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1.

Discuss nutrition
1.1 Definition/description of Terms:

Undernutrition
risk of infection

inadequate in energy
& or nutrients

Nutrition
Science that deals with:

- biological processes by which living organisms


consume food & utilize the nutrients it contains for
normal body structure & functions:
energy utilization
growth, maintenance, development
reproduction
homeostasis
adaptation
response to environment
- factors that influence food preferences:
psychological
social
cultural
economic
technological

- proper balance diet to promote health, esp. in


human beings
Food
Any substances that is eaten or taken in & assimilated into
the body
Give nourishment to living organisms
Nutritionally adequate diet satisfies 3 needs:

- fuel (chemical energy) for all the cellular work of the


body
- organic raw materials for biosynthesis
- essential nutrients (substances that animals cant
make for itself from any raw material)

Nutritional status
State of the body as a result of bodys food intake & use of
energy
Can identify nutritional needs of an individual or population
based on

- developed standards for the amount of nutrients we


need plans to meet these needs

disease
Lack of medical care

rural, traditional diets


Optimal nutritional status
risk of chronic &
infectious diseases

adequate &
prudent
affluent modern diets
nutritionally adequate
but imprudent
inactivity, alcohol
smoking, stress

Obesity
coronary heart disease
diabetes
hypertension
stroke
indicates nutrition transition
rural, traditional
diets
Fat
Sugar
Fiber

Low
Low
High
Monotonous,
little variety
Mainly
carbohydrate
staples

affluent modern
diets
Western diets
High
High
Low
Diverse,
Varied
High in animal
protein

Malnutrition
Affects individuals at every stage of life (cycle)
Have major impact on health & productivity of an
individual or a population
Impairment of health resulting from imbalance of
nutrients thru:

- malabsorption
- improper diet: poor diet or overeating
too much or too little of one or more nutrients
or energy

Symptoms:

- appear rapidly
- take a lifetime to develop (chronic)
- an important health concerns:
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- osteoporosis, cancer, heart disease (w/c is also


due to other risk factors such as age, gender
and genetics)
Two forms: overnutrition or undernutrition
Overnutrition
Excess intake of 1 nutrients & calories
Food consumed in excess of energy needed is stored as
body fat
energy store & insulation
obesity: risk of high BP, ! disease, diabetes, other
chronic health problems
Excess of specific nutrients (vitamins & mineral
supplements) consumed

adverse/toxic reaction in the body

Undernutrition
Deficient intake of 1 nutrients or energy
Starvation: most severe form
- deficiency of energy (calorie) weight loss, poor growth,
inability to produce, & death (if severe enough)
Symptoms often reflect body functioning that rely on the
deficient nutrient
Common forms:
Iron deficiency
rapid growth & need of iron common in children &
adult
chronic loss of iron due to blood loss (hook-worm
infection, malaria, & other acute/chronic infections)
diets w/ inadequate amounts of iron-containing foods
to meet individual needs, or those that limit iron
bioavailability
iron deficiency anemia
risk of maternal & fetal mortality, premature
delivery & low birth weight

children: stunt growth & retard mental devt.,


resistance to infections, morbidity due to
disease
older child & adult: fatigue & productivity

Iodine deficiency

goiter (12% of global popn) - iodine: essential


constituents of thyroid hormone

preventable brain damage & mental retardation


pregnancy: incidence of stillbirths, spontaneous
abortion, developmental abnormalities such as
cretism
children: IQs & impaired school performance
adults: associated w/ apathy & decision-making
capabilities

Vit B12 deficiency


changes in the stomach that occur w/ age (risk
for older adults)
Vit. A deficiency
- often accompanied by anemia
rapid growth & devt. (infancy, early childhood,
pregnancy, lactation)
low intake/absorption of vitamin (A) & other
nutrients (fat, protein & zinc) in relation to the
need
- inc Vit A need: frequent infections (such as those
causing diarrhea) & illness (measles)
blindness; depress immune function that risk of
infection

Protein-energy malnutrition (PEM)


- protein & energy deficiencies usually occur
together
- protein deficiency can predominate in
growing, developing, or healing individuals
Protein roles
Synthesis of
new tissue
Immune func.
Melanin
synthesis

Protein deficiency
growth in height & weight

susceptibility to infection
Skin flakes; Digestive tract
cells die & cant be replaced
impair absorption
- refer to continuum of conditions ranging from
Kwashiorkor - pure protein deficiency, to
Marasmus - energy deficiency (pls. refer to #2)

Desirable body weight


Body wt. of a person in kg or lb that gives or would
give a normal body mass index in relation to height2
of that person
1.2 Nutritional Status: Formula used
Theres >1 way to compute for desirable/ideal wt:
Thanhaussers method
- in absence of Ht. & Wt. table
- formula:
Ht (cm) 100cm = wt. (kg) for western standard (10% wt for Filipinos)
1 in. = 2.54 cm
eg, 157cm100cm=57kg57(10%) =51kg
normalrange: 10 of Desired body wt
> normal range: underweight
< normal range: overweight

Body Mass Index (BMI)


- anthropometric measure that uses height & wt. to
estimate nutritional status in adults
- 1st used by Adolphe Quetelet in 1870 and was known as
Quetelets Index
- (BMI), where:

- Nomogram in determining BMI


Morbidly obese
40 70 kg/m2
Obese
30 39.9 kg/m2
Overweight
26 29.9 kg/m2
Normal
18.5 25.9 kg/m2
Underweight
8.5 18.4 kg/m2
- Values of BMI in healthy individuals usually fall within
the range 18.5 to 25.9 kg/m2
- Both high and low BMI are associated with increased
morbidity and mortality
< normal BMI range: underweight; >: obesity
- BMI can also indicate body shape. Ex, many African
populations are very tall and slim and hence have a
very low BMI, whereas Inuit, who are short and stocky,
have a high BMI

1.3 Compute your desirable body weight & comment


on your nutritional status
Examples:
Computed DBW:
157cm100cm=57kg57(10%) =51kg
Actual body wt.: 40 kg
Comment: underweight
Computed DBW:
157cm100cm=57kg57(10%) =51kg
Actual body wt.: 60 kg
Comment: Normal weight
Computed DBW:
157cm100cm=57kg57(10%) =51kg
Actual body wt.: 70 kg
Comment: overweight
Normal range: the DBW

Estimation frame size using elbow breath


Elbow breath
MEN Height
in 1-inch heels
5 ft 2 in. 5 ft 3 in
2 - 2 in.
5 ft 4 in. 5 ft 7 in
2 - 2 in.
5 ft 8 in. 5 ft 11 in
2 - 3 in.
6 ft 0 in. 6 ft 3 in
2 - 3 in.
5 ft 4 in. & over
2 - 3 in.
Elbow breath
WOMEN Height
in 1-inch heels
4 ft 10in. 4 ft 11 in
2 - 2 in.
5 ft 0 in. 5 ft 3 in
2 - 2 in.
5 ft 4 in. 5 ft 7 in
2 - 3 in.
5 ft 8 in. 5 ft 11 in
2 - 3 in.
6 ft & over
2 - 2 in.
- elbow breath: distance bet bony protrusions of elbow
(right arm raised to horizontal, elbow flex to 900, w/ back
of the hand facing the measurer)
- medium frame: w/n range indicated
- small frame: measurements < indicated
- large frame: measurements > indicated
- elbow

Differentiate the clinical features of the 2 types of undernutrition


Marasmus
often in children fed w/ diluted infant formula due to
limited supply (children fed w/ cassava instead of
protein-rich milk)
less in breast-fed infants
severe PEM (energy but also protein & other nutrients
deficiency)
protein:calorie is normal but total intake is not enough
to prevent weight loss
fat stores have been used to provide energy
- generalized wasting: muscle & body fat
- decreased body wt., & wrinkled face
emaciated look, not so apathetic
thin & dry hair

no edema present
- increased lipofuscin in most visceral organs (esp,
heart & liver)

diarrhea frequently present


pulse, BP & temperature low
anemia
growth failure
impaired immune responses infections

Kwashiorkor
common in children
seen in hospitalized adults who have high-protein needs
due to infection or trauma & a low-protein intake
because they are unable to eat (intravenous 5%
dextrose or clear diet)
protein deficient: serum albumin & transferring severely
diminished
fat stores retained, energy intake is adequate
apathetic & lethargic w/ severe anorexia
skin depigmentation & thickening; dermatosis
- flaky paint skin lesions on face & extremities are dry
& hyperkeratotic
- fine depigmented, reddish hair color that may fall out in
patches from normal brown hair
- linear depigmentation of hair
generalized edema
abdomen distended due to:
flaccid abdominal muscle
hepatomegaly (enlargement of liver due to fat
accumulation because theres not enough protein to
transport it)
& / or ascites (because theres not enough protein
to keep fluid in the blood)
general atrophy of viscera or villous atrophy of the intestine
may interfere nutrient absorption
diarrhea is common
anemia: usual feature but not generally life-threatening
generalized growth failure (absent /mild)

2. Discuss the fat soluble vitamins as to:


Fat soluble/lipid soluble vitamins are polar hydrophobic compounds that can only be absorbed efficiently when there is normal
fat absorption. They are transported in the blood, like any other apolar lipid, in lipoproteins or attached to specific binding proteins. They
have diverse functions, e.g., vitamin A, vision; vitamin D, calcium and phosphate metabolism; vitamin E, antioxidant; vitamin K, blood
clotting. As well as dietary inadequancy, conditions affecting the digestion and absorption o the lipid-soluble vitaminssuch as
steatorrhea and disorders of the biliary systemcan lead to deficiency syndromes, including: night blindness and xerophthalmia
(vitamin A); rickets in young children and osteomalacia in adults (vitamin D); neurologic disorders and anemia of the newborn (vitamin
E); and hemorrhage of the newborn (vitamin K). Toxisity can result from excessive intake of vitamins A and D. Vitamin A and beta
carotene (provitamin A), as well as vitamin E, are antioxidants and have possible roles in atherosclerosis and cancer prevention.

