NUTRITION & DIETETICS NUTRITION

Nutrition - the science of food, the nutrients and other substances therein, their action, interaction and balance in relation to health and disease, and the processes by which organism ingests, digests, absorbs, transports, utilizes and excretes food substances.
Dietetics - refers primarily to the therapeutic and food service aspects of the delivery of nutritional services in hospitals and other health care institutions (PD 1286).

Physical and Psychological Dimension

Physical- efficiency of the body to function appropriately and meet daily energy requirements. Intellectual-Use of cognitive abilities to learn and adapt to changes in the environment. Emotional- capacity to express feeling appropriately Social-Ability to interact with people in an acceptable manner. Spiritual-Cultural beliefs that give purpose to human existence.

Classification of Nutrients
1. According to function a. Body-building b. Energy-giving c. Regulate body process 2. According to chemical nature a. organic b. Inorganic 3. According to essentiality Essential or Non-Essential

4. According to concentration a. Macronutrients water, protein, fats and carbohydrates b. Micronutrients vitamins & minerals

BASIC TOOLS IN NUTRITION

10 Nutritional Guidelines for Filipinos (2002) 1st edition in 1990

Developed by: Clinical Nutrition Section Medical Nutrition Division, FNRI-DOST

1. Eat a variety of foods everyday. 2. Breastfeed infants from birth to 4-6 months and then give appropriate foods while continuing breastfeeding. 3. Maintain childrens normal growth through proper diet and monitor their growth regularly. 4. Consume fish, lean meat, poultry or dried beans 5. Eat more fruits, vegetables and root crops 6. Eat foods prepared with edible oil/cooking oil daily. 7. Consume milk, milk products or other calcium rich foods such as small fish and dark green leafy vegetables everyday 8. Use iodized salt, but avoid excessive intake of salty foods 9. Eat clean and safe foods. 10. Exercise regularly, do not smoke and avoid drinking alcoholic beverages.

RECOMMENDED ENERGY AND NUTRIENT INTAKES (RENI)

Philippines, 2002 Edition RENI Committee, Task Forces, and the FNRI-DOST Secretariat

Food Exchange List the grouping of common foods according to their energy, carbohydrate, fat and protein values.
LIST FOOD GROUP EX Household MEASURE CHO (g) PRO (g) FATS (g) ENERGY (Cals)

IA

Veg A

1 2
1 1 1 1 1

1cup raw or 1/2cup cooked 2cups raw or 1cup cooked

1/2cup raw or cup cooked varies varies 4T varies

3
3 10 12 12 12

1
1 8 8 8

10 5 tr

16
16 40 170 125 80

IB II III

Veg B Fruit Milk Full cream Low fat skimmed Rice Meat & Fish Low fat Med fat High fat Fat Sugar

IV V

1 1 1 1

varies Varies Varies varies

23 -

2 8 8 8

1 6 10

100 41 86 122

VI VII

1 1

1 teaspoon 1 teaspoon

5 -

45 20

NUTRITION FACTS FOOD LABELING - a format on packaged foods that gives nutrition information & a list of ingredients as required by law.

Principles of Nutrition

1.

2.

DIGESTION- is the process by which food is broken down in the gastrointestinal tract. Mechanical Digestion- process of physically breaking down food into smaller pieces. Mastication- tearing and grinding effort of teeth and tongue on the food. Peristalsis- rhythmic contractions of muscles helps move food through the GIT

3. Segmentation- the forward and backward muscular action, assists in controlling the food mass. Chemical Digestion Process of splitting complex molecules into simpler ones. HORMONES Gastrin- signals the stomach to produce gastric secretions for the protection of the mucosal lining.

Hormones

Secretin- stimulates the release of bile by the liver and bicarbonate by the pancreas to aid in digestion. Cholecystokinin- causes the contraction of the gallbladder for fat digestion as well as other pancreatic enzymes for protein and carbohydrate breakdown.

Enzymes

1.

2.

3.

Protein , specific in kind and quantity, for breaking down specific nutrients. Peptidase- for breakdown proteins into amino acids. Pancreatic lipase- digests fats molecules into essential fatty acid compounds and glycerol. Maltase,Sucrase,Lactase- aid in reduction of sugars into fructose, glucose and galactose.

ABSORPTION

The process by which nutrients are carried into the bodys circulation system and delivered to cells. Specialized structures ensure maximum absorption of essential nutrients primarily in the small intestine. Absorption process include diffusion and pinocytosis.

METABOLISM

1.

2.

Encompass the total chemical changes in the body by which it maintains itself. CATABOLISM breaking down of food components into smaller molecular particles(destructive phase). ANABOLISM process of synthesis from which substances are formed( Constructive phase).

EXCRETION

The elimination of waste by-products of food breakdown. CHYME-is a mixture of partially digested food with digestive secretions found in the stomach and small intestine. By products of digestion normally include cellular wastes, water, bile salts,mucous, undigested food and dietary fiber and bacteria.

Assessment of Nutritional Status

1.

2.

3.

CLINICAL EXAMINATION distribution of body fat, appearance of skin, hair, nails, teeth and wound or lesions. FOOD RECORD AND DIET HISTORYdata on the food a person eats for a 24-hour period. FAMILY TREE

4. BIOCHEMICAL ANALYSIS- samples of body tissues such as blood and urine tests to see how the body uses nutrients. 5. ANTHROPOMETRIC MEASUREMENTSheight, weight and limb circumference. 6. SKIN-FOLD THICKNESS- using skin calipers or other tools.

7. WEIGHT-FOR HEIGHT TABLESestimating body weight using the Metropolitan Life Insurance Company Weight-for-Height tables is one common way to determine a persons desired weight based on sex and body frame size. 8. BMI ( body mass index) bw(kg) or bw(lb) x 703.1 ht2 ( meters) ht2 ( inches)

BMI- 18.5-24.9 healthy range BMI- 25-29 mod. Overweight BMI 30+ obesity BMI 40+ morbid obesity

9. UNDERWATER WEIGHING- method for estimating total body fat, weighing a person on a standard scale and then again submerged in water. The difference between the two measurements is an estimation of body fat. 10. BIOELECTRICAL IMPEDANCE- method that uses low energy electrical current. The more fat a person has, the more impedance to an electrical flow will occur.

11. INFRARED LIGHT TO BICEP- used to assess the fat composition in proportion to muscle 12. DUAL X-RAY PHOTON ABSORPTIOMETRY ( DEXA) xray system that separates body weight into fat , fat free, soft tissue and bone

Impact of Culture on Diet

Personal habits regarding food develop as part of our social and cultural background as well as, our lifestyle. All of our food habits are related to our way of life, our values, beliefs and individual situations.

