Chapter 16 Nutrition and WellnessChapter XXChapt.docx

Chapter 16:
Nutrition and Wellness
Chapter XX:
Chapter Title
Learning Outcomes
Cognitive Domain
Note: AAMA/CAAHEP 2015 Standards are italicized.
1. Spell and define the key terms
2. Identify body systems
3. List major organs in each body system
4. Identify the anatomical location of major organs in each body
system
5. Describe the normal function of the digestive system
6. Analyze health care results as reported in graphs and/or
tables (BMI)
7. Describe dietary nutrients including carbohydrates, fats,
proteins, minerals, electrolytes, vitamins, fiber, and water.
Discuss the body’s basal metabolic rate and its importance in
weight management.
Copyright © 2016 Wolters Kluwer • All Rights Reserved
2

Learning Outcomes
8. Explain how to use the food pyramid and MyPlate guides to
promote healthy food choices
9. Read and explain the information on food labels
10. Identify the special dietary needs for weight control,
cardiovascular disease, and hypertension
11. Define the function of dietary supplements
12. List the components of physical fitness
13. Discuss suggestions for a healthy lifestyle
14. Explain the importance of disease prevention
15. List and describe the effects of the substances most
commonly abused
16. Recognize the dangers of substance abuse
3
Learning Outcomes (cont'd.)
Psychomotor Domain
1. Teach a patient how to read food labels (Procedure 16-1)
2. Document patient care accurately in the medical record
3. Develop a meal plan utilizing the basic principles of nutrition
(Procedure 16-2)
4. Instruct a patient according to the patient’s special dietary
needs (Procedure 16-2)
5. Coach patients appropriately considering a. cultural diversity,
b. developmental life stage, and c. communication barriers

4
Affective Domain
1. Incorporate critical thinking skills when performing patient
assessment
2. Incorporate critical thinking skills when performing patient
care
3. Show awareness of a patient’s concerns regarding dietary
changes
4. Protect the integrity of the medical record
5. Demonstrate a. empathy, b. active listening, and c. nonverbal
communication
6. Demonstrate the principles of self-boundaries
5
7. Demonstrate respect for individual diversity, including a.
gender, b. race, c. religion, d. age, e. economic status and f.
appearance
8. Explain to a patient the rationale for performance of a
procedure

6
ABHES Competencies
1. Comprehend and explain to the patient the importance of diet
and nutrition
2. Effectively convey and educate patients regarding the proper
diet and nutrition guidelines
3. Identify categories of patients that require special diets or
diet modifications
4. Document accurately
As a medical assistant, you should consider yourself a role
model for your patients. Throughout your career, you will have
many opportunities to teach patients the essentials of good
health and disease prevention by knowing how behaviors affect
short-term and long-term health.
Back to Learning Outcomes
Introduction
Together, diet and exercise offer important benefits for
overall health maintenance and disease prevention for people of
all ages.
Digestion and Metabolism
Digestion begins in mouth as enzymes in saliva start to break
down chewed food
Partly digested food passes through digestive tract, where
enzymes continue to break down food

In small intestines, process of absorption nutrients into
bloodstream
Nutrients taken to liver to be further broken down and filtered
to every cell in the body
Any nutrients not needed are eliminated from the body or stored
as fat for future energy use
metabolism: sum of chemical processes that result in growth,
energy production, elimination of waste, and body functions
performed as digested nutrients are distributed;
conversion of oxygen and calories to energy
Digestion consists of both the physical and chemical
breakdown of complex food into simpler substances that the
body can use for energy.
Digestion and Metabolism (cont’d.)
Catabolism creates energy
Measured in calories
Needed for cell growth
Needed for heat production
Nutrients reassembling to produce substances required by body
= anabolism
catabolism: the destructive phase of metabolism in which
larger molecules are converted into smaller molecules
The speed of these metabolic processes is particular to each
individual, which explains why some people seem to be able to
eat more and maintain a healthy weight, whereas others
consume the same amount of food and gain weight.

anabolism: the constructive phase of metabolism, when
smaller molecules are converted to large ones
Essentials of Nutrition
Making healthy food choices is best way to maintain a state of
wellness including homeostasis
Diet that includes all nutrients in adequate amounts increases
body’s ability to maintain wellness
homeostasis: maintaining a constant internal environment by
balancing positive and negative feedback
calories: a unit of heat content or energy. The amount of heat
necessary to raise 1 g of water from 14.5 to 15.5˚C (small
calorie)
Essentials of Nutrition (cont’d.)
Nutrients
Essential elements found in food include:
Vitamins and minerals
Carbohydrates
Proteins
Fiber
Fat
Micronutrients

