The document outlines a course on human nutrition and its impact on intellectual development, emphasizing the importance of a balanced diet for growth and health management. It covers topics including metabolism, diseases related to nutritional deficiencies, weight management, and the effects of diet on conditions like cancer and HIV. Additionally, it discusses factors influencing food choices and the principles of diet planning, aiming to equip students with essential knowledge for effective nutrition in health promotion.

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HUMAN NUTRITION AND INTELLECTUAL DEVELOPMENT
Purpose
The course will enable the student to learn about the importance of a balanced diet in
growth and development of a person. The student will acquire knowledge on the
management of medical and surgical conditions in relationship to nutrition and health
promotion.
Learning Outcomes
At the end of the course the student will be able to:
1. Define nutrition and health in relationship to the body,
2. Describe the process of metabolism and the effect on body functions;
3. Explain the composition of a balanced diet and its importance on the body,
4. Discuss the diseases associated with nutrition deficiency and the effect on health,
5. Explain medical and surgical conditions associated with nutritional effects,
6. Discuss nutritional services and nutrition in health promotion of an individual
Content
Definition of nutrition, nutrients, dietetics and balanced diet. Food: classes, source and
nutrient content. Biochemical structures, functions and energy: carbohydrates, proteins
and lipids. Vitamins and minerals. Nutritional assessment. Enteral nutrition in medical
care: oral use of enteral formulas, tube feedings, feeding routes, formula selection.
Parenteral nutrition support: indications for parenteral support, Parenteral solutions:
parenteral nutrients, formula preparation. Administering parenteral nutrition: insertion
and care of intravenous catheters, administration of parenteral solutions, managing
metabolic complications, discontinuing intravenous feedings. Anthropometric
measurements: Weight management: overweight and underweight: overweight; fat cell
development, fat cell metabolism, set-point theory. BMI and causes of obesity; genetics
and environment. Problems of obesity; health risks, perceptions and prejudices,

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dangerous interventions. Aggressive treatment of obesity; drugs and surgery. Weight
loss strategies; eating plans, physical activity, behavior and attitude. Nutrition and its
effect on cancer and HIV infection: medical nutrition therapy. Manifestations of
nutritional and metabolic disorders: physical, neurological psychological and psychiatric.
Nutritional supplementation and disease management. Nutrition for special groups,
nutrition deficient conditions such kwashiokor, marasmus and beriberi.
Learning -Teaching Strategies
Lectures, group discussions, audio-visual aids.
Assessments
End of trimester written examination and 3CAs.
Required Resources
Roth, A.R. & Townsend, C.F. (2003). Nutrition and Diet Therapy (8th
ed). Thompson
Delmar Learning. ISBN: 0766835677.

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Factors influencing food choices
1. Personal preferences- People choose food because of the taste of the food.They
like certain flavors
2. Habit – Eating a familiar food and not having to make any decisions can be
comforting
3. Social interactions- Meals are social events and sharing food is part of hospitality.
Social customs almost compel people to accept food or drink offered by a host or
shared by a group
4. Ethnic heritage or traditions- people eat food they grew up eating. Every country,
region and locality as its own typical foods and ways of combining them into
meals.
5. Availability, convenience and Economy- People eat foods that accessible, quick
and easy to prepare
6. Positive and negative associations- People tend to like foods with happy
associations- such as hots dogs at ball games or cake and ice cream at birth day
parties . By the same token, people can attach intense and unalterable dislikes to
foods that they ate when they felt sick or forced on them when they were hungry.
7. Emotional confort- Some people cannot eat when they are emotionally upset.
Others may eat in response to a variety of emotional stimuli
8. Values- Food choices may reflect peoples religious beliefs, political views or
environmental concerns
9. Body weight and image- People select certain foods and supplements that they
believe will improve their physical appearance and avoid those that might be
detrimental
10. Nutrition and health – Many consumers make food choices that are beneficial to
the health. Manufactures and cooks have responded to scientific findings linking
nutrition to health
THE NUTRIENTS
Foods provide nutrients – substances that support growth and maintenance , and repairs
of the body ‘s tissues . The six classes are ;

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Carbohydrates
Lipids
Proteins
Vitamins
Mineral
Water
Foods rich in the energy –yielding nutrients (carbohydrates, fats and proteins), provide
the major materials for building the body’s use or storage . Energy is measured in
kcalories. Vitamins , minerals and water facilitate a number of activities in the body.
Without exaggeration, nutrients provide the physical and metabolic basis for nearly all
that we are and all that we do.
THE SCIENCE OF NUTRITION
The science of nutrition is the study of the nutrients and other substances in foods and the
body’s handling of them. Its foundation depends on several other science , including
biology and biochemistry.
Nutrition research
1.Epidemiological studies
a) Cross sectional
b) Case control
c) Cohort
2. Laboratory based studies
3. Human interventions or clinical trials
Type of research Strengths Weakness
Epidemiological studies
Determine the incidence and
distribution of diseases in a
population
Can narrow down the list of
possible causes
Can raise the questions to
pursue through other types
of studies
Cannot control variables
that may influence the
development or the
prevention of a disease
Cannot prove cause and
effect
Laboratory based studies Can control conditions Cannot apply results from

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Explore the effect of a
specific variable on a tissue
, cell or molecule . They
often conducted in the test
tubes (in vitro ) or on
animals
Can determine the effects
of the a variable
test tubes or animals to
human beings
Human intervention or
clinical trials involve
human beings who follow a
specified regimen
Can control conditions
Can apply findings to some
groups of human beings
Cannot generalize findings
to all human beings
Cannot use certain
treatments for clinical or
ethical reasons
Nutrition Assessment
• Obtaining, verifying and interpreting data in order to identify existing or potential
problems
• Judging a person’s nutritional status, situation, and vulnerability to poor nutrition
by taking measurements and/or asking questions.
• It leads to problem diagnosis and helps to design appropriate plan of care or
interventions.
• It generates the information needed for a comprehensive approach to nutrition
intervention
• Based on results, patients can be referred for specialized care if/when necessary.
Methods of Assessment
1. Anthropometric measurements
2. Biochemical (Laboratory) assessments
3. Clinical assessment (signs of deficiencies, Physical)
4. Historical Information - Dietary ( 24 hour recall, food diary,)Economic and social
status, drug use
This is the measurement of body size, weight and proportions. Information from the
measurements is then used to calculate indicators of nutritional status. Anthropometric
measurements include:

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– Weight/Height
– Circumferences – waist, hip, MUAC, head
– Skin fold thickness.
The following indicators of nutrition status can be computed from the above
measurement
 Weight (% change over time)
 BMI (for adults) and weight-for-height/age (for children)
 Waist/hip ratio
 Body surface area
Measurement taken periodically and compared with previous measurements
reveal patterns and indicate trends in a person’s overall nutrition status , but they
provide little information about specific nutrients
Biochemical Assessment
Why is biochemical assessment needed?
Complements anthropometric assessments by:
– Better informing decisions for management
– Providing clear grading of patient nutritional status
Situations that triggers biochemical assessments
• Clients on certain medications
• Clients experiencing or vulnerable to certain symptoms
• Clients diagnosed with certain infections
Clients with existing medical conditions (e.g. MDR-TB, HIV, diabetes,
hypertension, anaemia
Importance
Detects toxicity, imbalances and deficiency developing. Blood samples and urine are
used. Results are compared with the normal values. Labarotary analysis uncover early
signs of malnutrition. Values for references include;

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COMPONENT GENDER VALUE
Haemoglobin Male:
Female:
13-18g/dl.
11.5-16.5g/d
Sodium Male & Female 135-145mm
Potassium Male & Female 3.5-5.0mmo
Chloride ” 96-106mmo
Ammonium Male:
Female:
34-58mmol/
17-51mmol/
Urea Male & Female 2.5-7.0mmo
Creatinine ” 60-130mmo
Total Proteins ” 2.12-2.62mm

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Albumin ” 35-50g/litre.
Globulin ” 20-40g/litre.
Calcium ” 2.2-2.64mm
8.8-10.6mg/
Physical/ clinical assessment
This involves physical appearance, muscle and fat wasting,, swallow function, appetite
and effect .
Body part or system Signs/Symptoms Possible deficiency
Hair Lackluster, Thinness, sparseness, dryness,
dyspigentation, easy pluckability, texture
change
Proteins, protein-energ
biotin.
Face Paleness, Moon face (swollen), Greasy
scaling around nostrils (nasolabial)
Riboflavin, Niacin, Pyri
Eyes Pale white eyes and eyelid lining (pale
conjunctivae), Redness and fissuring of
eyelid corners dullness and dryness
(corneal or conjunctival xerosis), redness,
lesions of conjunctivae (Bitot’s spots)
Iron, folate, vitamin A, C
Mouth Angular redness, lesions or scars at the
corners of the mouth (stomatitis), swelling
and redness of lips and mouth (cheilosis)
Riboflavin Niacin pyrid

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Tongue Smoothness, slickness (filiform papillary
atrophy), beefiness, redness, pain
(glossitis), swollen, magenta color
Niacin, pyridoxine, ribo
folate, iron
Historical Information
Dietary history
Obtaining a diet history involves interviewing the client on the past and/or current food
practices. Measuring/estimating adequacy of the food consumed (variety, amount,
frequency, with whom, sources of food, preparation)
 Total energy and nutrient intake
 Macro- and micronutrient intake
 Water and fluid intake
 Eating habits
 Drug and alcohol intake
 Food preparation methods
 Factors hindering food intake
Tools used to collect dietary history
1. Food record diaries
2. 24 hour recall
3. Food frequency
4. Diet diversity
Appetite assessment
Total food consumption
Will also provide an insight into any relevant past illnesses or circumstances that may
directly or indirectly impact on the client’s nutrition needs and health status.
Important historical data includes;
• Medical history
• Drug history
Diet and Health
Diet has always played a vital role in supporting health. Early nutrition researches
focused on identifying nutrients in food that would prevent such common diseases. With

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this knowledge, developing countries have been successful in protecting against nutrient
deficiency diseases. More recently nutrition has focused on chronic diseases associated
with energy and nutrient excesses.
In summary , within a range set by genetics , a persons choice of diet influences long
term health. Diet has no influence on the some diseases, but is linked to others. Personal
life choices, such as engaging in physical activity and using tobacco or alcohol, also
affect health for the better or worse
PLANNING A HEALTHY DIET
Principles of Diet planning
a) Adequancy- the diet provides sufficient energy and enough of all nutrients to meet
the needs of the healthy people
b) Balance- The art of balancing the diet involves consuming enough but not too
much of each type of food
c) Kcalorie (Energy ) control- The amount of energy coming into the body from
foods should balance with the amount of energy being used by the body to sustain
its metabolic and physical activities
d) Nutrient density- Select foods that deliver the most nutrients for the least food
energy.
e) Moderation – Foods rich in fat and sugar provide enjoyment and energy but
relatively few nutrients. In addition , they promote weight gain when eaten in
excess. A person practicing moderation would eat such foods only on occasion
and would regularly select foods low in fatas and sugar
f) Variety- People should select food from each of the food groups daily and vary
their choices within each food groups fr om day to day. This is because within the
same food groups contain different arrays of nutrients, no food is guaranteed
entirely free of substances that in excess could be harmful and finally , as the
adage goes, variety is the spice of life
In summary, A well planned diet delivers adequate nutrients , a balanced array of
nutrients and an appropriate amount of energy. It is based on nutrient dense foods,
moderate in substances that can be detrimental to health and varied in its selections.

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FOOD CLASSES
Carbohydrates
Protein
Fats
Minerals
Vitamins
MACRO NUTRIENTS
Every few years, carbohydrates are vilified as public enemy number one and are accused
of being the root of obesity, diabetes, heart disease and more. Carb-bashers shun yogurt
and fruit and fill up on bun-less cheeseburgers. Instead of beans, they eat bacon. They
dine on the tops of pizza and toss the crusts into the trash. They so vehemently avoid
carbs and spout off a list of their evils that they may have you fearing your food. Rest
assured, you can and should eat carbohydrates. In fact, much of the world relies on
carbohydrates as their major source of energy. Rice, for instance, is a staple in Southeast
Asia. The carbohydrate-rich potato was so important to the people of Ireland that when
the blight devastated the potato crop in the mid 1800s, much of the population was wiped
out.
What are Carbohydrates?
The basic structure of carbohydrates is a sugar molecule, and they are classified by how
many sugar molecules they contain.
• Simple carbs: Simple carbohydrates, usually referred to as sugars, are naturally
present in fruit, milk and other unprocessed foods. Plant carbohydrates can be
refined into table sugar and syrups, which are then added to foods such as sodas,
desserts, sweetened yogurts and more. Simple carbohydrates may be single sugar

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molecules called monosaccharides or two monosaccharides joined together called
disaccharides. Glucose, a monosaccharide, is the most abundant sugar molecule
and is the preferred energy source for the brain. It is a part of all disaccharides and
the only component of polysaccharides. Fructose is another common
monosaccharide. Two common disaccharides in food are sucrose, common table
sugar, and lactose, the source of frequent gas and bloating that some experience
from drinking milk.
• Complex carbs: Complex carbohydrates are any that contain more than two
sugar molecules. Short chains are called oligosaccharides. Chains of more than
ten monosaccharides linked together are called polysaccharides. They may be
hundreds and even thousands of glucose molecules long. The way glucose
molecules link together makes them digestible (starch) or non-digestible (fiber).
Polysaccharides include the following.
o Starch is a series of long chains of bound glucose molecules. It’s the
storage form of glucose for grains, tubers and legumes and is used during
the plant’s growth and reproduction.
o Fiber is also long chains of glucose molecules, but they are bound in a
way we cannot digest.
o Glycogen is the storage form of glucose in humans and other animals. It’s
not a dietary source of carbohydrate because it is quickly broken down
after an animal is slaughtered.
Carbohydrates in the Body
Whether they’re from a doughy bagel, a sugary cola or a fiber-rich apple, carbohydrates’
primary job is to provide your body with energy. From each of these sources and others,
carbohydrates provide you with 4 kcals/gram.
• Carbs are fuel. Glucose is the primary fuel for most of your cells and is the
preferred energy for the brain and nervous system, the red blood cells and the
placenta and fetus. Once glucose enters the cell, a series of metabolic reactions