Characteristics of Ethnic Diets

Food habits develop from personal, cultural, social, economic and psychological influences. Many foods in our culture take on symbolic meaning related to major life experiences. Since ancient times , ceremonies and religious rites involving food have been important.

Food Preferences/Preparations
Jewish Orthodox Basic dietary law is the Rules of Kashruth. Foods selected and prepared are called kosher. No pork is allowed, meat is cleansed of all blood. Combining of meat and milk is not permitted. Only fish with fins and scales are allowed.

Jewish Orthodox

No eggs with a blood spot are used. Representatives foods include bagels, blintzes, knishes, lox and matzo.

Mexican

Follow food habits of early Spanish settlers and Indians. Dried beans, chili peppers, and corn are staple items. Small amount of meat and eggs are eaten. Some fruits are consumed depending on availability. Coffee is main beverage. Representative foods include tortillas and rice.

Asian/Chinese/Japanese

Believe that refrigeration diminishes flavor, use fresh foods and cook quickly. Woks are used for cooking. Vegetables are usually served crisp. Meats are used in small amounts and in combined dishes. Fresh fruits are eaten often. Rice is the staple grain.

Peanut oil is the main cooking fat. Sushi and any raw fish are carefully prepared.

Greek

Meals are simple but family oriented, with bread the center of the meal. Cheese especially feta is used liberally in the Greek diet. Lamb is favorite meat. Eggs are main dish but not used for breakfast. Vegetables are used as main entrees. Salad with cheese, olive oil and vinegar are consumed in the Greek diet.

Greek

Rice is the main grain. Rich pastries , like Baklava, are used for special occasions.

Native American

Food preferences vary with each region/tribe. Corn, cornmeal, blue corn breads are typical. Corn is a status food for most tribes. Fried food are common. Lard and shortening are main cooking fats.

Moslem/Arabs

Dietary laws are based on Islamic teachings Most meat are permitted except for pork. Moslem diets prohibits fermented fruits and vegetables. Beans, bulgur, rice are used in many ways as a protein source. Representative foods are bulgur and falafel.

Indian

Many Hindu people do not eat beef because of the belief in the cow as sacred. Milk is not provided to children in some areas because they believe that milk will hinder growth. Bananas are not given because of the belief that they cause convulsions.

CARBOHYDRATES
Carbohydrate Type
Simple Monosaccharide Glucose

Common Names

Naturally Occurring Food Sources

Blood sugar, dextrose Fruit sugar, laevulose Milk sugar

Fruits, sweeteners

Fructose Galactose Disaccharides Sucrose (glucose + fructose)

Fruits, honey, syrups, vegetables Part of lactose, found in milk

Table sugar

Sugar cane, sugar, beets, fruits, vegetables Milk and milk products

Lactose (glucose + galactose)

Milk sugar

Maltose (glucose + glucose)

Complex Polysaccharides Starches (strings of glucose) Fiber

Malt sugar

Germinating grains

Complex carbohydrates Roughage

Grains, legumes, potatoes Legumes, whole grains, fruits, vegetables

Functions of Carbohydrates 1. Energy source 2. Protein-sparing action 3. Anti-ketogenic effect 4. Control of fat oxidation 5. Regulatory 6. Sweetening agents

Summary of Carbohydrate Digestion and Absorption

Storing Carbohydrates Glycogen: muscles of an adult is 150g (600Cals); 90g (360Cals) are stored in the liver Glycogenesis the process of converting glucose to glycogen

Metabolism blood glucose homeostasis: 70-120 mg/dl. Gluconeogenesis process of producing glucose from fat and protein for protein structures) Lipogenesis: synthesis of fats in the abundance of carbohydrates Lipolysis: ketone bodies used for energy Ketone bodies created when fatty acids are broken down for energy

Blood Glucose Regulation

Insulin: regulates blood glucose levels Glucagon: a pancreatic hormone that releases glycogen from the liver

Recommended Intake Total CHO must comprise 50-70% of TER Simple CHO must only be 10% of the TER Dietary fiber must be 20-35grams/daily.

Fiber carbohydrates in plant foods that cannot be digested by humans

Classification of Fibers 1. Soluble Fibers dissolve in fluids; thickens substances 2. Insoluble Fibers do not dissolve in fluids; provide structure and protection for plants. 3. Functional fibers 4. Dietary fibers

Dietary Fibers and Food Sources

Fibers
Insoluble Cellulose Hemicellulose Lignin
Soluble Pectin Mucilage Guar and other gums

Food Sources
Whole grains, brown rice, whole wheat flour, whole wheat pasta, oatmeal, unrefined cereals, vegetables, wheat bran, seeds, popcorn, nuts, peanut butter, leafy green vegetables such as broccoli
Kidney beans, lentils, garbanzo beans, soybeans, apples, pears, bananas, grapes, citrus fruits, oat bran, oatmeal, barley, corn, carrots, white potatoes

Health Effects of Carbohydrates

1. Dental caries 2. Obesity 3. Diverticular disease 4. Colon Cancer 5. Heart Disease 6. Diabetes Control 7. Nutrient Deficiencies

Issues:
A. Artificial sweeteners (nonnutritive sweeteners) provide no energy. Approved: saccharine, aspartame, acesulfameK, sucralose, neotame Pending: alitame and cyclamate B. Glycemic index a method of classifying foods according to their potential for raising blood glucose.

GLYCEMIC INDEX OF SELECTED FOODS

LOW GI

HIGH GI

Peanuts Soybeans Cashews, cherries Barley, milk, kidney beans, garbanzo beans Butter beans Yogurt, tomato juice, navy beans, apples, pears, apple juice, bran cereals, black-eyed peas, peaches, chocolate, pudding, grapes, macaroni, carrots, green peas, baked beans, rye bread, orange juice, banana, wheat bread, corn pound cake, brown rice, cola, pineapple Ice cream, raisins, white rice Water melon, popcorn, bagel Pumpkin, doughnut, sports drinks, jelly beans Cornflakes Baked potatoes White bread

FATS / LIPIDS

It belongs to a group called lipids (chemically called Triglycerides), lecithin (Phospholipids) & cholesterol (Sterols) organic substances; greasy; insoluble in water. Of the lipids in food, 95% are fats and oil, and 5% are other lipids. Of the lipids stored in the body 99% are triglycerides.

Fats

From the Greek word lipos which means fat. Blood lipids= fats in the blood Hyperlipidemia= high levels of fat in the blood Lipoproteins= carriers of fat in human blood Insoluble in water but soluble in some solvents such as ether, benzene , and chloroform. Each gram of fat contains 9 calories.

