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Nutritional Review

RECOMMENDED DIETARY ALLOWANCES AND DIETARY REFERENCE INTAKES The Dietary Reference Intakes (DRIs) are nutrient-based reference values for use in planning and assessing diets and for other purposes (IOM, 2010). DRIs replaced older tools first published by the National Academy of Sciences in 1941. The DRI values comprise seven reports with more detailed guidance than the old system. The DRIs are composed of the following: • Estimated average requirements (EAR), expected to satisfy the needs of 50% of the people in that age group. • Recommended dietary allowances (RDA). After computing the EARs for each age/gender category, the Food and Nutrition Board (FNB) then established RDAs to meet the nutrient requirements of each category. • Adequate intake (AI), where no RDA has been established • Tolerable upper intake levels (UL), to caution against excessive intake of nutrients (like vitamin D) that can be harmful in large amounts.

REFERENCE IOM. Institute of Medicine, National Academy of Sciences. Dietary Reference Intakes, 2001. Web site accessed 3/14/10. http://www.iom.edu/ Object.File/Master/7/294/0.pdf

Reader Please Note: All tables in this Appendix A are derived from the ARS Nutrient Database for Standard Reference, Release 17. Foods are from single nutrient reports, sorted either by food description or in descending order by nutrient content in terms of common household measures. Mixed dishes are not included here. The food items and weights in these reports are adapted from those in 2002 revision of USDA Home and Garden Bulletin No. 72, Nutritive Value of Foods.

MACRONUTRIENTS Acceptable macronutrient distribution ranges for individuals have been set for carbohydrate, fat, n-6 and n-3 polyun-

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saturated fatty acids, and protein on the basis of evidence through the Institute of Medicine.

Carbohydrates and Fiber Carbohydrates (CHO) are essential for life and to provide energy to the body. The brain and central nervous system (CNS) require a continuously available glucose supply. When it is necessary, lean body mass is metabolized to provide glucose for these tissues. Generally, 90% of carbohydrates are absorbed from a mixed diet. The RDA for carbohydrate is set at 130 g/d for adults and children, based on the average minimum amount of glucose used by the brain. The median intake of carbohydrates is approximately 220–330 g/d for men and 180–230 g/d for women. To plan a balanced intake between 45 and 65% of kcal/d, it would equal 135 to 195 g carbohydrate on a 1200 kcal diet; 202–292 g CHO on an 1800 kcal diet; or 270–390 g CHO for a 2400-kcal diet. No recommendations based on glycemic index have been made. Intensely flavored artificial sweeteners that are approved for use in the United States include aspartame (NutraSweet), acesulfame-K (Sunette), neotame, saccharin (Sweet n Low), sucralose (Splenda), and stevia (Truvia). These are many times sweeter than natural sugars. Sugar replacers are natural sugar-free sugar alcohols such as mannitol, erythritol, isomalt, lactitol, maltitol, xylitol, and sorbitol. Unlike artificial sweeteners, these are used in the same amount as sugars and have the same bulk and volume. Labels indicate “sugar free” or “no sugar added. Sorbitol has a sweetness value of 60; mannitol has sweetness value of 50, or half that of table sugar. Both soluble and insoluble fiber play an important role in maintenance of health. Except in a few therapeutic situations, fiber should be obtained from food sources (20 and 35 g/d for adults). Men up to age 50 need 38 g/d; over age 50, 30 g/d. Women up to age 50 need 25 g fiber per day, women over age 50, 21 g fiber per day. All dietary fibers, regardless of type, are readily fermented by microflora of the small intestines, producing short-chain fatty acids (acetate, propionate, and butyrate). An overview of carbohydrate and fiber classifications is provided in Table A-1. A food list of fiber sources can be found in Table A-2.

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TABLE A-1 Carbohydrate and Fiber Class

Type

Food Sources

Comments

Monosaccharides

Glucose (dextrose)

Corn syrup, honey, fruits, vegetables

Fructose (levulose, fruit sugar)

High-fructose corn syrup, honey, fruits, vegetables

Galactose

Milk sugar

Mannose Sucrose (table sugar)

Found in poorly digested fruit structures Cane or beet sugars, maple sugar, grape sugar, some natural fruits and vegetables Milk, cream, whey

Most important; most widely distributed. Sweetness value  74. Sweetest, especially when fruit ripens. Most fruits contain 1–7%. Makes up 40% of the weight of honey. Sweetness value  173. Part of the lactose molecule. Sweetness value  32. Of little nutritional value Formed when glucose and fructose are linked together. Honey is a form of sucrose known as an invert sugar. Sweetness value  100. Glucose  galactose molecules in the mammary glands of lactating mammals. 7.5% of the composition of human milk, 4.5% of cow’s milk. Sweetness value  16. Made of two glucose molecules. Sweetness value  32. Most starches require cooking for best digestion. When cooked and cooled, they are effective thickeners (such as modified food starch). Muscle and liver storage form of glucose; only 18 hours can be stored in one day. Insoluble fibers increase fecal volume (bulk) and decrease colonic transit time by their ability to increase water-holding capacity; excess may deplete mineral status. The predominant sugar is used to name it.

Disaccharides

Lactose (milk sugar)

Maltose (malt sugar) Polysaccharides— digestible

Starch (amylose and amylopectin) Glycogen

Polysaccharides— indigestible (fiber)

Insoluble fibers: Cellulose

Insoluble hemicelluloses (xylan, galactan, mannan, arabinose, galactose) Algal polysaccharides (carrageenan) Lignin (noncarbohydrate)

Cutin (noncarbohydrate) Soluble fibers: Pectin (polygalacturonic acid)

Oligosaccharides

Miscellaneous carbohydrates

Malt, sprouting grains, partially digested starch Modified food starch, potatoes, beans, breads, rice, pasta, starchy products such as tapioca No foods Soybean hulls, fruit membranes, legumes, carrots, celery, broccoli, and many other vegetables. The most abundant organic compound in the world. Corn hulls, wheat and corn brans, brown rice, cereal

Processed foods such as baby food, ice cream, sour cream Wheat straw, alfalfa stems, tannins, cottonseed hulls Apple or tomato peels, seeds in berries, peanut or almond skins, onion skins Citrus pulp, apple pulp, strawberries, sugar beet pulp, banana, cabbage and Brassica foods, legumes (such as kidney beans), sunflower heads

Beta-glucans (glucopyranose) Gums (galactose and glucuronic acid) Psyllium Raffinose and stachyose

Oat and barley bran; soy fiber concentrate.

Fructans [fructooligosaccharides (FOSs), inulin, oligofructose]

Wheat, onions, garlic, bananas, chicory, tomatoes, barley, rye, asparagus, and Jerusalem artichokes

Chitin (Glucopyranose)

Supplement made from crab or lobster shells Synthesized

Polydextrose, polyols (sorbitol, mannitol, etc.) Algal polysaccharides (carrageenan)

Oats, guar gum, legumes, barley, xanthan from prickly ash trees Extracted from psyllium seeds or plantains Beans and other legumes

Isolated from algae and seaweed

Extracted from seaweed and algae. Polymer made of phenylpropyl alcohols and acids. Flaxseed lignin is an excellent antioxidant. Lignin may lower serum cholesterol levels.

Soluble fibers decrease serum cholesterol by decreasing the enterohepatic recycling of bile acids and increasing use of cholesterol in bile synthesis. This stabilizes blood glucose levels and maintains mineral nutriture. Little effect on fecal bulk or transit time. Lowers serum cholesterol Useful for gel formation which slow digestion and slows down transit time; helpful in diarrhea. High water binding capacity (choking hazard) Low-molecular-weight polymers containing 2–20 sugar molecules. They add flavor and sweetness to low-calorie foods and provide prebiotics to stimulate the growth of intestinal bacteria, especially bifidobacteria. May be used as a fat replacer. May reduce serum cholesterol Bulking agent or sugar substitute.

Forms a gel used as thickening agent. Can be toxic.

Sources: Byrd-Brenner C, et al. Wardlaw’s perspectives in nutrition. 8th ed. New York: McGraw-Hill, 2008; Gallagher M. Macronutrients in Krause’s food and nutrition therapy. Mahan LK, Escott-Stump S, editors. 12th ed. St Louis, MO: Elsevier, 2008.


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TABLE A-2 Food Sources of Dietary Fibera Dietary Fiber (g)

Calories

Navy beans, cooked, 1/2 cup

9.5

128

Bran ready-to-eat cereal (100%), 1/2 cup

8.8

78

Kidney beans, canned, 1/2 cup

8.2

Split peas, cooked, 1/2 cup Lentils, cooked, 1/2 cup Black beans, cooked, 1/2 cup

Food, Standard Amount

Food, Standard Amount

Calories

Potato, baked, with skin, one medium

3.8

161

Soybeans, green, cooked, 1/2 cup

3.8

127

109

Stewed prunes, 1/2 cup

3.8

133

8.1

116

Figs, dried, 1/4 cup

3.7

93

7.8

115

Dates, 1/4 cup

3.6

126

7.5

114

Oat bran, raw, 1/4 cup

3.6

58

3.6

42

Pinto beans, cooked, 1/2 cup

7.7

122

Pumpkin, canned, 1/2 cup

Lima beans, cooked, 1/2 cup

6.6

108

Spinach, frozen, cooked, 1/2 cup

Artichoke, globe, cooked, one each

6.5

60

White beans, canned, 1/2 cup

6.3

154

Shredded wheat ready-to-eat cereals, various, 1 ounce

Chickpeas, cooked, 1/2 cup

6.2

135

Great northern beans, cooked, 1/2 cup

Dietary Fiber (g)

6.2

3.5

30

2.8–3.4

96

Almonds, 1 ounce

3.3

164

105

Apple with skin, raw, one medium

3.3

72

3.2

33

Cowpeas, cooked, 1/2 cup

5.6

100

Brussels sprouts, frozen, cooked, 1/2 cup

Soybeans, mature, cooked, 1/2 cup

5.2

149

Whole-wheat spaghetti, cooked, 1/2 cup

3.1

87

2.6–5.0

90–108

Banana, one medium

3.1

105

74

Orange, raw, one medium

3.1

62

131

Oat bran muffin, one small

3.0

178

Guava, one medium

3.0

37 97

Bran ready-to-eat cereals, various, 1 ounce Crackers, rye wafers, plain, two wafers Sweet potato, baked, with peel, one medium (146 g)

5.0 4.8

Asian pear, raw, one small

4.4

51

Pearled barley, cooked, 1/2 cup

3.0

Green peas, cooked, 1/2 cup

4.4

67

Sauerkraut, canned, solids, and liquids, 1/2 cup

3.0

23

Whole-wheat English muffin, one each

4.4

134

Tomato paste, 1/4 cup

2.9

54

Pear, raw, one small

4.3

81

Winter squash, cooked, 1/2 cup

2.9

38

Bulgur, cooked, 1/2 cup

4.1

76

Broccoli, cooked, 1/2 cup

2.8

26

Mixed vegetables, cooked, 1/2 cup

4.0

59

Parsnips, cooked, chopped, 1/2 cup

2.8

55

Raspberries, raw, 1/2 cup

4.0

32

Turnip greens, cooked, 1/2 cup

2.5

15

Collards, cooked, 1/2 cup

2.7

25

Sweet potato, boiled, no peel, one medium (156 g)

3.9

119

Blackberries, raw, 1/2 cup

3.8

31

Okra, frozen, cooked, 1/2 cup

2.6

26

Peas, edible-pod, cooked, 1/2 cup

2.5

42

Food sources of dietary fiber are ranked by grams of dietary fiber per standard amount; also calories in the standard amount. All are 10% of AI for adult women, which is 25 g/d.

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Fatty Acids and Lipids The usual American diet contains 35–40% fat kcal. Fats are carriers for fat-soluble vitamins and essential fatty acids (EFAs). Fat is essential for cell membranes (especially the brain) serves as an insulating agent for organs and is a rich energy source. Generally, 95% of fat from the diet is absorbed. One to two percent of calories should be available as linoleic acid to prevent EFA deficiency. People with low body fat stores, very malnourished persons, psychiatric patients, and premature low birth weight (LBW) infants are at risk for EFA deficiency. Lipase is needed to metabolize long-chain triglycerides (LCT) into free fatty acids (FFAs). When parenteral fat emulsions contain LCT, large doses may compromise immune function, elevate serum lipids, impair alveolar diffusion capacity, or decrease reticular endothelial system function. Medium-

chain fatty acids (MCFAs) are produced from medium-chain triglycerides (MCTs). MCTs are transported to the liver via the portal vein and, therefore, do not require micelle or chylomicron formation. Omega-3 fatty acids reduce inflammation and help prevent certain chronic diseases. These essential fatty acids are highly concentrated in the brain. Two to three servings of fatty fish per week (about 1250 mg EPA and DHA per day) are beneficial for most people. If using fish oil supplements, 3000–4000 mg standardized fish oils would be needed per day. Safe and effective doses of omega-3 fatty acid supplements have not been established in children. EPA and arachidonic acids are transformed into eicosanoids for prostaglandin, leukotriene, thromboxane, and prostacyclin synthesis. Prostaglandins are used in many diverse hormone-like compounds. Omega-3 fatty acids should be used cautiously by people who have a bleeding disorder, take


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blood thinners, or are at an increased risk for hemorrhagic stroke. It is very important to maintain a balance between omega-3 and omega-6 fatty acids in the diet. The Mediterranean diet consists of a healthier balance between omega-3 and omega-6 fatty acids than the typical American diet. Omega-6 fatty acids play a role as proinflammatory agents and are useful when initiating a stress response. Sphingolipids are hydrolyzed throughout the GI tract to regulate growth, differentiation, apoptosis, and other cellular functions. They reduce low-density lipoprotein (LDL) levels and increase high-density lipoprotein (HDL) levels. Dietary constituents such as cholesterol, fatty acids, and mycotoxins alter their metabolism. The recommended intakes of total fat per day equal 20–35% of kcal. Of this, consume 1–2% from omega-3 fatty

acids and 5–8% from omega-6 fatty acids. Table A-3 describes more details.

Proteins and Amino Acids Amino acids and proteins are the building blocks of life. All growth and repair functions of the body require utilization and availability of amino acids in the proper proportion and amounts. Average total essential amino acid needs are as follows: infants, 40% essential; children, 36% essential; and adults, 19% essential. This translates into 52 g protein for teenaged boys aged 14–18 years and 46 g for teenaged girls aged 14, and women. Pregnant or nursing women need 71 g/d. Men aged 19 need 56 g protein per day. Need increase with injury, trauma, and certain medical conditions.

TABLE A-3 Fats and Lipids Class

Fatty Acid Component

Key Food Sources

Comments

Simple lipids Neutral fats (acyl-glycerols)

Mono- and diglycerides

Additive in low-fat foods

Glycerol with one or two esterified fatty acids

Triglycerides (triacylglycerols)

Fats and oils

Glycerol with three esterified fatty acids

Alpha linolenic acid (ALA)

Vegetable oils (soybean, canola, or rapeseed), flaxseeds, flaxseed oil, soybeans, pumpkin seeds, pumpkin seed oil, purslane, perilla seed oil, walnuts, walnut oil. Flaxseed and flaxseed oil should be kept refrigerated; whole flaxseeds should be ground within 24 hours of use.

An essential fatty acid. Once eaten, the body converts ALA to EPA and DHA, the two types of omega-3 fatty acids more readily used by the body. The adequate daily intake of ALA should be 1.6 and 1.1 g for men and women, respectively.

Eicosapentaenoic acid (EPA) and Docosahexanoic acid (DHA)

Cold-water fish such as salmon, mackerel, eel, tuna, herring, halibut, trout, sardines, and herring. Fish oil capsules should be refrigerated.

EPA and DHA (1 g/d) from fatty fish can reduce CHD and some types of cancer. Infants who do not receive sufficient DHA from their mothers during pregnancy are at risk for nerve or vision problems.

Linoleic acid

Safflower, sunflower, corn, soybean, peanut oils.

An essential fatty acid

Conjugated linoleic acid (CLA)

Naturally rich in milk fat

Group of isomers produced by rumen bacteria. CLA may have a role in weight management and other functions.

Arachidonic acid

Animal tissues (very low). There is no good dietary source.

Monounsaturated Omega-9 family

Oleic acid

Olive oil, canola oil, peanut oil, sunflower oil, and sesame oil. Avocados, olives, nut butters, such as peanut butter, nuts and seeds, such as macadamia nuts, pecans, and almonds

Compound lipids Phospholipids

Glycerophosphatides (lecithins, cephalins, plasmologens)

Egg yolks, liver, wheat germ, peanuts

Glycerol with two fatty acids and a nitrogen

Glycosphingolipids (ceramides, sphingomyelins)

Low in the food supply, mainly in dairy products, eggs, soybeans. Fruit has a tiny bit.

Sphingosine with one esterified fatty acid (a ceramide). Found in myelin of nerve tissue.

Cerebrosides, gangliosides

Low in the food supply.

Found in nerve and brain tissue. A ceramide linked to a monosaccharide or an oligosaccharide

Fatty acids, polyunsaturated Omega-3 family

Omega-6 family

Glycolipids

(continued)


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TABLE A-3

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Fats and Lipids (continued)

Class

Fatty Acid Component

Key Food Sources

Comments

Lipoproteins

Protein–lipid combination

Made by the liver

VLDL, LDL, HDL have various roles in health maintenance.

Miscellaneous lipids Sterols

Cholesterol

Liver, heart, and other organ meats

Steroid nucleus (synthesized from acetylcoenzyme A). Technically a wax.

Fat-soluble vitamins

A,D, E, and K

Various food sources

Lipid soluble; some are esterified with 1 fatty acid

Margarines, some cookies and crackers. The new food label includes the amount of trans fat in a serving.

These are made by hydrogenation of vegetable oils to form more solid products (i.e., margarine).The process increases the amount of saturation and converts natural cis double bonds to trans double bonds. To decrease intake, use leaner cuts of meat, fewer cold cuts. Choose skim milk, fat-free products in food choices and in cooking.

Carnitine

Produced in the liver from essential amino acids lysine and methionine.

Carnitine transports fatty acids into mitochondria, where they undergo beta-oxidation. When in short supply, production of ATP slows down or halts altogether, affecting heart or skeletal muscle. In renal failure, it is a useful additive to improve fatty acid metabolism.

Myo-inositol

Found as phospholipid in animals, phytic acid in plants.

Inositol phosphates liberated from glycerophosphatides acts as a secondary messenger in the release of intracellular of calcium, which in turn causes activation of certain cellular enzymes and produces hormonal responses. Possible role in diabetes mellitus or in renal failure.