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convert it to carbon dioxide, water and ATP (Adenosine Tri-Phosphate), the
energy currency of the cell. If you have more available glucose than your body
needs for energy, you will store glucose as glycogen (glycogenesis) in your liver
and skeletal muscle. When your blood glucose drops, as it does when you’re
sleeping or fasting, the liver will break down glycogen (glycogenolysis) and
release glucose into your blood. Muscle glycogen fuels your activity. The body
can store just a limited amount of glucose, so when the glycogen stores are full,
extra glucose is stored as fat and can be used as energy when needed.
• Carbs spare protein. If you go without eating for an extended period or simply
consume too little carbohydrate, your glycogen stores will quickly deplete. Your
body will grab protein from your diet (if available), skeletal muscles and organs
and convert its amino acids into glucose (gluconeogenesis) for energy and to
maintain normal blood glucose levels. This can cause muscle loss, problems with
immunity and other functions of proteins in the body. That’s how critical it is to
maintain normal blood glucose levels to feed parts of your body and your brain.
• Carbs prevent ketosis. Even when fat is used for fuel, the cells need a bit of
carbohydrate to completely break it down. Otherwise, the liver produces ketone
bodies, which can eventually build up to unsafe levels in the blood causing a
condition called ketosis. If you ever noticed the smell of acetone or nail polish
remover on the breath of a low-carb dieter, you have smelled the effects of
ketosis. Ketosis can also cause the blood to become too acidic and the body to
become dehydrated.
•
Carbohydrates in the Diet
Carbohydrates, protein and fats are macronutrients, meaning the body requires them in
relatively large amounts for normal functioning. The Recommended Dietary Allowance
(RDA) for carbohydrates for children and adults is 130 grams and is based on the average
minimum amount of glucose used by the brain.[1]
The Acceptable Macronutrient
Distribution Range (AMDR) for carbohydrates is 45–65%. If, for instance, you ate 1600

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kcals per day, the acceptable carbohydrate intake ranges from 180 grams to 260 grams.
Many people label complex carbs as good and sugars as bad, but the carbohydrate story is
much more complex than that. Both types yield glucose through digestion or metabolism;
both work to maintain your blood glucose; both provide the same number of calories; and
both protect your body from protein breakdown and ketosis. The nutrient-density of our
food choices is far more critical. For example, fresh cherries provide ample sugars, and
saltine crackers provide just complex carbs. Few would argue that highly processed
crackers are more nutritious than fresh cherries.
• Added Sugars: Americans eat only 42% of the recommended amount of fruit and
59% of the recommended vegetable amount. We eat only 15% of the
recommended servings of whole grains, but 200% of the recommended servings
of refined grains.[2]
Americans over-consume added-sugars, which make up 16%
of the total calories in the American diet. Nearly 60% of added sugars come from
soda, energy drinks, sports drinks, fruit drinks and grain-based desserts like cakes,
cookies and brownies.[3]
The problem with added sugars is that they do not come
packaged with an abundance of nutrients like a piece of fruit and a glass of milk
do. For this reason, many people call them empty calories.
• Glycemic Index: Sometimes people look to the glycemic index (GI) to evaluate
the healthfulness of carbohydrate-rich foods, but this too oversimplifies good
nutrition. The GI ranks carbohydrate-containing foods from 0 to 100. This score
indicates the increase in blood glucose from a single food containing 50 grams of
carbohydrate compared to 50 grams of pure glucose, which has a GI score of 100.
Foods that are slowly digested and absorbed - like apples and some bran cereals -
trickle glucose into your bloodstream and have low GI scores. High GI foods like
white bread and cornflakes are quickly digested and absorbed, flooding the blood
with glucose. Research regarding the GI is mixed; some studies suggest that diets
based on low GI foods are linked to lower risks of diabetes, obesity and heart
disease, but other studies fail to show such a link.

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Many factors influence a food’s GI score, including:
o The degree of ripeness of a piece of fruit (the riper the fruit, the higher the
score)
o The amount and type of processing a food has undergone
o Whether the food is eaten raw or cooked
o The presence of fat, vinegar or other acids
All of these factors complicate the usefulness of the GI. Additionally, many high-
calorie, low-nutrient foods such as some candy bars and ice creams have desirable
GI scores, while more nutritious foods like dates and baked potatoes have high
scores. It’s important to recognize that the healthfulness of a food depends largely
on its nutrient density, not its type of carbohydrate or its GI score.
Proponents of low-carbohydrate diets are incensed by the RDA and AMDR for
carbohydrates. “Nutrition experts are trying to kill us,” they argue and claim that
carbohydrates have made us overweight. However, research supports that diets of
a wide range of macronutrient proportions facilitate a healthy weight, allow
weight loss and prevent weight regain. The critical factor is reducing the calorie
content of the diet long-term[4][5]
• Fiber Needs: If we shunned all carbohydrates or if we severely restricted them,
we would not be able to meet our fiber needs or get ample phytochemicals,
naturally occurring compounds that protect the plant from infection and us from
chronic disease. The hues, aromas and flavors of the plant suggest that it contains
phytochemicals. Scientists have learned of thousands of them with names like
lycopene, lutein and indole-3-carbinol. Among other things, phytochemicals
appear to stimulate the immune system, slow the rate at which cancer cells grow,
and prevent damage to DNA.
All naturally fiber-rich foods are also rich in carbohydrates. The recommended
intake for fiber is 38 grams per day for men and 25 grams per day for women. The

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usual fiber intake among Americans, however, is woefully lacking at only 15
grams daily. Perhaps best known for its role in keeping the bowels regular, dietary
fiber has more to brag about. Individuals with high fiber intakes appear to have
lower risks of coronary heart disease, stroke, hypertension, diabetes and obesity.[6]
Fiber-rich foods are protective against colorectal cancer[7]
, and increasing fiber
intakes improves gastroesophageal reflux disease and hemorrhoids.[6]
Some fibers
also lower blood cholesterol and glucose levels. Additionally, fibers are food for
the normal (healthy) bacteria that reside in your gut and provide nutrients and
other health benefits. To boost your fiber intake, eat fruits, vegetables, whole
grains and beans frequently.
Fiber Content of Selected Foods
• Beans (navy, pinto, black, lima etc), 1/2 cup: 6.2 – 9.6 g
• 100% Bran cereal, 1/3 cup: 9.1 g
• Pear, medium: 5.5 g
• Whole-wheat English muffin, 1: 4.4 g
• Raspberries, 1/2 cup: 4.0 g
• Sweet potato with skin, medium: 3.8 g
• Apple with skin, 1 medium: 3.6 g
• Orange, medium: 3.1 g
• Potato with skin, 1 medium: 3.0 g
• Broccoli, cooked, 1/2 cup: 2.6 – 2.8 g
Carbohydrates are critical sources of energy for several body systems. Nourish your body
and help shield yourself from chronic disease by getting most of your carbohydrates from
fruits, whole grains, legumes, milk and yogurt. Limit added sugars and heavily processed
grains.

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Proteins
Understanding Proteins
What’s for dinner? In the U.S, this question is usually answered with some type of meat
like pot roast, chicken, salmon or meatloaf. Meat, because it’s rich in protein, is usually
central to the meal, and vegetables and grains are frequently the afterthought. This may
give the impression that a meal isn’t complete without meat and that we need lots of meat
or protein for good health. The truth is, most Americans eat much more protein than their
bodies require. And even if you choose to eat no meat at all, you can still meet your
protein needs.
Proteins in the Body
Like carbohydrates and lipids, proteins are one of the macronutrients. Though protein
provides your body with 4 kcals per gram, giving you energy is not its primary role.
Rather, it’s got way too many other things going on. In fact, your body contains
thousands of different proteins, each with a unique function. Their building blocks are
nitrogen-containing molecules called amino acids. If your cells have all 20 amino acids
available in ample amounts, you can make an infinite number of proteins. Nine of those
20 amino acids are essential, meaning you must get them in the diet.
• Some proteins are enzymes. Enzymes speed up chemical actions such as the
digestion of carbohydrates or the synthesis of cholesterol by the liver. They
increase the rate of chemical reactions so much that not having them because of a
genetic defect can be catastrophic.
• Some proteins are hormones. Hormones are chemicals that are created in one
part of the body and carry messages to another organ or part of the body. For
example, both glucagon and insulin are hormones that are made in the pancreas
and travel throughout the body to regulate blood glucose.
• Some proteins provide structure. The protein collagen gives structure to bones,
teeth and skin. Hair and nails depend on keratin.

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• Some proteins are antibodies. Without adequate protein, your immune system
cannot properly defend you against bacteria, viruses and other invaders.
Antibodies are the blood proteins that attack and neutralize these invaders.
• Proteins maintain fluid balance. Fluid is present in many compartments of your
body. It is within the cells (intracellular fluid), in the blood (intravascular fluid)
and between the cells (interstitial fluid). Fluids also flow between these spaces.
It’s the proteins and minerals that keep them in balance. Proteins are too large to
pass freely across the membranes separating the compartments, but since proteins
attract water, they act to maintain proper fluid balance. If your protein intake is
too low to maintain normal blood protein levels, fluid will leak into the
surrounding tissues and cause swelling called edema.
• Proteins transport nutrients and other compounds. Some proteins sit inside
your cell membranes pumping compounds in and out of the cell. Others attach
themselves to nutrients or other molecules to transport them to distant parts of the
body. Hemoglobin, which carries oxygen, is one such protein.
• Proteins maintain acid-base balance. Blood that is too acidic or too alkaline
will kill you. Fortunately, the body regulates its acid-base balance very tightly.
One mechanism uses proteins as buffers. Proteins have negative charges that pick
up positively charged hydrogen ions when conditions are too acidic. Hydrogen
ions can then be released when the blood is too alkaline. To illustrate the dire
consequences of an acid-base imbalance, think about what happens to proteins in
an environment too acid or alkaline. They get denatured which changes their
shape and renders them useless. Hemoglobin, for example, would not be able to
carry oxygen throughout your body.
• Protein is a back up source of energy. With so many jobs, you can see why
protein is not used as a primary source of energy. But rather than allowing your
brain to go without glucose in times of starvation or low carbohydrate intake, the
body sacrifices protein from your muscles and other tissues or takes it from the
diet (if available) in order to make new glucose from amino acids in a process
called gluconeogenesis.

19. 19
Proteins in the Diet
Bodybuilders drink protein shakes for breakfast and after working out. Dieters with no
time to stop for lunch grab protein bars. Are these strategies necessary for optimal
strength building and weight loss? Probably not.
Proteins in the body are constantly broken down and re-synthesized. Our bodies reuse
most of the released amino acids, but a small portion is lost and must be replaced in the
diet. The requirement for protein reflects this lost amount of amino acids plus any
increased needs from growth or illness. The Recommended Dietary Allowance (RDA)
for protein for adults is 0.8 g/kg of body weight. Because of their rapid growth, infants
have the highest RDA for protein at 1.5 g/kg of body weight. The RDA gradually
decreases until adulthood. It increases again during pregnancy and lactation to a level of
1.1 g/kg. The RDA for an adult weighing 140 pounds (63.6 kg) is a mere 51 grams of
protein, an amount many of us consume before mid-afternoon.
• Physical Activity. The RDA remains the same regardless of physical activity
level. There is some data, however, suggesting that both endurance and strength
athletes have increased protein needs compared to inactive individuals. Endurance
athletes may need as much as 1.4 g/kg, and strength athletes may require as much
as 1.7 g/kg.[8]
A bodybuilder weighing 200 pounds (90.9 kg) may then need as
much as 155 grams protein.
• Age. The Acceptable Macronutrient Distribution Range (AMDR) for protein for
men and women age 19 and older is 10–35% of total calories. For children age 4
and over, it is 10–30%, and for younger children, the range is 5–20%. For an adult
consuming 1600 kcals per day, the acceptable protein intake ranges from 40–140
grams per day, an amount easily met. Consider the 200-pound bodybuilder whose
protein needs are approximately 155 grams per day. With energy needs
approximately 4500 kcals per day, his protein needs are only 14% of his total
calories—well within the AMDR. With his energy needs so great, however, his
diet will need careful planning. If he requires engineered foods such as bars and

20. 20
shakes, it will most likely be to meet his energy needs rather than his protein
needs.
One population that needs special attention is the elderly. Though the RDA for
older adults remains the same as for younger adults, some research suggests their
needs may be 1.2 grams/kg body weight in order to prevent the common muscle
loss and osteoporosis that come along with aging.[9]
Though this doesn’t require
the elderly to eat large servings of food, they frequently have poor appetites and
dental problems that make chewing difficult. Helping them meet their nutritional
needs may take a little creativity and perseverance.
• Vegetarian Diets. People become vegetarian for a variety of reasons including
religious beliefs, health concerns, and a concern for animals or for the
environment. Oftentimes, “How can I get my protein?” is the first question asked
when people discuss their choice for vegetarianism. Yes, in the typical American
diet, most of our protein comes from animal foods. It is possible, however, to
meet all of your protein needs while consuming a vegetarian diet. You can even
eat adequate protein on a carefully planned vegan diet - a diet that excludes all
animal products, including eggs and dairy.
When you think of protein, like most people, you probably think of beef, chicken,
turkey, fish and dairy products. Beans and nuts might come to mind as well. Most
foods contain at least a little protein, so by eating a diet with variety, vegetarians
and vegans can eat all the protein they need without special supplements.
This list illustrates the amount of protein found in common foods that may be included in
your diet.
Approximate Protein Content of Selected Foods
• Poultry, beef, fish, 4 ounce: 28g
• Broccoli, 1 cup cooked: 6g
• Milk, 8-fluid ounce: 8g