Vitamin A found preformed and in precursor or provitamin forms in our diet.


1. vitA. Dietary Sources
Retinoids preformed vitamin A compounds which include retinal, retinol, and retinoic acid.
n Found only in foods of animal origin such as liver, fish, egg yolks, and dairy products
Carotinoids- provitamin which comprises carotenes and other related compounds
n found in plants including carrots, cantaloupe, apricots, mangoes, and sweet potatoes
n Alpha, Beta, Gamma carotenes, and cryptoxanthin are most important provitamin carotenoids
n Alpha carotene- found in leafy green vegetables, carrots and squash
n Beta cryptoxanthin- found in corn, green peppers and lemons
2. vitA. Daily Requirements
900 microgram per day men
700 microgram per daywomen
3. vitA. Biochemical and Physiologic Role
A. Visual pigments in the retina
- retinal form of vitamin combines with the protein opsin to form the visual pigment rhodopsin which helps
transform the energy from light into a nerve impulse, which allows us to see, to be sent to the brain.
B. Regulation of Gene Expression and Cell Differentiation
- regulated by all-trans-retinoic acid and 9-cis-retinoic acid
- means that it can turn on or off the production of certain proteins that regulate functions within the cells and
throughout the body.
- In order to affect gene expression:
Retinoic acid form of vitamin A enters specific target cell

(inside nucleus) retinoic acid binds to protein receptors

Retinoic acid-protein receptor complex then binds to regulatory regions of DNA

Changes the amount of messenger RNA (mRNA) that is made by the gene

Change in mRNA changes the amount of protein that is produced

Turning on (or off) of the gene increases (or decreases) the production of proteins

Affects various cellular functions (ex. Vitamin A turns on a gene that makes an enzyme in liver cells, which enable the liver to make
glucose by gluconeogenesis)
C. Maintenance of Epithelial Tissue
- Includes skin, linings of the eyes, intestines, lungs, vagina, and bladder
- If vitamin A is deficient, epithelial cell do not differentiate normally because vitamin A is not there to turn on or
off the production of particular proteins
Ex.: Epithelial tissue on many body surfaces contains cells that produce mucus for lubrication. When
mucus-secreting cells die, new cells differentiate into mucus-secreting cells to replace them, but when
vitamin A is deficient, the new cells do not differentiate properly and instead become cells that produce
a protein called keratin which is a hard protein that makes up the hair and fingernails.
D. Reproduction Growth and Immunity
- In reproduction, vitamin A play a role during embryonic development by directing cells to form the shapes
and patterns needed for a completely formed organism
- In growth, vitamin A affects the activity of cells that break down bone
- In immunity, vitamin A is needed for the differentiation that produces the different types of immune cells
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E. Beta Carotene (-carotene)


- Beta carotene (carotenoids) can be converted to vitamin A in the intestinal mucosa and unconverted
carotenoids also reach the blood and tissues where they may function as antioxidants, a role independent of
any conversion to vitamin A
- Beta carotene and other carotenoids are antioxidants that play a role in protecting cell membranes from
damage by free radicals
- Antioxidant properties of carotenoids have stimulated interest in their ability to protect against diseases in
which oxidative process play a role, such as cancer, heart disease, and impaired vision due to muscular
degeneration and cataracts.
4. vitA. Active Form
A. Retinoids
a. retinol
b. retinaldehyde
c. retinoic acid
B. Carotenoids
a. -carotenes
b. -carotenes
c. -carotenes
d. cryptoxanthin

In the retina, retinaldehyde functions as the prosthetic group of the light-sensitive opsin proteins, forming rhodopsin (in rods) and
iodopsin (in cones)
Any cones in the cells contain only one type of opsin and are sensitive to only one color
In the pigment epithelium of the retina, all trans retinal is isomerized to 11-cis-retionol and oxidized to 11-cis retinaldehyde
This reacts with a lysine residue in opsin, forming the holoprotein rhodopsin
Absorption of light by rhodopsin cause isomerization of the retinaldehyde from 11cis to al-trans and a conformational change in
opsin
Result in the release of retinaldehyde from the protein and the initiation of a nerve impulse
Formation of the initial excited form of rhodopsin, bathorhodopsin, occurs within Pico seconds of illumination
Then a series of conformational change leading to the formation of metarhodopsin II, which initiates a guanine nucleotide
amplification cascade and then a nerve impulse
Final step is hydrolysis to release an all-trans-retinaldehyde and opsin.
The key to initiation of the visual cycle is the availability of 11-cis-retinaldehyde hence vitamin A
In deficiency both the tie taken to adapt to darkness and the ability to see in poor light is impaired.

5. vitA. Synthesis
Carotenoid (Carotenes, Cryptoxanthin, and related compounds from plants)
Provitamin A (from animals)
Cleaved by enzyme carotene dioxygenase
(Asymmetric cleavage)
Retanaldehyde

Retinol

8-, 10-, 12-apo-carotenals

Retinoic acid

6. vitA. Manifestations of Deficiency:


Earliest sign of deficiency is a loss of sensitivity to green light, followed by impairment of adaptation to dim light, then followed
by night blindness.
Prolonged deficiency leads to xerophthamia (keratinization of cornea and skin, and blindness).
In differentiation of immune cells, mild deficiency leads to increased susceptibility to infectious disease.
Furthermore, synthesis of retinol-binding protein in response to infection is reduced, decreasing the circulating vitamin and
therefore, a further impaiment of immune responses.
Vitamin A is toxic in excess
Excessive intakes lead to accumulation beyond the capacity of binding proteins, so that unbound vitamin A causes
tissue damage.
Symptoms affect CNS ( headache, nausea, ataxa, anorexia, all associated with increased cerebrospinal fluid pressure), the liver
(hepatomegaly with histologic changes and hyperlipidemia), calcium homeostasis (thickening of the long bones, hypercalcemia,
calcification of soft tissues), and the skin (excessive dryness, desquamation, and alopecia).

Vitamin D
1. vitD. Dietary Sources
egg yolk, liver, fish oils, salmon, fortified margarine and milk, sunlight
2. vitD. Daily Requirements
5-15 mg recommended intake for adult
The recommended intake of vitamin D is based on the amount needed in the diet to maintain normal blood of 25-hydroxy
vitamin D3
The AI for adult men and women is set at 5 microgram per day. The AI is expressed in microgram but the vitamin D content of
foods and supplements may also be given as International Units ( IU ); one IU is equal to 0.025 microgram of vitamin D3
(40 IU=1 microgram of vitamin D.)
The AI for vitamin D for adults is contained in about 2 cups of vitamin D-fortified milk
3. vitD. Biochemical and Physiological Role
- Maintenance of calcium balance; enhances intestinal absorption of Ca2+ and mobilizes bone mineral.
- The principal function of vitamin D is to maintain normal blood levels of calcium and phosphorus. When calcium blood
levels drop too low, the parathyroid gland releases parathyroid hormone (PTH). PTH release stimulates enzymes in the
kidney to convert 25-hydroxy vitaminD3 to active form of the vitamin
4. vitD. Active Form
- Active vitamin D regulates calcium and phosphorus balance by altering gene expression in cells at the intestine and bone.
At the intestine, Vitamin D increases the absorption of calcium and phosphorus. This occurs because vitamin D increases
the expression of gene that code for intestinal calcium transport proteins
- At the bone, vitamin D works in conjunction with the PTH to increase bone breakdown, releasing calcium and phosphorus
into the blood. This occurs because vitamin D causes precursor cells in the bone to differentiate into cells that breakdown
the kidneys
- In addition to bone, intestine and kidney, receptors for active vitamin D have been found in the pancreas, parathyroid
gland, cells of the immune system and reproductive organs.
5. vitD. Synthesis
- Vitamin D is synthesized in the skin
- 7- Dehydrocholesterol (an intermediate in the synthesis of cholesterol that accumulates in the skin), undergoes a
nonenzymic reaction on exposure to ultraviolet light , yielding previtamin D
- Undergoes a further reaction over a period of hours to form the vitamin itself, cholecalciferol, which is absorbed into the
bloodstream.
6. vitD. Manifestations of Deficiency
- In the vitamin D deficiency, rickets, the bones of children are undermineralizrd as as result of poor absorption of calcium.
Similar problems occur in adolescent who are deficient during the growth spurt.
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Osteomalacia in adults results from demineralization of bone in women who have little exposure to sunlight, often after
several pregnancies. Although vitamin D is essential for prevention and treatment of osteomalacia in the elderly, there is
little evidence that it is beneficial in treating osteoporosis