Trans fatty acids

Fat-related substances

The main protein source in the American diet is animal protein from beef and poultry. To produce the nonessential amino acids from dietary intake of the essentials, it is recommended that the limited amino acids be consumed within a 24-hour period of each other. Protein synthesis requires all amino acids; an insufficient amount of any one may impede or slow formation of the polypeptide chain. For valine, leucine, and isoleucine, the requirement of each is increased by excess of the other branched-chain amino acids (BCAAs). Protein requirement is inversely related to calories when the latter are deficient. Generally, more than 90% of protein is absorbed from the diet. Foods of high biological value (HBV) contain approximately 40% EAAs. Table A-4 indicates which amino acids are essential and which can be made by the body (nonessential). Eight amino acids are generally regarded as essential for humans: threonine, valine, tryptophan, isoleucine, leucine, lysine, phenylalanine, methionine (names of these amino acids are easy to remember by the phrase “TV TILL PM”). Foods that contain all of the essential amino acids are called complete proteins. Incomplete proteins tend to be deaminated for sources of energy rather than being available for new tissue, healing, and growth. For biological value of proteins see Table A-5 and see Table A-6 for sources of protein.

MICRONUTRIENTS Minerals Minerals are inorganic compounds containing no carbon structures. There are 22 essential minerals known to be needed from the diet. Macrominerals (needed in large amounts) include calcium, phosphorus, magnesium, potassium, sodium, chloride, and sulfur. Trace minerals include iron, copper, selenium, fluoride, iodine, chromium, zinc, manganese, molybdenum, cobalt, and others.

Major Minerals Minerals that are needed at levels of 100 mg daily or more are known as macrominerals. Calcium: Calcium absorption is dependent upon the calcium needs of the body, foods eaten, and the amount of calcium in foods eaten. Vitamin D, whether from diet or exposure to the ultraviolet light of the sun, increases calcium absorption. Calcium absorption tends to decrease with increased age for both men and women. RDA for calcium is 1000 mg for most adults, 1300 mg for teenagers, and 1200 mg for those over 50 years.


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TABLE A-4 Amino Acids Essential Amino Acids

Type

Food Sources

Comments: Must be Consumed

Histidine

Aromatic

Dairy, meat, poultry, fish.

Precursor of histamine. Important for red and white blood cells. An important source of carbon atoms in the synthesis of purines. Histidine is needed to help grow and repair body tissues, and to maintain the myelin sheaths that protect nerve cells. It also helps manufacture red and white blood cells, and helps to protect the body from heavy metal toxicity. Histamine stimulates the secretion of the digestive enzyme gastrin. Extra is needed by infants and renal failure patients.

Isoleucine

Neutral

Meats, fish, cheeses, nuts

Belongs to the branched-chain amino acid group (BCAAs), which help maintain and repair muscle tissue. Important for stabilizing and regulating blood sugar and energy levels. Needed for synthesis of hemoglobin and energy regulation. Need 20 mg/kg body weight

Leucine

Neutral

Lysine

Basic

Methionine

Sulfur

Phenylalanine

Aromatic

Soybeans, lentils, nuts, seeds, chicken, fish, eggs.

Exhibits ultraviolet radiation absorption properties with a large extinction coefficient. Phenylalanine is part of the composition of aspartame, a common sweetener found in prepared foods (particularly soft drinks, and gum). Key role in the biosynthesis of other amino acids and some neurotransmitters. Healthy nervous system, memory and learning. Useful against depression. Need, along with tyrosine, 25 (total) mg/kg body weight

Threonine

Neutral

Soybeans, pork, lentils, beef, fish.

Important component in the formation of protein, collagen, elastin and tooth enamel. It is also important for production of neurotransmitters and health of the nervous system and the immune system. Need 15 mg/kg body weight

Tryptophan

Aromatic

Rich in flaxseed, salami, lentils, turkey, nuts, eggs. Limited in corn.

Formed from proteins during digestion by the action of proteolytic enzymes. Tryptophan is also a precursor for serotonin (a neurotransmitter) and melatonin (a neurohormone). Precursor of niacin. Tryptophan may enhance relaxation and sleep, relieve minor premenstrual symptoms, sooth nerves and anxiety, and reduce carbohydrate cravings. Need 4 mg/kg body weight.

Valine

Neutral

Meat, eggs, milk, cereal proteins.

Belongs to the branched-chain amino acid group (BCAAs). Constituent of fibrous protein in the body. Useful in treatments involving muscle, mental, and emotional upsets, and for insomnia and nervousness. Valine may help treat malnutrition associated with drug addiction. Needed for muscle development. Need 26 mg/kg body weight

Soybeans, cowpeas, lentils, beef, peanuts, pork salami, salmon, shellfish, chicken, eggs Limited in corn, wheat, and rice.

Limited in soy products.

Belongs to the branched-chain amino acid group (BCAAs). Second most common amino acid found in proteins; necessary for the optimal growth of infants and for the nitrogen balance in adults. Needed for wound healing and healthy skin and bones. Need 39 mg/kg body weight It is an essential building block for all protein, and is needed for proper growth and bone development in children. Lysine helps the body absorb and conserve calcium, form collagen and muscle protein, and synthesize enzymes and hormones. Need 30 mg/kg body weight Helps to initiate translation of messenger RNA by being the first amino acid incorporated into the N-terminal position of all proteins. Methionine supplies sulfur and other compounds required by the body for normal metabolism and growth. Reacts with ATP to form S-adenosyl methionine (SAM) which is the principal methyl donor in the body. It contributes to the synthesis of epinephrine and choline. Need 10.4  4.1 (15 total) mg/kg body weight

(continued)


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TABLE A-4 Amino Acids (continued) Conditional Amino Acids

Type

Food Sources

Comments: Must be Consumed in the Diet During Stress or Illness

Arginine, citrulline, ornithine

Basic

Peanuts, almonds, seeds

These three amino acids are part of urea acid cycle. Arginine plays an important role in cell division, wound healing, removing ammonia from the body, immune function, and the release of hormones. Extra needed in growing children. Citrulline supports the body in optimizing blood flow through its conversion to L-arginine and then nitric oxide (NO). Ornithine is a precursor of citrulline, glutamic acid, and proline; it is an intermediate in arginine biosynthesis.

Cysteine

Sulfur

Can be made from homocysteine but cannot be synthesized on its own. Limited in soy products.

Spares methionine. Component of nails, skin and hair. Antioxidant when taken with vitamin E and selenium. Extra needed in infancy, liver failure. Naturally occurring hydrophobic amino acid with a sulfhydryl group; found in most proteins. N-acetyl cysteine (NAC) is the most frequently used form and it helps toxify harmful substances in the body. Both cysteine and NAC increase levels of the antioxidant glutathione.

Glutamine

Acidic

Beef, chicken, milk, eggs, what.

One of the 20 amino acids generally present in animal proteins; the most abundant amino acid in the body. Over 61% of skeletal muscle tissue is glutamine. It contains two ammonia groups, one from precursor glutamate, and the other from free ammonia in the bloodstream. Glutamine is converted to glucose when more glucose is required by the body as an energy source. Glutamine assists in maintaining the proper acid/alkaline balance in the body, and is the basis for the synthesis of RNA and DNA.

Glycine

Neutral

Abundant in fish, meat, dairy products, beans.

The simplest amino acid; it has no stereoisomers. The body uses it to help the liver in detoxification of compounds and for helping the synthesis of bile acids. Glycine is essential for the synthesis of nucleic acids, bile acids, proteins, peptides, purines, adenosine triphosphate (ATP), porphyrins, hemoglobin, glutathione, creatine, bile salts, one-carbon fragments, glucose, glycogen, and L-serine and other amino acids. Beneficial for skin and wound healing. It has a sweet taste. Derived from proline and used almost exclusively in structural proteins including collagen, connective tissue in mammals, and in plant cell walls. The nonhydroxylated collagen is commonly termed procollagen.

Hydroxyproline

Proline

Cyclic

A diet low in ascorbic acid may lead to low levels of hydroxyproline. Derived from L-glutamate.

Serine

Neutral; also an alcohol

Taurine

Tyrosine

Aromatic

Needed for intracellular signaling. Involved in the production of collagen and in wound healing. Proline is the precursor for hydroxyproline, which the body incorporates into collagen, tendons, ligaments, and the heart muscle. Important component in certain medical wound dressings that use collagen fragments to stimulate wound healing.

Synthesized from glycine

Important for healthy brain and immunity. Variety of biosynthetic pathways including those involving pyrimidines, purines, creatine, and porphyrins. Serine has sugar-producing qualities, and is very reactive in the body. It is highly concentrated in all cell membranes, aiding in the production of immunoglobulins and antibodies. Need extra for hemodialysis patients.

Found in seafood and meat.

Functions with glycine and gamma-aminobutyric acid as a neuroinhibitory transmitter. Also needed for brain function and metabolism of magnesium, calcium and potassium. Extra needed for infants and in trauma, infection, renal failure.

Soy, poultry, dairy and other high protein foods.

Metabolically synthesized from phenylalanine to become the para-hydroxy derivative. Tyrosine is a precursor of the adrenal hormones epinephrine, norepinephrine, and the thyroid hormones L-tyrosine, through its effect on neurotransmitters, is used to treat conditions including mood enhancement, appetite suppression, and growth hormone (HGH) stimulation. Extra is needed for infants and in chronic renal failure. (continued)


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TABLE A-4 Amino Acids (continued) Nonessential and Other Amino Acids/Proteins

Type

Alanine

Neutral

Removes toxic substances released from breakdown of muscle protein during intensive exercise. Part of glucose–alanine pathway. Alanine comes from the breakdown of DNA or the dipeptides, anserine and carnosine, and the conversion of pyruvate for carbohydrate metabolism.

Asparagine

Acidic

Healthy CNS. Asparagine is synthesized from aspartic acid and ATP. One of the principal and frequently the most abundant amino acids involved in the transport of nitrogen and in amination/transamination. It serves as an amino donor in liver transamination.

Food Sources

Comments: Made by the Body if Enough Nitrogen is Available

Seafood, meat, casein, dairy products, eggs, beans, seeds, nuts, corn. Aspartic acid

Acidic

Used for immunity and removal of toxins and ammonia from the body. Aspartic acid is alanine with one of the  hydrogens replaced by a carboxylic acid group. It supports metabolism during construction of asparagine, arginine, lysine, methionine, threonine, isoleucine, and several nucleotides.

Carnitine

Produced in the liver, brain and the kidneys from methionine and lysine; responsible for the transport of long-chain fatty acids into the energy-producing mitochondria. Carnitine helps maintain a healthy blood lipid profile and promote fatty acid utilization within heart muscle.

Creatine

Synthesized in the liver, kidneys and pancreas out of arginine, methionine and glycine; increases the availability of cellular ATP. Donates a phosphate ion to increase the availability of ATP. Stored in muscle cells as phosphocreatine; helps generate cellular energy for muscle contractions.

Glutamic acid

Acidic

Gamma-aminobutyric acid (GABA) is formed from glutamic acid with the help of vitamin B6, is found in almost every region of brain, and is formed through the activity of the enzyme glutamic acid decarboxylase (GAD). GABA serves as an inhibitory neurotransmitter to block the transmission of an impulse from one cell to another in the CNS. The crystalline salt of glutamic acid, monosodium glutamate, contributes to the flavor called umami. Seaweed

Glutathione

Glutathione (GSH) is a tripeptide composed of three different amino acids, glutamate, cysteine and glycine, which has numerous important functions within cells. Glutathione plays a role in such diverse biological processes as protein synthesis, enzyme catalysis, transmembrane transport, receptor action, intermediary metabolism, and cell maturation. Glutathione acts as an antioxidant used to prevent oxidative stress in most cells and help to trap free radicals that can damage DNA and RNA. L-theanine

is the predominant amino acid in green tea and makes up 50% of the total free amino acids in the plant; the main component responsible for the taste of green tea. L-theanine is involved in the formation of the inhibitory neurotransmitter, gamma amino butyric acid (GABA). GABA influences the levels of two other neurotransmitters, dopamine and serotonin, producing a relaxation effect.

Theanine

Adapted from: Furst P, Steele P. What are the essential elements needed for the determination of amino acid requirements in humans? The American Society for Nutritional Sciences J Nutr 134:1558, 2004; Shils M, et al. Modern nutrition in health and disease. 9th ed. Baltimore: Lippincott Williams & Wilkins, 1999.

TABLE A-5 Biological Value of Proteins Food Source

Biological Value

Food Source

Biological Value

Whey protein

104

Casein

77

Egg

100

Soybean

74

Cow’s milk

95

Rice, white

67

Cottonseed

81

Wheat, whole

53

Beef

80

Sesame

50

Fish

79

Corn

49

From the Joint FAO/WHO Ad Hoc Expert Committee. Energy and protein requirements. WHO technical report no. 522. Geneva: World Health Organization, 1973, p. 67.


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TABLE A-6

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Protein Sources

Food

Serving

Weight (g)

Protein (g)

Hamburger, extra lean

6 ounces

170

48.6

Chicken, roasted

6 ounces

170

42.5

Fish

6 ounces

170

41.2

Tuna, water packed

6 ounces

170

40.1

Beefsteak, broiled

6 ounces

170

38.6

Cottage cheese or ricotta cheese

1 cup

225

28.1

Beef, fish, pork, chicken or turkey

3 ounces

85

21

Cheese pizza

2 slices

128

15.4

Yogurt, low fat

8 ounces

227

11.9

Tofu or vegetarian burger patty

1/2 cup

126

10–15

Lentils, cooked

1/2 cup

Skim milk

1 cup

Split peas, cooked

1/2 cup

Whole or chocolate milk

1 cup

Peanut or other nut butters

2 tablespoons

Kidney beans, cooked

1/2 cup

99

9

245

8.4

98

8.1

244

8

Varies

8

87

7.6

Cheddar cheese

1 ounce (1 slice)

28

7.1

Macaroni, cooked

1 cup

140

6.8

Soy milk

1 cup

245

6–9

Egg

1 large

50

6.3

Whole wheat bread

2 slices

56

5.4

White bread

2 slices

60

4.9

Rice, cooked

1 cup

158

4.3

Broccoli, cooked

5-inch piece

140

4.2

Nuts or seeds

2 tablespoons

Varies

3–5

Baked potato

2  5 inches

156

3

Corn, cooked

1 ear

77

2.6

Bread, cooked cereal or rice or pasta

1 slice

Varies

2

From: U. S. Department of Agriculture. Nutrient database, http://www.ars.usda.gov/SP2UserFiles/Place/12354500/Data/ SR22/nutrlist/sr22w203.pdf, accessed January 22, 2010.

Roles. For strong bones and teeth, nerve irritability, muscle contraction, heart rhythm, blood coagulation, enzymes, osmotic pressure, intercellular cement, maintenance of cell membranes, and protection against high blood pressure. About 60% is bound to protein, mostly albumin. About 30–60% absorption occurs with intakes of 400–1000 mg. Sources. Milk and cheese products remain the primary source of calcium for Americans. Phytates and excessive protein or zinc decrease absorption. Calcium from soy milk is absorbed only 75% as efficiently as from cow’s milk. Calcium is lost in cooking some foods, even under the best conditions. To retain calcium, cook foods in a minimal amount of water and for the shortest possible time. Table A-7 lists both dairy and nondairy sources of calcium. Signs of Deficiency. In hypocalcemia, there may be tetany, paresthesia, hyperirritability, muscle cramps, convulsions, and stunting in growth. No consistent data suggests that a high-protein diet depletes calcium.

Signs of Excess. With hypercalcemia, milk alkali syndrome, kidney stones or renal insufficiency can occur. Recommending excessive calcium use among the general, unsupervised public is not advisable. For bone health, vitamin D is the priority and should be given along with calcium. Chloride: Chloride constitutes about 3% of total mineral content in the body. It is the main extracellular ion, along with sodium. No RDA levels have been established for chloride. The upper limit (UL) for adults is 3.6 g/d. Roles. Digestion (HCl in stomach), acid–base balance, O2/ CO2 exchange in red blood cells (RBCs), and fluid balance. Sources. Table salt, salt substitutes containing potassium chloride, processed foods made with table salt, sauerkraut, snack chips, and green olives. Signs of Deficiency. Hypochlorhydria and disturbed acid–base balance.


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TABLE A-7 Dairy Sources of Calciuma Dairy Food, Standard Amount

Dairy Food, Standard Amount

Calcium (mg)

Calories

Calcium (mg)

Calories

Plain yogurt, nonfat (13 g protein/ 8 ounces), 8-ounce container

452

127

Cottage cheese, one cup

150

Romano cheese, 1.5 ounces

452

165

Frozen yogurt or ice cream

100

Varies

Pasteurized process Swiss cheese, 2 ounces

438

190

Non-food, standard amount

Calcium (mg)

Calories

Plain yogurt, low-fat (12 g protein/ 8 ounces), 8-ounce container

415

143

Fortified ready-to-eat cereals (various), 1 ounce

236–1043

88–106

Fruit yogurt, low-fat (10 g protein/ 8 ounces), 8-ounce container

345

232

Soy beverage, calcium fortified, one cup

368

98

Swiss cheese, 1.5 ounces

336

162

Sardines, Atlantic, in oil, drained, 3 ounces

325

177

Ricotta cheese, part skim, 1/2 cup

335

170

Fortified orange juice, one cup

300

120

Pasteurized process American cheese food, 2 ounces

323

188

Tofu, firm, prepared with calcium, 1/2 cup

253

88

Bread, calcium-fortified, one slice

200

70

Pink salmon, canned, or sardines, with bone, 3 ounces

181

118

Collards, cooked from frozen, 1/2 cup

178

31

Molasses, blackstrap, one tbsp

172

47

Feta cheese, 1.5 ounces

210

113

Provolone cheese, 1.5 ounces

321

150

Mozzarella cheese, part-skim, 1.5 ounces

311

129

Cheddar cheese, 1.5 ounces

307

171

Fat-free (skim) milk, one cup

306

83

Muenster cheese, 1.5 ounces

305

156

Pudding, ready to eat, one cup

300

Varies

Macaroni and cheese, one cup prepared

300

Varies

1% low-fat milk, one cup

290

102

Low-fat chocolate milk (1%), one cup

288

158

Oatmeal, plain and flavored, instant, fortified, one packet prepared

2% reduced fat milk, one cup

285

122

Reduced fat chocolate milk (2%), one cup

285

180

Buttermilk, low-fat, one cup

284

98

White beans, canned, 1/2 cup

Chocolate milk, one cup

280

208

Whole milk, one cup

276

146

Broccoli or kale, cooked from frozen, 1/2 cup

Yogurt, plain, whole milk (8 g protein/ 8 ounces), 8-ounce container

275

138

Okra, cooked from frozen, 1/2 cup

88

26

Soybeans, mature, cooked, 1/2 cup

88

149

Spinach, cooked from frozen, 1/2 cup

146

30

Soybeans, green, cooked, 1/2 cup

130

127

Turnip greens, cooked from frozen, 1/2 cup

124

24

Ocean perch, Atlantic, cooked, 3 ounces

116

103

99–110

97–157

Cowpeas, cooked, 1/2 cup

106

80

Almonds, 1 ounce

100

164

96

153

90–100

20

Ricotta cheese, whole milk, 1/2 cup

255

214

Blue crab, canned, 3 ounces

86

84

Blue cheese, 1.5 ounces

225

150

Beet greens, cooked from fresh, 1/2 cup

82

19

Mozzarella cheese, whole milk, 1.5 ounces

215

128

Source: Nutrient values from Agricultural Research Service (ARS) Nutrient Database for Standard Reference, Release 17. Foods are from ARS single nutrient reports, sorted in descending order by nutrient content in terms of common household measures. Food items and weights in the single nutrient reports are adapted from those in 2002 revision of USDA Home and Garden Bulletin No. 72, Nutritive Value of Foods. Mixed dishes and multiple preparations of the same food item have been omitted from this table. a Food sources of calcium ranked by milligrams of calcium per standard amount; also calories in the standard amount. All are 20% of AI for adults 19–50, which is 1,000 mg/d. Those containing 300 mg or more are highlighted in salmon, those with 200–299 mg are shaded lighter, and those with the lightest shading have 80–199 mg. Note: Both calcium content and bioavailability should be considered when selecting dietary sources of calcium. Some plant foods have calcium that is well absorbed, but the large quantity of plant foods that would be needed to provide as much calcium as in a glass of milk may be unachievable for many. Many other calcium-fortified foods are available, but the percentage of calcium that can be absorbed is unavailable for many of them.

