrictions in diet, such as --- reduction in calories; fat; saturated fat;
cholesterol, sodium, or other nutrients

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 • Hospitalized client

▪ Provided in collaboration with the primary care provider and the dietitian

▪ Reinforce information presented by dietitian

▪ Create an atmosphere that encourages eating

▪ Provide and assist with eating as needed

▪ Monitor the client's appetite and food intake

▪ Administer enteral and parenteral feedings

▪ Consult with primary care provider and dietitian about nutritional problems

• Assisting with special diets

▪ Altered diets used to treat disease, increase/decrease weight, restore

nutritional deficit, allow organ to rest/heal

▪ Diets modified in texture, kilocalories, specific nutrients, seasonings,

consistency

1. DIETARY CALCULATIONS OF CALORIE/ DAY INTAKE

- GRAMS EACH FOOD

❖ ESTIMATING ENERGY/ CALORIE NEEDS

- to create a tailored nutrition prescription, one must determine the patient’s energy/
calorie requirements

2. FEEDING GUIDELINES

E. EVALUATION

- the final step

- must be documented – based on skills & information gained & by the outcomes of
laboratory blood tests or other measures

- EX: achieving 5% wt. loss

- helps the health care professional if further intervention is needed

- monitoring the growth in children
- wt. changes in adults

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 • The goals established in the planning phase are evaluated according to specific
desired outcomes.

• If the outcomes are not achieved, the nurse should explore the reasons.
• Cause of problem identified? Outcomes realistic?
• Family included and supportive?
• Client's preferences considered?
• Do symptoms cause loss of appetite?
• Anything interfering with digestion or absorption?
1. I & O

2. WEIGHT GAIN/ LOSS

NORMAL WEIGHT

METABOLIC SYNDROME – insulin resistance syndrome

- at least 3 health conditions found together

- central obesity, hypertension, dyslipidemia
- gout, PCOS, & type 2 diabetes
- other conditions: cardiovascular disease, cancer, & other health conditions
are often found with this syndrome.

ACTIVITY
Developing a Nursing Care Plan

Interview someone who will act as your client and develop a Nursing care Plan (NCP).

Name of Client: _________________________ Age: ____________ Gender: ____

Present Weight: __________________ Height: __________________

BMI = ________________ BMI Classification = __________________________

Waist/ Hip Ratio

ASSESSMENT

1. Make a diet history for 1 week

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 (What has your patient been eating for the week?)

DETAILED RECORD OF FOOD EATEN

DATE/ TIME AMOUNT FOOD/ drinks (all intake)
EXAMPLE:
8AM 1 cup (200ml) Coffee
1 slice White loaf bread

2. How is your patient’s appetite? ________________________________

3. Is this diet typical? ____________ If NOT, explain why? ___________________
4. Foods that your client liked best:
________________________________________________________________
5. Foods disliked or avoided: ___________________________________________

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 6. Other observations: (unusual attitude, relationship)
7. History:
▪ Any recent illness, clinic consultation, or hospitalization? ____________
▪ If YES, what was the cause or the diagnosis?
____________________________
▪ Any recent medications your client has taken? (specify, if
any)_______________________________________________________
▪ Any laboratory tests done to your client? (specify, if
any)____________________

8. Ask your client if there are problems with eating or digestion (example:
constipation, diarrhea, vomiting) that he/ she has experienced lately? What are
her / his thoughts about the cause of the
condition._________________________________________________________
________________________________________________________________
________________________________________________________________
9. Try to identify the Nursing Diagnosis out of the gathered assessments

___________________________________________________________________

(nursing problem) + (cause / etiology) + (manifestations)

Are you now ready to identify your Nursing Interventions??

You can list the Nursing Interventions below that are appropriate or applicable to
the case of the patient. As much as possible, know why these interventions
should be done (write as the rationale for each intervention)

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

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______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

References:
Ferraro, K. & Winter, C.H. (2014). Diet Therapy in Advanced Practice Nursing: Nutrition Prescriptions for Improved
Patient Outcomes. McGraw-Hill Education

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 UNIT VI
NUTRITION THROUGHOUT THE LIFESPAN

Normal growth and development depend on nutrition to support heightened

physiologic and metabolic processes. Nutrition, in turn, depends on a multitude of social,
psychosocial, cultural, and environmental influences that affect individual growth
potential throughout the life cycle.

In this unit, we will learn that there are four types of growth interact during each
phase of development: (1) physical, (2) mental, (3) emotional, and (4) sociocultural.
Each type of growth must be evaluated when assessing a person’s nutrition status and
planning an effective counseling approach. Nutritional needs change with each growth
period and must be individualized according to the unique growth pattern of every child.

In each lesson of this unit, we will relate principles of nutrition to the remarkable
process of human growth and development

WEEK TOPIC LEARNING OUTCOME ACTIVITIES

10
1. Case study
At the end of the lesson, you will be able to: 2. Planning a
1. Assess the physiological and psychological changes pregnant menu
and development per stage of life which require
modifications in nutrition.
DAY
19

2. Identify nutritional needs during pregnancy, lactation

and infancy.

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 LESSON 1
PREGNANCY

NUTRITION THROUGHOUT THE LIFESPAN

A. Nutrition during PREGNANCY

1. Stages
2. Physiology of Pregnancy
3. Nutritional Problems and Interventions
4. Recommended Diet
- Energy & nutrients needs during pregnancy
- Food choices

A. PREGNANCY

Here, we explore the tremendous physiologic changes during pregnancy and

lactation and some possible complications. You will see how vital optimal nutrition is for
a successful course and outcome.

CHARACTERISTICS OF PREGNANCY
Pregnancy or Gestation is the period when the fertilized ovum implants itself in
the uterus, undergoes differentiation and grows until it can support extra-uterine life.
Human pregnancy lasts for a period of 266 to 180 days (37-40 weeks). It consists of
3 trimesters: first, second and third corresponding to three main phases: implantation,
organogenesis and growth.

NUTRITIONAL DEMANDS OF PREGNANCY

Years ago, traditional practices and diet during pregnancy were often restrictive
in nature. They were built on assumptions and folklore of the past, and had little or no
basis in scientific fact. Early obstetricians even supported the notion that semistarvation
of the mother during pregnancy was a blessing in disguise, because it produced a small,
lightweight baby who was easy to deliver. To this end, pregnant women were sometimes
encouraged to select a diet that was restricted in kilocalories, protein, water, and salt.1

Developments in both nutrition and medical science have refuted these ideas
and laid a sound base for positive nutrition in current maternal care. It is now known that

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the mother’s and the child’s health depend on the pregnant woman eating a well-
balanced diet with adequate essential nutrients. In fact, women who have always eaten
a well-balanced diet are in a good state of nutrition at conception, even before they know
that they are pregnant. Such women have a better chance of having a healthy baby
compared with women who have been undernourished before conception and remain so
throughout gestation.

The 9 months between conception and the birth of a fully formed baby is a
spectacular period of rapid growth and intricate functional development. Such activities
require increased energy and nutrient support. General guidelines for these nutrient
increases are provided in the comprehensive Dietary Reference Intakes (DRIs) issued
by the National Academy of Sciences.
The DRIs are based on the general needs of healthy populations. Women who
are poorly nourished when becoming pregnant or those with additional risks may require
more nutrition support. The Dietary Guidelines for Americans also outline specific
recommendations for pregnant and lactating women.

This chapter reviews the basic nutrition needs for the positive support of a normal
pregnancy, with emphasis placed on critical energy and protein requirements as well as
on key vitamin and mineral needs.

FACTORS DETERMINING NUTRITIONAL NEEDS

An expanding body of research and the best practices of clinicians reinforce that
maternal nutrition is critically important to the mother and the newborn. It lays the
fundamental foundation for the successful outcome of pregnancy—a healthy mother and
infant. Several vital factors that determine nutritional requirements of the woman during
her pregnancy are well recognized.

1. Age, Gravida, and Parity

Age plays a major role in pregnancy; the teenage girl adds her own growth and
maturation needs to those imposed by pregnancy. In addition, the number of
pregnancies (gravida) and the number of viable offspring (parity), as well as the time

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intervals between them, greatly influence the woman’s nutrient reserves, her increased
nutritional needs, and the outcome of the pregnancy.

2. Complex Physiologic Interactions of Gestation

Three distinct biologic entities are involved during gestation: the woman, the
fetus, and the placenta, which nourishes fetal growth. Together they form a unique
biologic whole. Constant metabolic interactions occur among them. Their functions,
although unique, are at the same time interdependent. It is this unique biologic
synergism that nourishes and sustains the pregnancy.

ENERGY NEEDS
The metabolic cost of pregnancy is significant over the course of gestation. The
exact amount of energy needs will vary greatly among women depending on her pre-
pregnancy weight, health status, and activity level.

1. Reasons for Increased Need

During the second and third trimesters of pregnancy, the mother needs more
kilocalories for two general reasons: (1) to supply the increased fuel demanded by the
metabolic workload for both the mother and the fetus; and (2) to spare protein for the
added tissue building requirements. For these reasons, the mother must consider the
nutrient and energy density of the food in her diet.

2. Amount of Energy Increase

The energy needs of pregnant women remain the same during the first trimester
of pregnancy as their kilocalarie needs before conception (i.e., no noticeable difference).

- The DRIs note an increased need of 340 kcal/ day during the second
trimester
- approximately 452 kcal/day during the third trimester, which is an
increase of about 15% to 20% over the energy needs of nonpregnant
women.

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 It is important for health care professionals to council women on how this relates
to daily life. For example, the increased energy needs of a woman during her second
trimester of pregnancy could be met by:

- one additional snack per day consisting of a medium banana (105 kcal),
an 8-oz serving of whole milk yogurt (138 kcal), and 1/8 cup of mixed nuts
(101 kcal).
- This snack provides 344 kcal.
- Providing examples of exactly what “extra energy needs” means is
important so that expecting mothers do not misunderstand the message
and assume that they need to “eat for two.”
- Increased complex carbohydrates, monounsaturated fats, and
polyunsaturated fats are the preferred sources of energy, especially
during late pregnancy and throughout lactation.

Active, large, teenage, or nutritionally deficient pregnant women may require

more energy than the DRI guidelines. The emphasis always should be on adequate
kilocalories to secure the nutrient and energy needs of a rapidly growing fetus. Sufficient
weight gain is vital to a successful pregnancy. Gestational weight gain is a predictor of
infant birth weight and birth weight is associated with body mass index (BMI) later in life
(see back cover of text for BMI table). This translates to each end of the spectrum; both
too little and too much weight gain during gestation have implications for the overall
health of the infant. Inadequate gestational weight gain increases the risk for preterm
deliveries, and for low birth weight babies who have increased risks for poor outcome.10
Alternatively, excessive weight gain poses both short-term and potentially long-term
complications for the mother and fetus.

PROTEIN NEEDS

Reasons for Increased Need

Protein serves as the building block for the tremendous growth of body tissues
during pregnancy. Sufficient protein is required to meet the growth needs in the following
ways:

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 1. Development of the placenta. The placenta is the fetus’s lifeline to the
mother. A mature placenta requires sufficient protein for its complete development as a
vital and unique organ to sustain, support, and nourish the fetus.

2. Growth of the fetus. The mere increase in size from one cell to millions of
cells in a 3.2-kg (7-lb) infant in only 9 months indicates the relatively large amount of
protein that is required for such rapid growth.

3. Growth of maternal tissues. To support pregnancy and lactation, the

increased development of uterine and breast tissue is required.

4. Increased maternal blood volume. The mother’s plasma volume increases

by 40% to 50% during pregnancy.

- More circulating blood is necessary to nourish the fetus and to support

the increased metabolic workload.
However, with extra blood volume comes a need for the increased synthesis of blood
components, especially hemoglobin and albumin, which are proteins that are vital to
pregnancy. An increase in hemoglobin helps to supply oxygen to the growing number of
cells.

Meanwhile, albumin production increases to regulate blood volume through osmotic

pressure. Most women (60% to 75%) will experience some level of edema during the
latter part of gestation; however, adequate albumin helps prevent an excessive
accumulation of water in tissues.

5. Amniotic fluid. Amniotic fluid, which contains various proteins, surrounds the
fetus during growth and guards it against shock or injury.

Amount of Protein Increase

The protein DRI (Dietary Reference Intake) for nonpregnant women is 46 g/day
and the DRI for pregnant women is 71 g/day. This represents an increase of 25 g/day
more than the average woman’s protein requirement. However, it should be noted that

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the average nonpregnant woman aged 20 to 39 years old in America already consumes
74 g of protein per day. Thus, individual nutrition counselling for women intending to
become pregnant and pregnant women would be beneficial in the early stages to help
design personalized dietary advice, because additional protein may or may not be
warranted. On the other hand, high-risk or active pregnant women may require more
protein than their current diet provides.

Food Sources
Complete protein foods of high biologic value include eggs, milk, beef, poultry,
fish, pork, cheese, soy products, and other animal products (e.g., lamb, venison,
and so on).
Other incomplete proteins from plant sources such as legumes and grains
contribute additional valuable amounts of amino acids. Protein-rich foods also contribute
other nutrients, such as calcium, iron, zinc, and fat-soluble vitamins.

KEY MINERAL AND VITAMIN NEEDS

Many nutrients are needed in higher quantities during pregnancy to meet the
greater structural and metabolic requirements of gestation. These increases are
indicated in the DRI tables in Appendix B. Although all nutrients are important for a
successful pregnancy, only the nutrients that pose a specific risk for deficiency are
discussed below.

a. Minerals
The physiologic and metabolic changes that take place during pregnancy are
vast and will vary greatly between women.13 But in all cases, the nutrient needs of the
mother must be met before the nutrient needs of the placenta will be met and finally,
before the needs of the fetus are fulfilled. As such, all nutrients are of great importance
in the mother’s diet. Teratogenic effects may develop as a result of a maternal diet that
is deficient in many of the minerals, (e.g., Kestan disease, goiter, cretinism, fetal growth
restriction). We will only cover the more common mineral deficiency concerns in the
United States.

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1.Calcium.
A good supply of calcium—along with phosphorus, magnesium, and vitamin D—
is essential for the fetal development of bones and teeth as well as for the mother’s own
body needs. Calcium is also necessary for blood clotting. A diet that includes at least 3
cups of milk or milk substitute daily (e.g., calcium-fortified soy milk), generous amounts
of green vegetables, and enriched or whole grains usually supplies enough calcium.
During pregnancy, physiologic changes occur in the mother’s absorption capacity to help
meet the needs of some nutrients; for example, calcium and zinc are both more
bioavailable during pregnancy. This enhanced absorption helps the mother to meet her
nutrient needs as well as those of the growing fetus. Calcium supplements may be
indicated for cases of poor maternal intake or pregnancies that involve more than one
fetus. Because food sources of the two major minerals (i.e., calcium and phosphorus)
are almost the same, a diet that is sufficient in calcium also provides enough
phosphorus.

2.Iron.

Particular attention is given to iron intake during pregnancy. Iron is essential for
the increased hemoglobin synthesis that is required for the greater maternal blood
volume as well as for the baby’s necessary prenatal storage of iron.

As with most supplemental forms of nutrients, bioavailability is suboptimal

compared with food sources; hence, the reinforcement of a balanced diet with ample
iron is still important.

VITAMINS
The DRIs for pregnant women are slightly higher for most vitamins. As total
energy intake increases, so do the nutrients contained in the foods consumed.
Therefore, the recommended intake for most nutrients is achieved through a selection of
nutrient dense foods.

As with the mineral section, we will limit the discussion here to those vitamins
that are of specific concern during pregnancy because of inadequate dietary intake.

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1.Folate.
- Folate is important for both mother and fetus throughout pregnancy.
- Tetrahydrofolic acid (TH4) participates in DNA synthesis, cell division,
and hemoglobin synthesis.
- It is particularly relevant during the early periconceptional period (i.e.,
from approximately 2 months before conception to week 6 of gestation) to
ensure adequate nutrient availability in the endometrial lining of the uterus
for embryonic tissue development.
- The neural tube forms during the critical period from 21 to 28 days’
gestation, and it grows into the mature infant’s spinal column and its
network of nerves.

Although the exact mechanism by which folate helps thwart neural tube defects
(NTDs) is unknown, it is thought to be a result of a complex relationship between folate
availability, genetics, and other environmental factors.16 While folate intake alone does
not guarantee that a pregnancy will be NTD-free, there is enough evidence to support
the use of folate supplements and/or food fortification to reduce the overall occurrence.

Spina bifida and anencephaly are the two most common forms of NTDs, which are
defined as any malformation of the embryonic brain or spinal cord.

Spina bifida occurs when the lower end of the neural tube fails to close (see
Figure 7-7). As a result, the spinal cord and backbone do not develop properly.
The severity of spina bifida varies in accordance with the size and location of the
opening in the spine.

Disability ranges from mild to severe, with limited movement and function.
Anencephaly occurs when the upper end of the neural tube fails to close. In this case,
the brain fails to develop or is entirely absent. Pregnancies that are affected by
anencephaly end in miscarriages or death soon after delivery.

The current DRIs recommend a daily folate intake of 600 mcg/day during
pregnancy and 400 mcg/day for nonpregnant women during their childbearing years.3

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Women who are unable to achieve such dietary recommendations by eating foods that
are fortified with folate may do so with a dietary supplement.

- All enriched flour and grain products as well as fortified cereals contain a
well-absorbable form of dietary folic acid.
- Other natural sources of folate include liver; legumes (e.g., pinto beans,
black beans, kidney beans); orange juice; asparagus; and broccoli.

2.Vitamin D.
As was mentioned in Chapter 7, vitamin D deficiency is thought to be a common
worldwide problem, including among pregnant women. There is concern that vitamin D
deficiency during pregnancy may be associated with adverse outcomes for both the
mother and the fetus, including preeclampsia, gestational diabetes, and preterm birth.
However, causality has not yet been determined and research studies investigating the
connection between vitamin D deficiency and such pregnancy complications are
contradictory.19,20 The current DRIs recommend pregnant and lactating women
consume 15 mcg/d (600 IU) to ensure the absorption and use of calcium and
phosphorus for fetal bone growth.2 Increased vitamin D needs can be met by the
mother’s intake of at least 3 cups of fortified milk (or milk substitute) in her daily food
plan. Fortified milk contains 10 mcg (400 IU) of cholecalciferol (i.e., vitamin D) per quart.

The mother’s exposure to sunlight increases her endogenous synthesis of

vitamin D as well. Lactose-intolerant women or vegetarians can obtain adequate vitamin
D from fortified soymilk or rice milk products.
Registered dietitians are an excellent resource for pregnant women who need help
planning an individualized balanced diet.

WEIGHT GAIN DURING PREGNANCY

Amount and Quality
Appropriate weight gain is a positive reflection of good nutritional status, and it
contributes to a successful course and outcome of pregnancy. The average
gestational weight gain is 10 to 16.7 kg (22 to 36.8 lb).21 Table 10-2 provides an
approximation of this weight distribution. The Institute of Medicine recommends

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setting weight gain goals together with the pregnant woman in accordance with her pre-
pregnancy nutritional status and her BMI.21 Table 10-3 provides the
recommended total gestational weight gain as well as the average rate of weight gain
relative to pre-pregnancy BMI.

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 Important considerations in each case are the quantity and quality of weight gain
as well as the foods consumed to bring it about, which should involve a
nourishing, well-balanced diet. Inappropriate weight gain (i.e., too much or too little) is
associated with adverse pregnancy outcomes, such as preterm birth,
increased risk of cesarean delivery, low birth weight infant, postpartum weight retention,
and failure to initiate breastfeeding.

Severe caloric restriction during pregnancy is potentially harmful to the

developing fetus and the mother.
Such a restricted diet cannot supply all of the energy and nutrients that are essential to
the growth process.
Thus, weight reduction never should be undertaken during pregnancy. Special
care for pregnant women who are suffering from eating disorders (e.g., anorexia
nervosa, bulimia nervosa) is essential for the health of both the mother and the fetus.

Rate of Weight Gain

Approximately 1 to 2 kg (2 to 4 lb) is the average amount of weight gained during
the first trimester of pregnancy. Thereafter, the rate of weight gain should be reflective of
a woman’s prepregnancy BMI. Women with a prepregnancy BMI between 18.5 and 24.9
kg/ m2 generally gain ≈0.4 kg (14 oz) per week during the
remainder of the pregnancy. The rate of weight gain for underweight women should be
slightly more and overweight and obese women should average a slower rate of weight
gain (see Table 10-3).21

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 Unusual patterns of weight gain should be monitored closely. For example, a
sudden sharp increase in weight after the twentieth week of pregnancy may indicate
abnormal edema and impending hypertension.
Alternatively, an insufficient or low maternal weight gain is a predictor of small for
gestational age (SGA) infants with increased risks for complications.

GENERAL CONCERNS DURING PREGNANCY

1. GASTROINTESTINAL PROBLEMS
a. Nausea and Vomiting
Nausea and vomiting affect 69% of women during early pregnancy in the United
States.22 It can be distressing and disruptive to daily life. For the majority
of women experiencing nausea and vomiting, it will persist throughout the entire day. As
a matter of fact, less than 2% of women experience “morning sickness”
(i.e., nausea and vomiting limited to the morning hours). It is likely caused by hormonal
adaptations to human chorionic gonadotropin (hCG) during the first
trimester, and it generally peaks at about 9 to 11 weeks’ gestation. For about half of the
women with nausea and vomiting, it will resolve around 14 weeks; and
90% of women will have no additional symptoms after 22 weeks’ gestation. In most
cases it is self-limiting and does not indicate further complication.

To date, there is inadequate evidence to support the efficacy of any particular

pharmacologic or nonpharmacologic intervention for the treatment of nausea and
vomiting during pregnancy.24 Pregnant women often resort to alternative treatments
(e.g., acupuncture, accupressure) for the relief of symptoms; however, these methods
do not appear to be consistently effective for treating nausea and vomiting in this
population. Some studies show improvements in symptoms with the use of ginger and
vitamin B6, although findings are inconsistent and high-quality research is limited.24-26

Although the data does not indicate any treatment will be effective in all patients,
some dietary and lifestyle interventions are worth trying because they have no negative
side effects. The following dietary actions may help with the relief of symptoms27,28:
• Avoid an empty stomach by eating small, frequent meals and snacks that are fairly dry
and bland with low-fat and low-fiber.

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• Drink liquids between (rather than with) meals.
• Avoid odors, foods, or supplements that trigger nausea.
• Try ginger (125 to 250 mg) or vitamin B6 supplements (10 to 25 mg).

If nausea and vomiting persist and become severe and prolonged, then the
woman should be evaluated for hyperemesis gravidarum, a condition in which
medical treatment is usually required. Approximately 1% of pregnant women develop
hyperemesis gravidarum, and women who have experienced this condition with their first
pregnancy are at a greater risk for recurrence during any additional pregnancies
(15.2%).29 Patients with hyperemesis gravidarum
should be closely followed for hydration, electrolyte balance, and appropriate weight
gain. Pregnancy outcome and fetal growth are both compromised in pregnancies with
persistent hyperemeis gravidarum that prevents adequate nutrition and weight gain.
Prescription antiemetic medication may benefit
some women in this situation (see the Drug-Nutrient Interaction box, “Antiemetic
Medications”).

b. Constipation
Although it is usually a minor complaint, constipation may occur during the latter
part of pregnancy as a result of the increasing pressure of the enlarging uterus
and the muscle-relaxing effect of progesterone on the gastrointestinal tract, thereby
reducing normal peristalsis.
Helpful remedies include adequate exercise, increased fluid intake, and consumption of
high-fiber foods such as whole grains, vegetables, dried fruits
(especially prunes and figs), and other fruits and juices.
Pregnant women should avoid artificial and herbal laxatives.

c. Hemorrhoids
Hemorrhoids are enlarged veins in the anus that often protrude through the anal
sphincter, and they are not uncommon during the latter part of pregnancy. This
vein enlargement is usually caused by the increased weight of the baby and the
downward pressure that this weight produces. Hemorrhoids may cause considerable
discomfort, burning, and itching; they may even rupture and bleed under the pressure of
a bowel movement, thereby causing the mother anxiety.

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 Hemorrhoids are usually controlled by the dietary suggestions given for
constipation. Sufficient rest during the latter part of the day may also help to relieve
some of the downward pressure of the uterus on the lower intestine.
Hemorrhoids resolve spontaneously after delivery in many women, in which case long-
term treatment is not necessary.

d. Heartburn
Pregnant women sometimes have heartburn or a “full” feeling. These discomforts
occur especially after meals, and they are caused by the pressure of the enlarging
uterus crowding the stomach. Gastric reflux may occur in the lower esophagus, thereby
causing irritation and a burning sensation. The full feeling comes from general gastric
pressure, the lack of normal space in the area, a large meal, or the formation of gas.
Dividing the day’s food intake into a series of small meals and avoiding large meals at
any time usually help to relieve
these issues. Comfort is sometimes improved by the wearing of loose-fitting clothing.

HIGH-RISK PREGNANCIES
Identifying Risk Factors
Pregnancy-related deaths claim the lives of 600 to 700 women in the United
States annually.30 Identifying risk factors and addressing them early are critical to the
promotion of a healthy pregnancy. Nutrition related risk factors are listed in the Clinical
Applications box, “Nutrition-Related Risk Factors In Pregnancy.”
To avoid the compounding results of poor nutrition during pregnancy, mothers
who are at risk for complications should be identified as soon as possible. Health care
professionals should not wait for clinical symptoms of poor nutrition to appear. The best
approach is to identify poor food patterns and to prevent nutrition problems from
emerging.
Examples of dietary patterns that are not optimal for maternal and fetal nutrition
are as follows:
(1) insufficient food intake;
(2) poor food selection; and
(3) poor food distribution throughout the day.

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CLINICAL APPLICATIONS
Nutrition-Related Risk Factors in Pregnancy

RISK FACTORS AT THE ONSET OF PREGNANCY

• Age: ≤18 years old or ≥35 years old
• Frequent pregnancies: three or more during a 2-year period
• History of poor obstetric performance or fetal outcome
• Poverty, food insecurity, or both
• Bizarre or trendy food habits or eating disorder
• Abuse of tobacco, alcohol, or drugs
• Therapeutic diet that is required for a chronic disorder
• Poorly controlled preexisting condition (e.g., diabetes, hypertension)
• Weight: ≤85% or ≥120% of ideal body weight

RISK FACTORS DURING PREGNANCY

• Anemia: low hemoglobin level (i.e., less than 12 g) or hematocrit level (i.e., less than 34%)
• Inadequate weight gain: any weight loss or weight gain of less than 1 kg (2 lb) per
month after the first trimester
• Excessive weight gain: more than 1 kg (2 lb) per week after the first trimester
• Substance abuse (i.e., alcohol, tobacco, drugs)
• Gestational diabetes, hypertensive disorder of pregnancy, hyperemesis gravidarum,
pica, or another pregnancy related condition
• Poor nutritional status, especially involving folic acid, iron, or calcium
• Multifetal gestation

Recognizing Special Counseling Needs

Every pregnant woman deserves personalized care and support during
pregnancy. Women with risk factors such as those in the following discussion have
distinct counseling needs. In each case, the clinician must work with the mother in a
sensitive and supportive manner to help her develop a healthy food
plan that is both practical and nourishing. Dangerous practices (e.g., fad dieting, extreme
macrobiotic diets, attempted weight loss) should be identified early and
amended. In addition to avoiding dangerous practices, several topics require sensitive
counseling, including those related to age and parity, detrimental lifestyle habits, and
socioeconomic problems.

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Age and parity.
Pregnancies at either age extreme of the reproductive cycle carry special risks.
Adolescent pregnancy adds many social and nutritional risks as its social upheaval and
physical demands are imposed on an immature teenage girl. Sensitive counseling
necessitates both helpful information and emotional
support with good prenatal care throughout.

Alternatively, pregnant women who are older than 35 years old and having their
first child also require special attention. Pregnancy rates among women who are more
than 35 years old continue to rise in the United States.32 These women are at a higher
risk for obstetric and perinatal complications such as preeclampsia,
gestational diabetes, and cesarean delivery.

In addition, women with an extremely high parity rate (i.e., those who have had
several pregnancies within a limited number of years) are at an
increased risk for poor pregnancy outcomes36,37 and are often facing the increasing
physical and economic pressures of child care.

Obesity.
Obesity poses health concerns at any stage of life, including pregnancy.
Excessive gestational weight gain, particularly in normal and overweight women,
increases the risk for adiposity in the offspring and perhaps the complications of obesity
later in life.Thus, individual and specific person-centered counselling
for pregnant women is ideal to help improve overall pregnancy outcome.

Alcohol.
Alcohol use during pregnancy can lead to fetal alcohol spectrum disorders
(FASDs), of which fetal alcohol syndrome (FAS) is the most severe form (Figure
10-1). Fetal alcohol spectrum disorders comprise the leading causes of preventable
mental retardation and birth defects in the United States. It is difficult to determine the
exact prevalence of FAS; however, one study estimated that between 2 and 7 per 1000
live births in the United States are affected by FAS. Alcohol is a potent and well-
documented teratogen. There are no safe amounts, types, or times during pregnancy

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that are acceptable for the consumption of alcohol. FAS is 100% preventable by
abstaining from alcohol during pregnancy.

Nicotine.
An estimated 12.3% of pregnant women continue to smoke cigarettes during
pregnancy. Maternal cigarette smoking or exposure to secondhand
smoke (also known as environmental tobacco smoke) during pregnancy is associated
with placental complications, preterm delivery, fetal growth restriction,
congenital abnormalities, and sudden infant death syndrome (SIDS).
Women who stop smoking at the onset of pregnancy have similar pregnancy
outcomes as nonsmokers, meaning that they are able to avoid such smoking-related
complications for their infant.
Drugs.
Drug use, whether medicinal or recreational, poses problems for both the mother
and the fetus, especially when it involves the use of illicit substances.
Drugs cross the placenta and enter the fetal circulation, thereby creating a potential
addiction in the unborn child. Neonatal abstinence syndrome (NAS) is a condition from
which the infant suffers after birth because of the abrupt discontinuation of a drug
chronically used throughout gestation. Substances that may result in NAS include
opioids (heroin, methadone, buprenorphine,
and prescription opioid medications), selective serotonin reuptake inhibitors (SSRIs),
tricyclic antidepressants, methamphetamines, and inhalants.

Dangers come from the drugs themselves, the use of contaminated needles, and
the impurities that are contained in illicit substances. Self-medication with over the-
counter drugs also may present adverse effects.
Pregnant women should always check the label for safety notices of use during
pregnancy or speak with their doctor or pharmacist regarding medications.
Medications made from vitamin A compounds (e.g., retinoids such as tretinoin
[Accutane], which are prescribed for severe acne) have caused birth defects and
the spontaneous abortion of malformed fetuses by women who conceived during acne
treatment. Thus, the use of this medication without contraception is
contraindicated.

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Caffeine.
Caffeine use is common during pregnancy.
Caffeine crosses the placenta and enters fetal circulation.
Studies on caffeine use and pregnancy risks have been controversial with conflicting
results over the past several decades. Three large-scale reviews of the available
literature did not find consistent evidence that either normal or high intakes (defined as
≥300 mg/d) of caffeine during pregnancy posed a risk for congenital malformations,
growth restriction, or spontaneous abortion (miscarriage).48-50 Of note, two of the
reviews were funded by the Caffeine Committee of the International Life Sciences
Institute and the
National Coffee Association. The use of caffeine and safety during pregnancy is
difficult to study; however, it will continue to be a hot topic of research for years
to come.

Pica.
Pica is the craving for and the purposeful consumption of nonfood items (e.g., chalk,
laundry starch, clay). It is a practice that is sometimes seen in pregnant or malnourished
individuals. Although the etiology is unknown, pica is significantly associated with iron
deficiency anemia as well as other contributing factors,

Fetal alcohol syndrome. (From Moore M: Pocket Guide to Nutritional Assessment and Care, 6th ed. St.
Louis, Mosby, 2009.)
• Small head circumference
• Flattened nasal bridge
• Epicanthal fold
• Microphthalmia
• Low set ears
• Small midface
• Indistinct philtrum (groove)
• Thin upper lip
• Small jaw

❖ Teratogen a substance that causes a birth defect.

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CLINICAL APPLICATIONS
Low Birth Weight Baby
- Infants who weigh less than 2500 g (5 lb, 8 oz) at birth often present with
medical complications and require special care in the newborn intensive
care unit.

FACTORS THAT INFLUENCE THE TREND TOWARD LOW BIRTH WEIGHT BABIES
• Premature delivery
• Intrauterine growth restriction
• Health complications of the mother, including disease or infection
• Maternal use of cigarettes, alcohol, and drugs
• Inadequate maternal weight gain and/or poor dietary habits
• Poor socioeconomic factors
• Inadequate or late prenatal care stress.

Although pica may occur in any population group, worldwide it is most common
among pregnant women. The practice of eating nonfood substances can introduce
pathogens (e.g., bacteria, worms) and inhibit micronutrient absorption, thereby resulting
in various deficiencies. Most patients do not readily report the practice of pica; therefore,
practitioners should always ask patients directly about their consumption of any nonfood
substance.

Socioeconomic difficulties.
Special counseling is often needed for women and young girls who live in low-
income situations. Poverty particularly puts pregnant women in grave danger, because
they need resources for food, medical care, and shelter. Dietitians and social workers on
the health care team can provide special counseling and referrals. Community resources
include programs such as the Special Supplemental.

Nutrition Program for Women, Infants and Children, known as WIC, which has
helped to improve the health and well-being of many children in the United States.
WIC also provides nutrition education counseling regarding the nutrition needs of both
the mothers and their babies.

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COMPLICATIONS OF PREGNANCY
For the majority of pregnant women, their gestation will progress without complication.
However, for others, preexisting conditions or health problems that develop along with
the pregnancy will present difficulties.

One such example is hyperemesis gravidarum, which was discussed earlier in this
chapter. Other issues may affect only the fetus, such as neural tube defects. Although
there are a large number of obstacles that may complicate pregnancy, we will focus only
on the more common conditions here.

Anemia
Iron-deficiency anemia is the most common nutritional deficiency worldwide and
is a risk factor for delivering low birth weight infants. Approximately 42% of pregnant
women worldwide experience iron-deficiency anemia (Hb <110 g/L). Although a
disproportionate amount of these cases occur in underdeveloped countries, the
prevalence ranges greatly, from about 6% in North America to 55.8% in Africa.
Anemia is more prevalent among poor women, many of whom live on marginal
diets that lack iron-rich foods, but it is by no means restricted to lower socioeconomic
groups.
Dietary intake must be improved and supplements used as necessary to avoid
the long-term detrimental effects on the fetus of iron deficiency during gestation. As a
result of the severe complications of both iron- and folate-deficiency anemia, the World
Health Organization currently recommends an intermittent (once, twice, or three times
weekly on nonconsecutive days) iron and folic acid dietary supplement as a safe,
effective, and inexpensive way to prevent anemia during pregnancy for women living in
areas with a high risk for anemia.

Intrauterine Growth Restriction

Women with high-risk pregnancies have an elevated risk of intrauterine growth
restriction (IUGR). A fetus with IUGR is at risk for preterm birth and being small for
gestational age, both of which are associated with increased infant morbidity and
mortality. Many factors contribute to IUGR, but low pre-pregnancy weight, inadequate
weight gain during pregnancy, inadequate folate and iron status, and the use of
cigarettes, alcohol, and other drugs are modifiable risk factors. Furthermore, infants who

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suffer from IUGR are at higher risk for the development of chronic diseases as adults,
including cardiovascular disease and hypertension.

Hypertensive Disorders of Pregnancy

The etiology of hypertension development during pregnancy is unknown, but it is
a leading cause of pregnancy-related deaths worldwide. Hypertension is defined as a
blood pressure of ≥140 mm Hg systolic or ≥90 mm Hg diastolic. Hypertensive disorders
of pregnancy include several classifications:
• Chronic hypertension: preexisting hypertension or hypertension that appears before
20 weeks’ gestation.
• Gestational hypertension: high blood pressure diagnosed after 20 weeks’ gestation.
Blood pressure returns to normal within 6 weeks’ postpartum.
Affects 5% to 10% of all pregnancies.
• Preeclampsia: gestational hypertension plus proteinuria (≥300 mg/d of protein in the
urine). Affects 2% to 5% of all pregnancies.
• Eclampsia: preeclampsia plus seizures.
• Preeclampsia superimposed on chronic hypertension: preexisting hypertension
with the development of proteinuria during gestation. Affects 20% to 25% of
women with chronic hypertension.

Hypertension is called the silent disease because it has no symptoms. However, there
are other indicators that alert patients to report to their doctor if they experience signs
such as severe headaches, blurred vision, chest pain, nausea, or a sudden weight gain
(i.e., edema). Specific treatment varies according to individual severity and presentation;
however, in any case, optimal nutrition is important, and prompt medical attention is
required. Salt restriction is not advised because it does not prevent preeclampsia or
intrauterine growth restriction (IUGR) a condition that occurs when a newborn weighs
less than 10% of predicted fetal weight for gestational age.

Women with mild preexisting hypertension or gestational hypertension, without

additional comorbidities, are usually not at risk for poor pregnancy
outcome. Complications of severe hypertensive and preeclampsia/eclampsia often
require hospitalization and, in advanced cases, induced labor. Preeclampsia is

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thought to be a disorder of the placenta and there are currently no known cures.
Preeclampsia/eclampsia is associated with poor fetal outcomes such as maternal
and fetal morbidity and mortality, IUGR, low birth weight, and preterm delivery. Thus,
early and consistent prenatal care is imperative in order to identify symptoms early.

Gestational Diabetes
Gestational diabetes is defined as glucose intolerance with onset during
pregnancy, and the definition applies regardless of whether medication (e.g., oral
hypoglycemic agents, insulin) or only diet modification is used for treatment. Women
found to have diabetes at their initial prenatal visit (usually by fasting or random blood
glucose test) are assumed to have had undiagnosed diabetes before becoming pregnant
and are therefore diagnosed with overt diabetes and not gestational diabetes. The
prevalence of gestational diabetes in the United States is approximately 7% of all
pregnancies annually. The treatment for gestational diabetes follows a similar protocol
as that for type 2 diabetes, with diet and exercise of paramount importance as a first-line
treatment plan.
Prenatal clinics routinely screen pregnant women between 24 and 28 weeks’
gestation with either a “One- Step” or a “Two-Step” oral glucose tolerance test for
diagnosis. Particular attention is given to women who are at higher risk for the
development of gestational diabetes, including those who are 30 years old and
older who are overweight (i.e., those with a BMI of ≥26 kg/m2) and who have a history of
any of the following predisposing factors:
• Previous history of gestational diabetes
• Family history of diabetes
• Ethnicity associated with a high incidence of diabetes
(Asian, Hispanic, African Americans, and Native Americans)
• Glucosuria
• Obesity
• Previous delivery of a large baby weighing 4.5 kg (10 lb) or more

Women with gestational diabetes are at higher risk for caesarean delivery and
fetal damage such as birth defects, stillbirth, macrosomia, and neonatal hypoglycemia.
Additionally, these women have a 7-fold increased risk of developing type 2 diabetes
later in life. Therefore, identifying and providing close follow-up testing and treatment

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with a well-balanced diet, exercise, and medication (as needed) are important
interventions.