Carbohydrates
Provide energy:
Found in grain, fruits, vegetables, legumes and sugar
Complex carbohydrates
Simple carbohydrates
Refined sugars:
High calories—no nutritious value
Carbohydrates are chemical substances that are broken
down by the body into simple sugars (glucose), which provide
energy to all cells of the body.
Proteins
Contain amino acids:
Provide energy
Build and repair tissue
Assist with antibody production
80 found in nature:
Human body needs 20
Body produces 11
Other 9 called essential amino acids
Some animal proteins provide all necessary
A combination of both types of proteins, complete and
incomplete, will ensure a proper amount of protein in the diet.
Essential amino acids: amino acids nutritionally required by an
organism and that must be supplied in its diet

Complete proteins:
Milk
Cheese
Eggs
Meat (includes fish and poultry)
Incomplete proteins:
Plants
Beans
Legumes
Nuts and seeds
Fats
Concentrated source of heat production and energy:
Provide essential fatty acids
Heart, skeletal muscle and other tissues derive energy
Composed of:
Carbon
Hydrogen
Oxygen
Fats have important functions:
Cushion and protect organs
Sustain temperature
Proper cell functioning
Fats, also known as lipids, serve as a concentrated source of
heat production and energy and provide essential fatty acids.

Vitamins
Organic substances that enhance breakdown of proteins,
carbohydrates, and fats
Used in formation of blood cells and hormones
Production of vital neurochemicals
Fat-soluble vitamins:
A, D, E, and K
Absorbed with foods that contain fat
Excess stored in body in liver, kidneys, and body fat
The consumption of additional fat-soluble vitamins should
be avoided because the body stores these vitamins, and an
excess can result in serious illness.
Water soluble:
Vitamins C
B-complex
Thiamin
Folic acid

Riboflavin
Niacin
Should be consumed daily
Excess excreted by body daily
Checkpoint Question
Based on what Jack Stone, the medical assistant at Great Falls
Medical Center, knows about vitamins, why is it important to
follow the recommended dosage of a fat-soluble vitamin?
Checkpoint Answer
Fat-soluble vitamins are usually absorbed with foods that
contain fat and are stored in the liver, kidneys, and body fat.
Minerals
Body uses minerals in differing amounts
Minerals required in small amounts = trace minerals:
Flourine
Zinc
Copper
Cobalt
Chromium

Minerals are inorganic substances used in the formation of
hard and soft body tissue, muscle contraction, nerve conduction,
and blood clotting.
minerals: inorganic substances (such as sodium, potassium,
calcium, phosphorus, magnesium, iron, iodine, fluorine,
zinc, copper, cobalt, and chromium) used in the formation
of hard and soft body tissue; necessary for muscle contraction,
nerve conduction, and blood clotting
Cholesterol
Produced by all animals
Contained in animal products:
Meat
Poultry
Seafood
Eggs
Dairy
Necessary for body functioning
National Cholesterol Education Program (NCEP) recommends
adult daily consumption of <300 mg of dietary cholesterol to
avoid excess cholesterol in bloodstream
Any excess cholesterol in the blood can result in plaque
buildup inside the blood vessels, eventually causing occlusion
or blockage of the blood vessel.

Lipoproteins
Substances composed of lipids and proteins that transport
cholesterol between the liver and arterial walls
Found only in body—not food
Amounts and types are indicators of risk of heart disease
Two types of lipoproteins:
Low-density lipoproteins (LDL):
Transports cholesterol from liver to walls of large and medium-
sized arteries
Excess LDL causes plaques
Impairs circulation
As LDL levels rise--risk of heart disease increases
LDL or “bad” cholesterol (above 160 mg/dL= increased risk;
optimal < 100 mg/dL )
High-density lipoproteins (HDL):
Carries cholesterol away from arterial walls to liver
Removes cholesterol from body
High levels of HDL
Reduction in risk of heart disease
Called “good” cholesterol
HDL level above 60 mg/dL lowers risk of heart disease; <40
mg/dL major heart disease risk factor