Signs of Excess. Disturbed acid–base balance. Magnesium: Magnesium is a mineral needed by every cell of the body; half of the stores are found inside cells of body tissues and organs, and half are combined with calcium and phosphorus in bone. Only 1% of magnesium in the body is found in blood. The body works hard to keep blood levels of magnesium constant. Results of two national surveys indicated that the diets of most adult men and women do not provide the recommended amounts of magnesium. Adults aged 70 years and over eat less magnesium than younger adults, and non-Hispanic black subjects consume less mag-

nesium than either non-Hispanic white or Hispanic subjects. Despite poor intakes, magnesium deficiency is rarely seen in the United States in adults. RDA varies by age but is typically 420 mg for men and 320 mg for women. UL for supplemental magnesium for adolescents and adults is 350 mg/d. Roles. Magnesium is needed for more than 300 biochemical reactions including normal muscle contraction, nerve transmission and function, heart rhythm, energy metabolism and protein synthesis, enzyme activation (ADP, ATP), glucose utilization, bone matrix and growth, and normal Na/K pump. Maintaining an adequate magnesium intake is a


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TABLE A-8 Food Sources of Magnesiuma Food, Standard Amount

Food, Standard Amount

Magnesium (mg)

Calories

57

120

Magnesium (mg)

Calories

Pumpkin and squash seed kernels, roasted, 1 ounce

151

148

Oat bran, raw, 1/4 cup

55

58

Brazil nuts, 1 ounce

107

186

Soybeans, green, cooked, 1/2 cup

54

127

Bran ready-to-eat cereal (100%), 1 ounce

103

74

Tuna, yellowfin, cooked, 3 ounces

54

118

Artichokes (hearts), cooked, 1/2 cup

50

42

Peanuts, dry roasted, 1 ounce

50

166

Lima beans, baby, cooked from frozen, 1/2 cup

50

95

Bulgur, dry, 1/4 cup

Halibut, cooked, 3 ounces

91

119

Quinoa, dry, 1/4 cup

89

159

Spinach, canned, 1/2 cup

81

25

Almonds, 1 ounce

78

164

Beet greens, cooked, 1/2 cup

49

19

Spinach, cooked from fresh, 1/2 cup

78

20

Navy beans, cooked, 1/2 cup

48

127

Buckwheat flour, 1/4 cup

75

101

Tofu, firm, prepared with nigari,b 1/2 cup

47

88

Cashews, dry roasted, 1 ounce

74

163

Okra, cooked from frozen, 1/2 cup

47

26

Soybeans, mature, cooked, 1/2 cup

74

149

Soy beverage, one cup

47

127

Pine nuts, dried, 1 ounce

71

191

Hazelnuts, 1 ounce

46

178

Mixed nuts, oil roasted, with peanuts, 1 ounce

67

175

Oat bran muffin, 1 ounce

45

77

White beans, canned, 1/2 cup

67

154

Great northern beans, cooked, 1/2 cup

44

104

Pollock, walleye, cooked, 3 ounces

62

96

Oat bran, cooked, 1/2 cup

44

44

Black beans, cooked, 1/2 cup

60

114

Brown rice, cooked, 1/2 cup

42

108

Haddock, cooked, 3 ounces

42

95

Source: Nutrient values from Agricultural Research Service (ARS) Nutrient Database for Standard Reference, Release 17. Foods are from ARS single nutrient reports, sorted in descending order by nutrient content in terms of common household measures. Food items and weights in the single nutrient reports are adapted from those in 2002 revision of USDA Home and Garden Bulletin No. 72, Nutritive Value of Foods. Mixed dishes and multiple preparations of the same food item have been omitted from this table. a Food Sources of Magnesium ranked by milligrams of magnesium per standard amount; also calories in the standard amount. (All are  10% of RDA for adult men, which is 420 mg/d). b Calcium sulfate and magnesium chloride.

positive lifestyle modification for preventing and managing high blood pressure. Elevated blood glucose levels increase the loss of magnesium in the urine, which in turn lowers blood levels of magnesium; this explains why low blood levels of magnesium are seen in poorly controlled type 1 and type 2 diabetes.

strokes, and postmenopausal osteoporosis. Poor growth, confusion, disorientation, loss of appetite, depression, tetany with muscle contractions and cramps, tingling, numbness, abnormal heart rhythms, coronary spasm, abnormal nerve function with seizures or convulsions, hyperirritability, and even death can occur.

Sources. Magnesium is present in many foods but usually in small amounts. Eating a wide variety of foods, including five servings of fruits and vegetables daily and plenty of whole grains, helps to ensure an AI. The center of the chlorophyll molecule in green vegetables contains magnesium. Intake from a meal may be 45–55% absorbed. Beware of excess phytates. Water can provide magnesium, but the amount varies according to the water supply. “Hard” water contains more magnesium than “soft” water. Dietary surveys do not estimate magnesium intake from water, which may lead to underestimating total magnesium intake and its variability (see Table A-8).

Signs of Excess. Magnesium toxicity (hypermagnesemia) is often associated with kidney failure, when the kidney loses the ability to remove excess magnesium. Mental status changes, nausea, osmotic diarrhea, appetite loss, muscle weakness, difficulty breathing, respiratory failure, extremely low blood pressure, and irregular heartbeat can occur. High doses of magnesium from laxatives can promote diarrhea, even with normal kidney function. The elderly are at risk of magnesium toxicity; kidney function declines with age and use of magnesium-containing laxatives and antacids is common.

Signs of Deficiency. When magnesium deficiency occurs (hypomagnesemia), it is usually due to excessive loss of magnesium in urine from diabetes, antibiotics, diuretics, or excessive alcohol use; gastrointestinal (GI) system disorders; chronically low intake of magnesium; chronic or excessive vomiting, diarrhea, and fat malabsorption. Magnesium deficiency can cause metabolic changes that may contribute to heart attacks,

Phosphorus: Phosphorus is second only to calcium in quantity in the human body. About 80% is in the skeleton and teeth as calcium phosphate; 20% is in extracellular fluid and cells. About 10% is bound to protein. RDA for adult men and women is 700 mg/d. UL for adults varies from 3–4 g/d. Roles. Energy metabolism (ADP, ATP); fat, amino acid, and carbohydrate metabolism; calcium regulation; vitamin utilization; bones and teeth; osmotic pressure; DNA coding; buffer


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salts; fatty acid transport; oxygen transport and release; leukocyte phagocytosis; and microbial resistance. Sources. Protein-rich foods such as meat, poultry, fish, egg yolks, dried beans and nuts, whole grains, enriched breads and cereals, milk, cheese, and dairy products. Also found in peas, corn, chocolate, and seeds. Excessive intake of soft drinks increases phosphorus intake, often causing an unbalanced intake of calcium. About 70% of oral intake is absorbed. In the United States, milk and cheese products contribute the main sources of phosphorus for infants, toddlers, and adolescents; meat, poultry, and fish products contribute more to the diets of adults. Signs of Deficiency. Hypophosphatemia leads to neuromuscular, renal and hematological changes, as well as rickets or osteomalacia. Deficiency is rare but may occur in those persons who take phosphate binders, persons receiving total parenteral nutrition without phosphate, and prematurity. Signs of Excess. Hyperphosphatemia is especially problematic in renal failure. Nutritional secondary hyperparathyroidism may occur, with fragile bones and fractures.

TABLE A-9 Food Sources of Potassiuma Food, Standard Amount

Potassium (mg)

Calories

Sweet potato, baked, one potato (146 g)

694

131

Tomato paste, 1/4 cup

664

54

Beet greens, cooked, 1/2 cup

655

19

Potato, baked, flesh, one potato (156 g)

610

145

White beans, canned, 1/2 cup

595

153

Yogurt, plain, nonfat, 8-ounce container

579

127

Tomato puree, 1/2 cup

549

48

Clams, canned, 3 ounces

534

126

Yogurt, plain, low-fat, 8-ounce container

531

143

Prune juice, 3/4 cup

530

136

Carrot juice, 3/4 cup

517

71

Blackstrap molasses, one tbsp

498

47

Halibut, cooked, 3 ounces

490

119

Soybeans, green, cooked, 1/2 cup

485

127

Tuna, yellowfin, cooked, 3 ounces

484

118

Lima beans, cooked, 1/2 cup

484

104

Potassium: Potassium constitutes about 5% of total mineral content in the body. It is the main intracellular ion. No specific RDA exists.

Winter squash, cooked, 1/2 cup

448

40

Soybeans, mature, cooked, 1/2 cup

443

149

Rockfish, Pacific, cooked, 3 ounces

442

103

Roles. Nerve conduction, muscle contraction, glycolysis, glycogen formation, protein synthesis and utilization, acid–base balance, cellular enzyme functioning, and water balance.

Cod, Pacific, cooked, 3 ounces

439

89

Banana, one medium

422

105

Spinach, cooked, 1/2 cup

419

21

Tomato juice, 3/4 cup

417

31

Tomato sauce, 1/2 cup

405

39

Sources. Fruits and vegetables, dried beans and peas, whole grains, and whole and skim milk. In the United States, milk and cheese products, meat, poultry, and fish products contribute the most; vegetables follow. Table A-9 provides a list of foods that contain over 500 mg potassium per serving. Signs of Deficiency. Hypokalemia includes muscle weakness, cardiac arrhythmia, paralysis, bone fragility, decreased growth, weight loss, and even death. Signs of Excess. Hyperkalemia promotes paralysis, muscular weakness, arrhythmias, heart disturbances, and even death. Sodium: Sodium constitutes about 2% of total mineral content in the body. It is the main extracellular ion, along with chloride. No specific RDA is set; 2300 mg/d is the UL for adults. Roles. Nerve stimulation, muscle contraction, acid–base balance, regulation of blood pressure, and glucose transport into cells. Sodium is the major extracellular fluid cation. Sources. Milk, cheese, eggs, meat, fish, poultry, beets, carrots, celery, spinach, chard, seasoned salts, baking powder and soda, table salt (NaCl), many drugs and preservatives, some drinking water. High-sodium processed foods include: salty snack foods; ketchup and mustard; cured and processed meats; processed cheese; canned soups, vegetables, beans, and meats; soup, rice, and pasta mixes; soy sauce or hoisin sauce; monosodium glutamate (MSG); garlic salt, onion salt, celery salt, and seasoned salts. More than 95% of sodium from a mixed diet is absorbed.

Peaches, dried, uncooked, 1/4 cup

398

96

Prunes, stewed, 1/2 cup

398

133

Milk, nonfat, one cup

382

83

Pork chop, center loin, cooked, 3 ounces

382

197

Apricots, dried, uncooked, 1/4 cup

378

78

Rainbow trout, farmed, cooked, 3 ounces

375

144

Pork loin, center rib (roasts), lean, roasted, 3 ounces

371

190

Buttermilk, cultured, low-fat, one cup

370

98

Cantaloupe, 1/4 medium

368

47

1–2% milk, one cup

366

102–122

Honeydew melon, 1/8 medium

365

58

Lentils, cooked, 1/2 cup

365

115

Plantains, cooked, 1/2 cup slices

358

90

Kidney beans, cooked, 1/2 cup

358

112

Orange juice, 3/4 cup

355

85

Split peas, cooked, 1/2 cup

355

116

Yogurt, plain, whole milk, 8-ounce container

352

138

Source: Nutrient values from Agricultural Research Service (ARS) Nutrient Database for Standard Reference, Release 17. Foods are from ARS single nutrient reports, sorted in descending order by nutrient content in terms of common household measures. Food items and weights in the single nutrient reports are adapted from those in 2002 revision of USDA Home and Garden Bulletin No. 72, Nutritive Value of Foods. a Food sources of potassium ranked by milligrams of potassium per standard amount, also showing calories in the standard amount. The AI for adults is 4700 mg/d potassium.


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Signs of Deficiency. Hyponatremia occur from water intoxication with resulting anorexia, nausea, muscle atrophy, poor growth, weight loss, confusion, coma, and even death. Signs of Excess. Hypernatremia may cause confusion, high blood pressure, calcium excretion from bones, heart failure, edema, and coma. Sulfur: Sulfur exists as part of the amino acids methionine, cystine, and cysteine and as part of the antioxidant glutathione peroxidase and other organic molecules. No specific RDA is set. Roles. Amino acids (methionine, cystine, cysteine), thiamin molecule, coenzyme A, biotin and pantothenic acid, connective tissue metabolism, penicillin, sulfa drugs, insulin molecule, heparin, and keratin of skin, hair, and nails. Sources. Meat, poultry, fish, eggs, dried beans and legumes, Brassica family vegetables (broccoli, cabbage, cauliflower, Brussels sprouts), and wheat germ. Signs of Deficiency. Not specific but likely to occur with hypoalbuminemia. Signs of Excess. Uncommon because excess is excreted in the urine as sulfate, usually in combination with calcium. This may result in hypercalciuria (often after a high-protein meal).

Trace Minerals Trace minerals are elements that are found in minute amounts in body tissues and are specific to the function of certain enzymes. They are typically not found in free ionic state but are bound to other proteins. Copper: Copper is an antioxidant. Concentrations of copper are highest in the liver, brain, heart, and kidney; skeletal muscle also contains a large percentage because of total mass. About 90% of copper is bound as ceruloplasmin and is transported to other tissues mainly by albumin. Absorption occurs in the proximal jejunum. RDA is 900 mg daily for men and women. UL was set at 10 mg/d. Roles: Skeletal development, immunity, formation of RBCs and leukopoiesis, phospholipid synthesis, electron transport, pigmentation, aortic elasticity, connective tissue formation, and CNS and myelin sheath structure. Part of metalloenzymes including cytochrome c-odixase. Sources: Barley and whole grains, oysters and shellfish, nuts, dried beans and legumes, cocoa, eggs, prunes, and potatoes. Note: Milk is low in copper. Daily intake of copper in the United States is 2–5 mg; however, many persons have a lower intake than this because fresh foods are low in copper. Meat, poultry, and fish are primary sources in the United States. Approximately 30–60% of oral intake is absorbed, enhanced by acid and decreased by calcium. 94% of copper is tightly bound to ceruloplasmin. Signs of Deficiency. Hypochromic anemia, cardiomyopathy, leukopenia, neutropenia, skeletal abnormalities and osteo-

931

porosis, decreased skin and hair pigmentation, Menke’s steel hair (kinky-hair) syndrome, and reduced immune response. Deficiency is rare in adults, except with celiac disease, protein-losing enteropathies, and nephrotic syndrome. Requirement is increased by excessive zinc intake. Signs of Excess. Excess is rare, but liver cirrhosis, biliary cirrhosis, and Wilson’s disease may contribute to the retention of copper. Abnormalities in RBC formation, copper deposits in the brain, diarrhea, tremors, and liver damage occur. Eye rings are present in Wilson’s disease. Excesses may decrease vitamin A absorption. Fluoride: Fluoride is found in nearly all drinking waters and soils. The American Dietetic Association affirms that fluoride is an important element for all mineralized tissues and that appropriate consumption aids bone and tooth health (American Dietetic Association, 2005). Eighty to ninety percent of oral intake is absorbed. RDA is 3–4 mg/d for men and women. UL is set at 10 mg/d. Roles.: Calcium uptake; some role in prevention of calcified aortas; resistance to dental caries, collapsed vertebrae, and osteoporosis; formation of hydroxyapatite; and enamel growth. Sources. Fluoridated water, tea, mackerel, salmon with bones, infant foods to which bone meal has been added. Signs of Deficiency. Dental caries, calcification of aorta, and anemia. Possibly bone thinning and osteoporosis. Signs of Excess. Bony outgrowths at the spine. Tooth mottling, pitting, and discoloration (fluorosis) occur at doses of greater than 2–3 ppm in the drinking water. Excess can result in neurological problems; this feature is used in rat poison, for example.

Iron Functional iron is found in hemoglobin (two-thirds), myoglobin (almost one-third), and enzymes. Storage iron is found in ferritin, hemosiderin, and transferrin. Iron is conserved and reused at a rate of 90% daily; the rest is excreted, mainly in bile. Dietary iron must be consumed to meet the 10% gap to prevent deficiency. To increase iron absorption, use sulfur amino acids and vitamin C (especially with nonheme foods); cook foods in an iron skillet; choose iron-enriched rice and do not rinse before cooking. Take iron separately from calcium supplements. Excessive calcium intake and oxalic, tannic, and phytic acids can reduce absorption. Avoid coffee and tea for 1 hour after eating; the tannic acid blocks iron absorption. Serum iron is largely bound to transferrin. About 5–15% is absorbed as ferrous iron; 15–25% of oral intake of heme iron is absorbed (meat, fish, and poultry); 2–20% of oral intake of nonheme iron is absorbed (legumes, grains, and fruit). The RDA is 8 mg for men and postmenopausal women; 18 mg for premenopausal women. Pregnant women need 27 mg/d and breastfeeding women need 9 mg. Teenage girls (ages 14–18 years) need 15 mg iron per day (27 mg if pregnant; 10 mg if breastfeeding). Teenage boys (ages 14–18 years) need 11 mg iron per day The UL for iron is 45 mg/d.


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Roles. Responsible for carrying oxygen to cells through hemoglobin and myoglobin, skeletal muscle functioning, cognitive functioning, leukocyte functions and T-cell immunity, cellular enzymes, and cytochrome content for normal cellular respiration. Sources: Beans, beef, dried fruit, enriched grains, fortified cereals, pork. In the United States, grain products provide the highest amount of dietary iron (see Table A-10). Signs of Deficiency. Hypochromic and microcytic anemia, fatigue and weakness, pallor, pale conjunctiva, koilonychia (thin, spoon-shaped nails), impaired learning ability, cheilosis, glossitis, pica, tachycardia. Deficiency is defined as having an abnormal value for two of three laboratory tests of iron

status (erythrocyte protoporphyrin, transferrin saturation, or serum ferritin). Iron deficiency anemia is defined as iron deficiency plus low hemoglobin. Iron deficiency anemia is the most common nutrient deficiency in the world, especially among toddlers, teenage girls, and women of childbearing age. Signs of Excess. Iron deposits (hemosiderosis); vomiting or diarrheas with GI distress, hemochromatosis, drowsiness. Excess may occur from taking iron supplements daily or from consuming multiple sources, including transfusion overload with sickle cell anemia or thalassemia major. Zinc: Zinc is distributed in the body with proteins such as albumin, transferrin, ceruloplasmin, and gamma-globulin.