Preexisting Disease
Preexisting diseases (e.g., cardiovascular diseases, hypertension, type 1 or 2
diabetes, HIV, eating disorders) can cause complications during pregnancy.
Inborn errors of metabolism (e.g., phenylketonuria) and food allergies or intolerances
(e.g., celiac disease, lactose intolerance) must also be taken into consideration
and maintained under good control to mitigate any flare-ups or compromised nutrient
intake. All potential preexisting diseases will not be discussed here, because pregnant
women may have any combination of preexisting conditions.
In each case, a woman’s pregnancy is managed— usually by a team of
specialists—in accordance to the principles of care related to pregnancy and the
particular disease involved.

ACTIVITY
CASE STUDY

SCENARIO:
Mrs. Delima is a 19-year-old married primigravida, who tested positive for urinary
human chorionic gonadotropin (hCG) 2 weeks earlier. Mrs. Delgado is 160 cm (5 feet 3
inches) tall with an average pre-gravid weight of 57 kg (125 lb). Her current gestational
age is 6 weeks. Her history for chronic disorders and other serious health problems is
negative.
During her initial nutrition interview, Mrs. Delima indicated that the pregnancy
was unplanned. She seemed especially worried about the effects of her irregular diet on
the baby. As college students, she and her 21-year-old husband had erratic meals,
dominated by junk food. Mrs. Delima’s 24-hour diet history revealed an inadequate
intake of dark-green or red, yellow- orange vegetables and milk products, as well as
meat or eggs and citrus fruits. The couple realized that these types of foods were an
important part of a nutritious diet but felt inexperienced as cooks and lacked the time and
money to prepare healthful meals every day.
At the end of the initial counseling session, the nutritionist told the couple about a
series of prenatal group discussions conducted by members of the clinic’s perinatal

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health team, including sessions on pregnancy, labor and delivery, and the care and
feeding of the infant. These are attended primarily by a mixture of experienced parents
and young, first-time parents to be and are offered as a means of introducing practical
aspects of pregnancy and parenting.
The Delimas attended every prenatal group meeting and kept all consequent
diet-counseling sessions. Their food choices improved in time, and Mrs. Delgado’s
weight gain progressed normally, to a total of 13 kg (28.5 lb) by the time of delivery. The
Delimas had a healthy 4 kg (8 lb 13 oz) baby girl.

Questions for Analysis

1. What health professionals ideally should be included on the health care team caring
for Mrs. Delima? Describe the significance of each role to the outcome of her pregnancy.
What are the roles of Mr. and Mrs. Delima?
2. What nutritional deficiencies would you expect in Mrs. Delima’s diet? What practical
problems would you expect her to encounter in attempting to improve her diet?
3. Write a 1-day meal plan/ recommendation for Mrs. Delima, taking into account her
lifestyle and schedule, as well as the amounts of nutrients considered adequate for
pregnancy.
4. Would you encourage Mrs. Delima to breast-feed? If so, then why? What factors
would you expect might discourage her from trying? How would you discuss these
factors?

LESSON 2
LACTATION
1. Common Nutritional Problems and Interventions
2.Breastfeeding trends
a. breastfeeding techniques
3.Physiology of lactation
4.Composition of human milk
5.Benefits of breastfeeding
6.Nutrition for breastfeeding women

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 WEEK TOPIC LEARNING OUTCOME ACTIVITIES

At the end of the lesson, you will be able

to:
1. Discuss lactation management techniques.
2. Review infant feeding trends & strategies.
3. Identify women`s health concerns during
lactation.

Lactation is the secretion and yielding of milk by females after giving birth. The
milk is produced by the mammary glands, which are contained within the breasts.

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PHYSIOLOGY OF LACTATION

Lactation is the process by which milk is synthesized and secreted from the
mammary glands of the postpartum female breast in response to an infant sucking at the
nipple. Breast milk provides ideal nutrition and passive immunity for the infant,
encourages mild uterine contractions to return the uterus to its pre-pregnancy size (i.e.,
involution), and induces a substantial metabolic increase in the mother, consuming the
fat reserves stored during pregnancy.

STRUCTURE OF THE LACTATING BREAST

- Mammary glands are modified sweat glands.

- The non-pregnant and non-lactating female breast is composed primarily
of adipose and collagenous tissue, with mammary glands making up a
very minor proportion of breast volume.
- The mammary gland is composed of milk-transporting lactiferous ducts,
which expand and branch extensively during pregnancy in response to
estrogen, growth hormone, cortisol, and prolactin.
- Moreover, in response to progesterone, clusters of breast alveoli bud
from the ducts and expand outward toward the chest wall.
- Breast alveoli are balloon-like structures lined with milk-secreting cuboidal
cells, or lactocytes, that are surrounded by a net of contractile
myoepithelial cells.
- Milk is secreted from the lactocytes, fills the alveoli, and is squeezed into
the ducts.
- Clusters of alveoli that drain to a common duct are called lobules; the
lactating female has 12–20 lobules organized radially around the nipple.
- Milk drains from lactiferous ducts into lactiferous sinuses that meet at 4 to
18 perforations in the nipple, called nipple pores.
- The small bumps of the areola (the darkened skin around the nipple) are
called Montgomery glands.
- They secrete oil to cleanse the nipple opening and prevent chapping and
cracking of the nipple during breastfeeding.
-

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 THE PROCESS OF LACTATION

The pituitary hormone prolactin is instrumental in the establishment and maintenance of

breast milk supply. It also is important for the mobilization of maternal micronutrients for
breast milk.

Near the fifth week of pregnancy, the level of circulating prolactin begins to increase,
eventually rising to approximately 10–20 times the pre-pregnancy concentration. We
noted earlier that, during pregnancy, prolactin and other hormones prepare the breasts
anatomically for the secretion of milk. The level of prolactin plateaus in late pregnancy,
at a level high enough to initiate milk production. However, estrogen, progesterone, and
other placental hormones inhibit prolactin-mediated milk synthesis during pregnancy. It
is not until the placenta is expelled that this inhibition is lifted and milk production
commences.

After childbirth, the baseline prolactin level drops sharply, but it is restored for a 1-hour
spike during each feeding to stimulate the production of milk for the next feeding. With
each prolactin spike, estrogen and progesterone also increase slightly.

When the infant suckles, sensory nerve fibers in the areola trigger a neuroendocrine
reflex that results in milk secretion from lactocytes into the alveoli. The posterior pituitary
releases oxytocin, which stimulates myoepithelial cells to squeeze milk from the alveoli
so it can drain into the lactiferous ducts, collect in the lactiferous sinuses, and discharge
through the nipple pores. It takes less than 1 minute from the time when an infant begins
suckling (the latent period) until milk is secreted (the let-down).

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Figure 1 summarizes the positive feedback loop of the let-down reflex.

Figure 1. Let-Down Reflex. A positive feedback loop ensures continued milk production
as long as the infant continues to breastfeed.

The prolactin-mediated synthesis of milk changes with time. Frequent milk

removal by breastfeeding (or pumping) will maintain high circulating prolactin levels for
several months. However, even with continued breastfeeding, baseline prolactin will
decrease over time to its pre-pregnancy level. In addition to prolactin and oxytocin,
growth hormone, cortisol, parathyroid hormone, and insulin contribute to lactation, in part

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by facilitating the transport of maternal amino acids, fatty acids, glucose, and calcium to
breast milk.

CHANGES IN THE COMPOSITION OF BREAST MILK

In the final weeks of pregnancy, the alveoli swell with colostrum, a thick,
yellowish substance that is high in protein but contains less fat and glucose than mature
breast milk. Before childbirth, some women experience leakage of colostrum from the
nipples. In contrast, mature breast milk does not leak during pregnancy and is not
secreted until several days after childbirth.

*Cow’s milk should never be given to an infant. Its composition is not suitable and its
proteins are difficult for the infant to digest.
Compositions of Human Colostrum, Mature Breast Milk, and Cow’s Milk (g/L)
(Table 3)
Human colostrum Human breast milk Cow’s milk*
Total protein 23 11 31
Immunoglobulins 19 0.1 1
Fat 30 45 38
Lactose 57 71 47
Calcium 0.5 0.3 1.4
Phosphorus 0.16 0.14 0.90
Sodium 0.50 0.15 0.41

Colostrum is secreted during the first 48–72 hours postpartum. Only a small
volume of colostrum is produced—approximately 3 ounces in a 24-hour period—but it is
sufficient for the newborn in the first few days of life. Colostrum is rich with
immunoglobulins, which confer gastrointestinal, and also likely systemic, immunity as the
newborn adjusts to a nonsterile environment.

COLOSTRUM – A fluid that is first secreted by the mammary glands for the first few days after birth,
preceding the mature breast milk. Colostrum contains up to 20% protein, including a large amount of
lactalbumin, more minerals, and immunoglobulins that represent the antibodies found in material blood. It
has less lactose and fat than mature milk.

After about the third postpartum day, the mother secretes transitional milk that
represents an intermediate between mature milk and colostrum. This is followed by

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mature milk from approximately postpartum day 10 As you can see in the accompanying
table, cow’s milk is not a substitute for breast milk. It contains less lactose, less fat, and
more protein and minerals. Moreover, the proteins in cow’s milk are difficult for an
infant’s immature digestive system to metabolize and absorb.

The first few weeks of breastfeeding may involve leakage, soreness, and periods
of milk engorgement as the relationship between milk supply and infant demand
becomes established. Once this period is complete, the mother will produce
approximately 1.5 liters of milk per day for a single infant, and more if she has twins or
triplets. As the infant goes through growth spurts, the milk supply constantly adjusts to
accommodate changes in demand. A woman can continue to lactate for years, but once
breastfeeding is stopped for approximately 1 week, any remaining milk will be
reabsorbed; in most cases, no more will be produced, even if suckling or pumping is
resumed.

Mature milk changes from the beginning to the end of a feeding. The early milk,
called foremilk, is watery, translucent, and rich in lactose and protein. Its purpose is to
quench the infant’s thirst. Hindmilk is delivered toward the end of a feeding. It is
opaque, creamy, and rich in fat, and serves to satisfy the infant’s appetite.

During the first days of a newborn’s life, it is important for meconium to be

cleared from the intestines and for bilirubin to be kept low in the circulation. Recall that
bilirubin, a product of erythrocyte breakdown, is processed by the liver and secreted in
bile. It enters the gastrointestinal tract and exits the body in the stool. Breast milk has
laxative properties that help expel meconium from the intestines and clear bilirubin
through the excretion of bile. A high concentration of bilirubin in the blood causes
jaundice. Some degree of jaundice is normal in newborns, but a high level of bilirubin—
which is neurotoxic—can cause brain damage. Newborns, who do not yet have a fully
functional blood–brain barrier, are highly vulnerable to the bilirubin circulating in the
blood. Indeed, hyperbilirubinemia, a high level of circulating bilirubin, is the most
common condition requiring medical attention in newborns. Newborns with
hyperbilirubinemia are treated with phototherapy because UV light helps to break down
the bilirubin quickly.

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TRENDS
Approximately 37% of infants worldwide are exclusively breastfed for the first 6
months of life, compared with only 18.8% in the United States. Although the rates are
still low in the United States compared with other countries, breastfeeding has been on
the rise initiation and continuation are highest among well educated, older women.
The Healthy People 2020 report lists specific goals to increase the prevalence
and duration of breastfeeding in the United States:
• Increase the proportion of infants who are breastfed at least 1 year to 34%.
• Increase the proportion of employers that have worksite lactation support
programs to 38%.
• Increase the proportion of live births that occur in facilities that provide
recommended care for lactating mothers and their babies to 8%.
• Reduce the proportion of breastfed newborns who receive breast milk
substitutes within the first 2 days of life to 14% or less.

THE BABY-FRIENDLY HOSPITAL INITIATIVE

The Baby-Friendly Hospital Initiative, which was launched by the World Health
Organization and the United Nations Children’s Fund, has worked to promote
breastfeeding rates worldwide since 1991. 10 steps for successful breastfeeding
that are recommended by the Baby-Friendly Hospital Initiative. Almost all women who
choose to breastfeed their infants can do so, provided they have the necessary
information and support from their family, community, and health care system. Well-
nourished mothers who exclusively breastfeed provide adequate nutrition to their infants,
as well as a host of other beneficial components.

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 TEN STEPS TO SUCCESSFUL BREASTFEEDING

Cultural Considerations

As a health care provider, be sure to note the perceived obstacles to the initiation
and continuation of breastfeeding so that education and alternatives may be presented
at the appropriate time (i.e., before delivery). The American Academy of Pediatrics notes
the following potential obstacles3:

• Insufficient prenatal education about breastfeeding

• Disruptive hospital policies and practices

• Inappropriate interruption of breastfeeding

• Early hospital discharge in some populations

• Lack of timely routine follow-up care and postpartum home health visits

• Maternal employment (especially in the absence of workplace facilities that

support breastfeeding)

• Lack of family and broad societal support

• Media portrayal of bottle-feeding as normal

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 • Commercial promotion of infant formula through the distribution of hospital
discharge packs containing breast milk substitutes

• Coupons for free or discounted formula

• Misinformation about what medical conditions may be contraindications for
breastfeeding
• Lack of guidance and encouragement from health care professionals

REFERENCES
1. National Center for Chronic Disease Prevention and Health Promotion. Rates of any and exclusive breastfeeding by
sociodemographics among children born in 2011. Atlanta, Ga: Centers for Disease Control and Prevention; 2014.
Available at: <www
.cdc.gov/breastfeeding/data/nis_data/rates-any-exclusive-bf-socio-dem-2011.htm>.
2. Centers for Disease Control and Prevention. Rates of any and exclusive breastfeeding by state among children born
in 2011.Atlanta, Ga: Department of Health and Human Services; 2014.Available at:
<www.cdc.gov/breastfeeding/data/nis_data/rates-any
-exclusive-bf-state-2011.htm>.
3. Gartner LM, et al. Breastfeeding and the use of human milk.Pediatrics. 2005;115(2):496-506.

Supply and Demand

Milk production is a supply-and-demand procedure. The mammary glands are
stimulated to produce milk each time that the infant feeds. Therefore, the more milk that
is taken from the breast (i.e., during breastfeeding or pumping), the more milk the
mother produces, thereby always meeting the infant’s needs.
As a result of this supply-and-demand production, mothers of multiple infants
(e.g., twins, triplets) are able to produce more milk with the additional stimulation.
Some mothers of multiples choose to pump and then bottle-feed the infants the breast
milk so that other members of the family can help with feedings.

Complications
Although breastfeeding is a natural physiologic process, it is not without
complications. Many women find breastfeeding difficult and these problems rapidly lead
to the cessation of breastfeeding. Not all issues are physiologic in nature though; some
problems women face are psychologic and perception-based. For example, the two
most common reasons women stop breastfeeding are (1) their perception that the baby
is not satisfied with breast milk alone and (2) they do not think they are making enough
milk. Mothers have reported discontinuation of breastfeeding within the first month of the
infant’s life because of the following common reasons:

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• Physiologic and nutritional: Sore, cracked, or bleeding nipples; engorged breast; the
baby had trouble latching on; breastfeeding was too painful; breast milk alone did not
satisfy my baby; I did not have enough milk; and I had trouble getting the milk flow to
start.
• Psychosocial: Breastfeeding was too tiring or inconvenient; I did not want to breastfeed
in public.
• Medical and infant self-weaning: My baby lost interest; I was sick and had to take
medicine; my baby weaned himself.

Almost all of the complications encountered during breastfeeding could either be

prevented or be treated by motivated and educated health care practitioners and
mothers. A thorough understanding of the physiology of lactation and the psychosocial
factors influencing the success of breastfeeding are imperative to effectively support a
nursing mother. The article by Bergmann and colleagues (full reference provided in
the reference section for this chapter at the back of the book.) is an excellent resource
for understanding the common medical problems of breastfeeding.

NUTRITIONAL NEEDS
1. Energy and nutrients.
Lactation requires energy for both the process and the product. Some of this
energy will be met by the extra fat that is stored in the mother during pregnancy. The
increased calorie recommendations are 330 kcal/day (plus 170 kcal/day from maternal
stores) during the first 6 months of lactation and 400 kcal/day during the second 6
months of lactation over the woman’s nonpregnant, nonlactating energy requirements.
The requirement for protein during lactation is 25 g/day more than a woman’s average
need of 46 g/day, for a total of 71 g/day (i.e., 1.1 g/kg body weight per day).

When considering the energy requirement for the development of a zygote to a

7.5-lb infant, it is no surprise that energy intake is a critical part of a healthy pregnancy.
Likewise, providing that infant with enough nutrition through exclusive breastfeeding
to double their birthweight in about 5 months will require a substantial amount of energy
and nutrients provided by the mother through her diet and stored body fat.

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This additional energy need for the overall total lactation process is based on the
following four factors:
a. Milk content:
An average daily milk production for lactating women is 780mL (26oz). The
energy content of human milk averages 0.67 to 0.74kcal/g. Thus 26oz of milk has a
value of about 525 kcal.
2. Milk production:
The metabolic work involved in producing this amount of milk is about 80%
efficient and requires from 400 to 450kcal. During pregnancy the breast is developed for
this purpose, stimulated by hormones from the placenta, and forms special milk-
producing cells called lobules. After birth the mother’s production of the hormone
prolactin continues this milk-production process, which the suckling infant stimulates.
Thus, milk production depends on the demand of the infant.
The suckling infant stimulates the brain’s release of the hormone oxytocin from
the pituitary gland to initiate the letdown reflex for the release of the milk from storage
cells to travel down to the nipple. This reflex is easily inhibited by the mother’s fatigue,
tension, or lack of confidence, a particular source of anxiety in the new mother. She may
be reassured that a comfortable and satisfying feeding routine is usually established in 2
to 3 weeks.
3. Maternal adipose tissue storage:
A component of the energy need for lactation (170kcal/day in the first 6 months)
is drawn from maternal adipose tissue stores deposited during pregnancy in normal
preparation for lactation to follow in the maternal cycle. Depending on the adequacy
of these stores, additional energy input may be needed in the lactating woman’s daily
diet.
4. Exercise:
Lactating women generally balance energy expenditure from exercise with
increased energy intake and alterations in prolactin to maintain an adequate milk supply.
In some women, the weight gained during pregnancy may be largely retained and
contribute to obesity.
Some overweight women who are breast-feeding have concerns whether a
weight-loss program might endanger the growth of their infants. Research with
overweight women who were exclusively breast-feeding has shown that a diet and
exercise program that led to a weight loss of around 0.5 kg/week (approximately 1

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lb/week) from 4 to 14 weeks postpartum did not affect infant growth. However, the
mother who is involved in any specific weight-loss program during lactation should be
monitored closely as should her infant.

• Protein
The recommendation for protein needs during lactation is 71 g/day during both
the first 6 months and the second 6 months. This is an increase of about 25 g/day from
the regular needs of the adult woman.

• Minerals
The DRI standard for calcium during lactation is 1000 mg/ day, the same as for
the nonpregnant or pregnant adult woman. The amount of calcium that was required
during gestation for the mineralization of the fetal skeleton is now diverted into the
mother’s milk production. Iron, because it is not a major mineral component of milk and
because of lactational amenorrhea, need not be increased during lactation.

• Vitamins
The DRI standard for vitamin C during lactation is 120 mg/ day. This is a
considerable increase from the regular 75mg/ day for adult women. Increases beyond
the mother’s prenatal intake are also recommended for vitamin A because it is a
constituent of milk, and for the B-complex vitamins because they are involved as
coenzyme factors in energy metabolism. Therefore the quantities of vitamins needed
invariably increase as the kcalorie intake increases.

• Food Intake

In general, 7 to 8 oz of grains, at least one half of which are whole grains; 3 cups
of vegetables; 2 cups of fruits; 3 cups of fluid milk or dairy products; 6 to 6.5 oz of lean
meats, poultry, fish, dried beans, and nuts; and 6 to 7 tsp of oils per day are
recommended to meet nutrient needs during lactation (www.ChooseMyPlate.gov).
2. Fluids.
Because milk is a fluid, breastfeeding mothers need ample fluids for adequate
milk production; their fluid intake should be approximately 3 L/day. Water and other
sources of fluid such as juices, milk, and soup contribute to the fluid that is necessary to

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 produce milk. Beverages that contain alcohol and caffeine should be avoided, because
these substances pass into the breast milk.

Sample meal plan showing the distribution of the different nutrients

Normal Recommended Recommended
recommended intake during intake during
Nutrient intake pregnancy lactation
Energy (kcal) 2,000 2,450 2,500
Protein (g) 46 71 71
Vitamin A (μg) 700 770 1,300
Iron (mg) 18 27 9
Folic acid (μg) 400 600 500
Iodine (μg) 150 220 290
Calcium (mg) 1,000 1,000 1,000
Zinc (mg) 8 11 12
Vitamin B12 (μg) 2.4 2.6 2.8

Things to avoid during breastfeeding

• Minimize caffeine intake.
• Be careful with drugs.

• Alcohol and smoking should be avoided. They can make your baby feel sleepy, nervous
and irritable.

• Resist the temptation of losing weight through diet or medication.

LONG-TERM IMPACTS OF FEEDING METHODS

Risks of Using Breast Milk Substitutes
Medical professionals agree that breastfeeding is the normal means by which an
infant should be fed and that other feeding methods carry risks for the infant.
For decades, the literature has presented many “benefits of breastfeeding.” However,
many researchers believe that it is more useful to present the risks of formula feeding as
opposed to the benefits of feeding in a normal manner. Another way to look at it is to
assume that the many “benefits of breastfeeding” are only the normal expectations of
infant feeding; therefore, infants who are receiving other forms of breast milk substitutes
are suffering a loss.
Advantages of Breastfeeding

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 Many physiologic and practical advantages of breastfeeding are gained by both
the mother and the infant. Several such benefits are listed in Box 10-3.
The antibodies in human milk that are passed to the nursing infant make a significant
contribution to the infant’s immune system. This accounts for the reduced
risk of many diseases and infections. In addition, research indicates that breastfed
infants are cognitively advanced compared with formula-fed infants, despite
differences in environments, with a positive relationship seen between the duration of
breastfeeding and the intelligence quotient of the child. In a recent publication on the
long-term advantages of breastfeeding, the World Health Organization concluded that
“there is strong evidence of a causal effect of breastfeeding on IQ”.
The mother receives many health benefits as well. Some noted advantages of
breastfeeding for the mother are decreased bleeding; an earlier return to pre-pregnancy
weight; and decreased risks of breast cancer, ovarian cancer, and osteoporosis.
ADDITIONAL RESOURCES
The Academy of Nutrition and Dietetics and the American Academy of Pediatrics encourage and strongly support
breastfeeding for all able mothers for the first 12 months of life and continued thereafter for as long as mutually
desired. The American Academy of Pediatrics keeps updated breastfeeding information available for the public at
www.healthychildren.org.

The World Health Organization has written and posted an entire chapter entitled “Infant and Young Child Feeding” for
medical students and allied health professionals that is freely available online at
whqlibdoc.who.int/publications/2009/9789241597494_eng.pdf. A multitude of additional resources about this topic are
available from the World Health Organization at www.who.int/topics/breastfeeding/en/.

LACTATION SPECIALIST - health care professionals with specialized knowledge and clinical expertise in
breastfeeding and human lactation. Also known as a
lactation consultant.

BOX 10-3 Benefits of Breastfeeding Compared with Using Breast Milk

Substitutes (i.e., Formula)
BENEFITS FOR INFANTS BENEFITS FOR MOTHERS
• Optimal nutrition for infant • Strong bonding with infant
• Strong bonding with mother • Increased energy expenditure, which may lead to
faster
return to pre-pregnancy weight
• Safe, fresh milk • Faster shrinking of the uterus
• Enhanced immune system • Reduced postpartum bleeding
• Reduced risk for acute otitis media, nonspecific • Money saved by not buying formula and from not
gastroenteritis, severe lower respiratory tract having
infections, and to pay the increased medical expenses associated
asthma with formula feeding
• Protection against allergies and intolerances • Improved bone density and decreased risk for hip
fracture

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 • Promotion of the correct development of the jaw • Time saved by not having to purchase, prepare,
and teeth and mix
formula
• Association with higher intelligence quotient and • Decreased risk for chronic diseases such as type
school 2 diabetes and breast and ovarian cancer
performance through adolescence as a function of
parental skill
• Reduced risk for sudden infant death syndrome • Delayed return of the menstrual cycle
• Reduced risk for chronic diseases such as • Decreased risk for postpartum depression;
obesity, type 1 enhanced
and 2 diabetes, heart disease, and childhood self-esteem in the maternal role
leukemia
• Reduced risk for infant morbidity and mortality
From James DC, Lessen R. Position of the American Dietetic Association: promoting and supporting breastfeeding.
J Am Diet Assoc. 2009;109(11):1926-1942.

SELECTED NUTRITIONAL COMPONENTS OF HUMAN

Table MILK (Per 100ml)
Milk Component Colostrum Transitional Mature Cow’s Milk
Kilocalories 57 63 65 65
FS-Vitamins
A (mcg) 151 88 75 42
D (IU) - - 5 2.5
E (mg) 1.5 0.9 0.25 0.07
K (mcg) - - 1.5 6
WS-Vitamins
Thiamin (mcg) 1.9 5.9 14 43
Riboflavin (mcg) 30 37 40 145
Niacin (mcg) 75 175 160 82
Pantothenic acid (mcg) 183 288 246 340
Biotin (mcg) 0.06 0.35 0.6 2.8
Vitamin B12 (mcg) 0.05 0.04 0.1 1.1
Vitamin C (mg) 5.9 7.1 5 1.1

Breast Milk for the Preterm Infant

The levels of nutrients in mother’s milk shift according to the gestational age of
the infant at birth. The preterm infant is often denied its mother’s milk by some hospital
workers because they think of it as mature milk having too little protein and too much

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lactose to meet the child’s needs. An analysis of the nutritional quality of preterm milk,
however, reveals energy and fat concentrations that are 20% to 30% greater, protein
levels 15% to 20% greater, and lactose levels 10% lower than those found in mature
milk. Premature milk can meet the preterm infant’s nutritional and developmental needs,
if the mother is committed to breast-feeding and/or expressing breast milk and feeding
by bottle or feeding tube to her infant.

Breast Milk During Weaning

Nutrient levels continue to change with time to match changing growth patterns
and developing digestive abilities. Mother’s milk does provide sufficient kcalories and
nutrients to keep babies well fed without supplemental formula or food. Even when the
infant is being weaned, the nature of human milk ensures adequate nutrients, just in
case the new, solid-food diet cannot meet the child’s needs. Human milk collected
during gradual weaning has been found to have increased concentrations of protein,
sodium, and iron. Lactose levels are lower, possibly so that increased amounts of
kcalories can be supplied by fats, a more concentrated source.

Breast Milk and the Cesarean Section Infant

The quality of human milk is not influenced by the way the baby comes into the
world. Many women fear that a baby born by cesarean section cannot be nursed
because they think that this method of delivery delays or prevents the production of
mature milk. Milk production is stimulated by the release of the placenta, which occurs
whether the delivery is vaginal or not. Studies confirm that no significant difference exists
in the length of time it takes for mature milk to come in after vaginal
or cesarean deliveries.

Thus, premature or cesarean deliveries should not discourage women from

breast-feeding. Mothers should not underestimate the nutritive quality of their milk simply
because it does not appear as rich and thick as cow’s milk. After all, cow’s milk is made
for young calves, who are up and running around after birth and have a much shorter,
faster growth period. For the human infant, in nutritional and immunologic terms, breast
milk remains the best milk.

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Mothers’ Facts and Fancies About Breast-Feeding
In early counseling, mothers express a variety of concerns about breast-feeding.
Following are a few such statements:

“My Breasts Aren’t Big Enough”

When it comes to breast-feeding, all women are created equal.
The only parts of the breast that participate in milk production are the glandular and
nervous tissue and the nipple; these are basically the same in healthy women. The only
difference between a size 32A and a size 42DD is the amount of fat tissue the breast
contains.

“Breast-Feeding Causes Cancer”

Actually, investigators have been looking to breast-feeding as a possible means
of preventing breast and ovarian cancer. Epidemiologic studies suggest a decreased risk
for these cancers in women who breast-feed, but additional evidence is needed before a
consensus may be reached.

“Breast-Feeding Will Ruin My Figure”

Because the caloric demand of breast-feeding exceeds that of the nonpregnant
woman by about 400 to 500 kcalories, a slightly faster rate of weight loss may be
expected, although hormonal adaptations may limit the extent to which weight loss is
experienced during lactation. Oxytocin, the hormone manufactured to stimulate the
letdown reflex, also stimulates uterine contractions, helping reduce the uterus to its pre-
pregnancy size more rapidly.

“Breast-Feeding Is Painful”
It may be painful in the first few days or even weeks as mother and baby
establish a pattern of feeding and proper latch and release techniques. Milk should not
be allowed to collect in the breast to the point of engorgement, the nipples should be
kept clean and dry, and a variety of feeding positions may be used while nursing to
decrease the chances of having a painful experience. Mastitis is a painful infection of the
breast that requires medical attention and often antibiotic treatment.

“Breast Milk Is Not Nutritious”

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 The thin, bluish appearance of breast milk has some women convinced that it is
no more nourishing than water. Let them look at Table 11-3; they will be pleasantly
surprised at how well breast milk meets the nutritional needs of the infant.

“I Will Have to Change My Diet to Breast-Feed”

Foods that were eaten during pregnancy may be consumed during lactation.
Some women report that after they eat onions, cauliflower, cabbage, or other foods their
infants do not like the taste of their breast milk. Other women say that eating chocolate
or drinking coffee, for example, “makes their babies fussy” when breast-feeding.
Scientific evidence does not discourage moderate intake of these foods or drinks. A well-
balanced diet that includes a variety of colorful foods and fluids is encouraged during
breast-feeding.
“I Cannot Go to Work or School if I Breast-Feed”
Breast milk can be stored for up to 5 days in the refrigerator or up to 5 months in
the freezer. Many working mothers take advantage of this by expressing their milk and
storing it for use by care providers. In fact, women often express milk on their breaks at
school or work. (Some places of employment even have lactation rooms and provide
breast pumps at the workplace.) Expressing milk not only relieves the pressure
of buildup but it also allows the milk to be stored for later use at home.
Other women would like to breast-feed but are worried about special “what if” situations,
such as the following:

“What if the Baby Is Premature?”

Mother’s milk changes to meet the infant’s needs at all stages of development.

“What if the Baby Has Down Syndrome?”

Infants with Down syndrome can be nursed; however, it does require time,
patience, and the use of slightly different nursing techniques. The mother should be told
about the special nursing needs of infants with Down syndrome to avoid disappointment
or a feeling of failure should breast-feeding become impractical for her particular living
situation.

“What if I Have Twins?”

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 Believe it or not, it has been done. It takes time, patience, and good coordination
to breast-feed twins, but it is possible. Triplets, however, are another matter altogether.
Women have successfully nursed triplets, but often they did very little else
until the babies were weaned. This mother will need emotional support, whether she
attempts to nurse or, finding the amount of time and patience required overwhelming,
prefers to bottle-feed.

“What if I Have Pierced Nipples or Have Had Breast Surgery?”

Nipple jewelry appears to interfere with breast-feeding; however, a mother who
wishes to maintain her piercing while breast-feeding may use retainers. Women should
be made aware that serious complications because of nipple piercing have been
reported, requiring pharmaceutical or surgical treatments that have required up to 12
months for resolution. Very little is known about later breast-feeding successes or
complications after earlier removal of a nipple piercing. Breast augmentation
and reduction surgeries have shown mixed results related to successful breast-feeding;
however, this issue has not been adequately investigated. One retrospective study has
shown that previous breast reduction does not impair the ability to breast-feed, while a
separate study found that breastfeeding success was 25% lower in women who had
undergone breast augmentation. Women should be informed about the current lack of
knowledge surrounding these issues but presented with guidance for decision making.

“What if I Become Pregnant?”

Some women may purposefully choose to breast-feed to avoid pregnancy, but
this is not a dependable contraception method.
Well-nourished women of the world tend to be more fertile and may find themselves
pregnant and breast-feeding at the same time. Women who breast-feed must
understand that the lack of a menstrual period during lactation (lactational amenorrhea)
does not mean they cannot become pregnant. Contraceptives may be required if
another pregnancy is not desired at the current time. If pregnancy occurs, then the
woman should discuss appropriate infant-feeding solutions with her health care team.

Advantages and Barriers to Breast-Feeding

These factors need to be reviewed with each individual mother in her particular situation
so that she can make the informed decision that is best for the infant and herself.

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Many nutritional, physiologic, psychologic, and practical advantages to breast-feeding
exist; six are identified as follows:
1. Human milk changes to meet changing nutrient and energy
needs of the newborn and the maturing infant during the first months of life. It is always
there in the correct form to meet the growing infant’s needs.
2. Infants experience fewer infections because the mother
transfers certain antibodies and immune properties in human
milk to her nursing infant. In addition, no exposure of the
infant to infectious organisms in the environment that can contaminate preparation and
equipment for bottle-feeding, especially in poorer living situations.
3. Fewer allergies and intolerances occur, especially in allergy prone infants, because
cow’s milk contains a number of potentially allergy-causing proteins that human milk
does not have.
4. Ease of digestion is greater with breast milk because human
milk forms a softer curd in the gastrointestinal tract that is easier for the infant to digest.
5. The convenience and economy of breast milk are greater
because the mother is free from the time and expense involved in buying and preparing
formula, and her breast milk is always ready and sterile.
6. Breast-feeding provides psychologic bonding because the mother and infant relate to
one another during feeding, regular times of rest and enjoyment, and cuddling and
fulfillment.

Despite the advantages of breast-feeding, some women do have to deal with perceived
barriers associated with misinformation, personal feelings of modesty, family pressures,
or outside employment, among other factors. Addressing these barriers, such as the
following, before delivery rather than after will increase the likelihood that the mother
breast-feeds her infant:

• Misinformation, a major barrier, creates negative impressions and ideas. Women in

today’s world often lack positive role models in extended families or experienced friends
with whom they can discuss their feelings and obtain much practical guidance.
Experienced breast-feeding mothers or lactation consultants can fill this need, especially
for young first-time mothers.

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• Personal modesty and anxiety, or a fear of appearing immodest in breast exposure,
may hinder some mothers from breast-feeding. Sensitive counseling, especially with a
positive role model as described previously, can help to allay some of these personal
fears. Most of women’s breastfeeding is done in the privacy of the home rather than
around others; therefore early support during initial experiences would be helpful.

• Family pressures, especially from the husband, not to breastfeed have strong
influences on the mother, even though she may want to do so. Initial counseling and
education about breast-feeding should include both parents whenever possible.
Reasons for negative attitudes can be explored and misinformation clarified with sound
education.

• Outside employment, with a limited maternity leave and job loss if the mother does not
return to work at that time, can complicate the mother’s decision, even though she may
want to breast-feed her baby. However, if the mother does have the will, then it is
possible to breast-feed and be employed. After breast-feeding is well established, she
can regularly express milk by hand or with a breast pump into sterile disposable nursing
bags to use with disposable holder, cap, and nipple ensemble. Rapid chilling and strict
sanitation are required, but it can be planned, given the commitment.

Some companies provide child care facilities for their employees, recognizing
that helping employees with this modern need is good business. The mother can plan
occasional formula feeds to fill in with the sustained breast-feeding.
All of these approaches to breast-feeding have real rewards for the infant. In
addition, they can strengthen the mother’s confidence in her maternal capabilities. The
importance of these intangible benefits should not be underestimated.

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Breastfeeding Techniques That Work:

Look at some time-tested breastfeeding positions that may help nursing go smoothly.

1. Cradle Hold:

It is a natural and most comfortable position for older babies who can handle their head
better.

Here are the basic steps for this technique:

• Sit comfortably with your baby at the level of your heart

• Cradle your little one in your arm with her tummy against yours and head resting in
your elbow bend. Her ear, shoulders and hip should follow a straight line.
• Place your baby’s lower arm under your breast or your underarm with her mouth
near to your breast.
• Using your free hand to support your breast.
• Rest your thumb above the areola and the rest of the fingers beneath the breast.
• Now gently fondle your nipple on her lower lip. In response to the rooting reflex,
her mouth opens wide that takes some time.
• Pull her quickly onto the breast and let her latch-on.
• Another variation, the laid back breastfeeding, the mother rests in a reclined
position with tummy to tummy contact with the baby where her instincts work to get
on the breast. It is a learning process that takes time for the baby to latch-on.

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2.Cross Cradle Hold:

This is the common breastfeeding position that is also known as crossover hold. It offers
a great support to the baby and the mother ill have complete control over her baby with
just one hand.

Here are the basic steps for this technique:

• Sit comfortably with your baby at the level of your heart

• Cradle your little one in your arm with her tummy against yours and your hand at
her head base and neck. Her ear, shoulders and hip should follow a straight line.
• Place your baby’s lower arm out of the way with her mouth near to your breast.
Here you will use opposite arms from the cradle hold position.
• Use your free hand to support your breast.
• Rest your thumb above the areola and the rest of the fingers beneath the breast.
• Now gently fondle your nipple on her lower lip. In response to the rooting reflex, her
mouth opens wide that takes some time.
• Pull her quickly onto the breast and let her latch-on. Do not lean over your baby,
instead pull her near you.
This position works well when you:

• Nurse a newborn
• Are learning how to position an infant correctly

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3. Football Hold:

The football hold is ideal for a mother whose breasts are very large or who had a C-
section. It is also a perfect position for premature babies or tiny babies as it gives
excellent control for mother over the baby.

Here are the basic steps for this technique:

• Place your baby so that her legs and body are beneath your arm and your hand at
the base of the head and neck.
• Place your palm below the breast and let your little one latch-on by pulling her in
close. Hold your baby’s head with her chin and nose touching your breast.
• When the baby latches on, the mother should make sure that her shoulders are in
a relaxed state.
This position works well when:

• You have undergone a C-section and want to hold your baby against the incision of
the abdomen
• Your breasts are large
• You want to check in your baby latch-on
• Your little one is restless and fussy
• You have inverted nipples

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4. Football hold For Twins:

If you are a mother of twin babies, you might want to feed them separately or
simultaneously. If you wish to feed them simultaneously, you could try the clutch or
‘football hold’ to allow each infant to latch onto each breast.

Here are the basic steps for this technique:

• With one baby in each of your arms, hold them while partially bending your elbow.
• You can also place your babies on a pillow each.
• Support their neck with your palm, let them incline towards your body.
• Let your babies latch on and suckle.

This method is a good choice when:

• You have undergone a C-section

• Your breasts are large
• You have a tiny baby
• You have a forceful milk ejection reflex

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5. Side Lying Position:

The side-lying position is best when the mother needs some rest while nursing her baby.
It is a bit tricky, but once both the mother and her baby gets hang of it, it will become the
most favorable position. It is best recommended for those who have undergone a c-
section.

Here are the basic steps for this technique:

• Position yourself and your infant towards side tummy to tummy.

• Bend your upper leg and position your upper knee with pillows.
• Lift your breast upward by placing fingers below and then take your baby close to
latch-on.
This position is a good choice when:

• You need to lie flat after a C-section

• You are facing discomfort while sitting due to hemorrhoid pain
• You want to take a rest.

Latching On:

If your newborn latches on to your nipple but not the areola, problems can occur like
sore nipples and poor milk supply. In such a case, you have to repeat some steps for
your baby to latch-on properly:

• Sit with your tummy facing against her tummy.

• Ensure that your baby’s ear, shoulder and hip lie straight and nose is on the same
level as nipple.

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 • Touch nipple to your little one’s lips
• Bring her close to your chest
• When her mouth open wide, bring her quickly so that she latches-on.