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• Peanut butter, 2 Tbsp: 8g
• Kidney beans, 1 cup: 13g
• Whole-wheat bread, 1 slice: 4g
A complete protein includes all of the essential amino acids. Complete proteins include
all animal proteins and soy. Incomplete proteins lack one or more essential amino acids.
Beans, nuts, grains and vegetables are incomplete proteins. Previously, registered
dietitians and physicians advised vegetarians to combine foods that contained incomplete
proteins at the same meal to give the body all the necessary amino acids it needed at one
time. Today we know this is unnecessary. Your body combines complementary or
incomplete proteins that are eaten in the same day.[10]
If you eat a variety of foods, you will meet your protein needs. Recreational athletes
rarely need protein supplements. Professional athletes should consult a registered
dietitian (RD) who is also a Certified Specialist in Sports Dietetics (CSSD). If you are
vegetarian or vegan, it’s wise to see a registered dietitian for careful planning of your diet
to meet not just your protein needs, but other nutrients as well.
Fats
Understanding Fats
It all started in the ‘80s. Doctors, nutritionists and public health officials told us to stop
eating so much fat. Cut back on fat, they said, to lose weight and fend off heart disease
among other ills. Americans listened, but that didn’t improve our food choices. Rather,
low-fat food labels seduced us, and we made pretzels and fat-free, sugar-rich desserts our
grocery staples. Today we know to focus on the quality of the fat instead of simply the
quantity.
Fats in the Body

22. 22
Say NO to very low-fat diets. Why? Many people find them limiting, boring, tasteless
and hard to stick to. And because fat tends to slow down digestion, many low-fat dieters
fight hunger pangs all day or eat such an abundance of low-fat foods that their calorie
intake is too great for weight loss.
Dietary fat has critical roles in the body. Each gram of fat, whether it’s from a spoon of
peanut butter or a stick of butter, provides 9 kcals. This caloric density is a lifesaver when
food is scarce and is important for anyone unable to consume large amounts of food. The
elderly, the sick and others with very poor appetites benefit from high-fat foods. Because
their tiny tummies can’t hold big volumes, small children too need fat to provide enough
calories for growth.
• Fats are an energy reserve. Your body can store just small amounts of glucose
as glycogen for energy, but you can put away unlimited amounts of energy as fat
tissue. This is a problem in our world of excess calories, but was necessary in
earlier times when food was scarce. You’ll use this stored energy while you’re
sleeping, during periods of low energy intake and during physical activity.
• Fats provide essential fatty acids (EFA). Fatty acids differ chemically by the
length of their carbon chains, the degree of saturation (how many hydrogen atoms
are bound to carbon) and the location of carbon-carbon double bonds. These are
critical differences that give each fatty acid unique functions.
Our bodies are amazing machines capable of producing most of the needed fatty
acids. There are two fatty acids that it cannot make at all, however. They are
called LA (linoleic acid) and ALA (alpha linolenic acid). This makes LA and
ALA "essential", meaning they must be obtained through the diet. In the body,
fatty acids are important constituents of cell membranes, and they are converted
to chemical regulators that affect inflammation, blood clotting, blood vessel
dilation and more. Clinical deficiencies are rare. A deficiency of LA is usually
seen in people with severe malabsorption problems. Its symptoms are poor growth

23. 23
in children, decreased immune function, and a dry, scaly rash. In the few cases of
ALA deficiency that doctors and researchers are aware of, the symptoms were
visual problems and nerve abnormalities.
• Fats carry fat-soluble nutrients. Dietary fats dissolve and transport fat-soluble
nutrients, such as some vitamins and also disease-fighting phytochemicals like the
carotenoids alpha- and beta-carotene and lycopene. To illustrate, researchers were
able to detect only negligible amounts of absorbed carotenoids in the blood of
individuals who had eaten a tossed salad with fat-free salad dressing. With
reduced-fat dressing, the study participants absorbed some carotenoids, but with
full-fat dressing, they absorbed even more.[11]
• Fats add to the texture and flavor of foods. You already know that fat makes
food taste good. That’s partly because fats dissolve flavorful, volatile chemicals.
They also add a rich, creamy texture, giving food a satisfying mouthfeel. Imagine
the texture of fat-free chocolate. Not good, probably. Finally, fats provide a
tenderness and moistness to baked goods.
Fats in the Diet
Fats and oils (collectively known as lipids) contain mixtures of fatty acids. You may refer
to olive oil as a monounsaturated fat. Many people do. Really, however, olive oil contains
a combination of monounsaturated, saturated and polyunsaturated fatty acids, but it has
more monounsaturated fatty acids than other types. Similarly, it is technically incorrect to
call lard a saturated fat. It does contain mostly saturated fatty acids, but both
monounsaturated and polyunsaturated fatty acids are present as well.
There is no Recommended Dietary Allowance (RDA) or Adequate Intake (AI) for total
fat intake for any population other than infants. Depending on the age, the AI for infants
is 30 or 31 grams of fat per day. The Acceptable Macronutrient Distribution Range
(AMDR) is 20–35% for men and women age 19 years and older. For an adult consuming
1600 kcals then, the acceptable fat intake ranges from 35 to 62 grams daily. The AMDR
for children is higher and varies by age, starting out at 30–40% for children ages 1 to 3

24. 24
and gradually approaching the AMDR for adults. Experts discourage low-fat diets for
infants, toddlers and young children because fat is energy-dense, making it appropriate
for small, finicky appetites and to support growth and the developing central nervous
system. The AIs for LA and ALA for adults range from 11–17 grams and 1.1 to 1.6
grams, respectively.
• Saturated Fats. Because your body can make all the saturated fatty acids it
needs, you do not need any in the diet. High intakes of most saturated fatty acids
are linked to high levels of LDL (low-density lipoprotein), or bad, cholesterol and
reduced insulin sensitivity.[12]
According to the Dietary Guidelines for Americans
2010, we should limit our intake of saturated fatty acids to 10% of our total
calorie intake (18 grams for someone eating 1600 kcals daily) to reduce LDL
cholesterol and our risk for heart disease. The American Heart Association favors
a greater restriction to just 7% of total calories (12 grams for a 1600 kcal diet). If
you tried to eat no saturated fatty acids, however, you would soon find that you
had little to eat. Remember that fats are combinations of fatty acids, so even nuts
and salmon (good sources of healthy fats) contain some saturated fatty acids.
What does bacon grease look like after the pan has cooled? Its firmness is a hint
that bacon is high in saturated fat. Many saturated fats are solid at room
temperature. Dairy fat and the tropical oils (coconut, palm and palm kernel) are
also largely saturated. The greatest sources of saturated fat in the American diet
are full-fat cheese, pizza and desserts.[13]
The benefit you experience from reducing your intake of saturated fats depends
on many factors, including what you replace them with. Loading up on fat-free
pretzels and gummy candies may be tempting, but is a misguided strategy because
diets high in heavily refined carbohydrates typically increase triglycerides and
lower the beneficial HDL (high-density lipoprotein) cholesterol, both risk factors
for heart disease. A better strategy is to replace the foods rich in unhealthy fats
with foods rich in healthy fats. Cooking with oils is better than cooking with

25. 25
butter or lard. A quick lunch of a peanut butter sandwich instead of a slice of
pizza will do your heart some good. Trading out some of the cheese on your
sandwich for a slice or two of avocado is another smart move. If your calories are
in excess, switch from whole milk or 2% reduced-fat milk to 1% low-fat milk or
nonfat milk to trim both calories and saturated fats.
• Trans Fats. Food manufacturers create both saturated and trans fats when they
harden oil in a process called hydrogenation, usually to increase the shelf life of
processed foods like crackers, chips and cookies. Partial hydrogenation converts
some, but not all, unsaturated fatty acids to saturated ones. Others remain
unsaturated but are changed in chemical structure. These are the health-damaging
trans fats.
Many experts consider trans fats even worse than saturated fats because, like
saturated fats, they contribute to insulin resistance[14]
and raise LDL cholesterol,
but there's more bad news. They also lower HDL cholesterol (the good
cholesterol).[15]
The American Heart Association recommends that we keep our
trans fatty acid intake to less than 1% of total calories (less than 2 grams if
consuming 1600 calories daily). Achieving this might be trickier than you realize
because many foods touting No Trans Fats on their labels actually contain traces
of these artery-scarring fats. That’s because the law allows manufacturers’ to
claim zero trans fats as long as a single serving contains no more than 0.49 grams.
If you eat a few servings of foods with smidgens of trans fat like margarine
crackers and baked goods, you can easily exceed the recommended limit.
Identify traces of trans fats by reading the ingredients lists on food labels.
Partially hydrogenated oil is code for trans fat. You know that there are at least
traces of trans fat present. When oil is fully hydrogenated (the label will say
hydrogenated or fully hydrogenated), it will not contain trans fats. Instead, the
unsaturated fatty acids have been converted to saturated fatty acids.
• Unsaturated Fats. As discussed, unsaturated fatty acids improve blood
cholesterol levels and insulin sensitivity when they replace saturated and trans

26. 26
fats. There are two classes of unsaturated fatty acids: monounsaturated fats and
polyunsaturated fats.
Monounsaturated fat souces include avocados, nuts, seeds and olives. Peanut,
canola and olive oils are additional sources.
There are several types of polyunsaturated fats, and they each have different roles
in the body.
o Omega-3 fatty acids have been in the spotlight recently because of their
role in heart disease prevention. ALA is an omega-3 fatty acid, and you
can find it in walnuts, ground flaxseed, tofu and soybeans, as well as
common cooking oils like canola, soybean and walnut oils. Remember
that your body is unable to create ALA, so it’s essential to get it in the
diet. From ALA, your body makes two other critically important omega-3
fatty acids (EPA and DHA), but the conversion is very inefficient. It’s
better to get EPA and DHA from fish. Not only are EPA and DHA
important to the heart, but they also promote visual acuity and brain
development in the fetus, infant and child; they seem to slow the rate of
cognitive decline in the elderly; and they may decrease the symptoms
associated with arthritis, ulcerative colitis and other inflammatory
diseases. You will find them in bluefish, herring, lake trout, mackerel,
salmon, sardines, and tuna.
o Omega-6 fatty acids are a second type of polyunsaturated fats. LA is an
omega-6 fatty acid and has to be acquired through the diet. Sources of
omega-6 fatty acids are sunflower seeds, Brazil nuts, pecans and pine nuts.
Some cooking oils are good sources too, such as corn, sunflower,
safflower and sesame oils.[16]
When you work on reducing whole-milk dairy, solid fats (like butter and bacon grease),
and processed foods containing partially hydrogenated oils, be sure to replace them with
unsaturated fats rather than simply adding extra calories to your usual diet. Otherwise you

27. 27
can expect to loosen your belt as you put on the pounds.
Don’t fear fats. Instead choose them wisely, making sure you do not exceed your calorie
needs. Enjoy foods with monounsaturated and polyunsaturated fats while limiting the
saturated and trans fats.
Micronutrients are those nutrients we require in relatively small quantities. They are
vitamins and minerals, and our good health requires them in milligram and microgram
amounts. Recall that fats, carbohydrates and proteins are macronutrients, meaning that we
require them in relatively large quantities. We consume the macronutrients in gram
amounts. For example, we might have 200 grams of carbohydrate, 100 grams of protein
and 50 grams of fat, yet only 18 mg of iron and 400 micrograms of folate.
Vitamins are carbon-containing molecules and are classified as either water-soluble or
fat-soluble. They can be changed and inactivated by heat, oxygen, light and chemical
processes. The amount of vitamins in a food depends on the growing conditions,
processing, storage and cooking methods. Minerals do not contain carbon, and are not
destroyed by heat or light. Unlike other nutrients, minerals are in their simplest chemical
form. Minerals are elements. Whether found in bone, seashells, cast iron pots or the soil,
they are they same as the minerals in our food and our bodies. The mineral content of
plant foods varies with the soil content and the maturation of the plant.
Water-Soluble Vitamins
If you look to vitamins for a jolt of energy, you are looking in the wrong place – even if a
supplement bottle says, “promotes energy,” or makes some other similar vague statement.
Vitamins are not energy boosters. Many B vitamins do, however, participate in energy-
yielding chemical reactions in the body. This is confusing because calorie is another word
for energy. It’s clearer to say that B vitamins help the body get calories from food. While
you’re unlikely to get more pep by taking vitamins, eating vitamin-rich foods will
certainly help you maintain health.

28. 28
1. Vitamin B1 - Thiamin
o Functions: Assists in carbohydrate and amino acid metabolism
o Recommended Intakes of Thiamin: Your thiamin needs are proportional
to your energy or calorie needs. The more calories you consume, the
greater your need for this vitamin. The beauty is that the more calories you
consume, the more thiamin you automatically consume anyway. The RDA
for adult women and men is 1.1 and 1.2 mg, respectively.
o Sources of Thiamin: Though thiamin is found in most food groups,
Americans get most of their thiamin from fortified breakfast cereals and
enriched grains such as rice and pasta. Pork, beans and peas are additional
sources.
o When You Get Too Much or Too Little Thiamin: There are no known
toxicity symptoms of thiamin. Thiamin deficiency is not common in the
U.S., however alcoholics and those who eat a junk food-heavy diet are at
risk. A diet of highly processed, but unenriched foods provides ample
calories with little thiamin. Additionally, alcohol contributes calories
without providing good nutrition, and it interferes with thiamin absorption.
Thiamin deficiency disease is called beriberi and is characterized by
weight loss, confusion, irritability, nerve damage and muscle wasting.
Beriberi became understood in the nineteenth century when refining grains
became popular. Populations whose major source of energy was white or
polished rice became inflicted with a fatal nerve disease thought to be an
infection, but it was really a lack of this B vitamin.
2. Vitamin B2 - Riboflavin
o Functions: Assists in carbohydrate and fat metabolism
o Recommended Intakes of Riboflavin: The RDA for riboflavin also
reflects energy needs with higher riboflavin intakes recommended for
those whose calorie needs are higher. The RDA for adult women and men
is 1.1 and 1.3 mg, respectively.