TABLE A-10 Food Sources of Irona Food, Standard Amount

Heme (H) or Nonheme (N)

Iron (mg)

Calories

Clams, canned, drained, 3 ounces

H

23.8

126

Fortified ready-to-eat cereals (various), 1 ounce

N

1.8–21.1

54–127

Oysters, eastern, wild, cooked, moist heat, 3 ounces

H

10.2

116

Organ meats (liver, giblets), various, cooked, 3 ouncesb

N

5.2–9.9

134–235

Fortified instant cooked cereals (various), one packet

N

4.9–8.1

Varies

Soybeans, mature, cooked, 1/2 cup

N

4.4

149

Pumpkin and squash seed kernels, roasted, 1 ounce

N

4.2

148

White beans, canned, 1/2 cup

N

3.9

153

Blackstrap molasses, one tbsp

N

3.5

47

Lentils, cooked, 1/2 cup

N

3.3

115

Spinach, cooked from fresh, 1/2 cup

N

3.2

21

Beef, chuck, blade roast, lean, cooked, 3 ounces

H

3.1

215

Beef, bottom round, lean, 0 inch fat, all grades, cooked, 3 ounces

H

2.8

182

Kidney beans, cooked, 1/2 cup

N

2.6

112

Sardines, canned in oil, drained, 3 ounces

H

2.5

177

Beef, rib, lean, 1/4 inches fat, all grades, 3 ounces

H

2.4

195

Chickpeas, cooked, 1/2 cup

N

2.4

134

Duck, meat only, roasted, 3 ounces

H

2.3

171

Lamb, shoulder, arm, lean, 1/4 inches fat, choice, cooked, 3 ounces

H

2.3

237

Prune juice, 3/4 cup

N

2.3

136

Shrimp, canned, 3 ounces

H

2.3

102

Cowpeas, cooked, 1/2 cup

N

2.2

100

Ground beef, 15% fat, cooked, 3 ounces

H

2.2

212

Tomato puree, 1/2 cup

N

2.2

48

Lima beans, cooked, 1/2 cup

N

2.2

108

Soybeans, green, cooked, 1/2 cup

N

2.2

127

Navy beans, cooked, 1/2 cup

N

2.1

127

Refried beans, 1/2 cup

N

2.1

118

Beef, top sirloin, lean, 0 inch fat, all grades, cooked, 3 ounces

H

2.0

156

Tomato paste, 1/4 cup

N

2.0

54

Source: Nutrient values from Agricultural Research Service (ARS) Nutrient Database for Standard Reference, Release 17. Foods are from ARS single nutrient reports, sorted in descending order by nutrient content in terms of common household measures. Food items and weights in the single nutrient reports are adapted from those in 2002 revision of USDA Home and Garden Bulletin No. 72, Nutritive Value of Foods. Mixed dishes and multiple preparations of the same food item have been omitted from this table. a Food Sources of iron ranked by milligrams of iron per standard amount; also calories in the standard amount. All are  10% of RDA for teen and adult females, which is 18 mg/d. b High in cholesterol.


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Animal sources are better utilized; vegetarian diets must be monitored for zinc deficiency. Ten to forty percent of zinc from meals is absorbed in the duodenum and the jejunum. Vitamin D can increase bioavailability. Phytates, excess copper, and fiber form complexes and reduce absorption, as do calcium and phosphate salts. Zinc absorption is affected by level of zinc in the diet and interfering substances, such as phytates, calcium, cadmium, folic acid, copper, or excessive fiber. Albumin is the major plasma carrier. RDA is 11 mg for men and 8 mg for women. UL is 40 mg. Roles. ACTH-stimulated steroidogenesis in adrenals; sexual maturation; fatty acid, carbohydrate, protein, and nucleic acid metabolism; CO2 transport; amino acid breakdown from peptides; oxidation of vitamin A; reproduction; growth; enzymes including alcohol dehydrogenase, alkaline phosphatase, and lactic acid dehydrogenase; wound healing; catalyst for hydrogenation; immunity; night vision; alcohol detoxification in the liver; heme synthesis; taste and smell acuity; synthesis of glutathione; and collagen precursors. Zinc supplementation has been shown to be effective in reducing morbidity and mortality from diarrhea, malaria, HIV infection, sickle cell anemia, renal disease, and GI disorders. Zinc gluconate lozenges do not always alleviate cold symptoms in children and adolescents but may be somewhat helpful. Sources. Beans, seafood (e.g., lobster, shrimp, oysters), poultry, meat (red meat such as beef and liver especially), eggs, milk, peanuts, oatmeal, whole grains (e.g., whole wheat, rye bread, wheat germ), and yeast. The average American diet contains 10–15 mg/d. Meat, poultry, and fish are the primary sources of zinc. Signs of Deficiency. Zinc is so prevalent in cellular metabolism that even minor impairment in supply is likely to have multiple biological and clinical effects. Deficiency reduces antibody responses and cell-mediated immunity and may cause dermatitis, skin lesions, growth failure (dwarfism), hypogonadism, decreased taste acuity (hypogeusia), alopecia, diarrhea, glossitis, stomatitis, and impaired wound healing. Zinc deficiency has a significant impact on development and on immune function; premature infants and children are at greatest risk. In children with zinc deficiency, severe growth depression is seen. Strict vegetarians, preschoolers who do not eat meat, adolescent females, and those on a chronically high-phytate diet may also be at risk, especially if other disease states are present.

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Roles. Mineral metabolism in animals and humans, cell membrane functioning. It may function in a role similar to estrogen in bone metabolism and strengthening. Sources. Drinking water, wine, cider and beer, noncitrus fruits, potatoes, peanuts, and legumes. Note: Protein foods and grains are low in boron. Infant foods, fruits and fruit juices, milk and cheese foods, and beverages provide the most. Signs of Deficiency. None known at this time. Signs of Excess. Reproductive and developmental effects are possible. Chromium: Chromium is closely related to insulin action. Absorption ranges from 0.5 to 2%. Chromium needs transferrin for distribution. RDA is 20 mg/d for women and 35 mg/d for men. No UL has been set. Roles. Insulin molecule (part of glucose tolerance factor known as chromodulin); fatty acid, triglyceride, and cholesterol metabolism; normal glucose metabolism; nucleic acid stability; regulation of gene expression; and peripheral nerve functioning. Sources. Oysters, liver, potatoes, eggs, vegetable oil, brewer’s yeast, whole grains and bran, shortening, nuts, and peanuts. Dairy products, fruits, and vegetables are low in chromium. Phytates and oxalates can decrease absorption. Signs of Deficiency. Hyperglycemia refractory to insulin, weight loss, glucosuria, peripheral neuropathy, encephalopathy. Deficiency may be found in severe malnutrition, in diabetes, or in elderly patients with cardiovascular disease. Signs of Excess. Dermatological allergy, nausea, vomiting, convulsions, irritation, gastrointestinal ulcers. Cobalt: Most cobalt is in vitamin B12 stores in the liver. Cobalt may share intestinal transport with iron and is increased in patients with low iron intake and iron stores. No specific RDA is set. Roles. Treatment of some anemias, part of structure of cobalamin in vitamin B12, role in immunity, and healthy nerves and RBCs. Sources. Seafood (such as oysters and clams), meats (such as liver), poultry, some grains, and cereals. Note: Cow’s milk is very low. More than 50% of dietary cobalt is absorbed.

Signs of Excess. Vomiting, diarrhea, low levels of serum copper, hyperamylasemia may result. Excessive zinc intake is probably self-limiting because of GI distress that occurs. Zinc toxicity can occur in renal dialysis if not carefully monitored.

Signs of Deficiency. Weakness, anemia, and emaciation. Deficiency is usually in conjunction with vitamin B12 deficiency and low intake of protein foods. Lack of intrinsic factor, gastrectomy, or malabsorption syndromes may also cause deficiency.

Ultra-Trace Minerals

Signs of Excess. Polycythemia, bone marrow hyperplasia, reticulocytosis, and increased blood volume may result.

Boron: Boron can be found in the brain and the bone; it is also found in the spleen and thyroid. It is found in foods such as sodium borate; it is absorbed at a rate of 90%. No RDA has been set, but a UL of 20 mg was established.

Iodine: With the iodization of salt, iodine deficiency has been almost eliminated in the United States and Western nations. Fortification results in fewer goiters and less cretinism, stillbirths, spontaneous abortions, and mental or


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growth retardation. Millions of people are at risk in other nations. The thyroid gland maintains 75% of the body’s iodine; the rest is in the gastric mucosa and bloodstream. Iodide content of vegetables varies by the content of the local soil. Absorption is 50–100% from the gut. RDA is 150 mg/d for both men and women. UL is 1.1 mg/d. Roles. Energy metabolism, proper thyroid functioning, normal growth and reproduction, prevention of goiter, and regulation of cellular metabolism and temperature. Iodine is found with T3 and T4 distribution. Sources. Iodized salt, seaweed, and seafood (clams, oysters, sardines, lobster, and saltwater fish). Other lesser sources may include cream (in milk), eggs, drinking water in various areas, plant leaves (broccoli, spinach, and turnip greens), cranberries, and legumes. Iodized salt should be encouraged for pregnant women. Goitrogens in cabbage, turnips, rapeseeds, peanuts, cassava, and soybeans may block uptake of iodine by body cells; heating and cooking inactivate them. Signs of Deficiency. Enlarged thyroid gland or related goiter; hypercholesterolemia; weight gain; cold intolerance; thinning hair; cognitive impairment; deafness; decreased metabolic rate; neuromuscular impairments. In infants, abnormal fetal growth, brain development, and cretinism can result. Signs of Excess. Excess may depress thyroid activity and elevate thyroid-stimulating hormone (TSH) levels. High levels of thyroid hormone with goiter or myxedema can occur. Manganese: Manganese affects reproductive capacity, pancreatic function, and carbohydrate metabolism. Less than 5% is absorbed from diet. It is transported bound to a macroglobulin, transferrin, or transmanganin. Manganese, cobalt, and iron compete for pathways. Human milk tends to be low in manganese levels. An AI level has been set at 2.3 mg for men and 1.8 mg for women. The UL has been established at 11 mg. Roles. Polysaccharide and fatty acid metabolism, enzyme activation, tendon and skeletal development, possible role in hypertension, fertility and reproduction (role in squalene as a precursor of cholesterol and sex hormones), melanin and dopamine production, energy and glucose production. Sources. Tea, coffee, whole grains, wheat germ and bran, blueberries, peas, beans and dried legumes, nuts, spinach, and cocoa powder. Sources of manganese are plant foods, not animal foods. In the United States, grain products are primary sources.

from the stomach and small intestine and excreted in the urine. RDA is 45 mcg for both men and women. The UL is 2 mg. Roles. Flavoproteins; copper antagonist; component of sulfite oxidase, aldehyde oxidase, and xanthine oxidase; iron storage; energy metabolism; and degradation of cysteine and methionine through sulfite oxidase. Sources. Legumes, whole-grain breads and cereals, dark green leafy vegetables, milk and dairy products, and organ meats. Milk and cheese products and grains provide the most from diet. Signs of Deficiency. Tachycardia, tachypnea, visual and mental changes, elevated plasma methionine, low-serum uric acid, headache, lethargy, nausea, and vomiting. Long-term parenteral nutrition that is deficient in molybdenum is a concern. Signs of Excess. Hyperuricemia and gout-like syndrome can occur. Excesses are rare. Selenium: Cellular and plasma glutathione are the functional parameters for measuring selenium status. Selenium intake in the United States is generally very good; deficiency is rare. More than 50% dietary intake is absorbed (average range, 35–85%). It is transported via albumin from the duodenum. RDA level for selenium was set at 55 mg/d; UL was set at 400 mg. Roles. Selenium functions within mammals primarily as selenoproteins. Glutathione catalyzes the reduction of peroxides that can cause cellular damage. Protein biosynthesis (selenomethionine and selenocysteine), sparing of vitamin E, protection against mercury toxicity; some role in thyroid function and immunity. Sources. Seafood and fish, chicken, egg yolks, meats (especially kidney and liver), whole-grain breads and cereals, wheat germ, foods grown in selenium-rich soil including garlic, dairy products, Brazil nuts, and onions. Dietary selenium is found with protein in animal tissue (muscle meats, organ meats, and seafood). Grains and seeds have variable amounts dependent on the soil. Signs of Deficiency. Muscle weakness and pain, carcinogenesis, and cardiomyopathy. Keshan’s disease with cardiomyopathy is a selenium deficiency in China where soil levels are quite low. Kashin-Beck’s disease occurs in preadolescents and adolescents; it has effects similar to osteoarthritis with stiffness and swelling of the elbows, knees, and ankles.

Signs of Deficiency. Nausea, vomiting, transient dermatitis, weight loss, ataxia, skeletal and cartilage abnormalities occur. Beware of excess calcium, phosphorus, iron, or magnesium supplementation.

Signs of Excess. Selenosis causes garlicky odor on the breath and decaying of teeth. Nausea, vomiting, hair and nail loss, fatigue, headache, and chronic dermatitis can also occur.

Signs of Excess. Excesses accumulate in the liver and CNS. Parkinsonian tremors, difficulty in walking, facial muscle spasms, ataxia, hyperirritability, or hallucinations can occur.

Less-Studied Ultra-Trace Minerals

Molybdenum: Molybdenum is important mostly for its role in xanthine oxidase. About 40–100% of intake is absorbed from the duodenum in protein-bound form. It is readily absorbed

Aluminum, Arsenic, Cadmium, Lead, Lithium, and Tin: Not much is known about the roles, functions, or purpose in the human body of these minerals. For all age groups, grain products (mainly cornbread, pancakes, biscuits, muffins, and yellow cake) provide the highest amount of aluminum in the


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diet. Organic arsenic is found in dairy products, meats, poultry, fish, grains and cereal. Inorganic arsenic is toxic. Nickel: There may be roles in iron and zinc metabolism, hematopoiesis, DNA and RNA, and enzyme activation. Less than 10% of nickel is absorbed. It is transported by serum albumin. Nickel hypersensitivity can occur from prior dermal contact. No RDA has been set, but UL was established at 1 mg/d. Sources. Nuts, legumes, cereals, sweeteners, chocolate candy, and chocolate milk powders. Silicon: There may be roles in normal bone growth and calcification; collagen and connective tissue formation in the presence of calcium. Natural food and water sources do not seem to cause adverse health effects. No RDA or UL have been established.

935

protein deficiency can decrease transport. Dietary vitamin A is transported via chylomicrons; 90% of vitamin A is stored in the liver. Its provitamins include beta-carotene and cryptoxanthin. AI for infants is based on the amount of retinol found in human milk. RDA is 900 mg for men and 700 mg for women, adjusted for differences in average body size. UL is 3000 mg/d. Functions. Vision (especially night), gene regulation, growth, prevention of early miscarriage, immunity against infection (measles and many others), corticosterones, weight gain, proper bone, tooth, and nerve development, membrane functions, and epithelial tissue integrity in lungs and trachea especially. Vitamin A supplementation is used to treat some forms of cancer and degenerative retinitis pigmentosa. Sources. See Table A-11 for sources.

Sources. Most plant-based foods. Grains and beer are good sources. Vanadium: Vanadium seems to have a role in thyroid metabolism. High doses may cause biochemical changes that precede cancer. No RDA has been set. UL was established at 1.8 mg/d.

TABLE A-11

Food Sources of Vitamin Aa

Food, Standard Amount

Sources. Shellfish, whole grains, mushrooms, black pepper, parsley, and dill seed.

VITAMINS Vitamins were first named “vital amines” in 1912 because they seemed to be important to life. Once it was known that they contain few amine groups, the “e” was dropped. There are 13 known vitamins (four fat-soluble and nine water-soluble vitamins). They are organic compounds, containing carbon structures. The best nutritional strategy for promoting optimal health and reducing the risk of chronic disease is to obtain adequate nutrients from a wide variety of foods. Eating more whole grains, fruits and vegetables is the recommendation, rather than taking supplements. Supplements are needed in special cases, such as in pregnancy and in some medical conditions. Supplements are most useful when taken as a multivitamin supplement that meets 100% of the daily recommended values. Although fat-soluble vitamins should not be consumed above UL doses, meeting 100% DRI levels is safe.

Fat-Soluble Vitamins Vitamin A (Retinol, Retinal, Retinoic Acid): Vitamin A is best known for its role in vision and skin integrity. From 7–65% of vitamin A from the diet is absorbed in the mucosal cells of the small intestine. There, dietary retinyl esters are hydrolyzed by pancreatic triglyceride lipase (PTL), and the intestinal brush border phospholipase. Once in the cell, retinol is complexed with cellular retinol-binding protein type 2 (CRBP2), a substrate for reesterification of the retinol by the enzyme lecithin/retinol acyltransferase (LRAT). Retinol-binding protein (RBP) is used for transport. Retinyl esters are incorporated into chylomicrons. Stress can increase excretion; zinc or

Organ meats (liver, giblets), various, cooked, 3 ouncesb

Vitamin A (g RAE)

Calories

1490–9126

134–235

Carrot juice, 3/4 cup

1692

71

Sweet potato with peel, baked, one medium

1096

103

Pumpkin, canned, 1/2 cup

953

42

Carrots, cooked from fresh, 1/2 cup

671

27

Spinach, cooked from frozen, 1/2 cup

573

30

Collards, cooked from frozen, 1/2 cup

489

31

Kale, cooked from frozen, 1/2 cup

478

20

Mixed vegetables, canned, 1/2 cup

474

40

Turnip greens, cooked from frozen, 1/2 cup

441

24

Instant cooked cereals, fortified, prepared, one packet

285–376

75–97

Various ready-to-eat cereals, with added vitamin A, 1 ounce

180–376

100–117

Carrot, raw, one small

301

20

Beet greens, cooked, 1/2 cup

276

19

Winter squash, cooked, 1/2 cup

268

38

Dandelion greens, cooked, 1/2 cup

260

18

Cantaloupe, raw, 1/4 medium melon

233

46

Mustard greens, cooked, 1/2 cup

221

11

Pickled herring, 3 ounces

219

222

Red sweet pepper, cooked, 1/2 cup

186

19

Chinese cabbage, cooked, 1/2 cup

180

10

Source: Nutrient values from Agricultural Research Service (ARS) Nutrient Database for Standard Reference, Release 17. Foods are from ARS single nutrient reports, sorted in descending order by nutrient content in terms of common household measures. Food items and weights in the single nutrient reports are adapted from those in 2002 revision of USDA Home and Garden Bulletin No. 72, Nutritive Value of Foods. Mixed dishes and multiple preparations of the same food item have been omitted from this table. a Food Sources of vitamin A ranked by micrograms. Retinol Activity Equivalents (RAE) of vitamin A per standard amount; also calories in the standard amount. (All are 20% of RDA for adult men, which is 900 mg/d RAE). b High in cholesterol.