Functions of Fat

Provide energy Carry-fat soluble vitamins Supply essential fatty acids Protect and support organs and bones. Insulate from cold. Provide satiety to meals.

Fats

Visible fats = fats that are purchased and used as fats such as butter, margarine, lard and cooking oils. Invisible fats= are those found in other foods such as meats, cream , whole milk, cheese, egg yolk, fried foods, pastries, avocados and nuts.

Dietary Fats & Oils Sources 1. Saturated Fats fats whose carbon atoms contain all of the hydrogen atoms they can; considered a contributory factor in atherosclerosis. Examples bacon, butter, grated coconut, coconut-cream, coconut oil, cream cheese, latik, margarine, mayonnaise, sandwich spread, sitsaron, whipping cream (heavy/light) 2. Polyunsaturated Fats OIL (corn, marine, soybean, rapeseed, canola, rice, sunflower, safflower, sesame) 3. Monounsaturated Fats Avocado, peanut butter, pili nut, peanut oil, olive oil, shortening

Essential fatty acids/ Omega Fatty Acids

Omega-3 fatty acids: linolenic acid, eicosapentaenoic acid, and docosahexaenoic acid; PUFA; in fish and fish oils and vegetable oils which increases the deformability of RBS and in turn reduce the viscosity of the blood Omega-6 fatty acids: linoleic acid and arachidonic acid; PUFA Omega-9 fatty acid: oleic acid; a MUFA

Summary of Fat Digestion & Absorption

Lipid Transport
Lipoproteins forms in which lipids are transported in plasma; consist of lipid and protein constituents 1. Chylomicrons: largest and least dense (float the fastest; transports diet-derived lipids (mostly triglycerides) via intestinal lymphatics to the blood and then to adipose tissue. 2. Pre-beta lipoproteins: they are VLDL; the lipids made in the liver and those collected from the chylomicron remnants are packaged with proteins as VLDL and shipped to other parts of the body; major reservoir of fat circulating in the blood during fasting state

3. Beta lipoproteins: are LDL: transports most of the total plasma cholesterol in the artery walls. 4. Alpha lipoproteins: are the HDL; 50% protein, 30%phopholipids and 20% cholesterol; source of good cholesterol; scavengers

Functions of Fats
A. Storage form of energy B. Transporter of fat-soluble vitamins C. Sources of essential fatty acids D. Thermal insulation E. Vital organ protection F. Cell structure G. Contribute to feeling of fullness, taste and smell H. Regulator of body functions

Dietary Requirement and Allowance:

* Fats should constitute 20-30% of the TER * 30-40% of the TER * 20% might be ideal * PUFA: 10% MUFA:10-15% SFA:7-10% * Cholesterol not more than 300mg/day

Health Effects of Lipids/Fats

1. Cancer 2. Heart disease 3. Weight control. Fats can easily cause weight gain because of the following reasons: a. high kcal value 9kcal/gram b. low satiety a high fat intake causes a decrease of leptin level which causes increased appetite and low activity c. high food intake because of increased palatability 4. Efficient metabolism after weight loss, there is increased lipoprotein lipase which enables you to store more fats. 5. Gallbladder problems decrease in fat intake may cause poor gallbladder movement. Increase in fat intake may increase cholesterol deposition.

Critical Thinking Exercise

Francesca is a 40 year old Italian schoolteacher who has been heavy most of her life. She is active and loves playing handball and racquetball. She was always active during school and does not know why she cannot lose her weight. She has about 100 pounds to lose. She has an Italian mother who loves to cook. Francesca loves her mom and does not want to offend her by not eating the food.

She wants to lose weight and she asked her doctor for a referral to a dietitian to discuss the best way to lose weight.

QUESTIONS: 1. What data do you currently have about Francesca? What has contributed to her current problem?

3. What is the cause of Francescas weight? 4. What basically an Italian diet composed of? 5. What are two reasonable, measurable goals for Francesca and her weight loss program and why? 6. What is the recommended percentage of fat in the diet during weight loss?

7. Give an examples of meals for Francescas diet plan. 8. How often should Francesca weight herself? 9. What other signs will indicate that Francesca is losing weight? 10. Who else could benefit from Francescas change in diet and activity?

PROTEINS

organic substances composed of amino acids; contain the element C, H, O and N 20 kinds of amino acid

Amino Acids
Essential Amino Acids
Histidine Phenylalanine Isoleucine Valine Leucine Tryptophan Lysine Threonine Methionine

Non-essential Amino Acids

Alanine Serine Arginine Tyrosine Aspartic acid Glutamic acid Cysteine Cystine Glutamine Glycine

Summary of Protein Digestion and Absorption

Metabolism of Protein
1. Anabolism - involves the incorporation of amino acids in the synthesis of tissue proteins 2. Catabolism - involves the breakdown of amino acids into their component parts Nitrogen Balance

Nitrogen Equilibrium: N in = N out Positive nitrogen: N in > N out Negative nitrogen: N in < N out

Quality of Protein Foods

Complete proteins Sources: * fish, shellfish *chicken, turkey, duck *beef *soybeans *hard cheese, cheddar, Swiss, soft cheese, cottage cheese, ricotta *milk, yogurt, ice milk/ reduced fat ice cream *lamb, pork, egg Incomplete proteins Sources: *cereals *grains *vegetables *legumes

Functions of Proteins
1. Providing energy 2. Creation of Communicators and Catalysts: enzymes and hormones 3. Immune system response: antibodies 4. Maintaining fluid and electrolyte balance 5. Maintaining acid-base balance 6. Transportation: lipoproteins and hemoglobin

Health Effects of Protein 1. Excess: heart disease, cancer, adult bone loss (osteoporosis), weight control, kidney disease
2. Protein Energy Malnutrition a. Acute PEM: wasting (KWASHIORKOR) *caused by recent severe food restriction b. Chronic PEM: stunting (MARASMUS) *caused by long-term food deprivation
Recommended Protein Intake: 10-15% of the TER

WATER - serves as the solvent for nutrients and waste product in the body.

Functions:
Carries nutrients and waste product throughout the body. Maintains the structure of large molecules Participates in chemical reaction Acts as a lubricant and cushion. Helps regulation of body temperature Maintains blood volume

Water Balance 1. Dehydration: resulting from excessive water loss, accompanied by loss of electrolytes. 2. Overhydration: water intoxication; resulting from excessive intake of fluids without an equivalent amount of salt. Water Recommendations Infants require 1.5L per 1000Cal intake Children (1-18 years): if weight is 10-20 kilos: 1000ml+50ml per kg excess of 10; if the weight is more than 20 kls: 1500ml + 20ml per kg in excess of 20kls. Adults: need 1L per 1000Cal intake.Older person: 1.5L Pregnant women: extra 300ml; lactating (1-6mos.): additional 750 to 1000ml.