29. 29
o Sources of Riboflavin: Diary products, fortified cereals and enriched
grains are major contributors of dietary riboflavin. Mushrooms and organ
meats such as liver are additional sources.
o When You Get Too Much or Too Little Riboflavin: The body readily
excretes excess riboflavin, so there are no apparent toxicity symptoms.
Like thiamin deficiency, riboflavin deficiency is uncommon, but
alcoholism increases an individual’s risk. The symptoms include swollen
mouth and throat, dermatitis and anemia.
3. Niacin - Nicotinamide, Nicotinic Acid
o Functions:
▪ Assists in carbohydrate and fat metabolism
▪ Helps with cell differentiation
▪ Participates in DNA replication and repair
o Recommended Intakes of Niacin: The RDA for adult women and men is
14 and 16 mg, respectively.
o Sources of Niacin: Meat, poultry, fish, fortified breakfast cereals and
enriched grains are good sources of niacin.
o When You Get Too Much or Too Little Niacin: Large doses of nicotinic
acid - one form of niacin – lower LDL (bad) cholesterol and raise HDL
(good) cholesterol. Doctors may prescribe it for cholesterol management,
but patients frequently reject it for its common side effect. Flushing or
itching, heat and tingling on the face and upper body make this a difficult
treatment for many to stick with. Because of this and the potential for
liver damage, the Tolerable Upper Intake Level (UL) for niacin for adults
is 35 mg/day. Severe niacin deficiency leads to pellagra characterized by
the 4 Ds: dermatitis, dementia, diarrhea and eventually death. Niacin
deficiency is rare in the U.S. today, but was once common in the southern
states where residents subsisted on corn. Without proper treatment, corn
binds niacin making it unavailable to the body. Niacin deficiency became
less common after World War II when food manufacturers began

30. 30
enriching grains with niacin and other nutrients and because the postwar
affluence allowed people to purchase niacin-rich meat, poultry and fish.
4. Vitamin B6 – Pyridoxine, Pyridoxal, Pyridoxamine
o Functions:
▪ Assists in protein and carbohydrate metabolism
▪ Supports blood cell synthesis and neurotransmitter synthesis
o Recommended Intakes of B6: Since B6 is important in protein
metabolism, individuals with very high protein diets require increased B6.
The RDA for men and women is 1.3 mg until age 51 when it increases to
1.7 mg per day for men and 1.5 mg per day for women.
o Sources of B6: Fortified breakfast cereals are especially good sources of
vitamin B6. Other sources include bananas, chickpeas, white potatoes,
sunflower seeds, beef and poultry.
o When You Get Too Much or Too Little B6: Many people falsely
believe that water-soluble vitamins have only minor toxicity symptoms.
Large doses of vitamin B6 cause nerve damage that may be irreversible.
The UL for vitamin B6 is 100 mg/day. Alcoholism increases the risk of
vitamin B6 deficiency just as it does for many other B vitamins. Otherwise
deficiencies are rare. Symptoms include anemia, dermatitis, depression,
confusion and convulsions.
5. Vitamin B12 - Cobalamin
o Functions:
▪ Participates in the metabolism of folate
▪ Helps protect the myelin sheath, the coating that surrounds and
protects nerve fibers
o Recommended Intakes of B12: The RDA is 2.4 micrograms for both
men and women.
o Sources of B12: There are no sources of B12 in foods of vegetable origin,
so strict vegans will need a supplement. Fish, beef, poultry and dairy
contain naturally occurring vitamin B12. Vegans can obtain B12 from

31. 31
fortified breakfast cereals and fortified soy products as well as
supplements.
o When You Get Too Much or Too Little B12: There are no known
toxicity effects of vitamin B12. A healthy individual who switches from
an omnivorous diet to a vegan diet will not become vitamin B12 deficient
right away because we can store enough B12 in the liver to last two years.
Older people are at risk for vitamin B12 deficiency because many have a
stomach condition that decreases the absorption of this vitamin. Too little
vitamin B12 causes a type of anemia called megaloblastic anemia. The red
blood cells grow very large and have a short life span. Because of vitamin
B12’s role in protecting the myelin sheath, a deficiency also causes
neurological symptoms including tingling, numbness, cognitive changes,
disorientation and dementia. These neurological defects may or may not
be reversible. Pernicious anemia is the form of B12 deficiency resulting
from an autoimmune disease that damages the stomach and inhibits
vitamin B12 absorption. Pernicious anemia is treated with vitamin B12
injections.
6. Folate – Folic Acid (synthetic form)
o Functions:
▪ Assists in DNA synthesis and cell division
▪ Participates in amino acid metabolism
▪ Required for the maturation of cells including red blood cells
o Recommended Intakes of Folate: The RDA for men and women is 400
micrograms. The RDA during pregnancy increases to 600 micrograms.
o Sources of Folate: Fortified breakfast cereals and enriched grains are
important sources of folic acid. Other reliable sources of folate include
legumes, green leafy vegetables, orange juice, wheat germ and liver.
o When You Get Too Much or Too Little Folate: Excess folic acid may
mask a deficiency of vitamin B12 by reversing or preventing anemia.
Unfortunately, the neurological effects of a lack of vitamin B12 still
continue without early obvious signs. The UL for adults is 1,000

32. 32
micrograms from folic acid supplements and fortified foods. Because
folate is required for cell division, too little folate causes megaloblastic
anemia just as a lack of vitamin B12 does. Inadequate folate stores and
intakes are linked to increased risks of birth defects such as spina bifida
and anencephaly (neural tube defect in which all or part of the brain is
missing). Low folate intake is also linked to increased risks of heart
disease and cancer.
7. Vitamin C – Ascorbic Acid
o Functions:
▪ Enhances iron absorption
▪ Helps with collagen synthesis
▪ Acts as an antioxidant
▪ Regenerates vitamin E
▪ Plays a role in immune function
▪ Assists in the synthesis of neurotransmitters, DNA and hormones
o Special interest in vitamin C in the treatment or prevention of the
common cold: A review of the research does not suggest that vitamin C
supplements prevent colds in the general public. However, among those
subjected to extreme cold or engaging in extreme physical activity,
vitamin C doses ranging between 250 mg/day to 1000 mg/day reduced the
incidence of colds by 50%. Taken before the onset of a cold, supplemental
vitamin C appears to slightly reduce the length of the cold.
o Recommended Intakes of Vitamin C: The RDA for men and women is
90 and 75 milligrams respectively. Smokers should add and additional 35
milligrams per day.
o Sources of Vitamin C: Vitamin C is present in fruits and vegetables. Rich
sources include bell peppers, citrus fruits, strawberries, pineapple,
kiwifruit, potatoes, tomatoes, broccoli and leafy greens.
o When You Get Too Much or Too Little Vitamin C: The UL is 2,000
mg. Excess vitamin C may cause nosebleeds, nausea and gastrointestinal
distress including cramps and diarrhea. In individuals with kidney disease,

33. 33
too much vitamin C may lead to kidney stones. Some research suggests
that large doses of vitamin C may increase oxidation within the body, the
opposite effect of its antioxidant role. Vitamin C deficiency is called
scurvy and is characterized by bleeding in the gums, small hemorrhages
on the arms and legs, bone pain, fractures and depression.
Fat-Soluble Vitamins
Fat-soluble vitamins accumulate in the liver and fat tissues. These reserves may be
released when dietary intakes are low. There is research, however, suggesting that blood
levels of vitamin D may be low even in the presence of significant storage in the fat.
Because they can be stored so readily, the fat-soluble vitamins may be toxic in large
doses.
1. Vitamin A – Retinol, Retinal, Retinoic Acid, Provitamin A - Carotenoids
o Functions:
▪ Required for night vision and color vision
▪ Needed for cell differentiation
▪ Supports immune function
▪ Aids both male and female reproductive processes
▪ Required for bone health
o Additional Functions of Carotenoids: Research is mounting that
carotenoids have health benefits. For example, lutein and zeaxanthin may
protect the eye from cataracts and age-related macular degeneration.
Lycopene, crytoxanthin, beta-carotene and alpha-carotene might be
cancer-protective.
o Recommended Intakes of Vitamin A: The RDA for males and females
aged 14 years and older is 900 and 700 micrograms, respectively.
o Sources of Vitamin A: Sources for preformed vitamin A come from
animal foods only. They include liver, egg yolks and whole milk.
Carotenoids are precursors to vitamin A. Sources of these precursors,

34. 34
referred to as provitamin A, include broccoli, spinach, carrots, sweet
potatoes, cantaloupe, peaches and other dark green and yellow/orange
fruits and vegetables.
o When You Get Too Much or Too Little Vitamin A: The UL for vitamin
A is 3000 micrograms. Excess preformed vitamin A can cause birth
defects including cleft palate and spontaneous abortions. Pregnant women
should not take supplements or medications containing preformed vitamin
A (retinol). Instead they should use pre-natal supplements that have beta-
carotene as the vitamin A source. High doses of vitamin A are also linked
to increased hip fractures in older women. Excess beta-carotene can cause
carotenodermia, a harmless condition that turns the skin yellowish in
color. Even though beta-carotene is an antioxidant, supplements may
increase the risk of lung cancer among smokers. Too little vitamin A may
cause night blindness and even permanent blindness, increased infections,
impaired growth and reproductive function.
2. Vitamin D – Cholecalciferol
o Functions:
▪ Regulated blood calcium levels
▪ Supports bone health
o Recommended Intakes of Vitamin D: The AI for males and females
aged 1 to 70 is 600 IU (International Units). After age 70, the AI jumps to
800 IU.
o Sources of Vitamin D: The best source of vitamin D is sunlight. Ultra
violet light triggers the synthesis of vitamin D in your skin. With increased
use of sunscreen and fewer work hours and leisure time outdoors, many
people do not synthesize adequate vitamin D. There are few food sources
of naturally occurring vitamin D. They include fatty fish such as salmon
and tuna, egg yolks, beef liver and some mushrooms. Fortified milk,
orange juice, breakfast cereals and other foods are additional sources.
o When You Get Too Much or Too Little Vitamin D: The UL for adults
and children aged 9 and older is 4,000 IU. Excess vitamin D can cause

35. 35
hypercalcemia, dangerously high levels of calcium in the blood.
Hypercalcemia can cause bone loss and kidney stones. It may also affect
the nervous system, heart, lungs, kidneys and blood vessels. Vitamin D
deficiency results in weak bones. In children, this is called rickets and is
characterized by bowlegs and other skeletal deficiencies. In adults, low
vitamin D levels cause osteomalacia and osteoporosis, which lead to an
increased risk of bone fractures. Researchers are studying vitamin D for
it’s potential role in the prevention of certain cancers and autoimmune
diseases such as multiple sclerosis and Crohn’s disease. It is possible that
low vitamin D could increase the risk of developing one of these diseases.
3. Vitamin E – Tocopherol
o Functions. Protects cell membranes from oxidation
o Recommended Intakes of Vitamin E: The RDA for men and women is
19 mg.
o Sources of Vitamin E: Seeds, nuts, vegetable oils and fortified breakfast
cereals are among the best sources of vitamin E.
o When You Get Too Much or Too Little Vitamin E: Vitamin E is
relatively nontoxic, but large doses from supplements may interfere with
blood clotting. The UL is 1,000 mg of supplemental vitamin E, however,
some studies have shown increased mortality with lower doses. Vitamin E
deficiency is rare in healthy people. It manifests as hemolytic anemia, the
early destruction of red blood cells because of the lack of vitamin E to
protect them from oxidation.
4. Vitamin K – Phylloquinone, Menaquinones
o Functions:
▪ Assists in blood clotting
▪ Aids bone formation
o Recommended Intakes of Vitamin K: The AI (Adequate Intake) for men
is 120 micrograms and 90 micrograms for women.
o Sources of Vitamin K: Animal foods contain little vitamin K. Good
sources include Brussels sprouts, broccoli, spinach and other leafy green

36. 36
vegetables, black-eyed peas and soybeans. We get additional vitamin K
from the normal bacteria thriving in our colons.
o When You Get Too Much or Too Little Vitamin K: Both vitamin K
toxicity and deficiency are rare. When present, a deficiency of vitamin K
causes impaired blood clotting. Suboptimal intakes of vitamin K are
linked to reduced bone density and increased risk of fractures.
Major Minerals
Major minerals are the ones that the body requires in amounts of at least 100 milligrams
per day. They are sodium, potassium, chloride, phosphorus, calcium, magnesium and
sulfur. The first four are included in the discussion of fluid and electrolytes.
1. Calcium
o Functions:
▪ Major component of bones and teeth
▪ Required for muscle contraction
▪ Required for nerve transmission
▪ Plays a role in cellular metabolism
▪ Aids blood clotting
o Recommended Intakes of Calcium: The AI for adults aged 19 to 50 is
1000 mg. Because calcium is so critical to preventing bone disease later in
life, the AI is higher for adolescents and teens since they can still build
bone mass. The AI for males and females aged nine to 18 is 1300
milligrams. For those aged 51 and older, the AI is 1200.
o Sources of Calcium: Americans get about half of their calcium from
dairy foods. Chinese cabbage, kale and turnip greens contain absorbable
calcium. Spinach and some other vegetables contain calcium that is poorly
absorbed. Sardines and other canned fish with bones are additional
sources. Some foods such as orange juice and bread are fortified with
calcium, and some tofu is processed with calcium making it another
source of this mineral.