Vitamin E
A fat soluble substance with an anti-oxidant function
First identified as a fat-soluble component of graits that was necessary for fertility in lab rats
Has chemical name for vitamin e, tocopherol, is from the Greek word tos (meaning child birth) and pheros (meaning to bring forth).
Promoted as a cure for infertility, an anti-scar medication, a defense against air pollution, and a fountain of youth.
1. vitE. Dietary Sources
Vitamin E can be found in vegetable oils, leafy green vegetables, nuts and peanuts
2. vitE. Daily Requirement
The recommendation for vitamin e intake is based on the amount needed to maintain plasma concentrations of alphatocopherol that protects the red blood cells from breaking
RDA for adult men and women is set at 15 mg/day of Alpha-tocopherol; the RADA does not change with advancing age.
For infants, an adequate intake for vitamin e had been set based on the amount consumed by infants fed principally with
human milk
RDA for children and adolescent have been estimated for adult values
Vitamin E is relatively non-toxic. The UL is 1000mg/day from supplemental sources.
Supplement should not be taken by individuals taking blood-thinning medications because it reduces blood clotting and
interferes with the action of Vitamin K.
3. vitE. Biochemical and Physiological Role
Vitamin E functions as an antioxidant. It neutralizes reactive oxygen compounds before they damage unsaturated fatty acids in
the cell membranes.
By protecting the cell membranes, vitamin E is important in maintaining the integrity of the RBC, cells in the nervous tissue and
cells of the immune system
Vitamin E is a chain-breaking, free radical trapping anti-oxidant in cell membrane and plasma lipoproteins.
It reacts with the lipid peroxide radicals formed by peroxidation of polysaturated fatty acids before they can establish chain
reaction
The tocopheroxyl radical is reduced back to tocopherol by the reaction with vitamin C from plasma. The resultant
monodehydroascorbate free radical then undergoes enzymatic or non-enzymatic reaction to yield ascorbate or
hydroascorbate, neither of which is a free radical.
The stability of the tocopheroxyl free radical means that it can penetrate further into the cells and potentially propagate a chain
reaction. Therefore vitamin E may also inhibit an enzyme that allows the build-up of atherosderotic plaque and increase the
synthesis of an enzyme needed to produce eicesinoid that help lower BP and reduce blood clotting formation.
4. vitE. Active Forms
Alpha tocopherol
The form that can meet the vitamin e requirements in humans
The other forms do not meet the vitamin E needs because they must be converted to alpha-tocopherol in humans and cannot be
transported by the alpha-tocopherol transfer protein
There are also differences between the natural and synthetic alpha-tocopherol found in dietary supplement and fortified foods.
5. vitE. Synthesis
6. vitE Manifestation of Deficiency
Vitamin E deficiency results in resorption of fetuses and testicular atrophy.
Although vitamin E deficiency is uncommon, supplements are
promoted to grow hair;
restore, maintain, and or increase sexual potency and fertility;
alleviates fatigue;
maintain immune function;
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enhance athletic performance;


reduces symptoms of PMS;
slow aging;
prevent heart disease and cancer
and treat a host of other medical problems
Vitamin E protects membranes, therefore a deficiency can cause membrane changes; RBC nerve tissue are particularly
susceptible
Newborn infants have low blood tocopherol level because there is little transfer of vitamin e from mother to fetus until the last
week of pregnancy. In these infants, ruptured RBC may cause hemolytic anemia

Vitamin K
Discovered as a result of investigations into the cause of bleeding disorder (hemorrhagic or sweet clover disease) of cattle, and of
chickens fed on a fat free diet.
Vitamin K was name for KOAGULATION, the Danish word for COAGULATION, or blood clotting.
1. vitK. Dietary Sources
The best sources of vitamin K are the leafy green vegetables such as spinach, broccoli, brussel sprouts, kale and turnip
greens, and some plant oils.
Some vitamin K are also secreted by bacteria in the human gastrointestinal tract.
The following are some of the dietary sources of vitamin K:
Mustard greens
Kiwi
Soy bean oil
Carrots
Lentils
Tomato
Margarine

Whole wheat bread


Apricots
Beef liver
Sun Flower seeds
Almonds
Oat meal

2. vitK. Daily Requirements


Unlike other fat soluble vitamins, vitamin K is used rapidly by the body, so a constant supply is necessary.
Adequate intake for men is 120 microgram per day, for women is 90 microgram per day.
Adequate intake for infants is set based on the amount typically consumed in beast milk.
3. vitK. Biochemical and Physiologic Role
Vitamin K is needed for the production of the blood clotting factors, this proteins are needed to produce fibrin, the proteins that
forms the structure of a blood clot.
Vitamin K is the co-enzyme for carboxylation of glutamate in the post synthetic modifications of calcium binding proteins.
Vitamin K is the co-factor for the carboxylation of glutamate residues in the post synthetic modification of proteins to
form the unusual amino acids -carboxyglutamate (Gla), which chelates the calcium ion.
Initially, vitamin K hydroquinone is oxidized to the epoxide, which activates glutamate residues in the protein
substrate to a carbanion, that reacts non enzymatically with carbon dioxide to form -carboxyglutamate.
Vitamin K epoxide is reduced to the quinone by a warfarin-sensitive reductase, and the quinone is reduced to the
actual hydroquinone by either the same warfarin-sensitive reductase or warfarin-insensitive quinone reductase.
In the presence of warfarin, vitamin K epoxide can not be reduced accumulate and is excreted.
If enough vitamin K is provided in the diet, it can be reduced to the active hydroquinone by the warfarin-insensitive
enzyme, and carboxylation can continue, with utilization of vitamin K and excretion of epoxide.
A high dose of vitamin K is the antidote to overdose of warfarin.
Prothrombin and several other proteins of the blood clotting system ( Factors VII,IX and X, and proteins C and S)
each contains between 4 to 6 -carboxyglutamate residues which chelate calcium ion and so permit the binding
of the blood clotting proteins to membranes.

Carboxyglutamate residue
non-enzymatic
O2

O2
Glutamate residue

Glutamate Carbanion
Vitamin K
epoxidose

Vitamin K hydroquinone

Vitamin K
epoxide

disulfide
vitamin K quinone reductase
NADP+
quinone
reductase

sulfhydryl Vitamin K
quinone

NADPH
Fig. 1 Role of vitamin K in biosynthesis of -carboxyglutamate
Vitamin K is also important in the synthesis of bone calcium-binding proteins.
Treatment of pregnant women with warfarin can lead to fetal bone abnormalities (fetal warfarin syndrome).
Two proteins are present in bone that contains -carboxyglutamate, osteocalcin, and bone matrix Gla protein.
Osteocalcin also contains hydroxyproline, so its synthesis is dependent on both vitamin K and C: its synthesis is
induced by vitamin D.
4. vitK. Active Forms
Phylloquinone
The normal dietary source
Found in the green vegetables
Menaquinones
The form of vitamin K found in supplements.
Synthesize by the intestinal bacteria
With differing lengths of side chain:
Menadione
Menadiol
Menadiol diacetate
*This three synthetic compounds can be metabolized to phylloquinone
5. vitK. Synthesis
6. vitK. Manifestations of Deficiency
Abnormal blood coagulation is the major symptom of vitamin K deficiency.
An abnormal precursor of prothormbin (pre-prothrombin) containing little or no -carboxyglutamate, and incapable of
chelating calcium ion, is released into the circulation.
Inability to form blood clots due to vitamin K deficiency or drugs that interfere with vitamin K activity can caused death
from excessive blood loss.

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Vitamin
A

Retinol

Calciferol

Tcopherols,
Tocotrienols

Phylloquinone,
Menaquinones

Source:
Liver fish,
carrot,
peaches,
leafy
greens,
fortified milk
Egg yolk,
liver, fish,
tuna,
salmon,
fortified
margarine
and milk
Vegetable
oil, leafy
greens,
nuts,
peanuts
Vegetable
oil, leafy
greens,
intestinal
bacteria

Recommended
Intake for
adults
700 900 mmg

Deficiency
manifestation
Night blindness;
Xerophthalmia
(keratinization of
cornea skin)

5 1 mmg

Rickets poor
mineralization of
bone
Osteomalacia
(bone
demineralization)

15 mmg

Serious
neurological
function
(extremely rare)

90 120 mmg

Impaired blood
clotting,
hemorrhagic
disease

Tolerable Upper
intake level

Groups at risk

Toxicity

Those living in
poverty.
Children and
pregnant women.
Those of low fat or
low protein
Breast-fed infants,
children and elderly
(especially with
dark skin and little
sun exposure,
people with kidney
disease
Those with poor fat
absorption.
Premature infants

Headache,
vomiting, hair
loss, liver
damage, skin
changes, birth
defects
Calcium
deposits in
the soft
tissue, growth
retardation,
kidney
damage
Inhibition of
vitamin K
activity

3000 mmg/day

People with longtern antibiotics use,


newborns
(especially
premature)

Brain damage

ND (insufficient
evidence to set
an UL)

50 mmg/day

1000 mmg/day

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3. Identify descriptions of the water soluble vitamins to include:


Water-soluble
vitamins

Vitamins B1
(thiamin)

Vitamin B2
(riboflavin)

Niacin
(nicotinic
acid,
nicotinamide)

Dietary
Sources

Daily
Requireme
nts

Whole
grain
and
enriche
d
breads,
cereals
, flours; Adult male:
organ
1.5
meats,
mg/day
pork,
Adult
other
female:
meats,
1.1
poultry,
mg/day
fish,
legume
s, nuts,
milk,
green
vegeta
bles

Milk,
organ
meats,
eggs,
green
leafy
vegeta
bles

Adult male:
1.7
mg/day
Adult
female:
1.3
mg/day

Meat,
poultry,
fish,
whole
Adult male:
grain
19
and
mg/day
enriche
Adult
d
female:
breads,
15
flours,
mg/day
cereals
, nuts,
legume
s