VITAMINS

organic, essential nutrients required in small amounts to perform specific functions that promote growth, reproduction or maintenance of health and life Do not provide energy but they assist the enzymes that release energy from energyyielding nutrients

Classification
1. Water-soluble: C and B-complex Thiamin (B1) Riboflavin (B2) Niacin (B3), Pantothenic acid (B5) Pyridoxine (B6) Folate Cobalamin (B12) Biotin.

2. Fat-soluble A, D, E, K

General Properties of fat and water-soluble vitamins

FAT-SOLUBLE Soluble in fat and fat solvents Intake in excess of daily need stored in the body Deficiency symptoms slow to develop Small amounts excreted in bile Not absolutely necessary in the diet everyday Have precursors or provitamins WATER-SOLUBLE Soluble in water Minimal storage of dietary excesses Deficiency symptoms often develop rapidly Excreted in urine Must be supplied in the diet everyday Generally do not have precursors

Contain only elements C, H, O

Absorbed into the lymphatic system Needed only by complex organisms Some are relatively low levels (6-10x the RDA)

Contain C, H, O, N and others

Absorbed into the blood through portal vein Needed by simple and complex organisms Toxic only at mega dose levels (10> the RDA)

WATER-SOLUBLE VITAMINS VITAMIN Thiamine (B1) FUNCTION Coenzyme energy metabolism; muscle nerve function CLINICAL ISSUES (DEFICIENCY/TOXICITY) Deficiency: beriberi (ataxia, disorientation, tachycardia); marginal (headaches, tiredness); wet beriberi (edema); dry beriberi (nervous system): Wernicke Korsakoff syndrome (alcoholism) Deficiency: ariboflavinosis with cheilosis, glossitis, seborrheic dermatitis FOOD SOURCES Lean pork, whole or enriched grains and flours, legumes, seeds, and nuts

Riboflavin (B2)

Coenzyme energy metabolism

Milk/dairy products; meat, fish, poultry, and eggs; dark leafy green (broccoli); whole and enriched breads and cereals Meats, poultry, and fish; legumes; whole and enriched cereals; milk

Niacin (B3) precursor tryptophan

Cofactor to enzymes involved in energy metabolism; glycolysis and TCA cycle

Deficiency: pellagra Toxicity: vasodilation, liver damage, gout, and arthritic reactions

WATER-SOLUBLE VITAMINS
CLINICAL ISSUES VITAMIN FUNCTION
(DEFICIENCY/TOXICITY)

FOOD SOURCES

Pyridoxine (B6)

Forms coenzyme Deficiency: dermatitis, pyridoxal altered nerve function, phosphate (PLP) weakness, anemia; for energy OCAs decrease B6 metabolism; CNS; levels hemoglobin Toxicity: ataxia, sensory synthesis neuropathy

Whole grains/cereals, legumes, poultry, fish, pork, eggs

Folate (folic acid, folacin, PGA)

Coenzyme metabolism (synthesis of amino acid, heme, DNA, RNA); fetal neural tube formation

Deficiency: megaloblastic anemia; many drugs affect folate use Toxicity: megadoses may mask pernicious anemia

Widely available leafy green vegetables, legumes, ascorbic acidcontaining foods

WATER-SOLUBLE VITAMINS
CLINICAL ISSUES (DEFICIENCY/TOXICITY) Deficiency: pernicious anemia, CNS damage FOOD SOURCES Animal sources

VITAMIN Cobalamin (B12)

FUNCTION Transport/storage of folate; metabolism of fatty acids/amino acids Metabolism of carbohydrate, fat, and protein

Biotin

Deficiency: produced by avidin and long term antibiotics

Liver, kidney, peanut butter, egg yolks, intestinal synthesis Widespread in foods Widespread milk, eggs, peanuts Friuts/vegetables (citrus fruits, tomatoes, peppers, strawberries , broccoli)

Pantothenic acid

Part of Coenzyme A

Deficiency: not possible

Choline

Synthesis of acetylcholine and lecithin Antioxidant, coenzyme, collagen formation, wound healing, iron absorption, hormone synthesis

Deficiency: rare Toxicity: body odor, liver damage, hypotension Deficiency: scurvy Toxicity: cramps, nausea, kidney stone formation, gout (1 to 15g), rebound scurvy

Vitamin C

Angular stomatitis: riboflavin or other B vitamins, iron

Scarlet tongue in niacin deficiency

cheilosis

FAT - SOLUBLE VITAMINS

VITAMIN Vitamin A Precursor: carotenoids Preformed vitamin: retinoids FUNCTION Maintains epithelial tissues (skin and mucous membranes); rhodopsin formation for vision; bone growth; reproduction CLINICAL ISSUES (DEFICIENCY/TOXICITY) Deficiency: xerophthalmia; night blindness; keratomalacia; degeneration of epithelial tissue; inhibited growth (respiratory and GI disturbances) Toxicity: hypervitaminosis A (from supplements) with blistered skin, weakness, anorexia, vomiting, enlarged spleen and liver FOOD SOURCES Deep green, yellow, and orange fruits and vegetables; animal fat sources: whole milk, fortified skim, and lowfat milk; butter; liver; egg yolks, fatty fish

Vitamin D Precursor: 7dehydrocholest erol Active form: cholecalciferol

Calcium and Phosphorous absorption; bone mineralization

Deficiency: bone malformation, rickets (children), osteomalacia (adults) Toxicity: hypercalcemia, hypercalciuria

Animal (fat) sources: butter, egg yolks, fatty fish, liver, fortified milk; body synthesis

Early conjunctival xerosis (X1A)

Classification of Xeropthalmia

Classification of Xeropthalmia Ocular Signs

Night Blindness Conjuctival Xerosis Bitots Spot Corneal Xerosis Corneal ulceration/keratomalacia < 1/3 of surface Corneal ulceration/keratomalacia >1/3 corneal surface Corneal scar Xerophthalmia fundus

Classification
XN X1A X1B X2 X3A X3B XS XF

Ocular Signs

Classification of Xeropthalmia Ocular Signs

Night Blindness Conjuctival Xerosis Bitots Spot Corneal Xerosis Corneal ulceration/keratomalacia < 1/3 of surface Corneal ulceration/keratomalacia >1/3 corneal surface Corneal scar Xerophthalmia fundus

Classification
XN X1A X1B X2 X3A X3B

Classification

Night Blindness
Conjuctival Xerosis Bitots Spot Corneal Xerosis

XN
X1A X1B X2 X3A X3B XS

XS Dryness, wrinkling, increased pigmentation XF

Corneal ulceration/keratomalacia < 1/3 of surface Corneal ulceration/keratomalacia >1/3 corneal surface Corneal scar