Here is what you need to look for after your baby latches-on:

• Chin touches your breast

• Tongue is seen when the lower lip is pulled
• Lips should be outward the breast
• The sucking motion will be along the jaw
• The ears, shoulder and hip will lie in a straight line
• You should feel a rhythmic tug on your breast
• Ears wiggle
• Cheeks are round
• You will not hear smacking or clicking noises
• You will hear swallowing
• While your baby takes off breastfeeding,your nipples are not flattened
• Your baby ends the feeding with great satisfaction that are shown by signs like –
looks relaxed, falls of the breasts with open hands and immediately falls asleep.

TIPS FOR EVERY BREASTFEEDING TECHNIQUE:

Support Your Body:

• Use a comfortable chair that has armrests and take pillows for extra support to
your arms and back.
• Keep a footstool or coffee table so that you rest your feet and do not bend over
much. A pillow or a folded blanket on your lap also keep you comfortable.
• Whatever may be the nursing position, you should make sure you bring your baby
near to your breast.

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Support Your Breast:

• Breasts turn heavier and larger when lactating. You should use your hand to
support them using a C-hold (4 fingers below the breast ad thumb above) or a V-
hold (between index and middle finger).

Support Your Baby:

• Use your hand and arm along with folded blanket or pillows to offer a support to
your baby’s head, neck, back and hips.
• You can wrap her in a blanket or hold in your arms for making her feel comfortable.

Alternative Feeding:

• Experiment and find the best position that you and your baby feel comfortable.
• Regularly alternate the breast holds since continuous hold can put pressure and
can cause sore nipples.
• Alternating the breast holds will also boost milk production.

Relax Before Nursing:

Close your eyes, take a few deep breaths and stay calm, Also keep water, juice or a
glass of milk while you nurse since you may feel dehydrated.

Time to Stop Feeding:

If you feel there is need to stop the feed for any reason, slowly insert your finger near the
corner of your baby’s mouth. A gentle pop will break the feed and can pull off your little
one.

Which technique did you try to breastfeed your baby? How long did you nurse him?
Please share your experience and advice with us. Breastfeeding Techniques -
Everything You Need To Know

Written by HARINI SANTHOSH

DECEMBER 23, 2019

https://www.momjunction.com/articles/breastfeeding-techniques_00350719/

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 UNIT REVIEW

The lactating mother supplies all the hydration and nutrients that a growing infant
need for the first 4–6 months of life. During pregnancy, the body prepares for lactation by
stimulating the growth and development of branching lactiferous ducts and alveoli lined
with milk-secreting lactocytes, and by creating colostrum. These functions are
attributable to the actions of several hormones, including prolactin. Following childbirth,
suckling triggers oxytocin release, which stimulates myoepithelial cells to squeeze milk
from alveoli. Breast milk then drains toward the nipple pores to be consumed by the
infant. Colostrum, the milk produced in the first postpartum days, provides
immunoglobulins that increase the newborn’s immune defenses. Colostrum, transitional
milk, and mature breast milk are ideally suited to each stage of the newborn’s
development, and breastfeeding helps the newborn’s digestive system expel meconium
and clear bilirubin. Mature milk changes from the beginning to the end of a feeding.
Foremilk quenches the infant’s thirst, whereas hindmilk satisfies the infant’s appetite.

QUIZ
Critical Thinking Questions

1. Describe the transit of breast milk from lactocytes to nipple pores.

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

2. A woman who stopped breastfeeding suddenly is experiencing breast engorgement

and leakage, just like she did in the first few weeks of breastfeeding. Why?

3. Using the tools in nutrition (Unit II), determine a food intake plan for a 27-year-old
woman who is 5 feet 2 inches tall, weighs 130 pounds, exercises for less than 30
minutes per day, and is exclusively breastfeeding her 2-month-old infant.

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 LESSON 3
INFANCY
INFANCY

1. Nutritional Problems and Intervention

2. Factors Affecting Nutritional Status
a. Growth and development
b. Introduction of solid foods

3. Guidelines in Feeding
4. Recommended Diet

WEEK TOPIC LEARNING OUTCOME ACTIVITY

1. Identify nutritional variations throughout the life 1. Study Questions

cycle.
2. Describe nutritional needs of infants, children and
adolescents
3.Assess an infant’s/ child`s nutritional needs.
4. Describe methods to promote good nutritional
intake.

In this lesson, we will be learning nutrition in relation to human growth and

development. At every stage of life, nutrition plays a vital role. In childhood, nutrition is a
critical component of growth and development. During pregnancy, key nutrients are
needed for fetal growth, proper weight gain and maintaining a healthy body. As we age,
nutrition plays a key role in preventing many chronic conditions, such as cancer, obesity,
diabetes and heart disease. Although there are many important nutrients at each stage
of life, these are of highest priority.

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INFANCY
Growth is rapid during the first year of life, with the rate tapering off somewhat
during the latter half of the year. Most infants more than double their birth weight by the
time they are 6 months old, and they triple it by the time they reach about 12 to 15
months of age. Growth in length is not quite as rapid, but infants generally increase their
birth length by 50% during the first year and double it by 4 years of age.

INFANCY (Birth to 1 Year)

Physical Characteristics of a Full-Term Infant
The full-term infant is born after successful growth and development during a
normal gestation period of about 40 weeks (280 days). During the first year of life the
infant generally triples in weight, growing rapidly from an average birth weight of about
3.5¯kg (7.5 lb) to a 1-year-old child ready to walk and weighing about 10 kg (22 lb).
Thus, energy requirements during this first year of tremendous growth are high.

Full-term infants have the ability to digest and absorb protein, a moderate
amount of fat, and simple carbohydrates. They have some difficulty with starch because
amylase, the starch-splitting enzyme, is not produced at birth. However, as starch is
introduced, this enzyme begins to function. The renal system functions well in infancy,
but more water relative to body size is needed than in the adult to manage the renal
solute load in urinary excretion. The first baby teeth do not erupt until about the fourth
month; therefore, food must initially be liquid and later semiliquid.

Nutrition for the Full-Term Infant

The first food for infants, breast milk or infant formula, generally

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provides all the nutrients required by a healthy infant for the first 6 months of life.
Exclusive breast-feeding can, in fact, be adequate for the first 12 months of life (with the
exception of iron and vitamin D); however, most mothers choose to supplement their
infants’ diets with complementary foods around the sixth to seventh month.
Nearly all infants born in a hospital receive an injection of vitamin K shortly after
birth to ensure an adequate level of this nutrient, and it is important that infants born at
home also receive supplemental vitamin K.
It may be necessary to provide vitamin D supplements to breast-fed infants,
because breast milk may not supply adequate vitamin D to prevent deficiency
and the development of rickets. This is especially critical in the case of African-American
mothers, who are less able to initiate the synthesis of vitamin D in their skin, or for
mothers who wear special clothing for religious reasons that limits their skin exposure to
the sun
It is important that breast-feeding mothers be well nourished to supply
optimal levels of nutrients in their milk. Infants have limited nutritional stores from
gestation, and this is especially true for iron. Around 6 or 7 months of age, semisolid
foods such as iron-fortified cereals may be added to the diet to help meet increasing
nutritional needs.

Psychosocial and Motor Development

The core psychosocial developmental task during infancy is the establishment of

trust in others. Much of the infant’s early psychosocial development is tactile in nature
from touching and holding, especially with feeding. Feeding is the infant’s primary means
of establishing human relationships. The close mother-infant or caregiver-infant bonding
in the feeding process fills the basic need to build trust. The need for sucking and the
development of the oral organs—the lips and mouth—as sensory organs represent
adaptations that ensure an adequate early food intake for survival. As a result, food
becomes the infant’s general means of exploring the environment and is one of the early
means of communication.

The infant has an additional “nonnutritive” sucking need that is satisfied,

especially with the extra effort required in sucking while breast-feeding. As muscular
coordination involving the tongue and the swallowing reflex develops, infants gradually
learn to eat a variety of semisolid foods, beginning around 6 to 7 months of age. As

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physical and motor maturation proceed, infants begin to show a desire for self-feeding.
When these stages of development occur, the exploration of new motor skills and
autonomy should be encouraged. If their needs for food and love are fulfilled in this early
relationship with the mother, father, other caregivers, and family members, then trust is
developed. Infants evidence this trust by an increasing capacity to wait a few minutes for
feedings until they are prepared.

Breast-Feeding
- The ideal food for the human infant is human milk.
- It has specific characteristics that match the infant’s nutritional
requirements during the first year of life.
- The process of breast-feeding today, as in the past, is successfully
initiated and maintained by most mothers who try.
- However, sometimes problems occur when getting started, as well as a
high degree of variability among nursing mothers as to frequency of
feedings, intake per feeding, and infant growth.
- Thus, in providing support for mothers who want to breast-feed their
babies, experienced nutritionists and nurses, many of whom are certified
professional lactation consultants, advise flexibility rather than a rigid
approach.

- The World Health Organization (WHO) and the United Nations Children’s
Fund created the Baby Friendly Hospital Initiative (BFHI); this program
has increased the breastfeeding initiation rate of mothers in participating
hospitals.
- Many hospitals use lactation consultants to oversee compliance with the
actions and to promote breastfeeding practices that are optimal, yet
realistic, for mother and infant.

- The newborn rooting reflex, oral need for sucking, and basic hunger
drive usually induce and maintain breast-feeding by the healthy mother.
- The mother should follow the baby’s lead with an on-demand schedule.
- The mother can feed the baby for about 10 to 15 minutes on each breast.

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- When the baby is satisfied, he or she can be released from the breast.
- The nipple should air dry to prevent irritation and soreness.
- The mother’s diet and rest are important factors in establishing lactation
and breast-feeding.
- Natural thirst guides adequate fluid intake.
- Sufficient rest and relaxation for the mother are essential.
- An adequate energy intake is especially important in the early weeks to
establish regular milk production.
- A gradual weight loss occurs as maternal fat stores are slowly depleted,
but the mother should not expect a rapid return to her pre-pregnancy
weight.
- Overweight mothers with a BMI between 25 and 30kg/m2 can lose about
1 lb/wk while successfully breastfeeding their infants by reducing energy
intake by approximately 500kcal per day and engaging in aerobic
exercise on 4 days per week.
- However, rigorous dieting should not be undertaken by breast-feeding
mothers.
- Breast-feeding may influence feeding behavior and taste preferences into
childhood.
- Acceptance of a wide variety of tastes and preferences for foods may
occur if the infant is breast-fed.
- Odorous compounds, found in foods and beverages, transfer into breast
milk; such flavor exposure during breast-feeding often affects acceptance
of same-flavored foods in childhood.
- Studies suggest that breast-fed infants are less likely to become
overweight as children compared with infants who are formula-fed.
- Infants who develop a pattern of eating in moderation are less likely to
become overweight, and breast-fed infants have more control regarding
the amount of milk they consume than do formula-fed infants.
- Formula-fed infants may be urged to empty their bottle, even though they
may turn away when they are satisfied.
- Force-feeding is less likely to occur in the breast-fed infant but should be
avoided in all infants.

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 - Feeding should be discontinued at the first sign that the infant has had
enough.
- Children who gain weight more rapidly during the first 4 months of life are
more likely to be overweight by middle childhood.
- When possible, infants should be breast-fed.

Bottle-Feeding
- Formula feeding by bottle may be preferred by some mothers for a variety
of reasons.
- If the mother does not choose to breast-feed or stops breast-feeding
before her infant reaches the age of 1 year, then bottle-feeding of an
appropriate formula is an acceptable alternative.
- A variety of commercial formulas that attempt to approximate the
composition of human milk are available.
- Some of the cow’s milk–based formulas are adjusted with whey protein to
more nearly approximate the protein ratio in human milk.
- A topic of current interest is the nutritional benefit of substantial amounts
of the long-chain fatty acids arachidonic acid (ARA) and docosahexaenoic
acid (DHA) provided in breast milk.
- These fatty acids appear to play a special role in development of the brain
and tissue of the retina.
- Based on the presence of ARA and DHA in human breast milk and the
normal metabolic conversion of linoleic acid to ARA and α-linolenic acid to
DHA (along with evidence linking ARA and DHA to visual acuity and
cognitive development), the U.S. Food and Drug Administration (FDA)
approved the addition of these long-chain polyunsaturated fatty acids to
infant formula.
- Special formulas have been developed for infants with allergies, lactose
intolerance, diarrhea, fat malabsorption, or other problems, and several
types of constituent proteins and carbohydrates are used.
- These special formulas include cow’s milk protein, soy protein, and
casein hydrolysate, and elemental formulas (Table 12-5).

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- Hypoallergenic formulas have been developed for infants who are allergic
to cow’s milk or commercial formulas based on cow’s milk and have
existing symptoms of that allergy.
- Even partially hydrolyzed proteins can provoke an allergic response in
infants with hypersensitivity to cow’s milk.
- In the preparation of hypoallergenic formulas, all proteins are completely
hydrolyzed to free amino acids.
- Although some infants allergic to cow’s milk tolerate soy formulas, they
are not hypoallergenic.
- When feeding formula, the baby should be cradled in the arm as in
breast-feeding, keeping the baby’s head upright as much as possible to
avoid milk running into the ear canals and causing an ear infection.
- The close human touch and warmth are important. When the infant is
obviously satisfied, extra milk should not be forced, regardless of the
amount remaining in the bottle.
- Any remaining formula should be thrown away and not refrigerated for
reuse.
- Infants usually take the amount of formula they need.
- Today most infants are fed on demand versus scheduled, which works
out to be about every 2 to 3 hours.
- Healthy infants soon establish their individual feeding patterns according
to their individual growth requirements.
- Only infant formula and water are appropriate for bottle-feeding; other
fluids such as juice, flavored drinks, and carbonated beverages should
not be provided through bottles.

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Cow’s Milk

Regular unmodified cow’s milk is not suitable for infants for several reasons, as follows:
• It causes gastrointestinal bleeding.
• Its renal solute load is too concentrated for the infant’s renal system to handle; this
leaves too small a margin of safety for maintaining water balance, especially during
illness, diarrhea, or hot weather.
• Early exposure to cow’s milk increases the risk of developing allergies to milk proteins.
• It adversely affects nutrition status. Cow’s milk is low in iron, and iron status in the
infant is lowered even further by the associated gastrointestinal bleeding and blood loss
caused by the cow’s milk. In addition, cow’s milk is a poor source of vitamins C and E
and essential fatty acids.

Infants have need for fat; thus, they should not be fed reduced-fat milks such as
nonfat or 2% fat. Low-fat or nonfat milks do not provide (1) sufficient energy to support
growth requirements, which leads the infant to consume increased volumes of milk and
excessive protein, and (2) sufficient linoleic acid, the essential fatty acid needed for
growth and development of body tissues found in the fat portion of milk. A specific form
of eczema has been observed in infants deficient in linoleic acid, and a
low-fat diet in infancy may impair physical and intellectual development.

To meet the special needs of infants, the American Academy of Pediatrics

recommends breast milk or formula as the major food source up to 1 year of age, with a

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gradual additionof appropriate foods beginning at 6 to 7 months. No need exists for
special for older infants; such formulas also present an added expense to the family.

Solid Food Additions

- Nutritional and medical authorities agree that for the first 6 to 7 months of
life the optimal single food for the infant is human breast milk or an
appropriate formula.
- No nutritional basis exists for introducing solid foods to an infant earlier
than 6 to 7 months of age; before this age, it may contribute to
overfeeding.
- Until then, the infant does not need any additional food and is not able to
adequately handle other foods. In addition to nutritional reasons,
developmental reasons exist for delaying the addition of solid foods until
the age of 6 to 7 months.
- The following developmental tasks must have been mastered before the
infant is prepared to receive solid foods:
• The infant can communicate desire and interest in food by opening his or her mouth
and leaning forward or, conversely, leaning back or turning away, participating in the
feeding process.
• The infant can sit up with support and has good control of the trunk and neck.
• The infant has developed the ability to move food to the back of the mouth for
swallowing.

- Developmental abilities to use the hands and fingers are required before
self-feeding can be initiated. Self-feeding efforts begin first with a whole
hand (palmar) grasp and then move to a more refined finger (pincer)
grasp by the end of the first year.
- The first item for self-feeding may be a piece of Melba toast that can be
grasped with the whole hand. As solid food is gradually added, the
amount of breast milk or formula consumed is reduced accordingly.
- Both cultural patterns and the age and educational level of the mother
influence infant-feeding practices.

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 - Some of these practices, such as adding cereal to the infant’s bottle to
help the baby sleep through the night, are related more to the
convenience of the mother than to the benefit of the infant.
- It may not be in the infant’s best interest to sleep through the night at a
very early age or to adapt as early as possible to three meals a day.
- In addition, cereal displaces formula when added to the bottle. Smaller
amounts of food, eaten on a more frequent basis, may contribute to the
pattern of eating in moderation.

- Two foods that require special attention in infant feeding are honey and
fruit juices.
- Honey should never be given to an infant who is younger than 1 year,
because it can lead to botulism, a fatal condition in infants.
- Some fruit juices, including apple, pear, and prune, contain sorbitol, which
can lead to diarrhea in infants and toddlers.
- If given, fruit juice should be limited to no more than 4 oz per day.

NUTRITIONAL PROBLEMS AND INTERVENTION

Parents and caregivers should be mindful of certain diet-related problems that may arise
during infancy.
• Certain foods are choking hazards, including foods with skins or foods that are very
small, such as grapes.
• Other examples of potential choking hazards include raw carrots and apples, raisins, and
hard candy.
• Parents should also avoid adding salt or seasonings to an infant’s food.

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 • Heating an infant’s food presents a risk of accidental injury or burns, which may occur
if the food is heated unevenly or excessively. Keep in mind that an infant cannot
communicate that the food is too hot.
• Also, parents and caregivers should never leave a baby alone at mealtime, because an
infant can accidentally choke on pieces of food that are too big or have not been
adequately chewed.
• Raw honey and corn syrup both contain spores of Clostridium botulinum. They
produce a poisonous toxin in a baby’s intestines, which can cause the foodborne illness
botulism.
• After the age of one, it is safe to give an infant honey or corn syrup. However, honey as
an ingredient in food, such as in cereal, is safe for all ages because it has been
adequately heat treated.

Overnutrition
Overnutrition during infancy is a growing problem. Overfed infants may develop dietary
habits and metabolic characteristics that last a lifetime. According to the American Journal of
Clinical Nutrition, the consequences of overnutrition and growth acceleration in infancy include
long-term obesity, along with Type 2 diabetes and cardiovascular disease later in life. Singhal, A.
et al. “Nutrition in Infancy and Long-Term Risk of Obesity: Evidence from Two Randomized
Control Trials.” Am J Clin Nutr 92 (2010): 1133–44. Therefore, parents and other caregivers
should restrain from overfeeding, and ideally give their infants breast milk to promote health and
well-being.

Food Allergies
Food allergies impact four to six percent of young children in America. Common food
allergens that can appear just before or after the first year include peanut butter, egg whites,
wheat, cow’s milk, and nuts. For infants, even a small amount of a dangerous food can prove to
be life-threatening. If there is a family history of food allergies, it is a good idea to delay giving a
child dairy product until one year of age, eggs until two years of age, and shellfish, fish, and nuts
until three years of age.

However, lactating women should not make any changes to their diets. Research shows
that nursing mothers who attempt to ward off allergies in their infants by eliminating certain foods
may do more harm than good. According to the American Academy of Allergy, Asthma, and
Immunology, mothers who avoided certain dairy products showed decreased levels in their breast
milk of an immunoglobulin specific to cow’s milk. This antibody is thought to protect against the
development of allergies in children. Even when an infant is at higher risk for food allergies, there

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is no evidence that alterations in a mother’s diet make a difference. Ever, J. “Nursing Mom’s Diet
No Guard Against Baby Allergies.” Medpage Today. © 2012 Everyday Health, Inc. March 7,
2012.

Early Childhood Caries

Primary teeth are at risk for a disorder known as early childhood caries from breast milk,
formula, juice, or other drinks fed through a bottle. Liquids can build up in a baby’s mouth, and the
natural or added sugars lead to decay. Early childhood caries is caused not only by the kinds of
liquids given to an infant, but also by the frequency and length of time that fluids are given. Giving
a child a bottle of juice or other sweet liquids several times each day, or letting a baby suck on a
bottle longer than a mealtime, either when awake or asleep, can also cause early childhood
caries. In addition, this practice affects the development and position of the teeth and the jaw.
The risk of early childhood caries continues into the toddler years as children begin to consume
more foods with a high sugar content. Therefore, parents should avoid giving their children
sugary snacks and beverages.

Gastroesophageal Reflux
Small amounts of spitting up during a feeding is normal. However, there is cause for
concern if it is too difficult to feed an infant due to gastroesophageal reflux. This condition occurs
when stomach muscles open at the wrong times and allow milk or food to back up into the
esophagus. Symptoms of gastroesophageal reflux in infants include severe spitting up, projectile
vomiting, arching of the back as though in pain, refusal to eat or pulling away from the breast
during feedings, gagging or problems with swallowing, and slow weight gain. For most infants,
making adjustments in feeding practices addresses the issue. For example, a parent can feed
their baby in an upright position, wait at least an hour after eating for play time, burp more often,
or give a child smaller, more frequent feeding.

Diarrhea and Constipation

Diarrhea is often caused by a gastrointestinal infection and can dehydrate an infant. It is
characterized by stool frequency and consistency that deviates substantially from the norm. If an
infant has had several bouts of this condition, they will need to replace lost fluids and electrolytes.
A common recommendation is to give a child an oral rehydration solution. Because of the
immune protective factors in breast milk, breastfed infants are less likely to contract
gastrointestinal viral illness and experience diarrhea.

Infant constipation

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 Infant constipation is the passage of hard, dry bowel movements, but not necessarily the
absence of daily bowel movements—is another common problem. This condition frequently
begins when a baby transitions from breast milk to formula or begins eating solid foods.
Pediatricians can provide the best guidance for handling the problem. Common
recommendations include applying a small amount of water-based lubricant to an infant’s anus to
ease the passage of hard stools, and feeding an infant on solid foods pureed pears or prunes, or
providing barley cereal in place of rice cereal. Parents can also offer their child a little more water
in between feedings to help alleviate the condition.

Colic
Colic is a common problem during infancy, characterized by crankiness and crying jags.
It is defined as crying that lasts longer than three hours per day for at least three days per week
and for at least three weeks (which is commonly known as the “rule of 3’s”), and is not caused by
a medical problem. About one-fifth of all infants develop colic, usually between the second and
third weeks. Crying spells can occur around the clock, but often worsen in the early evening.
Also, colicky babies may have stomachs that are enlarged or distended with gas.

There is no definitive explanation for colic. Often, colic occurs when a child is unusually
sensitive to stimulation. In breastfeeding babies, colic can be a sign of sensitivity to the mother’s
diet. Lactating mothers can try to eliminate caffeine, chocolate, and any other potentially irritating
foods from their meals. Medline Plus, a service of the US National Library of Medicine. “Colic and
Crying.” Last updated August 2, 2011. However, since colic usually subsides over time, any
improvement that occurs with food elimination may coincide with the natural healing process.

Parents and caregivers who are feeding bottle formula to colicky babies should talk with
pediatricians about replacing it with a protein hydrolysate formula. American Academy of
Pediatrics. “Colic.” Whether breastfeeding or bottle-feeding, it is also important not to overfeed
infants, which could make them uncomfortable and more likely to have crying fits. In general, it is
best to wait between two and three hours from the start of one feeding to the start of the next. If
food sensitivity is the cause, colic should cease within a few days of making changes. Eventually,
the problem goes away. Symptoms usually begin to dissipate after six weeks and are gone by
twelve weeks. Medline Plus, a service of the US National Library of Medicine. “Colic and Crying.”

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Newborn Jaundice

Yellowing skin is one sign of newborn jaundice.

Newborn jaundice is another potential problem during infancy. This condition can
occur within a few days of birth and is characterized by yellowed skin or yellowing in the
whites of the eyes, which can be harder to detect in dark-skinned babies. Jaundice
typically appears on the face first, followed by the chest, abdomen, arms, and legs. This
disorder is caused by elevated levels of bilirubin in a baby’s bloodstream. Bilirubin is a
substance created by the breakdown of red blood cells and is removed by the liver.
Jaundice develops when a newborn’s liver does not efficiently remove bilirubin from the
blood. There are several types of jaundice associated with newborns:

• Physiologic jaundice. The most common type of newborn jaundice and can affect
up to 60 percent of full-term babies in the first week of life.
• Breast-milk jaundice. The name for a condition that persists after physiologic
jaundice subsides in otherwise healthy babies and can last for three to twelve
weeks after birth. Breast-milk jaundice tends to be genetic and there is no known
cause, although it may be linked to a substance in the breast milk that blocks the
breakdown of bilirubin. However, that does not mean breastfeeding should be
stopped. As long as bilirubin levels are monitored, the disorder rarely leads to
serious complications.
• Breastfeeding jaundice. Occurs when an infant does not get enough milk. This
may happen because a newborn does not get a good start breastfeeding, does
not latch on to the mother’s breast properly, or is given other substances that
interfere with breastfeeding (such as juice). Treatment includes increased
feedings, with help from a lactation consultant to ensure that the baby takes in
adequate amounts.

Newborn jaundice is more common in a breastfed baby and tends to last a bit longer. If
jaundice is suspected, a pediatrician will run blood tests to measure the amount of
bilirubin in an infant’s blood. Treatment often involves increasing the number of feedings
to increase bowel movements, which helps to excrete bilirubin. Within a few weeks, as
the baby begins to mature and red blood cell levels diminish, jaundice typically subsides

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 with no lingering effects. American Pregnancy Association. “Breastfeeding and
Jaundice.”

GUIDELINES IN FEEDING

Feeding Guide for the First Year

Making appropriate food choices for your baby during the first year of life is very
important. More growth occurs during the first year than at any other time in your child's
life. It's important to feed your baby a variety of healthy foods at the proper time. Starting
good eating habits at this early stage will help set healthy eating patterns for life.

Recommended feeding guide for the first year

Don't give solid foods unless your child's healthcare provider advises you to do so. Solid
foods should not be started before age 4 months because:

• Breast milk or formula provides your baby all the nutrients that are needed for growth.

• Your baby isn't physically developed enough to eat solid food from a spoon.

• Feeding your baby solid food too early may lead to overfeeding and being overweight.

The American Academy of Pediatrics (AAP) recommends that all infants, children, and
adolescents take in enough vitamin D through supplements, formula, or cow's milk to
prevent complications from deficiency of this vitamin. In November 2008, the AAP
updated its recommendations for daily intake of vitamin D for healthy infants, children,
and adolescents. It's now recommended that the minimum intake of vitamin D for these
groups should be 400 IU per day, starting soon after birth. Your baby's healthcare
provider can recommend the proper type and amount of vitamin D supplement for your
baby.

Guide for formula feeding (0 to 5 months)

Age Amount of formula per feeding Number of feedings per 24 hours

1 month 2 to 4 ounces 6 to 8 times

2 months 5 to 6 ounces 5 to 6 times

3 to 5 months 6 to 7 ounces 5 to 6 times

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 Feeding tips for your child
These are some things to consider when feeding your baby:

• When starting solid foods, give your baby one new food at a time — not mixtures (like
cereal and fruit or meat dinners). Give the new food for 3 to 5 days before adding
another new food. This way you can tell what foods your baby may be allergic to or can't
tolerate.

• Start with small amounts of new solid foods — a teaspoon at first and slowly increase to
a tablespoon.

• Start with dry infant rice cereal first, mixed as directed, followed by vegetables, fruits,
and then meats.

• Don't use salt or sugar when making homemade infant foods. Canned foods may
contain large amounts of salt and sugar and shouldn't be used for baby food. Always
wash and peel fruits and vegetables and remove seeds or pits. Take special care with
fruits and vegetables that come into contact with the ground. They may contain botulism
spores that cause food poisoning.

• Infant cereals with iron should be given to your infant until your infant is age 18 months.

• Cow's milk shouldn't be added to the diet until your baby is age 1. Cow's milk doesn't
provide the proper nutrients for your baby.

• The AAP recommends not giving fruit juices to infants younger than 1 year old. Only
pasteurized, 100% fruit juices (without added sugar) may be given to older babies and
children, but should be limited to 4 ounces a day. Dilute the juice with water and offer it
in a cup with a meal.

• Feed all food with a spoon. Your baby needs to learn to eat from a spoon. Don't use an
infant feeder. Only formula and water should go into the bottle.

• Don't give your child honey in any form for your child's first year. It can cause infant
botulism.

• Don't put your baby in bed with a bottle propped in his or her mouth. Propping a bottle
has been linked to an increased risk for ear infections. Once your baby's teeth are
present, propping the bottle can also cause tooth decay. There is also a risk of choking.

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• Help your baby to give up the bottle by his or her first birthday.

• Don't make your child "clean the plate." Forcing your child to eat all the food on his or
her plate even when he or she isn't hungry isn't a good habit. It teaches your child to eat
just because the food is there, not because he or she is hungry. Expect a smaller and
pickier appetite as the baby's growth rate slows around age 1.

• Babies and young children shouldn't eat hot dogs, nuts, seeds, round candies, popcorn,
hard, raw fruits and vegetables, grapes, or peanut butter. These foods aren't safe and
may cause your child to choke. Many healthcare providers suggest these foods be
saved until after your child is age 3 or 4. Always watch a young child while he or she is
eating. Insist that the child sit down to eat or drink.

• Healthy babies usually require little or no extra water, except in very hot weather. When
solid food is first fed to your baby, extra water is often needed.

• Don't limit your baby's food choices to the ones you like. Offering a wide variety of foods
early will pave the way for good eating habits later.

• Don't restrict fat and cholesterol in the diets of very young children, unless advised by
your child's healthcare provider. Children need calories, fat, and cholesterol for the
development of their brains and nervous systems, and for general growth.

Feeding guide for the first year (4 to 8 months)

Item 4 to 6 months 7 months 8 months

Breastfeeding or 4 to 6 feedings per 3 to 5 feedings per 3 to 5 feedings per
formula day or 28 to 32 day or 30 to 32 day or 30 to 32
ounces per day ounces per day ounces per day
Dry infant cereal 3 to 5 tbs. single grain 3 to 5 tbs. single grain 5 to 8 tbs. single grain
with iron iron fortified cereal iron fortified cereal cereal mixed with
mixed with formula mixed with formula formula
Fruits 1 to 2 tbs., plain, 2 to 3 tbs., plain, 2 to 3 tbs., strained or
strained/1 to 2 times strained/2 times per soft mashed/2 times
per day day per day
Vegetables 1 to 2 tbs., plain, 2 to 3 tbs., plain, 2 to 3 tbs., strained,
strained/1 to 2 times strained/2 times per mashed, soft/2 times
per day day per day
Meats and 1 to 2 tbs., strained/2 1 to 2 tbs., strained/2
protein foods times per day times per day

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Snacks Arrowroot cookies, Arrowroot cookies,
toast, crackers toast, crackers, plain
yogurt
Development Make first cereal Start finger foods and Formula intake
feedings very soupy cup. decreases; solid
and thicken slowly. foods in diet increase.

Feeding guide for the first year (9 to 12 months)

Item 9 months 10 to 12 months
Breastfeeding or 3 to 5 feedings per day or 30 to 3 to 4 feedings per day or 24 to 30 ounces
formula 32 ounces per day per day
Dry infant cereal 5 to 8tbs. any variety mixed with 5 to 8 tbs. any variety mixed with formula
with iron formula per day
Fruits 2 to 4 tbs., strained or soft 2 to 4 tbs., mashed or strained, cooked/2
mashed/2 times per day times per day
Vegetables 2 to 4 tbs., mashed, soft, bite- 2 to 4 tbs., mashed, soft, bite-sized pieces/2
sized pieces/2 times per day times per day
Meats and 2 to 3 tbs. of tender, chopped/2 2 to 3 tbs., finely chopped, table meats, fish
protein foods times per day without bones, mild cheese/2 times per day
Starches 1/4-1/2 cup mashed potatoes,
macaroni, spaghetti, bread/2
times per day
Snacks Arrowroot cookies, assorted Arrowroot cookies, assorted finger foods,
finger foods, cookies, toast, cookies, toast, crackers, plain yogurt,
crackers, plain yogurt, cooked cooked green beans, cottage cheese, ice
green beans cream, pudding, dry cereal
Development Eating more table foods. Make Baby may change to table food. Baby will
sure diet has good variety. feed himself or herself and use a spoon and
cup.

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 THE START HEALTHY FEEDING GUIDELINES

REFERENCES:

https://2012books.lardbucket.org/books/an-introduction-to-nutrition/s16-03-infancy-and-nutrition.html
http://www.medpagetoday.com/MeetingCoverage
Research. http://www.mayoclinic.com/health/infant-and-toddler-health/MY00362. Last updated March 16, 2011
Copyright 1998-2012
http://www.nlm.nih.gov/medlineplus/ency/article/000978.htm Last updated August 2, 2011.
https://www.birthinjuryguide.org/birth-injury/symptoms/infant-feeding-problems/; Updated February 19, 2019
https://www.pregnancybirthbaby.org.au/baby-development; Health Direct, Government of Australia
https://www.cdc.gov/nutrition/infantandtoddlernutrition; Last Reviewed October 17, 2019
https://www.stanfordchildrens.org/en/topic/default?id=feeding-guide-for-the-first-year-90-P02209, STANFORD
CHILDREN’s HEALTH Copyright 2020
https://www.drugs.com/cg/normal-diet-for-infants-0-to-12-months.html, Last Updated February 3, 2020

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 ACTIVITY

Study Questions:

1.Is it okay for an infant to experience weight loss immediately after birth? If an infant
does lose weight, does it mean he or she is at nutritional risk?

2. How much water does a breastfed or formula-fed infant need each day?

3. Is it necessary to give breastfed infants supplements of vitamins and/or minerals? If

so, which ones?

4. Describe the process for introducing solid foods into an infant’s diet.

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 LESSON 4
PRESCHOOLERS/ CHILDHOOD
1. Nutritional Problems and Interventions
2. Guidelines in Feeding
3. Energy and nutrient needs
4. Influences on childhood food habits and intake
5. Nutritional growth in childhood

WEEK LEARNING OUTCOME ACTIVITY

At the end of the lesson, you will be able to: 1. Study Questions
1.Describe assessment and intervention strategies for
common childhood health concerns.

Childhood is a period of life from 1-12 years of age. Nutrition for kids is based on
the same principles as nutrition for adults. Everyone needs the same types of nutrients
— such as vitamins, minerals, carbohydrates, protein and fat. Children, however, need
different amounts of specific nutrients at different ages.

During the latent period of childhood, after infancy and before adolescence, the
growth rate slows and becomes erratic. During some periods, plateaus are reached. At
other times, small spurts of growth occur. This overall growth deceleration affects
appetite accordingly. At certain times, children will have little or no appetite; at other
times, they will eat voraciously. Parents who know that this is a normal pattern can relax
and avoid making eating a battleground with their children.

Physical Characteristics and Growth

Toddler (1 to 3 Years)

After the rapid growth of the first year, the growth rate of children slows.
However, although the rate of gain is less, the pattern of growth produces significant
changes in body form.

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 - The legs become longer, and the child begins losing “baby fat.”
- Less total body water exists, and more of the remaining water is inside
cells.
- The young child begins to look and feel less like a baby and more like a
child.
- Energy demands are lower because of the decelerated growth rate.
However, important muscle development is taking place.
- In fact, muscle mass development accounts for about one half of the total
weight gain during this period.
- As the child begins to walk and stand erect, more muscle is needed to
strengthen the body and support these movements.
- For example, a special need exists for big muscles in the back, the
buttocks, and the thighs.
- The overall rate of skeletal growth slows, with increased deposits of
mineral in existing bone rather than a lengthening of bones.
- The increased mineralization strengthens bones to support the increasing
body weight.
- The child has six to eight teeth at the beginning of the toddler period. By 3
years of age, the remaining deciduous teeth have erupted.

NUTRITIONAL PROBLEMS AND INTERVENTIONS

1. Protein Energy Malnutrition:

The primary cause of malnutrition is an inadequate and faulty diet which is followed by poverty
and other socioeconomic factors which precipitate various other infections due to unhygienic
living conditions.
The predisposing factors for PEM are:
a. Due to poverty mother cannot provide sufficient food to the child.
b. Use of starchy gruels which provide bulk food but of less calorific value, malted cereals can
meet the caloric requirement.
c. Malnutrition inhibits the synthesis of enzymes results in loss of appetite leading to less
consumption of food.
d. Chronic Infections
e. Infestations like ascariasis particularly giardiasis leads to anorexia.

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The two type of PEM are Kwashiorkor, and Marasmus [for details refer Unit 2 on Nutrients
especially proteins.

2. Vitamins and Deficiency:

Vitamin A deficiency is a major Nutritional problem affecting young children leading to blindness.
Severe form of Vitamin A deficiency like Xerophthalmia arises when the diet contains practically
no whole milk, butter and very limited amounts of fish, fruits and vegetables and so lack of both
retinol and carotenes. Protein energy malnutrition further aggravates the deficiency

3. Food Behaviour:
Food plays a vital role in the development of the whole person throughout the growing years.
Food could become a means of communication. It has cultural and social meanings. It is
associated with emotion and its acceptance or rejection in personal matter.

The environment in which a child lives determines the food behaviour and the quality of nutrition
the child receives. The family plays a major responsible role for child’s food habit and established
an emotional climate; the other interdependent factors being the number of family members,
income, education, the attitude towards food, parental knowledge of nutrition [either
traditional/modern] varied attitudes towards child rearing Authoritarian or non-authoritarian or any
other.

4. Diet for a Preschool Child:

Toddlers have a very short span of attention and are easily distracted from eating. Their response
to food is rather inconsistent. The muscle coordination is limited and eating behaviour is generally
messy. When opportunity is provided, the preschooler learns things faster by taking advantage of
parents.

Mothers must be reassured that child will remain well nourished as long as the foods contains all
the required nutrients. Young children have good taste sensitivity. They prefer mildly flavoured
foods, colourful fruits are preferably liked; extreme temperature of foods is usually disliked. Three
times meal pattern along with mid morning and mid afternoon snacks are the best for extremity
active children, in between snacks are preferred.

5. Establishing Good Habits:

Meals should be served at regular meal times in a pleasant environment. The child should be
comfortably seated. Children enjoy colorful meals; their appetites vary from day to day. The
quantity served for the children should not be too large. The portions should be small.

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Types of food suitable for a preschooler:
a. Fresh fruit juices
b. Milk and Milk beverages, curd, cheese pieces
c. Fruit pieces like slices of apple, papaya, mango, sapota, etc.
d. Vegetables [Boiled/raw]: carrots, cucumber, potato, tomato, cauliflower, beans, etc.
e. Malted cereals like Ragi, Cornflakes, puffed rice, rice flakes, etc.
Note:
Too young children should not be given things like nuts, puffed rice, popcorns, or vegetable
pieces as they can choke on them and aspirate food items.

OTHER FEEDING PROBLEMS

A preschool child is sometimes a difficult child. His appetite us erratic and his behavior
capricious. He loses interest in food between the second and third year and this
becomes a source of of irritation between the child and the mother. What are some of
these problems that pose such a big headache to worried mothers?

EATING TOO LITTLE

He is probably a thin child who likes few foods (sometimes called food jagging) or
whose appetite is lost because of too much parental urging. He could also be too tired
of the same foods eaten every day.

As long as what he eats are the right foods, there is no need to hurry him. Go
slow on adding new foods and start the meals with the food he likes best.Seve less that
he will eat. Heaping his plate high reminds him of how much he is going to refuse and
this depresses hia appetite. Simple dishes like “sinigang” and “tinola” appeal to him.