Metabolic/physio
logic role

Central role in
energy-yielding
metabolism and
metabolism of
CHO
(decarboxylatio
n of pyruvate
and alpha-keto
acids), nervous
function

Active Form

Thiamine
diphosphate

Fulfills its role in


metabolism as
the coenzymes
flavin
mononucleotide
(FMN) and
flavin adenine
dinucleotide
(FAD);
oxidation,
reduction
enzymatic
reactions

Mononucleotide(
FMN) or Flavin
Adenine
dinucleotide

Oxidationreduction
reaction,
functional part
of NAD and
NADP

Nicotinamide
Adenine
Dinucleotide
(NAD+) and
Nicotinamide
Adenine
Dinucloetide
Phosphate
(NADP+)

Synthesis

Thiamin
diphosphat
e
(Thiamin
diphospaht
ase)

Thiamin

FMN formed
by ATP
dependent
phosphoryl
ation of
riboflavin
whereas
FAD is
synthesize
d by a
further
reaction
with ATP in
w/c the
AMP
moiety of
ATP is
transforme
d to FMN
Nicotinate is
converted
to
desamidoNAD+ by
reaction
first w/ 5phosphorib
osyl 1pyrophosp
hate
(PRPP)
and then
by

Manifestations
of deficiency

Infants: dyspnea,
cyanosis,
diarrhea,
vomiting
Adults: beriberi
(fatigue,
peripheral
neuritis),
WernickeKorsakoff
syndrome/We
rnickes
encephalopat
hy (apathy,
ataxia, visual
probs.)

Angular
stomatitis
(mouth
lesions),
dermatitis,
photophobia,
neurologic
changes

Pellagra
(dermatitis,
mucous
membrane
inflammation,
weight loss,
disorientation)

Vitamin B6
(pyridoxine,
pyridoxal,
pyridoxamine
)

Vitamin B12
(cyanocobala
min)

Pantothenic
acid (first
designated as
Vitamin B3)

Meat,
poultry,
Adult male:
fish,
2.0
potatoe
mg/day
s,
Adult
sweet
female:
potatoe
1.6
s,
mg/day
vegeta
bles

Involved in amino
acid
metabolism;
enzyme
systems
involving amino
acid
transaminases,
phosphorylases
,
decarboxylases

Pyridoxal
phosphate

In animal
foods
only:
organ
meats,
muscle
meats,
poultry,
fish,
eggs,
milk

Myelin formation,
branched chain
keto acid
metabolism,
folate
interconversion
s, DNA
synthesis

Methylcobalamin
adenosylcobal
amin and
hydroxocobala
min

Adults: 2
ug/day

Meat,
poultry,
fish,
whole
grain
cereals 4-7 mg/day
,
(safe
legume
and
s,
allowabl
mushro
e range)
oms,
salmon
,
smaller

Acyl-group
transfer
reactions (as
part of
coenzyme A
and Acyl carrier
protein)

---------

on w/ ATP.
The amido
group of
glutamine
then
contribute
to form the
coenzyme
NAD+. This
may be
phosphoryl
ated further
to form
NADP+
Most tissues
contain
enzyme
pyridoxal
kinase w/c Infants:
is able to
irritability,
catalyze
seizures,
the
normocytic
phosphoryl
anemia,
ation by
vomiting,
ATP of
weakness
unphospho Adults: facial
rylated
seborrhea
forms of
Stomatitis,
vitamin to
glossitis
their
respective
phosphate
esters.
Pernicious
Anemia(when
lack of
intrinsic
Synthesized
factor)=Megal
by
oblastic
microorgan
anemia with
isms
degeneration
of the spinal
cord,
neurologic
abnormalities

----------

Normally not
seen alone
but with
chemical
agonist:
depression,
depressed
immune
system,
muscle
weakness

Vitamin C
(Ascorbic
Acid)

Folic Acid
(pteroylgluta
mic acid)

Biotin
(sometimes
called Vitamin
H)

in fruits
and
vegeta
bles
Citrus
fruits,
tomato
es,
melons
,
cabbag
e,
broccol
i,
60 mg/day
strawb
erries,
fresh
potatoe
s,
green
leafy
vegeta
bles

Organ
meats,
deepgreen
vegeta
bles;
muscle
meats,
poultry,
fish,
eggs,
whole
grain
cereals

Organ
meats,
egg
yolks,
nuts,
legume
s

Connective tissue
formation,
catecholamine
synthesis,
cholesterol
metabolism,
anti-oxidant,
absorption of
certain minerals
such as iron

Ascorbic acid

Adult male:
200
ug/day
Adult
female:
180
ug/day
Pregnancy:
400
ug/day

Amino acid and


nucleic acid
biosynthesis,
one carbon
transfer
reactions

30-100
ug/day
(safe
and
allowabl
e range)

Coenzymes for
CO2
carboxylation
reactions in
gluconeogenesi
s, lipogenesis,
fatty acid
-------synthesis and
for carboxyl
group exchange

Tetrahydrofolate
(Ammonium
folate)

First, vague
aches and
pains; if longterm, scurvy
(hemorrhages
into skin,
alimentary
It is derived
and urinary
from
tract, anemia,
glucose by
wound
Lhealing
gulonolacto
delayed,swoll
ne oxidase
en bleeding
gums, loss of
dental
cement)

Folate
derivatives
on diet are
cleared by
specific
intestinal
enzymes to
monogluta
myl folate
for
absorption.
Most of this Megaloblastic
reduced to
anemia
tetrahydrof
olate in
intestinak
cell by
folate
reductase
w/c uses
NADPH as
donor of
reducing
equivalent
Dermatitis can
progress to
mental and
neurologic
changes,
nausea,
anorexia,
peripheral
---------vasoconstricti
on, impaired
fat and
carbohydrate

Carnitine

Energy
metabolism and
Acyl-group
transport

Meat

---------

----------

Muscle
weakness,
fatigue

4. Discuss milk
4.1. Describe human milk: to include its composition and importance.
General composition of milk
Milk is an oil in water type of emulsion stabilized by complex phospholipids and proteins adsorbed on the surface of
fat globules.
The proteins are in colloidal disperdion, while the lactose is in true solution containing minerals, especially calcium
and phosphorus.
Mixed with these are organic acids or their salts, vitamins, enzymes and some special components such as:
Lactenins
special constituent in milk possessing antibacterial properties against certain streptococci.
Bifidus factors
substances which aid in the growth of certain microorganisms found in the breast-fed
babys intestines. This is an important factors to facilitate the growth of nonpathogenic microorganisms for the synthesis of vitamin K and other vitamins needed
by the newborn. Some of these factors are:
A growth factor composed of N- acetylglucosamine, oligosaccharides and
polysaccharides.
A tetrasaccharide composecd of N-acetylglucosamine, D-glucose, d-galctose and
L-fucose.
Gynolactose- secondary sugar component containing N2
Glucosamine and galactosamine.
Composition of Human milk
I. Carbohydrates
Lactose synthesized by the mammary gland from glucose of the blood, wherein one ,ole of glucose must form one form
of galactose, which then combines with another mole of glucose to form lactose, in the following scheme,
Outline Form
Glucose-1-PO4 + uridine triphosphate (UTP) UDP glucose + Ppi
UDP- glucose --- UDP galactose epimerase UDP galactose
UDP galactose + Glucose-1-PO4 galactosyl transferase lactose 1- PO4 + UDP
In the mammary gland
Lactose 1 PO4 ------ Phosphate Lactose + H3PO4
Other milk sugars:
L-fucosyl- lactose
Gynolactose
Allolactose
II. Milk Proteins
Are synthesized by the mammary gland from the essential and non- essential acids in the blood. Intermediary
products from fatty acids, glucose and bicarbonates may also contribute to the carbon skeleton of the proteins.
Proteins in the human milk includes:
Casein
is a phosphoprotein, insoluble at its I pH of 4.6 but is present as soluble calcium caseinate in milk
whose pH is about 7.0

Non- Casein Proteins


Lactalbumin
B-lactoglobulins
immunological properties
IgA
IgG
IgM
Amino acids
III. Milk Lipids
Human milk fat contains mostly long-obtained fatty acids, above 10-carbon atoms.
They are in the form of very small globules.
These milk fats are derived mostly from acetate.
Some are derived from glucose like glycerols, others are derived from stearic and oleic acids from the blood.
IV. Pregnanediol
Not a constant constituent of milk but a hormone present in the serum of pregnant women, which may find its way
into the infant through milk.
It has an inhibitory effect on bilirubin conjugation and as a result may cause hyperbilirubinemia in very young infants
who are fed by pregnant mothers.
V. Ash or Mineral Salts
Are present in the required quantity but iron may be deficient as the infant grows.
o Thus, foods rich in iron must supplement the milk diet of infants.
VI. Vitamins
Milk is an excellent source of vitamin A, riboflavin and pantothenic acid.
It is deficient in vitamin C and Vitanmin D and other members of the B complex
4.2 Differentiate true milk from colostrums
COLOR
CHOLESTEROL AND LECITHIN
PROTEIN
IMMUNE GLOBULIN
FAT

Colustrum
Yellowish due to carotenes and
Vitamin A
Higher which gives it a laxative
effect
Higher so that it coagulates on
boiling
Higher, serving as secondary
means of neonatal immunization
(placental transmission is the first)
higher

True milk
Bluish due to Ca++ salt of casein
and emulsified fats
Lower
Lower, does not clot on boiling
but forms a film
Lower but it has higher albumin
and casein content
Lower