Checkpoint Question
A parent of one of the children seen at Great Falls Medical
Center ask Jack Stone, CMA(AAMA), about complete proteins
and where are they found. How should he answer this question?
Checkpoint Answer
A complete protein is one that contains all nine essential amino
acids. Complete proteins are found in milk, cheese, eggs, and
meats.
Fiber
Needed to help with elimination of waste
Vegetables, raw and cooked fruits, whole-grain foods contain
fiber
Some patients with chronic colitis, or ileitis may follow low
fiber diet
Also encouraged to avoid fatty foods, and eat lots of whole
grains
High fiber diet for constipation or to regulate bowel movements

Nutritional Guidelines
Multiple government agencies involved in establishing healthy
diet guidelines:
United States Department of Health and Human Services
(DHHS)
United States Department of Agriculture (USDA)
National Academy of Sciences
Food and Nutrition Board
Web sites provide additional information
MyPyramid and MyPlate Guidelines
USDA developed food guidance system—MyPyramid
Help people maintain healthy diets, exercise level
Developed in 2005
Includes five basic food groups plus “oils”:
Grains
Vegetables
Fruits
Milk
Meat and beans

Anatomy of MyPyramid.

MyPyramid guide based on a 2,000-calorie diet.
Rolled out updated in 2011 — MyPlate:
Does not give specific information about serving sizes
Reminder to Americans to choose reduced portions at meals
Include a plate of 50% fruits and vegetables
Drink fat-free or 1% milk
Eat whole grains
Decrease dietary sodium by comparing and choosing those with
low numbers
Drink water instead of sugary drinks

MyPlate icon.
Grains
USDA recommends whole grains for half of daily servings
Entire grain kernel that contains fiber, vitamins, carbohydrates,
proteins and antioxidants
When selecting food groups—look for:
Whole wheat
Bulgur
Whole-grain corn
Oatmeal
Whole oats
Wild rice at beginning of list
Check for high percentage of daily fiber
Foods in the grain food group include bread, cereal,
oatmeal, crackers, rice, and
pasta.

Substitute whole wheat flour when baking
Choose whole-grain snacks — popcorn or baked tortilla chips
Eat whole grain cereals — muesli or toasted oat
Vegetables
Five categories:
Dark green
Orange
Dry beans and peas
Starchy
Other
The key to choosing foods within this group is to select a
variety of
vegetables from different categories.
Eat fresh, seasonal:
Processed foods contain sauces, seasoning adding sodium and
fat
Look for vegetables without added salt
Choose foods with high levels of potassium
Eat salad daily — minimal dressing

Prepare vegetable main dishes — soups or stews
Fruits
Includes:
Fresh
Fruit juice
Frozen, dried and canned fruit
Get majority of servings from whole fruit—not juice:
Whole fruit contains fiber
Check labels for items that do not contain added sugar:
Fruit stored in 100% juice or water—not syrup
Eat a wide variety of fruits for maximum nutritional benefit:
Add fresh fruit to cereal
Drink 100% orange or grapefruit juice
Snack on cut-up or dried fruit
Substitute applesauce for portion of oil in recipes
Milk
Includes milk products that retain calcium content:
Butter and cream cheese do not

Important to select low-fat or nonfat:
Nonfat or low-snack choices:
Pudding
Yogurt
Lactose free options available
Also referred to as the “milk, yogurt, and cheese group,”
this food group
includes all milk and milk products that retain their calcium
content.
Meat and Beans
High fat and cholesterol content make varying food choices
important
Select variety for greatest nutritional benefit:
Example—sunflower seeds and almonds high in vitamin E
Salmon and trout contain omega-3 fatty acids
Eggs, beef, poultry, pork—good sources of proteins
Vegetarians should alternate protein sources
The meat and beans group includes all foods made from
meat, poultry, eggs, dry beans, peas, nuts, and seeds.
Select lean cuts of beef:
Round steaks
Roast

Top loin sirloin
Buy 90% or greater lean ground beef
Skinless chicken or turkey
Prepare without adding fat
Prepare meatless main dishes
Eat fish more often than meat or poultry
Substitute nuts in dishes containing meat or poultry
Oils
Fats that are liquid form at room temperatures:
Vegetable oils
Natural plant and fish sources
Recommended daily servings are small—several teaspoons
Most important guideline in this category—avoid exceeding
recommended amounts
Most people consume enough oils in the foods they eat:
Olives and fish
Salad dressing
Nuts
Fats that are solid at room temperature, such as butter,
shortening, and beef or chicken fat, are not considered oils.
Checkpoint Question
Who publishes the MyPyramid and MyPlate food guidance
systems and why?