Xerophthalmia fundus

XF

Early conjunctival xerosis (X1A)

Keratomalacia (X3B)

Bitots spot (X1B): Bitots spot (X1B)

Corneal scarring (XS)

Ectasia of cornea (XS)

Xerophthalmia fundus (XF)

FAT - SOLUBLE VITAMINS

CLINICAL ISSUES (DEFICIENCY/TOXICITY) Deficiency: primary deficiency rare; secondary deficiency (caused by fat absorption) neurologic disorders Toxicity: none, but supplements contraindicated with anticoagulation drugs

VITAMIN Vitamin E alpha tocopherol

FUNCTION Antioxidant for PUFA and vitamin A; antioxidant with selenium and ascorbic acid

FOOD SOURCES Vegetable oil, whole grains, seeds, nuts, green leafy vegetables

Vitamin K Active form: menaquinon es

Cofactor in synthesis of blood clotting factors; protein formation

Deficiency: blood coagulation inhibited; hemorrhagic disease (infants) Toxicity: therapeutic vitamin K (menadione form) reactions in neonates, causing hemolytic anemia and hyperbilirubinemia

Green leafy vegetables, intestinal synthesis

MINERALS - inorganic elements that remains as ash when food is burned; non-caloric; the body cannot synthesize them -about 1% to 6% of body weight is mineral.
A. Macronutrient minerals essential for human nutrition present in amounts greater then 5 grams. e.g. Calcium, Sodium, Phosphorous, Potassium, Sulfur, Chlorine, Magnesium B. Micronutrient minerals essential for human nutrition present in amounts less than 5 grams. e.g. Iron, Iodine, Zinc, Selenium, Manganese, Copper, Molybdenum, Cobalt, Chromium

MAJOR MINERALS
MINERAL Calcium (Ca) FUNCTION Bone and tooth formation; blood clotting; muscle contraction/rela xation; CNS; blood pressure Bone and tooth formation (component of hydroxyapatite); energy metabolism (enzymes); acidbase balance Structure/storage; cofactor; nerve and muscle function; blood clotting CLINICAL ISSUES (DEFICIENCY/TO XICITY Deficiency: reduced bone density; osteoporosis Toxicity: constipation, urinary stones; reduced iron and zinc absorption Deficiency: rare Toxicity: increased calcium excretion FOOD SOURCES Milk (whole, low-fat, skim), milkbased products, green leafy vegetables, legumes Dairy foods, egg, meat, fish, poultry ABSORPTION ISSUES Absorption based on need: increased by vitamin D; decreased by binders, inactivity coffee/tea Absorbed with calcium

Phosphoro -us (P)

Magnesiu m (Mg)

Deficiency: secondary with muscle twitching, weakness, convulsions from fluid volume deficit (FVD) Deficency only if protein malnourished

Whole grains, legumes, green leafy vegetables (broccoli), hard water Proteincontaining foods

Sulfur (S)

Component of protein structures

MINERAL

FUNCTION

CLINICAL ISSUES (DEFICIENCY/TOXICITY)

FOOD SOURCES

Sodium (Na)

Major extracellular electrolyte for fluid regulation; body fluid levels; acid-base balance; nerve impulse and contraction; blood pressure/volume Major intracellular electrolyte for fluid regulation; muscle function

Deficiency: headache; muscle cramps, weakness, decreased concentration, memory and appetite loss Toxicity: sodiumsensitive hypertension Deficiency: muscle weakness, confusion, decreased appetite, cardiac arrhythmias caused by FVD from vomiting/diarrhea or diuretics Toxicity: from diet or supplements if renal disease present Deficiency: FVD caused by vomiting/diarrhea

Table salt; naturally in many foods; processed foods

Potassium (K)

Unprocessed foods, fruits, vegetables, dairy products, meats, legumes

Chloride (Cl)

Acid-base balance; gastric hydrochloric acid for digestion

Table salt

TRACE MINERALS
MINERAL Selenium (Se) FUNCTION Antioxidant cofactor with vitamin E; prevents cell and lipid membrane damage Coenzyme in antioxidant reactions and energy metabolism; wound healing; nerve fiber protection; iron use Carbohydrate metabolism, part of glucose tolerance factor
CLINICAL ISSUES (DEFICIENCY/TOXICITY)

FOOD SOURCES Meat, fish, eggs, whole grains

Deficiency: possible Keshans disease/cancer Toxicity: liver damage, vomiting, diarrhea Deficiency: bone demineralization and anemia Toxicity: Wilson's disease or with supplements producing vomiting/diarrhea Deficiency: possible link with cardiovascular disorders; hypoglycemia, hyperglycemia, and unresponsive insulin Deficiency: unknown

Copper (Cu)

Organ meats (liver), seafood, green leafy vegetables Animal food, whole grains

Chromiu m (Cr)

Mangane se (Mn)
Molybdenu m (Mo)

Part of metabolic reaction enzymes

Whole grains, green leafy vegetables, legumes Many foods

Coenzyme

Deficiency: unknown

NUTRITION & THE LIFE CYCLE

Nutritional Recommendations in Pregnancy Protein Intake N requirement based on age and sex plus 9 to 10g/day throughout the pregnancy. Emphasize high-quality, complete protein foods.
Energy Requirements N requirement based on age and activity w/ additional of 300kcal for the 2nd and 3rd trimester of pregnancy Teens aged 13 to 16 yrs old: recommended wt. gain is between 30 to 35 lbs. Kcal adequacy: constant wt. gain of approx. 0.4kg/wk after the 1st trimester. Carbohydrate Intake Generous amount; emphasize minimal processed foods, complex CHO and limit concentrated sweets

Problems of Pregnancy with Nutritional Implications

Mild nausea and (1) Eat dry eat dry toast, dry cereals, or crackers (2) try vomiting; called chewing gum or candies (3) SFF (4) avoid greasy morning sickness foods and foods w/ o offensive odors; (5) omit juice, water, milk, coffee, or tea; (6) dont d drink liquids w/ meals.
Heartburn (1) SFF (2) Relax and eat slowly (3) Chew food thoroughly (4) Drink liquids between meals (5) Avoid spicy or greasy foods (6) Sit up while eating; elevate the head while sleeping (7) Wait an hour after eating before lying down; Wait two hours after eating before exercising (1) Drink at least 8glasses of water or other fluids that are non-caffeine and non-alcoholic; (2) exercise regularly (3) Respond promptly to the urge to defecate Substitute soy milk; if milk is totally omitted for medical reason, try to obtain calcium, phosphorous from other foods.
(1)

Constipation

Lactose Intolerance

Pica

Correct calcium deficiency or IDA if present through supplementation and emphasizing balance diet (2) seek advice from health care professionals

in

Benefits of Breastfeeding/Lactation
For Infants: Provides the appropriate composition and balance of nutrients with high bioavailability Protects against food allergies breast milk contains less Pro and minerals that infant formulas, it reduces the load on the infants kidneys never warm the breast milk in a microwave oven because the antibodies will be destroyed Newborns lack intestinal bacteria to synthesize Vit. K, so they are routinely given a Vit. K supplement

For Mothers Contracts the uterus Delays the return of regular ovulation Conserves iron stores (by prolonging amenorrhea) May protect against breast and ovarian cancer Water: A sensible guideline is to drink a glass of milk, juice, or water at each meal and each time the infant nurses.