EATING TOO MUCH

This may be due to heredity, temperament, appetite, or mother’s insisitence on a “clean

plate”. The only danger on this problem is overweight and indigestion. Restrain from
serving rich foods such as cakes, pies, pastries, and ice cream. Remember that obesity
in adulthood can be traced back to overweight in childhood.

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DAWDLING
A child who dawdles is one who lingers or dilltdallies with his food during
mealtime. He maybe tring to get attention or may not be feeling well at all. Oftentimes,
he is given portions which are too large. The best advice to is have him regularly
checked by a pediatricianand to avoid fussing over him. Let the child enjoy eating.

GAGGING
A child who gags is one who feels like voimiting especially when fed coarse
foods. This situation can be remedied by encouraging self-feeding. Put him in a bright
well-ventilated clean eating place, so much the better with other children, and supply him
with a colorful plate, an eyecatching cup, spoon and fork, which he can manage with his
hands. Sometimes gagging could also be due to negligence in training the infant to eat
chopped foods.

AVERSION TOWARDS SOME FOODS

Some pediatricians advises giving fruits as substitutes of vegetables and forget
them for a while. If no issue is made about them, chances are that his appetite for them
may develop. Guthrie claims that unpalatable preparation of vegetables is to be blamed
with aversions. FNRI suggests mixing vegetables with familiar foods like noodles and
eggs, or stuffing them inside mashed potates or “kamote.”

Milk is another item which some children refuse to take. If lactose intolerance is
the prime suspect, a doctor knows best. If it is plain milk intolerance, the best advice is to
give it in some forms like flavored milk desserts, cheese, “leche flan,”cream soups, “halo
halo,” “mais con cielo’” “gulamna’” ot “pinipig’” with milk and fruits. It may be used to
replace water in cooking cereals.

FEEDING BETWEEN MEALS

Should children be given snacks? Those against it say that snacks lessen
appetite for the next meal and that it promotes tooth decay. Proponents for feeding
between meals believe that given the right kind of food at a reasonable time, snacks can
contribute greatly towards improving the over-all nutriture of the child. An allowance of
about 2 hoursbefore mealtime will not spoil the appetite. More of fruits and fruit juices,

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small sandwiches, cereals with milk and less of cakes, cookies, and empty calorie
softdrinks and candies are recommended. What is also important is establishing a
routine for the child, meaning a regular time to play, sleep, snacks, and meals.

THE HANDICAPPED CHILD

Nutrition has been found to play a role in preventing the condition from occurring
originally. There is evidence to indicate that when maternal reserves are very low during
pregnancy, neuropsychological defects develop in the offsprings. Protein-calorie
malnutrition during early childhood has also been linked to changes in psychologic
functioning as observed in the low intelligence test scores.

With the increase of teen-age marriages, teen-age pregnancy has become a

great risk factor in the incidence of handicapped children. Low birth weight infants are
often bor to teen-age mothers and with this an increased probability of mental
retardation, cerebral palsy, and epilepsy.

Nutritional needs of the handicapped child are the same as that of a “normal”
child. In fact, proper nutrition may be very crucial in his life as it may be the only means
for him to survive and develop his potentialiries.

His food intake patterns are greatly influenced by his relationship with people
around him. Parents paly an important role in the nutritional management of their
handicapped child. They should encourage sel-feeding I order to pave the way to
independence. They should schedule his meals carefully with enough time for him to
enjoy and learn the eating process. Foods with varying texture and consistencies, with
delicate flavor and aroma appeal to blind children. Special feeding equipment and
special preparation of food are needed by a child with cerebral palsy; whereas, a deaf
child depends much upon visual stimuli. A mental retarded one goes for colorful
delicious foods. He can even be taught good eating habits.

Hence, not only is nutrition an important aspect in the care of a handicapped

child, but it is also vital in preventing the conditions from occurring and from becoming
serious.

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 GUIDELINES IN FEEDING

Preschool-age children (ages 3 to 5) are still developing their eating habits and
need encouragement to eat healthy meals and snacks. These children are eager to
learn. They will often imitate eating behaviors of adults. They need supervision at
mealtime as they are still working on chewing and swallowing skills.

These are some helpful mealtime hints for preschool-age children:

• Make meals, give regularly scheduled snacks, and limit unplanned eating.
• Discourage poor behavior at mealtime. Focus on eating, not playing with food, or playing
at the dinner table.
• Running or playing while eating can cause a child to choke. Have your child sit when
eating.
• Keep offering a variety of foods. Have the attitude that, sooner or later, your child will
learn to eat almost all foods.
• Make mealtime as pleasant as possible. Don't put pressure on your child to eat. Don't
force your child to "clean" his or her plate. This may lead to overeating, which can cause
your child to gain too much weight. Children will be hungry at mealtime if snacks have
been limited during the day.
• Provide examples of healthy eating habits. Preschoolers copy what they see their
parents doing. If you have unhealthy eating habits, your child will not learn to eat
healthy.

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 Healthy food choices

The MyPlate icon is a guideline to help you and your child eat a healthy diet.
MyPlate can help you and your child eat a variety of foods while encouraging the right
amount of calories and fat.

The USDA and the U.S. Department of Health and Human Services have
prepared food plates to help parents select foods for children age 2 and older.

The MyPlate icon is divided into 5 food group categories, emphasizing the nutritional
intake of the following:

• Grains. Foods that are made from wheat, rice, oats, cornmeal, barley, or another cereal
grain are grain products. Examples include whole-wheat, brown rice, and oatmeal. Aim
for mostly whole-grains.
• Vegetables. Vary your vegetables. Choose a variety of colorful vegetables. These can
include dark green, red, and orange vegetables, legumes (peas and beans), and starchy
vegetables.
• Fruits. Any fruit or 100% fruit juice counts as part of the fruit group. Fruits may be fresh,
canned, frozen, or dried, and may be whole, cut up, or pureed. The American Academy
of Pediatrics recommends no more than 4 ounces of juice per day for children 1 to 3
years of age, and 4 to 6 ounces per day for children 4 to 6 years of age.
• Dairy. Milk products and many foods made from milk are considered part of this food
group. Focus on fat-free or low-fat products, as well as those that are high in calcium.
• Protein. Go lean on protein. Choose low-fat or lean meats and poultry. Vary your protein
routine. Choose more fish, nuts, seeds, peas, and beans.
Oils are not a food group, yet some, like nut oils, have essential nutrients and can be
included in the diet. Animal fats, which are solid fats, should be avoided.

Encourage exercise and everyday physical activity with a healthy dietary plan.

Here are some tips to follow:

• Try to control when and where food is eaten by your children by providing regular daily
meal times. Include social interaction and demonstrate healthy eating behaviors.
• Involve children in the choosing and preparing of foods. Teach them to make healthy
choices by helping them to pick foods nutritious based.

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• Select foods with these nutrients when possible: calcium, magnesium, potassium, and
fiber.
• Most Americans need to cut the number of calories they consume. When it comes to
weight control, calories do count. Controlling portion sizes and eating nonprocessed
foods helps limit calorie intake and increase nutrients.
• Parents are encouraged to provide recommended serving sizes for children.
• Parents are encouraged to limit children’s screen time to less than 2 hours daily.
Instead, encourage activities with that call for more movement.
• Children and adolescents need at least 60 minutes of moderate to vigorous physical
activity on most days for good health and fitness and for healthy weight during growth.
• To prevent dehydration, encourage children to drink fluid regularly during physical
activity and drink several glasses of water or other fluid after the physical activity is
completed.
To find more information about the Dietary Guidelines for Americans 2015–2020 and to
determine the appropriate dietary recommendations for your child’s age, sex, and
physical activity level, visit the Online Resources page for the links to the
ChooseMyPlate.gov and 2015–2020 Dietary Guidelines sites. Please note that the
MyPlate plan is designed for people older than age 2 who don't have chronic health
conditions.

Always talk with your child’s healthcare provider regarding his or her healthy diet and
exercise requirements.

ENERGY AND NUTRIENT NEEDS OF PRE SCHOOL CHILDREN

Through parental education, the practice nurse plays an important role in ensuring the
nutritional needs of children are adequately met, writes Ruth Taylor

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Nutrition in children of all ages is instrumental for
healthy development in all areas of living physical,
psychological and social well-being. A diet inadequate
in nutrient dense foods may result in delayed
development, psychomotor delay and behavioural
disorders. These are all preventable by educating
parents and families about basic nutrition.

Nutrition can be defined as what foods the individual

consumes and how the body uses them.

Young children should not be regarded as young

adults. As they are still growing, in order to achieve satisfactory growth, children require
larger amounts of nutrients per unit of body weight than adults. Therefore, when children
are fed foods which contain inadequate amounts of nutrients, they may fail to grow and
develop adequately. Lack of adequate nutrition will cause failure to gain weight in the
short term and in the longer term will result in small stature.

Energy

Energy requirements for pre-school children increase as the child grows older:

• A one year old girl requires 1,165 kcal/day

• A one year boy needs 1,230 kcal/day
• A four year old girl requires 1,545 kcal/day
• A four year a boy needs 1,715 kcal/day.2

Fats

A low-fat diet for children can result in insufficient energy. Fat is a concentrated
source of energy, fat soluble vitamins and essential fatty acids. Fats also make food
more palatable. A diet with adequate amounts of fat enables children to take in energy in
a limited volume of food as they have small stomachs and cannot eat large volumes. It is
necessary to educate parents particularly that low fat milks and foods are not suitable for
young children.

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Fiber

Fiber foods are bulky and young children with small appetites who are offered a
diet high in fibre, may not ingest adequate energy. Phytate, a substance associated with
cereal fibre, can bind with and prevent the efficient absorption of certain minerals such
as calcium, phosphorus, iron, copper and zinc.1 Children who may be eating sufficient
amounts of these minerals but are consuming too much fibre, may actually become
deficient in these minerals.

Dietary fibre should be encouraged but not excessively so in small children.

Wholemeal bread, wholemeal breakfast cereals, pulse vegetables, fruit and vegetables
all should be encouraged, particularly as the child gets older.

Protein

Protein intake ranges from 14.5g/day in 1-3 year olds up to 19.7g/day in 4-6 year
olds.2 All pre-school children should have adequate intake of protein and they can eat
meat, dairy produce, eggs, chicken and fish to meet their protein needs.

Iron

Iron intakes in children have been shown to be low and many pre-school children
have been found to be anaemic. A study carried out in a general practice setting in 1995
found that 36% of one-year olds were anaemic. Following the introduction of education
programmes for mothers by primary care professionals, one year later it was found that
the percentage of anaemic children had decreased to 24% of 122 children screened at
14 months. The practice nurse can educate parents with regard to increasing iron in the
diet through iron rich foods such as red meat, liver, fortified cereals and green
vegetables. Vitamin C increases the absorption of iron from food and a small drink of
juice should be offered at mealtimes.

Carbohydrates

Carbohydrates are an important source of energy. Starchy foods such as pasta,

bread and rice should be plentiful in the diet. Payne in 1991 found that the main source
of sugar in the diet of pre-school children was pure fruit juices and blackcurrant

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syrups.5 There are strong links between sugar intake and the incidence of dental caries,
particularly in pre-school children. To minimise the risks, parents should be encouraged
to discontinue the use of feeding bottles after the age of one and to encourage the use
of feeding cups. Also, frequent consumption of sugary drinks, sweets and snacks should
be discouraged as these influence the child's appetite.

Fluid

Fluid intake is a matter of concern in pre-school children. A study carried out in

1995 demonstrated that squash was the most popular drink, with milk coming in second.
Plain water was much lower in popularity.6 The authors suggest that children as young
as two become conditioned to the sweet taste of squash so that they refuse to drink
water. Children with a high intake of squash may have a diminished appetite and as a
result miss out on valuable nutrients at meal times. Again, a high intake of squash will
affect children's dentition.

INFLUENCES ON PRE SCHOOL FOOD HABITS AND INTAKE

As the infant enter the toddler’s stage on to pre school age, he is enveloped by
social and emotional experiences which affect his attitudes and basic eating habits. As
a result, feeding him adequately involves a lot of factors such as psychologiacl, socio-
cultural and economic, in addtion to his food preferences and common disorders.

PSYCHOLOGICAL FACTORS

A child at 2 years old learns by imitation. He enjoys doing things that memebers
of the family do. He has constant fears of separation. Between 2 and 3 years , he shows
signs of stubbornness and rebellion. At around 3 he reaches that stage of emotional
development where he feels love and affection for his parents. He or she wants to be
like father or mother. Between 4 and 6 his curiosity and imagination become very vivid.
He tries to find a reason for everything. All of these traits exert a great effect on the
child’s reactions towards food. In turn these response determine how well he is..

Taking into consideration a child’s psychological development, a few guidelines

on feeding are necessary:

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 1. Set a good example of eating the right food. Avoid showing
dislikes towards certain foods.
2. Associate food with love and undestanding. When a child learns to
enjoy eating, he has more chances to form good eating habits and
attitudes.
3. Not all children have the same response towards food. Some may
have stronger feelings about what food and how much they want
to eat. A large child may eat more than a small one.; an active
more than a less active; a fretful less than a happy one.
4. What a child feels about himself and his world shows up on his
sentiments about food. Respect his food likes and dislikes. If he
rejects food, it does not necessarily mean he does not like it
altogether.
5. A child is very keen on the taste, flavor, texture, and temperature
of food. Intoduce one new food at a time.
6. Satisfy his curiousity by giving him an oppurtunity to handle
ingredients and acquainting him with names and pictures of
foodstuffs.
In addition, Lowenberg, famous for her work among preschoolers,
believes that if a child wins an adult’s approval because the
setting for his eating has been patterned for success, then he is
on his way to becoming a ‘successful eater”. Accidental spillage
of food and mess on the dining table should not be a reason for
scolding the child. If he eats his food happily with a few
unintentional spills of food, he can still feel that he has been
successful. For the young child, success promote success in
eating.

SOCIO-ECONOMIC-CULTURAL FACTORS

Statistics show that preschoolers from low-income groups are malnourished

compared to higher income levels. This calls for a need to provide cheap sources of of

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rich nutrients, to educate mothers on good nutrition, and to grow and develop low-cost
nutritious foods.

Because milk, eggs, and meats are expensive protein sources,, products such as
Mongo, coconut flour, and skim milk, dried fish flour, coco noodles, and coco-cereal
have been developed. Dried beans and legumes like “mongo”, soybeans, “patani”,
“paayap”, and “bataw”, when cooked with small amounts of fish or meat and eaten with
rice become complete protein foods. “Tokwa” and “tulya” are also inexpensive
substitutes for meat protein. Fish can be equal to milk in supplying calcium to the diet.
Dried “dilis’ contains about the same concentration of calcium as skim milk powder.

Poor living conditions anad unhygienic sorroundings often result in lowered

resistance to infectious disease. In some areas, water supply and and proper sewage
disposal are inadequate. Cleanliness s not emphasized in the home. Thus parasitism
prevails in Filipino children. The most common are ascaris anf trichuris. Parasites in the
body bring about anorexia, diarrhea and anemia.

FOOD PREFERENCES

Preschoolers like simple dishes that are lukewarm in temperature and not spicy. Some
examples are “arroz caldo”, fish “sinigang’ “mongo guisado”, fish and meat patties, and
“gulaman” with fruits. Strong -flavored dishes like” kari-kari”, “adobo”, and vegetables like
cabbager, cucumber, and radish are repulsive to their sensitive taste buds. Colorful fruit
juices and fresh fruits shaped into different attractive molds are appealing to them.

They do not like extremely hot or cold, or dry tough foods. Boiled “gabi” or “talong” are
drab in color and do not interest them. All children have individual differences and the
above preferences do not apply to all. However, the mother should be aware of her
child’s food patterns if she is to prepare nourishing meals.

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INDICATIONS OF GOOD NUTRITION

The weight and hight of the child should be normal for his age, sex, and body
build. He exudes a feeling of well-being, of interest in all activities usual foe his age. His
posture is erect, arms and legs straight, abdomen pulled in, and chest out. His head is of
normal size and shape and his sleleton with no malformations. The teeth are straight,
without crowding in a well-shaped jaw. At around 6 years old, 24 teeth, 4 of which are
permanent molars, start to appear. The skin is smooth, slightly moist, with a healthy
glow. The eyes are clear, bright, with no signs of fatigue. The hair is shiny, muscle firm,
gums light pink in color, lips moist, and tongue without lesions.

He has good attention span for his age, not easily irritated or restless. Appetite,
digestion and elimination are regulaer. He is able to communicate and handle abstract
materials in thinking. He is social and out-going, loving and affectionate.

References

Claudio, V. and Ruiz, O. (2002). Basic Nutrition for Filipinos 5th Edition, Manila, Philippines, Meriam and
Webster Bookstore.
Benton, D 2010, ‘The Influence of Dietary Status on the Cognitive Performance of Children’, Molecular
Nutrition and Food Research, vol. 54, no. 4, pp. 457-70, viewed 27 October
2016, https://www.ncbi.nlm.nih.gov/pubmed/20077417
Chugani, HT 1998, ‘A Critical Period of Brain Development: Studies of Cerebral Glucose Utilization with
PET’, Preventive Medicine, vol. 27, no. 2, pp. 184-8, viewed 27 October
2016, https://www.ncbi.nlm.nih.gov/pubmed/9578992

371
 Ge, KY & Chang, SY 2001, ‘Definition and Measurement of Child Malnutrition’, BES: Biomedical and
Environmental Sciences, vol. 14, no. 4 pp. 283-91, viewed 27 October
2016, https://www.ncbi.nlm.nih.gov/pubmed/11862608
Jolliffe, CJ & Janssen, I 2007, ‘Development of Age-Specific Adolescent Metabolic Syndrome Criteria that
are Linked to the Adult Treatment Panel III and International Diabetes Federation Criteria’, Journal of
the American College of Cardiology, vol. 49, no. 8, pp. 891-98, viewed 27 October
2016, https://www.ncbi.nlm.nih.gov/pubmed/17320748
Nyaradi, A, Li, J, Hickling, S, Foster, J & Oddy, WH 2013a, ‘The Role of Nutrition in Children’s
Neurocognitive Development, From Pregnancy Through Childhood’, Frontiers in Human Neuroscience, vol.
7, no. 97, viewed 27 October 2016, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3607807/
• Nyaradi, A, Li, J, Hickling, S, Whitehouse, AJ, Foster, JK & Oddy, WH 2013b, ‘Diet in the Early Years of Life
Influences Cognitive Outcomes at 10 Years: A Prospective Cohort Study’, Acta Paediatrica, vol. 102, no. 12,
pp. 1165-73, viewed 27 October 2016, https://www.ncbi.nlm.nih.gov/pubmed/23879236
• Tanumihardjo, SA, Anderson, C, Kaufer-Horwitz, M, Bode, L, Emenaker, NJ, Haqq, AM, Satia, JA, Silver, HJ
& Stadler, DD 2007, ‘Poverty, Obesity, and Malnutrition: An International Perspective Recognizing the
Paradox’, Journal of the American Dietetic Association, vol. 107, no. 11, pp. 1966-72, viewed 27
October2016, https://www.ncbi.nlm.nih.gov/pubmed/17964317
• https://www.ausmed.com/cpd/articles/nutrition-for-children, Author: James Graham.Published: 02 November
2016

ACTIVITY

Study Questions:

1.Why are preschool children considered the most vulnerable age group?
2.Discuss the mother’s influence on a preschooler’s food preferences
3.Discuss the relation of malnutrition to the incidence of infections and
disease in childhood.
4. What factors besides nutrition affect growth of a child?

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 SCHOOL AGE

The period between 7-12 years is characterized by a slow steady growth,

increased body proportions, enhanced mental capabilities, and more motor coordination.
Body reserves are being laid down in preparation for the increased needs during the
adolescent stage. Growth rates within this period. Girls usually outdistance boys by the
latter part of the pre-adolescent stage. The gain in weight averages 1.8 - 3.1 annually.

The child now starts to assert his individuality, is less dependent on his parents,
and forms a social life outside his family circle. School activities hold much interest in
him and keep him busy at most times. It is about this time that a child can be taught to
see the relationship of food to a healthy body.

NUTRITIONAL PROBLEMS AND INTERVENTIONS

Food behavior reflects the child’s development changes. Conflict often arise
between the unrealistic parental expectations and the child’s struggle against inferiority
feelings. Knowing and understanding the problems in feeding him is one great stop
towards an improved food behavior.

INADEQUATE MEALS

Breakfast which provides ¼ to 1/3 of the daily nutrient allowances is often missed
or hurriedly eaten by school children. Some reasons could be one of the following:
nothing to eat, late bedriser, arrival of the schoolbus, phobia of being late to school, rush
in preparing oneself for school.

A study made on the breakfast habits of some elementary students showed that
majority ate breakfast but quality and quantity-wise, it fell short of the one fourth daily
allowances for calories, protein, calcium, vitamin A and ascorbic acid.

Why is breakfast necessary to a school child?

A good breakfast consists of a vitamin C-rich food like “calamansi juice”, a cereal
like oatmeal, “fried rice”, or “pan de sal” and a protein-rich food such as egg., “tuyo”

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cheeses or milk. It breaks the night’s fast, reduces irritability and sluggishness during the
day, and provides energy and vitality for the days work.

Lunch has also become a dietary problem because so many children take their
lunch away from home. A school lunch program mentioned earlier in this chapter can
greatly alleviate undesirable effects. In its absence, a packed lunch rather than pocket
money to buy food with, is recommended. It will only save money and give nutritious
food, but will also train the child’s senses for proper food choices and combinations.

Sandwiches and hearty items such as “adobo”, “longganisa”, “tinapa” with rice,
red eggs and tomatoes are favorites among Filipino school children. Sandwiches can be
prepared by using leftovers as fillers such as meatballs, fried fish and egg. To prevent
the child from buying softdrinks, a thermos bottle containing milk, fruit juice, or soup is
helpful. It increases the nutrient content of the packed lunch and makes it something
drinkable. Pickles, tomatoes, or “singkamas” sticks provide something crisp.

“Lunch swapping” is gaining popularity among youngsters at school. A well-

prepared balanced lunch is swapped with someone else’s cookies, cake, or a bottle of
soft drink. This practice should be discouraged.

POOR APPETITE

School work that is too demanding, extra-curricular activities that are too tiring,
new experiences outside the home, confections and soft drinks in the school canteen or
nearby store, all these factors take away a child’s relish for food. Thus, school
administration should provide not only a scholastic environment but a happy relaxed
atmosphere for the school children. Snacks or “meriendas’ which are integral part of the
youngster’s daily meal must be nutritious and low-cost.

Carbohydrate-rich snack products which provide little or no vitamin and minerals

at all must be replaced with wholesome ones such as: milk and fruit beverages, peanuts,
“turon-munggo”, fresh fruits, and breads. High-protein snack foods have recently been
developed, examples of which are: coco crunchies (coconut, wheat, and shrimp flour),
banana peel kropek (peel has more nutrients than pulp), “camote-gabi-corn-or shrimp”
chips, carrot or cassava pretzels, squash and mungbean biscuits.

SWEET TOOTH

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 Children like sweets because their hungry growing bodies recognize the need for
extra Calories. The craving for sweets id oftentimes caused unwittingly by parents. It is
used as a reward or “pasalubong” tokens. Aside from depressing the appetite, sugars
set up in the mouth a favorable environment for the growth and development of
cariogenic streptococci. These germs produce acids that cause tooth decay and leave
behind deposits that injure the gums. Therefore, jams, jellies, chocolates and other
candies must be seen around the house. Limit them strictly to special occasions.

GUIDELINES IN FEEDING

Children between the ages of 7-12 years are growing rapidly and their appetites

are increasing. It is especially important for children in this age group to get
wellbalanced, nutritious meals and snacks to ensure good nutrition for growth and to
help prevent excessive weight gain.

During these years, many changes are happening. Be aware that children may
start skipping meals or dieting. They may spend more time in sedentary activities
such as TV, video games or computer. Changes that go along with puberty will
begin. Peer pressure will often be at its greatest during this time.

Parents and caregivers should limit television, computer and video game time.
The American Academy of Pediatrics recommends limiting screen time to no
more than 1-2 hours of quality programming a day. The Centers for Disease
Control and Prevention recommends at least 60 minutes or more of physical
activity each day.
Feeding Guidelines for children 7-12 years of age

Food Group Food Samples and Serving Sizes

Dairy Products 1 cup of milk (low-fat or skim is best) 1 cup low-fat yogurt 1
3-4 servings per day Good source of protein, ounce of cheese
calcium, Vitamin A and Vitamin D
Meat/Protein Foods 2-3 ounces fish, poultry, meat ½ cup beans 2 tablespoons
2 servings per day Good source of protein, iron, peanut butter 1 egg
zinc and B vitamins

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 Breads/Cereals/Starches 6-8 servings per day 1 slice bread ½ cup cooked cereal, rice, pasta ¾ cup dry
Good source of complex carbohydrates, fiber, B cereal 4 crackers
vitamins, minerals
Vegetables ½ cup cooked vegetables 1 cup lettuce/salad Offer dark
3-4 servings per day Good source of Vitamin A green or yellow vegetables every other day
and C, potassium and fiber
Fruits 2-3 servings per day Good source of 1 cup fresh fruit ¼ cup dried fruit ½ cup canned fruit ½ cup
Vitamin A and C, potassium and fiber juice
Fats/Oils/Others Good source of Vitamin E 3-5 teaspoons per day, such as butter, margarine, oil Limit
chips, candy, desserts, ice cream and sodas since they
provide very little

The following is a sample menu of a day filled with healthy meals and snacks:

Breakfast Snack
¾ cup 100% fruit juice 2 cups low fat popcorn
¾ cup Cheerios 1 cup low fat yogurt
1 cup low fat milk

Lunch
Turkey or Ham sandwich: 2 slices of bread,
1 oz. meat, 1 slice mozzarella cheese,
1 Tbsp. reduced-calorie mayonnaise
1 medium banana
6 baby carrots with low fat ranch dressing
1 cup low-fat milk

Dinner
2 -3 ounces of roasted chicken
1 cup broccoli
1 cup mashed potatoes
1 cup low-fat milk

PM Snack (optional)
4 graham cracker squares
1 Tbsp. peanut butter

Foods Not Recommended

High-fat foods:

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 - Avoid foods with more than 30% of calories from fat. Reading the
Nutrition Facts label will help you determine if the food is too high in fat.
- A general rule of thumb is for the particular food to have less than 5 gm of
fat per serving. Try to limit the amount of fried food in the diet

Foods that cause dental cavities:

- Avoid soda, gum, hard candies, lollipops and other sugary foods.

Sugar-sweetened beverages:

- These drinks will fill children up and provide very few nutrients. Offer
water and milk (in appropriate amounts) first and limit juice and soda.

Caffeinated beverages:

- Caffeine can cause dehydration and restlessness. These beverages may

replace healthier beverage choices.

https://www.pennstatehershey.org/documents/10293686/10323773/Nutrition+Guidelines+for+Your
+School+Age+Child/cb19dd0f-b577-4447-ab45-d31cf127ae5

ENERGY AND NUTRIENT NEEDS

Helping your school-age child eat a healthy diet can enhance his growth and
optimize his development. The Centers for Disease Control and Prevention reports few

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children in the U.S. consume enough nutritious foods such as fruits, vegetables and
whole grains or limit low-nutrient fare, which can lead to malnutrition, obesity or both.
Malnutrition in children can result in difficulty learning, poor growth, fatigue, dizziness,
weakness, a low body weight and decaying teeth.

Calories

The number of calories a school-age child needs each day depends on his age,
gender and activity level. Your child’s pediatrician will make sure his weight is within a
healthy range and he’s growing at a consistent pace. According to the American Heart
Association, calorie needs for girls ages 4 to 18 range from 1,200 to 1,800 per day,
while boys typically require 1,400 to 2,200 per day. These needs gradually increase
from the lower end to the higher as children grow and develop. Ideally, most of these
calories will derive from nutritious foods.

Protein

Protein is important for growth, strength and muscle maintenance in school-age

children. Most kids get enough protein, according to the Cleveland Clinic, and more is
unnecessary and potentially risky. Children ages 4 to 9 need 19 gram of protein per
day. This increases to 34 grams from age 9 to 13. For teens ages 14 to 18, girls
typically need 46 grams of protein daily, whereas boys this age need 52 daily grams.
High-protein foods include lean red meat, chicken, turkey, seafood, eggs, dairy foods,
peanut butter, soy products, legumes, nuts and seeds.

Carbohydrates

Carbohydrates are the main source of energy for school-age children. The
recommended dietary allowance for carbohydrates is 130 grams of carbohydrates for
children of all ages, according to the Dietary Guidelines for Americans. This amount
provides enough carbohydrates to fuel the brain with sufficient amounts of glucose.
Choosing carbohydrate sources such as whole grains, milk products, fruits, vegetables
and legumes more so than refined grains and added sugars will help increase the
nutrition of your child’s diet.

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Fat

Fats, especially omega-3 fatty acids, are important for your child’s cognitive
development. The American Heart Association recommends that school-age children
and teens gain 25 to 35 percent of their daily calories from fats -- especially mono- and
polyunsaturated fats. Sources of these healthy fats include vegetable oils, avocados,
peanut butter, hummus, nuts and seeds. Foods high in omega-3 fatty acids include
purified fish oils, canola oil, walnut oil, walnuts, soybeans, soybean oil, al gal oil,
flaxseeds, flaxseed oil and pumpkin seeds.

Vitamins and Minerals

Your child’s pediatrician may recommend he take a multivitamin supplement

containing essential vitamins and minerals, especially if your school-age child is a
picky eater. Important nutrients for school-age children include calcium found in dairy
products and dairy-free calcium-fortified beverages, iron in meats and iron-fortified
grains, vitamin A found in fruits, vegetables and dairy products, vitamin D in fish and
dairy products and iodine, which is abundant in seafood, dairy products, enriched
grains and iodized salt. Look for child multivitamins containing these key nutrients, and
always get the okay from your child’s pediatrician before offering your child a
supplement.

INFLUENCES ON SCHOOL AGE FOOD HABITS AND INTAKE

1. PSYCHOLOGICAL FACTORS

Because he is more confident of himself, he is now in a position where he can

express his food choices. He has the strong urge to eat his “gang” eats in any place, at
anytime, no matter what. One step towards teaching him good eating habits is to let him
feel responsible for his own well-being. Make him accountable for his diet. With some
guidance from the parents, he might even cooperate by eating wholesome foods he
does not like. Parents at this period should take time out, free themselves from fatigue,
and spend time with the children. Outings, picnics, or just being together having fun
bring security and confidence to the child. A happy child is a healthy child.

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 2. SCHOOL ENVIRONMENT

School life plays a big role in educating the child on good eating habits. School-
teacher relationship can do much toward achieving the child’s needs on one hand and
challenging him on the other. The school can incorporate nutrition in subjects like Home
Economics, Health Education, and Character Education. It can offer nutritious foods in
the school canteen. It can support the School Feedig Program.

3. FOOD PREFERENCES

At this age, the child eats wider variety of foods and has more food likes than
dislikes. At around 8-9 years old, he wants more than just plain simple dishes he has
been used to. He can eat what most adults do. Sometimes he develops fondness for
food products seen on TV commercials and appetite for food favorites of his movie
idol. Mass media, therefore, particularly the television and the radio, has
responsibility in educating the child towards better food habits. Movie personalities
can exemplify good dietary practices. If given opportunity and the encouragement, a
child can learn over a period of time how to select for himself an adequate diet.

Nutritional growth in school age

School-age children (ages 6 to 12 years) need healthy foods and nutritious

snacks to fuel their busy bodies. They have a consistent but slow rate of growth,
requiring them to eat four to five times a day (including snacks). Eating healthy after-
school snacks is important, as these snacks may contribute up to one-third of the total
calorie intake for the day. Remember that school-age children may also be eating more
foods outside of the home.

Many food habits, likes and dislikes are established during this time. This makes
it a perfect time to experiment with new foods, as school-age children are often willing to
eat a wider variety of foods than their younger siblings. Family, friends and the media
(especially TV) influence their food choices and eating habits. Be sure to talk about
nutrition, encouraging the child to make their own healthy choices.

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 Helpful Tips to Ensure Good Nutrition Habits for School-age Children

• Always serve breakfast, even if it has to be “on the run.” Some ideas for a quick,
healthy breakfast include fruit, milk, bagel, cheese toast, cereal, peanut butter
sandwich and fruit smoothies.
• Take advantage of big appetites after school by serving healthy snacks, such as
fruit, vegetables and dip, yogurt, turkey or chicken sandwich, cheese and
crackers, or milk and cereal.
• Show your children what healthy eating looks like by setting a good example at
mealtimes.
• Make healthy foods easily accessible.
• Allow children to help with meal planning and preparation.
• Serve meals at the table, instead of in front of the television, to avoid distractions.
• Fill half of the plate with colorful fruits and vegetables.
• Provide calorie-free beverages (water) throughout the day, to avoid filling up on
non-nutritive calories.
• Encourage physical activity daily; this can include organized sporting activities or
something as simple as dancing in the living room.

INDICATIONS OF GOOD NUTRITION

Three methods are commonly used to ascertain the health of a school child.

1. Medical and clinical examinations: these include the eye-ear-nose-throat tests, the
stools for the presence of parasites, the urine for signs of infection, and the total general
appearance including mental, social and emotional abilities.

2. Anthropometric examinations: these include the height, weight, arm-chest

circumference.

3. Dietary analysis: a diet history form is filled up and the general eating habits are
analyzed.

A healthy school is generally alert in class, adept, and active in school and family
activities. He enjoys playing, studying and making friends.

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REFERENCES

https://healthyeating.sfgate.com/nutrition-requirements-school-age-children-3781.htmlByErin Coleman, R.D., L.D.

Updated December 07, 2018

https://www.choc.org/programs-services/nutrition/nutrition-school-age-children/
Claudio, V. and Ruiz, O. (2002). Basic Nutrition for Filipinos 5th Edition, Manila, Philippines, Meriam and Webster
Bookstore.

QUIZ

Study Questions?

1. Give the relation of nutrition to dental health.

2. Would you recommend coffee on a breakfast menu of a child? Why?

3. Review some of TV/ Social media commercials. Comment on their effects on the
dietary habits of children.

4. List down some methods that can be utilized to educate school children on good
eating habits through mass media.

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5. Enumerate and discuss in your own word the three influences on pre school age
food habits and intake. (5 points each; Total of 15 Points)

1.

2.

LESSON 5
ADOLESCENCE
1. Nutritional problems and intervention
2. Recommended Diet
3. Physical growth and development
4. Nutrient needs
5. Nutritional concerns for adolescents

WEEK LEARNING OUTCOME ACTIVITY

1. Study Questions
At the end of the lesson, you will be able to:
1.Apply knowledge of the nutrient needs of the
adolescents.

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 Adolescence is the second-fastest growth stage in life after infancy. The
adolescent’s growth spurt during this period creates an increased need for many
nutrients. Eating right assures an adequate amount of key nutrients: calcium, iron and
vitamins A, C and D. Some teens have a need for even more nutrients if they are active
in sports, following a special diet, have an eating disorder or are pregnant.

There is no agreed definition of adolescence; the WHO defines it as ages 10-18

while the American Academy of Pediatrics defines it as 13-18 years. The overriding fact
is that this period is characterised by rapid, physical, emotional, social, sexual,
psychological, development and maturation. Along with social factors, these
characteristics make adolescents vulnerable to a range of nutritional issues.

NUTRITIONAL PROBLEMS AND INTERVENTIONS:

1. Unhealthy eating habits

The bulk of data on the eating habits among adolescents comes from the west
and particularly the USA. The data indicate that some dietary patterns are consistently
observed among adolescents which put them at risk of unhealthy eating.
- These include snacking (on energy-dense but nutrient-poor items);
- meal skipping; irregular eating patterns;
- and a wide use of fast food for meals and snacks.
- More than 50% of respondents in the National Adolescent School Health
Survey (US Dept Health and Human Services, 1989) reported missing
breakfast while snacking was reported by 90% in the same survey.
- Only 39% reported eating nutritious snacks, the majority reported snacks
of “junk” food - chips, soda, sweets and cake.
- Healthy snacks can be important for adolescents owing to their high
energy requirements but fast foods - a popular choice – can contribute to
high intakes of saturated fat.
- Other common habits include eating away from home, low intake of fruits,
vegetables and dairy products.
- Self-image and body weight concerns particularly in girls may lead to
faulty dieting practices.

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 - Tooth decay and periodontal disease may result from a combination of
poor oral hygiene and poor eating habits.

Because adolescence is characterized by increasing maturity and a trend

towards autonomy and independence, adolescents are generally curious, adaptive and
open to new ideas. They may explore unconventional dietary practices (e.g. vegetarian
diets). As they mature, their own choices and preferences gain priority over eating habits
acquired in the family and they have more control over what they eat, when and where.
This is an important window for nutritional education interventions with potential to
impact lifetime eating habits and health.

2. Undernutrition and pregnancy

Undernutrition - manifesting as stunting or underweight - is associated with
deficiencies in earlier childhood.
- Other causes include unhealthy eating habits and poor access to food
may be an issue in developing countries.
- The increased metabolic requirements of pregnancy in affected
adolescents increase their risk of nutritional deficiencies, maternal
morbidity and mortality, low birth weight.
- Low birth weight babies are at increased risk of stunted growth and all the
known co-morbidities of later life.

3. Obesity
Obesity among both adolescents and adults is increasing worldwide in both poor
and rich economies. While genetic factors have a role, environmental factors (a
sedentary life style and high fat diets) play the dominant role. The major long-term
consequence of adolescent obesity is persistence into adulthood and association with an
increased risk of cardiovascular and metabolic disease in later life. It is estimated that at
least one half of cardiovascular mortality is nutrition-related and up to half of type-2
diabetes cases are nutrition-related. In addition, obesity in adolescent has other
undesirable health consequences. According to a review by the WHO (1990) obesity-
related issues include sleep disturbances; psychological and social problems; poor self-
esteem and body image. In women obesity during adolescence may affect future marital
and social economic status.

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4. Micronutrient deficiency
Iron is the most widespread micronutrient deficiency. Deficiency is most
prevalent among pregnant women, followed by pre-school children and adolescents –
particularly girls. Key causes include poor dietary intake, reduced bioavailability and
increased losses due to intestinal worms. Efforts to mitigate iron deficiency should
include diets rich in Vitamin C (to increase bioavailability of iron) and Vitamin A (to
increases the effectiveness of iron).
As maximum bone growth occurs during this period adolescents are prone to
calcium deficiency and increased tendency to bone fracture. Later on in life calcium
deficiency in adolescence is associated with high post-menopausal bone loss. These
deficiencies and effects can be reversed by adequate intake of calcium. Studies have
also reported a positive impact of zinc on linear growth among adolescents with zinc
deficiency – particularly boys.
Iodine deficiency is still an issue in parts of the world without access to iodized
salt. To prevent the deleterious mental effects of iodine deficiency on the fetus, normal
iodine status must be achieved prior to pregnancy; and for this to happen adolescents,
particularly girls, should be targeted in places where iodine deficiency is endemic.
Although Vitamin A deficiency has in the past been seen as primarily a problem of
children under the age of five years, it is now recognized from the impact of
supplementation studies that it may be widespread among women, and an important
contributor to maternal mortality. It may also be common among adolescent girls; and as
indicated above, it is entangled with iron deficiency. Therefore, adolescence is a good
time to prevent vitamin A deficiency. This can be achieved primarily through education
and food.

5. Eating disorders
Unnecessary dieting is highly prevalent in western societies especially among
adolescent girls. There is a broad spectrum of eating disturbances with bulimia nervosa
(excessive eating followed by self-induced vomiting or periods of fasting) and anorexia
nervosa (aversion to food) representing the extreme. Risks associated with eating
disorders include stunted growth, delayed puberty and progression to overt eating
disorders. Self-esteem seems to play a major role. School-based primary prevention
programs targeting girls may be the best way to tackle eating disorders.