37. 37
o When You Get Too Much or Too Little Calcium: The UL for calcium
is 2,500 milligrams. Excess calcium may cause mineral imbalances
because it interferes with the absorption of iron, magnesium, zinc and
others. Too little calcium causes osteoporosis. Some research connects
low calcium intake to increased risks of high blood pressure, colon cancer
and preeclampsia (high blood pressure and excess protein in the urine of a
woman more than 20 weeks pregnant).
2. Magnesium
o Functions:
▪ Assists enzymes in more than 300 chemical reactions in the body
▪ Supports cellular activity
▪ Participates in muscle contraction
▪ Aids blood clotting
▪ A component of bone
o Recommended Intakes of Magnesium: The RDA for men and women
aged 19 to 30 years is 400 and 310 milligrams per day, respectively. For
older adults, the RDA bumps up to 420 milligrams and 320 milligrams for
men and women, respectively.
o Sources of Magnesium: Leafy greens, potatoes, whole grains, nuts, seeds
and legumes are good sources of magnesium.
o When You Get Too Much or Too Little Magnesium: The UL for
magnesium is 350 milligrams from supplements or medicines because it
may cause diarrhea. Severe toxicity may cause confusion, loss of kidney
function, difficulty breathing and cardiac arrest. Individuals with kidney
disease are at higher risk for magnesium toxicity. Overt symptoms of
magnesium deficiency in healthy people are rare. However, a magnesium
deficiency can occur in individuals with kidney disease, alcoholism or
prolonged diarrhea. Early signs of poor magnesium status are loss of
appetite and weakness. Later signs are muscle cramps, irritability,
confusion and cardiac abnormalities. Many people consume suboptimal
amounts of magnesium, and low magnesium stores may be related to

38. 38
increased risk of cardiovascular disease, high blood pressure, type 2
diabetes and immune dysfunction.
3. Sulfur
o Functions:
▪ Helps maintain acid-base balance
▪ Assists in some of the liver’s drug-detoxifying pathways
▪ A component of some vitamins and amino acids
o Recommended Intakes of Sulfur: There is no Dietary Reference Intake
(DRI) for sulfur
o Sources of Sulfur: Since sulfur is a component of amino acids, protein-
rich foods are good sources of sulfur.
o When You Get Too Much or Too Little Sulfur: There are no known
deficiency or toxicity symptoms.
Trace Minerals
The minerals that the body requires in amounts less than 100 milligrams per day are
referred to as trace minerals. They are chromium, copper, fluoride, iodine, iron,
manganese, molybdenum, selenium and zinc. Because iron metabolism is the most
complicated of the nine, it will be discussed in greater detail.
1. Iron
o Functions:
▪ Carries oxygen throughout the body
▪ Assists in energy metabolism and other enzyme-mediated chemical
reactions
▪ Supports immune function
▪ Involved in the production of neurotransmitters, chemicals that
carry messages between nerve cells
▪ Participates in the development of the brain and nervous system
o Recommended Intakes of Iron: The RDA for men and postmenopausal
women is 8 mg. Because of their monthly blood losses, the RDA for

39. 39
premenopausal women jumps to 18 mg. The RDA during pregnancy
jumps even more to 27 milligrams to provide adequate iron stores for the
infant. If the mother’s iron status is poor, the baby will not have enough
stored iron to last the first six months of life.
o Sources of Iron: Iron has two types: heme and non-heme. Heme iron is
only present in animal flesh. Beef, liver, clams and oysters are excellent
sources of iron. Additional sources are poultry, fish and pork. Non-heme
iron can be found naturally in tofu, legumes, spinach, raisins, and other
plant foods. It is the form of iron used in fortified and enriched foods such
as breakfast cereals, bread and pasta. As an excess of iron is highly toxic,
the human body tightly regulates the amount of iron it absorbs. Depending
on the body’s need for iron, we absorb approximately 15 to 35% of the
heme iron we ingest, but significantly less of the non-heme iron. Eating
meats including fish and poultry and vitamin C-rich foods enhances the
absorption of non-heme iron. Thus, you will absorb more iron from
legumes, for example, if when you eat them, you also eat fresh tomatoes
or an orange.
o When You Get Too Much or Too Little Iron: The UL for males and
females aged 14 and above is 45 mg. It is 40 mg for younger individuals.
Side effects of too much iron are gastrointestinal and include nausea,
vomiting, diarrhea and constipation. Accidental overdose of
multivitamin/mineral supplements or other iron-containing products is the
leading cause of poisoning deaths among young children in the U.S.
Immediate emergency medical care is critical because death can occur
quickly. In addition to gastrointestinal symptoms, the child may
experience rapid heartbeat, dizziness and confusion.
Hemochromatosis is a genetic defect that causes excessive iron absorption.
Over time, iron can accumulate in and cause damage to various parts of
the body. The result could be diabetes, liver cancer, cirrhosis of the liver
and joint problems.

40. 40
Iron deficiency is the most common nutrient deficiency throughout the
world. In the U.S., individuals experiencing rapid growth or blood losses
are at increased risk for deficiency. These include young children over 6
months of age, adolescents, menstruating women and pregnant women.
Because they consume no heme iron, vegetarians are also at increased
risk. Iron deficiency results in anemia with symptoms ranging from
fatigue to rapid heart rate to decreased tolerance to cold to decreased
athletic performance. Pica, the eating of clay, paper, ice and other non-
food items, especially during pregnancy, may also be a symptom of iron
deficiency.
2. Chromium: Chromium enhances the effects of insulin, and may thus, play a role
in the development of glucose intolerance and type 2 diabetes. Whole grains,
brewer’s yeast, nuts and dark chocolate are sources of chromium. Clinical
assessment of chromium status is difficult.
3. Copper: Copper assists with the transport of iron. Rich sources of copper include
liver, shellfish, legumes, nuts and seeds. Deficiencies or excesses of copper are
rare in healthy people.
4. Fluoride: Fluoride helps prevent dental caries. Nearly 99% of the body’s fluoride
resides in the bones and teeth. The main source of fluoride is municipal water
supplies that add fluoride to the water. Excess fluoride discolors and damages
teeth.
5. Iodine: Iodine is a component of the thyroid hormones, which regulate metabolic
rate and body temperature. Sources of iodine include saltwater fish, liver,
legumes, potatoes, iodized salt and dairy products. Iodine deficiency inhibits the
synthesis of thyroid hormones resulting in hypothyroidism and it’s typical
problems including fatigue, weight gain and intolerance to cold. Inadequate iodine
intake is fairly common in some parts of the word and may affect as much as 30%
of the world’s population. In recent years, the use of iodized salt has decreased
deficiency cases. Under different circumstances, excess iodine can cause either

41. 41
hyperthyroidism or hypothyroidism. Both too little and too much iodine can cause
goiter, an enlargement of the thyroid gland.
6. Manganese: Manganese is important in many enzyme-mediated chemical
reactions including enzymes involved in the synthesis of cartilage in skin and
bone. Tea and coffee are significant sources of manganese in the American diet.
Additional sources are nuts, whole grains, legumes and some fruits and
vegetables. Magnesium deficiency is rare. Toxicity is also uncommon and is most
frequently the result of exposure to airborne manganese dust. The UL for
manganese is 11 mg per day.
7. Molybdenum: Molybdenum assists several enzymes including one required for
the metabolism of sulfur-containing amino acids. Peas, legumes and some
breakfast cereals supply molybdenum. Both molybdenum deficiency and toxicity
are rare. High doses of molybdenum, however, inhibit copper absorption.
8. Selenium: Selenium is required for immune function and for the synthesis of
thyroid hormones. Additionally, this mineral assists enzymes in protecting cell
membranes from damage. Depending upon the soil in which they are grown,
Brazil nuts are one of the richest sources of selenium. Organ meats, seafood, other
meats and whole grains are additional sources. Low selenium intake may decrease
an individual’s ability to fight viral infections. Some research also links low
intakes to some cancers. Toxicity causes brittle hair and nails and is most likely to
occur with supplements.
9. Zinc: Zinc is critical for normal growth and sexual maturation. It plays a role in
the immune system and is important to the proper function of at least 70 enzymes
including one that helps protect cells from damage. Oysters, beef and clams are
rich sources of absorbable zinc. Whole grains also contain zinc, but it is less
available for absorption. Zinc deficiency causes delayed growth and sexual
development, decreased immune function, altered sense of taste, hair loss and
gastrointestinal distress. Zinc deficiency is uncommon in healthy people in the
U.S. It is more common among populations that consume cereals as their primary
source of nutrition. Zinc toxicity is rare.

42. 42
For your overall health, each nutrient is as important as the next. Whether they are
macronutrients or micronutrients, vitamins, major minerals or trace minerals, they each
have a unique role. A deficiency in any will impact your wellbeing. Eating a diet with
both a variety of food groups and a variety within food groups is your best protection
against nutrient imbalances.
RELATIONSHIP BETWEEN DISEASE AND NUTRITION
DISEASES AND NUTRITION
THE ROLE OF NUTRIENTS IN DISEASE PATHOPHYSIOLOGY
Nutrients are the raw materials that support physiologic and metabolic functions needed
for maintenance of normal cellular activity. Malfunctioning of cellular activities due to an
inadequate level of support from available nutrients is initially expressed in biochemical
changes that will eventually develop into clinical symptoms characteristic of the

43. 43
particular roles of the nutrients involved. Nutrient deficiencies may develop because of
inadequate intake, impaired absorption, increased demand, or increased excretion.
Excessive intakes of some nutrients may promote deficiencies of others through impaired
absorption, increased demand, or increased excretion.
Nutrients with Nourishment and Pharmacologic Functions
✓ Nutrients that support immune function-zinc, vitamin C, protein, vitamin A,
vitamin B6, Folate
✓ Nutrients that provide antioxidant protection-vitamin C, carotenoids, vitamin E,
selenium
✓ Nutrients that support synthesis of enzymes and bioactive compounds-amino
acids, vitamin B6, fatty acids, selenium
✓ Nutrients involved in tissue synthesis-protein, energy, zinc, vitamin A, vitamin C,
iron
Both excess and deficient nutrient intakes may contribute to development of chronic
degenerative diseases. These diseases can be considered an expression of cumulative
cellular damage due to environmental assaults for which the threshold of exposure at
which damage is incurred is defined by genetics. Imbalances in dietary patterns are
among the environmental factors that contribute to the development of chronic diseases.
Either diet may be directly involved in the pathogenesis of the disease or it may
exacerbate pathological changes due to other environmental factors.
THE GOALS OF NUTRITION IN PREVENTION OF DISEASE ARE:
1. To optimize cellular activity and tissue/organ function
✓ Provide sufficient amounts to satisfy daily demands of adequacy, balance and
variety in food choices
✓ Maintain adequate reserves for intermittent increased demand through habitual
diet and dietary patterns

44. 44
2. To reduce the metabolic burden imposed on cardiac, pulmonary, renal, hepatic, and
musculoskeletal systems by environmental factors
✓ Minimize workload of organ systems by reducing stress on organs involved in
transport, metabolism and elimination of nutrients and metabolic waste.
✓ Eliminate compensatory responses required to maintain normal function
3. To support cellular defenses that protects tissue integrity
✓ Maintain immune system competence
✓ Promote efficiency of detoxification systems by controlling levels of reactive
chemical intermediates
✓ Prevent oxidative damage that is involved in pathogenesis of most chronic
diseases and reduction of efficiency of immune cells
Nutrition and the Immune System
• Malnutrition weakens immune system
• First line of defence (skin, mucous, cells of GI tract) break-down allowing more
antigens to invade inside the body
• Insufficient protein intake decreases immune cell number
• When T-cell number decreases regulatory T-cells decrease immune response is
delayed
• Obesity affects the body’s defence system
• Responses of T-cells and B-cells to antigens may be reduced
• Weight loss diets may also cause this same immune response
• Type of fat consumed can affect the immune system
• Total amount and type of fat in the diet affects immune system
• High-fat diets impair immune response
• Omega-6 fatty acids can suppress immune response, alter inflammatory response
• May increase risk of asthma

45. 45
• Omega-3 fatty acids – decrease inflammation, increase immune response and
limits tissue damage
Role of some Nutrients
• Vitamin A – needed to make healthy skin, mucous and lymphocytes; deficiency
can alter response of antibodies to antigens and cytokine responses
• Vitamin E – needed for phagocytosis, antibody production, lymphocyte responses
• Vitamin C – may decrease duration of virus symptoms
• Vitamin B6 – antibody production, lymphocyte responses
• Zinc – T-cell production, lymphocyte responses, resistance to
NUTRITION IN DISEASE MANAGEMENT
Overweight.
This is a state where the individual’s body weight is between 10% to 20% more than
the ideal body weight, or when the BMI is between 25-29.9.
Risk factors/causes.
• Energy imbalance between calories consumed on one hand, and calories
expended on the other hand
• A shift in diet towards increased intake of energy-dense foods that are high in fat
and sugar but low in vitamins minerals and other micronutrients.
• A trend towards decreased physical activity due the increasingly sedentary nature
of many forms of work, changing modes of transport and increasing urbanization
Implications.
• Is a risk factor to obesity

46. 46
• Is a risk factor to cardiovascular diseases
• Is a risk factor to other chronic diseases e.g. diabetes, gout osteoarthritis, some
cancers, respiratory problems, liver malfunctions etc.
Aim of the management.
To achieve and maintain the ideal/optimal body weight.
Management
• Recommend reasonable physical activity.
• Control total energy intake based on individual assessment by limiting energy
intake from total fat and simple sugars.
• Recommend high fibre, restricted fat diets based individual assessment.
• Refer to the calorie restricted diet,
Obesity
This is a state of adiposity in which the body fat is above the ideal where the individual’s
body weight is 20% more than the ideal body weight, or when the BMI is more than 30.
The ideal body weight of a person depends on age, sex, height and body frame. Obesity
is a chronic disorder of excessive accumulation of fat in the body, whereas overweight
refer to the excess amount of body weight in all tissues.
Risk factors/causes
• Energy imbalance between calories consumed on one hand, and calories
expended on the other hand
• A shift in diet towards increased intake of energy-dense foods that are high in fat
and sugar but low in vitamins minerals and other micronutrients.
• A trend towards decreased physical activity due the increasingly sedentary nature
of many forms of work, changing modes of transport and increasing urbanization
• Genetics e.g. number of fat cells.