Checkpoint Answer
The USDA developed MyPyramid food guidance system in
1992. In 2011, they provided a new, simplified visual reference
known as MyPlate. The goal is to help people maintain a
healthy diet and sufficient exercise levels.
Understanding Food Labels
Most manufacturers except meat and poultry
Required to list nutritional information on package
Food and Drug administration regulates mandatory food
labeling
Includes measurements of:
Calories and fat content
Cholesterol and sodium
Carbohydrates and dietary fiber
Protein and vitamins
Calcium and other nutrients
The Nutritional Labeling and Education Act was passed in
1990 to help consumers identify nutritional content in food
products.

Food label gives amount in one serving size:
Percentage of total daily intake listed on right
A DV (daily value) of 0% is listed for those things that should
be kept to minimum
Sample food label.
Checkpoint Question
Jack Stone explains to a parent that food labels contain
nutritional information about the food or product. What
information is listed on the right side of a food label?

Checkpoint Answer
The right side of the food label gives the percentage of the total
daily intake recommended that is contained in one serving.
Therapeutic Nutrition
Each part of lifespan requires different nutritional needs
Patient’s medical condition or situation will require:
Diet restrictions
Special foods
Medical assistant will teach patient how to follow physician
ordered diet:
Example — chronic conditions such as diabetes or heart disease
Regardless of the reason for the therapeutic diet, the
purposes include facilitating the healing process, promoting
healthy weight, assisting with chewing and swallowing, and/or
influencing the components found in blood, such as cholesterol
or blood glucose levels.
Checkpoint Question

List four possible reasons for a patient’s need for a special
therapeutic diet.
Checkpoint Question
The purposes of therapeutic diets are to:
Facilitate the healing process
Promote healthy weight
Assist with chewing and swallowing
Influence the components found in blood such as cholesterol
Wellness
Physical Fitness
Healthy and balanced diet and regular exercise required to
maintain physical fitness
Physical movement helps:
Maintain healthy musculoskeletal system
Normal weight
Positive mental attitude
Improves immune system
Causes production of endorphins
That tend to produce euphoria
Physical fitness is characterized by endurance, flexibility,
and strength.
Endorphins: chemical that are often called the body’s ” natural
painkillers” that tend to produce a euphoria or “good feeling.”
release often caused by physical movement or exercise

euphoria: a feeling of well-being
Wellness (cont’d.)
Components of Physical Fitness
Cardiovascular health and endurance — aerobic activities
Flexibility — stretching exercise
Bone and muscle strength:
Exercise for strong bones
Weight lifting and resistance training increase muscle strength
and endurance
Checkpoint Question
What types of physical activities promote cardiovascular health
and endurance?
Checkpoint Answer
Aerobic activities, such as running, bike riding, rowing, and
swimming, can improve cardiovascular system functioning and
endurance.

Weight Management
Rate of obesity in U.S. has doubled in past 20 years:
1/3 adult population obese
17% children and adolescents
Obesity rate doubled in children
Tripled in adolescents
Excess body fat can result in a higher risk of certain health
conditions, such as hypertension, heart disease, type 2 diabetes,
gallbladder disease, respiratory disorders, and certain kinds of
cancers.
When helping overweight children and adolescents:
Goal is to slow unhealthy weight gain
Maintain normal growth and development
Eating more nutritious, lower-calorie foods
Increasing physical activity
Even small amount of weight loss beneficial
Physiologic Issues
Reduce and maintain healthy weight—move more, eat less
Three ways body expends energy:
Basal metabolic rate
Physical activity

Thermic effect of food
Reducing and maintaining a healthy weight depends on a
familiar formula––increased physical activity + taking in fewer
calories = reduction in body weight.
Basal Metabolic Rate
Approximately 60% to 70% of the body’s energy is expended
through BMR basic activities:
Respiration
Heartbeat
Maintaining body temperature
An individual’s BMR refers to the amount of energy used in
a unit of time to maintain vital functions by a fasting, resting
subject.
basal metabolic rate (BMR): the amount of energy used in a
unit of time to maintain vital functions by a fasting, resting
subject
Level of Physical Activity
20% to 30% of body’s total energy expenditure
Calories
“Thermic effect” = amount of energy needed to digest food
Four caloric sources include:
Carbohydrates