BOTTLE FEEDING the infant should be cuddled and held in an upright position during the feeding to prevent middle ear infections when an infant is extremely sensitive or allergic to infant formulas, a synthetic formula (made from soybeans) may be given.

METABOLIC DISORDERS
1. galactosemia lack of the liver enzyme transferase transferase converts galactose to glucose - suffers diarrhea, vomiting, edema, liver does not function normally, galactosuria, mental retardation diet therapy: exclusion of anything containing milk from any mammal; give lactose-free, commercially prepared formula. 2. Phenylketonuria (PKU) lacks the liver enzyme phenylalanine hydroxylase diet therapy: commercial infant formula called lofenalac.

3. Maple Syrup Urine Disease (MSUD) congenital defect resulting in the inability to metabolize three amino acid (leucine, isoleucine and valine) : hypoglycemia, apathy and convulsions :diet therapy special formula and low-Pro foods are used

Childhood and Adolescence: Children aged one to twelve

Children should be offered nutrient-dense foods Fats should not be limited before the age of 2 years Sensitive to and reject hot (temperature) foods and like crispy, mild flavors, and familiar foods
Common Eating Problems 1. Food jags 2. Food gag 3. food dawdling

Adolescence: tends to begin between the ages of 10 and 13 in girls and between 13 and 16 in boys. like foods that are popular but have low nutrient density. Adolescent Problems Related to Nutrition
Anorexia Nervosa: a psychological disorder causes the person to drastically reduce kcal. hair loss, low BP, weakness, amenorrhea, brain damage Bulimia a syndrome in which the client alternately binges and purges by inducing vomiting and using laxatives and diuretics to get rid of ingested foods

Marijuana makes one hungry esp. for sweets *One marijuana cigarette is as harmful as 4 to 5 tobacco cigarettes. Cocaine highly addictive and extremely harmful *cardiac irregularities, heart attacks, and cardiac arrests.

Adulthood Young adulthood: 18 to 40 years of age: alive w/ plans, desires and energy Middle adulthood: 40 to 65 years of age: decrease in physical activities Late adulthood: 65 years onwards Nutrient Requirements There is a general decrease in kcal due to: slowing of metabolic rate; decreased physical activity; loss of muscle mass or lean body mass (sarcopenia)

PUBLIC HEALTH NUTRITION

Malnutrition: a state of disease caused by sustained deficiency, excess, or imbalance of the supplies of calories, nutrients, or both, that is available for use in the body.
Causes of Malnutrition Inadequate food intake Large-sized family Lack of education Poor health status Faulty food habits & practices Poor environmental conditions

MEDICAL NUTRITION THERAPY

Meal Distribution System a. Centralized b. decentralized

a. b. c.

Nutritional Care Services: Assessment and screening monitoring counseling

The Routine Hospital Diets a. The Regular Diet: general, house, full hospital diet. Highly spiced foods, rich fatty foods and gas formers should also be avoided. b. The Soft Diet: modifications in consistency and texture. Foods allowed are low in fiber diet and connective tissues and are generally bland in flavor.

c. The Liquid diet: 2 types a. Clear liquid diet without residue or fiber; to relieve thirst and help maintain water balance; 600-900 kcal/day. Preferably, feeding is done every 2-3 hours and each feeding should not exceed 300ml of liquids, between 6AM to 10PM.
Indications for use: used just immediately before and after surgery.

b. Full liquid diet liquid at room temperature or could be liquefied at body temperature. Indications for use: fever, infections, lesions in the mouth, GIT disturbances, nausea and vomiting, with esophageal disorders

Variations of the Routine Hospital Diets a. The Light Diet: transition between the soft and regular diets; for elders who cannot tolerate rich and heavy foods. b. The Mechanical Soft Diet: dental soft or mechanically altered diet. c. The Cold Liquid Diet: consists of cold smooth liquids. d. Tube Feedings: requires a consistency that can pass through a polyvinyl tube.

Vegetarian Diets

low in SFA and cholesterol; high fiber; disadvantage is inadequate or low level of Vit B12, iodine, calcium, zinc, riboflavin, and vitamin D.

a. Vegan Diet: total vegetarian or strict vegetarian diet. Foods allowed are strictly of plant origin. b. Lacto-vegetarian: milk and milk products + items of plant origin. c. Ovo-vegetarian: eggs and eggs products + items of plant origin d. Lacto-ovo-vegetarian: eggs + milk and milk products + items of plant origin e. Semi-vegetarian: lacto-ovo-vegetarian foods + fish + chicken + items of plant origin f. Pesco-vegetarian: fish and fish products + items of plant origin

Diet as Tolerated: (D.A.T.) FL to regular diet; a temporary measure lasting no more than one day; for newly admitted patient with problem in digestion Diet Orders: divided in qualitative and quantitative terms that leave no room for misinterpretation restricted diet amount or type of nutrient e.g. Cholesterol restricted diet

Controlled adjustment of levels of nutrients from dayto-day as needed e.g. controlled pro, potassium, sodium in client w/ kidney failure undergoing dialysis

Completeness of Diet Order

Case: (+) Type 2 Diabetes, (+) HPN Low Sodium (2g/day) Low Cholesterol (300mg/day) to be given in 5 to 6 feedings/day Carbohydrate: 300g Protein : 75g Fats : 55g

Diets Modified in Composition

1.

Low Calorie: an allowance of foods and drink with an energy value below that is required for maintenance in order to bring about weight reduction.