47. 47
Implications
• Is a risk factor to cardiovascular diseases
• Is a risk factor to other chronic diseases e.g. diabetes, gout osteoarthritis, some
cancers, respiratory problems, liver malfunctions etc.
Aim of management
• Achieve and maintain ideal body weight by bringing about gradual weight loss
• to correct fault food habits
Management
• Recommend suitable exercise program and encourage physical activity for
gradual weight loss.
• Control total energy intake based on individual assessment by limiting energy
intake from total fat and simple sugars.
NB: A maximum reduction of 1000kcl daily is required to loose about 1kg a week and a
reduction of 500kcl daily brings about a weight loss of about half a kg a week. Drastic
reduction of calorie intake is not advisable. Put the client on a weight reduction diet
regime (30-25kcal/kg bwt/day).
• Recommend high fibre, restricted fat diets based individual assessment.
• Offer nutritional education to the clients with emphasis on weight
management the fad diets and other un healthy practices in weight control.
• Recommend support systems for the clients in case there is need for
behaviour modification.
• Refer to the calorie restricted diet,
DIETARY CONSIDERATIONS.
Proteins

48. 48
Give slightly higher than normal as it gives a feeling of satiety and also helps to maintain
a good nutritional status. Provide approximately 20% of total energy from proteins. This
should include good quality proteins in the form of low fat milk, lean and whole pulses.
Fats
Provide 20% or less of totals energy from fats. Emphasize on the use of unsaturated fats
so as to reduce the risk of heart problems. Restrict or avoid fried foods
Carbohydrates
Provide the rest of energy 60% from carbohydrates which should be mainly in complex
form like starches and dietary fibre. Limit simple forms like sugars.
Minerals and vitamins
Reduced diet should provide adequate amount of essential nutrients like minerals and
vitamins to maintain a good nutrition status
Alcohol
Alcohol should be restricted as it provides a lot of kilocalorie per kg 7kcl. If desired
alcohol may be provided in limited amounts
N.B. diet adjustments should be gradual as such people experience excessive appetite.
Use of appetite suppressants is not recommended.
Increase intake of
• Vegetables such as Broccoli, mushroom, zucchini, cabbage, lettuce, cucumber
• Fruits such as pineapple, cherimoya, peach, grapefruit
• Tubers such as sweet potatoes
• Low fat milk
• Diuretic foods such as celery, apples, watermelon (diuretic drugs are not
recommended)
Avoid
• Saturated fats
• Fried Foods
• Refined baked foods

49. 49
UNDERNUTRITION
Undernutrition defines a state when the body does not have enough of the required
nutrients.
Causes
- Inadequate food intake.
- Disease/illness.
- Household food insecurity.
Symptoms/implications
- Marasmus:
o Severe weight loss.
o Ribs prominence
o Muscle wasting wih emaciated limbs.
o Alert and irritable.
o Normal hair
o Thin flaccid skin hanging loosely (old mans appearance).
- Kwashiokor:
o Bilateral oedema and fluid accumulation.
o Brittle thinning hair can be pulled out easily.
o Reduced muscle tissue which may be masked.
o Face may seem swollen (moon face).
o Apathetic and irritable.
o Hair color change (yellowish/reddish).
o Loss of apetite.
Nutritional implications
- Reduced metabolic rate.
- Impaired protein synthesis and metabolism.
- Impaired liver function.

50. 50
- Impaired kidney function.
- Impaired immunity.
- Impaired electrolyte balance.
Aims of nutritional management
- To correct nutritional imbalances.
- To correct nutritional imbalances.
- Restoration of patho-physiological function.
Dietary management
Severely malnourished patients do not exhibit classical signs of infection and therefore
should be routinely treated for infection regardless of signs or symptoms. Therefore on
admission all beneficiaries are given broad-spectrum antibiotics and are immunized
against measles (when appropriate). If prophylaxis co-trimoxazole is being used (HIV),
still add an additional systematic antibiotic
Essential Steps in Inpatient Management
1. Treat/prevent hypoglycaemia
2. Treat/prevent hypothermia
3. Treat/prevent dehydration
4. Correct electrolyte imbalance
5. Treat/prevent infection
6. Correct micronutrient deficiencies
7. Start cautious feeding
8. Achieve catch-up growth
9. Provide sensory stimulation and emotional support
10. Prepare for follow-up after recovery
CARDIOVASCULAR DISEASES

51. 51
Cardiovascular diseases/disorders are diseases/disorders that affect the heart and blood
vessels. These includes atherosclerosis, Chronic cardiac failure, and
hyper/hypotension..some of the risk factors include; Diet, Age, Diabetes, obesity,
smoking and heredity among others.
3.1.0 Atherosclerosis
This is a generative process that begins with the accumulation of soft fatty streaks along
the inner arterial walls especially at the branch points. These streaks gradually enlarge
and become hardened with minerals forming plaques.
Risk factors include: high calorie intake, high saturated fat and cholesterol intake,
increased serum LDL ( harmful cholesterol) levels above 5mmol/litre, ,sedentary
lifestyles, stress, hypertension, obesity and diabetes.
Implications
• Obstruction of normal blood flow,
• tissue damage,
• increased blood pressure
aim of management.
• To normalize blood lipids
• To control the modifiable risk factors
• To prevent complications.
Management.
• reduce total fat intake(15-20%) -LDL –( saturated fat to 7% and dietary
cholesterol 200mg/day)
• Reduce body weight for the over weight clients to the ideal BMI
• Avoid smoking and alcohol
• Recommend physical activity

52. 52
3.1.1 myocardial infarction
This is sudden tissue death caused by blockages of vessels that feed the heart muscle, also
called heart attack/cardiac arrest.
Risk factors include hypertension, arteriosclerosis. Other contributors include abnormal
blood clotting, spasms of the coronary artery, rheumatic heart disease, infections of the
membranes covering the heart and electrical disturbances that alter the hearty rate.
Implications.
• Strained cardiac function
Aim of nutritional management
• To reduce the work load of the heart.
• To relieve pain and stabilize the heart rhythm.
• To treat infections and the underlying causes.
• To regulate electrolyte balance.
Dietary Management
• Withhold food intake -nil per oral until shock resolves.
• When shock resolves provide between 1000-1200 kcal that progresses from low
sodium soft foods of moderate temperature in frequent and small feeding.
• After recovery adjust the diet to meet the individual needs and to deal with the
underlying conditions such as hyperlipidemia, hypertension, obesity diabetes.
• Avoid caffeine as it stimulates metabolic rate and increase the workload of the
heart.

53. 53
A healthy heart requires minimal consumption of saturated fats and cholesterol, reduced
use of salt and sugar, avoiding use of tobacco and too much coffee and regular exercise.
Congestive Heart Failure (CCF)
This is a syndrome in which the heart can no longer adequately pump blood through the
circulatory system.
Risk factors include; uncontrolled atherosclerosis and hypertension,
Implications
• Pulmonary edema
• Reduced blood flow to all organs
• Fluid retention hence stagnation of fluids in all organs .
• Enlarged heart and rapid heartbeat.
• Malnutrition due to high energy needs.
Aim of Management
• To reduce the workload of the heart
• To pro adequate nutrients
• To reduce weight for the overweight
Management.
• Restrict sodium, caffeine and fat
• Encourage gradual weight loss where necessary
• Recommend liquid formula of high nutrient density as oral supplement or Enteral
or tube feeding to prevent or reverse malnutrition . in some cases total parenteral
nutrition may be required.

54. 54
• Selection of Enteral or parenteral formulas should be done carefully to ensure that
energy ,fluid, sodium intake will not overload the body
• Adjust dietary fiber to avoid constipation but avoid amounts and types that
produce gas and abdominal distention
• For overweight patient advice to reduce weight to normal body weight
• Restrict cholesterol intake to 300 mg /day
• Reduce intake of saturated fats
• Encourage intake of unsaturated fats (oils)
• Increase intake of dietary fibre to control glucose/fat absorption
• Reduce alcohol intake and encourage the patient to avoid smoking to prevent
development of atherosclerosis
Hypertension
Hypertension is a cardiovascular disorder characterised by persistently elevated diastolic
BP of above 95mmHg.
Uncontrolled Hypertension can affect various body organs and can lead to impired
vision,, kidney failure, stroke, paralysis, heart attack and brain damage.
Risk factors include; Diet, Race, Stress, Age, Diabetes, obesity, smoking, Atherosclerosis
and heredity among others.
Implications.
• Strained cardiac and vascular function.
• Cellular Electrolyte imbalance
• Aneurysms (balloon out and busting of the arteries)
• Arterial lining injuries which accelerates the plaque formation.

55. 55
Aim of nutritional management.
• To control blood pressure within the normal ranges.
• To achieve a gradual weight loss in overweight and obese individuals and
maintain their weight slightly below the normal.
• To reduce sodium intake based on the severity of hypertension.
• To maintain adequate nutrition
• Regulate fat intake.
Nutritional management
Provide low calorie diet if the patient is overweight until ideal body weight is
achieved.
. Regulate fat intake. Encourage intake of unsaturated fats (oils) The poly unsaturated
and monounsaturated fatty acids lower BP, the level of triglycerides and LDL
cholesterol and consequently lead to increase in HDL cholesterol that carries
cholesterol in the blood back to the liver for recycling or disposal. fats should be
20% of total kcl
Restrict alcohol intake
Restrict sodium. To achieve this, encourage choice of food low in sodium and limit
the amount of salt added to food, restrict processed foods and use of sodium
containing spices.
Avoid stimulants e.g. caffeine and spirits
Avoid cigarette smoking, which may lead to atherosclerosis
In some cases it may be necessary to restrict fluid intake
• Encourage Physical activity for those leading a sedentary lifestyle.Physical acthas
measurable biological effects affecting cholesterol levels, insulin sensitivity and
vascular reactivity. These effects are dose dependant such that the more the
exercise, the greater the health benefits.

56. 56
stroke/transient ischemic attack
This is a temporal reduction in blood flow to the brain that causes temporal symptoms
which depend on which part of the brain is affected.
Risk factors.
Atherosclerosis
Hypertensioionn or a combination of the two.
Implications
• light headedness
• visual disturbances
• paralysis
• staggering
• numbness
dysphagia ( inability to coordinate swallowing appropriately)
aim of management.
To treat the underlying risk factors.
management
• Restricted energy intake, total fat and sodium
• Tube feeding may be indicated initially till the client is safely able to chew and
swallow.
• some patients may need assisted feeding.

57. 57
BURNS
Major burns result in severe trauma. Energy requirements can increase as much as 100%
above resting energy expenditure, depending on the extent (Total Burnt Surface Area -
TBSA) and depth of the injury (degree of burns).
Causes
- Fire.
- Chemicals.
- Contact with hot liquids.
- Sunburn.
- Electricity or lightning.
- Prolonged exposure to hot liquids.
Nutritional implications
- Catabolism of trauma.
- Wasting and weight loss.
- Anorexia.
- Failure to feed.
- Generalized discomfort and depression.
- Loss of fluids and electrolytes.
- Heat lost.
- Infections.
- Demand of tissue regeneration.
- Anemia.
- Malnutrition.
Aims of nutritional management
• Achieving and maintaining optimum body weight.
• Promoting wound healing.
• Preventing infection and rapid or severe weight loss.
• Attaining normal hydration status and electrolyte balance.

58. 58
Dietary management
Daily calorie requirements using Curreri formula (1979).
Adults
=[24Kcal x Kg usual body weight] + [40 KCal x TBSA {% burn}]
whereby TBSA stands for the total % burn.
Daily protein requirement
=[1g x bwt] + [3g x TBSA]
Children
Daily calorie requirement
=[60KCal x Kg usual body weight] + [35KCal x TBSA]
Daily protein requirement
=[3g x Kg. Usual Body weight] + [1g x TBSA]
For these patients a high protein high calorie diet is vital for faster recovery.
In adults and children TBSA of more than 10%, protein should comprise 20% of the total
caloric requirement. TBSA 1% to 10%, 15% of the total caloric requirements.
For children younger than 1 year of age, a conservative recommendation of 3g to 4g
protein per kilogram can be given because of infants inability to tolerate high renal solute
loads. Excessive high protein intake could result in azotemia, hyperammonemia, or
acidosis.
Nutrient delivery could be either: oral, enteral, or parenteral.

59. 59
Oral diet
– A high protein, high calorie oral diet is indicated for the patient who is
able to eat.
– Oral nutrition supplements can be used to meet calorie and protein goals.
– Small frequent meals and nutrient dense snacks maybe required to meet
nutrient needs during recovery.
– Foods that the patient is accustomed to eating should be provided.
– If possible treatment and tests and should be scheduled so that they do not
interfere with meal times.
– An oral diet during the day supplemented with tube feeding at night is
indicated for patients who do not consistently meet at least 75% of protein
and calorie requirements.
– Avoid drinks high in caffeine such as tea, coffee etc. because they will
bind Vitamin C which is important for cell regeneration and immunity.
Enteral
- Continuous enteral feeding with or without oral intake is indicated for patients
who are unable to meet a minimum of 75% KCal and protein requirements via
oral diets plus nocturnal tube feeding and for intubated patients with adequate
bowel function.
- For pediatric patients the starting hourly rate should be 1ml to 2ml per kilogram
of body weight, and the volume of feeding should increase gradually 5ml to 15ml
every 8, 12, or 24 hrs depending on the patients tolerance.
- For adult patients the rate should start at 10ml to 40ml per hour depending on
patient tolerance. Volume can be increased gradually in 20ml to 25ml increments
every 8, 12 or 24 hours depending on patient tolerance. Free water requirements
can be met by intermittent flushes of a prescribed amount of water.
- Residual gastric volume should be checked every 4 hours when gastric feedings
are given. If the residual is more than 1.5times the hourly rate, the feeding should
be stopped and the physician should be notified.