Fats
Proteins
Alcohol
Determine daily caloric requirement
Take in fewer calories than need = lose weight
Take in more calories than need = gain weight
To calculate needs:
Not physically active: weight (lbs) x 14 = estimated
calories/day
Moderately active: weight (lbs) x 17 = estimated calories/day
Active individuals: weight (lbs) x 20 = estimated calories/day
Body Mass Index
Adults over age 20 years —condition of being overweight or
obese based on their BMI level only
For children, it is age, gender and BMI
Limitations:
Can overestimate body fat in muscular person
Underestimate body fat in person with decreased muscle mass
Growth charts available to track BMI
With the increased incidence of obesity, physicians are
turning to BMI for assessing patients’ risk for obesity.
body mass index (BMI): a measurement of an individual’s ratio

of fat to lean body mass. It is calculated by using the following
formula: [weight (pounds) ÷ height (inches)2] ×
703. A BMI over 30 is considered obese
Body Mass Index (BMI) Table.

Checkpoint Question
A patient asks Jack Stone what is meant by BMR and how is
this different from the BMI. How should Jack answer this
question?
Checkpoint Answer
The BMR is the basal metabolic rate and refers to the rate at
which the body performs the basic functions such as heart beat,
respiration, and maintaining body temperature. The BMI is a
measurement of an individual’s ratio of fat to lean body mass.
Sociologic and Psychological Issues
Food has become social entertainment
Emotional eating
To stop the growing epidemic of obesity:
Make lifestyle changes
Make better food choices
Be more active
Starts with changing bad habits
Be an example for patients
Learn why people eat and how food plays a part in our social
and psychological well-being

Checkpoint Question
What are the ill effects of excess body fat?
Checkpoint Answer
Excess body fat can result in a higher risk of certain health
conditions, such as hypertension, heart disease, type 2 diabetes,
gallbladder disease, respiratory disorders, and certain kinds of
cancers.
Staying Well
Maintain proper body weight and nutrition
Necessary for good health
Difficult to follow rigid diet
Confining exercise regimen
Subtle changes can improve health
Eating more slowly, sleeping more, and taking the stairs
instead of an elevator are just a few of the things that you can
do every day to make you feel
better.
Stress

Certain amount needed to function
Too much harmful
High stress levels cause:
Headaches
Leg cramps
Keeps list of suggestions in patient education area
Talk to patients about stress levels
Stress reduction techniques:
Positive thinking
30 minutes daily doing activity that is enjoyable
Calm thought when angry
Know limits
Get a good night’s sleep
High levels of stress can contribute to health problems in
predisposed individuals
Stress-reducing techniques include:
Relaxation exercises
Guided imagery
Medication
predisposed: genetically programmed
guided imagery: self-relaxation technique, sitting comfortably
while imagining a quiet, peaceful place

Pollution
Can negatively affect health
Respiratory problems, general discomfort
Damage to ozone layer:
Increased instances of skin cancer, eye damage
To minimize harmful effects:
Avoid secondhand smoke
Heavy traffic
The Clean Air Act of 1990 is a federal law that limits the
amounts of certain pollutants that may be released into the air in
the United States.
Seat Belt Use and Airbags
22,000 died in 2012 as a result of motor vehicle accidents
Proper seatbelt use can prevent up to half:
Prevent “2nd crash”
Should fit properly
Lap + shoulder restraint greatest protection
Air bags help with frontal impact crashes
Are NOT seat belt substitute
Air bags + lap belts and shoulder restraints greatly reduce risk
of head injury
More than 3,000 were killed in U.S. in 2012
Distraction includes:

Visual — taking eyes off of the road
Manual — taking hands off steering wheel
Cognitive — taking mind off task of driving
Sending text messages = one of most dangerous activities
because it involves all three types of distractions
Talking on cell phones
Eating or drinking
Using PDA or GPS
Watching video
Changing radio station, CD, or MP3 player
Checkpoint Question
What human health effects are thought to be caused by air
pollution?
Checkpoint Answer
Air pollution can result in several health problems including
respiratory problems, burning eyes or irritated throats, birth
defects, certain cancers, and brain damage.
Dental Health
Important part of person’s overall health