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OTHER NUTRITION-RELATED CONCERNS

1. Fitness and sports

Athletic performance and recovery from training are enhanced by attention to

nutrient intake. Developing an ideal nutrition plan for health and performance includes
identifying the right quantity, quality and proper timing of food and fluids needed to
support regular training and peak performance.

2. Acne vulgaris

- also known as acne, is a long-term skin disease that occurs when hair follicles
are clogged with dead skin cells and oil from the skin. Acne is characterized by areas of
blackheads or whiteheads, pimples, greasy skin, and possible scarring. The resulting
appearance can lead to anxiety, reduced self-esteem and, in extreme cases, depression
or thoughts of suicide.

3. Anorexia nervosa

- it is a condition where people eat very little and thus have a low body weight. an
emotional disorder characterized by an obsessive desire to lose weight by refusing to
eat.

4. Bulimia nervosa where people eat a lot and then try to rid themselves of the food.
An emotional disorder involving distortion of body image and an obsessive desire to lose
weight, in which bouts of extreme overeating are followed by depression and self-
induced vomiting, purging, or fasting

5. Pica - where people eat non-food items

Eating disorders
People with an eating disorder experience extreme disturbance in their
eating behavior and related thoughts and feelings. They have an overwhelming
drive to be thin and a morbid fear of gaining weight and losing control over their
eating. Eating disorders can cause serious physical and psychological problems.
They are not a lifestyle choice.

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 Eating disorders can be effectively treated and the earlier the treatment the
better the recovery. Families and friends often need support and assistance too,
and are involved in the treatment process.

A physical health check is essential to rule out possible medical

complications that can arise from the condition. It is also very important to have
the right information about your diet and about healthy eating, as there is plenty
of wrong or misunderstood information about food and nutrition out there.

Talking with a professional counsellor is necessary to help change your

thoughts, feelings and behaviors related to the eating disorder, and to help deal
with the stressful things that might be happening in your life, like relationship
problems, school issues and other things. If you have complications like severe
depression or anxiety, medications may be useful.

Preventing acne
No single food causes acne, but what you eat may influence acne. For some
teenagers, foods like chocolate or greasy takeaways can have an effect on their
skin. As a general rule to prevent acne, try to eat fewer processed foods, and eat
and drink healthily.

PHYSICAL GROWTH AND DEVELOPMENT IN ADOLESCENCE

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 Physical changes of puberty mark the onset of adolescence (Lerner & Steinberg,
2009). For both boys and girls, these changes include a growth spurt in height, growth of
pubic and underarm hair, and skin changes (e.g., pimples). Boys also experience growth
in facial hair and a deepening of their voice. Girls experience breast development and
begin menstruating. These pubertal changes are driven by hormones, particularly an
increase in testosterone for boys and estrogen for girls. The physical changes that occur
during adolescence are greater than those of any other time of life, with the exception of
infancy. In some ways, however, the changes in adolescence are more dramatic than
those that occur in infancy—unlike infants, adolescents are aware of the changes that
are taking place and of what the changes mean. In this section, you will learn about
the pubertal changes in body size, proportions, and sexual maturity, the social and
emotional attitudes and reactions toward puberty, and some of the health concerns
during adolescence, including eating disorders.

Puberty Begins

Puberty is the period of rapid growth and sexual development that begins in
adolescence and starts at some point between ages 8 and 14. While the sequence of
physical changes in puberty is predictable, the onset and pace of puberty vary widely.
Every person’s individual timetable for puberty is different and is primarily influenced by
heredity; however environmental factors—such as diet and exercise—also exert some
influence.

Hormonal Changes

Puberty involves distinctive physiological changes in an individual’s height,

weight, body composition, and circulatory and respiratory systems, and during this time,
both the adrenal glands and sex glands mature. These changes are largely influenced
by hormonal activity. Many hormones contribute to the beginning of puberty, but most
notably a major rush of estrogen for girls and testosterone for boys. Hormones play
an organizational role (priming the body to behave in a certain way once puberty begins)
and an activational role (triggering certain behavioral and physical changes). During
puberty, the adolescent’s hormonal balance shifts strongly towards an adult state; the
process is triggered by the pituitary gland, which secretes a surge of hormonal agents
into the blood stream and initiates a chain reaction.

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 Puberty occurs over two distinct phases, and the first phase, adrenarche, begins
at 6 to 8 years of age and involves increased production of adrenal androgens that
contribute to a number of pubertal changes—such as skeletal growth. The second phase
of puberty, gonadarche, begins several years later and involves increased production of
hormones governing physical and sexual maturation.

Physical Growth: The Growth Spurt

During puberty, both sexes experience a rapid increase in height and weight
(referred to as a growth spurt) over about 2-3 years resulting from the simultaneous
release of growth hormones, thyroid hormones, and androgens. Males experience their
growth spurt about two years later than females. For girls the growth spurt begins
between 8 and 13 years old (average 10-11), with adult height reached between 10 and
16 years old. Boys begin their growth spurt slightly later, usually between 10 and 16
years old (average 12-13), and reach their adult height between 13 and 17 years old.
Both nature (i.e., genes) and nurture (e.g., nutrition, medications, and medical
conditions) can influence both height and weight.

Before puberty, there are nearly no differences between males and females in
the distribution of fat and muscle. During puberty, males grow muscle much faster than
females, and females experience a higher increase in body fat and bones become
harder and more brittle. An adolescent’s heart and lungs increase in both size and
capacity during puberty; these changes contribute to increased strength and tolerance
for exercise.

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Physical Growth and Mental Development

Growth failure and micronutrient inadequacy during childhood and adolescence

can delay growth and create high risk of chronic diseases in adulthood. Puberty is
accompanied by a growth spurt that increases the requirements for both macronutrients
and micronutrients. These higher requirements are balanced by a more efficient use of
protein for development rather than energy. For females, pubertal timing is affected by
childhood body mass index (BMI) and percentage of body fat; data for males are
inconclusive.

NUTRIENT NEEDS

A Teenager’s Nutritional Needs

Calories
A surge in appetite around the age of ten in girls and twelve in boys foreshadows
the growth spurt of puberty. How much of a surge? Let's just say that Mom and Dad

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might want to oil the hinges on the refrigerator door and start stockpiling a small cache of
their own favorite snacks underneath the bed.

Calories are the measurement used to express the energy delivered by food. The body
demands more calories during early adolescence than at any other time of life.

• Boys require an average of 2,800 calories per day.

• Girls require an average of 2,200 calories per day.
Typically, the ravenous hunger starts to wane once a child has stopped growing,
though not always. Kids who are big and tall or who participate in physical activity will
still need increased amounts of energy into late adolescence. During middle and late
adolescence, girls eat roughly 25% fewer calories per day than boys do; consequently,
they are more likely to be deficient in vitamins and minerals.

Nutrients
The nutrients protein, carbohydrates, and fats in food serve as the body's energy
sources.

• Each gram of protein and carbohydrate supplies 4 calories, or units of energy.

• Fat contributes more than twice as much: 9 calories per gram.

Protein
Of the three nutrients, we're least concerned about protein. Not because it isn't
important—50% of our body weight is made up of protein—but because adolescents in
the United States get twice as much protein as they need.

The densest sources of protein include teenage favorites such as:

• Beef - Chicken - Turkey

• Pork - Fish - Eggs
• Cheese

Carbohydrates
Carbohydrates, found in starches and sugars, get converted into the body's main
fuel: the simple sugar glucose. Not all carbs are created equal, however. In planning
meals, we want to push complex-carbohydrate foods and go easy on simple

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carbohydrates. Complex carbs provide sustained energy; that's why you often see
marathon runners and other athletes downing big bowls of pasta before competing. As a
bonus, many starches deliver fiber and assorted nutrients too. They are truly foods of
substance: filling yet low in fat.

• Most nutritionists recommend that complex carbohydrates make up 50% to 60%

of a teenager's caloric intake.
• Simple carbs, on the other hand, seduce us with their sweet taste and a brief
burst of energy but have little else to offer and should be minimized in the diet.

Dietary Fat
Fat should make up no more than 30% of the diet. Fat supplies energy and
assists the body in absorbing the fat-soluble vitamins: A, D, E, and K. But these benefits
must be considered next to its many adverse effects on health. A teenager who indulges
in a fat-heavy diet is going to put on weight, even if he's active. It would take a workout
befitting an Olympic athlete to burn off excess fat calories day after day.

Fatty foods contain cholesterol, a waxy substance that can clog an artery and
eventually cause it to harden. The danger of atherosclerosis is that the blockage will
affect one of the blood vessels leading to the heart or the brain, setting off a heart attack
or a stroke. Although these life-threatening events usually don't strike until later in adult
life, the time to start practicing prevention is now, by reducing the amount of fat in your
family's diet.

Dietary fat contains varying proportions of three types:

• Monounsaturated fat —the healthiest kind; found in olives and olive oil; peanuts,
peanut oil and peanut butter; cashews; walnuts and walnut oil, and canola oil.
• Polyunsaturated fat —found in corn oil, safflower oil, sunflower oil, soybean oil,
cottonseed oil, and sesame-seed oil.
• Saturated fat —is the most cholesterol laden of the three; found in meat and
dairy products like beef, pork, lamb, butter, cheese, cream, egg yolks, coconut
oil, and palm oil.

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 You want to limit your family's intake of saturated fat to no more than 10% of your
total daily calories. The other 20% of daily calories from dietary fat should come equally
from the two unsaturated kinds of fat, both of which are contained mainly in plant oils.

If your family eats a lot of packaged and processed foods: Make a habit of
reading the food labels. You may be surprised to see how much fat, sugar, and salt
(sodium), is in the foods you eat every day. And almost all packaged goods that contain
fat are likely to have partially hydrogenated fat, because it has a longer shelf life.

Vitamins and Minerals

A well-rounded diet based on the USDA guidelines should deliver sufficient
amounts of all the essential vitamins and minerals. Adolescents tend to most often fall
short of their daily quotas of calcium, iron, zinc, and vitamin D.

Unless blood tests and a pediatrician's evaluation reveal a specific deficiency, it's
preferable to obtain nutrients from food instead of from dietary supplements.

RECOMMENDED DIET

Eating healthy food is important at any age, but it’s especially important for
teenagers. As your body is still growing, it’s vital that you eat enough good quality
food and the right kinds to meet your energy and nutrition needs.

Being a teenager can be fun, but it can also be difficult as your body shape
changes. These physical changes can be hard to deal with if they aren’t what you
are expecting. There can be pressure from friends to be or look a certain way,
and this might affect the foods you eat. It’s not a good time to crash diet, as you
won’t get enough nutrients, and you may not reach your full potential. Following a
sensible, well-balanced diet is a much better option, both for now and in the long
term.

As a teenager, you’ll start to become more independent and make your

own food choices. You’ll hang out with your friends or get a part-time job so you
can buy the things you like. Because you are still growing, you need to take extra
care to get enough of some important vitamins and minerals to feel good and be
healthy.

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 Eating three regular meals a day with some snacks will help you meet your
nutrition needs. Skipping meals means you will miss out on vitamins, minerals
and carbohydrates, which can leave you lacking energy or finding it hard to
concentrate. Here is a guide to help you understand the value of what you eat.

1. Breads, grains and cereals are carbohydrates that provide energy for your brain and
muscles. They’re also an excellent source of fibre and B vitamins. Without enough
carbohydrates you may feel tired and run down. Try to include some carbohydrates at
each mealtime.

2. Fruit and vegetables have lots of vitamins and minerals which help boost your immune
system and keep you from getting sick. They’re also very important for healthy skin and
eyes. It’s recommended you eat two serves of fruit and five serves of vegetables a day.

3. Meat, chicken, fish, eggs, nuts and legumes (e.g. beans and lentils) are good sources of
iron and protein. Iron is needed to make red blood cells, which carry oxygen around your
body. During your teenage years, you’ll start to menstruate, or get your period, and this
leads to loss of iron. If you don’t get enough iron, you can develop anaemia, a condition
that can make you feel tired and light-headed and short of breath. Protein is needed for
growth and to keep your muscles healthy. Not eating enough protein when you are still
growing, or going through puberty, can lead to delayed or stunted height and weight. Not
enough protein is common when you go on strict diets. Include meat, chicken, fish or
eggs in your diet at least twice a day. Fish is important for your brain, eyes and skin. Try
to eat fish 2 to 3 times a week.

If you are vegetarian or vegan and do not eat meat, there are other ways to meet your
iron needs, for example, with foods like baked beans, pulses, lentils, nuts and seeds.

4. Dairy foods like milk, cheese and yoghurt help to build bones and teeth and keep your
heart, muscles and nerves working properly. You’ll need three and a half serves of dairy
food a day to meet your needs.

5. Eating too much fat and oil can result in you putting on weight. Try to use oils in small
amounts for cooking or salad dressings. Other high-fat foods like chocolate, chips, cakes
and fried foods can increase your weight without giving your body many nutrients.

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6. Fluids are also an important part of your diet. Drink water to keep hydrated, so you won’t
feel so tired or thirsty. It can also help to prevent constipation.

NUTRITIONAL CONCERNS FOR ADOLESCENTS

Dietary habits, which affect food preferences, energy consumption and nutrient intakes,
are generally developed in early childhood and particularly during adolescence. The
home and school environments play a major role in determining a child's attitude to, and
consumption of individual foods.

Teenagers, as well as being exposed to periodic food fads and slimming trends,
tend to skip meals and develop irregular eating habits. One of the most frequently
missed meals is breakfast. Studies show that breakfast plays an important role in
providing needed energy and nutrients after an overnight fast and can aid in
concentration and performance at school.

Snacks generally form an integral part of meal patterns for both children and
teenagers. Younger children cannot eat large quantities at one sitting and often get
hungry long before the next regular mealtime. Mid-morning and mid-afternoon snacks
can help to meet energy needs throughout the day. Fast-growing and active teenagers
often have substantial energy and nutrition needs and the teaching of food and nutrition
in the school curricula will enable children to have the knowledge to make informed
choices about the foods in their regular meals and snacks.

Energy needs

Normally, the energy requirements of adolescents tend to parallel their growth

rate, and individuals meet their energy needs by means of their appetite with adequate
precision. As a result, the majority of adolescents maintain energy balance, and a varied
food intake provides sufficient nutrients to ensure optimal growth and development.

Stress and emotional upsets however can seriously affect the energy balance in
adolescents, resulting in the consumption of too little or too much food. Mild or severe
infections, nervousness, menstrual, dental or skin problems (acne) can result in

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alterations of appetite, and those adolescents on marginal diets are the most vulnerable.
Emotional stress is often associated with food faddism and slimming trends, both of
which can lead to eating disorders such as anorexia nervosa.

On the other hand, the prevalence of overweight and obesity in children and
adolescents is now a major nutritional problem and the condition is likely to persist into
adulthood. Developing adolescents are particularly concerned about their body image
and excessive weight can have profound effects on their emotional wellbeing as well as
on their physical health. The cause of obesity is multifactorial and socio-economic,
biochemical, genetic, and psychological factors all closely interact.

Lack of activity plays an important role in the development, progression and

perpetuation of obesity in adolescence. Surveys of young people have found that the
majority is largely inactive and health professionals and governments are now
encouraging higher levels of physical activity among children and adolescents. Physical
inactivity does not only have a prime role in the development of overweight and obesity,
but also on the development of chronic diseases such as heart disease, certain cancers,
diabetes, hypertension, bowel problems and osteoporosis in later life. In addition,
physical activity is related to improvements in body flexibility, balance, agility and co-
ordination and strengthening of bones. The current recommendation is for children to try
to be physically active for at least 60 minutes daily. To know more about physical
activity.

REFERENCES

Nutrition in adolescence – Issues and Challenges for the Health Sector. WHO Discussion paper on
adolescence. ISBN 92 4 159366 0 (NLM classification: WS 115); WHO 2005.

AHA Scientific Statement. Progress and Challenges in Metabolic Syndrome in Children and
Adolescents. http://www.americanheart.org/presenter.jhtml?identifier=3003999

http://www.pediatriconcall.com/fordoctor/Conference_abstracts/report.aspx?reportid=414

https://www.nestlenutrition-institute.org/country/za/news/article/2015/09/01/nutrition-issues-in-adolescence,
Nutrition in Adolescence last Updated September 01, 2015

https://www.thewomens.org.au/health-information/staying-well/adolescent-girls/food-and-nutrition-for-
adolescents

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 https://courses.lumenlearning.com/wmopen-lifespandevelopment/chapter/physical-growth-and-development-
in-adolescence/

Committee on Nutrition (Copyright © 2016 American Academy of Pediatrics)

https://www.healthychildren.org/English/ages-stages/teen/nutrition/Pages/A-Teenagers-Nutritional-
Needs.aspx, Last Updated 3/1/2016

https://www.eufic.org/en/healthy-living/article/child-and-adolescent-nutrition
Last Updated : 08 June 2006
World Health Organization (1990). Prevention in childhood and youth of adult cardiovascular disease: time
for action. WHO, Geneva

ACTIVITY
STUDY QUESTIONS:

1. Give suggestions on how to encourage better breakfast habits?

2.How does peer group relationship influence food choices and eating habits of a
teenager? Give specific examples.

3.List down indicationsof good nutrition among adolescents.

4. What advise would you give to a teen ager with an acne problem?

QUIZ:

1. What is the usual treatment for people with anorexia nervosa, and what do most
experts say about their recovery?

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2. What is the typical profile of a person with bulimia nervosa?

3. Describe an eating binge and all the behaviors that constitute purging.

4. How does binge-eating disorder differ from bulimia?

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 LESSON 6
ADULTHOOD

1. Physiologic changes accompanying aging

2. Psychological impact of aging
3. Nutrient needs/ Dietary requirements
4.Nutrition-related concerns of mature adults
5.Nutritional Problems and Interventions
6.Recommended Diet

WEEK TOPIC LEARNING OUTCOMES ACTIVITY

1. Discuss common nutrition-related medical
problems of the older adult.
2.Know the difference of food preferences
and requirement which suits the specific life
stage.

Adulthood, the period in the human lifespan in which full physical and intellectual
maturity have been attained. Adulthood is commonly thought of as beginning at age 20
or 21 years. Middle age, commencing at about 40 years, is followed by old age at about
60 years. Proper nutrition needs emphasis in adulthood, since it is the longest period of
the life cycle and possibly the peak productive years.

PHYSIOLOGIC CHANGES ACCOMPANYING AGING

The process of growing old or the period of old age is referred to as senescence .
the study of the phenomena of old age is gerontology and the treatment of it’s
accompanying disease is geriatrics. A person belonging to this period is referred to as
an elderly in the Philippines and senior citizen in the United States. A senile is often
clinically connotated with an old man with mental and physical weaknesses., a meaning
which should not be attached to a normal aged person.

The period of senescence is characterized by disturbed regulatory and functional

mechanisms in the body. The effects are observed in the following systems:

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1. GASTROINTESTINAL
Diminished secretion of digestive enzymes, decreased motility, decreased
absorption and utilization of nutrients.
2. CIRCULATORY
Reduced cardiac output, loss of elasticity of blood vessels, slow rate of blood
flow especially through the kidney.
3. EXCRETORY
Diminished amount of functioning nephrons and slow excretion of wastes.
4. ENDOCRINE
Reduction in secretion of the thyroxin and pituitary hormones, decreased cellular
metabolism and ability to withstand stress.
5. NERVOUS
Diminished conductance of the nerve impulse and decreased sensory sensitivity.
6. RESPIRATORY
Loss of pulmonary functional tissues.
7. MUSCULAR
Diminished muscular coordination
8. REPRODUCTIVE
Atrophy o the corpus luteum, decreased production of estrogen and testosterone
9. SKELETAL
Increased proportion of lime to water in the bones causing them to become brittle
and to break easily.

Physiological changes occur with aging in all organ systems. The cardiac output
decreases, blood pressure increases and arteriosclerosis develops. The lungs show
impaired gas exchange, a decrease in vital capacity and slower expiratory flow rates.
The creatinine clearance decreases with age although the serum creatinine level
remains relatively constant due to a proportionate age-related decrease in creatinine
production. Functional changes, largely related to altered motility patterns, occur in the
gastrointestinal system with senescence, and atrophic gastritis and altered hepatic drug

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metabolism are common in the elderly. Progressive elevation of blood glucose occurs
with age on a multifactorial basis and osteoporosis is frequently seen due to a linear
decline in bone mass after the fourth decade. The epidermis of the skin atrophies with
age and due to changes in collagen and elastin the skin loses its tone and elasticity.
Lean body mass declines with age and this is primarily due to loss and atrophy of
muscle cells. Degenerative changes occur in many joints and this, combined with the
loss of muscle mass, inhibits elderly patients' locomotion.

These changes with age have important practical implications for the clinical
management of elderly patients: metabolism is altered, changes in response to
commonly used drugs make different drug dosages necessary and there is need for
rational preventive programs of diet and exercise in an effort to delay or reverse some of
these changes.

NUTRIENT NEEDS/ DIETARY REQUIREMENTS

Many Americans are consuming too many calories—the Weight Control

Information Network reports that 68 percent of adults in the U.S. are overweight or
obese. However, Americans filling their diet with processed foods may still be missing
the nutrients they need, despite getting too many calories. Choosing nutrient-dense
foods and abiding by your calorie recommendations will help you reach your nutrition
needs while maintaining a healthy body weight.

Calorie Needs

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 Your individualized caloric needs are based on your physical activity level and
body weight. If you’re overweight or obese, you need about 1,000 to 1,600 calories per
day to lose weight, according to the U.S. Department of Health and Human Services,
or about 10 calories per pound of your ideal body weight, says the University of
Washington. Use your body weight to determine your caloric needs for healthy weight
maintenance—13 calories per pound if you’re sedentary, 16 calories per pound of
you’re moderately active and 18 calories per pound of body weight if you regularly
engage in high-intensity exercise.

Protein Needs

Protein is needed for almost every function in the human body. Adults require
protein to maintain lean muscle mass and for healthy hair, skin and nails. Protein can
also increase satiety, which might help you avoid overeating. Men need at least 56
grams of protein and women need 46 grams, while pregnant and nursing women
require at least 71 grams of protein each day. Active adults may need even more
protein than these minimum requirements. Protein-rich foods include eggs, poultry,
lean meats, seafood, dairy foods, soy products, seitan, nuts, seeds and legumes.

Carbohydrate Needs

Although carbs have gotten a bad reputation among the dieting community in
recent years, carbohydrates are your body’s main source of energy. The Institute of
Medicine recommends eating at least 130 grams of carbs each day, or about 45 to 65
percent of your daily calorie intake from carbs—equivalent to 225 to 325 grams of
carbs per day for a 2,000-calorie diet, as carbs provide 4 calories per gram. Choose
nutrient-dense, high-fiber carbohydrates from whole grains, fruits, vegetables and
legumes. Healthy carbs are also found in low-fat dairy products, such as milk and
yogurt.

Healthy Fats Needs

Replacing saturated and trans fats with healthier, unsaturated fats is beneficial
for your heart. The Institute of Medicine recommends eating 20 to 35 percent of your
calories from fats, or about 44 to 78 grams per day for a 2,000-calorie diet. Choose

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healthy fats, such as vegetable oils, nuts, seeds, fish oil, peanut butter, avocados and
hummus.

Vitamins and Minerals

Eating a well-balanced diet on a regular basis can help you meet most of your
micronutrient—vitamin and mineral—needs. However, ask your doctor about taking a
multivitamin supplement that's customized for your specific needs to make sure you’re
meeting your nutrition requirements on a regular basis.

Eating right and staying fit are important no matter what your age. As we get
older our bodies have different needs, so certain nutrients become especially important
for good health.

Calcium and Vitamin D

Older adults need more calcium and vitamin D to help maintain bone health. To
meet these needs, select calcium-rich foods and beverages and aim for three servings
of low-fat or fat-free dairy products each day. Other sources of calcium include fortified
cereals and fruit juices, dark green leafy vegetables, canned fish with soft bones, and
fortified plant-based beverages. Good sources of vitamin D include fatty fish, such as

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salmon, eggs and fortified foods and beverages. If you take a calcium supplement or
multivitamin, choose one that contains vitamin D.

Vitamin B12

Some adults older than 50 may not be able to absorb enough vitamin B12.
Fortified cereal, lean meat and some fish and seafood are sources of vitamin B12. Ask
your doctor or a registered dietitian nutritionist if you need a vitamin B12 supplement.

Dietary Fiber

Eat fiber-rich foods to stay regular. Dietary fiber also may help lower your risk for
heart disease and reduce your risk for Type 2 diabetes. Eat whole-grain breads and
cereals, and more beans and peas — along with fruits and vegetables which also
provide dietary fiber.

Potassium

Consuming adequate potassium, along with limiting sodium (salt) intake, may
lower your risk of high blood pressure. Fruits, vegetables, beans and low-fat or fat-free
dairy products are good sources of potassium. Also, select and prepare foods with little
or no added salt. Add flavor to food with herbs and spices.

Know Your Fats

Most of the fats you eat should be polyunsaturated and monounsaturated fats,
which are primarily found in nuts, seeds, avocados, vegetable oils and fish. Choose
foods that are low in saturated fat and trans fat to help reduce your risk of heart disease.

NUTRITION-RELATED CONCERNS OF MATURE ADULTS

Geriatric nutrition is concerned mainly with the conservation of good health and
the prevention of chronic degenerative diseases to which an elderly is prone to such as
arthritis, rheumatism, gout, coronary heart disease and diabetes. Advancements in
medical knowledge, improvements in socio-economic conditions, and research in
nutrition have considerably prolonged life expectancy of the aged.

CALORIES

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 The demand for calories is decreased because of the reduced basal metabolism
and physical activity. Food and Agriculture Organization(FAO) recommends a decrease
in o 7.5% for each decade of 50-59 and 60-69 and 10% for 70 years and above. This is
in reference to the standard 25 year old Filipino man weighing 49 kgs, all engaged in
moderate physical activities. Researchers have noted the importance of cutting down
Calories during the aging period because statistics have shown that by 60, the average
adult has accumulated about seven extra kilograms.

CARBOHYDRATES AND FAT

Around 50-60% of the total Calories should come from carbohydrates; and about
25-30% from fats in the form of polyunsaturated fatty acids. Studies have shown a link
between the kind of carbohydrate and fat with the occurrence of coronary heart disease.
Sucrose and saturated fatty acids have been known to increase the triglyceride and
cholesterol levels in the blood. However, rich source of cholesterol and saturated fatty
acids are among the “protective foods” like egg, milk, organ meats. Hence, severe
restriction of these foods is not advisable.

Not only the quality but also the quantity of fat should be watched out in the diet
of a elderly. Digestion and absorption of fat have been found to be slow in the aged. Too
much fat in the diet may cause indigestion.

PROTEIN

Its allowance in the aged is maintained at 1.12 gm/kg body weight based on a
net protein utilization of of 63%. Protein is necessary for the prevention of progressive
tissue wasting and susceptibility to disease and infection.

There is no increased requirement for protein under normal circumstances

because the overall mass of actively metabolizing tissues decreases with age. However,
older persons who have had poor dietary habits or illness will benefit greatly from an
increased intake. Some studies have shown a poor protein intake as due to low intake
with incomplete digestion and assimilation of nutrients. Since proteins are not stored in
the body, they must be provided in the diet daily.

VITAMINS AND MINERALS

Calcium, iron, and vitamins A and C are two important minerals and vitamins
commonly found lacking in the diet of the aged because of the low intake of meat, milk,

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green leafy vegetables, and fruits. When calcium is inadequately supplied, bones
become thin and fragile due to demineralization of the bony tissue and this results in a
condition called osteoporosis. When calcium is poorly absorbed and metabolized
because of lack of Vitamin D, bones fracture easily and this condition referred to as
osteomalacia or adult rickets.

Nutritional Anemia has also been found to occur frequently among older persons.
This is brought about by a multiple deficiency of nutrients, among which are iron, Vitamin
c, folic Acid, Vitamin B12, copper and cobalt. Womans iron allowances at the age of 50
and above drops to as low as 7.0 mg/day, a decrease of more than 50% from the
previous reproductive years. At around this time, menopause takes place, marking the
permanent cessation of menstruation.

Special emphasis must also be placed on Vitamin C. It is often found deficient

among aged people. It facilitates absorption of calcium and iron and together with
Vitamin e has been found to retard cellular aging.

An adequate intake of thiamin is important because it can counteract the poor

appetite commonly found among the aged and also it helps regulate the muscle tone of
the gastro-intestinal tract and the normal functioning of the nerves.

One research claims that absence of riboflavin in the diet hastens premature
senility. This requires further investigations.

Vitamin D has also been found to be deficient among elderly people with serious
diseases. This is often brought about by liver injury, antibiotic therapy, and poor
intestinal absorption.

WATER with the slow excretion of waste matter, water becomes important as a
carrier. It helps control constipation which frequently occurs among older people
because of reduced gastric motility, diminished bulk or fiber in the diet, and deceased
physical activity, Approximately 6-8 glasses/day are needed.

NUTRITIONAL PROBLEMS AND INTERVENTIONS

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 Common feeding problems such as food choices and lack of appetite affect the
overall nutriture of the elderly. Physical, psychological, socio-economic cultural factors
and illnesses affect the intake of food and/it’s utilization.

1. PHYSICAL FACTORS

Poor teeth and gums, inferior quality dentures, difficulty in swallowing, lack of
motor coordination affect the choice of foods and appetite for them. Physical discomfort
such as heartburn and gas pain may reduce food intake. A diminished sense of taste
and smell takes away the pleasure of eating. Cumber-some handling of eating utensils
maybe a source of frustration and loss of interest in food.

2. PSYCHOLOGICAL FACTORS

Closely associated with geriatric nutrition is the mental or psychological of the

aged. It is observed that dietary management should not only keep him physically alive,
but also socially and psychologically young. For him food is not only a biologic necessity
but more of a medium of socialization. It is not what he eats but with home that
determines his nutrient adequacy. In addition the need for medication and treatment
decreases as the mental and social needs of the aged are provided.

The loss of one’s spouse , close friends , and relatives sets up a feeling of
“aloneness” and insecurity” in the aged resulting usually in somatic complaints and poor
appetite. Furthermore, loss of one’s job, social position, and sexual attractiveness and
the threat of death creates on him a fear of being cheated, lied to, or robbed. All these
factors are intensified when there is also loss of vision and/or hearing.

Studies show that an elderly tends to be most satisfied with life when he remains
involved in society rather than disengaged from it. A hobby, an interest, or social activity
give him a feeling of usefulness and of being wanted. Evidence indicates that sodium
and calcium retention In the body is reduced in the presence of emotional instability.

According to Weiner (J. Am. Dietet. A, 1969), an aged person may exhibit any of
the following reactions:

A. ANXIETY - He is constantly worried about his environment, his health, and everything
about himself. He is insecure and this feeling is expressed in his complaint against food,
in refusal to eat, or in self-indulgence on “empty calorie” foods. His worry may produce
changes in the motility of the gastro-intestinal tract., thus showing symptoms of diarrhea

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or constipation. With the anxious person, it is best to reassure him that everything will be
all right. The physical presence of a comforting person imparts to him a feeling of
security.

B. DEPRESSION - He does not eat sufficiently, often out od conscious or unconscious

desire to die. He does not want to be reassured and has numerous complaints about the
food. This person needs to be told firmly that eating is imperative and that he is going to
be helped to eat as much as he requires to stay adequately nourished. He needs to be
faced with a will that is stronger than his. Some degree of external control maybe
reassuring , in spite of his complaints to the contrary. Spoon feeding to get him started
may assure him that he will be fed despite his objection or his wish to die.

C. SUSPICION - He does not eat because he is insecure about the food and the people
around him. The best approach for this kind of person is to leave him alone with his food
and allowing him to eat at his own pace. A matter-of-fact tone of voice should be used
when being pressed for answers to his insistent questions.

D. CONFUSION - He Does not know what is going on around him. The confused state
may result from a head trauma, diabetic or hepatic coma, or in recovery from a stroke.
Confusion may lead to anxiety, depression or suspicion. He should be helped to see,
hear and understand what is going on and what is being served to him.

Cultural patterns also play a great role in determining human behavior. In our
society, the aged is perceived as old-fashioned , useless, querulous and unattractive.
The notions are imprinted in the mind s of the youth so that upon reaching old age, they
apply this concepts to themselves.

An awareness, therefore, of the emotional needs of people and their reactions to

inability to meet their own needs can be an asset in the management of a dietary
regimen.

3. SOCIO_ECONOMIC CULTURAL FACTORS

Retirement from work brings with it reduction in financial resources. Lack of

money most often is the cause of selection of inexpensive “empty calorie” foods and
reduced intake of meat, milk, and eggs. Low income may also mean poor quality of
dentures or none at all.

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 An elderly person is easy prey to food fallacies and superstitious beliefs. He has
the wrong idea that food are small because he is inactive. He does not drink milk
because of the erroneous view that it is only for babies, has constipating and gas-
producing effects. He believes that a fat person is a healthy person, thus, he does not
mind nibbling all day long or eating starchy and sweetstuffs. He also uses up his money
buying “organic’ foods, “medicinal” herbs, concoctions, and pills which promise the
“fountain of youth.”

4.ILLNESSES

In the aged, the high incidence of illness and the lifetime accumulation of the
results of physical stresses are among the cause of variability in nutritive requirements.
Infections, injuries, gastrointestinal symptoms, obesity, diabetes, gout and surgeries all
have their nutritional implications. Disease combined with economic and psychological
factors results in poor nutritional status.

Unfavorable effects of drug-diet interrelationship especially in the aged affect

nutrient absorption, gastro-intestinal flora, and electrolyte balance. Recent findings also
show that the senior citizens of United States have resorted to drugs for solace.
Sedatives and tranquilizers are overprescribed. Pharmacological solution to the aged’s
problems may only worsen his pathetic situation.

Other nutritional problems and interventions

MACULAR DEGENERATION

An eye disease that progressively destroys the macula, the central portion of the
retina, impairing central vision. Macular degeneration rarely causes total blindness
because only the center of vision is affected. However, injury to the macula in the center
of the retina can impair the ability to see straight ahead clearly and sometimes make it
difficult to read, drive, or perform other daily activities that require fine central vision

Supplements of zinc together with the antioxidants vitamin C, vitamin E and beta-
carotene reportedly slow the progression of dry AMD. In people with intermediate-stage
disease dry AMD, zinc reduced the risk of the disease progressing to the advanced
stage by 11%, and the antioxidants reduced the risk by 10%. When the two were
combined, the risk was reduced by 19%. The daily doses of the antioxidants used in this
study were 500 milligrams of vitamin C, 400 milligrams of vitamin E and 15 milligrams of

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beta-carotene (a molecule the body converts to vitamin A). The daily dose of zinc was
80 milligrams with 2 milligrams of copper added to prevent copper deficiency sometimes
associated with high zinc intake. These amounts are well above the usual levels
recommended by the Food and Drug Administration (FDA

Retinopathy is a disease of the retina . The retina is the nerve layer that lines the back
of your eye. It is the part of your eye that "takes pictures" and sends the images to your
brain. Many people with diabetes get retinopathy. This kind of retinopathy is called
diabetic retinopathy (retinal disease caused by diabetes).

If blood sugar levels stay high, diabetic retinopathy will keep getting worse. New
blood vessels grow on the retina. This may sound good, but these new blood vessels
are weak. They can break open very easily, even while you are sleeping. If they break
open, blood can leak into the middle part of your eye in front of the retina and change
your vision. This bleeding can also cause scar tissue to form, which can pull on the
retina and cause the retina to move away from the wall of the eye (retinal detachment).
This is called proliferative retinopathy. Sometimes people don't have symptoms until it is
too late to treat them. This is why having eye exams regularly is so important

Causes:

If you are not able to keep your blood sugar levels in a target range, it can cause
damage to your blood vessels. Diabetic retinopathy happens when high blood sugar
damages the tiny blood vessels of the retina.

When you have diabetic retinopathy, high blood pressure can make it worse.
High blood pressure can cause more damage to the weakened vessels in your eye,
leading to more leaking of fluid or blood and clouding more of your vision.

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Can diabetic retinopathy be prevented?

You can lower your chance of damaging small blood vessels in the eye by
keeping your blood sugar levels and blood pressure levels within a target range. If you
smoke, quit. All of this reduces the risk of damage to the retina. It can also help slow
down how quickly your retinopathy gets worse and can prevent future vision loss.

How is it treated?

Surgery, laser treatment, or medicine may help slow the vision loss caused by
diabetic retinopathy. You may need to be treated more than once as the disease gets
worse.

Diabetes damages small blood vessels throughout the body, leading to reduced
blood flow. When these changes affect the tiny blood vessels in the eyes, diabetic
retinopathy may occur.

RECOMMENDED DIET

Older people need the same basic “protective foods” as adults. However, they
tend to incline towards two extremes. On the one hand some eat badly and too little,
meaning more of nibbling and less of sugar meals, more of coffee, tea, softdrinks, and
alcoholic beverages and less of milk and fruit juices. At the other extreme, some eat
excessively as their main surviving pleasure, a sedative which brings drowsiness,
immobility, and overweight.

No teeth or poor dentures restrict their food to those that are mashed, chopped,
or pureed. For those with sensitive digestive systems, something hot at each meal, four
or five light bland meals rather than three substantial ones are beneficial. While rough
fiber is not recommended for the elderly’s diet, the fiber of tender vegetables, fruits, and
whole grain cereals will promote normal peristalsis in addition to their being good
sources of vitamins and minerals.

Milk is an important food in the diet of the aged. It is a good source of protein,
calcium, riboflavin and when fortified an excellent source of vitamin D. A glass of hot milk
before going to bed may induce sleep. However, for those who cannot tolerate milk,

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dried “dilis,” “tilapia,” dried kanduli, small shrimps, “kuhol”, “tulya”, “balut”, “susong pilipit”,
“malunggay” leaves and “saluyot” leaves are very good substitutes.

Finger foods have been found to be favorites among the aged because they
require less effort and are easier to handle.

A good breakfast, pleasant eating sorroundings, and familiar foods should be

stressed when feeding the elderly. Old age is not the time to introduce new foods.
Hence, fortified and enriched foods can help greatly in improving the nutrient intake of
the aged.

Fats may retard digestion. If there is discomfort, avoid fatty meat and fish, fried
foods, gravies, sauces, rich desserts and dishes containing coconut milk.

It is recommended that the heavier meal be eaten at noon rather than at night.
Coffee and tea late in the day may prevent a good sound sleep.

BALANCED DIET FOR ADULTS (in grams)

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 ACTIVITY

STUDY QUESTIONS:

1. What are some of the consequences of a decreased immunity among elders?

2. Compared with a younger adult, does a person older than 65 need more, less, or
about the same amount of protein?

3. Why are elders at risk of vitamin D deficiency?

4. Discuss minerals that may need special attention in assessment of an elder’s

nutrition status?

5. What problems might elders encounter with dietary supplements?

6. What is the role of physical activity in osteoporosis prevention? What nutritional

factors are important?

References

https://pubmed.ncbi.nlm.nih.gov/7336713/ BY G R BOSS, J E Seegmiller

https://www.apa.org/topics/aging-depressionhttps://www.physio-pedia.com/Psychological_Factors_in_Ageing
https://healthyeating.sfgate.com/nutrition-needs-during-adulthood-6698.html
ByErin Coleman, R.D., L.D.Updated December 12, 2018

Claudio, V. and Ruiz, O. (2002). Basic Nutrition for Filipinos 5th Edition, Manila, Philippines, Meriam and Webster
Bookstore.