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Signs of Deficiency. Impaired vision is the first sign. Xerophthalmia, night blindness (nyctalopia), follicular hyperkeratosis or thickening of skin around hair follicles, drying of the whites of the eyes, eventual blindness, spots on the whites of the eyes, infections, and death. Vulnerable Populations. Anorexia nervosa, burns, biliary obstruction, cancer, cirrhosis, celiac disease, cystic fibrosis, drug use (cholestyramine, mineral oil, and neomycin), hookworm, hepatitis of infectious origin, giardiasis, kwashiorkor, malaria, measles, pancreatic disease, pneumonia, pregnancy, prematurity, rheumatic fever, tropical sprue, and zinc deficiency. Signs of Excess. Headache, anorexia, abdominal pain, blurred vision, muscle weakness, drowsiness, irritability, peeling of skin, peripheral neuritis, papilledema, serum vitamin A 100 g/dL. Long-term supplementation with retinol (such as 25,000 IU/d) may have adverse effects on blood lipid levels and bone health. Vitamin A is known for its teratogenic affects; pregnant women should consider taking it in the form of beta-carotene. Caution should be given to supplement use in women of childbearing age because many women don’t know they are pregnant in the earliest stages; supplements with retinol should be avoided during the first trimester. Carotenoids: There are more than 500 natural carotenoids. Two beta-carotene molecules are equivalent to one molecule of vitamin A. The bioavailability of carotenoids from vegetables is low; fat is required for adequate absorption. Between 9 and 17% of dietary carotenes are absorbed. Dietary carotenoids may prevent some types of cancer through enhancement of immune response, inhibition of mutagenesis, and protection against oxidative damage to cells; alphacarotenes, beta-cryptoxanthin, lutein, zeaxanthin, and lycopene contribute to these important functions. Persons at risk for developing lung cancer (i.e., current smokers and workers exposed to asbestos) should not take beta-carotene supplements. No specific RDA recommendations were made for beta-carotene. Sources. Beta-carotene is found in deep yellow, orange, or dark green fruits and vegetables such as pumpkin, sweet potato, carrots, spinach, kale, turnip greens, cantaloupe, apricots, romaine lettuce, broccoli, papaya, mango, and tangerine. Signs of Excess. Hypercarotenodermia involves yellowing of skin and the whites of eyes. Vitamin D (Calcitriol, D3): Vitamin D for humans is obtained from sun exposure, food and supplements. It is biologically inert and has to undergo two hydroxylation reactions to become active as Calcitriol (1,25-dihydroxycholecalciferol), or 1,25-dihydroxyvitamin D3. Steps in metabolism include 7dehydrocholesterol S previtamin D3 S cholecalciferol (D3) S 25-hydroxycholecalciferol S calcitriol (1,25-dihydroxycholecalciferol, the active form). Bile salts are required for absorption; 90% of dietary intake is absorbed. Dietary vitamin D is absorbed with lipid into the intestine by passive diffusion; it is synthesized in the skin from cholesterol that enters the capillary system.

Transport occurs via chylomicrons to the liver. Although five forms of vitamin D have been discovered, the two forms that matter are vitamins D2 (ergocalciferol) and D3 (cholecalciferol). There is decreased production from the skin with aging. 2.5 mcg of vitamin D is considered sufficient to prevent vitamin D-deficiency rickets, higher levels of 5 g/d are recommended for infants and children throughout the period of skeletal development. The AI increases to 10 g/d for adults aged 51 and older and to 15 g/d for adults 71 years and older. The UL for infants is 25 g/d and for children and adults, 50 g/d. Functions. The main functions of vitamin D are bone metabolism, calcium homeostasis, and expression of hundreds of genes. Calcitriol plays a key role in the maintenance of many organ systems; the volume and acidity of gastric secretions; growth of soft tissues including skin and pancreas; bone calcification, growth and repair; tooth formation; parathormone (PTH) management; and renal/intestinal phosphate absorption. Sources. Brief and casual exposure (10–20 minutes daily) to natural sunlight can be encouraged. Check nutrition labels for vitamin D fortification when using soy or rice milks. Food sources of vitamin D are listed in Table A-12.

TABLE A-12 Food Sources of Vitamin D Foods with Naturally Occurring Vitamin D

International Units

Herring, 3 ounces

1384

Cod liver oil, one tablespoon

1350

Halibut, 3 ounces

510

Catfish, 3 ounces

425

Salmon, canned, 3 ounces

390

Mackerel, 3 ounces

306

Sardines, canned in oil, 1.75 ounces

250

Tuna, canned in oil, 3 ounces

200

Egg yolk, one yolk

20

Beef liver, 3 ounces

15

Swiss cheese, 1 ounce

12

Vitamin D–Fortified Foods Soy milk, one cup

119

Milk, one cup

100

Fortified orange juice, one cup Fortified breakfast cereal, one cup

100 20–100

Fortified yogurt, one cup

80

Fortified margarine, one tablespoon

60

Source: Nutrient values from Agricultural Research Service (ARS) Nutrient Database for Standard Reference, Release 17. Foods are from ARS single nutrient reports, sorted in descending order by nutrient content in terms of common household measures. Food items and weights in the single nutrient reports are adapted from those in 2002 revision of USDA Home and Garden Bulletin No. 72, Nutritive Value of Foods. Mixed dishes and multiple preparations of the same food item have been omitted from this table.


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Signs of Deficiency. Hypocalcemic tetany is a low calcium condition in which the patient has overactive neurological reflexes, spasms of the hands and feet, cramps and spasms of the voice box (larynx). Vitamin D from sunlight exposure is low during the winter months. Hypovitaminosis D is related to lowered vitamin D intake, less exposure to ultraviolet light (UVB), anticonvulsant use, renal dialysis, nephrotic syndrome, hypertension, diabetes, winter season, and high PTH and alkaline phosphatase levels. Hypovitaminosis D is common in general medical in-patients. Bowed legs, rickets in children, and osteomalacia in adults may occur. Vulnerable Populations. The prevalence of vitamin D deficiency is high. The National Health and Nutrition Examination Survey (NHANES) team found that 9% of U. S. children were vitamin D deficient ( 15 ng/mL of blood) and another 61% were vitamin D insufficient (15–29 ng/mL). Those individuals with dark skin or who wear protective clothing may also not absorb sufficient vitamin D from sun exposure alone. Living near the North or South Pole in winter is a risk for deficiency. Biliary obstruction, celiac disease, cystic fibrosis, drug use (bile salt binders, glucocorticoids, phenobarbital, primidone, and mineral oil), end-organ failure, Fanconi’s disease, hepatic disease, hypertension, primary hypophosphatemia, hypoparathyroidism, inflammatory bowel disease, intestinal malabsorption, lymphatic obstruction, multiple sclerosis, nephrotic syndrome, neurological and psychiatric conditions such as depression and bipolar disorders, pancreatitis, parathyroid surgery, postmenopausal status, prematurity, renal disease and dialysis, small bowel resection, and tropical sprue. Pregnant women should enjoy a few minutes in the sun each day, if possible. Low levels may increase the risk of breast, colon, and prostate cancers; depression, poor brain function, severe dementia in older adults; tuberculosis; pneumonia; bacterial infections and gum disease; autoimmune diseases, such as multiple sclerosis and type 1 diabetes. Signs of Excess. Patients often complain of headache and nausea, and infants given excessive amounts of vitamin D may have GI upset, bone fragility, and retarded growth. Stupor, confusion, anorexia, nausea, vomiting, constipation, weakness, hypertension, renal stones, polyuria, polydipsia, cardiac arrhythmias, itchy skin, increased bone density on xray, calcium deposits throughout the body, increased serum calcium, increased calcium in the urine, elevated serum 25hydroxycholecalciferol or elevated serum 1,25-dihydroxycholecalciferol levels. In the absence of sufficient vitamin K, excessive vitamin D can cause soft tissue calcification. Vitamin E (Tocopherol, Tocotrienols): Tocotrienols plus other forms affect cholesterol metabolism, carotid arteries, and immunity against cancer. The natural form is D-alpha-tocopherol (need 22 IU). The DL-alpha-tocopherol form is synthetic and less effective. Vitamin E is absorbed in the upper small intestine by micelle-dependent diffusion. Overall, 20–40% is absorbed with meals; bile and pancreatic secretions are needed and VLDLs and LDLs carry it to tissues. An IU of vitamin E is equal to 0.67 mg of RRR-alpha-tocopherol and 1 mg of all-rac-alpha-tocopherol. RDA is 15 mg for adults. UL is 1000 mg. Functions: The main function of vitamin E is as a lipid-soluble membrane antioxidant, along with vitamin C and selenium. It

937

protects unsaturated phospholipids of the membrane from oxidative degradation through free-radical scavenging. Other roles include anticoagulant and vitamin K antagonist; intracellular respiration; hemopoietic agent; roles in muscular, vascular, reproductive, and CNS systems; some role in reproduction; neutralizes free radicals; protects against cataracts; may relieve discomforts of rheumatoid arthritis; protects against effects of the sun, smog, and lung disease; protects brain cell membranes. Sources. Tocopherols and tocotrienols are synthesized only by plants so plant products, especially oils, are the best sources of Vitamin E. Requirements increase with use of PUFAs; if normal needs are 15 mg/d, normal requirements double daily with high PUFA intakes. Gamma-tocopherol is more common in the U. S. food supply (as from soybean oil); it is less useful to the body (see Table A-13). Signs of Deficiency. Symptoms of deficiency in humans are rare, but can manifest clinically as loss of deep tendon reflexes, impaired vibratory and position sensation, changes in balance and coordination, muscle weakness and visual disturbances. Other targets of deficiency include the vascular and reproductive systems. Rupture of RBCs, impaired vitamin A storage, and prolonged blood coagulation may also occur. For supplementation, pharmacists evaluate equivalent vitamin E dosing as follows: DL-alpha-tocopheryl

acetate

DL-alpha-tocopherol DL-alpha-tocopheryl D-alpha-tocopheryl

acid succinate

acid succinate

1 mg

1 IU

0.91 mg

1.1 IU

1.12 mg

0.89 IU

0.826 mg

1.21 IU

Vulnerable Populations. Alzheimer’s disease, arthritis, biliary cirrhosis, bronchopulmonary dysplasia, cardiovascular diseases, cystic fibrosis, drug use (cholestyramine, clofibrate, oral contraceptives, and triiodothyronine), high intake of PUFA in diet, malabsorption syndromes, malnutrition, musculoskeletal disorders, pancreatic diseases, pregnancy, prematurity, pulmonary diseases, and steatorrhea. Signs of Excess. Vitamin E is one of the least toxic vitamins, but at high doses, it can antagonize the utilization of other fat-soluble vitamins. Excessive intake has caused isolated cases of dermatitis, fatigue, pruritus ani, acne, vasodilation, hypoglycemia, GI symptoms, increased requirement for vitamin K, impaired coagulation, and muscle damage. Vitamin K: First isolated from alfalfa, the forms of vitamin K are phylloquinone (K1) in green plants; menaquinone (K2) from human bacterial synthesis and menadione (K3) in pharmaceutical form. Vitamin K absorption is optimal with bile and pancreatic juice; 10–70% of dietary intake is usually absorbed. The phylloquinones are absorbed by and energydependant process in the small intestine; the menaquinones and menadione are absorbed in the small intestine and colon by passive diffusion. Because intestinal bacteria make about 50% of the bodily requirement, a sterile gut or malabsorption can create deficiency. Vitamin E excesses can reduce absorption of vitamin K. Warfarin (Coumadin) blocks regeneration of active, reduced vitamin K, thus prolonging clotting time,


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TABLE A-13 Food Sources of Vitamin Ea Food, Standard Amount

AT (mg)

Calories

Fortified ready-to-eat cereals, 1 ounce

1.6–12.8

90–107

Sunflower seeds, dry roasted, 1 ounce

7.4

165

Almonds, 1 ounce

7.3

164

Sunflower oil, high linoleic, one tbsp

5.6

120

Cottonseed oil, one tbsp

4.8

120

Safflower oil, high oleic, one tbsp

4.6

120

Hazelnuts (filberts), 1 ounce

4.3

178

Mixed nuts, dry roasted, 1 ounce

3.1

168

Turnip greens, frozen, cooked, 1/2 cup

2.9

24

Tomato paste, 1/4 cup

2.8

54

Pine nuts, 1 ounce

2.6

191

Peanut butter, two tbsp

2.5

192

Tomato puree, 1/2 cup

2.5

48

Tomato sauce, 1/2 cup

2.5

39

Canola oil, one tbsp

2.4

124

Wheat germ, toasted, plain, two tbsp

2.3

54

(osteocalcin) and arterial calcification linked to cardiovascular disease (McCann and Ames, 2009). Vitamin K is also linked with sphingolipid metabolism in the brain. Sources. Plant foods such as green leafy vegetables are better sources of vitamin K than animal foods. Fish, liver, meat, eggs, cereal, and some fruits contain smaller amounts (see Table A-14). Signs of Deficiency. Hemorrhage with prolonged clotting time is the key sign of deficiency, which might even lead to a fatal anemia. Vitamin K deficiency can be found in lipid malabsorption, chronic antibiotic therapy, and liver disease where

TABLE A-14 Food Sources of Vitamin K Food and Serving Size Kale, cooked 1/2 cup

Vitamin K (g) 531

Spinach, cooked 1/2 cup

444

Collard greens, cooked 1/2 cup

418 348

Peanuts, 1 ounce

2.2

166

Beet greens, cooked 1/2 cup

Avocado, raw, 1/2 avocado

2.1

161

Swiss chard, cooked 1/2 cup

286

Carrot juice, canned, 3/4 cup

2.1

71

Turnip greens, cooked, 1/2 cup

265

Peanut oil, one tbsp

2.1

119

Mustard greens, cooked 1/2 cup

210

Corn oil, one tbsp

1.9

120

Spinach, raw one cup

Olive oil, one tbsp

1.9

119

Broccoli 1/2 cup

Spinach, cooked, 1/2 cup

1.9

21

Brussels sprouts, cooked 1/2 cup

109

Dandelion greens, cooked, 1/2 cup

1.8

18

104

Sardine, Atlantic, in oil, drained, 3 ounces

1.7

177

Scallions (including bulb and green tops), raw 1/2 cup

Blue crab, cooked/canned, 3 ounces

1.6

84

Cabbage, cooked 1/2 cup

81 97 65

Brazil nuts, 1 ounce

1.6

186

Lettuce (green leaf), raw one cup

Herring, Atlantic, pickled, 3 ounces

1.5

222

Prunes, stewed one cup

Source: Nutrient values from Agricultural Research Service (ARS) Nutrient Database for Standard Reference, Release 17. Foods are from ARS single nutrient reports, sorted in descending order by nutrient content in terms of common household measures. Food items and weights in the single nutrient reports are adapted from those in 2002 revision of USDA Home and Garden Bulletin No. 72, Nutritive Value of Foods. Mixed dishes and multiple preparations of the same food item have been omitted from this table. a Food sources of vitamin E ranked by milligrams of vitamin E per standard amount; also calories in the standard amount. (All provide 10% of RDA for vitamin E for adults, which is 15 mg a-tocopherol [AT]/d).

145 110 cooked, 45 raw

Okra, cooked one cup

64

Parsley one tablespoon

62

Cucumber, raw one large

49

Asparagus, cooked four spears

48

Tuna, canned 3 ounces

37

Celery, raw one cup

35

Black-eyed peas, cooked 1/2 cup

31

Kiwi one medium

30

Blackberries or blueberries, raw one cup

29

which is best monitored through international normalized ratio (INR) where the timing level of 2–3 is desired. AI is 120 mg for men and 90 mg for women. No UL has been established, but data are limited and one should not assume that high vitamin K consumption is harmless.

Artichoke, cooked one cup

25

Peas 1/2 cup

24

Grapes (red or green) one cup

23

Functions. Vitamin K is important for normal blood clotting, calcium metabolism, and bone mineralization. Low vitamin K intakes are associated with an increased incidence of hip fractures. Genetic loss of less critical vitamin K–dependent proteins, dietary vitamin K inadequacy, human polymorphisms or mutations, and vitamin K deficiency induced by chronic anticoagulant (warfarin/Coumadin) therapy are all linked to age-associated conditions: bone fragility after estrogen loss

Soy beans or mung beans, cooked 1/2 cup

16–17

Oil, canola, or olive one tablespoon

8–10

Strawberries, sliced one cup

23

Green beans, cooked 1/2 cup

20

Source: Nutrient values from Agricultural Research Service (ARS) Nutrient Database for Standard Reference, Release 17. Foods are from ARS single nutrient reports, sorted in descending order by nutrient content in terms of common household measures. Food items and weights in the single nutrient reports are adapted from those in 2002 revision of USDA Home and Garden Bulletin No. 72, Nutritive Value of Foods. Mixed dishes and multiple preparations of the same food item have been omitted from this table.


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bleeding and hypoprothrombinemia can result. Giving an injection of vitamin K upon birth prevents hemorrhagic disease of newborns. In addition, there are 16 known vitamin K–dependent (VKD) proteins; five of them have critical functions with preferential distribution of dietary vitamin K1 to the liver to preserve coagulation function when vitamin K1 is limiting (McCann and Ames, 2009).

of bread and one serving of cereal will provide 15% of the daily RDA. Some nutrients are thiamin sparing; others destroy the nutrient. Thiamin is spared by fat, protein, sorbitol, and vitamin C; antagonists include raw fish, tea, coffee, blueberries, and red cabbage. Avoid cooking with excessive water and alkaline products such as baking soda; thiamin is lost readily.

Vulnerable Populations. Individuals who practice pica or have calcium disorders, use certain medications (anticoagulants, cholestyramine, mineral oil, phenytoin, neomycin or other antibiotics, or large doses of aspirin), hepatic biliary obstruction, hepatocellular disease, malabsorption syndromes, postmenopausal women at risk for hip fractures, prematurity, and small bowel disorders. Individuals who take large doses of vitamin A or E may also acquire a vitamin K deficiency.

Signs of Deficiency. Anorexia, calf muscle weakness, weight loss, cardiac and neurologic signs. Eventually, beriberi occurs with mental confusion, muscular wasting, edema, peripheral neuropathy, and tachycardia. Energy deprivation and inactivity are causes of dry (nonedematous) beriberi. Wernicke’s encephalopathy is due to thiamin deficiency and often associated with malnutrition and alcoholism. TPN without multivitamin use can lead to symptoms of Wernicke’s encephalopathy.

Signs of Excess. Prolonged bleeding time. Menadione can be toxic if given in excessive dose; severe jaundice in infants or hemolytic anemia may result. Seek consistency in vitamin K intake while using warfarin; aim for 120 g/d for men and 90 g/d for women. Although dietary sources do not appear to be dangerous, excessive menadione can be toxic and may cause hemolytic anemia.

REFERENCE McCann JC, Ames B. Vitamin K, an example of triage theory: is micronutrient inadequacy linked to diseases of aging? Am J Clin Nutr. 90:889, 2009.

Vulnerable Populations. Individuals who have alcoholism, cancers, cardiomyopathies, CHO (high intakes), celiac disease, children with congenital heart disease before and after surgery, congestive heart failure, fever, high parenteral glucose loading, lactation and pregnancy, tropical sprue, and thyrotoxicosis are at risk. Signs of Excess. Respiratory failure and death with large doses (1000 times nutritional needs). With 100 times the normal dose, headache, convulsions, muscular weakness, cardiac arrhythmia, and allergic reactions have been noted. Massive doses greater than 1000 times the estimated needs suppress the respiratory center and lead to death.