4.3 Differentiate cows milk from human milk


Human Milk
1. greater albumin/ globulin fractions than casein

Cows Milk
Greater casein fraction than albumin/globilin
fractions
2. Forms lighter, easier to digerst milk cords due to Forms heavier, harder to digest milk curds due to
abundance of albumin
abundance of casein
3. fatty acids are of long chained non volatile types
Fatty acids are of shorter chained volatile types
4. Presence of IMMUNE ANTIBODIES passively NONE
transmitted
5. Less vitamins but the quality are those needed by More Vitamins
human infant

4.4 Describe the different milk products


1. Skimmed milk
fluid remaining after removing or pouring off the cream which rises after allowing milk to stand for sometime.
very deficient in vitamin A
2. Butter
produced by churning or agitating milk or cream, after previous souring by lactic acid/bacteria to permit the fat
globules to coalesce more easily
excellent source of vitamins A and D
3. Buttermilk
the fluid left after milk has been churned in butter making. It differs from skimmed milk only on the loss of some
casein due to the previous souring
4. Homogenized milk
milk where the fat globules has been reduced in size by forcing the milk through very small apertures under
pressure
advantage:
a. the reduced-in-size fat globules do not rise as cream when the milk is allowed to stand.
b. the resulting greater surface area of the fats increases their digestion by lipases.
c. The increased fat surface will increase the amount of proteins that can be encased in it, making a less
amount of protein available when clotting occurs, thus even much softer curd is formed.
5. Evaporated milk
whole cows milk which has had about 60% of the water removed, homogenized and hermitically sealed in cans.
6. Condensed milk
also reduced to about the same concentration as evaporated milk, but sugar (50%) is added as preservative
disadvantage:
o When reconstituted for infant feeding, the calorie content may be adequate but deficient in protein.
7. Dry milk
may be prepared from whole milk, half-skimmed or skimmed milk. The nutritional value of dried milk is the same
as the milk from which it was made with only loss of the heat-labile vitamins.
** The percentage of milk fat serves as an index of the nutritional value of the milk product thus, determining also its price.
Commercially therefore, the fat of milk is its most valuable component, since it is marketed as cream and butter, or as a
composition of cheese.
4.5 Discuss the factors modifying the general composition of milk
1. Species
animals that grow faster has milk containing more protein for soft tissue building
a. quantitative differences (comparative) between different species
Species
Water
Proteins
Fats
Lactose
Ash
Calories/lb.
Human
++++
+
++
++++
+
316
Cow
+++
+++
++
+++
+++
310
Goat
++
+++
+++
++
+++
318
Carabao
+
++++
++++
++
++++
--b. qualitative differences between cows milk and goats milk
i.
goats milk gas higher proportion of lactalbumin than cows milk.
ii.
thiamine and riboflavin are higher in goats milk.
iii.
goats curd tension is lower, simulating human milk.
iv.
goats milk is lower in iron- resulting in anemia in countries where it is abundantly used.

2. Individual differences age


the total volume of milk secreted depends on the demands of the infant, together with the secretory capacity of
the mammary gland.
Young mothers, as a rule secrete more milk than older ones not because they are primiparas, but because of
youthful health and vigor.
There are variations in the day to day secretions even in the same species or animal.
Since milk is under hormonal control, pronounced effects upon lactation are observed in some endocrine
dysfunction.
3. Period of lactation
The first one or two weeks after delivery shows the normal composition of the colostrum, and even true milk
shows a daily variation for at least eight weeks.
The first colostrum shows an extremely high protein content, with a corresponding high content of essential
amino acids.
After the third week, the lactose and fats dominate the milk composition.
4. Diet

High carbohydrate intake increases the volume and lactose.


High fat increases the fat content, but diminishes the volume.
High protein intake increases also the volume, and proteins.
A poor nutritive condition influences not only the quantity, but also the quality of milk contents such as vitamins,
etc.

5. Fraction of a single nursing


At the beginning of a single nursing, the milk secreted is very rich in proteins, with low fat content.
As secretion or nursing progresses, the protein gradually diminishes with a concomitant increase in fats, so that
at about the end of the nursing period, the fats are much higher and proteins are lower than at the start.
4.6 Outline the synthesis of milk lactose
Lactose synthesized by the mammary gland from glucose of the blood, wherein one mole of glucose must form one
mole of galactose, which then combines with another mole of glucose to form lactose.
Outline formation:
a. glucose-1-PO4 + uridine triphosphate (UTP) UDP-glucose + PPi
b. UDP-glucose ---UDP-galactose epimerase UDP galactose
c. UDP galactose + glucose-1-PO4 ---galactosyl transferase lactose-1-PO4 + UDP
d. In the mammary gland
Lactose-1-PO4 ---phosphatase lactose + H3PO4
5. Discuss the recommended nutritional requirement
5.1 Define/ Describe the RDA
Recommended Dietary Allowance represents a
supposedly safe but arbitrary margin above the minimum
requirement for a specified age, sex and body weight. This
margin means that a great majority of a group will have a
sufficient intake if they reached the safe allowance level.
FAO & WHO publications cover the recommended
requirements for calories, proteins, iron, calcium & most
vitamins. Likewise, the food and Nutritional Council [FNRC
have made various recommendations that are applicable to the
Filipino men & women]
In arriving at these recommendations, the general
procedure that they have followed was to ascertain the
minimum requirement for each nutrient [Minimum requirement
means the level below which signs of deficiency symptoms
occur or optimum health could not be possible.] To this, safety

allowances were provided depending upon each particular


nutrient sources, food availability, and food utilization were
added. The allowances were estimated for people in
normal health only, they do not provide for the increase
needs for nutrients during some disease conditions.
However these recommendations if followed should
improved nutritional staus.
The recommended allowances were intended to
sere as basis for estimating national food needs, as goals
in production, and as guide in planning or evaluating
dietaries of groups of people. The recommendations may
be used by individual if they fit within the context of the
reference man & woman, otherwise, adjustment have to
be made.

The RDA formulated in 1960 used also the reference


man & woman, as those who are weighing 53 & 40 kg
respectively in the 20-29 years old group. These weights were

considered low when compared to the FAO standard. So,


a desirable weight was computed allowing an increment of
3 kg for both man & woman, making it 56 & 49 kg.

5.2 Compare the proposed body weight with the actual findings of FNRC & FAO standard
Proposed Body Weight Compared with the Actual findings & FAO
Proposed
Actual
Reference man
56 kg
53 kg
Reference woman
49 kg
6 kg
- 1 yrs old
9 kg
8 kg
1 3 yrs old
12 kg
11 kg
4 6 yrs old
17 kg
15.5 kg
7 9 yrs old
25 kg
20.5 kg
10 12 yrs old
33 kg
25 F
28 M
Boys
Proposed
13 15 yrs old
44 kg
16 19 yrs old
48 kg
Note: Body weight are for the mean age in each group

Actual
39 kg
46 kg

FAO Standard
65 kg
55 kg
9 kg
12 kg
18 kg
27 kg
36 kg
FAO Standard
49 kg
54 kg

5.3 Describe the energy allowance


Energy Allowances
Energy is measured in terms of calorie. For allowances and
intakes, the kilocalorie is used. A kilocalorie is defined as the
amount of heat required to raise the temperature of 1000
grams of water through 1o C.
Energy expenditures are of three kinds:
a.) Basal Metabolism- energy expended to maintain
metabolism during complete mental and physical rest.
b.) Additional Energy Expenditure- mainly for muscular
requirement, involved in performing physical work.
c.) Specific Dynamic Action of Food- additional energy
expenditure mainly metabolic resulting from the
consumption of food. This is about 10% of the BMR.
Simple maintenance living usually needs about 33% more
calories beyond the basal metabolism. Very active person, e.g.
workers engaged in heavy industries, strenuous exercise,
needs 2-3 times the basal requirements. While energy
requirement is closely related to body weight or surface area of
the body, it should be noted that chronically underfed person
maybe 10% or more below their proper weight. Energy intake
should therefore be ideally calculated according to the ideal
body weight rather than actual body weight. A stable body
weight and energy intake, which just balances with energy
expenditure does not necessarily mean that the diet is
calorically adequate.

I.