Indications for Use: when weight reduction is desirable as in obesity or in OW, cardiac, hypertensive, arthritic or diabetic individuals; when energy requirements are reduced as in hypothyroidism, prolonged bed rest or in elderly.

formula: TER: [ABW(kg) x PA value (using Krause Method)] 250 to 1000Cals

to lose lb/wk: deduct 250Cals to lose 1 lbs/wk: deduct 500Cals to lose 1 lbs/wk: deduct 750Cals to lose 2 lbs/wk: deduct 1000Cals

2. High Calorie: to produce a gain in body weight, to meet increased energy needs, or to prevent or minimize the catabolism of tissues. Indications for use: underweight, hypercatabolic conditions: hyperthyroidism, injury, burns, fever and infections when a full diet can be tolerated. formula: TER: [ABW(kg) x PA value (using Krause Method)] + 250 to 1000Cals to gain lb/wk: add 250Cals to gain 1 lbs/wk: add 500Cals to gain 1 lbs/wk: add 750Cals to gain 2 lbs/wk: add 1000Cals

3. High Protein Diet: provides 1.5g or more/KDBW/day Indications for use: protein deficiency (1 o 2); pre & post surgery; hypercatabolic conditions (e.g. injury, burns, fever an infections), hepatitis, etc. formula: step 1: g of Pro/day=ABW x 1.5g/KDBW 2: Calories of pro=___g of Pro/day (4Cals/g of Pro) 3: NPC Method: TER-Cals of Pro 4: CHO: NPC x % distribution/4 Fats: NPC x % distribution/9 5: Diet Rx: ______________________

4. Low Protein: provides about 30g of Pro/day, 2/3 of which is HBV while 1/3 is LBV
Indications for use: acute glumerulonephritis w/ impaired function; CRF w/ impaired renal function w/o HPN; advanced liver disease w/ hepatic insufficiency. formula: step 1: g of Pro/day=30g 2: Calories of pro=120Cals 3: NPC Method: TER-120Cals of Pro 4: CHO: NPC x _____ Fats: NPC x _____ 5: Diet Rx: ______________________

5. Low fat: provides no more than 15% of the total calories Indications for use: cholecystitis, cholelithiasis, atherosclerosis; hepatitis, pacreatitis, fat malabsorption, weight reduction formula: C: TER x .7 4Cals/g = ____g P: TER x .15 4Cals/g = ____g F: TER x .15 9Cals/g = ____g

6. Low Cholesterol: amount & type of fat; <300mg/day Indications for use: hypercholesterolemia; CAD; adults w/ family history of heart disease (as primary preventive measure) formula: C: TER x .7 4Cals/g = ____g P: TER x .15 4Cals/g = ____g F: TER x .15 9Cals/g = ____g

7. Low Carbohydrate: provide no more than 50% of total Calories. Complex carbohydrates are preferred

Indications for use:

25% CHO: functional hyperinsulinism, dumping syndrome 40% CHO: fat- and CHO- induced hyperlipoproteinemia; CHO induced hyperlipoporteinemia, COPD 50% CHO: fat and CHO-induced hyperlipoproteinemia

8. Sodium restricted a. Mild: light salt in cooking, no salty processed foods & condiments (2-3g) b.Moderate: (1000mg) no salt in cooking, limit veggies that are high in natural salt; meat & milk in moderation. c. Strict: (500mg) like moderate restriction, but strict limitations on milk, meat & eggs. Delete commercial foods w/ milk *regular Na diet: 2800 to 6000mg Na *1T salt: 500mg Na Indications for use: conditions of sodium or saline excesses as in CHF; liver disease w/ ascites, glumerulonephritis, nephrotic syndrome; ARF, CRF
Food Groups Na Content/ Exchange

Fruit Vegetable Rice Pan de sal Slice bread Meat/fish/poultry Egg Butter Margarine milk

2mg 2 2 135 120 25 20 50 55 120

end...

c u all xt wk!

Medical Nutrition Therapy for Surgical Conditions

The Surgical Process

Three Phases: 1) pre-op 2) the surgery procedure itself, 3) postop

Two forms of surgery based on the urgency of operation: 1) emergency 2) elective

Pre-operative Diet: 1) Diet for elective surgery high protein high Calorie with vitamin and mineral supplementation; if obese, low Calorie diet 2) Diet for emergency operations parenteral feeding is recommended (IV, subcutaneous, IM) 3) Diet immediately before surgery: light evening meal the day before the surgery then restricted to clear liquids and then all foods are withheld for at least 8 hours. Post-operative Diet: NPO immediately after the operation to CL diet to FL diet, a soft, and eventually to a regular diet. A high Calorie, high Pro diet is recommended.

Enteral Nutrition Support Characteristics of Tube Feeding and Preparation a. the mixture should pass the 2 mm tube with relative ease b. dilution is 1kcal/ml c. total volume should not exceed 2300ml/day or 100 ml/hr. Indications for Use of Tube Feeding 1. Inability to ingest food normally 2. Physiologic deterrents to food intake 3. Obstruction of GIT 4. Psychiatric illness 5. Impairment of digestion and or absorption 6. Protein-calorie malnutrition 7. Intestinal surgery 8. Transition from TPN to conventional foods 9. Renal failure; hepatic failure 10. Inborn errors of metabolism

Types of Formula and Their Use

a. Intact Formulas: polymeric formulas; unaltered molecules of CPF; i. standard formulations ii. blenderized whole food formulations.

b. Hydrolyzed Formulas: monomeric formulas; predigested CHON and simple carbohydrates, plus a small amount of oil or a blend of medium chain triglycerides (MCTs) and oil;
c. Modular Formulas: incomplete liquid supplement that contains specific nutrients, usually a single macronutrient (carbohydrate, protein or fat).

Tube Feeding Administration

1.

2.

3.

Continuous drip method: administered via gravity or a pump; total volume should not exceed 100ml per hour. Bolus feeding: rapid installation of feeding into the GI tract by syringe or funnel. Combination: a combination of continuous drip (at night) and bolus feedings (during the day) can be used

Enteral Feeding Complications and Suggestions 1. Diarrhea assess the administration of the formula, the handling techniques, tubing, addition of medications and fluids 2. Aspiration elevate the head to 30-45 degrees 3. Clogged Tubes flush tube with 50-150 cc of fluid; avoid use of crushed medications 4. Constipation provide adequate fluids; assess need for a fiber-containing formula 5. Abdominal distention assess volume of formula administered; assess for lactose intolerance and tolerance for fiber 6. Nausea and vomiting consider holding feeding for 12 hours; assess volume of feeding; consider anti-nauseant or anti-emetic or anti-gas medication 7. Contamination of formula closed systems can hang for up to 24-48 hours; if open systems up to 4-8 hours; avoid topping off the bag; use sanitary techniques

Parenteral Feeding
1.

2.