60. 60
Parenteral
- Parenteral nutrition should be given when the gastrointestinal function is not
functional. It should be tailored to the nutrient recommendations.
- For adult patients hypertonic solutions are administered by infusion pumps
beginning at slow infusion rates beginning at 40ml per hr. The rate increase by
20ml to 40ml every 8 to 12hrs as tolerated until energy and protein requirements
are attained.
- For pediatric patients, the infusion of dextrose can be initiated at a concentration
of 10% and advanced as tolerated to a maximum of 20% dextrose concentration.
Alternatively 20% dextrose can be infused at a rate of one half of maintenance
fluid for 12 hours and then advanced to full maintenance fluids as tolerated.
Patients on tube feeding and/or parenteral nutrition in nonintensive care receiving tube
feedings, the following parameters should be monitored daily: intake and output, urine
sugar/acetone, and consistency of bowel movements. In intensive care patients receiving
parenteral, tube feeding or both, the following parameters should be monitored daily:
sodium, potassium, BUN, creatinine, glucose, Hb, hematocrit, intake and output, urine
sugar/acetone and consistency of bowel movement.
SURGERY
A well nourished patient usually tolerates major surgery better than a severely
malnourished patient, since malnutrition is associated with a high incidence of operative
complications and death.
Preoperative nutrition care
In post operative care nutrition support in patients with inadequate intake who require a
major operation and cannot undergo immediate surgery require:

61. 61
- A chemically defined or elemental liquid diet with minimal residue can be used
pre-operatively for patients with nutritional risks.
- It is important that stomach is empty of food at the time of operation to avoid the
danger of aspiration during the induction of anesthesia or upon awakening.
- In elective cases, no food is allowed by mouth (nill by mouth) for atleast six hours
before surgery.
- Low fibre foods orally, a liquid diet for 2 – 3 days preceding surgery.
Postoperative nutrition care
The aim is:
- To reduce nutritional deficit that ordinarily develop in untreated patients during
the period of post operation.
- Length of nill by mouth after surgery maybe influenced by the patients pre-
existing nutritional status, severity of operative stress and the nature and severity
of the illness.
- If the period of postoperative starvation is expected to be longer than one week.
Nutrition support maybe beneficial even for a mildly malnourished individual.
- Introduction of solid foods depends on condition of the GI tract, oral feeding is
often delayed for the first 24 – 48hrs following surgery to await the return of the
bowel sounds or passage of flatus.
- Progress over a period of several meals from clear liquids, and finally to solid
foods.
Dietary management in HIV infection/AIDS
aims at
This is a syndrome which results from a weakened immune system as a result of the HIV
virus infection resulting to body’s inability to fight infections.

62. 62
Causes.
• Transfusion of Blood infected with the virus.
• Sexual contact with infected person/s
• Use of contaminated needles and injections/skin pricking instruments
• Trans-placental transmission from infected mothers to child.
• Breastfeeding by infected mothers to the babies.
Implications
• suppresed body immunity
• Increased Susceptibility to infections
• Altered metabolism-High catabolic rate.
• malnutrition
• Altered body weight ( overweight or underweight).
THERAPEUTIC DIETS: DIETARY MODIFICATION
This section deals with types of diet, their caloric contribution and how to interpret
imprecise diet orders recommended by the medical officers or health workers for
individual patients.
Diets can be grouped into two types namely:
• Normal diet
• Modified diet
Normal diet
This is a regular diet either vegetarian or non vegetarian well balanced and adequate for
nutrition. It is designed to provide adequate nutrition for optimal nutrition and health (the
use of specific nutrition services to treat illness, injury or health conditions) status in

63. 63
persons who do not require medical nutrition therapy. This diet is used when there is no
required diet modification or restrictions. It is the foundation of all diets. Individual
requirements for specific nutrients may vary based on age, sex, height, weight, activity
level and different physiological status.

64. 64
MODIFIED DIETS
These are normal diet qualitatively or quantitatively modified as per patients special
needs and in line with the general principles of meal planning. In disease condition
tissues do not either receive proper nutrients owing to insufficient amount or cannot
utilize nutrients owing to fault digestion, absorption or metabolism of food elements thus
affecting the nutritional homeostasis of the sick person. The diet therefore need to be
modified. To meet the nutritional needs of the sick person
General objective of nutritional therapy
1. Maintain good nutritional status
2. To correct nutrient deficiencies which may have occurred due to the disease
3. To afford rest to the whole body or to specific organs affected by the disease
4. To bring changes to the body weight whenever necessary
5. to adjust the nutrients to a level the body can properly metabolize e.g. in diabetes
Factors that will determine dietary modification
1. Disease symptoms,
2. Severity of the problem,
3. Nutritional status of the patient
4. Condition of the patient and metabolic changes involved
THERAPEUTIC MODIFICATION OF NORMAL DIET
MODIFIED CONSISTENCEY
MODIFICATION IN FIBRE CONTENT
This can be high or low fibre diet. Diseases affecting digestive system generally require
modification in fibre content
MODIFICATION IN ENERGY INTAKE

65. 65
High or low energy depending upon the metabolic modification in activity patterns and
the weight of a patient
MODIFICATION IN THE CONTENT OF ONE OR MORE NUTRIENTS
✓ High or low protein diet
✓ low sodium diet
✓ moderate fat diet/fat restricted diet
✓ high carbohydrates
EXCLUSION OF CERTAIN FOODS
In allergic conditions certain specific foods to which the individual is extremely
allergic to are excluded from the diet. Most people are allergic to protein foods like
milk, eggs, peanut and seafood so these foods have to be eliminated
BLAND DIET
Are described to avoid irritation of any kind to the elementary tract as in the case of
peptic ulcers. such diets are chemically, mechanically and thermally. blood strong
spices, stimulants and strongly flavoured vegetables and fruits as irritants are avoided.
The foods served should be at room temperature.
INCREASING THE FREQUENCY OF FEEDING
In some disease conditions patients may not be able to eat very large amounts of food
at one time. It may thus become essential to give smaller meals at frequent intervals
as in the case of fevers, diarrhea, ulcers e.t.c
MODIFICATION IN THE MODE OF FEEDING

66. 66
Inpatients who are not able to take food orally specific feeding methods like tube or
intravenous feeding may have to be adopted to meet the nutritional needs. There two
common methods of such modification
1. Parenteral nutrition- intreavenous feeding
2. Enteral –Oral feedin-feeding by gut
ENTERAL NUTRITION
Encompasses delivery of nutrients by the oral route and via tube into the gastro-intestinal
tract (GIT). It is usually recommended for patients who have a functional or partially
functional GIT, but are unable to meet total nutrient needs via the oral route.
Indications
1. During periods of decreased oral intake due to physical impairment e.g.Protein-
energy malnutrition, less than 50% of required nutrient intake orally for 7-10
days, severe dysphasia (difficulty swallowing), metabolic stress, major bowel
resections, low-output fistulas, trauma and coma. Neurological disorders and
psychological conditions.
2. Increased nutrient requirements such as during trauma, surgery, burns, sepsis,
cancer, malnutrition etc.
3. Impaired gastro-intestinal capabilities e.g. malabsorption, inflammatory bowel
syndrome, fistulas, pancreatitis etc.
Contraindcations
1. Intestinal obstruction that prohibits use of intestine.
2. Paralytic illeus.
3. Intractable vomiting.
4. Peritonitis.
5. Severe diarrhea.
6. High out put fistulas between the GI tract and the skin.
7. Severe acute pancreatitis.

67. 67
Tube feeding
This is the delivering of food by tube in to the stomach or intestine.
Indication
- Whenever oral feeding is impossible or not allowed.
Tube feeding routes
The decision regarding the type of feeding route/tube depends on the patients medical
status and the anticipated length of time that the tube feeding will be required.
1. Mechanically inserted tubes;
a. Nasogastric tubes whereby a feeding tube is pushed through the nose into
the stomach.
b. Naso-duodenal tubes whereby the tube is pushed through the nose past the
pylorus into the duodenum.
c. Naso-jejunal tube whereby the tube is passed during the endoscopy from
the nose past the pylorus into the jejunum.
2. Surgically inserted tubes
a. Oesophagostomy: A surgical opening is made at the lower neck through
which a feeding tube is pushed into the stomach.
b. Gastrostomy: A surgical opening is made directly into the stomach.
c. Jejunostomy: A surgical opening is made into the jejunum.

68. 68
Figure 1: Enteral routes of administration.
Advantages of enteral nutrition
1. There is a stimulation of GI hormones and consequent regulated metabolism and
utilization of nutrients.
2. It ensures adequate nutrient supply to the mucosal wall, and protection against
atrophy of intestinal villi.
3. It offers physiological protection against ulcers due to its buffering effect from
gastric acids.
Methods of administration
Method Administration Remarks
Bolus feeding Initially – 50ml then increase gradually
up to a maximum of 250 to 400ml over
approximately 30 minutes, 3 to 4
hourly daily (in 24 hrs).
• Most appropriate
when feeding in to
the stomach.
• Check aspirate

69. 69
before each feeding.
• Feeds may poorly
tolerated causing
nausea, vomiting,
diarrhea, cramping
or aspiration
Intermittent slow
gravity feeding.
400 – 500ml infused by gravity over
approximately 30minutes to 1 hr. 3 to
4 hourly daily (in 24 hrs).
• Patient retains
freedom of
movements in
between feeds.
• Improved tolerance
of feeds.
Continuous Total volume of feed required is
slowly administered; approximately
100ml/hour over 18 – 24hrs.
• Most suitable when
feeding in to the
duodenum or
jejunum where
elemental diets are
most appropriate.
• May also be suitable
for feeding in to the
stomach.
• Method may slow
peristalsis.
• Feeds are better
tolerated.
Tube feeding complications
Sometimes a client does not respond to a tube feeding as expected. If the client continues
to lose weight, for example health care professionals must find out why. Perhaps they
have underestimated energy and nutrient requirements.

70. 70
Commonly seen complications can be classified into: gastro-intestinal, mechanical,
metabolic, and pulmonary. The next table summarizes the complications alongside
prevention/management strategies
Complications of tube feeding
Complications Prevention/management
Gastro intestinal complications
• Diarrhea
• Constipation
• Nausea or vomiting
- Slow feeding rate.
- Supplemental fluid and electrolytes.
- Use lactose free formula.
- Prevent formula contamination.
- Consider different formula.
- Check antibiotic therapy.
- Give supplemental fluid.
- Use fibre containing formula.
- Reduce flow rate
- Use isotonic formula
- Discontinue feeding until underlying
condition is managed.
Mechanical complications
• Tube clogging
• Dislocation of tube
- Select appropriate tube size.
- Flash with water.
- Dilute formula with water.
- Ascertain tube placement before each feed.
- Clearly mark tube at insertion site.

71. 71
• Nasopharyngeal irritation
• Esophageal erosion
- Use small lumen tube.
- Use pliable tube.
- Discontinue tube feeding
- Recommend parenteral nutrition
Metabolic complications
• Hyperglycemia
• Tube feeding syndrome
• Hypernatremia
(dehydration)
• Hyponatremia (over-
hydration)
• Wasting
- Reduce flow rate.
- Give oral hypoglycemic agents or insulin.
- Change formula
- Reduce protein intake or increase water
intake.
- For conscious patients education and
counseling is needed.
- Increased water intake and reduce sodium
- Replace sodium loses
- Re-asses nutrient requirement, check
volume administration, change to nutrient
dense formula
Pulmonary complications
• Pulmonary aspiration - Incline head of bed 300
– 450
during
feeding 1 hr after feeding.
- Check tube placement.
- Monitor symptoms of gastric reflux.
- Check abdominal distension.
- Check residual volumes before feeds.
- Change to jejunal feeding.
- Reduce volume of feed.