5.4 Describe the 6 basic food groups


FOOD GROUPS
(recommended servings)
Green, leafy and yellow vegetables;
1 or more servings/day
(1 servings= cooked or 1 c raw)

This is important because calorie inadequacy may reduce


physical activity either in adults or in children.
Calorie intakes are usually regulated by appetite and food
availability. In adults, the appetite is so finely adjusted to
the bodily needs that a satisfied appetite and a constant
body weight are normally achieved. This indicates perfect
calorie balance. Period of hunger at certain times of the
day or season of the year in an individual indicates calorie
deficiency. Appetite, however, is not a reliable guide to the
requirement for essential nutrition. This may be harmful in
children who often have to go out without breakfast at
certain seasons of the year. Nutrient intake may not be
adequate in poor quality imbalance diet, which
nevertheless do met the calorie requirement, thus prevent
hunger and satisfy the appetite.
CALORIE REQIUREMENT BASED ON PHYSIOLOGICAL
ACTIVITY AND SEX
Females
Males
1. Sedentary habit
1800-2000
2500-2700
2. Moderate activity
2100-2200
2800-3000
3. Very active
2400-2600
3100-3200
A decrease of 3% is suggested by FAO for each decade
of 30-35 years and 40-49 years. For decades of 50-59 &
60-69 the decrement is increased to 7.5%. After 70 years,
a further decrement of 10% is recommended.
Examples of foods belonging to each group

Alugbati, ampalaya leaves, kamote tops, kangkong,


malunggay, saluyot leaves, mustard, petsay, squash
leaves, squash leaves, squash fruit, pepper leaves, carrot,

II. Vitamin C- Rich Foods


1 or more servings/day
(1 servings= 1 med. fruit)
III. Other fruits and vegetables
2 or ore servings/day
( 1 serving= c cooked or 1 c raw)
IV. Fat Rich Foods
3 tbsp. daily
V. Protein-Rich Foods
A.) Whole milk, all kinds
Pregnant & Nursing mothers = 2 cups
Children = 3-4 cups
B.) Meat, Fish, Poultry
1 serving = 1 matchbox size [3serving/day]
C.) Eggs: 2- 3 weeks
D.) Legumes: cup cooked
VI. Rice & other Energy Fods
Rice = 3 servings/day
[1 serving = c. raw or c. cooked]
Root crops
[1 serving = 1 med size or 1 cup sliced]

Atis, kasuy, durian, guava, guyabano, kamatsili, mango,


melon, papaya, pomelo, mansanitas, siniguelas,
strawberry, tomatoes
Abitsuelas, ampalaya, abocado, banana, chico, duhat,
eggplant, mabolo, macopa, malunggay fruit, okra, patola,
pineapple, langka or jackfruit, kaimito, kadyos, labanos,
santol, sigarilyas, sitao, sili fruit, watermelon.
- Butter
- Enriched margarine
- Coconut
- Lard
- Coconut milk - Cooking oil
- Coconut oil
- Beef
- Legumes & Nuts
- Chicken
- Liver
- Fishes [bolinao & other small fishes]
- Pork
- Sausage
- Shrimps
- Tulya or clams
- Bread
- Enriched rice
- Corn
- Pinipig ampaw
- Kamote
- Ube
- Kamoteng kahoy - Gabi
- Sugars
- Candied fruits
- Bodbod - Palitaw

5.5 State the RDA of food by using the Food Composition Table
6. Make a dietary prescription and orresponding dietary plan
Underweight diet prescription and dietary plan
Underweight Causes
Results when the energy intake does not fully meet
the energy requirements.
Occurs in people who are very active, tense, and
nervous, and who obtain too little rest.
Sometimes irregular habits of eating and poor
selection of foods are responsible for an inadequate
caloric intake.
Some patients with mental illness reject food to such
extent that severe weight loss results; this condition is
referred to as anorexia nervosa.
Modifications of the diet
before weight gain can be effected, the direct cause
for the inadequate caloric intake must be sought.
Energy: approximately 500 kcal in excess of the daily needs
will result in a weekly gain of about 0.5 kg. For
moderately active individuals diets containing 3000 to
3500 kcal will bring about effective weight gain.
Somewhat higher levels are required when fever is
high, or gastrointestinal disturbances are interfering
with absorption, or metabolism is greatly increased.
Protein: A daily intake of 100 g protein or more is usually
desirable since body protein as well as body fat must
be replaced.

Minerals and vitamins: if the quality of the diet resulting in


weight loss was poor, considerable body deficits
of minerals and vitamins may likewise have
occurred. Usually the high-calorie diet will provide
liberal levels of all these nutrients. When
supplements are prescribed, it is important that
the patient understand that they are in no way a
substitute for the calories and protein provided by
food.
Planning the daily diet
Patient cannot always adjust immediately to a
higher caloric intake.
It is better to begin with the patients present
intake and to improve the diet both
quantitatively and qualitatively day by day until
the desired caloric level is reached
The caloric intake may be increased by using
the additional amounts of foods from the Four
Food Groups, thus increasing the intake of
protein, minerals, and vitamins
Some patients make better progress if given
small frequent feedings; but for many patients
midmorning and midafternoon feedings have
been found to interfere with the appetite for the
following meal.

The following list of foods illustrates one way in which the Four Food Groups may be adapted to a high calorie
level.
List of Food
Sample Menu
3 to 4 cups milk
Breakfast
1 cup light cream
5 to 7 ounces meat, fish, poultry, or cheese
Half grapefruit
1 egg
Oatmeal
4 servings vegetables including:
Fried egg
1 serving green or yellow vegetable
Whole-wheat toast
2 servings white or sweet potato, corn, or beans
Butter
1 serving other vegetable
Milk
2 to 3 servings fruit, including one citrus fruit
Coffee
1 serving whole-grain or enriched cereal
3 to 6 slices whole-grain or enriched bread
Lunch
4 tablespoons or more butter or fortified margarine
high calorie foods to complete the caloric
Chicken souffl
requirement; cereals such as macaroni, rice,
Mushroom sauce
noodles, spaghetti, honey, molasses, syrups,
Buttered green beans
hard candies, cakes, cookies, ice cream,
Shredded carrot and raisin salad
puddings, sauces
Whole-wheat roll and butter
Fresh peaches
Milk
Dinner
Boiled trout
Creamed potato
Buttered spinach
Rye bread with butter
Lemon-flake ice cream
Brownies
Milk
Tea with lemon
7. Discuss the food exchange list
7.1 Describe the food exchange list
Exchange List
Is a food group system that is useful in planning diets
to meet specific energy and macronutrient goals.
First developed in 1950 by the American Dietetic
Association and the American Diabetes Association
as a meal-planning tool for individuals with diabetes.
Since then, its use has been expanded to planning
weight-loss diets and weight loss in general.
The latest revision of the Exchange List divides foods
into three main groups based on their macronutrient
content:
o The carbohydrate group includes
exchange lists for foods that are sources of
carbohydrates: starches, fruits, milk, and
vegetables. It also defines a list of other
high-carbohydrate foods and indicates how
fit these foods into a diet based on
exchanges.
o The meat and meat-substitute group includes an exchange list with four
subgroups: very lean, lean, medium-fat, and
high-fat meat.

Fat group includes an exchange list


with subgroups of monosaturated,
polyunsaturated, and saturated fats.
o (See also the correlate from Dr. Salubre
below)
The serving sizes for foods within each exchange
list are different from those in the Food Guide
Pyramid.
The exchanges are set so that each food within a
list contains approximately the same amount of
energy carbohydrate, protein, and fat.
The food groupings of the exchange list differ
from the food guide pyramid groups because the
lists are designed to meet energy and
macronutrient criteria, whereas the pyramid
groups are designed to be good sources of
certain nutrients regardless of their energy
content.
Example: a potato is included in the starch
exchange list because it contains about the same
amount of energy, carbohydrate, protein, and fat
as breads and grains, but in the food guide
o

pyramid a potato is in the vegetable group because it


7.2 Describe the components of the meal exchange list
7.2.1 calorie, fat, protein, and CHO content in each of the list
7.2.2 food included in each of the list
Method for dietary calculations:
A physician prescribes the amounts of carbohydrate,
protein, and fat that are to be used in measured diets.
Using the values for the exchange lists; the dietitian or
nurse calculates the number of exchanges to be
furnished by the diet.
Become familiar with the patients usual pattern of
meals, the food likes and dislikes, and so on. The
amount of money that can be spent, the preparation
facilities, and the cultural patterns must be
considered.
Include basic food to ensure adequate levels of
minerals and vitamins: ex. 2 cups milk; 5 oz. Meat; 2
servings vegetables; two servings fruit; breads and
cereals.
List the carbohydrate, protein, and fat values for the
milk, vegetables, and fruit.
Subtract the carbohydrate value of these foods from
the carbohydrate level prescribed. Divide the
difference by 15 to determine the number of bread
exchanges. Subtract from the protein prescribed.

is a good source of vitamins, minerals, and fiber.

Divide the difference by 7 to determine the


number of meat exchanges.
Total the fat values for milk and meat and
subtract from the total fat prescribed. Divide the
difference by 5 to determine the number of fat
exchanges.
Check the calculations to be certain that they are
correct. It is not a good idea to split the fruit,
bread, and meat exchanges into half. The
calculations for carbohydrate should be within 7
gm of the prescribed level, and those for protein
within 3 gm of the prescribed level.
Divide the total exchanges for the day into meal
patterns according to the physicians diet order
and the patients preference.

Energy and Macronutrient Values of the Exchange List


Exchange Group
Carbohydrate
Group
Starch
Fruit
Milk
Nonfat
Low Fat
Reduced Fat
Whole
Other Carb.
Vegetables
Meat/Meat Substitute
Very lean
Lean
Medium Fat
High fat
Fat Group

Serving Size

Energy (kcals)

CHO
(g)

Protein (g)

Fat (g)

cup pasta, cereal, rice, 1


slice bread
1 small apple, peach, or pear;
banana; cup canned fruit

80

15

0-1

60

15

90
110
120
150
Varies
25

12
12
12
12
15
5

8
8
8
8
Varies
2

0
3
5
8
Varies
0

35
55
75
100
45

0
0
0
0
0

7
7
7
7
0

0-1
3
5
8
5

1 cup milk or yogurt

Serving sizes vary


cup cooked vegetables, 1
cup raw
1 oz. meat or cheese

1 tsb. butter, margarine, or oil;


1 tbsp. salad dressing

Sample Menu: (Food List)


Breakfast

Sandwich
Bread 2 slices
Roast beef 2 oz.
Mayonnaise 1 teaspoon

Milk 1 cup
Cantaloupe medium
Whole flakes cup
Toast 1 slice
Egg 1
Butter 1 teaspoon
Cream, light 2 tablespoons

Dinner
Asparagus tips
Baked acorn squash
Pears, water packed 2 halves
Potato, baked 1 small
Roll, dinner 1
Roast pork, lean 3 oz
Butter on potato 1 teaspoon

Lunch
Milk 1 cup
Radishes and celery sticks
Apple 1 small

Reference:
Smolin and Grosvenor. Nutrition: Science and Applications, 4th ed. 2003. pp. 43-44, 100, 136.