Peripheral Parenteral Nutrition (PPN): via the small veins, usually in the arms. Total Parenteral Nutrition (TPN): also called Central Parenteral Nutrition (CPN) or intravenous hyperalimentation (IVH). superior or inferior vena cava or the jugular vein.

Dietary Management of Specific Surgical Conditions 1. Gastric Surgery as Gastrectomy - production of pepsin and HCl is impaired; reduced protein and impaired fat digestion; reduced utilization of iron and vitamin B12; 50% of patients often lose weight after gastric surgery.

Ice held in the mouth or small sips of water. Some patients tolerate warm water better than ice or cold water. Increase in amounts of fluid given. Bland foods/solid foods as tolerated.

2.

Dumping syndrome stomach contents are emptied into the jejunum at an abnormally fast rate.

SFF; dry diet Low fiber, high protein, high fat, low simple CHO with vitamin and mineral supplementation. Learn to relax; rest before mealtime, eat slowly and chew food well.

3. Cholecystectomy the day after the operation, give low fat starting with liquids and gradually progressing to a low-fat, soft diet until a regular diet is well tolerated. 4. Rectal surgery any operation done in the rectum; clear liquid diet within the first 24 hours after the operation followed by a non-residue diet. High-residue foods: milk, potatoes, raw to softcooked eggs, most cheeses except cottage cheese, butter, lard and lactose. 5. Burns tissue injury or destruction caused by excessive heat, caustics (acids or alkalis), friction, electricity or radiation.

Classification of Burns
Child %

Adult %

1.

2.

3.

First degree simple redness of the affected areas. Second degree erythema + blisters; 15% for adults and 10% for children. Third degree actual destruction of the skin and underlying tissues.

Dietary Management: formula to calculate caloric requirements:

Adults: (25kcal) x preburn body weight in kg + (40 kcal x %BSA burned) Children: 30 to 100 kcal [RDA for age] + preburn body weight in kg + (40 kcal x %BSA burned)

Medical Nutrition Therapy for Infections and Respiratory Disorders Classification of Infections: acute, chronic and recurrent. 1. Cholera (El Tor); disease of the intestines caused by Vibrio cholerae. Symptoms consist of diarrhea, vomiting and severe muscle cramps. Dietary Management: acute stages NPO for 12 hrs w/ IVF and electrolytes; ORT + resistant starch. As stools are formed, start w/ broth, tea, toast to normal diet; Gatorade. 2. Dengue Fever by Aedes aegypti; the dengue virus causes increased permeability that leads to bleeding known as DHF. The liver may be enlarged, soft and tender. Dietary Management: high Calorie, liquid diet to soft highcalorie diet, moderate in fat w/ water and fruit juices to prevent dehydration. Candies may be given to stop vomiting.

3. Typhoid Fever by Salmonella typhosa; Diarrhea and Payers patches (i.e., ulceration and hemorrhaging of the intestinal walls) are common symptoms. Dietary Management: diet for fevers plus a low fiber diet.

4. Rheumatic Fever inflammatory conditions affecting the connective tissue and causing joint pain, swelling, fever, rash, and carditis. Long-term effects results in RHD. Dietary Management: high calorie, high protein, full liquid diet to soft then regular diet. In case the patient is using steroids, low sodium diet; high intake of Vitamin C and A.
5. Malaria caused by the genus Plasmodium, a parasitic protozoan found in mosquitoes particularly the genus Anopheles. Dietary Management: high calorie, high protein, moderate fat with vitamin and mineral supplementation and liberal fluid intake.

6. Tuberculosis tubercle bacillus (Mycobacterium tuberculosis and M. Africanum, and M. bovis from cattle)
Extrapulmonary tuberculosis (ETB)

Dietary Management: high calorie, high protein, sufficient calcium, adequate iron and vitamin C and B6; adequate fluids.

Medical Nutrition Therapy for Diseases of the GIT

Diverticular Disease

1. Achalasia LES fails to relax normally after swallowing so that food can enter the stomach. Dietary Management: liquid foods + supplementary foods; bland foods; avoid foods that reduce LES; tube feeding if severely malnourished 2. Esophagitis acute or chronic inflammation of the esophageal wall; H. pylori (HP) bacteria and excessive use of aspirin and other NSAIDs may cause esophagitis. Dietary Management: diet modified in consistency, liquid to soft diet; avoid foods with an acid pH, fatty meals and spicy foods; avoid foods which lower LES pressure. 3. GERD partially digested food in the stomach backs up into the esophagus. Dietary Management: SFF; upright position 2hrs after meals; lose weight; take medicines regularly; avoid foods that lower LES pressure; avoid smoking and wearing tight-fitting clothes.

4. Gastritis inflammation of the mucous membrane of the stomach resulting in tissue damage and erosion, which expose the underlying cells to gastric secretion and pathogens. Dietary Management: acute gastritis withhold food for 24 hours then oral diets (CL to FL to SD to regular diet). Chronic gastritis folate and vitamin B12 supplementation. 5. PUD a chronic sore or crater extending through the protective membrane lining and penetrating the underlying tissue of the gut. Pharmacologic treatment: use of antibiotics, antacids, H2 blockers Dietary Management: if the ulcer is bleeding, NPO and IVF of dextrose and amino acids then progress to FL then to regular diet. 6. Diarrhea the passage of stools of liquid to semi-solid consistency at frequent intervals along the digestive tract; common categories are: acute and chronic Dietary Management: NPO for 12 hours with IVF and electrolytes then to oral fluids; TPN is sometimes needed; liberal fluids; vitamin and minerals supplementation; Oral Rehydration formula (WHO): tsp table salt, 1 tsp baking soda, 1 cup orange juice, 4 tbsp sugar and 1 liter (1.05 quarts) of clean water.

7. Constipation infrequent and difficult passage of small amounts of hard, dry stools. Atonic: lazy bowel because of loss of rectal sensibility; the feces are large and hard Spastic: caused by an overstimulation of the intestinal nerve endings which results in irregular contractions of the bowel; the stools are dry, hard and small. Dietary Management: atonic and spastic require a high fiber diet with liberal fluid intakes. However, acute attacks of spastic constipation, a low fiber diet is most beneficial. Fiber: a high fiber diet is 20-35 g/day 8. Diverticulosis the presence of diverticula (sacs or pouches) in the colon Dietary Management: high fiber and adequate fluid intake 9. Diverticulitis inflammation of small pouches (diverticula) in the colon wall and lining due to chronic constipation. Dietary Management: acute oral feedings from CL to FL or an oral feeding with elemental formula. 10. Hemorroids enlarged veins (varicose) which occur in the lower part of the rectum at the anal opening. Dietary Management: high fiber diet (25-35 g) with plenty of water (8-10 glasses/day)

Thank You!