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 UNIT VII
DIET THERAPY

Dietary planning and intervention have been regarded as a complementary

management in the treatment or prevention of some diseases. This is why nurses should
be aware of the different dietary modifications that are suitable for each patient. This
chapter will provide the needed information on the different types of diet therapy and
their various indications.
TOPICS
A. General diets
1. Regular/full Diet
2. High fiber diet
3. Vegetarian diets
4. Therapeutic diets
LESSON 1
GENERAL DIETS

WEEK TOPIC LEARNING OUTCOME ACTIVITIES

1. Motivation
At the end of the lesson, you will be able 2. Study Questions
to:
DAY
1. Differentiate the kinds of standard
hospital diets

Did you answer all the study questions from the previous
modules?

EXCELLENT!

You may now continue with this module.

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DIET THERAPY

 The application of nutritional science to promote human health and treat disease

 involves the modification of food intake

 A means of management for such metabolic diseases or it supports the overall

therapeutic program

OBJECTIVES OF DIET THERAPY

· To rest a particular organ

· To adjust the diet to the body's ability to use certain foods

· To produce a specific effect as a remedy (e.g., regulation of blood sugar in diabetes)

. To increase or decrease body weight

▪ To overcome deficiencies by the addition of food rich in some necessary element

(e.g., supplementing the diet with iron in treating macrocytic anemia)

▪ To eliminate food substances to which the patient may be allergic

 To provide ease of digestion by omitting irritating substances, such as fiber,

spices, or high-fat foods

Does the change in diet help the person to recover from disease?

- Yes, certainly. When sugars are withdrawn from food, insulin is not required to
digest them.
- When fats are taken off the diet, the liver can relax and take time to recover.
- Drinking fluids certainly helps to overcome losses of water and minerals.

Some points to remember

While modifying the diet of a patient, keep the following points in mind:

1. Do not plan a completely different diet because:

- Diets based on a person's daily diet have better acceptance.

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 - Such diet do not make a patient feel that he/she is eating something
completely different from the family members.

- It is difficult to prepare.

2. Try to include only those foods which are liked by the patient, otherwise food may not
be eaten at all.

3. Serve the meal in an attractive way to make them feel like eating.

TYPES OF MODIFICATION OF A NORMAL DIET

The types of modifications that may have to be made are as follows:

1. In diet consistency

2. In nutrient content

3. In interval and frequency of feeding

1. Modifications in diet consistency

- In some diseases the thickness of the food has to be changed.
- The food can then be served in two consistencies:

1. Liquid
2. Semi solid
Sometimes, it becomes difficult to eat normal food.
- For example, in diarrhea and fever you serve a liquid diet.
- This liquid diet includes milk, fruit juices, coconut water, tea, soups, cold drinks,
etc.

2. Modifications in nutrient content

- Depending on the nature of the diseases, modifications may need to be made in
one or more nutrients in the diet.
- The modifications can be in terms of an increase or decrease in amount of the
nutrient.

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 - For example, salt has to be reduced in high blood pressure, intake of
carbohydrates has to be restricted in case of diabetes and fluid intake has to be
increased in the case of diarrhoea.

3. Modifications in interval and frequency of feeding

- Normally you eat 3-4 meals a day, that is, breakfast, lunch, tea and dinner.
- In sickness, you find it difficult to eat the amount you usually eat at one time.
- However, your body must get all the nutrients in correct amounts.
- Small amounts of food at intervals of 2-3 hours and as many as 8-10 small meals
in a day instead of 3-4 meals facilitates speedy recovery.

TYPES OF DIETS

 Diets used in the treatment of disease are termed by specific names that show a
special composition and often indicate the purpose for which the diet is intended.

A - General Diets

1. Regular/ Normal/ Full Diet

2. High Fiber
3. Low Fiber
4. Vegetarian
5. Therapeutic

1. Regular Diet – “Normal diet”/ “full diet”/ house/ dat (diet as tolerated)
composed of all types of foods and is well balanced
capable of maintaining a state of good nutrition.
It is intended for convalescing patients who do not require a therapeutic diet.

INDICATIONS

When no dietary modification is needed and solid foods can be tolerated.

No dietary restrictions
Includes the basic food groups

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 For ambulatory patients
Bed patients not requiring therapeutic diets

2. Vegetarian Diet
Vegetarian diets are used by individuals who abstain from eating all or specific foods of
animal origin.

TYPES

Dietary restrictions based on patients own restrictive practices.

1. Lacto-ovovegetarian - Diet include milk products & eggs will meet the
Recommended
2. Lactovegetarian diets – include milk products
3. Pure vegetarians/ Vegans- eat only plants

Note:
Special attention is needed in planning a strict vegetarian diet to meet all dietary
needs.
Potential nutrient deficiencies include energy, zinc, protein, iron, Vitamin B12,
riboflavin, calcium, magnesium and iodine.
Infants, children and pregnant and lactating women are at greater risk.

PURE VEGAN DIETS: benefits

Low in fat
High in fiber
Cholesterol-free ↓
Decreased risk of:
Coronary heart disease
obesity
Type II diabetes
Constipation
Certain cancers – breast & colon

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3. THERAPEUTIC DIETS
- are modifications of the regular diet and are designed to meet specific patient needs.

These include modifications in:

- method of preparation (e.g., baking, boiling, or broiling),
- consistency (e.g., ground or chopped),
- total calories (e.g., high or low calorie),
- nutrients (e.g., altering carbohydrate, protein, fat, vitamins, and minerals)
allowing only specific foods (e.g., diabetic diet).

LESSON 2
DIETS MODIFIED IN CONSISTENCY

1. Clear liquid
2. Full liquid
3. Cold liquid T&A diet
4. Soft bland
5. Mechanical soft
6. Soft bland
7. Bland
8. Residue restricted
9. Low fiber

WEEK LEARNING OUTCOME ACTIVITIES

1. Matching type
At the end of the lesson, you will be able to: quiz
2. Menu planning
1. Design a therapeutic diet using the principles, 3. Modifying a
types of therapeutic diets, and their indications regular diet into a
and contraindication. standard hospital
diet
2. Utilize knowledge of diet therapy in assisting
clients needing dietary modifications.
3. Modify a menu to an altered consistency diet
(e.g., clear liquid diet, pureed diet,
mechanically altered diet).
4. Give examples of therapeutic diets and their
uses.

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 1. CLEAR LIQUID
A short-term, highly restrictive diet composed only of clear fluids or foods that are fluid at
body temperature
It requires minimal digestion and leaves a minimum residue.

Non-stimulating
Non-gas forming
No-irritating diet
400 - 500 kcal

FOODS ALLOWED

Allows visually clear and minimum residue liquids.

Water, Bouillon
Fat-free broth
Carbonated beverages
Tea, Coffee, regular & decaf
Gelatin (plain)
Popsicles
Sugar, honey, hard candy
Fruit juices, strained & clear
-apple, cranberry, grape
-NO MILK OR FATS
-Orange juice may cause distention

INDICATIONS
Initial feeding after surgery or parenteral nutrition
In preparation for surgery (pre-op) and various diagnostic tests of the bowel
for acute episodes of nausea and vomiting to promote bowel rest.

CONTRAINDICATIONS
Long-term use
Intended for a very short durations (3 days or less) due to nutritional
inadequacies.

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2. FULL LIQUID DIET
consists of foods that are in a liquid state at body temperature.
A full liquid diet includes all the liquids served on a clear liquid diet
with the addition of strained cream soups, milk and milk drinks, ice cream,
puddings, and custard.
The full liquid diet is inadequate in iron, folic acid, niacin, fiber and possibly
Vitamin A and thiamin.
Can be supplemented to approximate the nutritional value of a regular or high-
calorie, high-protein diet

FOODS ALLOWED

includes regular foods blended and strained in liquid form

all foods allowed on clear and full liquid diets.
All the foods in clear liquid diet
includes regular foods blended and strained in liquid form
all foods allowed on clear and full liquid diets.
All the foods in clear liquid diet

INDICATIONS
As a transitional diet between a clear liquid diet and a soft diet
some postoperative cases
acute illnesses
inflammatory conditions of the gastrointestinal (GI) tract
Clients who have difficulty chewing or swallowing
Important - feedings consist of 6 to 8 ounces or more be given every 2 to 3 hours
while the patient is awake.

CONTRAINDICATIONS
Severe lactose intolerance

3. SOFT DIET
Normal diet modified in consistency to have limited fiber

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 often called a low fiber diet (free from most of the fibers of a normal diet)
soft in texture (easily digestible)
and consists of liquids and semi-solid foods.
It contains only materials and foods that are soft in consistency and easily
chewable.

INDICATION
serves as an intermediate diet between liquid and normal diet.
helpful when you have gastrointestinal problems
contain nutrition that is adequate and sufficient for most people.
It is indicated in certain postoperative cases
for convalescents who cannot tolerate a regular diet
in acute illnesses
in some gastrointestinal disorders
To decrease peristalsis and limit stimulation of the GI tract, typically used with
PUD and GERD.

FOODS ALLOWED
Little or no spices are used in its preparation.
includes all liquids other than alcohol
foods that may be incorporated into a soft poultry
vegetables (including baked, mashed, and scalloped potatoes).

PERMITTED DESSERTS ARE:

custards
gelatin puddings
soft fruits
simple cakes and cookies.

Foods prohibited in a soft diet include fried foods, raw vegetables, and nuts.

MODIFICATIONS
Low residue - No fiber or tough connective tissue

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 Traditional bland – no chemical, thermal, physical stimulants
Cold soft – tonsillectomy

The planning of diet whether normal, soft or liquid has the same basic objective—to
maintain, or restore the good health of the person through a proper diet. The
modifications are based on the changed needs of the individual, due to age or sickness.

Normal Diet forms the basis of all modifications of diets for age and sickness; but due
attention must be paid to nutritional needs of the individual. Normal diet is planned
according to the recommended daily dietary intakes, which are designed to meet the
needs of all healthy persons and may not meet the needs of sick persons. The nutritional
requirements depend on the activity, the increased or decreased demands for certain
nutrients, which need to be considered in planning the diet.

Practical Work
Plan and prepare diets for person suffering from Diarrhea; Fever; Constipation.

MODIFICATIONS IN FOOD TO BE
DISEASES Diet Nutrient Interval and Taken Avoided
consistency content frequency of
feeding
Diarrhoea Liquid/semi solid Low fibre Frequent Soups, banana, Whole cereals,
meals, biscuits, chillies, whole
intervals of sago khichdi, pulses, fried
1-2 hrs potato, food,guava, fruit w/
boiled egg, curd, skin, leafy
refined cereals vegetables,
pastries, milk

Fever Semi solid diet High calorie, Frequent Milk, egg, Whole cereals,
high protein meals at 2-3 chicken, fish, chillies, whole
hrs interval juices, fruits, pulses,
soups, lassi, fried food, guava,
dalia, kheer fruit
with skin, leafy
vegetables,
pastries, milk
Diabetes No change Normal diet Meals taken Vegetables, roti, Sugar, sweet,
with no sugar at dal, honey, jam,
fixed time, milk, curd, fruit, jellies, cakes,
take six egg. pastries,
small sweetened fruits,
meals/day cold
drinks, tinned fruit

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Hypertension No change Low calorie, No change Roti, dal, Food rich in
low vegetables, milk, cholesterol & salt
cholesterol, fruits like cheese, butter,
low salt egg yolk, pickles,
chutneys, papad,
sauces
Jaundice Start with liquids Low fat Small Roti, vegetable, Fried food-puri,
slowly go to a frequent dal, pakoda,
skimmed milk, meals at 1-2 samosa
fruit, sugar hrs intervals
normal diet
Constipation No change High fibre, No change Atta with husk, Refined foods like
drink lots of whole pulses, suji, rice, candies,
water green leafy veg., bread
guava

LESSON 3
DIETS MODIFIED IN COMPOSITION

1. LOW CALORIE
 Calorie restriction, or caloric restriction (CR)

 dietary regimen that restricts calorie intake, where the baseline for the restriction
varies

 People who are interested in going on a very low-calorie diet (VLCD) should first
consult a physician.

 A very low-calorie diet is any diet plan that allows 800 calories or less in a day;
and the diet is overseen by a physician.

 The length of such a diet is relatively short, usually between 3 and 6 months. Any
longer and serious health complications may arise.

2. VERY LOW CALORIE DIET (VLCD)

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 As you can see, a VLCD is different from what a person might casually call a
"low-calorie diet," which would commonly consist of 1500 to 1800 calories per
day.

 If you're interested in something less aggressive, there are plenty of diet plans
that will allow for more moderate calorie restriction.

3. HIGH CALORIE DIET

 one furnishing more calories than needed to maintain weight, often more than
3500–4000 calories per day.

 A diet containing more than 4,000 calories per day.

 Some medical conditions require a high-calorie diet to help maintain or promote

weight gain.

 People with liver disease are at risk of malnutrition due to poor intake and altered
nutrient metabolism.

 To meet their needs, most people with liver disease should increase the amount
of calories they eat each day.

 People with Huntington's Disease have higher calorie needs because of their
constant fidgeting which increases their metabolic rate.

 Cancer patients tend to have higher calorie needs because of a poor appetite
related to treatment.

 Eating more calorie-dense foods, such as whole milk, cheese and nuts, can help
you increase your calorie intake when you have a poor appetite.

 Severe Burns

 Underweight

 Competitive Athletics

4. HIGH PROTEIN DIET

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 a diet that contains large amounts of protein, consisting largely of meats, fish,
milk, legumes, and nuts.

 It may be indicated in protein depletion that results from any cause, as a

preoperative preparation, or for patients with severe burns and sepsis.

 It may be contraindicated in liver failure or when kidney function is so impaired

that added protein could result in azotemia and acidosis.

5. LOW PROTEIN DIET

 is any diet in which the protein intake is reduced. Anyone diagnosed with kidney
or liver disease may be prescribed a low-protein diet.

 In any case, a diet which is especially low in protein should only be undertaken
under medical direction.

 Reduce amount of protein

 Some of each type of protein should still be consumed each day from the
two main sources:

 Animal products (fish, poultry, eggs, meat, dairy products) – considered

high quality or complete protein.

 Vegetable products (breads, cereals, rice, pasta, dried beans) –

considered low quality or incomplete protein.

6. LOW FAT DIET

 According to the USDA, a low-fat diet – as the name implies – is a diet that
consists of little fat, especially saturated fat andcholesterol, which is thought to
lead to increased blood cholesterol levels and heart attack.

 It is important to know that dietary fat is needed for good health, as fats supply
energy and fatty acids, in addition to supplying fat-soluble vitamins like A, D, E,
and K

7. LOW CARBOHYDRATES DIET

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 dietary programs that restrict carbohydrate consumption usually for weight
control or for the treatment of obesity.

 Foods high in digestible carbohydrates (e.g. bread, pasta) are limited or replaced
with foods containing a higher percentage of proteins and fats (e.g., meat,
poultry, fish, shellfish, eggs, cheese, nuts, seeds, peanuts, and soy products)
and other foods low in carbohydrates (e.g., most salad vegetables) although
other vegetables and fruits (especially berries) are often allowed.

 The amount allowed of these foods varies with different low-carbohydrate diets.

 Such diets are sometimes ketogenic (i.e. they restrict carbohydrate intake
sufficiently to cause ketosis) for example, the induction phase of the Atkins diet.

 Some sources, though, consider less restrictive variants to be low-

carbohydrate as well.

 Apart from obesity, low-carbohydrate diets are often used as treatments for some
other conditions, most notably diabetes and epilepsy, but also for chronic fatigue
syndrome (see ketosis) and polycystic ovarian syndrome

8. LOW SODIUM DIET

 is a diet that includes no more than 1,500 to 2,400 mgs of sodium per day. (One
teaspoon of salt has about 2,300 mg sodium.)

 People who follow a vigorous or moderate exercise schedule are usually advised
to limit their sodium intake to 3,000 mg per day and those with moderate to
severe heart failure are usually advised to limit their sodium intake to 2,000 mg
per day.

 The human requirement for sodium in the diet is about 69 mg per day, which is
typically less than one-tenth as much as many diets "seasoned to taste".

 For certain people with salt-sensitive blood pressure, this extra intake may cause
a negative effect on health.

9. LOW POTASSIUM DIET

 Potassium is a mineral that assists in maintaining normal blood pressure and
proper contraction of the heart.

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 The nervous system, digestive system, muscles and heart are kept healthy.

 It is found in whole grains, vegetables, milk, fruits, peas and dried beans.

 Need of a low potassium diet

If an individual has kidney problems, excess potassium can accumulate up to
dangerous levels in the blood. This causes irregular heartbeats, confusion or a
heart attack. In this case, a low potassium diet is recommended. If the diet
contains less than 2000 mg of potassium per day, then it is called as a "low
potassium diet".

 Low potassium foods

1 serving of the following can be considered to be low potassium food. 1 serving
implies ½ cup. More than 1 serving of the following can make it high potassium
food.

 General foodsBread (bread products)

 Cake – angel, yellow

 Coffee ( maximum 8 ounces)

 Cookies (without nuts or chocolate)

 Noodles

 Pasta

 Pies (without chocolate or high-potassium foods)

 Rice

 Tea (maximum 16 ounces)

10. LOW PURINE DIET

 A low-purine diet is an eating plan that limits foods that contain purine. Purines
are a natural substance found in some foods.

 When your body digests purine, a waste product called uric (say: yur-ick) acid is
produced.

 A buildup of uric acid crystals in the joints can cause a type of arthritis known as
gout.

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  Purines are found in many healthy foods. The purpose of a low-purine diet is not
to completely avoid purines.

 Instead, the goals are to limit and monitor how much purine is in the food you
eat, and to learn how your body responds when you eat different foods that
contain purine.

Avoid Limit Enjoy

Chicken, beef, pork At least 12 cups of fluid,

Beer
and duck such as water or fruit juice

Low-fat and fat-free dairy

Crab, lobster,
Soft drinks that contain sugar products, such as cheese
oysters and shrimp
and yogurt
Lunch meats,
Fatty food especially high-fat Eggs (in moderation)
versions

Organ meats, such as liver,

Liquor Peanut butter and nuts
from any animal source

Rice, noodles, pasta and

Bacon, veal and venison
potatoes

Yeast Fruits

Anchovies, sardines, herring,

mussels, codfish, scallops, Vegetables
trout and haddock

Gravy Beans

Wine (in moderation)

Coffee (in moderation)

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 ACTIVITY

INSTRUCTION: Fill in the right column on what nutritional approach is best for the
conditions/ illnesses on the left column.

APPROACHES TO NUTRITIONAL PROBLEMS ASSOCIATED WITH CANCER AND

CANCER THERAPY

PROBLEM NUTRITIONAL APPROACH

Loss of appetite and early satiety 1.

Dry mouth 2.

Chewing and swallowing difficulties (sore

mouth or throat) 3.

Taste/smell alterations 4.

Nausea and vomiting 5.

Constipation 6.

Abdominal gas/bloating 7.

Diarrhea 8.

ACTIVITY
STANDARD HOSPITAL DIET

NAME: ______________________________ DATE PASSED: _______________

YEAR & SECTION: _________________________________

There are certain diseases that require modification of the nutritional components of a
regular diet. Each of these diets has a purpose and rationale. Modifications may be done
qualitatively, such as in terms of consistency, texture or nutrients, or quantitatively, as in
modifications in the size and number of feedings or control of specific nutrients.

I. ОBJECTIVES

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Whatever modification is done to a patient's diet, acceptance of food is largely influenced
by the nursing personnel. It is important for patients to be educated on the diet given to
them.

At the end of 3 hours, you should be able to:

1. differentiate the kinds of standard hospital diets,

2. plan different sets of standard hospital diets, and

3. prepare different sets of standard hospital diets.

II. PROCEDURES

1. Plan a normal diet for lunch meal and modify this to soft and mechanically soft

diet.

SOFT DIET MODIFICATION

Sample Menu for Modification

Lunch
NORMAL DIET SOFT DIET MECHAICALLY SOFT
DIET

SOUP

MEAT

RICE

VEGETABLES

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 FRUIT
OR DESSERT

2. During tray presentation, discuss the characteristics of soft diet.

CHARACTERISTICS OF A SOFT DIET

FOOD
DIET INDICATIONS CHARACTERISTICS
SELECTIONS

SOFT

MECHANICALLY
SOFT

UNIT VII.B
ENTERAL TUBE FEEDING
The most effective way to feed a patient is through the gastrointestinal tract (GI).
But if the patient has at least a partially functioning gut, but is unable to meet his
nutritional needs via the oral (po) route, then enteral nutrition therapy via tube feeding
should be considered.

Enteral nutrition (EN) promotes the usual physiologic integrity of the GI tract, has
less risk of harm (line infections, sepsis) and is more economical than parenteral
nutrition.

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 WEEK LEARNING OUTCOME ACTIVITIES

At the end of the lesson, you will be able to: 1. Study Questions
2. Return demonstration on
1. Skillfully demonstrate how to enterally NGT insertion and
feed clients. removal, and NGT
2. Compare intact enteral formulas with feeding
hydrolyzed formulas.
3. Choose the most appropriate enteral
formula for a given patient.
4. Evaluate an enteral feeding schedule
for appropriateness and adequacy.
5. Propose interventions to combat
various nutrition-related problems that
may occur with enteral nutrition.
6. Compare enteral nutrition to
parenteral nutrition.
7. Discuss the components of parenteral
nutrition and the usual concentration
of macronutrients provided.

What is enteral feeding?

Enteral feeding refers to intake of food via the gastrointestinal (GI) tract. The GI tract is
composed of the mouth, esophagus, stomach, and intestines.

Enteral feeding may mean nutrition taken through the mouth or through a tube that goes
directly to the stomach or small intestine. In the medical setting, the term enteral feeding
is most often used to mean tube feeding.

A person on enteral feeds usually has a condition or injury that prevents eating a regular
diet by mouth, but their GI tract is still able to function.

Being fed through a tube allows them to receive nutrition and keep their GI tract working.
Enteral feeding may make up their entire caloric intake or may be used as a supplement.

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When is enteral feeding used?

Tube feedings may become necessary when you can’t eat enough calories to meet your
nutritional needs. This may occur if you physically can’t eat, can’t eat safely, or if your
caloric requirements are increased beyond your ability to eat.

If you can’t eat enough, you’re at risk for malnourishment, weight loss, and very serious
health issues. This may happen for a variety of reasons. Some of the more common
underlying reasons for enteral feeding include:

• a stroke, which may impair ability to swallow

• cancer, which may cause fatigue, nausea, and vomiting that make it difficult to
eat

• critical illness or injury, which reduces energy or ability to eat

• failure to thrive or inability to eat in young children or infants

• serious illness, which places the body in a state of stress, making it difficult to
take in enough nutrients

• neurological or movement disorders that increase caloric requirements while

making it more difficult to eat

GI dysfunction or disease, although this may require intravenous (IV) nutrition instead

Types of enteral feeding

According to the American College of Gastroenterology, there are six main types of
feeding tubes. These tubes may have further subtypes depending on exactly where they
end in the stomach or intestines.

The placement of the tube will be chosen by a doctor based on what size tube is
needed, how long enteral feeds will be required, and your digestive abilities.

435
A medical professional will also choose an enteral formula to be used based on tube
placement, digestive abilities, and nutritional needs.

The main types of enteral feeding tubes include:

• Nasogastric tube (NGT) starts in the nose and ends in the stomach.
• Orogastric tube (OGT) starts in the mouth and ends in the stomach.

• Nasoenteric tube starts in the nose and ends in the intestines (subtypes include
nasojejunal and nasoduodenal tubes).

• Oroenteric tube starts in the mouth and ends in the intestines.

• Gastrostomy tube is placed through the skin of the abdomen straight to the
stomach (subtypes include PEG, PRG, and button tubes).

• Jejunostomy tube is placed through the skin of the abdomen straight into the
intestines (subtypes include PEJ and PRJ tubes).

Procedure for placing the tube

NGT or OGT

Placement of a nasogastric tube or orogastric tube, while uncomfortable, is fairly

straightforward and painless. Anesthesia isn’t required.

Typically a nurse will measure the length of the tube, lubricate the tip, place the tube in
your nose or mouth and advance until the tube is in the stomach. The tube is usually
secured to your skin using soft tape.

The nurse or doctor will then pull some gastric juice out of the tube using a syringe.
They’ll check the pH (acidity) of the liquid to confirm that the tube is in the stomach.

In some cases, a chest X-ray may be needed to confirm placement. Once placement is
confirmed, the tube may be used immediately.

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NASOENTERIC OR OROENTERIC

Tubes that end in the intestines often require endoscopic placement. This means
using a thin tube called an endoscope, which has a tiny camera on the end, to place the
feeding tube.

The person placing the tube will be able to see where they’re putting it via the
camera on the endoscope. The endoscope is then removed, and placement of the
feeding tube may be confirmed with aspiration of gastric contents and X-ray.

It’s common practice to wait 4 to 12 hours before using the new feeding tube.
Some people will be awake during this procedure, while others may require conscious
sedation. There’s no recovery from the tube placement itself, but it may take an hour or
two for the sedation medications to wear off.

GASTROSTOMY OR JEJUNOSTOMY

Placement of gastrostomy or jejunostomy tubes is also a procedure that may

require conscious sedation, or occasionally general anesthesia.

An endoscope is used to visualize where the tube needs to go, and then a tiny
cut is made in the abdomen to feed the tube into the stomach or intestines. The tube is
then secured to the skin.

Many endoscopists choose to wait 12 hours before using the new feeding tube.
Recovery may take five to seven days. Some people experience discomfort at the tube
insertion site, but the incision is so small that it typically heals very well. You may receive
antibiotics to prevent infection.

Enteral access device Length of Pros Cons

use
Nasogastric tube (NGT; Short-term Easy to place, variety of Not indicated if bleeding disorder,
through the nose) use sizes available for patient nasal/facial fractures and certain
comfort esophageal disorders

437
Orogastric tube (through Short-term Lower incidence of sinusitis Not tolerated for long periods of time
the mouth) use than NGTs in alert patients; tube may damage
teeth
Nasoenteric tube (generally Short-term Smaller diameter than May be difficult to position; smaller
thought of as a tube use NGTs and less patient size tubes may make administration
beyond the stomach) discomfort; may be used in of some medications difficult, and an
delayed gastric emptying infusion pump is needed
Oroenteric tube (postpyloric Short-term Same as orogastric tubes Same as orogastric tubes
feeding tube) use
Gastrostomy tube (can be Short-term Easily cared for and Compared with oral and nasal route,
placed radiologically, use replaceable; large size tube this technique is more invasive
endoscopically or Long-term allow for bolus feeding, and
surgically) use administration of
medications
Jejunostomy tube (can be Long-term Decreases the risk of food Technically more difficult to place;
placed radiologically, use and fluids passing into the smaller size tubes may make
endoscopically or lungs; allows for early administration of some medications
surgically) postoperative feeding more difficult, and an infusion pump
is needed

ENTERAL VS. PARENTERAL FEEDING

In some cases, enteral feeding may not be an option. If you’re at risk for malnutrition and
don’t have a functional GI system, you may need an option called parenteral feeding.

Parenteral feeding refers to giving nutrition through a person’s veins. You’ll have a type
of venous access device, such as a port or a peripherally inserted central catheter (PICC
or PIC line), inserted so you can receive liquid nutrition.

If this is your supplementary nutrition, it’s called peripheral parenteral nutrition (PPN).
When you’re getting all of your nutritional requirements through an IV, it’s often called
total parenteral nutrition (TPN).

Parenteral feeding can be a life-saving option in many circumstances. However, it’s

preferable to use enteral nutrition if at all possible. Enteral nutrition most closely mimics
regular eating and can help with immune system function.

438
Possible complications of enteral feeding

There are some complications that can occur as a result of enteral feeding. Some of the
most common include:

• aspiration, which is food going into the lungs

• refeeding syndrome, dangerous electrolyte imbalances that may occur in people

who are very malnourished and start receiving enteral feeds

• infection of the tube or insertion site

• nausea and vomiting that may result from feeds that are too large or fast, or from
slowed emptying of the stomach

• skin irritation at the tube insertion site

• diarrhea due to a liquid diet or possibly medications

• tube dislodgement

• tube blockage, which may occur if not flushed properly

There are not typically long-term complications of enteral feeding.

When you resume normal eating, you may have some digestive discomfort as your body
readjusts to solid foods.

Who shouldn’t have enteral feeding?

The main reason a person wouldn’t be able to have enteral feeds is if their stomach or
intestines aren’t working properly.

Someone with a bowel obstruction, decreased blood flow to their intestines (ischemic
bowel), or severe intestinal disease such as Crohn’s disease would likely not benefit
from enteral feedings.

439
The outlook

Enteral feeding is often used as a short-term solution while someone recovers from an
illness, injury, or surgery. Most people receiving enteral feeds return to regular eating.

There are some situations where enteral feeding is used as a long-term solution, such
as for people with movement disorders or children with physical disabilities.

In some cases, enteral nutrition can be used to prolong life in someone who is critically ill
or an older person who can’t maintain their nutritional needs. The ethics of using enteral
feeding to prolong life have to be evaluated in each individual case.

Enteral feeding can seem like a challenging adjustment for you or a loved one. Your
doctor, nurses, a nutritionist, and home health care providers can help make this
adjustment a successful one.

Figure 1: Enteral Access

Figure 2: Catheters - Parenteral Nutrition – Temporary

440
441
Figure 3: Catheters - Parenteral Nutrition – Long Term

Medically reviewed by Katherine Marengo, LDN, RD — Written by Megan Dix, RN,

BSN — Updated on October 29, 2018

https://www.healthline.com/health/enteral-feeding#indicationshttps://gi.org/topics/enteral-
and-parenteral-
nutrition/#:~:text=Enteral%20nutrition%20generally%20refers%20to,a%20tube%20(tube
%20feeding).

442
 ❖ Procedure for placing the NGT – CHECKLIST – (IN THE
APPENDICES)

ACTIVITY
BLENDERIZED FEEDING

1. Based on the total food allowances for normal diet, plan and prepare a 1500 kcal

blended formula, following calculations as for normal diet.

Table

Meal Plan for Blended Formula

No. of CHO PRO FAT Meal Distribution

Food Ex- ENERGY
Exchanges changes g g g kcal B L D Sn

I. Veg A

Veg B

II. Fruits

IX. Milk

V. Meat

443
 VI. Sugar

VII. Fat

Total

Total kCal: ________________________

Carbohydrate: __________g Protein: ____________g Fats: ___________g

Amount of formula before dilution: _______________ml

Amount of water added to get the right consistency __________ml

444
 UNIT VIII
DIETARY MANAGEMENT OF SOME COMMON MEDICAL CONDITIONS

Dietary management of some common medical conditions are individualized

basing on a person’s health status. For example, recommendations to increase calcium
intake to provide possible protection against osteoporosis is not the same as
management for coronary heart disease (CHD) prevention, because dairy products—
which contribute the most calcium to the diet—are also major sources of saturated fatty
acids (SFAs), which are known to increase plasma cholesterol levels and CHD risk. In
this chapter, you will be able to study the different dietary recommendations developed
in reducing the overall risk of diet-related chronic diseases.

WEEK TOPIC LEARNING OUTCOME ACTIVITIES

1. Computations and preparations
At the end of the lesson, you will be and their rationale.
able to:
2. Actual preparation of the
1. Plan a one-day menu based prescribed therapeutic dietary
from the calculated RENI regimen (to include evaluation
2. Plan a meal for a person and computation)
with specific disease
condition.
Day
3. Give examples of
appropriate nutrition
interventions for various
symptoms and
complications of
malabsorption syndrome.
4. Compare a low-fat diet to a
regular diet.

445
NUTRITION THERAPY FOR OBESITY AND WEIGHT CONTROL

Worldwide obesity has nearly tripled since 1975. In 2016, more than 1.9 billion
adults, 18 years and older, were overweight. Of these over 650 million were obese. 39%
of adults aged 18 years and over were overweight in 2016, and 13% were obese. Most
of the world's population live in countries where overweight and obesity kills more people
than underweight. 38 million children under the age of 5 were overweight or obese in
2019. Over 340 million children and adolescents aged 5-19 were overweight or obese in
2016. Obesity is preventable. (WHO, 2020)

1. What factors contribute to obesity?

a. Genetics → Polygenic (genetic susceptibility): Genes related to appetite control,
energy regulation, and obesity development.
Example: ob gene codes for the peptide ‘leptin’ expressing in adipose tissue, which
helps the brain to control eating.

b. Drug-induced obesity → Glucocorticoids

Antidiabetic drugs: Insulin, Sulphonylureas, Thiazolidinediones
Antipsychotic drugs
Antiepileptic drugs
Miscellaneous: Antihistamines, Cyproheptadine, Cyclophosphamide, 5-Fluorouracil

c. Endocrine induced obesity →Hypothyroidism: due to a fall in basal metabolic rate

Cushing syndrome
Polycystic ovarian syndrome (PCOS): Insulin resistance is common
Hypothalamic disease
Pituitary disorders: growth hormone deficiency

d. Environment (life style induced obesity) → The environment includes all of the
circumstances that we encounter daily that push us toward fatness or thinness:
Overeating
Physical inactivity → Sedentary life and vehicles

446
 2. Describe the possible health consequences of overweight and obesity.
People who are overweight and obese more commonly suffer and die from
serious diseases, such as hypertension, diabetes, and heart disease.

a. Obesity and diabetes

Obesity accounts for 80%~85% of the overall risk of developing type 2 diabetes.
Central (and especially visceral) obesity is specifically associated with type 2 diabetes.
Obesity predisposes to type 2 diabetes by causing both insulin resistance and β-cell
dysfunction.

b. Obesity and CVD

Obesity is an independent risk factor for cardiovascular diseases, including
hypertension, coronary-heart disease (CHD), cardiac failure, arrhythmias and
cardiovascular death.
Visceral obesity may increase cardiovascular risk by generating high FFA levels, which
induce insulin resistance, stimulate very low density lipoprotein (VLDL) production by the
liver, and promote triglyceride deposition in the myocardium.

c. Obesity and liver disease

Obesity is a major risk factor for non-alcoholic fatty liver disease (NAFLD).
Hepatocyte damage and inflammation are initiated by high FFA levels, release of
cytokines.

d. Obesity and cancer

Obesity contributes to the risk for several malignancies, including cancers of the
endometrium (30% of total risk), colon, oesophagus and breast, and lymphoma.
Suggested mechanisms include dietary factors and physical inactivity (colorectal
cancer), gastro-esophageal reflux (esophageal cancer) and cirrhosis complicating fatty
liver disease (hepatocellular carcinoma).

e. Obesity and other diseases

Obesity increases the risk of osteoarthritis of the knees, hips and hands.
Lung volumes are decreased due to mechanical restriction.

447
Polycystic ovarian syndrome (PCOS): characterized by failure of ovulation, causing
multiple ovarian cysts and infertility.
Gallbladder diseases: Being overweight is associated with an increase in gallstones.
Psychosocial problems.

3.Describe reasonable dietary strategies for achieving and maintaining a healthy

body weight.
Healthy eating
Emphasize nutritional adequacy: Nutritional adequacy is difficult to achieve on fewer
than 1200 kcal a day, a multivitamin supplement can help people following low-energy
diets to achieve nutrient adequacy.
Eat small portions: The amount should leave a person feeling satisfied—but not stuffed.
Lower energy density: Chose more foods containing water, rich in fiber, low in fat help to
lower energy density.

4.What are “FITT” of exercises standing for?

FITT principle
F (Frequency): How often per week.
I (Intensity): How hard one exercises.
T (Type): Choice of activity.
T (Time): Duration of session.

NUTRITION AND DIABETES

1.How is diabetes diagnosed?

Criteria for diagnosis of diabetes:
Symptoms of diabetes plus casual plasma glucose concentration 11.1 mmol/L OR
Fasting plasma glucose 7.0 mmol/ OR
2-hour post-prandial glucose 11.1mmol/L during an oral glucose tolerance test (OGTT)

Criteria for IGR (impaired glucose regulation)

IFG: Impaired fasting glucose, fasting plasma glucose is >6.1mmol/L and <7.0mmol/L.
IGT: Impaired glucose tolerance, 2-hour post-prandial glucose >7.8mmol/L and
<11.1mmol/L during an oral glucose tolerance test.

2.What are the goals of medical and nutrition therapy for people with diabetes?
a. Attain and maintain optimal metabolic outcomes, including →Glucose level in normal

448
range, or as close to normal range as possible, to prevent or reduce risk of
complications
Lipid or lipoprotein profile that reduces risk for macrovascular disease
Blood pressure levels that reduce risk for vascular disease.

b. Prevent and treat chronic complications. Modify nutrient intake and lifestyle as
appropriate for prevention and treatment of obesity, dyslipidemia, cardiovascular
disease, hypertension, and nephropathy.

c. Enhance health through food choices and physical activity.

d. Address individual nutritional needs with regard to personal and cultural preferences
and lifestyles while respecting the individual’s wishes and willingness to change.

3.Describe the meal-planning strategies that are used to control carbohydrate

intake.
The carbohydrate found in foods is the major macronutrient influencing post-prandial
glucose variations.
It influences pre-meal insulin requirements. The total amount of daily carbohydrate
intake, not its source, is the focus of this meal planning approach.
Food carbohydrate sources are starches, fruits, milk/yogurt, and sweets.

Method: Carbohydrates can be counted in one of the following two ways:

The amount of food containing 15 g carbohydrate counts as one carbohydrate choice.
Total grams of carbohydrate in a meal or snack can be counted by use of food label
information or other sources of nutrient analysis information.

4.Meal planning for DM patients using exchange list.

a. Assess current food intake and eating pattern using diet history or food records.

b. Categorize usual food intake into exchange amounts based on portions and foods
consumed at each meal and snack. Calculate total grams of carbohydrate, protein, and
fat and translate into energy.

c. Determine appropriate energy prescription. Generally 250~500 kcal per day can be
subtracted/added for a 0.5~1 pound per week weight loss/gain.

449
d. Translate energy prescription into exchanges, staying as close to current pattern of
intake as possible. Calculate grams of carbohydrate, protein, and fat from exchanges
and determine percentages of energy contributed by each macronutrient

e. Adjust exchanges as needed to reach goal percentages for each macronutrient.

f. Compare usual intake to energy prescription and mutually determine how to distribute
exchange groups among meals and snack.

NUTRITION AND CARDIOVASCULAR DISEASES

1.What is DASH diet?

Dietary Approaches to Stop Hypertension (DASH) diet
- DASH is an eating plan low in saturated fat, total fat and cholesterol, and high in fruits,
vegetables and low fat dairy foods.

The plan is rich in calcium, magnesium, potassium as well as protein and fiber. The diet
reduced systolic pressure by an average of 6 mm Hg and diastolic by 3 mm Hg in
normotensive individuals; in those with hypertension, the systolic dropped an average of
11 mm Hg and the diastolic about 6 mm Hg.

Selecting the lower-end of the number of servings, the diet provides about 1900
kilocalories and 70 grams protein, while the higher-end of the number of servings offer
2550 kilocalories and 105 grams protein. Number of servings may need to be reduced
for individuals if weight loss is desired.

450
Source: U.S. Department of Health and Human Services; NIH Publication No. 99-4082.
Originally printed 1998 http://dash.bwh.harvard.edu

Sample DASH Diet Menus

451
KEY CONCEPTS

■ Nutrition therapy for GI disorders may help minimize or prevent symptoms. For some
GI disorders, nutrition therapy is the cornerstone of treatment.