Flossing important
Keeping teeth in good repair promotes better health
Unattended cavities have a profound effect on the gums as
well as on the sinuses and the throat.
Positive Mental Outlook
Cannot control certain events—can control reactions to them
Look at bright side of things
Many instances of terminally ill patient who fare better due to
positive outlook
Pay attention to positive—downplay negative
Having a positive mental outlook can benefit your health
and well-being and possibly even prolong life.
Genetics
Good genes can be negated by bad health habits
Infectious Disease Prevention
Body protects a healthy person from most germs or pathogens
Can control how many germs enter body — use following
precautions:
Wearing PPE when handling body fluids
Use safe practices in kitchen and bathroom
Preventing spread of infection takes care and attention

Studies have shown that genetics play a large role in what
diseases a person contracts, but patients should not use this as
an excuse to ignore risk factors.
Proper handwashing is known to be the best defense against
illness.
Substance Abuse
Excessive use of and dependency on drugs
Some are legal:
Alcohol
Nicotine
Others illegal:
Marijuana
Cocaine
Should seek help from trained specialist or counselors
Information available from various national organizations
Because substance abuse can be highly detrimental to your
patients’ health, it is important that you have information
available about substance abuse available for patients who may
have a substance abuse problem.
Alcohol
Most commonly abused legal substances

Overconsumption can lead to health problems:
High blood pressure
Cardiomyopathy
Fetal alcohol syndrome
Liver damage
Some can drink in moderation, others prone to addiction
Considered mind-altering substance—depressant
Effects:
Lack of coordination
Slurred speech
Blurred vision
Long term effects include:
Cirrhosis of liver
Certain cancers
Increased risk of stroke
Nutritional deficiencies
The effects of alcohol intoxication include a lack of
coordination, slurred speech, blurred vision, and impaired brain
function.
Drugs
Marijuana and hashish:
Impair short-term memory and comprehension

Increase heart rate and appetite
Long-term used develop psychological dependence
Inhaled as unfiltered smoke-users take in cancer causing agents
Drugs
Cocaine and crack:
Extremely addictive
Stimulate central nervous system
Psychological and physical dependency
Can cause sudden death by disrupting brain’s control of the
heart and respiration
Side effects:
Dilated pupils
Increase pulse rate
Elevated blood pressure
Insomnia
Loss of appetite
Paranoia
Seizures

Stimulants and amphetamines
Same effect as cocaine
Increased heart rate and blood pressure
Symptoms
Dizziness
Sleeplessness
Anxiety
Psychosis
Hallucinations
Paranoia
Physical collapse
Long term effects
Hypertension, heart disease, stroke, renal and liver failure
Depressants and barbiturates
Physical and psychologic dependency
Can lead to respiratory depression, coma and death—
particularly with alcohol
Withdrawal can lead to restlessness, insomnia, convulsions and
death
Hallucinogens all interrupt brain message that control intellect
and instincts
Large doses can produce:
Seizures and coma
Heart and lung failure

Hallucinogens
LSD, PCP or “angel dust”, mescaline, peyote
Interrupt brain messages that control the intellect and keep
instincts in check
Large doses can produce:
Seizures
Coma
Heart and lung failure
Chronic users complain of:
Persistent memory problems
Speech difficulties
Lack of pain sensors may result in severe self-inflicted injuries
Narcotics are addictive
Heroin, cocaine, morphine, opium
Produce euphoria, drowsiness and blood pressure and pulse
fluctuations
Overdose can lead to seizures, coma, cardiac arrest, death
Any of these substances can impair a fetus’s health:
Fetal alcohol syndrome
“Crack baby”
Provide positive reinforcement and offer services to patients for
cessation programs
The most important role of the medical assistant in educating
patients about any type of substance abuse is to be supportive

and have a list of community resources available to assist
patients who need them.
Smoking Cessation
Health risks well documented:
Nicotine reaches the brain in six seconds
Damages the blood vessels
Decreases heart strength
Associated with many cancers
Withdrawal symptoms include:
Anxiety
Progressive restlessness
Irritability and sleep disturbances
Nicotine is highly addictive whether ingested by inhaling or
chewing.

Chapter 16 Nutrition and WellnessChapter XXChapt.docx

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