Water-Soluble Vitamins Thiamin (Vitamin B1): Known as the “morale” vitamin, thiamin is beneficial for nerve and heart function. Thiamin is absorbed by the proximal small intestine by active transport in low doses and passive diffusion in high doses. High-CHO intakes, pregnancy, lactation, increased basal metabolic rate, and antibiotic use will all increase needs. As energy intake from protein and fat increases, thiamin requirement decreases. The extent of absorption varies widely. Thiamin hydrochloride is the common supplemental form. The DRIs for thiamin include AIs for infants as found in human milk; RDAs are based on levels of energy intake. RDA is 1.2 mg/d for men and 1.1 mg/d for women. No UL was established. Functions. Thiamin is mainly a coenzyme for decarboxylations of 2-keto acids and transketolations. It prevents beriberi and has a role in cell respiration, RNA and DNA formation, protein catabolism, growth, appetite, normal muscle tone in cardiac and digestive tissues, neurologic functioning. It is a coenzyme in the energy-producing Krebs’ cycle, with thiamin pyrophosphate (TPP) at the pyruvic acid step. Magnesium, manganese, riboflavin, and vitamin B6 are synergists. Thiamin is essential for conversions derived from the amino acids methionine, threonine, leucine, isoleucine, and valine. Acetylcholine synthesis also requires thiamin. Sources. Liver, fortified cereals, dried legumes such a split peas, brown rice, organ and lean meats, whole grains such as oats and whole wheat, nuts, cornmeal, enriched flour or bread, dried milk, wheat germ, dried egg yolk or whole egg, green peas, and seeds. Note: Two slices of bread or one slice

Riboflavin (Vitamin B2): Riboflavin is important in CHO metabolism and maintenance of healthy mucous membranes. Riboflavin is absorbed in the free form by a carrier-mediated process in the proximal small intestine. The DRIs for riboflavin include AIs for infants and RDAs based on the amount required to maintain normal tissue reserves based on urinary excretion, RBC riboflavin contents, and erythrocyte glutathione reductase activity. RDA is 1.3 mg/d for men and 1.1 mg/d for women. Requirements are higher during pregnancy and lactation. No UL was established. Functions. It is the main coenzyme in redox reactions of fatty acids and the tricarboxylic acid (TCA) cycle. Cell respiration, oxidation reduction, conversion of tryptophan to niacin, component of retinal pigment, involvement in all metabolisms (especially fat), purine degradation, adrenocortical function, coenzyme in electron transport as flavin adenine dinucleotide (FAD) and flavin mononucleotide (FMN), healthy mucous membranes, skin and eyes, growth, and proper functioning of niacin and pyridoxine. Sources. Milk, yogurt, cheese, egg whites, liver, beef, chicken, fish, legumes, peanuts, enriched grains and fortified cereals. Body size, growth, activity excesses, and fat metabolism affect daily requirements. Avoid excesses of niacin and methylxanthines. Light destroys riboflavin; buy milk in opaque cartons. As protein intake increases, the need for riboflavin decreases. Riboflavin is spared by dextrins and starch and is found in greater amounts in protein foods. Cheilosis causes a magentacolored tongue.


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Signs of Deficiency. Deficiencies are first evident in the tissues that have rapid cellular turnover such as the skin and epithelia. Seborrheic dermatitis of the nasolabial folds, ears, and/or eyelids; itchy and burning eyes or lips, mouth, and tongue; cheilosis (fissures and scaling of lips); angular stomatitis; glossitis with purplish-red, swollen tongue; peripheral neuropathy; dyssebacea (sharkskin); corneal vascularization; photophobia; lacrimation; normochromic normocytic anemia with erythroid hypoplasia; pancytopenia due to generalized marrow hypoplasia. Riboflavin deficiency is most commonly found in developing countries like India and can lead to deficiency of vitamins B6 and B2 and impairment of psychomotor function. Riboflavin metabolism is affected by infections, drugs, and hormones. Vulnerable Populations. Alcoholism, cancers, chronic infections, drug use (broad-spectrum antibiotics and chloramphenicol), gastrectomy, and low oral intake during childhood, pregnancy, or lactation. Signs of Excess. There is no known toxicity. Niacin (Nicotinic Acid, Nicotinamide): Niacin is absorbed in the stomach and small intestine by carrier-mediated facilitated diffusion. Niacin requirements are related to protein and calorie intake. Intake for infants is established as AIs. RDA is 16 mg/d for men and 14 mg/d for women. UL was established at 35 mg for men and women. Functions. Niacin serves as coenzyme for several dehydrogenases. It is part of nicotinamide adenine dinucleotide (NAD) and NADH in over 200 enzymes involved with metabolism of CHO, protein, and fat. It is involved with intracellular reactions and biosynthetic pathways; energy metabolism; growth; conversion of vitamin A to retinol; metabolism of fatty acids, serum cholesterol, and triglycerides. It has a role in DNA repair and gene stability, thus affecting cancer risk. It prevents pellagra (along with other B-complex vitamins). It is needed to treat tuberculosis as Isoniazid. Nicotinic acid is used as a vasodilator; nicotinamide is less vasodilating. Sources. Beef and lean meats, organ meats, poultry, tuna and salt water fish, peanut butter, peanuts and legumes, enriched breads and fortified cereals. Diet supplies 31% of niacin intake as tryptophan. Milk and eggs are good sources of tryptophan but not niacin. Sixty milligrams of tryptophan are needed to equal 1 mg of niacin. Signs of Deficiency. Signs start with beefy tongue, stomatitis with swelling and soreness of the oral mucosa; esophagitis with gastritis; diarrhea with proctitis; inflammation and erythema of the mucosal surfaces of the genitourinary tract; symmetric pigmented rash with scaling and hyperkeratosis; worsening of the skin rash in areas of sun exposure or trauma; headaches, insomnia, depression, anxiety; tremors or rigidity of limbs; loss of tendon reflexes; numbness and paresthesias in limbs. Severe deficiency leads to pellagra with Casal’s collar, a rough, red dermatitis, diarrhea, dementia (the three Ds of pellagra). Vulnerable Populations. Alcoholism, cancers, chronic diarrhea, cirrhosis, diabetes, and tuberculosis. Undernourished people in Africa.

Signs of Excess. Toxicity is generally low but may cause histamine release, flushing of skin (when using 1–2 g of nicotinic acid daily in an effort to lower cholesterol levels), or even liver toxicity. Megadoses should be avoided. Pantothenic Acid (Vitamin B-5): Pantothenic acid is a coenzyme in fatty acid metabolism. Pantothenic acid is available “from everywhere.” It is absorbed by passive diffusion and active transport in the jejunum. Fifty percent is bioavailable from diet. Needs increase by one-third in pregnancy and lactation. AI for adult men and women is 5 mg/d. UL is not established. Functions. Coenzyme A is essential in the formation of acetyl CoA and energy production from the macronutrients. It also affects synthesis of cholesterol and fatty acids, adrenal gland activity, acetyl transfer, antibodies, normal serum glucose, electrolyte control and hydration, heme synthesis, and healthy RBCs. It changes choline to acetylcholine and prevents premature graying in some animals. Sources. Pantothenic acid is present in all plant and animal tissues. The most important sources are meats, particularly heart and liver, but mushrooms, avocados, broccoli, egg yolks, yeast, skim milk, and sweet potatoes are also good sources. Signs of Deficiency. Deficiency is rare but can impair lipid synthesis and energy production. Symptoms include paresthesia in the toes and soles of the feet, burning sensations in the feet, depression, fatigue, insomnia, and weakness. Vulnerable Populations. Alcoholism, elderly women, liver disease, chronic ulcerative colitis, and pregnancy. Signs of Excess. Rarely, excess causes mild intestinal distress or diarrhea. Vitamin B6 (Pyridoxine): This group includes numerous 2-methyl-3,5-dihydroxymethylpyridine derivatives exhibiting the biologic activity of PN, including pyridoxol, pyridoxal, and pyridoxamine. Vitamin B6 is absorbed by passive diffusion of the dephosphorylated forms PN, PL, or PM, primarily in the jejunum and ileum. Pyridoxal phosphate (PLP) is the active form. Some studies suggest that a higher RDA is desirable for some individuals. About 96% of dietary vitamin B6 is absorbed. High-protein intakes may deplete vitamin B6 levels, thus needs increase with increased protein intake. Needs decrease with fatty acids or with other B-complex vitamins. The DRIs for vitamin B6 include AIs for infants. Infants need three times as much vitamin B6 as adults. RDA is 1.3–1.7 mg/d for men and 1.3–1.5 mg/d for women. The UL was established at 100 mg/d for adult men and women. Functions. Vitamin B6 is primarily known for its role in amino acid metabolism, histamine synthesis, gene expression, and hemoglobin synthesis. PLP is involved in practically all reactions in the metabolism of amino acids and in several aspects of the metabolism of neurotransmitters, glycogen, sphingolipids, heme, steroids, coenzymes (-ases), conversion of tryptophan to niacin, fat metabolism (changing linoleic to arachidonic acid), synthesis of folic acid, homocysteine metabolism, glandular and endocrine functions, antibodies, dopamine and serotonin metabolism, glycogen phosphorylase, and immunity.


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Sources. Wheat and whole-grain cereals (such as oatmeal), legumes and nuts (garbanzo beans, soybeans, and peanuts) are the highest sources. Signs of Deficiency. The vitamin is widely distributed throughout the diet; deficiency is rare but may present as convulsions in infants; depression, confusion, irritability; hypochromic, microcytic anemia. Peripheral neuropathies; glossitis, cheilosis, angular stomatitis; impaired immunity; seborrheic dermatitis involving the face and neck; blepharitis may also occur. Vulnerable Populations. Alcoholism, use of certain medications (cycloserine, Dilantin, hydralazine, isoniazid, oral contraceptives, and penicillamine), elderly status, pregnancy, schizophrenia, isoniazid treatment and no vitamin replacement for tuberculosis. Signs of Excess. Toxicity is relatively low. Sensory neuropathy with gait changes, peripheral sensations, and muscle incoordination. Biotin (Vitamin B-7): Biotin is a coenzyme for carboxylations. RDA is 30 mg/d for adult men and women. UL is not established. Functions. Coenzyme in CO2 fixation, deamination, decarboxylation, synthesis of fatty acids, CHO metabolism, oxidative phosphorylation, leucine catabolism, and carboxylation of pyruvic acid to oxaloacetate. Sources. Liver, kidney, pork, milk, egg yolk, yeast, cereal, nuts, legumes, and chocolate. Note: Biotin can be synthesized by intestinal bacteria. Be wary of extended antibiotic use or prolonged unsupplemented TPN use. Probably, 50% of dietary biotin is absorbed from the small intestine. Biotin is called the “anti–raw egg white” factor; avidin in raw egg white decreases biotin availability. Signs of Deficiency. Inflammation of the skin and lips. Other symptoms include dermatitis, alopecia, paralysis, depression, nausea, hepatic steatosis, hypercholesterolemia, and glossitis. Vulnerable Populations. Individuals who consume excessive intake of avidin from raw egg whites. People with genetic conditions (beta-methylcrotonylglycinuria and propionic acidemia), or inadequate provision with long-term parenteral nutrition. Signs of Excess. There are no known toxic effects. Folic Acid (Vitamin B-9): Folate generally refers to pteroylmonoglutamin acid and its derived compounds. Folate is found naturally in food; folic acid is the supplemental form. Pteroylglutamic acid is the pharmacological form. Folic acid works primarily as a coenzyme in single-carbon metabolism. Some folic acid can be made in the intestines with help from biotin, protein, and vitamin C. Synthetic folic acid increases serum levels more effectively than food sources of folate. Only 25–50% of dietary sources are bioavailable. Absorption occurs by active transport mainly in the jejunum, but can also be absorbed by passive diffusion when ingested in large amounts. The DRIs express folate in “dietary folate equivalents or DFEs,” which account for the difference between food

941

sources and the more bioavailable supplemental sources. DFEs from fortified foods provide 1.7 times the micrograms of natural folic acid. Fortification of more commonly eaten foods has been implemented to provide adequate folic acid for vulnerable populations. About 90% of circulating folacin is bound to albumin. Drugs that interfere with utilization include aspirin, sulfasalazine (Azulfidine), methotrexate, antacids, anticonvulsants such as phenytoin (Dilantin), oral contraceptives, pyrimethamine, trimethoprim. The DRI is described as AIs for infants. RDA is 400 mcg for adults. Pregnant women need 600 mcg and lactating women need 500 mcg. UL is 1000 mcg/d. Functions. Needed for growth; hemoglobin; amino acid metabolism. Prevents excessive buildup of homocysteine to protect against heart disease and some forms of cancer. Prevents megaloblastic and macrocytic anemias. Reduces the incidence of neural tube defects. Folate is required for synthesis of phospholipids, DNA, proteins, new cells, and neurotransmitters. Choline is used as a methyl donor (to convert homocysteine to methionine) when folate intake is low. Folic acid is needed during pregnancy to prevent spina bifida, cleft palate, some heart or other birth defects. Sources. Foods with highest folate content include fortified cereals, pinto and navy beans (cooked), lentils, beets, asparagus, spinach, romaine lettuce, broccoli, and oranges. Analysis of foods for their folate content is complex and difficult. Folate exists in 150 different forms, and losses of 50–90% typically occur during storage, cooking, or processing at high temperatures (see Table A-15). Signs of Deficiency. Decrease in total number of cells (pancytopenia) and large RBCs with a macrocytic or megaloblastic anemia. Deficiency is common, especially during pregnancy, with oral contraceptive use, in malabsorption syndromes, in alcoholics, in teens, and in elderly individuals. Neural tube defects such as spina bifida or anencephaly may result from impaired biosynthesis of DNA and RNA. Vulnerable Populations. Alcoholics, cancer, medication use (aspirin, cycloserine, Dilantin, methotrexate, oral contraceptives, primidone, and pyrimethamine), hematological diseases (pernicious anemia, sickle cell anemia, and thalassemia), vitamin B12 deficiency, malabsorption syndromes, and pregnancy. Signs of Excess. No adverse effects of high oral doses of folate have been reported. Although parenteral administration of amounts some 1000 times the dietary requirement produce epileptiform seizures in the rat. Vitamin B12 (Cobalamin, Cyanocobalamin): Vitamin B12 is known for its role as a coenzyme in metabolism of propionate, amino acids, and single-carbon fragments. It is known as a blood cell and nerve cell growth stimulator, along with folic acid. It is the “extrinsic factor” needed from diet to complement the “intrinsic factor” found in the stomach. Many people with achlorhydria or over age 50 lose the ability to absorb vitamin B12 from foods and should consider using more fortified foods. RDA is 2.4 mcg for adults. Pregnant women need 2.6 g and lactating women need 2.8 g. No UL was established.


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TABLE A-15 Food Sources of Folic Acid

Food

Folic Acid or Folate (g)

Cereal, ready to eat, one cup

100–400

Cereal, cooked (oatmeal, farina, grits), one cup

75–300

Turkey giblets, cooked, one cup

486

Lentils or black-eyed peas, cooked, one cup

358

Pinto beans, cooked, one cup

294

Chickpeas (garbanzo beans), one cup

282

Okra, frozen, cooked, one cup

269

Spinach, cooked, one cup

263

Black beans, cooked, one cup

256

Enriched long-grain white rice, cooked, one cup

238

Beef liver, cooked, 3 ounces

221

Enriched egg noodles, cooked, one cup

221

Spinach, canned, one cup

210

Collards, cooked, one cup

177

Turnip greens, cooked, one cup

170

Broccoli, cooked, one cup

168

Enriched spaghetti, cooked, one cup

167

Brussels sprouts, cooked, one cup

157

Artichokes, cooked, one cup

150

Beets, cooked, one cup

136

Peas, cooked, one cup

127

Papaya, one whole

116

Cream-style corn, canned, one cup

115

Orange juice, one cup

110

Source: Nutrient values from Agricultural Research Service (ARS) Nutrient Database for Standard Reference, Release 17. Foods are from ARS single nutrient reports, sorted in descending order by nutrient content in terms of common household measures. Food items and weights in the single nutrient reports are adapted from those in 2002 revision of USDA Home and Garden Bulletin No. 72, Nutritive Value of Foods. Mixed dishes and multiple preparations of the same food item have been omitted from this table.

Functions. Coenzymes, blood cell formation, nucleoproteins and genetic material, nutrient metabolism, growth, nerve tissue, thyroid functions, metabolism, transmethylation, myelin formation, homocysteine metabolism and prevention of heart disease. Sources. Vitamin B12 is not found in plant foods; monitor vegetarian diets. For best absorption, riboflavin, niacin, magnesium, and vitamin B6 are also needed (see Table A-16). Signs of Deficiency. Constipation, poor balance, loss of appetite, numbness and tingling in hands and feet, megaloblastic anemia. Some psychiatric disturbances such as depression, poor memory, dementia, or confusion. Biochemical deficiency such as serum cobalamin level 150–170 pg/mL or serum methylmalonic acid (MMA) 0.35 g/dL; a return in MMA to normal after cobalamin therapy indicates prior deficiency. Vulnerable Populations. Adolescents with poor diet with low intake of meat/fish/dairy products or strict vegetarian (vegan) diets are at risk. Senior citizens and those with severe,

chronic malnutrition are also at risk. Others at risk include those with pernicious anemia (autoimmune atrophic gastritis), disorders of the gastric mucosa, genetic defects (apoenzymes, absence of transcobalamin II, absence of ileal receptors), extensive disease affecting the stomach, intestinal infections, malabsorption (tropical sprue, celiac sprue, pancreatic insufficiency, Crohn’s disease, fish tapeworm, HIV infection, or ileal resection), prolonged exposure to nitrous oxide or megadoses of folic acid. Monitor persons after total gastrectomy for megaloblastic anemia because intrinsic factor is not available. Some gastric bypass patients may also become deficient. Individuals who take zantac, pepcid, tagamet, metformin, omeprazole (Prilosec), lansoprazole (Prevacid) may also be at risk. Signs of Excess. No toxicity is known. Choline: Choline is a methyl-rich nutrient that is required for phospholipid synthesis and neurotransmitter function. Internal synthesis of phosphatidylcholine is insufficient to maintain choline status when intakes of folate and choline are low. AI is set at 550 mg/d for adult men and 425 mg/d for adult women. UL level has been set at 3.5 g/d. Functions. Lipotropic agent, some role in muscle control and in short-term memory with the neurotransmitter acetylcholine, component of sphingomyelin, emulsifier in bile, and component of pulmonary surfactant (CO2/O2 exchange). It helps the body absorb and use fats, especially for cell membranes. Choline is used as a methyl donor to convert homocysteine to

TABLE A-16 Food Sources of Vitamin B12 Food Boneless lamb chop, cooked, 3 ounces Fortified cereals, one cup

Vitamin B12 (g) 2.7 1–6 (varies)

Light tuna canned in water, drained, 3 ounces

2.5

Salmon, cooked, 3 ounces

2.4

Ground beef, 90% lean, cooked, 3 ounces

2.3

Eye round roast and steak, cooked, 3 ounces

1.4

Plain yogurt, low fat, one cup

1.4

Roast turkey, 3 ounces

1.3

Milk, skim, one cup

1.3

Beef hot dog, cooked

0.9

Cottage cheese, low-fat, 4 ounces

0.7

Boneless top loin pork roast, cooked, 3 ounces

0.6

Fortified soy milk or rice milk, one cup

0.6

Chicken breast, cooked, one cup

0.5

Dark meat chicken, cooked, one cup

0.4

Cheddar cheese, one slice

0.2

American cheese, one ounce

0.2

Source: Nutrient values from Agricultural Research Service (ARS) Nutrient Database for Standard Reference, Release 17. Foods are from ARS single nutrient reports, sorted in descending order by nutrient content in terms of common household measures. Food items and weights in the single nutrient reports are adapted from those in 2002 revision of USDA Home and Garden Bulletin No. 72, Nutritive Value of Foods. Mixed dishes and multiple preparations of the same food item have been omitted from this table.