■ Small, frequent meals may help to maximize intake in patients who have anorexia.
Avoiding high-fat foods may lessen the feeling of fullness.

■ After nausea and vomiting subside, low-fat, easily digested carbohydrate foods, such
as crackers, toast, oatmeal, and bland fruit, usually are well tolerated. Patients should
avoid liquids with meals because liquids can promote the feeling of fullness.

■ The National Dysphagia Diet has three different solid food textures and four different
liquid consistencies. A speech and language pathologist recommends the appropriate
level for solids and liquids based on a swallowing evaluation.

■ Pureed foods are less calorically dense than normal textured foods. They are also

less visually appealing. Patients with dysphagia are monitored for poor intakes and
weight loss.

452
■ People with GERD should lose weight if overweight; not smoke; avoid large meals and

bedtime snacks; eliminate individual intolerances; and avoid alcohol, highly spicy foods,

and fatty foods. Other approaches that may be effective include eating a high-fi ber diet

and eliminating regular and decaffeinated coffee, chocolate, and peppermint and
spearmint fl avors.

■ There is no evidence that diet causes ulcers or promotes their healing. Patients are

commonly advised to avoid items that stimulate gastric acid secretion and any foods not
tolerated.

■ Nutrition therapy for dumping syndrome consists of eating small, frequent meals;
eating protein at each meal; and avoiding concentrated sugars and sugar alcohols.
Liquids should be consumed 1 hour before or after eating instead of with meals.

ACTIVITY # ___
DIABETIC DIET

NAME: _________________________ DATE DUE: _________________

Aside from maintaining near normal blood glucose levels for Diabetes Mellitus
(DM), nutrition therapy aims to achieve optimum serum lipid levels, maintain DBW,
prevent complications, and improve overall health of a diabetic. The steps involved in
medical nutrition therapy for individuals with diabetes mellitus (given below) can help you
in planning a diabetic diet.

I - OBJECTIVES: At the end of the lesson, you will be able to:

453
 1. plan a meal for a person with DM.
2. Prepare, serve, and evaluate a diabetic diet.
The Medical Nutrition Therapy for DM is as follows:

1. Attain a normal blood glucose levels, lipid and lipoprotein profiles and blood
pressure levels.
2. Prevent complications.
3. Improve the patient’s health.

II – PROCEDURE

1. Plan a one-day diabetic diet using the following diet prescription:

- Diet Rx = 1600 kcal
- CHO = 60%; CHON = 15%; fat = 20%
2. Prepare assigned meal and discuss the following during presentation (via
recorded video presentation)
c. How your meal can achieve optimum serum levels
d. How your meal can maintain DBW
e. How your meal can prevent complications
f. How your meal can achieve almost normal blood glucose levels.
3. Tray presentation
a. Breakfast
b. Lunch
c. Dinner
d. AM/ PM snack
4. Submit worksheets on: ________________

COMPUTATION OF DIABETIC DIET TABLE

454
 FOOD EXCHANGE CHO PROTEIN FAT TOTAL
ITEM CALORIE
VEG A
VEG B
FRUIT
MILK
RICE
MEAT
EGG
FAT
TOTAL

CHO = _______ gm

PROTEIN = _______ gms

FAT = ________ gms

455
 ACTIVITY

DIETS FOR GASTROINTESTINAL (GI) DISORDERS

Anyone can experience GI discomforts such as indigestion, nausea, abdominal cramps

and gas. They are usually associated with some unusual types of food eaten.

I – OBJECTIVES

There are significant implications associated with GI disorders. It is important to identify

the causes of the disorder and correct them immediately through nutrient modification.

At the end of the lesson, you should be able to:

1. Identify the food items that are allowed and those that are restricted in certain GI
disorders.
2. Plan and prepare meals for the different disorders of the gastrointestinal tract.
II – PROCEDURE

CASE 1 – A man suffering from dumping syndrome

CASE 2 – A woman with celiac disease

CASE 3 – A man diagnosed with peptic ulcer

1. Discuss the characteristics and dietary management of the assigned disease

condition.
DISEASE CHARACTERISTICS DIETARY RATIONALE
CONDITION MANAGEMENT OF DIET

456
 2. Plan and prepare a therapeutic diet for the assigned case. Present dinner meal
for tray evaluation

CASE STUDY

Barbara is a 72-year-old woman with a “Type A” personality who was diagnosed with a
peptic ulcer more than 40 years ago. At that time, her doctor told her to follow a bland
diet and eat three meals per day with three snacks per day of whole milk to “quiet” her
stomach. She meticulously complied with the diet to the point of becoming obsessive
about eating anything that may not be “allowed.” She lost 15 pounds by following the
bland diet because her intake was so restricted. She recently began experiencing ulcer
symptoms and has put herself back on the bland diet, convinced it is necessary in order
to recover from her ulcer. Yesterday, she ate the following:

■ Barbara’s 1600-calorie MyPlate plan calls for 1.5 cups of fruit, 2 cups of vegetables, 5
grains, 5 oz of meat/ beans, 3 cups of milk, and 5 teaspoons of oils. How does her intake
compare? What food groups is she undereating? Overeating? What are the potential
nutritional consequences of her current diet?

457
■ What other information would be helpful for you to know in dealing with Barbara?

■ Barbara clearly wants to be on a bland diet; what would you tell her about diet
recommendations for PUD? What recommendations would you make to improve her
symptoms and meet her nutritional requirements while respecting her need to follow a
“diet”?

STUDY QUESTIONS

1. The patient asks if coffee is bad for his peptic ulcer. Which of the following would be

the nurse’s best response?

a. “Coffee does not cause ulcers, and drinking it probably does not interfere with
ulcer healing. You may try eliminating it from your diet to see what impact it has on your
symptoms and then decide whether or not to avoid it.”

b. “Both caffeinated and decaffeinated coffee can cause ulcers and interfere with
ulcer healing. You should eliminate both from your diet.”

c. “You need to eliminate caffeinated coffee from your diet, but it is safe to drink
decaffeinated coffee.”

d. “You can drink all the coffee you want; it does not affect ulcers.”

2. Which statement indicates the patient needs further instruction about GERD?

a. “I know a bland diet will help prevent the heartburn I get after eating.”

b. “Lying down after eating can make GERD symptoms worse.”

c. “High-fat meals can make GERD symptoms worse.”

d. “Losing excess weight can help prevent symptoms of GERD.”

3. Which of the following snacks would be best for a patient who wants to eat who has
nausea?

a. Cheese

b. Peanuts

c. Banana

458
 d. A milkshake

4. The nurse knows her instructions have been effective when the patient with dumping
syndrome verbalizes, she should

a. Avoid lying down after eating.

b. Drink liquids between, not with, meals.

c. Eat simple sugars in place of starches.

d. Avoid protein.

5. A patient with dumping syndrome asks why it is so important to avoid sugars and

sweets. Which of the following is the nurse’s best response?

a. “Sugars and sweets provide empty calories, so they should be limited in

everyone’s diet.”

b. “Sugars draw water into the intestines and cause cramping and diarrhea.”

c. “Sugar makes blood glucose levels increase; hyperglycemia is a complication

of dumping syndrome.”

d. “Avoiding sugars and sweets helps ensure that they will not displace the intake
of protein, which you need for healing.”

6. Which of the following is an appropriate breakfast for a patient on a level 1 dysphagia

diet?

a. Poached egg

b. Cream of wheat

c. Granola with milk

d. Toast cut into small pieces

7. A patient who develops pernicious anemia after gastric surgery needs supplemental

a. Protein

b. Iron

c. Folic acid

459
 d. Vitamin B12

8. The best dessert for a patient with GERD is

a. Chocolate cake

b. Peppermint ice cream

c. Cheesecake

d. Applesauce

EVALUATION OF THE COURSE:

1. What lesson and activity did I enjoy most and why?

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

2.What is the most important lesson which I can apply in my daily life? Please
elaborate your answer.

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

3.What are the new insights/discoveries that I learned?

______________________________________________________________________
______________________________________________________________________

460
______________________________________________________________________
______________________________________________________________________

4.What topics do I find least important?

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

461
REFERENCES:

TEXTBOOK:

1. Caudal, Ma. Lourdes. (2008) Basic Nutrition and Diet Therapy Textbook for
Nursing Students Revised Ed.,C & E Publishing Inc.
Other Books:

2. Adela, Jamorabo-Ruiz, Virginia Serraon-Claudio. Basic Nutrition for Filipinos, 5th

edition 2002
3. Cataldo, DeBruyne, Whitney., Nutrition and Diet Therapy 6th edition. Wadsworth
Publishing Company 2003
4. Claudio, V. and Ruiz, O. (2002). Basic Nutrition for Filipinos 5 th Edition, Manila,
Philippines, Meriam and Webster Bookstore.
5. Dellova, Carmela V. ABC’s of Nutrition and Diet Therapy for Healthcare Students
and Practitioners, Valenzuela, Philippines: Mutya Publishing 2006
6. Dudek, Susan G. (2014). Nutrition Essentials for Nursing Practice. Lippincott
Williams & Wilkins.
7. Ferraro, K. & Winter, C.H. (2014). Diet Therapy in Advanced Practice Nursing:
Nutrition Prescriptions for Improved Patient Outcomes. McGraw-Hill Education
8. Gordon, W. and Smith, A. (2009). Contemporary Nutrition 7th Editition, USA, Mc
Graw-Hill Higher Education.
9. Grodner, M., Sara Long Roth, and Bonnie C. Walkingshaw (2007) Foundations
and Clinical Applications of Nutrition: A Nursing approach. Fourth edition. Mosby.
10. Peckenpaugh, Nancy.(2007) Nutrition Essentials and Diet Therapy10th
ed.Elsevier (Singapore)Pte Ltd.
11. Rolfes, Sharon R., Kathryn Pinna, and Ellie Whitney (2008) Understanding
Normal and Clinical Nutrition. Eight edition. Brooks Cole.
12. Schlenker, E.D. and Gilbert, J. (2015). Williams’ Essentials of Nutrition and Diet
Therapy. Mosby, an imprint of Elsevier Inc.
13. Sherer, Kim and Judi R. Davis (1994) Applied Nutrition and Diet Therapy for
Nurses. W. B. Saunders Company.
14. Tucker, Shiela (2010) Nutrition and Diet Therapy for Nurses. Prentice Hall.
15. Whitney, Ellie et. al. (2006) Nutrition for Health Care. 3 rd Edition. Brooks Cole.

462
 16. Whitney, E.N.. (2002). Understanding Nutrition 9 th Edition, Thomson asia Pte Ltd.

A. Internet Sources

1. http://www. Nutrition.bmj.com/nutrition/journal
2. http://www.dost.gov.ph
3. http://www.nnc.gov.ph
4. http://www.gov.ph/node/237
5. https://www.fnri.dost.gov.ph
6. https://nutrition.org/
7. https://www.who.int

Nutrition Myths and facts.

https://rover.edonline.sk.ca/system/guides/nutrition_myths_and_facts.pdf

The American Dietetic Association is the world’s largest of food and nutrition
professionals. https://ohiovalleyhospital.org/wp-
content/uploads/2014/03/Nutrition_Fact_vs_Fiction.pdf

The Human Body and Social Emotional Learning

https://www.brainpop.com/health/nutrition/nutrition/

Food and Agriculture Organization of the United Nations

http://www.fao.org/nutrition/education/food-dietary-guidelines/background/development-
process/en/

U.S. Department of Health & Human Services (HHS)

https://www.hhs.gov/fitness/eat-healthy/dietary-guidelines-for-americans/index.html

American Dietetic association

https://ohiovalleyhospital.org/wp-content/uploads/2014/03/Nutrition_Fact_vs_Fiction.pdf

Obesity and Overweight

463
https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight

https://www.medicalnewstoday.com/articles/326132

http://www.nutrientsreview.com/carbs/monosaccharides-galactose.html

iRubric Home
https://www.rcampus.com/indexrubric.cfm

APPENDICES

• Procedure checklist for return demonstration

• Key answers
• Rubrics
• FEL tables
• Syllabus

464
 SCHOOL OF NURSING
General Luna Road, Baguio City

PERFORMANCE CHECKLIST ON
NGT INSERTION, IRRIGATION, FEEDING, LAVAGE AND REMOVAL

Name of Student: _____________________________ Date: _____________________

Year: __________ Section / Group: _____Clinical Instructor: _____________________

Directions: Pease rate the performance of student on each step or task using the following rating scale:
0 = Not performed 1 = Able to perform with assistance 2 = Able to perform correctly

PROCEDURE 0 1 2 Comments

I – NGT INSERTION
1. Check physician’s order for insertion of nasogastric tube.
2. Explain the procedure to the patient and gain consent.
3. Gather / prepare materials and supplies.
4. Cut a 2-inch piece of plaster and split the bottom part.
5. Perform hand hygiene.
6. Ensure the patient’s privacy and assist him to sit upright if tolerated.
7. Determine any previous breaks / operations to nose as this may affect
passage.
8. Let patient blow nose / clean nostrils gently. Remove any dentures.
9. Drape the chest with bath towel or disposable pad and have emesis basin
and tissues handy.
10. Apply disposable gloves.
11. Measure the distance to insert the tube by placing tip of tube at patient’s
nostrils and extending to the tip of earlobe, and then to the tip of xiphoid
process. Mark tube with a piece of tape.
12. Lubricate the tip of the tube (at least 1 – 2 in) with a water-soluble
lubricant.
13. Ask the patient (if the patient is able to cooperate) hyperextend neck.
14. Insert the tube into the nostril while directing the tube downward and
backward while asking the patient to do slow deep breathing.

465
15. Once the tube reaches oropharynx, instruct the patient to tilt head forward
and encourage him / her to swallow (the process may also be aided by
sipping water through a straw).
16. Observe the patient during the procedure; check the tube for coiling in the
pharynx by inspecting patient’s throat.
17. Continue advancing the tube until the tape marking is reached.
18. If there are signs of distress, such as gasping, coughing, cyanosis, and the
inability to speak or hum, discontinue the procedure and remove the tube.
While keeping one hand on the tube, determined that the tube is in the patient’s stomach:
19. Attach the asepto-syringe to the end of the tube, introduce 10-20 ml of air
into the stomach while listening to the gurgling sound on the epigastric
area of the abdomen.
20. Aspirate a small amount of stomach contents and visualize / check for
color and consistency.
21. Measure the pH of aspirated fluid using pH paper.
22. Obtain a radiograph of placement of tube (as ordered by the physician).
23. Plug / cover end of tube.
24. Secure the tube with tape to the patient’s nose.
25. Split tape lengthwise at one end leaving at least 1 inch on the other end.
26. Place unsplit end over the bridge of patient’s nose and wrap the split ends
under the tubing and around the tube.
27. Secure nasogastric tube to patient’s gown by using a safety pin.
28. Remove gloves and dispose off equipment.
29. Perform hand hygiene.
30. Assist patient into comfortable position.
31. Document the procedure, type and size of tube, a description of gastric
contents and which nostril is used and the patient’s response.

Directions: Pease rate the performance of student on each step or task using the following rating scale:
0 = Not performed 1= Able to perform with assistance. 2= Able to perform correctly
PROCEDURES 0 1 2 Comments
II – NGT IRRIGATION AND FEEDING
32. Unplug end of tube.
33. Connect the syringe barrel to pinched / kinked tube and check tube
placement.
34. Pour the feeding solution to the syringe barrel.

466
35. Unplug and permit the feeding tube to flow in a slowly manner at the
prescribed rate.
36. After giving the prescribed feeding, irrigate the tube using sterile water.
37. Plug / cover the end of tube and make relevant documentations.
III - GASTRIC LAVAGE
38. Uncover / unplug the end of the tube while kinking it.
39. In a kidney basin with NSS solution, aspirate 10 ml (PEDIA) using a
disposable syringe and introduce into the unkinked NGT./ In adults,
introduce 200 – 300 ml into the syringe barrel, letting it flow by gravity.
40. Kink tube and wait for few minutes.
41. For PEDIA, unkink tube, aspirate same amount and dispose into a
basin.
For ADULT, unkink tube, lowered distal end of tube to allow stomach
contents to flow freely into a basin.
42. Repeat 2nd and 3rd procedures until return flow is clear. Cover the end
of tube.
43. Document.
IV – REMOVAL OF NGT
44. Check physician’s order.
45. Identify the patient
46. Explain the procedure.
47. Wash hands.
48. Put on gloves.
49. Ask the client to take a deep breath and to hold it (this will close the glottis
thereby preventing accidental aspiration of any gastric content).
50. Coil NGT on dominant hand.
51. Pinch then withdrawn NGT until reaching the distal end.
52. Dispose soiled tube and gloves properly.
53. Provide oro-nasal care.
54. Bring patient back to comfortable position.
55. Wash hands.
Evaluate using the following:
56. Patient is comfortable
57. No abdominal distention
58. Document

467
 TOTAL = 116 POINTS

___________________________ ___________________________
Name and Signature of Student Name and Signature of Clinical Instructor

Updated by: SN Clinical Instructors

Reviewed by: (SGD) Evangeline I. Soliba, RN, MAN
Program Chair, BSN

Approved by: (SGD) Helen D. Alalag, RN, MAN

Dean, School of Nursing

468
469
470
471
472
473
474
NURSING CARE PLAN RUBRIC
Grading Criteria
Incomplete Poor Fair Good
5 pts 10 pts 15 pts 20 pts
Assessment
Includes subjective, Assessment Assessment data is Identifies some Utilizes multiple sources
objective and historical portion is not well organized. significant, accurate for data. Correctly
data that support nursing incomplete or Subjective and and relevant data from identifies subjective and
diagnosis. inaccurate. objective data are more than one source. objective data which is
not identified. Does not consistently clear, specific, and
Assessment data is identify subjective and relevant. All data is
irrelevant or does objective data correctly. clustered in a coherent
not support nursing Most assessment data manner and is related to
diagnosis. supports nursing a nursing diagnosis.
diagnosis.
Diagnosis
Relevant NANDA Diagnosis Diagnosis are not One or two diagnosis Three or more diagnosis
approved diagnosis portion is NANDA approved, are identified that are are identified and are
written in proper form incomplete or appropriate for appropriate for patient clearly supported by
(includes stem, related to irrelevant. patient or not and are NANDA assessment data, and
prioritized. Diagnosis approved and clearly reflect accurate clinical

475
or R/T, and as evidenced not clearly supported supported by judgement. They are
or AEB) by assessment assessment data. May appropriate for patient,
data. not be listed in order of well prioritized, NANDA
priority, or lack the approved, and written in
proper format. correct format.
Planning (Goal Setting)
Includes patient/ family Goal portion is Goal statement are Goal statements are Short and long term
short term and long term incomplete or not relevant to identified that relate to goals are identified that
goals based on the completely nursing diagnosisis. the nursing diagnosis, clearly relate to the
nursing diagnosis. Goals unrelated to Outcomes are and are patient focused. nursing diagnosis, are
must be patient focused, nursing consistently not Criteria for written in a patient
realistic, and have clear diagnoses. client centered, measurement included focused manner, and
measurable criteria with a measurable or have but may not be clear or are realistic. Each goal
target date/ time. achievable target contain realistic time contains clear criteria for
dates. frame for evaluation. measurement and a
time frame for
evaluation.
Implementation
Nursing interventions or Interventions Interventions are Identifies three or less Identifies at least 3-5
actions that directly relate portion is unclear or do not interventions for each specific interventions for
to the etiology of the incomplete, not clearly focus on the goal that relate to the each outcome criteria in
nursing diagnosis and the relevant to etiology of the etiology of the nursing order to help the
patient goal and desired patient, or no nursing diagnosis or diagnosis. Not all patient/family reach the
outcome. Each rationales relate to patient goal interventions may be desired goal.
intervention must include provided. outcomes. specific. Rationales Interventions are
referenced rationale Rationales provided included but may be specific in action and
(including source and do not demonstrate weak, or references are frequency, and include
page number if an understanding of incomplete or from rationales which are
applicable). the purpose of the sources that may not be researched and clearly
interventions or no reliable. referenced with very
references are reliable sources.
provided.
Evaluation
Outlines the methods to Evaluations Evaluation portion Clearly states how each Evaluation portion
be used in evaluating portion is does not consistently outcome would be contains data that is
outcome criteria, incomplete or contain data that is evaluated. Able to listed as criteria in goal
expectations for goals does not relate listed as criteria in correctly identify criteria statement and lists
being met, and what to diagnosis, goal statement. May for goal being met, expectations for meeting
would determine that the goal statement also not describe partially met, or unmet. the goal. Clear
goal is met, partially met, or interventions. goal as met, partially Identifies revisions for explanation of the
or unmet. Explain how the met, or not met. May careplan but may not criteria for goals being
plan of care would be also not include include acurate met, partially met, or not
revised or continued in revision or new rationale for revision or met. Includes plan for
each case including a new evaluation references may be from continuation or revision,
realistic evaluation date/time. sources that may not be clearly referenced
date/time. reliable, or a new date rationale for revisions
is not provided for from reliable sources,
reevaluation. and a new evaluation
date/time.

476
PEER EVALUATION

Name of
Name of Group
Needs group
Acceptable Excellent Member Being
Improvement member
3 pts 5 pts Evaluated
1 pts evaluating
(N/A)
(N/A)

Involvement Name of Name of Group

Minimally Involved in the work and Extremely involved in the group Member Being
involved in the contributed to review of work; took a leadership member Evaluated
work. Submitted the overall project role and made significant evaluating.
own work but making comments and contributions.
otherwise not recommendations.
actively involved

Respect Name of Name of Group

Ignored or Responded to other Actively sought group group Member Being
disrespected group members' members' opinions and member Evaluatd
other group opinions, accepted them ensured that input was evaluating :
members' and made modifications incorporated into project.
opinions or agreed to Gave positive feedback
modifications based on and/or encouragement
the group opinions.

Staying on Name of Name of Group

task Did not submit Complied with task Took a leadership role group Member Being
own contribution deadlines and requests and/or set an example for member Evaluatd
to the project for input from team task completion evaluating :
OR required members.
multiple
reminders to
participate in
task

Attitude Name of Name of Group

Displayed a Displayed a compliant Displayed a positive group Member Being
negative attitude attitude about the attitude about the member Evaluatd
about the assignment and working assignment and working evaluating :
assignment and with group members. with group members.
working with Fostered communication
group members and completion of task

477
Sharing the Name of Name of Group
workload Completed own Contributed to the overall Took a leadership role, group Member Being
task prior to project and assisted in guided and executed member Evaluatd
deadline and reviewing the combination of individual evaluating :
submitted it to presentation. Shared in contributions and worked
the group. May the development of the on presentation as a
have cursorily presentation with others whole with others.
reviewed the and made helpful
overall comments toward a more
presentation. cohesive presentation

RUBRICS for WRITTEN ASSIGNMENT

Poor Fair Acceptable Excellent

Review of basic Requirements and Firm understanding of Superior
requirements and concepts are requirements and understanding of
concepts is needed. adequately understood; concepts; attention to requirements and
CRITERIA _____pts. review of these detail should correct concepts; make noted
elements and attention noted deficiencies. adjustments and
to detail may improve _____pts. continue to produce
performance. superb work.
_____pts. _____pts.

FORMAT Three of the four Two of the four One of the four All elements were
elements were elements were missing. elements were present without error
missing. missing. or with minor errors.
Title Page SIGNIFICANT
Abstract SEVERE ERRORS ERRORS noted in MINOR ERRORS All areas present with
Content (In-text Citations) noted in all present present elements. noted in present MINOR ERRORS
Reference Page elements. elements. noted.
Significant errors in title
Severe errors in title page, missing or Minor errors in title
page, missing incorrect abstract, page, missing or
abstract, missing in- missing or incorrect in- incorrect abstract,
text citations, text citations, missing missing or incorrect
missing reference or incorrect reference in-text citations,
page. page. missing or incorrect
reference page.

STRUCTURE: Information Some areas of the Information was Articulated well and
ORGANIZATION/ presented was work were presented logically presented information
READABILITY poorly placed inappropriately placed. and in an appropriate logically and clearly.
throughout the order.
work. Choppy, incomplete Ideas were easily

478
Assignment prepared in a presentation of Work flowed well and understood and
logical, coherent manner. Information information reduced ideas were easily followed.
presented did not quality of work. followed.
flow; lacked Work was easy to
cohesiveness. Topics were not Minor instances of read and author's
properly aligned, confusion were noted; position was clear.
Information resulting in confusion confusion did not
presented was for the reader. significantly reduce
extremely difficult to the quality of work.
read and confusing.

CONTENT
No elements of the Several elements of Most elements of the All elements of the
assignment were the assignment were assignment were assignment were
Elements of the addressed. missing. addressed. addressed.
assignment were
appropriately addressed. Work was not Work was minimally Work related to the Work appropriately
related to the related to the assignment as noted addressed each area
assignment as assignment as noted in in the course syllabus of the assignment as
noted in the course the course syllabus. with minimal exclusion noted in the course
syllabus. of assigned elements. syllabus.

CRITICAL THINKING Weak analysis of Minimal analysis of Provided good Unusually sharp
SKILLS information was information was analysis of the topic. insight into material
present. present. was noted.
Several resources
Critical analysis of Resources other Few resources were were used to support Initiated thoughtful
information, use of than the course text used to support information analysis of the topic.
additional resources to were not used in information presented. presented.
support claims, developing and Used multiple
evaluation of various supporting claims. Minimal evaluation of Theories and resources to support
theories and concepts. theories and concepts concepts related to work.
Critical evaluation was noted. the assignment were
of the theories and presented and Addressed many
concepts presented evaluated sides of an issue and
was not present. appropriately. all required elements
of the assignment.

Integrated theories
and concepts
previously learned
from this and other
disciplines; anticipated
next steps in
progression of ideas.

POINTS Max: Max: Max: Max:

Total Possible: Earned: Earned: Earned: Earned:

479
Total Earned:

480
EXCHANGE LISTS FOR MEAL PLANNING Radish Patola
Squash flowers Pepper fruit
Upo Tomato
- a grouping of foods in which the Pigeon pea pods Sweet pea pods (sitsaro)
(kadyos, Coconut shoot (ubod)
carbohydrates, fats, proteins, and bunga(1) Lima bean, pods (patani, bunga)
calories are similar for the serving Squash fruit Mungbean sprout (toge)
Singkamas tubber (lamang ugat)
sizes listed.
- A dietitian can create an appropriate Group B Vegetables
PROCESSED OR CANNED
dietary program prescribing the Asparagus 1 cup
number of calories and units of each Baby corn 2 pcs long (8 cm long)
Green peas 1 Tbsps.
exchange category to be consumed Golden sweet corn 2 Tbsps
daily, as well as a plan for when they Mushroom 1/3 cup
Tomato juice ½ cup, pure
should be eaten.
- The patient selects preferred foods
from the lists. II - LIST 2 - FRUIT LIST
1 exchange = 10 grams carbohydrate = 40
kcalories
I - VEGETABLE EXCHANGE
Group A vegetables This list shows the kinds and amounts of foods to
use for one fruit exchange.
- contain negligible carbohydrates, protein and Include at least one exchange in the diet daily.
energy if 1 exchange or less is used FOOD Wt. (g) Edible MEASURE
VEGETABLE A: LEAFY VEGETABLES Portion
A.P E.P.
- 1 exchange = 1cup raw (25g) or 1/2 cup
Fresh:
cooked (45g) 1/2 of 8 cm diameter
Ampalaya leaves Chayote leaves Apple 86 65 or
Cabbage Gabi leaves 1 (6cm diameter)
Camote leaves Celery Atis (3) 70 45 1 (5 cm diameter)
Pechay Kangkong Balimbing (1) 153 135 1-1/2 of 9 x 5 cm
Peppper leaves Lettuce
Mustard leaves Malunggay leaves BANANA:
Saluyot Spinach Lakatan 51 40 1 (9 x 3 cm)
String beans Squash leaves Latundan 55 40 1 (9x 3 cm)
leaves
Saba 70 40 1 (10 x 4 cm)
VEGETABLE B: NON- LEAFYVEGETABLES Cashew (3) 78 70 1 (7 x 6-1/2 cm)
- 1 exchange = 1/2 cup raw (40g) or 1/2 cup cooked Chico 54 45 1 (4 cm diameter)
(45g) Dalanghita (3) 300 135 2 (6 diameter each)
20 (2cm diameter
Ampalya fruit Baguio beans (abitsuelas) Duhat 80 60
each
Cauliflower Bamboo shoot (labong)
1 segment of 6-1/2
Katuray flowers Banana heart (puso na saging) Durian 150 30
x 4-1/2 cm
Chayote fruit Mushroom, fresh
10 (2 cm diameter
Cucumber Okra
each)
Eggplant Onion bulb Grapes (1) 69 55
or 4 (3 cm diameter
Malunggay pods Papaya green
each)

481
 2 (4 cm diameter (orange,pineapple, prune)
Guava (1)(3) 81 80
each) Bottled (sweetened):
80 1/3 cup
1 slice (8 x 6 x 2 Orange, guwayabano,
Guyabano (3) 86 60 cm) mango
or 1/2 cup Others:
3 segments (6 cm
Jackfruit ripe 118 40 Banana cue 20 1/2 of 9-1/2 x 4 cm
diameter each)
5( 2 cm diameter Buko water 180 1 cup
Lychees 77 50
each) 1/2 of 9-1/2x3-1/2 x
Turon 20
MANGO: 1 cm
Green (3) 90 65 1 slice (11 x 6 cm) III - MILK EXCHANGES
Medium ripe 90 65 1 slice (11 x 6 cm)
1 slice (12 x 7 cm) - The milk allowance in the meal plan
Ripe (2)(3) 103 60
or 1/2 cup cubed can be used as a drink.
Indian 140 80 1 (6 cm diameter)
- Added to cereals, or mixed with
Mangosteen 3 (6 cm diameter
212 55
(1) each) coffee or tea and other foods.
1 slice (12 x 10 x 3
Melon 317 200 cm) - + Equivalent to 1 cup cow's milk
or 1-1/3 cup
plus 2 exchanges
1 slice (10 x 6 x 2
Papaya ripe
133 85 cm) - of fat or 1/2 cup evaporated milk
(2)(3)
or 3/4 cup
Pear (1) 118 85 1 (6 cm diameter) plus 2 exchanges of fat.
1slice (10 x 6 x 2 - ++ Buttermilk refers to pasteurized
Pineapple 129 75 cm)
or 1/2 cup skim milk that has
Star apple 123 65 1/2 of 6 cm diameter - been sourced by lactic acid
Strawberry
168 165 1-1/4 cups producing bacteria.
(1)(3)
Watermelon 1 slice (12 x 6 x 3 1 exchange of
226 140
(1) cm) or 1 cup each of the CHO PRO
Fat (g) Energy (Kcalories)
Canned, drained: sub-groups of (g) (g)
Apple sauce 45 3 tablespoons milk contains:
Wt. (g)
Fruit cocktail 40 3 tablespoons measure
E.P
Peach halves 65 1-1/3 halves Whole Milk 12 8 10 170
Pineapple, crushed 60 3 tablespoons Milk,
1 slice (7 cm evaporated, 125 1/2 cup
Pineapple, sliced 35 untiluted
diameter)
Dried: + Milk, fresh
250 1 cup
carabao's
Mango chips 10 2 (2 x 8 cm each) Milk, fresh
250 1 cup
Prunes seedles 15 3 pieces cow's
Raisins seedles 15 2 tablesppons Milk,
30 1/4 cup
powdered
Canned juices:
Sweetened (apple, mango,
pineapple- 60 1/4 cup Low fat Milk: 12 8 5 125
grapefruit,pineapple-orange) Powdered 30 1/4 cup
80 1/3 cup lite Low fat
250 1 tetra-brick
Unsweetened Milk

482
 Skimmed Bihon, macaroni,
(Non- sotanghon, 75 1 cup
12 8 80
Fat)/Very spaghetti
Low Fat Milk: Others
++ Buttermilk:
185 2/3 cup Breakfast cereals 25 1/2 cup
liquid
powdered 25 1/4 cup Cornstarch 25 5 teaspoon
Long life Flour, all purpose 25 3 tablespoon
250 1 cup
skimmed milk Starches contain 15 grams of carbohydrate and 80
Yoghurt 125 1/2 cup
calories per serving. One serving equals:
IV - RICE EXCHANGES
- 1 exchange = 23 grams 1 slice Bread (white, pumpernickel, whole
wheat, rye)
carbohydrate,
2 slices Reduced-calorie or "lite" bread
- 2 grams protein =100 calories ¼ (1 oz) Bagel (varies)
- (1) These foods are good sources ½ Hamburger bun
of fiber. 1⁄ 3 C Barley or couscous, cooked
A. Rice and rice 1⁄ 3 C Legumes (dried beans, peas or
Wt (g) E.P Measure
products lentils), cooked
Rice, cooked 80 1/2 cup ½C Pasta, cooked
Lugaw 435 3 cups
½C Bulgar, cooked
Rice Products
1 slice (1/4 of 15cm ½C Corn, sweet potato, or green peas
Bibingka. biko 40
diameter, 2cm thick 3 oz Baked sweet or white potato
Cassava cake 45 1/2 of 15 x 3 x 2 cm
¾ oz Pretzels
Kalamay: latik 50 1 (4 x 6 x 2 cm)
3C Popcorn, hot air popped or
Ube 55 1 slice (7 x 3 x 1-1/2 cm) microwave (80% light)
1 (6 cm diameter x
Kutsinta 60
2-1/2 cm)
Bread
Pan de sal 40 3 pcs
Rolls 40 1 pc
45 2 slice
Whole wheat bread

Bakery products
Sponge cake 40 1 slice
Lady fingers 30 5 pcs
Mamon tostado 30 3 pcs
Hopia 35 1 1/2 round
Ensaymada 35 1 pcs
Corn products
Corn boiled 65 1 pc
Baby corn 90 1 cup
Noodles, cooked:

483
 Shank , round (hita), 30 1 slice matchbox
meat (laman: at walang size
taba), (5 x 3 -1/2 x 1-
V - LIST 5 - MEAT AND FISH EXCHANGE shoulder , round, rump 1/2 cm
PRO Fat Energy (tapadera)
(g) (g) (kcalorie) c. Lean pork
Low Fat Meat and Fish 8 1 41 30 1 slice, matchbox
Tenderloin, well trimmed size
Medium-Fat Meat and Fish 8 6 86
6-1/2 x 3 x 1-1/2
High-Fat Meat and Fish 8 10 122 cm
d. Chicken
A. LOW FAT MEAT AND FISH EXCHANGES 1 small leg (13-
Wt. (g) Leg (hita) or 30 1/2 cm long x 3
Food Measure
E.P. cm diameter
1. Lean meat
a. beef 30 1 slice, matchbox 2. Variety meats / Internal
size organs
Shank , lean meat (5 x 3 1/2 x 1-1/2 chicken Gizzard - chicken
(laman),Round , tenderloin , cm Heart (puso) - pork, beef,
porterhouse steak , sirloin carabeef 35 3/4 cup
steak , centerloin Liver - pork, bef, carabeef,
b. Carabeef chicken
Lung - pork, beef, carabeef
Spleen - pork, beef,
carabeef , Tripe -beef

3. Fish 1-1/4
Alamang, tagunton 30
1 slice (7 x 3 x 2 tablespoons
35
Large variety (e.g. bangus, cm) Aligue: Alimango 15 1 tablespoons
dalag, lapu-lapu, etc.) 1/4 cup or 1/2
Alimango / Alimasag, laman 20
piece medium
Meduim variety:
Lobster 30 2 tablespoons
Hasa-hasa, dalangang bukid 35 1 (18 x 4-1/2 cm
Talangka 30 75 pcs A.P
Galunggong 35 1 (14 x 3-1/2 cm
Shrimps: Puti 25 5 (12 cm each)
Hito 35 1/2 of 22 x 5 cm
Sugpo 25 2 (13 cm each)
Small variety:
Octopus (pugita) 30 1/2 cup
Sapsap, Tilapya, Tamban 35 2 (10 x 5 cm each) Squid (pusit) 25 3 (7 x 3 cm each)
Dilis 35 1/4 cup 1/3 cup shelled or
Shells: halaan 75
4. Other Seafoods 3 cups w/ shell
5. Beans

484
Pigeon pea seeds, dried 55 1/3 cup 1 slice (4 cm
6. Cheese Leg (pata) 30 diameter x 2 cm
Cottage cheese 60 1/3 cup thick)
2. Variety meats / internal
A. Fish Products organs
Dried:/ Daing: Brain (utak) - pork, beef,
35 3/4 cup
Lapu-lapu 20 1/4 of 30 x 40 cm carabeef
Sapsap 20 3 (9 x 5 cm each) 3. Fish
Tinapa: 1 slice (15 x 7 x 2
Karpa 35
Bangus 30 1/4 of 20 x 8 cm cm)
Galunggong 30 1 (16 x 4 cm) 4. Egg
Tuyo: Chicken 60 1 pc.

Alamang 15 1/3 cup Quail's egg 70 9 pcs.

3(11-1/2 x 8 cm salted duck's egg 60 1 pc.
dilis, sapsap, 20
each) 5. Cheese
pusit 15 1 (8 x 1 cm) 1 slice (6 x 3 x 2
Cheese, cheddar 35
Canned: cm)

Salmon 40 1/3 cup flaked 6. Chicken

Tuna in brine 30 1/3 cup flaked I medium or 2

Wings 25
B. Meat Products small

1 slice (11 x 4 x Head 35 2 heads

Tocino (lean) 45
0.5 cm) 7. Beans
Soybean (utaw) 40 1/2 cup

B. MEDIUM FAT MEAT AND FISH EXCHANGES 8. Processed Foods

Food a. Fish Products

1 slice, matchbox Sardines canned in oil /

1. Medium Fat Meat 30 45 1 (10 x 4-1/2 cm)
size tomato sauce

(5 x 3 -1/2 x 1-1/2 1-1/2 of 6 x 4 x 3

a. Beef Tuna sardines 50
cm) cm each
Tuna spread, canned 30 2 tablespoons
Flank , brisket, plate ,chuck
b. Meat Products
b. Pork Corned beef 40 3 tablespoons

485
 3 of 9 cm 3 slices of 8 x 8 x
Salami 50
Ham sausage 55 diameter x 0.3 1 cm each
cm thick each Vienna sausage 70 4 (5 x 2 x 2 cm)
c. Bean Products
Soybean cheese, soft (tofu) 100 1/2 cup
Soybean cheese, soft
60 1 (6 x 6 x 2 cm) VERY LEAN PROTEIN
(tokwa)
35 calories and 1 gram of fat per
C. HIGH FAT MEAT AND FISH EXCHANGES serving. One serving equals:
Food
1 oz Turkey breast or chicken breast,
1 slice (3 cm
. Pork 35 skin removed
cube)
1 oz Fish fillet (flounder, sole, scrod,
2. Variety meats / internal
cod, etc.)
organ
Tongue (dila) - pork, beef 35 3/4 cup 1 oz Canned tuna in water
3. Egg 1 oz Shellfish (clams, lobster,
Duck's egg 70 1 pc. scallop, shrimp)
Balut 65 1 pc.
¾C Cottage cheese, nonfat or low-
Penoy 60 1 pc.
fat
4. Nuts
Peanuts, roasted 25 1/3 cup 2 Egg whites
5. Cheese 1 oz Fat-free cheese
1 slice (6 x 3 x 2-
Cheese, filled 50 ½C Beans, cooked (black beans,
1/2 cm)
kidney, chick peas or lentils):
1 slice 6 x 3 x 2
Cheese, pimiento flavored 40 count as 1 starch/bread and 1
cm
very lean protein
6. Processed Foods
Meat Products
Lean Protein choices have 55 calories
Longanisa, chorizo style 25 1 (12 x 2 cm)
and 2–3 grams of fat per serving. One
1-1/2 of 12 x 1-
Frankfurters 60 serving equals:
1/3 cm

486
1 oz Chicken—dark meat, skin ** Choose these very infrequently
removed

1 oz Turkey—dark meat, skin removed

1 oz Lean beef (flank steak, London VI - FAT

broil, tenderloin, roast beef)* - Fat is a concentrated source of

1 oz Lamb, roast or lean chop* energy.