CORRELATE FROM DR. NENA SALUBRE


MODIFICATION IN CALORIE CONTENTS
I. CALCULATION OF DIETARY PRESCRIPTION
A. Calorie allowance the proper calorie allowance for the adult s that which over an extended period of time will
maintain his weight or near his ideal body weight for his height and sex.
All computations for dietary purposes should be based on the desirable or ideal body weight and not on the actual
weight, since the objective of proper nutrition is to maintain the desirable weight.
There is more than one way of getting the desirable or ideal weight. In the absence of Height and Weight Table, the
Thanhaussers method can be used, which is simple enough and comes out with a figure, which falls within the
range of the standard height and weight table for age and sex.
THANHAUSSERS TABLE
Ht. (cm) 100 = wt. (kg) for western standard, deduct 10% for Filipinos
Example:
Height is 52 (62 in.) = convert this to cm by multiplying 2.54
= 157 cm
157 cm 100 = 57 kg (western standard) 5.7 (10%)
= 51 kg DBW for Filipinos
*DBW desirable body weight
COMPUTING FOR CALORIE ALLOWANCE:
Step I Calculate the basal calorie used for 24 hours based on DBW
*BMR = 1 cal/kg.DBW/ hour

Step II Calculate energy needs for Physical Activity (PA)


Short method is to allow:
a. Bed rest (Hospitalized patients) ----------------------------------- 10% of basal needs
b. Sedentary
------------------------------------------------------------30% of basal needs
c. Light work
------------------------------------------------------------50% of basal needs
d. Moderately active
-----------------------------------------------75% of basal needs
e. Very active
------------------------------------------------------------100% of basal needs
Step III Compute for Specific Dynamic Action (SDA) of food
*10% of the sum of BMR and PA
Then take the summary of total energy requirement by adding the BMR, PA and SDA. Round it off to the nearest
hundred.
Sample computation using above formula in a hospitalized patient:
Step I
BMR = 1 cal/kg. x 51 kg x 24 hours
= 1224 cals.
Step II

PA

Step III.

SPA

= bed rest (allow 10% of basal needs)


= 10% of 1224
= 122 cals.

= 10% of of BMR + PA
= 10% (1224 + 122)
= 10% (1346)
= 135 cal.
Therefore, the TER = 1224 + 122+ 135 = 1481 or 1500 cal/day
B. Protein-Carbohydrates and Fats may be divided as follows:
a. Protein grams
b. Carbohydrates
c.

Fats

= 15% of TER (cal) .


4 cal/gram
= 50% of TER (cal) .
4 cal/gram
= 35% of TER (cal) .
9 cal/gram

or
a. Protein
b. Carbohydrates
c. Fats

= 1-1.5 grams per kg IBW


= 40-50% of the nonprotein calorie
= remaining calorie

Sample computation:
Carbohydrate

= 50% of 1500 cal .


4 cal/gram

= 750 cal .
4 cal/gram

= 188 grams

Protein = 15% of 1500 cal .


= 225 cal .
= 56 grams
4 cal/gram
4 cal/gram
Fats

= 35% of 1500 cal .


9 cal/gram

= 525 cal
9 cal/gram

= 48 grams

C. Dietary prescriptions for carbohydrates, protein and fats are expressed in grams. The conversion factor from
calorie to gram is 4, 4, and 9 respectively.
D. In uniting the dietary prescriptions calorie are rounded up to the nearest 100, carbohydrate, protein and fats are
rounded up to the nearest five (5).

Dietary prescription:
TER calorie

= carbohydrates-proteins-fats

Example:
1500 cal = 190 grams 55 grams 50 grams
II. Meal Exchange List
q

Divided as a practical guide for planning diets without accurately weighing the foods. Instead, the foods are given in
household measurements for example, it is easier to remember and prepare 1 exchange of bread and 1 exchange
of meat = 1 matchbox size instead of weighing an oz. or 30 grams of meat

There are six food exchanges. Each list is composed of foodstuffs with their corresponding household
measurements. The measurements vary such that each food within the exchange list gives definite amounts of
carbohydrates, proteins, fats and calories. The six exchange list are as follows:
CHO (gram)

List I Vegetable Exchange


I-A 1 exchange
I-B 1 exchange
List II Fruit Exchange
1 exchange
List III Milk Exchange
1 exchange
List IV Rice Exchange
1 exchange
List V Meat Exchange
1 exchange
List VI Fat Exchange
1 exchange

PRO (gram)

FAT (gram)

CALORIES

NEGLIGIBLE
3

18

10

40

12

10

170

23

100

68

45

If one examines each exchange list it will be noted that foods of similar composition are group together to yield
the same amount of CHO, Pro, Fat and Calories, as long as one observe the given measurement for each food
item.

Examples: See list II 1 small apple will give the same CHO, Pro, Fat and Calories as 1/3 medium sized mabolo
or 2 medium sized narangita.
See list IV 1/2 cup, cooked, well-packed rice can be exchange for 2 slices of bread or 2 pieces of
small pandesal or 1 cup oatmeal.

This is the origin of the word exchange, i.e within a list, 1 foodstuff may be exchange or substituted for another
by carefully observing the measurements for each food.

The use of the exchange list system is not limited to calculating diabetic diets. The doctor and dietician also finds
it useful for estimating the CHO, Pro, Fat and Calories (or any of these) for a given diet or menu.

It should be emphasized that these food values are closed approximation of actual chemical analysis. For
calculating average daily intake, the exchange list system is satisfactory (accurate enough and very practical)

III. CALCULATIONS OF EXCHANGES


The method used in planning calculated diet is based on the idea of food exchange list. The common foods
allowed are divided into six groups according to their composition. In each of these groups are listed the kinds and
amounts of food that have approximately the same nutritional value in carbohydrate, fat and protein. Nutritive adequacy of
the diet is assured by including the 6 Basic Food Groups and tries to meet all the dietary allowance. Food may not
necessarily weigh but portions are controlled by measurement.

Steps in Planning the Dietary Pattern


1. Compute for the amount of milk, vegetables and fruits included in the diet

Give milk only if desired.

Usually, only one exchange of the B vegetable is given.

The vegetable A group may be given as desired within certain limits.

Unless the carbohydrate is severely restricted, give at least three exchanges of fruits.
2. Sub-total the carbohydrate coming from milk, B vegetable and fruits.
Take the difference from the total described carbohydrate.
Divide the remaining carbohydrate by 23 to get the number of rice exchange to give.
The number of rice exchange must be computed to nearest half of an exchange to avoid awkward and
impractical measurements.
3. Sub-total the protein coming from milk, B vegetable and rice exchanges.
Take the difference from the total prescribed protein and divide the remainder by 6 to get the number of
meat exchanges.
The number of meat exchange must be computed to a whole number that will give the nearest prescription
for protein.
4. Sub-total the fat coming from milk and meat.
Subtract from the total prescribed fat and divide the number of exchanges of fat.
5. Sum up all carbohydrate, protein, fats and calories to check whether the prescribed levels are met.
A margin of error of 5 grams above or below the prescribed levels of CHO, PRO and FAT is allowed so that
odd fractions are avoided.
6. Allow sugar to compensate for CHO deficiency. (No
1 teaspoon refined sugar is equivalent to 5 grams CHO = 20 calories
o 3 tsp. = 1 tbsp.
o 1 tbsp. = 15 grams CHO or 60 calories

allowance

in

Sample Calculations
Dietary prescription: 1600 cal -----225 65 70 (CHO-Pro-fat)
Food list
No. of
CHO gm
Pro gm
exchange
I. Vegetable A
As desired
Vegetable B
1
3
1
II. Fruit
3
30
III.Milk
1/2
6
4
Partial sum
39
Prescribed CHO ---------- 225
Partial sum CHO --------- 38
Difference ----------------136
186/23 = 8 rice exchange
IV. Rice
3
184
16
Partial sum
21
Prescribed PRO ----------- 65
Partial Sum PRO --------- 21
Difference ----------------- 44
41/3 = 6 meat exchange
V. Meat
6
43
Partial sum
Prescribe FAT ------------ 70
Partial sum FAT --------- 29
Difference ---------------- 41
41/5 = 8 exchange
VI. Fat
8
Total
223
69

FAT gm

Cal

16
120
85

800

24
28

408

40
69

360
1789

diabetic

diet)

Sugar 1 teaspoon with coffee ------------------------------------------------------- 20


LIST I
VEGETABLE EXCHANGE
GROUP A LEAFY VEGETABLE

Leafy vegetable or vegetables high in water of\r fiber


contains negligible calories, CHO, PRO, FAT, if 1
exchange measure is used.
Given as desired, if raw

Measure per exchange:


Leafy 1 exchange = 1 cup raw (25 grams) or cup
cooked (45 grams)
2 exchanges of I-A vegetables = 1 exchange of I-B
vegetables
Group A Vegetables:
Alugbati (Malabar night shade leaves)
Dabong (Bamboo shoots)
Gozo (seaweed)
Ispinaka (Spinach)
Katuray (Season Flower)
Kamote Dahon (Camote leaves)
Kamunggay dahon (Horse raddish leaves)
Kapayas hilaw (green papaya)
Letsugas (lettuce)
Lato (seaweed)
Mustasa (mustard)
Pako (fern)
Petsay (Chinese cabbage)
Pepino (cucumber)
Paliya dahon ug bunga (Bittermelon leaves and fruits)
Repolyo (cabbage)
Sayote dahon ug bunga (Chayote leaves and fruits)
Sikwa (sponge gourd)
Siguidilias (winged beans)
Sili dahon (pepper leaves)
Takway (Taro leaves)
Tamates (tomato)
Talinum
Tokog banog (Jute)
Talong (eggplant)
Upo (bottle gourd)
Those marked with X are good sources of vitamin A and
iron. At least one serving be included in the diet each day.
GROUP B NON-LEAFY VEGETABLES
1 Exchange = 3 grams carbohydrates
1 gram protein
16 calories
Measure: 1 exchange = cup raw (40 grams) or
cup cooked (45 grams)
Group B Vegetables:

Abitsuelas (snap green bean)


Bataw (hyacnith bean)
Guisantes (sweet pod)
Kadios, lab-as (pigeon pea pod fruit)
Kamungay bunga (horse radish fruit)
*kalabasa pula (red squash fruit)
*karot (carrot)
langka hilaw (jackfruit unripe)
Okra
Paayap (cowpes)
Remolatsa
Saguing puso (banana heart)
Sinkamas (yam bean, turnip)
Batong (yard long bean)
Taugi (mongo sprout)

Note: you may substitute for this serving of vegetables 1


cup cooked may be of any of the vegetables a group or a
combination of vegetables included
Those marked with (*) are high in vitamin A value. At least
one serving should be included in the diet each day.
LIST II
FRUIT EXCHANGE
1 Exchange = 10 grams Carbohydrates
40 Calories
FRUITS
v Atis (Sugar
apple)
v Bayabas
(Guava)
v Baungon
(Pomelo)
v Dalanghita,
Okban (Native
Orange)
Durian
v Guyabano
(Soursoup)
v Istroberi
(Strawberry)
Kaimito (Star
Apple)
v Kamunsal (Aztec
Kamunchill)
v Kasuy Bunga
(Cashew Fruit)
Lanzones
(Lanson)
Letsiyas
(Laychees)

WEIGHT
(gram)
50

MEASURE
1 small

35

1 medium

60

2 segments

140

2 medium

30
70
120

1/3 of fruit
1 halfmoon
slice
1 cup

60

1 small

70

10 pods

140

2 medium

75

7-10 pcs.

65

5 pcs.

Lumboy (Black
Plum)
Mabolo
Makopa
(Coracac apply)
v Manga (Ripe
Mango)
v Mangostan
(Mangostene)
v Mansanas
(Apple)
v Mansanitas
(Chinese Date,
Indian Jujube)
v Milon (Spanish
Melon)
Nangka
(Jackfruit Ripe)
Pakwan
(Watermelon)
v Papaya (Ripe
Papaya)
v Peras (Pears)
v Pinya (Fresh
Pineapple)
v Saging (Lacatan,
Tundan, bungan,
cardaba
(banana)
Sambag
(Tamarind)
Sineguelas
(Spanish Plum)
Tambis
(Macopa)
Tiesa (Carristal
Tiesa)
Ubas (Grape)
CANNED FRUITS
v Orange
Pineapple
(Unsweetened)
OTHERS
Butong (young
coconut)
Buting tubig
(Buko Juice
Lemonsito Juice

50

20 pcs.

55
60

medium
6 pcs.

120

1 med. Slice

60

3 pcs. Med

60

1 small

75

cup

50

1 small

245

cup

30

1 small slice

155

1 small slice

90
65

1 pc. Medium
1 small slice

75

1 small piece

40
20
50
120

1 small

30

12 pcs.

WEIGHT (gram)
120 grams

1 Exchange = 12 grams CHO


8 grams PRO
10 grams FAT
170 Calories

MEASURE
Cup
Cup

MEASURE
Cup

240 gram

1 Cup

120 grams

Cup

Note:
Those with ( * ) are rich source of Vitamin C. Include
at least 1 exhange daily in the diet

WEIGHT
(grams)
240
240
120

FOOD

MEASURE

*Carabaos milk (fresh)


1 cup
Cows milk (fresh)
1 cup
Evaporated milk (to
1/2 cup
reconstitute
evaporated milk to whole
milk, dilute with 1/2 cup
water)
**Powdered milk
30
1/4 cup or 4
(Skimmed)
tbsp (level)
Powders (whole)
30
1/4 cup or 4
(to reconstitute to whole
tbsp
milk add water enough
to make 1 cup)
NOTE: (*) omit 2 fat exchange from diet list contains
about 20 grams fat per cup.
(**) add 2 more fat exchanges to diet if
skimmed.
LIST IV
RICE EXCHANGES

22 pcs.
5 pcs.
Medium
5-6 pcs. Med

WEIGHT
(gram)
120 grams
120 grams

LIST III
MILK

1 Exchange = 23 grams CHO


2 grams PRO
100 Calories

I. Rice Cooked
II. Rice Equivalents
Bread
Pan
American
Pan de
bonete
Pan de limon
Pan de sal
Rolls
Corn
Corn; Boiled
Maha, Mais
Root Crops:
Gabi (Taro)
Kamote
(Sweet
Potato)
Kamoteng
Kahoy
(Cassava)

COOKED E.P.
Weight (grams)
75

1/2 cup

30

2 slices

30

1 piece

55
88
88
100
50
43

1 piece
2 pieces
1 piece
3/4
1 piece
1sliced 4x4
1/2 1/2 mm

95
100

1 pc.(10 x 6cm)
1pc. (101 / 2 x
6cm)

75

1pc. (5.5 x
4.5cm)

MEASURE

Patatas
(Potato)
Suman
(Kamoteng
Kahoy)
Ubi
Noodles
Bihon, Miki
Macaroni,
Spaghetti
Sotanghon
Other Cereals
Dry (flakes
and Puff
Variety)
Lugao
Oatmeal
Bakery
Products
Biscocho
*Cookies,
Araro
*Cookies
Assorted
Mamon
Saltines
Soda
*Sponge
cake

100

1pc. (7 x 6 cm)

50

1pc. (7.5 x 3 x 2
cm)

100

1cup cube

100
100

1 cup
1 cup

100

1 cup

25

1 cup

130
175

1 cup
1 cup

30
33

2 pieces
5 pieces

20

5 pieces

30
30
30
40

2 pieces
10 pieces
8 pieces
1

(*) decrease rice allowance by 1 exchange for these items


LIST V
MEAT EXCHANGES
1 Exchange = 3 grams Protein
4 grams Fat
66 Calories
FOOD
FISH
Large-(bangus,
mamsa, etc.
Medium-(danggit,
kitong,etc)
Small- (caraballas,
lagao, etc.)
very small (bolinao)
Flaked
(salmon,tun
a)
OTHER SEAFOODS
Hipon(small
shrimps)
Alimango,lambay
(crabs)
Pasayan (shrimps)

COOKED EP

MEASURE

30
30

1 slice match
box
1 piece (15 cm)

30

2 pieces

30
30

cup
2 tbsp. Heaping

45

cup

50

1 medium

50

2 medium

Nokos (squid)
Sisi (oyster)
Kinhason (clams)
MEAT
Chicken

40
90
50

2 pieces
cup
cup

50

Lean pork or beef


Other internal
organs
PROCESSED MEAT
Corned beef
Frankfurter
Ham
Vienna Sausage
EGGS
Balut
Chicken egg
Penoy (infertile)
Salted duck's egg
CHEESE
Cottage
Imported
Native
BEANS
Abitsuelas (snap
beans)
Garbanzos (chick
peas)
Munggo (mongo
bean)
Tokwa(gourling
cheese)
NUTS
Kasuy, roasted
(cashew)
Peanuts, boiled
Peanuts, roasted

30
40

1 breast/small
leg
1 slice matchbox
cup

30
45
30
30

3 tbsp.
1 piece
1 slice
3 pieces

60
50
55
55

1 piece
1 piece
1 piece
1 piece

60
30
30

cup
1 slice
1 piece

150

cup cooked

70

cup cooked

150

1 cup

70

1 piece

20

cup

65
30

1 cup with shell


2 tbsp.

LIST VI
FATS
1 Exchange = 5 grams
45 calories
FOOD
Avocado
Bacon
Butong Pakwan
(dried seeds)
Butter or
margarine
Coconut milk
French dressing
Mayonnaise
Sitsaron
Shortening,
cooking oil
Coconut grated

COOKED E.P.
70
8
10

MEASURE
1 medium
1 strip
cup

1 tbsp.

5
5
15
10
5

1 tbsp.
1 tbsp.
1 tbsp.
1 piece
1 tsp.

1 tbsp.

FOODS ALLOWED AS DESIRED


Contains negligible carbohydrates, protein, fats and calories

Buillon (fat free)


Coffee(unsweetened)
Flavor extract
Garlic
Gelatin
Kalamansi
Patis
Toyo
Vetsin
Herbs
Spices (in amounts needed to season)
Lemon
Mustard
Pickle, dill or sour (unsweetened)
Saccharine or cyclamate (sweeteners)
Tea (unsweetened)
Vegetable A on the list up to one exchange
Vinega

31