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methionine when folate intake is low. Choline magnesium trisalicylate is used to relieve pain, inflammation and tenderness caused by arthritis as a form of nonsteroidal anti-inflammatory medications

TABLE A-17 Food Sources of Vitamin Ca Food, Standard Amount

Vitamin C (mg)

Sources. Eggs, high-protein animal products such as liver, dairy foods, soybeans, peanuts, cauliflower, lettuce, and chocolate. Lecithin is a choline precursor, as is phosphatidylcholine. Liver can synthesize or resynthesize. Average daily intake is 400–900 mg. High-fat intake accelerates deficiency.

Guava, raw, 1/2 cup

188

Red sweet pepper, raw, 1/2 cup

142

Red sweet pepper, cooked, 1/2 cup

116

Kiwi fruit, one medium

70

Signs of Deficiency. Insufficient phospholipid synthesis occurs; neurotransmitter function and liver damage might occur.

Orange juice, 3/4 cup

Signs of Excess. Anorexia, fishy body odor, upset stomach.

943

Orange, raw, one medium

70 61–93

Green pepper, sweet, raw, 1/2 cup

60

Green pepper, sweet, cooked, 1/2 cup

51

Grapefruit juice, 3/4 cup

50–70

Vitamin C (Ascorbic Acid, Dehydroascorbic Acid): Vitamin C is needed via an exogenous source by all humans and is found in fruits and vegetables. About 90% of dietary intake is absorbed. Concentration of vitamin C in plasma and other body fluids does not increase in proportion to increasing daily doses of vitamin C. Saturation is complete at 200 mg. RDA for vitamin C is 75 mg for women and teen boys. Pregnant women need 85 mg and lactating women need 120 mg. Teen girls need 65 mg; 80 if pregnant or 115 if lactating. Men need 90 mg. Smokers need an extra 35 mg daily. The UL for vitamin C is 2000 mg/d.

Vegetable juice cocktail, 3/4 cup

50

Strawberries, raw, 1/2 cup

49

Brussels sprouts, cooked, 1/2 cup

48

Sweet potato, canned, 1/2 cup

34

Functions. Hydroxylation (lysine and proline) in collagen formation and wound healing, norepinephrine metabolism, tryptophan to serotonin transformation, folic acid metabolism, antioxidant as a scavenger of superoxide radicals and to protect vitamins A and E, changing ferric iron to ferrous iron, healthy immunity and prevention of infection, intracellular respiration, tyrosine metabolism, intercellular structures of bone, teeth, and cartilage, prevention of scurvy. It may defer aging through the collagen turnover process. Vitamin C also serves as a reducing agent, elevates HDL cholesterol in the elderly, and lowers total serum cholesterol. It is also needed for biosynthesis of carnitine and for metabolism of drugs and steroids. Dietary antioxidants, including vitamins C and E, may protect against atherosclerotic disease and cognitive impairment.

Tomato juice, 3/4 cup

33

Cauliflower, cooked, 1/2 cup

28

Pineapple, raw, 1/2 cup

28

Sources. For details see Table A-17. No more than 1 g/d is stored in liver tissue. An excretion of 50% of intake is normal. Men are found to have lower serum levels than women. Smoking decreases serum levels; increased intake removes greater amounts of nicotine. Avoid high levels of pectin, iron, copper, or zinc from the diet and do not cook fruits or vegetables in copper pans.

Vulnerable Populations. Those with achlorhydria, Alzheimer’s disease, burns, cancers, chronic diarrhea, nephrosis, pregnancy, severe trauma, surgical wounds, and tuberculosis. Older and very young are more likely to have weaker immune systems and need more vitamin C. Moderate-to-high alcohol intake reduces immune effectiveness; alcoholics are at risk of scurvy. High blood pressure and cholesterol can lead to immune problems and heart disease. Disease agents originating in the mouth may travel in addition to causing dental problems. Diabetes, high glucose, other abnormal labs can stress the immune system; pollutant exposure, steroid use, and radiation can deplete vitamin C levels. Individuals with gout, arthritis, bladder cancer, reflex pain after hip fracture, pneumonia, risk for stroke or macular degeneration or hip fracture, renal oxalate stones, pregnancy, Helicobacter pylori infection, or prolonged proton pump use should be evaluated closely.

Signs of Deficiency. The first symptom of deficiency is fatigue; treatment with vitamin C results in quick recovery and alleviation of symptoms. Insufficient (depletion) is 11–28 mol/L, considered latent scurvy with mood changes; mild but distinct fatigue and irritability; vague, dull, aching pains. Deficient is 11 mol/L with failure of wounds to heal, petechial hemorrhage, follicular hyperkeratosis, bleeding gums, eventual tooth loss, weak bones or cartilage and connective tissues, rheumatic pains in the legs, muscular atrophy, skin lesions, and psychological changes including depression and hypochondria. High blood lead levels will also deplete serum vitamin C.

Cantaloupe, 1/4 medium

47

Papaya, raw, 1/4 medium

47

Kohlrabi, cooked, 1/2 cup

45

Broccoli, raw, 1/2 cup

39

Edible pod peas, cooked, 1/2 cup

38

Broccoli, cooked, 1/2 cup

37

Kale, cooked, 1/2 cup

27

Mango, 1/2 cup

23

Source: Nutrient values from Agricultural Research Service (ARS) Nutrient Database for Standard Reference, Release 17. Foods are from ARS single nutrient reports, sorted in descending order by nutrient content in terms of common household measures. Food items and weights in the single nutrient reports are adapted from those in 2002 revision of USDA Home and Garden Bulletin No. 72, Nutritive Value of Foods. a Food sources of vitamin C ranked by milligrams of vitamin C per standard amount; also calories in the standard amount. (All provide  20% of RDA for adult men, which is 90 mg/d).

Signs of Excess. GI distress and diarrhea are most common.


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A

P

P

E

N

D

I

Dietetic Process, Forms, and Counseling Tips

INTRODUCTION TO THE PRACTICE OF DIETETICS The American Dietetic Association (ADA) is responsible for establishing the expectations for required education, practice guidelines, and standards of professional performance for dietetic professionals. The Commission on Dietetic Registration maintains credentialing authority for the roles of Registered Dietitian (RD) and Dietetic Technician Registered (DTR). A scope of practice framework can be used to assist dietetic professionals in defining their responsibilities and refining practice according to professional job analyses that are conducted every few years. Dietitians and dietetic technicians work in a variety of settings but tend to be concentrated in healthcare settings: acute care, long-term care, dialysis units, psychiatric facilities, community sites, and home health. They perform a variety of tasks including clinical services, food systems management, nutrition education, and public health functions. See Figure B-1. There are over 59 core dietetics position descriptions including not only the roles of traditional clinical dietitian;

20%

41% 8%

30% Self-employed Nonprofit

29% Government For-profit

Figure B-1 Employment sector of dietetics practitioners (n  8115) (Image courtesy of Compensation & Benefits Survey of the Dietetics Profession 2009.)

X

B

outpatient dietitian; or Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) nutritionist but also covering areas such as consulting, sales, and communications. Generally, dietetics professionals aim to improve the health of their clientele by influencing their food and nutrition decisions. Many dietetics practice groups have now established standards of practice that are specific to their area of expertise. The following guidelines are useful in consideration of an effective practice in dietetics. 1. Standards from The Joint Commission and other organizations set the expectation that quality care will lead to positive outcomes. Effective leadership and continuous performance improvement are critical for maintaining quality. 2. Regulations, such as those from the Centers for Medicare and Medicaid Services (CMS), have been written to protect vulnerable patients/residents from inadequate care. For example, in long-term care, the F325 tag related to §483.25 Nutrition states that, based on a resident’s comprehensive assessment, the facility must ensure that a resident (1) maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident’s clinical condition demonstrates that this is not possible; and (2) receives a therapeutic diet when there is a nutritional problem. All of the guidelines and directives are to be followed by dietitians and their supporting staff members accordingly. 3. Most dietitians work in settings that are supportive of interdisciplinary teamwork. Dietitians must be proactive, take on new skills, and overcome traditional stereotypes. The roles are expanding, for example, in bariatric surgery, in functional medicine, and in home care. 4. Many dietetics positions now include enhanced responsibilities in nutritionally focused physical assessment, certification in cardiopulmonary resuscitation, assessment for the use of adaptive feeding equipment, worksite wellness, swallowing evaluations, exercise prescription and education, functional nutrition assessments, and home care services. 5. For basic nutrition education, advice can be provided by many healthcare professionals. However, medical nutrition

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therapy (MNT) is an intensive approach to the nutritional management of chronic disease and requires significantly more education in food and nutrition science than is provided by other professional curricula. The RD is the single identifiable healthcare professional to have the most standardized education, supervised clinical training, and national credentialing, who meets the continuing education requirements for reimbursement as a direct provider of MNT. 6. State licensure laws protect the public from unscrupulous practices. Each licensure board establishes a relevant scope of practice for dietitians and nutritionists who practice in that state. Scopes of practice detail what can or cannot be performed by a person using the title of dietitian or nutritionist. 7. Application of the American Dietetic Association’s Nutrition Care Process with standardized terminology enables dietitians to perform at a higher level of comprehensive care than in the past. See Figure B-2. 8. The best patient care emphasizes coordinated, comprehensive care along the continuum of the healthcare delivery system. Multidisciplinary teams are best suited to develop, lead, and implement evidence-based disease management programs. Evidence-based care integrates research into practice, regardless of the setting. Indeed, research is the basis of the profession (Pavlinac, 2010). 9. Dietitians must take an evidence-based approach to care based on their education, training, skill level, and work experiences. Science and evidence-based education can help to overcome dangerous perceptions of consumers or misunderstandings by members of the medical community (Krebs and Primak, 2006). 10. Unique nutritional care guidelines should be used in specialty areas such as cancer, diabetes, cardiology and

Assessment

Monitoring & Evaluation

NUTRITION CARE PROCESS

Intervention

Figure B-2

Diagnosis

pulmonary, gastroenterology, geriatrics, HIV-AIDS, liver disease, nutrition support, pancreatic disease, renal failure, surgical or transplantation units, intensive care, and functional nutrition therapy. See Figure B-3 for the Functional Medicine Matrix Model™ that was used as part of a holistic assessment format. 11. Medical classification systems are used for a variety of purposes including statistical analyses, reimbursement, decision-support systems, and procedures. 12. Diagnostic-related groups (DRGs) classify hospital cases into similar categories for reimbursement, assuming a similar use of resources. In 2007, Medical Severity DRG (MS-DRG) codes were added to enhance payment for conditions that involve greater morbidity or risk for mortality. In 2008, Hospital Acquired Condition (HAC) was described, and some conditions were no longer considered to be complications if they were not present upon admission (POA). 13. Use correct nutrition diagnosis nomenclature for malnourished adults in clinical practice settings: “starvationrelated malnutrition” when there is chronic starvation without inflammation; “chronic disease–related malnutrition” when a mild to moderate inflammation is chronic; and “acute disease or injury–related malnutrition” for acute, severe inflammation ( Jensen et al, 2009). 14. For the coding of malnutrition in the medical record, use ICD-9 code 262. 15. Sentinel events are defined by The Joint Commission as unexpected occurrences leading to serious physical or psychological injury or death. The risk for a sentinel event requires an immediate investigation and response. Issues such as changes in functional status, the severity of a nutrition diagnosis, unintended weight changes (10% in 6 months), and changes in body composition such as the loss of subcutaneous fat are risks that should be examined. 16. Order-writing privileges by dietitians allow orders for nutritional prescriptions for enteral and parenteral nutrition to be implemented quickly and effectively. Order-writing must be established by the local facility with medical staff approval. 17. Age-specific competencies are needed to serve various populations. For example, children and adolescents require different meal plans and interventions from those for adults (Stang et al, 2006). Residents in longterm care facilities may need extra time and attention (Simmons and Schnelle, 2006). Individuals on nutrition support require monitoring while using age-specific guidelines (Durfee et al, 2006). 18. Evaluation of outcomes is significant. Customer satisfaction must meet or exceed basic patient expectations. Health-related quality of life (HRQL) is another important outcome measure. For example, the quality of life and nutritional status of older residents in long-term care facilities may be enhanced by a liberalization of diet prescriptions and person-centered care. This care involves residents in decisions about schedules, menus, and dining locations; weight loss, undernutrition, and other effects of poor nutrition and hydration are then decreased (Neidert, 2005).


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Functional Medicine Matrix ModelTM Oxidative/Reductive Homeodynamics

Immune Surveillance and Inflammatory Process

Detoxification and Biotransformation The Patient’s Story Retold ANTECEDENTS (predisposing)

Hormone and Neurotransmitter Regulation

Digestion and Absorption TRIGGERING EVENTS (activation)

Psychological and Spirtual Equilibrium

Structural/Boundary/ Membranes

Nutrition Status

Date:

Name:

Exercise

Sleep

Age:

Beliefs & Self-Care

Sex:

Relationships

Chief Complaints:

© Copyright 2008 Institute for Functional Medicine

Figure B-3 Used with permission from The Institute for Functional Medicine.

19. Ongoing review is needed to monitor progress. Difficulty in obtaining current laboratory values makes it hard to follow patient outcomes after discharge. With electronic medical records and careful maintenance of confidentiality, monitoring can be more effective. 20. Dietetics professionals are likely to advance to management positions, such as food service director, consultant, or patient case manager, because they possess strong nutrition knowledge and management skills. Nearly half of all RDs and DTRs supervise other employees (Ward, 2010). 21. Having supervisory responsibility is strongly associated with higher wages (Ward, 2010). In addition, having a masters degree or PhD and one or more specialty certifications (e.g., CDE, CNSD, and the various Certified Specialist credentials offered by the Commission on

Dietetic Registration) leads to an increased median wage (Ward, 2010). 22. Food and nutrition managers are in opportune positions to influence other managers, acquire resources, identify opportunities, and achieve desirable outcomes. 23. Levels of responsibility tend to increase with years of experience and with business skills such as leadership, marketing, and negotiation. Dietitians are encouraged to include management and leadership development as part of their continuing education portfolio.

REFERENCES Durfee SM, et al. Standards for specialized nutrition support for adult residents of long-term care facilities. Nutr Clin Pract. 21:96, 2006.


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Jensen GL, et al. Adult starvation and disease-related malnutrition: a proposal for etiology-based diagnosis in the clinical practice setting from the International Consensus Guideline Committee. Clin Nutr. 29:151, 2009. Krebs NF, Primak LE. Comprehensive integration of nutrition into medical training. Am J Clin Nutr. 83:945S, 2006. Neidert K. Position of the American Dietetic Association: liberalization of the diet prescription improves quality of life for older adults in long-term care. J Am Diet Assoc. 105:1955, 2005. Pavlinac JM. Research is the foundation of our profession. J Am Diet Assoc. 110:499, 2010. Simmons SF, Schnelle JF. Feeding assistance needs of long-stay nursing home residents and staff time to provide care. J Am Geriatr Soc. 54:919, 2006. Stang J, et al. Position of the American Dietetic Association: child and adolescent food and nutrition programs. J Am Diet Assoc. 106:1467, 2006. Ward B. Compensation & benefits Survey 2009: despite overall downturn in economy, RD and DTR salaries rise. J Am Diet Assoc. 110:25, 2010.

NUTRITION CARE PROCESS, FORMS, AND DOCUMENTATION TOOLS The nutrition care process involves four steps and a comprehensive understanding of factors related to nutritional intake. Following a thorough nutrition assessment with patient history and current status, identify key problems (nutrition diagnoses). Use the latest edition of the nutrition diagnostic language from the American Dietetic Association, which is available to members at http://www.eatright.org/Members/ content.aspx?id5477. Write a PES statement (problem, etiology, and signs and symptoms) for each problem. Determine the plan of care, with intervention goals and actions, designed according to the etiology of the problem. Finally, plan how monitoring and evaluation will occur. The final

TABLE B-1

step should be measurable and should be related to the identified signs and symptoms. Sample tools and forms are provided here; all tools should be adapted for the facility and for the age and complexity of patients in the population. Table B-1 provides a sample scope of practice policy. Table B-2 provides a nutrition intake history form for adults. Table B-3 lists the advantages and disadvantages of different forms of nutrition histories. Table B-4 provides a physical assessment checklist. Table B-5 shows a method for estimating energy requirements in adults. Table B-6 shows a method for estimating protein requirements in adults. Table B-7 provides a sample pediatric nutrition assessment tool. Table B-8 provides a chart that lists the biochemical analyses used in nutritional assessments. Table B-9 provides a summary of food–drug interactions. Table B-10 provides a sample worksheet for using the nutrition care process. Table B-11 is a form for a clinical case review and for audit purposes. Table B-12 provides tips for adult education and counseling. Table B-13 describes various health promotion intervention models. Table B-14 provides sample monitoring and evaluation audits for patient education.

Sample Hospital Nutrition Department Scope of Services

PURPOSE In order to provide care consistent with the mission of the hospital system, the nutrition department has defined its scope of services and goals. POLICY It is the policy of the hospital system for each department to provide care and/or services based on the defined scope of services and goals and to implement policies and procedures based on the scope of services and goals. DEPARTMENT MISSION The nutrition department commits itself to enhancing the quality of life throughout the patient’s life cycle and promoting and restoring health through the provision of quality nutritional care services in an environment that ensures dignity and respect for each person. The nutrition department has an obligation to ensure continuous quality improvement in the care and services it provides. PROCEDURE Care/Services Provided The department provides timely nutrition assessment, monitoring, counseling, education, discharge planning, and diet instruction, as defined in

department policies, to meet the needs of patients’ various backgrounds, which affect nutritional preferences and habits. Administration evaluates the activities of the department with regard to the provision of quality dietary intervention, patient treatment and outcomes, and the quality of meal service. Types of Patients/Customers Served Nutrition services are available for all segments of the hospital population—newborn, infant, child, adolescent, adult, and geriatric— including outpatient services, cardiopulmonary rehabilitation, emergency department, corporate wellness, and community events. Timeliness Clinical dietitians are scheduled for Monday through Saturday, with shift availability at all meal periods. One dietitian is scheduled for weekend coverage; Sunday coverage is an on-call assignment. When appropriate, formula calculations, calorie counts or nutrient analyses, and basic nutrition assessments can be completed via the computer system and any telephone within the system to facilitate timely treatments. STAFFING The clinical nutrition manager sets a staffing plan to meet the needs of the patient population. A staffing assessment is completed every 2 years or when deemed necessary. Dietitian schedules are prepared in advance, including hours of duty and on-call schedules.