- Each gram of fat provides almost
1 oz Pork, tenderloin or fresh ham*
2-1/2 times as much energy as an
1 oz Low-fat cheese (with 3 g or less equal weight of either
of fat per ounce) carbohydrate or protein.

1 oz Low-fat luncheon meats (with 3 g One Exchange of meat and fish when

or less of fat per ounce) fried or sauteed will absorb approximately

ONE exchange of fat.
¼C 4.5% cottage cheese
1 exchange = 5 grams fat = 45 kcalories
2 med. Sardines

* Limit to 1–2 times per week

Food Wt (g) E.P Measure

Saturated Fats
Medium-Fat Proteins : 75 calories and Bacon 10 1 strip - 10 x 3 cm
5 grams of fat per serving. Butter 5 1 tsp
Coconut, grated 20 2 tbsps
1 oz Beef (any prime cut), corned beef,
Coconut, cream 15 1 tbsp
ground beef**
Coconut oil 5 1 tsp
1 oz Pork chop Cream cheese 15 1 tbsp
Latik 10 2 tsps
1 Whole egg (medium)**
Margarine 5 1 tsp
1 oz Mozzarella cheese Mayonaise 5 1 tsp

¼C Ricotta cheese Sandwhich spread 15 1 tbsp

Sitsaron 10 2 (5 x 3 cm each)
4 oz Tofu (note this is a heart healthy
Whipping cream, heavy / light 15 1 tbsp
choice)

487
POLYUNSATURATED FATS Marshmallow 5 1 (2-1/2 cm diameter)
Oil (corn, marine, soybean, 5 1 tsp Pastillas, durian, gatas,
5 1 (5 x 1 x 1 cm)
rapesed-canola langka

MONOSATURATED FATS 1 (1-1/2 cm long x 1 cm

Sampaloc candy 5
Avocado 65 1/2 of 12 x 7 cm thick)

Peanut Buter 10 2 tsps Sugars (white, brown,

5 1 tsp
pure cane, syrup)
Pili nut 5 5 pcs
Tofee candy 5 1( 2-1/2 x 1-1/2 x 1 cm)
Peanut oil, olive oil 5 1 tsp
Yema 5 1 (5 x 1-1/4 cm)
Shortening 5 1 tsp

Food Wt. (g) Measure Sugar Kcalories

VII - SUGAR EXCHAGE LIST E.P. Exchanges
- One teaspoon of suger is
equivalent to 1 exchange.
Halo-Halo 410 2-1/3 cups 4 80
- The following list shows the kinds
Ice Candy
and amounts of sweets and other 100 1 pc 3 60
(frostee)
forms of sugar to use for 1 sugar
Ice drop 100 1 pc 4 80
exchange.
1 (4 x 2-1/2 x
Pulvoron 10 2 40
1 cm
- 1 exchange = 5 grams
carbohydrate = 20 kcalories

Beverage List
+ Nutritional information taken from product
5 1 ( 6 x 3-1/2 cm)
Banana chip label.
Caramel 5 1 (2 x 2 cm) ++Nutritional information taken from
Chewing Gum, bubble distributor company.
5 1 pc
gum
Condesed milk 10 2 tsps
Hard candy 5 1 (3 x 2 x 0.5 cm)
Honey 5 1 tsp
Jams, jellies, preserves 10 2 tsps

488
 SCHOOL OF NURSING
General Luna Road, Baguio City

UB VISION

In pursuit of perfection, the University of Baguio is committed to provide balanced quality education by nurturing academic excellence, relevant social
skills and ethical values in a fun-learning environment.

UB MISSION SCHOOL MISSION

The University of Baguio educates individuals to be The School of Nursing is a dynamic and value-oriented
empowered professionals in a global community. community committed to the advancement of the modern health
care system.
INSTITUTIONAL OBJECTIVES SCHOOL OBJECTIVES

The University of Baguio aims to produce a graduate who: The School of Nursing, through innovative approaches in a caring
1. exemplifies a higher standard of learning; environment, aims to produce a health care graduate who:
2. manifests the mastery of relevant skills; 1. exhibits the necessary knowledge, skills and attitudes in promoting
3. upholds a conduct that is rightful and just; and maintaining the holistic well-being of the patient;
4. undertakes scientific and significant researches; 2. demonstrates proficiency in the delivery of health-care services;
5. advocates sustainable programs for the community and the
3. practices ethico-moral and legal aspects of the nursing profession;
environment; and
6. leads and demonstrates exemplary performance in the field 4. conducts health-related researches and applies findings for the
of specialization. enhancement of the care of the patient;
5. participates actively in community services to improve quality of life;
and
demonstrates effective and efficient leadership capabilities through the
health care concepts, functions, and activities.
INSTITUTIONAL CORE VALUES PROGRAM EDUCATIONAL OBJECTIVES

COMPETENCE + INTEGRITY = SERVICE The Bachelor of Science in Nursing program aims to produce a
graduate who:

489
 COMPETENCE: University of Baguio is committed to nurturing 1. shows commendable nursing skills, knowledge and attitude
excellent professionals. in the health care system;
INTEGRITY: University of Baguio is committed to cultivating a 2. demonstrates proficiency of the required and relevant nursing
community with ethical values. skills;
SERVICE: University of Baguio is dedicated to building a community 3. applies bio-ethics principles and approaches consistent with
that advocates sustainable programs for the society and the the code of ethics for nurses;
environment. 4. conducts nursing researches and adapts evidence-based
practice in nursing;
5. engages in community services to promote and maintain the
health of clients; and,
6. exemplifies ideal managerial and leadership skills in the
practice of the nursing profession.

I. PROGRAM OUTCOMES (PO)

PROGRAM EDUCATIONAL
Program Outcomes for Bachelor of Science in Nursing: OBJECTIVES
The graduates have the ability to:
P1 P2 P3 P4 P5 P6
1. Articulate and discuss the latest developments in the specific field of practice; ✓ ✓ ✓ ✓ ✓ ✓
2. Effectively communicate orally and in writing using both English and Filipino; ✓ ✓ ✓ ✓ ✓ ✓
3. Work effectively and independently in multi-disciplinary and multi-cultural teams; ✓ ✓ ✓ ✓ ✓ ✓
4. Act in recognition in recognition of professional, social, and ethical responsibility; and ✓ ✓ ✓ ✓ ✓ ✓
5. Preserve and promote “Filipino historical and cultural heritage”. ✓ ✓ ✓ ✓ ✓ ✓
Program Outcomes Common to University:
Graduates of universities participate in the generation of new knowledge or in research and
development projects.
Program Outcomes Common to Health Sciences: The graduates have the ability to:
1. Demonstrate clinical competence in specific profession; ✓ ✓ ✓ ✓ ✓ ✓
2. Exhibit health professional & ethical practice; ✓ ✓ ✓ ✓ ✓ ✓
3. Practice inter-professional education; ✓ ✓ ✓ ✓ ✓ ✓
4. Exercise communication skills/become an educator; ✓ ✓ ✓ ✓ ✓ ✓
5. Continue to become a lifelong learner (personal/continuing professional development); ✓ ✓ ✓ ✓ ✓ ✓
6. Demonstrate leadership/managerial/systematic approach to health care; ✓ ✓ ✓ ✓ ✓ ✓

490
 7. Work as a researcher; and ✓ ✓ ✓ ✓ ✓ ✓
8. Practice as social advocate/ mobilizer. ✓ ✓ ✓ ✓ ✓ ✓
Program Goals/Program Educational Objectives (CMO 15 series 2017): Bachelor of Science in
Nursing graduates:
1. Apply knowledge of physical, social, natural and health sciences and humanities in the
✓ ✓ ✓ ✓ ✓ ✓
practice of nursing
2. Perform safe, appropriate, and holistic care to individuals, families, population groups, and
✓ ✓ ✓ ✓ ✓ ✓
community utilizing nursing process
3. Apply guidelines and principles of evidence-based practice in the delivery of care ✓ ✓ ✓ ✓ ✓ ✓
4. Practice nursing in accordance with existing laws, legal, ethical, and moral principles ✓ ✓ ✓ ✓ ✓ ✓
5. Communicate effectively in speaking, writing, and presenting using culturally-appropriate
✓ ✓ ✓ ✓ ✓ ✓
language
6. Report/document client care accurately and comprehensively ✓ ✓ ✓ ✓ ✓ ✓
7. Collaborate effectively with inter-, intra-, and multi-disciplinary and multi-cultural teams ✓ ✓ ✓ ✓ ✓ ✓
8. Practice beginning management and leadership skills in using systems approach in ther
✓ ✓ ✓ ✓ ✓ ✓
delivery of client care
9. Conduct research with an experienced researcher ✓ ✓ ✓ ✓ ✓ ✓
10. Engage in lifelong learning with a passion to keep current with national and global
✓ ✓ ✓ ✓ ✓ ✓
developments in general, and nursing and health developments in particular
11. Demonstrate responsible citizenship and pride in being a Filipino ✓ ✓ ✓ ✓ ✓ ✓
12. Apply techno-intelligent care systems and processes in health Care delivery ✓ ✓ ✓ ✓ ✓ ✓
13. Uphold the nursing core values in the practice of the profession ✓ ✓ ✓ ✓ ✓ ✓
14. Apply entrepreneurial skills in the delivery of nursing care ✓ ✓ ✓ ✓ ✓ ✓
15. Uphold UB-core values in the practice of the nursing profession ✓ ✓ ✓ ✓ ✓ ✓

II. PROGRAM INDICATORS (PI)

PROGRAM OUTCOMES (PO) PERFORMANCE INDICATORS (PI)

The graduates have the ability to:
1. Apply knowledge of physical, social, natural and health 1. Integrate relevant principles of social, physical, natural and health sciences
sciences and humanities in the practice of nursing and humanities in a given health and nursing situation
2. Apply appropriate nursing concepts and actions holistically and
comprehensively

491
2. Perform safe, appropriate, and holistic care to individuals, 1. Assess with the client (individual, family, population group, and/or
families, population groups, and community utilizing nursing community), one’s health status/competence
process 2. Formulate with the client a plan of care to address the health conditions,
needs, problems and issues based on priorities
3. Implement safe and quality interventions with the client to address the
health, problems and issues
4. Provide health education using selected planning models to targeted
clientele (individuals, family, population, group or community)
5. Evaluate with the client the health status/competence and/or
process/expected outcomes of nurse-client working relationship
6. Institute appropriate corrective actions to prevent or minimize harm arising
from adverse effects
3. Apply guidelines and principles of evidence-based 1. Provide appropriate evidence-based nursing care using a participatory
practice in the delivery of care approach based on:

a. variety of theories and standards relevant to health and healing

b. research
c. clinical practice
d. client preferences
e. client and staff safety
f. customer care standards
4. Practice nursing in accordance with existing laws, legal, 1. Adhere to ethico-legal considerations when providing safe, quality and
ethical, and moral principles professional nursing care
2. Apply ethical reasoning and decision making process to address situations
of ethical distress and moral dilemma
3. Adhere to established norms of conduct based on the Philippine Nursing
Law and other legal, regulatory and institutional requirements relevant to safe
nursing practice
4. Protect client rights based on Patient’s Bill of Rights and Obligations
5. Implement strategies/policies related to Informed consent as it applies in
multiple contexts
5. Communicate effectively in speaking, writing, and 1. Ensure a working relationship with the client and/or support system based
presenting using culturally-appropriate language on trust, respect, and shared decision-making using appropriate
communication/interpersonal techniques/strategies
6. Report/document client care accurately and 1. Document client’s responses/nursing care services rendered and
comprehensively processes/outcomes of the nurse client working relationship

492
 2. Ensure completeness, integrity, safety, accessibility and security of
information
3. Adhere to protocol and principles of confidentiality in safekeeping and
releasing of records and other information
7. Collaborate effectively with inter-, intra-, and multi- 1. Ensure intra-agency, multidisciplinary and sectorial collaboration in the
disciplinary and multi-cultural teams delivery of health care
2. Implement strategies/approaches to enhance/support the capability of the
client and care providers to participate in decision making by the inter-
professional team
3. Maintain a harmonious and collegial relationship among members of the
health team for effective, efficient, and safe client care
5. Collaborate with other members of the health team in the implementation of
programs and services
6. Apply principles of partnership and collaboration to improve delivery of
health services

8. Practice beginning management and leadership skills in 1. Participate in the development and improvement of policies and standards
using systems approach in their delivery of client care regarding safe nursing practice and relevant to human resource management

2. Manage resources (human physical, financial, time) efficiency and

effectively

3. Apply management and leadership principles in providing direction to

manage a community/village-based

4. Use appropriate strategies/approaches to plan community health programs

and nursing service
7. Evaluate specific components of health programs and nursing services
based on parameters/criteria
8. Maintain a positive practice environment
9. Participate in the planning and implementation of staff development
activities to enhance performance of nursing support staff
10. Evaluate performance of nursing support staff using a standard evaluation
tool.

493
 10. Engage in lifelong learning with a passion to keep current 1. Assume responsibility for lifelong learning own personal development and
with national and global developments in general, and maintenance of competence
nursing and health developments in particular
2. Demonstrate continued competence and professional growth

3. Engage in advocacy activities to influence health and social care service

policies and access to services

4. Model professional behaviour

5. Engage in advocacy activities to deal with health related concerns and

adopts policies that foster the growth and development of the nursing
profession

11. Demonstrate responsible citizenship and pride of being a 1. Accepts the responsibility in paying relevant taxes in the practice of the
Filipino. profession.

2. Customize nursing interventions based on Philippine culture and values.

3. Project the good image of a Filipino nurse.

12. Apply techno-intelligent care systems and processes in 1. Use appropriate technology to perform safe and efficient nursing activities
health care delivery.
2. Implement system of informatics to support the delivery of health care
13. Uphold the nursing core values in the practice of the 1. Demonstrate caring as the core of nursing, love God love of country and
profession love of people
2. Manifest professionalism, integrity, and excellence
3. Project the positive professional image of a Filipino Nurse
15. Uphold UB-core values in the practice of the nursing 1. Apply competence with integrity in their professional and personal
profession endeavors as UBians in the service of their client

III. COURSE INFORMATION

Course This course deals with the study of food in relation to health. It covers nutrients and other substances and their action,
Description: and interaction and balance in relation to health and diseases and the process by which organism ingests, digests,
absorbs, transports, utilizes and excretes food substances. It will also focus in the therapeutic and food service aspects
of the delivery of nutritional services in hospitals and other healthcare institutions.

494
 Units: 2 UNITS LEC/ 1 UNIT LAB
Hours: 2 Hours LEC/ 3 Hours LAB
Pre-requisite General Chemistry, Biochemistry, Anatomy and Physiology, Micro-Parasitology
Course(s):
Co-requisite None
Course:

IV. LEARNING PLAN

COURSE COVERAGE – FIRST GRADING

WEEK COURSE LEARNING TEACHING-LEARNING

COURSE CONTENT DURATION ASSESSMENT TASKS (AT) RESOURCES PRC
NO. OUTCOMES ACTIVITIES (TLA)
TOS
1 4. Define common terms I - INTRODUCTION TO 2 hours THEORY: THEORY:
used in the study of NUTRITION
LEC A. Online A. Online ▪ Laptop
nutrition.
(PO 1/ PI 1) A. Definition of terms • Lecture-discussion o Quiz via Google ▪ Internet
•Nutrition (CLO #1 ) meet connectivity
•Nutrients •Food o Assignment ▪ Rubric for
•Diet (for CLO1) assignment
•Health B. Offline B. Offline ▪ Worksheets
•Enzymes • Use of modules ▪ Printed
•Hormones (CLO #1 ) o Quiz modules
•Kilocalories / calories o Worksheets
(for CLO1)
> Good Nutritional Status
•Nutriture
> Medical Nutrition Therapy

495
1 5. Explain the anatomy of B. Basic Nutrition 2 hrs. THEORY: THEORY
the digestive system Concepts LEC FACE-TO-FACE (F2F) Online Laptop
and the corresponding 1. Review of Anatomy • Interactive Lecture o Quiz via Google Internet connectivity
functions of its parts. and Physiology of Digestive (CLOs 2 – 5) Meet Worksheets
(PO 1/ PI 1 & 2) System o (CLOs 2-5) ▪ Rubric for
2. Overview of digestion assignment
6. Describe the and absorption o Reading
mechanical and 3. Metabolism assignment ▪ Printed
chemical processes of 4. What is the importance of Offline / Online (CLOS 2- 5) modules
digestion, absorption, nutrition? • Use of modules Offline
and metabolism of 5. What is healthy eating? (CLO # 2-3) o Quiz
foods. - Balance o worksheets
(PO 1/ PI 1 & 2) - Moderation • Concept mapping (for CLOS2-3)
7. Describe how nutrition - Variety (CLO # 2-3)
affects one’s health
( PO 3/ P1)
8. Describe the principles
of a healthy diet.
( PO 3/ P1)

496
 2 • Describe the basic LABORATORY: LABORATOTY: Handouts (PDF)
tools used in nutrition II - BASIC TOOLS IN 3 hrs
by: NUTRITION LAB F2F Online Worksheet
Tools for healthy eating: Hands-on Learning - Quiz via Google classroom
1. Identify what specific foods are 1. FNRI & USDA Food (CLO 3, 5, 6, 7) (for CLOS1-3) Laptop
in each food category, as well as Guide Pyramid
the number of servings of each - Different types of Online Rubrics
food item to eat each day. Food Pyramid • Lecture-discussion Offline
(PO 1/ PI 1) (according to age (for CLOS1-3) - Quiz (essay type/ short Printed modules
brackets) answer)
2. Compare and contrast the food (for CLOS1-3)
pyramid from USDA and FNRI. Offline
(PO 1/ PI 1) • Use of modules
(for CLOS1-3)
3. Differentiate and interpret the
different food pyramid for each
age group based on FNRI.DOST
description.
(PO 1/ PI 1)
3 - 4 4. Explain the 10 Nutritional 2. 10 NGF / Pinggang Pinoy 3 hrs. LABORATORY: LABORATORY: Handouts (PDF)
guidelines for Filipinos and the by NNC LAB A. Online A. Online
“Pinggang Pinoy”. • Lecture - discussion - Quiz via Google classroom ( Worksheet
(PO 1/ PI 1) 3. RDA or RENI via Scheduled live classes Calculation of food value)
via Google hangout or Zoom (for CLOS 4-7) Laptop
5. Identify the required 4. FEL (Food Exchange List) (CLOs 4 – 7)
components of a food label. - Definition Rubrics
(PO 1/ PI 1) - Utilization • Peer teaching thru
discussion forum B. Offline Printed modules
6. Plan a balanced diet using the 5. Food Labeling (for CLOS 4-7) - Quiz ( Calculation of food
Food Exchange List as a guide. value)
(PO 2/ PI 1 & 2) (for CLOS 4-7)
B. Offline
7. Evaluate a “Nutrition Facts” • Use of modules
label to make better food (for CLOS 4-7)
choices.
(PO 2 / PI 3)

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 5 6. Classify nutrients III - Classification of Nutrients 2 hrs. THEORY: THEORY: Handouts
appropriately. 1. Classification by
LEC Online Online Laptop
predominant function
7. Describe the 2. The Six Essential • Lecture-discussion o Quiz via Google Internet connectivity
micronutrient/ Nutrients (CLOs 1 – 3) Meet (for CLOS1-3)
macronutrient content 3. According to function Offline Offline Printed modules
of various foods and 4. According to
meal items. essentiality • Use of modules o Quiz
8. Identify the essential 5. According to chemical (CLO4-6) (for CLOS1-3)
nutrients, its nature or property
importance and food 6. According to
sources. concentration
(PLO1 / PI1 & 2)

First Grading Examinations 2 hrs. LEC

6 Multiple choice exam
3 hrs =LAB
Subtotal 12 hrs.
LEC
18 hrs. LAB

COURSE COVERAGE – MIDTERMS

WEEK TEACHING-LEARNING
COURSE LEARNING OUTCOMES COURSE CONTENT DURATION ASSESSMENT TASKS (AT) RESOURCES PRC
NO ACTIVITIES (TLA)
TOS
7 1. Describe the functions and III – SIX ESSENTIAL NUTRIENTS 2 hrs – THEORY: THEORY:
general recommendations LEC Online Online Laptop
for carbohydrate, protein, A. Carbohydrates • Lecture- o Quiz via Google Internet
and fat in health prevention 1. Functions discussion Meet connectivity
and disease management. 2. Nature (CLOs 1 -4) (for CLOS1-4) Printed modules
(PLO 2/ PI 1) 3. Types Offline Offline
4. Deficiencies/toxicity • Use of o Quiz
5. Food sources modules (for CLOS1-4)
(CLO # 1 – 4)

498
7 2. Select the foods which are B. Protein 2 hrs. Theory: Online Handouts
primary sources of protein. 1. Functions LEC Online o Quiz via Google Laptop
(PO 1/ PI 1) 2. Types • Lecture- Meet Internet
3. Explain the effects of 3. Deficiencies/toxicity discussion (for CLOS1-5) connectivity
inadequate or excess 4. Food sources Offline Offline Printed modules
protein intakes. • Use of o Quiz/Assignment
(PLO 2/ PI 1 – 3) modules (for CLOS1-5)
4. Recognize the importance (CLO # 1 – 4)
of protein in the diet
(PLO 2/ PI 1 – 3)

5. Identify sources of C. Fats and waters 2 hrs. THEORY: Handouts

saturated, polyunsaturated 1. Functions LEC Online Online Laptop
and monounsaturated fatty 2. Types • Lecture- o Quiz via Google Internet
acids. 3. Deficiencies/toxicity discussion Meet (for CLOS1-5) connectivity
6. Explain the importance of 4. Food sources Offline Offline Printed modules
these fatty acids in one’s 5. Cholesterol • Use of o Quiz (for CLOS1-5)
8 diet. modules
7. Explain the effects of (CLO# 5 – 10)
excess fat intakes to the
body
(PLO 3/ PI 1)

8. Identify the physiologic D. Vitamins and Minerals 2 hrs. Theory: Online Handouts
functions of each vitamin 1. Functions LEC Online o Quiz via Google Laptop
and mineral. 2. Deficiencies/toxicity • Lecture- Meet Internet
9. Recognize the best food 3. Food sources discussion (for CLOS1-5) connectivity
9 sources of each mineral. Offline Printed modules
10. Identify potential toxicities • Use of Offline
associated with vitamins & modules o Quiz
minerals. (CLO# 5 – 10) (for CLOS1-5)
(PLO 2/ PI 1)

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9 11. Explain why water is important in E. Water 2 LEC Theory: Online
the body. 1. Chemical & physical Online o Quiz via edmodo Laptop
(PLO 2/ PI 2) properties of water • Lecture- (for CLOS1-5) Internet
12. State the sources of water in the 2. Distribution of water discussion Offline connectivity
body and the routes of water loss in the body (CLO 11-12) o Quiz Printed modules
from the body. 3. Functions of water Offline (for CLOS1-5)
(PLO 2/ PI 2) • Use of
4. Recommended modules
intake (CLO # 11-12)

5. Deficiency/
Dehydration

6. Toxicity/ Over
hydration
Given sets of data, students will be IV - DIETARY COMPUTATIONS LABORATORY LABORATORY
able to: A. Nutritional Assessment
(NUTRITION-FOCUSED NURSING Online Online ▪ Rubrics for
7. Comprehensively assess a CARE PLAN) • Lecture- o Quiz reflective
client`s nutritional status. discussion (CLOs 1-4) diary,
(PLO 5/ PI 1,2,3) 1. Common Anthropometric (Google Assignment/
Measurements classroom) o Self instruction NCP
3 hours
8. Evaluate the significance of a. Height (CLOs 1 – 4) worksheets ▪ Digitized
9 LAB
dietary assessment to b. Weight (CLOs 1-4) Handouts
patients of various age, c. Skinfold thickness • Reflective diary ▪ Worksheets
weight, height and nutritional d. Body Circumference (CLO 1) o Assignment ▪ Laptop
status. i. Head-chest ratio (CLOs 1- 4) ▪ Audio-visual
(PLO 5/ PI 1,2,3) ii. Mid-upper arm circumference tools
iii. Waist circumference o Recitation – real ▪ Books
iv. Waist-hip ratio time
(CLO # 1-4)

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 9. Develop a nursing care plan 3 hrs.
appropriate for the client. 2. Biochemical Tests LAB • Assign reading Hand outs
(PLO 6/ PI 1-4) 3. Clinical Observations Ebooks. Rubrics for
a. Clinical features of malnutrition (CLO 1-4) o Nursing Care Plan assignment
i. Kwashiorkor F2F (NCP) / Case study Laptop
10. Provides appropriate ii. Marasmus Case Analysis (Given a scenario)
interventions based on the iii. Obesity (CLO 1-3)
patient’s plan of care. iv. Overweight Books
(PLO 5/ PI 1,2,3) • Interactive
4. Dietary Intake discussion Offline: Printed modules/
a. Description & Components (Google worksheets
b. Dietary History discussion o Self instruction
c. Food records board) worksheets
d. Food frequency checklist (CLO 3-4) (CLO 2)
e. 24hr recall
Offline: o Quiz
• Use of (CLOs 1-4)
modules o Nursing Care Plan
(reading text/ (NCP) / Case study
printed pdf) Given a scenario)
(CLOs 1 – 2) (CLO 1-3)

• Reflective
diary
(CLO 1)

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 11. Creates and documents a B. NURSING DIAGNOSIS 2 hrs. F2F Online Worksheets
well-developed plan of care for a C. PLANNING LAB Case analysis Quiz (CLO 5)
client with problems in nutrition D. IMPLEMENTATION Laptop
(PLO 6/ PI 1-4) E. EVALUATION Online
Lecture-discussion Case study questions Books
Interactive discussion (CLO # 5)
(Google forum group) Rubrics
(CLO 5) Offline:
Quiz
Case study questions
Offline: (CLO # 5)
Use of modules
(CLO5)

12. Employ the steps in A. Body mass index and 3 hrs. Online Online Worksheets
calculating the nutrient needs of classification LAB Lecture-discussion Computation for nutrient
individuals and come up with a Interactive discussion content Laptop
menu plan based on the clients B. Determining Ideal Body Weight/ (Google forum group) (CLO 6)
needs. Desired Body Weight (CLO 5) Books
(PLO 2/ PI 1) 1. Infants
a. 1-6months b. 7-12months Offline Rubrics
10 Offline: Quiz
2. Children(13-18y/o) Use of modules (CLO # 6)
a. Gomez Classification (CLO5)
Case study questions
(CLO # 5)

Computation for nutrient

content
(CLO 6)

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 LABORATORY LABORATORY
13. Perform accurate skills 3. Adults Online: Online:
necessary in diet planning. a. BMI b. Hamwi • Lecture- o Assignment
Rubrics
(PLO 5/ PI 1 – 3) method discussion (CLO 7 - 8)
Hand outs
c. NDAP method 3 hrs. • (Video and/ Printed modules/
C. Weight Loss LAB audio o Quiz
worksheets
1. Percent Usual Body Weight conference) (CLOs 7 – 8)
2. Percent Weight Loss (CLO 8)
o Group dynamics
D. Weight Gain • Discussion (CLO # 7 - 8)
14. Calculate for the calorie E. Desirable Body Weight forums and o Individual
content of household portions (DRW) Determination blogs (worksheets)
of dishes F. Total Energy Requirement (CLO 7 - 8) (CLO 8)
(PLO 2/ PI 1) (TER) & distribution of TER • Peer teaching
Determining Total Energy ( Google Offline
Requirement forum group) o Group output
3 hrs.
1. Infants • Think, pair, (CLO # 8)
LAB
a. 1-6months share Printed modules /
11 b. 7-12months (CLO 8) o Quiz
Work sheets
2. Children
a. Narin’s and Weil Formula Offline: o Individual
b. Based on age and DBW Use of modules (worksheets)
3. Adolescent (CLOs 7 - 8) (CLO 8)
4. Adults
G. Application to Food 3 hrs.
Exchange List (FEL) & sample LAB
menu
2 hrs. LEC
12 Midterm Grading Examinations
3 hrs LAB
24 hrs.
LEC
Subtotal
36 hrs. LAB

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 COURSE COVERAGE – FINALS

WEEK TEACHING-LEARNING ASSESSMENT TASKS

COURSE LEARNING OUTCOMES COURSE CONTENT DURATION RESOURCES PRC
NO ACTIVITIES (TLA) (AT)
TOS
At the end of the discussion, the VI. NUTRITION THEORY: A. Online
students should be able to: THROUGHOUT THE 2 hrs A. Online o Quiz via Google Laptop
1. Assess the physiological and LIFESPAN LEC • Lecture- meet Internet connectivity
psychological changes and discussion (for CLOS1-5)
development per stage of life which A. PREGNANCY
require modifications in nutrition. 5. Stages B. Offline
(PLO 3/ PI 1) F2F o Quiz
6. Physiology of Pregnancy /Assignment
13 2. Identify nutritional needs during (for CLOS1
pregnancy, lactation and infancy. 7. Nutritional Problems and B. Offline
Interventions • Use of modules
(PLO 5/ PI 1,2,3) (CLO # 1- 2)
8. Recommended Diet
- Energy & nutrients needs
during pregnancy
- Food choices

3. Discuss lactation management B. LACTATION THEORY:

techniques. 1. Common Nutritional 2 hrs. Online Online Laptop
Problems and Interventions LEC • Lecture- o Quiz via Google Internet connectivity
4. Review infant feeding trends & 2.Breastfeeding trends discussion meet
strategies. a. breastfeeding techniques Offline (for CLOS1-5)
14 3.Physiology of lactation • Use of modules Offline
5. Identify women`s health 4.Composition of human milk (CLO # 3 - 9) Quiz (for CLOS1
concerns during lactation. 5.Benefits of breastfeeding
(PLO 1/ PI 1,2) 6.Nutrition for breastfeeding
women

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14 6. Describe nutritional needs of C. INFANCY
infants, children and adolescents 2 hrs. Theory: Online Laptop
1. Nutritional Problems and LEC Online o Quiz via Google Internet connectivity
8.Assess an infant’s/ child`s Intervention • Lecture- meet (for
nutritional needs. 2. Factors Affecting discussion CLOS1-5)
(PLO 15/ PI 1) Nutritional Status Offline Offline
(PLO 5/ PI 1,2,3) a. Growth and • Use of modules Quiz (for CLOS1
development (CLO # 3 - 9)
9.Describe methods to promote b. Introduction of solid
good nutritional intake. foods
3. Guidelines in Feeding
4. Recommended Diet

15 10.Describe assessment and D. PRE-SCHOOLERS &

intervention strategies for common SCHOOLERS / Childhood 2 hrs.
childhood health concerns. LEC
THEORY:
(PLO 2/ PI 1) 6. Nutritional
THEORY: Online
Problems and
Online o Quiz via Google
Interventions
meet
7. Guidelines in • Lecture-
(for CLOS1-5)
Feeding discussion
8. Energy and nutrient Laptop
Offline
needs Offline Internet connectivity
Quiz/Assignment
9. Influences on • Use of modules (for CLOS1
childhood food (CLO # 10 – 13)
habits and intake
10. Nutritional growth in
childhood

505
15 11.Apply knowledge of the nutrient E. ADOLESCENCE THEORY: THEORY: Laptop
needs of the adolescents. 1. Nutritional problems 2 hrs. Online Online Internet connectivity
(PLO 1/ PI 1 & 2) and intervention LEC • Lecture- o Quiz via Google
2. Recommended Diet discussion meet
3. Physical growth and (for CLOS1-5)
development Offline
4. Nutrient needs • Use of modules Offline
5. Nutritional concerns for (CLO # 10 – 13 Quiz/Assignment
adolescents (for CLOS1

12. Discuss common nutrition- F.ADULTHOOD THEORY: THEORY: Laptop

related medical problems of the Online Online Internet connectivity
older adult. 3. Physiologic • Lecture- o Quiz via Google
(PLO 2/ PI 1) changes discussion meet
(PLO 15/ PI 1) accompanying (for CLOS1-5)
aging Offline
13.Know the difference of food 2. Psychological impact of • Use of modules Offline
preferences and requirement which aging (CLO # 10 – 13 Quiz/Assignment
suits the specific life stages 3. Nutrient needs/ Dietary (for CLOS1
requirements
4.Nutrition-related concerns
of mature adults
5.Nutritional Problems and
Interventions
6.Recommended Diet
VI. DIET THERAPY
LABORATORY LABORATORY
16 5. Differentiate the kinds of A. General diets 3 Online Online:
standard hospital diets 1. Regular/full Diet LAB • Lecture- o Quiz
(PLO 1/ PI 1) 2. High fiber diet discussion (CLOS 1 - 4)
3. Vegetarian diets • Video Lecture ▪ Books
4. Therapeutic diets

506
 6. Design a therapeutic diet B. Diets modified in 3 hrs. • Interactive o Journal reaction ▪ Rubrics for
using the principles, types consistency LAB discussion (live (given a link of a assignment/
of therapeutic diets, and 1. Clear liquid webcasting) journal) COLLABORATION/
their indications and 2. Full liquid (CLOS 1 – 4) (CLO 1) ▪ Journal
contraindication. 3. Cold liquid T&A diet
(PLO 2/ PI 1) 4. Soft bland • Peer teaching ( o Case analysis
16 5. Mechanical soft Google forum per group ▪ Laptop/ Egadget/
6. Soft bland group) (CLO # 1 ) eDevice
7. Bland (CLOS 1-4)
8. Residue restricted o Assignment
9. Low fiber • Demonstration (CLO 1-3) ▪ Module
on NGT feeding
7. Utilize knowledge of diet 3 hrs, (CLO 4) o Journal reaction
therapy in assisting C. Diets Modified in LAB o (CLO 2-3) ▪ Checklist on ngt
clients needing dietary Composition Offline: insertion
modifications. 1. Low calorie Use of modules Offline
(PLO 2/ PI 1) 2. High calorie
3. High protein • Demonstration o Journal reaction
4. Low protein on NGT feeding (CLO 2-3)
5. Low fat • (when face-to-
16 o Case analysis
6. Low cholesterol face learning is
7. Low carbohydrate possible) (CLO # 1 )
8. Low salt/sodium restricted o Return
• (CLO 4)
9. Low potassium Demonstration
10. Low purine/ purine on NGT feeding
restricted F2F

507
 8. Skillfully demonstrate how D. Tube feeding 3 Demonstration • (when face-to-
to enterally feed clients. 1. Enteral feeding LAB Return Demonstration face learning is
(PLO 2/ PI 1) a. Types possible)
b. Indications & • (CLO 4)
contraindications for use
c. Complications and
problems
2. Types of enteral formulas
a. Intact
b. Hydrolyzed o
c. Modular
17
3. Feeding administration
a. Continuous drip
b. Bolus
c. Combination
4. Parenteral Feeding
a. Indications &
contraindications for use
b. Complications & problems

4. NGT INSERTION

508
 17 9. Plan a one-day menu VII. DIETARY 3 hrs. - F2F LABORATORY ▪ Work sheets
based from the calculated MANAGEMENT OF SOME LAB Problem-based learning Online: ▪ Rubrics
RENI COMMON MEDICAL Muddiest point o Group dynamics
(PLO 5/ PI 1-4) CONDITIONS (Forum post)
- including computations and o (CLO # 5)
preparations and their LABORATORY
rationale Online
- Provide opportunity for o Lecture-discussion
actual preparation of the o (CLOs 1-5)
prescribed therapeutic Offline:
- dietary regimen (to include o Interactive discussion o Group dynamics
evaluation and computation) (Small group /Google (SMS)
form) o (CLO # 5)
o (CLO 5)

Offline:
• Use of modules
• (CLOs 1-5)
18 Final Grading Examinations 3 hrs
Subtotal 54 hrs

V. REFERENCES

A. Books (Available in the library):

17. Adela, Jamorabo-Ruiz, Virginia Serraon-Claudio. Basic Nutrition for Filipinos, 5th edition 2002
18. Caudal, Ma. Lourdes. (2008) Basic Nutrition and Diet Therapy Textbook for Nursing Students Revised Ed.,C & E Publishing Inc.
19. Cataldo, DeBruyne, Whitney., Nutrition and Diet Therapy 6th edition. Wadsworth Publishing Company 2003
20. Claudio, V. and Ruiz, O. (2002). Basic Nutrition for Filipinos 5th Edition, Manila, Philippines, Meriam and Webster Bookstore.
21. Dellova, Carmela V. ABC’s of Nutrition and Diet Therapy for Healthcare Students and Practitioners, Valenzuela, Philippines: Mutya
Publishing 2006
22. Gordon, W. and Smith, A. (2009). Contemporary Nutrition 7th Editition, USA, Mc Graw-Hill Higher Education.
23. Grodner, M., Sara Long Roth, and Bonnie C. Walkingshaw (2007) Foundations and Clinical Applications of Nutrition: A Nursing approach.
Fourth edition. Mosby.
24. Peckenpaugh, Nancy.(2007) Nutrition Essentials and Diet Therapy10th ed.Elsevier (Singapore)Pte Ltd.
25. Rolfes, Sharon R., Kathryn Pinna, and Ellie Whitney (2008) Understanding Normal and Clinical Nutrition. Eight edition. Brooks Cole.
26. Sherer, Kim and Judi R. Davis (1994) Applied Nutrition and Diet Therapy for Nurses. W. B. Saunders Company.

509
 27. Tucker, Shiela (2010) Nutrition and Diet Therapy for Nurses. Prentice Hall.
28. Whitney, Ellie et. al. (2006) Nutrition for Health Care. 3rd Edition. Brooks Cole.

B. Internet Sources

8. http://www. Nutrition.bmj.com/nutrition/journal
9. http://www.dost.gov.ph
10. http://www.nnc.gov.ph
11. http://www.gov.ph/node/237
12. https://www.fnri.dost.gov.ph
13. https://nutrition.org/

C. Others (Journals, Magazines)

D. Other references of the teacher (not in the library):

1. Whitney, E.N.. (2002). Understanding Nutrition 9th Edition, Thomson asia Pte Ltd.
2. Phil. Nursing Law
3. 2012 National Nursing Core competency Standards
4. Relevant CHED Memos and Administrative Orders
5. CMO 15,s. 2017

VI. ABOUT THE TEACHER/ COURSE

Instructor’s Information (to be given during the class orientation)

Instructor’s consultation time (to be given during the class orientation) These should be included in the Online
classroom / Learning Materials
Classroom policies and (to be given during the class orientation) These should be included in the Online
instructions classroom / Learning Materials
Grading system (to be given during the class orientation; refer to Student Handbook)
Major requirement/s A powerpoint presentation with video presentation on Diet Therapy

510
 NAME POSITION SIGNATURE DATE
Preparers: JUVY E. CARAME Instructor
CESARIA A. YALONG Instructor
ALMIRA B. BULATAO Instructor
Noted JUVYLINE P. DIZON Head, AMS Section-Library
Reviewed and Recommending Approval EVANGELINE I. SOLIBA Program Chair-BSN
Approved HELEN D. ALALAG Dean, School of Nursing

511