72. 72
- Change from bolus to continuous feeding.
PARENTERAL NUTRITION
Def. :a method of feeding patients by infusing a mixture of all necessary nutrients into the
circulatory system, thus bypassing the GIT.
Also referred to as:
intravenous nutrition,
parenteral alimentation, and
artificial nutrition.
The gut should always be the preferred route for nutrient administration.
Therefore, parenteral nutrition is indicated generally when there is severe gastro-
intestinal dysfunction (patients who cannot take sufficient food or feeding formulas by
the enteral route) .
Categories of PN
If enteral feeding is completely stopped or ineffective, Total Parenteral Nutrition is used
(TPN).
If enteral feeding is just “not enough” , supplementation with Partial Parenteral
Nutrition (PPN) is indicated.
Characteristics of parenteral nutrition
1. TPN (Total Parenteral Nutrition) have similar requirements as enterally fed
patients

73. 73
2. The six major nutrients covered: carbohydrates, proteins, fats, vitamins, minerals
and water
3. Feeds must provide adequate calories
4. Nutrient form must be specialized for infusion into blood count prior digestion
5. Standardized concentration may be modified to suit individual requirements.
INDICATIONS
In well-nourished adults, 7 - 10 days of starvation with conventional
intravenous support (using 5% dextrose solutions) is generally accepted.
If the period of starvation is to extend beyond this time, or the patient is not well-
nourished, Total Parenteral Nutrition (TPN) is necessary to prevent the
potential complications of malnutrition.
Indications for TPN
Short-term use
Bowel injury, surgery, major trauma or burns
Bowel disease (e.g. obstructions, fistulas)
Severe malnutrition
Nutritional preparation prior to surgery.
Malabsorption - bowel cancer
Severe pancreatitis
Malnourished patients who have high risk of aspiration
Long-term use (HOME PN)
Prolonged Intestinal Failure
Crohn’s Disease
Bowel resection
Partial Parenteral Nutrition:

74. 74
PPN can be used to supplement Ordinary or Tube feeding esp. in malnourished patients.
Indications:
Short bowel syndrome
Malabsorption disorders
Critical illness or wasting disorders
Enteral versus parenteral nutrition
As far as gastrointestinal failure is concerned, long term parenteral nutrition is a
life-saving procedure.
Enteral nutrition has the advantage over parenteral nutrition of lower % of
infectious complications.
Parenteral nutrition has been shown to lead to changes in intestinal morphology
and function and an increase in permeability (with higher % of bacterial
translocation)
Nutritional Requirements
Energy: Glucose, Lipid
Amino acids (Nitrogen)
Water and electrolytes
Vitamins
Trace elements
Energy
✓ Basal energy requirements are a function of the individual's weight, age,
gender, activity level and the disease process.
✓ The estimation of energy requirements for parenteral nutrition relies on predictive
equations.
✓ Hospitalized adults require approximately 25-30 kcal/ kgBW/day. However, these
requirements may be greater in patients with injury or infection.
Energy Sources: Glucose
The most common source of parenteral energy supply is glucose, being:
➢ Readily metabolized in most patients,

75. 75
➢ provides the obligatory needs of the substrate , thus reducing
gluconeogenesis and sparing endogenous protein.
➢ 1 gm of glucose gives 4 Kcals.
Most stable patients tolerate rates of 4-5 mg.kg-1
.Min-1
, but insulin resistance in
critically ill patients may lead to hyperglycemia even at these rates, so insulin
should be incorporated acc. to blood sugar levels.
Route
Glucose in 5% solution can be safely administered via a peripheral vein, but
higher concentrations require a central venous line.
20, 25, or even 50 % solutions are needed to administer meaningful amounts of
energy to most patients for proper volume administration.
Energy Sources: Lipid
Fat mobilization is a major response to stress and infection.
Triacylglycerols are an important fuel source in those conditions, even when
glucose availability is adequate.
Need to be restricted in patients with hypertriglyceridemia.
Lipids are also a source for the essential fatty acids which are the building blocks
for many of the hormones involved in the inflammatory process as well as the
hormones regulating other body functions.
Ideally, energy from fat should not exceed 40% of the total (usually 20-30%).
Fat emulsions can be safely administered via peripheral veins, provide essential
fatty acids, and are concentrated energy sources for fluid-restricted patients.
They are available in 10, 20 and 30% preparations.
Though lipids have a calorific value of 9Kcal/g, the value in lipid emulsions is
10Kcal/g due to the contents of glycerol and phospholipids.
Nitrogen
Protein (or amino acids, the building blocks of proteins) is the functional and structural
component of the body, so fulfilling patient’s caloric needs with non-protein calories (fat
and glucose) is essential. Protein requirements for most healthy individuals are 0.8

76. 76
g/kg/day.With disease, poor food intake, and inactivity, body protein is lost with the
resultant weakness and muscle mass wasting.
Critically ill patients may need as high as 1.5-2.5 g protein/kg/day depending on
the disease process: (major trauma or burn > infection or after surgery > standard)
The amount should be reduced in patients with kidney or liver disease.
Daily Protein requirements
Nitrogen Balance = Protein intake in grams ÷ 6.25 – UUN (in grams) + 3
The nitrogen lost in urine derives primarily from amino acids released by protein
breakdown in response to catabolic mediators that include stress hormones
(corticosteroids, catecholamines) and cytokines.
It is a way to assess the sufficiency of protein intake for the patient.
Parenteral amino acid solutions provide all known essential amino acids.
Available a.a. preparations are 3.5 - 15 % (ie contains 3.5-15 gms of protein or
a.a.s/100 mL solution).
1gm of protein = 0.16 gm of N2.
Special a.a. solutions are also available containing higher levels of certain a.a.s,
most commonly the branched-chain ones (valine, leucine and isoleucine), aimed
at the management of liver diseases, sepsis and other stress conditions.
Conversely, solutions containing fewer a.a.s (primarily the essential ones) are
available for patients with renal failure.
Arginine was added to enteral formulae claiming positive effects on immune
function and length of hospital stay.
In some clinical trials, glutamine-enriched solutions improved nitrogen balance
and gut morphology.
❑ Fluids and electrolytes
20–40 mL/kg - daily – young adults
30 mL/kg – daily – older adults
Monitor Sodium, potassium, chloride, calcium, magnesium, and phosphorus.
Daily lab tests to monitor electrolyte status. Normalization of acid-base balance is
a priority and constant concern in the management of critically ill patients.

77. 77
Most electrolytes can be safely added to the parenteral amino acid/dextrose
solution. Sodium bicarbonate in high concentrations will tend to generate carbon
dioxide at the acidic pH of the amino acid/glucose mix.
❑ Vitamins
These requirements are usually met when standard volumes of a nutrient mix are
provided. Increased amounts of vitamins are usually provided to severely ill
patients.
Vitamins are either fat soluble (A,D,E,K) or water soluble (B,C). Separate
multivitamin commercial preparations are now available for both.
Multivitamin formulations for parenteral use for adult patients usually contain 12
vitamins at levels estimated to provide daily requirements.
Additional amounts can be provided separately when indicated. Most adult
vitamin formulae do not contain vitamin K, which is added according to the
patient’s coagulation status.
❑ Trace minerals
These are essential component of the parenteral nutrition regimen. A multi-
element solution is available commercially, and can be supplemented with
individual minerals. May be toxic at high doses.
Iron is excluded, as it alters stability of other ingredients. So it is given by
separate injection (iv or im).
Minerals excreted via the liver, such as copper and manganese, should be used
with caution in patients with liver disease or impaired biliary function.
Osmolarity:
PPN: Maximum of 900 milliosmoles / liter
TPN: as nutrient dense as necessary (>900 m.osmol and up as high as 3000).
Amino acids (10 m.osmol/gm), dextrose (5 m.osmol/gm) and electrolytes (2
m.osmol /mEq) contribute most to the osmolarity, while lipids give 1.5
m.osmol/gm.

78. 78
Routes of administration of parenteral feeds
Intravenous solutions can be provided in different ways. The methods used depends on
the persons immediate medical and nutrient need, nutrition status, and anticipated length
of time on IV nutrition support. They include:
1. Peripheral Parenteral Nutrition (PPN) – Refers to use of peripheral veins to
provide a solution that meet nutrient needs.
It provides partial nutritional requirements and therefore can only be used for 3 –
6 days when used a sole source of nutrients.
PPN can be administered in to peripheral veins if solutions used have low
osmolarity (250 – 600mOsml). The peripheral catheter should be changed every
24 – 48hrs. to reduce risk of thrombophlebitis.
PPN though not complete in carbohydrates, fats, and trace elements, should be
complete in proteins, electrolytes and water.
2. Total Parenteral Nutrition (TPN) – Refers to the use of central vein to provide a
solution that meets nutrient needs. To achieve this most of the solutions used are
of high osmolarity (> 600 mOsm/L) and are therefore administered into central
veins usually the superior vena cava which is reached via the internal jugular or
sub-clavian veins. The dosage should be according to requirements and must be
complete in all nutrients i.e. amino acids, carbohydrates, electrolytes, trace
elements, vitamins and water. TPN can be administered over unlimited periods of
time.

79. 79
Figure 2: Routes of parenteral administration.
Precautions in parenteral nutrition
1. Nutritional adequacy – TPN should be nutritionally adequate with calories ratios
similar to those in the physiological nutrition i.e.
• 50 – 60% from CHO (< 0.36g CHO/Kg/Hr).
• 12 – 35% from PRO.
• 25 – 35% from FAT (or up to 60% fat as long as dosage does not exceed
2g/kgBwt/day).
2. Calorie nitrogen ratio – An adequate energy provision is necessary to support the
use of protein for anabolism. The recommended non-protein calorie nitrogen ratio
(C:N) for the different conditions is as follows:
o For normal body maintenance C:N = 300:1 gN.
o Stressful conditions C:N = 150:1 gN.
o Renal failure C:N = 250: 1 gN.
o PPN C:N = 70:1 gN.

80. 80
o Children C:N = 300:1 gN.
3. Osmolarity – ensure appropriate osmolarity is infused via the appropriate veins to
avoid thrombosis and small blood vessel damage.
Calculation of the osmolarity of a parenteral nutrition solutions
o Multiply the grams of dextrose per liter by 5.
Example: 50g of dextrose x 5 = 250mOsm/L.
o Multiply the grams of protein per liter by 10.
Example: 30g of protein x 10 = 300mOsm/L.
o Fat is isotonic and does not contribute to osmolarity.
o Electrolytes further add to osmolarity.
Total osmolarity = 250 + 300 = 550mOsm/L
4. Infusion rate – Always check label and package inserts. The maximum infusion
rate recommended for specific solutions should not be exceeded in order to avoid
complications e.g. hyperglycemia if too much CHO is infused,
hypertriglyceridimia if too much fat is infused or hyperaminoacidemia if too
much amino acids are infused.
5. Infuse around the clock – To ensure total volume is given at appropriate rate
infused around the clock (over 24 hours).
6. Infuse parallel or premixed
o It is best to infuse parallel. If not possible solution could be premixed but
compatibility must be first ensured. Lipid solutions should not be
premixed as this could cause formation of fat globules resulting in fat
emboli.
o If parallel infusion is not possible then infuse directly.
o First CHO with electrolytes, second amino-acid with electrolytes, third fat.

81. 81
Administration of parenteral feeds
a) Parenteral feeding infusion should be started slowly and volume increased
gradually to ensure patient tolerance to lipid emulsion, concentrated dextrose and
total volume.
b) Vital signs should be monitored daily.
c) Discontinuation should also be gradual to avoid hypoglycemia.
d) Standard IV olutions can be used for a while as enteral nutrition is introduced.
Application:
The Solution
Manually mixed in hospital pharmacy or nutrition-mixing service,
premixed solutions,
Separate administration for every element alone in a separate line.
Venous access
PPN: (<900 m.osmol/L): a peripheral line can be enough.
TPN: Central venous access is fundamental Ideally, the venous line should he
used exclusively for parenteral nutrition.
Catheter can be placed via the subclavian vein, the jugular vein (less desirable because of
the high rate of associated infection), or a long catheter placed in an arm vein and
threaded into the central venous system (a peripherally inserted central catheter line)
Once the correct position of the catheter has been established (usually by X ray), the
infusion can begin.
Initiation of Therapy
TPN infusion is usually initiated at a rate of 25 to 50 mL/h. This rate is then increased by
25 mL/h until the predetermined final rate is achieved.
Administration

82. 82
To ensure that the solution is administered at a continuous rate, an infusion pump is
utilized to administer the solution. In hospitalized patients, infusion usually occurs over
22-24 h/day. In ambulatory home patients, administration usually occurs overnight (12-
16 h).
Monitoring
1- Effecacy: electrolytes (S. Na, K, Ca, Mg, Cl, Ph), acid-base, Bl. Sugar, body weight,
Hb.
2- Complications: ALT, AST, Bil, BUN, total proteins and fractions.
3- General: Input- Output chart.
4- Detection of infection; Clinical (activity, temp, symptoms) WBC count (total &
differential) Culture
Complications of TPN
Sepsis
Pneumothorax
Air embolism
Clotted catheter line
Catheter displacement
Fluid overload
Hyperglycemia
Rebound Hypoglycemia
Catheter-related complications
Catheter sepsis: which can be localized or systemic (skin portal, malnutrion, poor
immunity).

83. 83
ccc by: fever, chills, ±drainage around the catheter entrance site, Leukocytosis, +ve
cultures (blood & catheter tip).
ttt:1- exclusion of other causes of fever
2- short course of anti-bacterial and antifungal therapy (acc. to C&S)
3- Catheter removal may be required
Prevention: a rigorous program of catheter care:
✓ Only i.v. nutrition solutions are administered through the catheter, no blood may
be withdrawn from the catheter.
✓ Catheter disinfection and redressing 2 to 3 times weekly.
✓ The entrance site is inspected for signs of infection and if present, culture is taken
or the catheter is removed.
Other catheter-related complications:
Thromboembolism, pneumothorax, vein or artery perforation, and superior vena cava
thrombosis
Metabolic Complications
Hyperglycemia (an elevated blood sugar): Associated with the infusion of excess
glucose in the feeding solution or the diabetic-like state in the patient associated
with many critical illnesses.
It can result in an osmotic diuresis (abnormal loss of fluid via the kidney),
dehydration, and hyperosmolar coma.
ttt: decrease the amount of infused glucose (to<4 mg/kg/min) OR insulin can be
administered (either S.C. inj. or incorporation in the infusion bag).
Hypertriglyceridemia (High S. Triglycerides). Associated with excess infusion of
fat emulsion.

84. 84
N.B. Infusion of both glucose and fat emulsion in excess may result in pulmonary
insufficiency.
Excess glucose infusion –> excess carbon dioxide (CO2) production a result of glucose
metabolism.
Excess lipid infusion --> the lipid particles may accumulate in the lungs and reduce the
diffusion capacity of respiratory gases.
o liver toxicity (also know as parenteral nutrition cholestasis): It causes severe
cholestatic jaundice, elevation of transaminases, and may lead to irreversible liver
damage and cirrhosis.
Multiple causes have been proposed, including high infusion rates of aromatic amino
acids, high proportion of energy intake from glucose, e.t.c..
There is no specific treatment, other than anticholestatic therapy.
o Intestinal bacterial translocation:
The lack of direct provision of nutrients to the intestinal epithelia during total parenteral
nutrition →Trophism and altered permeability of the GI mucosa, thus compromising any
potential recovery of the patient’s ability for enteral feeding, and allowing bacterial
entery to blood stream → sepsis
Prevention is to provide a minimal enteral nutrition supply to avoid or minimize this
risk.
Other metabolic complications:
Electrolyte imbalance, mineral imbalance, acid-base imbalance, toxicity of
contaminants of the parenteral solution.
Catheters and tubing may become clotted or twist and obstruct. Pumps may also fail or
operate improperly.