(continued)


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TABLE B-1

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Sample Hospital Nutrition Department Scope of Services (continued)

STAFF CREDENTIALS AND REQUIREMENTS

STANDARDS OF CARE

Dietitians are registered through the Commission on Dietetic Registration; each must maintain their registration through continuing education. The education requirement is 75 hours during each 5-year period. Competency standards are developed, updated, and reviewed regularly by the clinical nutrition manager to meet the specific, changing needs of the facility.

Clinical dietitians apply the hospital-approved standards of nutrition care and the evidence-based guidelines of the American Dietetic Association.

ASSIGNMENTS

All inpatients are screened by the nursing department within 24 hours of admission to determine the need for further nutrition assessment. Clinical dietitians develop the screening triggers, which are approved by the medical staff. Patients receive nutrition intervention based on the priority/acuity levels assigned by the dietitians. The clinical dietitians perform subsequent re-screening according to policy and regulatory guidelines.

Full-time equivalents of clinical dietitians are assigned to patient care and ambulatory clinics. One full-time equivalent of a clinical nutrition manager leads the clinical/outpatient staff. Staff are assigned to community education programs upon request and scheduling allows. Based on the daily census and acuity, clinical and outpatient dietitians may adjust the daily staffing pattern to meet needs according to changes in patient acuity.

Priority for Nutrition Services Definitions/Indications

SCREENING

High Priority

Moderate Priority

Low Priority

Nutrition interventions that warrant frequent comprehensive patient reassessment to document the impact of the intervention on critical nutrition outcomes, medical status (i.e., labs, GI tolerance, etc.), and/or clinical progress.

Nutrition interventions that warrant early evaluation, which can be sufficiently tracked via brief f/u notes. Less frequent comprehensive patient reassessment is needed.

Nutrition interventions that bring closure and/or immediately resolve a patient’s nutrition diagnosis/problem OR when no nutrition intervention is needed. F/U is expected in the form of rescreening with reassessment as indicated by a change in status.

Examples: New or modified EN/PN or use of medical food supplements. Comprehensive nutrition education or counseling.

Examples: Stable EN or PN. Brief nutrition education for survival skills. Coordination of care.

Examples: Brief nutrition education. No nutrition diagnosis. Palliative care only.

Plan of care review standard

Update POC when reassessing patient.

Within 5 days, based on a brief chart review, communication w/ other patient care providers as appropriate and patient contact. State the nutrition diagnosis, response to intervention, and the new or modified plan.

Per rescreening standards

Reassessment standard

Within 3 days

Within 7 days

Per rescreening standards

ASSESSMENT AND NUTRITION DIAGNOSES

INTERVENTIONS: FOOD AND NUTRIENT DELIVERY

The clinical dietitians assess patients using the guidelines in the standards of care approved by the medical staff. Following the profession’s nutrition care process, a nutrition diagnosis is established as needed. The etiology of the diagnosis selected determines the type and extent of intervention that will be provided. The most common nutrition diagnoses in this facility are as follows:

According to the patient’s ability to take in sufficient energy, protein, carbohydrate, fat, vitamins, minerals and water, the clinical dietitian will approve or recommend alterations in the nutrition prescription, the addition or discontinuation of enteral/parenteral nutrition, and the use of specific supplements or bioactive substances (e.g., fish oil, lycopene, lutein, ginger, and multivitamin–mineral supplements).

Inadequate oral food/beverage intake (NI-2.1) Inadequate protein-energy intake (NI-5.3) Increased nutrient needs (NI-5.1) Evident malnutrition (NI-5.2) Inadequate energy intake (NI-1.4) Swallowing difficulty (NC-1.1) Involuntary weight loss (NC-3.2) Inadequate intake from enteral/parenteral nutrition (NI-2.3) Food and nutrition-related knowledge deficit (NB-1.1) Underweight (NC-3.1) Overweight/obesity (NC-3.3) Excessive energy intake (NI-1.5)

Most common food–nutrient delivery interventions in this facility are as follows: General/healthful diet (ND- 1.1) Commercial beverages (ND-3.1.1) Initiate EN or PN (ND-2.1) Modify rate, concentration, composition or schedule (ND-2.2) Modify distribution, type, or amount of food and nutrients within meals or at specified times (ND-1.2) Modified beverages (ND-3.1.3) Modified food (ND-3.1.4) Multivitamins/minerals (ND-3.2.1) Nutrition-related medication management (ND-6.1)

(continued)


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TABLE B-1

Sample Hospital Nutrition Department Scope of Services (continued)

INTERVENTIONS: EDUCATION The clinical dietitian performs a nutrition education needs assessment to determine patient/family knowledge and skill level. The patient’s age, barriers to learning, assessed needs, abilities, readiness, and length of stay will determine the level of education to provide. Because lifestyle factors, financial concerns, patient/family expectations, and food preferences affect the individualized education plan, most patients will be referred to ambulatory clinics if extensive education is required to resolve a nutrition diagnosis. The most common education intervention in this facility is Nutrition Education—Survival Information (E-1.3). INTERVENTIONS: COUNSELING The clinical dietitian provides individualized guidance and nutritional advice to the patient and/or family members. Techniques to promote behavioral change are used, as appropriate, and documented accordingly. Readiness to change is noted. Follow-up counseling includes an evaluation of the effectiveness of counseling given and recommendations for additional follow-up. There are no specific counseling interventions most often noted for the in-patient setting; this type of intervention is handled in the ambulatory clinics. INTERVENTIONS: COORDINATION OF CARE The clinical dietitians participate in both weekly and patient care meetings on assigned units. Discharge planning needs are identified throughout the assessment, re-assessment, and education processes. These needs are referred to the social worker or case manager and communicated to the team during meetings. The dietitian communicates with the referring agency, facility, or next dietitian provider when a specialized care plan is needed. The most common coordination of care interventions in this facility are as follows: Team meeting (RC-1.1) Referral to an RD with different expertise (RC-1.2) Collaboration/referral to other providers (RC-1.3)

2. Provide timely nutrition therapy, which results in measurable improvements to patient health from the time of admission to the time of discharge from therapy. Dietitians will follow outcomes of therapy via objective measures (e.g., weight, verbalization of learning, and blood glucose improvements) and chart them in their documentation. 3. Ensure that outpatient medical nutrition therapy and diabetes education programs, combined, will break-even financially. Billing and accounts receivable will be monitored by the program coordinator. Two or three free community education nutrition programs will be offered yearly to local county residents. 4. Ensure that patients will indicate 90% satisfaction rating with their inpatient nutrition care and ambulatory services. 5. Review and administer the expanded dietitian scope of practice for those staff members who have demonstrated competency and have certification (where available) in their specialty area. EXPANDED SCOPE OF PRACTICE Because malnutrition is a key factor in determining the prognosis of a patient, protein, energy, vitamin and mineral deficiencies can be detected and corrected earlier through a better utilization of RD skills by assigning order-writing and prescribing privileges to the qualified dietitian specialists on staff. Prescribing authority boosts patient satisfaction by offering quicker interventions, reduces costs with shorter lengths of stays, improves nutrition outcomes, and promotes greater professional satisfaction by those qualified dietitians. Currently, there are three levels of prescriptive authority for dieticians, which are implemented in healthcare facilities and defined as follows: •

MONITORING AND EVALUATION The clinical dietitian selects the appropriate measures to monitor and evaluate the effectiveness of interventions. The top nutrition monitors used in this facility are as follows: Total energy intake (FI-1.1) Enteral/Parenteral nutrition intake formula/solution (FI-3.1.2), initiation (FI-3.1.4), rate/schedule (FI-3.1.5) Nutrition physical exam findings: skin (S-3.1.6), gastrointestinal (S-3.1.3) Weight/weight change (S-1.1.4)

DEPARTMENT GOALS In support of the hospital mission to provide high-quality healthcare through continuous improvement and to exceed the expectations of patients and customers, the clinical nutrition staff of the food and nutrition department have the following goals: 1. Staff qualified, progressive Registered Dietitians who exceed baseline knowledge proficiency standards set by the American Dietetic Association. To accomplish this, all Registered Dietitians must set annual professional development goals on their performance evaluations. These goals are supported by the clinical nutrition manager, funded by Food and Nutrition Services, and tracked through the professional development portfolio of the Commission on Dietetic Registration (CDR).

No prescriptive authority: RDs recommend supplements, diets or diet changes, nutrition-related tests, or procedures to the physician. Recommendations may be written in the medical record or discussed with the physician, but a physician must write an order before recommendations are implemented. Dependent prescriptive authority: RDs have the authority to order diets, nutritional supplements, nutrition-related tests, or procedures according to protocols, algorithms, policies, or preapproved criteria that specify the type and magnitude of change. Physician approval of the nutritional treatment is not required as long as the orders and treatments provided fall within the guidelines of the protocol, algorithm, policy, or criteria approved in advance by the appropriate institutional authority (e.g., patient-care committee, medical executive committee). However, the RD can discuss the nutritional care provided with the physician and document the order appropriately in the medical record. Independent prescriptive authority: The RD may act autonomously to provide nutritional services that include ordering diets, nutritionrelated tests, or procedures authorized by the clinical privileges granted to the practitioner by the appropriate institutional authority. Physician approval is not required; however, the RD can discuss the nutritional care provided with the physician and document the order appropriately in the medical record.

Steps for Expanded Nutrition Scope of Practice with Dietitian Order-Writing Privileges: • • • •

Evaluate state licensure laws. Investigate the level of prescriptive authority permitted at the facility. Assure that current licensure and board certifications are accurate in the staff database. Discuss plans with each RD staff member with regard to credentialing, graduate study, fellowships, and other measures of basic and continuing competency. (continued)


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TABLE B-1 •

Sample Hospital Nutrition Department Scope of Services (continued)

When RDs are allowed to have complete order-writing privileges, patient care and outcome are better than they would be if a physician must first sign off on orders. • A literature review conducted on the clinical nutrition management list-serv noted that 42–57% of nutrition recommendations were actually put into action by the physician. • An average of 17 hours was required before orders were implemented by the MD. • Length of stay decreased by up to 5 days for patients who were given nutrition interventions earlier. Document success stories, cost savings, improved timeliness of care, shorter LOS than average related to early detection and intervention by the RD.

TABLE B-2

951

Detail the desired scope of dietetics practice using the ADA evidence analysis library, the appropriate standards of professional practice, and other evidence-based guidelines. Draft new nutrition policies and procedures. Define the desirable steps for expanded scope of practice (e.g., ordering nutrition-related lab tests; prescribing basic diet orders; changing therapeutic diet orders according to measures such as weight loss or gain, decreased functional ability, significant appetite change; developing standing orders for common nutrition problems and interventions; and writing or updating enteral/parenteral infusion orders). Construct an approval packet with letters of support for the nutrition committee to establish medical review/consent. When approved by the nutrition committee, obtain signatures from the executive board, chief of medical staff, director of nursing, and hospital director. Include the time period for the scope and a date of review.

Dietary Intake Assessment and Nutrition History

Methods for Assessing Dietary Intake

Advantages

Disadvantages

24-Hour Recall: An informal, qualitative method in which the patient recalls all of the foods and beverages that were consumed in the last 24 hours, including the quantities and methods of preparation.

Dietary information is easily obtained. It is also good during a first encounter with a new patient in which there are no other nutritional data. Patients should be able to recall all that they have consumed in the last 24 hours.

It is very limited and may not represent an adequate food intake for the patient. Data achieved using this method may not represent the long-term dietary habits of the patient. Estimating food quantities and food ingredients may be difficult, especially if the patient ate in restaurants.

Usual Intake/Diet History: This method asks the patient to recall a typical daily intake pattern, including amount, frequencies, and methods of preparation. This intake history should include all meals, beverages, and snacks. Include discussion of usual intake and lifestyle recall. This consists of asking the patient to run through a typical day in chronological order, describing all food consumption as well as activities. This method is very helpful because it may reveal other factors that affect patient’s nutritional and overall health.

This method evaluates long-term dietary habits and is quick and easy to do. Components usually include the following:

A limited amount of information on the actual quantities of food and beverages is obtained. Also, this method only works if a patient can actually describe a “typical” daily intake, which is difficult for those who vary their food intake greatly. In these patients, it is advisable to use the 24-hour recall method. Another disadvantage is that patients may not include foods that they know are unhealthy.

Ability to secure and prepare food Activity pattern Alcohol or illicit drug use Appetite Bowel habits—diarrhea, constipation, steatorrhea Chewing/swallowing ability Diet history—usual meal pattern Disease(s) affecting use of nutrients Food allergies/intolerances Medications Nausea or vomiting NPO status or dietary restrictions Pain when eating Satiety level Surgical resection or disease of the GI tract Taste changes or aversions Vitamin/mineral or other nutritional supplements Weight changes

(continued)


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TABLE B-2

Dietary Intake Assessment and Nutrition History (continued)

Methods for Assessing Dietary Intake

Advantages

Disadvantages

Food Frequency Questionnaire: This method makes use of a standardized written checklist where patients check off the particular foods or type of foods they consume. It is used to determine trends in patients’ consumption of certain foods. The checklist puts together foods with similar nutrient content, and frequencies are listed to identify daily, weekly, or monthly consumption.

It is possible to identify inadequate intake of any food group so that dietary and nutrient deficiencies may be identified. The questionnaire can be geared to a patient’s pre-existing medical conditions.

Patient error may occur in filling out how foods are prepared. Patients may over- or underestimate food quantities.

Dietary Food Log: Patient records all food, beverage, and snack consumption for a 1-week period. Specific foods and quantities should be recorded. The data from the food log may later be entered into a computer program, which will analyze the nutrient components of the foods eaten according to specific name brands or food types. Patients are asked to enter data into the food log immediately after food is consumed.

A computer can objectively analyze data obtained. Data on calorie, fat, protein, and carbohydrate consumption can be obtained. Also, since patients are asked to enter data immediately after eating, the data are more accurate than other methods.

Patients may err in entering accurate food quantities. In addition, it is possible that the week-long food log does not accurately represent a patient’s normal eating habits since he or she knows that the foods eaten will be analyzed, and thus, he or she may eat healthier for that week.

TABLE B-3

Adult Nutrition History Questionnaire

Patient Name ______________________________________________ Date__________ 1. Height ______feet ______inches 2. How much weight have you gained or lost in the past month? ____ 3 months? ____ 1 year? ________ Present weight ________ BMI _______ Usual weight ________ Desirable weight for height _____ 3. Have you ever had problems with your weight? Overweight Underweight Comment:__________________ 4. Describe your eating habits: Good Fair Poor 5. How often do you skip meals? Daily Seldom Never 6. Describe your appetite recently: Hearty Moderate Poor 7. If you snack between meals, describe your typical snack ________________ How often? ______ 8. When you chew your food, do you have problems or take a long time? Yes No 9. Do you wear dentures at mealtime? Yes No. If yes, do they fit comfortably? Yes No 10. List the vitamin/mineral supplements/herbs and botanicals you take:__________________ 11. How many alcoholic drinks do you consume in a day? None 1–2 drinks More than 2 drinks 12. Describe foods you DO NOT tolerate: ________________________ Why? _____________________ 13. List foods that you especially dislike:_______________________________________ 14. List your favorite foods:____________________________________________________ 15. List foods that you are ALLERGIC to: ______________What symptoms do you experience? ______ 16. What type of modified diet do you follow? __________ What types in the past? _______________ Who prescribed or suggested this diet for you? Doctor Friend Self-selected 17. How many meals do you eat at home each week? _____ at school(s)? ____ in restaurants? ____ 18. What is your current occupation? ____________________________ 19. How active are you on a daily basis? Sedentary ___ Moderate ___ Active ____


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TABLE B-3

Adult Nutrition History Questionnaire (continued) Usual Daily Intake

Time

Meal

Food/Method of Preparation

Amount Eaten

RD Calculations

Morning Snack Noon Snack Dinner Snack During the night

24-Hour Diet Recall Form Please be as specific as possible. Include all beverages, condiments, and portion sizes. Time

Food Item and Method of Preparation

Amount Eaten

Dietitian Comments: Calculations: Estimated energy needs: ___kcal/kg Est protein needs: ___g/kg Est fluid needs: __ml/kg Signed: __________________________________RD Date:_______________

Where

953


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TABLE B-4

Physical Assessment for Clinical Signs of Malnutrition

Certain risk factors and signs of nutrient deficiency or excess can be identified during the physical examination. One sign is rarely diagnostic; the more signs present, the more likely it is that they reflect a malnourished individual. Nutrient

Physical Signs of Deficiency

Nutrient

Energy

Severe undernutrition, emaciation

Niacin

Protein

Dull, dry depigmented hair; easily pluckable

Tremors

Edematous extremities

Sore tongue

Poor wound healing; pressure ulcers

Skin that is exposed to sunlight develops cracks and a scaly form of pigmented dermatitis

Pneumonia Carbohydrate Fat

Vitamin B6

Loss of subcutaneous fat

Vitamin K Thiamin

Fissures in the corners of the mouth Folate

Weakness, fatigue, and depression Pallor

Hair follicle blockage with a permanent “goose-bump” appearance

Dermatologic lesions

Dry, rough skin

Vitamin B12

Small, grayish, foamy deposits on the conjunctiva adjacent to the cornea

Vitamin C

Lemon-yellow tint to the skin and eyes Smooth, red, thickened tongue Impaired wound healing

Drying of the eyes and mucous membranes

Edema

Small hemorrhages in the skin or mucous membranes Prolonged bleeding time

Swollen, bleeding, and/or retracted gums or tooth loss; mottled teeth; enamel erosion

Weight loss

Lethargy and fatigue

Muscular wasting

Skin lesions

Occasional edema (wet beriberi) Malaise

Small red or purplish pinpoint discolorations on the skin or mucous membranes (petechiae)

Tense calf muscles

Darkened skin around the hair follicles Corkscrew hair

Distended neck veins Jerky eye movement

Chromium

Corneal lesions

Staggering gait and difficulty walking

Copper

Hair and skin depigmentation Pallor

Infants may develop cyanosis

Riboflavin

Tongue inflammation Inflammation of the lining of the mouth

Skin rashes Dry, flaky skin

Vitamin A

Dermatitis or skin eruptions

May also show signs of riboflavin deficiency

Irritability, fatigue Respiratory or neurological changes

Physical Signs of Deficiency

Round, swollen (moon) face

Iodine

Goiter

Foot and wrist drop

Iron

Skin pallor Pale conjunctiva

Tearing, burning, and itching of the eyes with fissuring in the corners of the eyes

Fatigue

Soreness and burning of the lips, mouth, and tongue

Thin, concave nails with raised edges

Cheilosis (fissuring and/or cracking of the lips and corners of the mouth)

Magnesium

Tremors, muscle spasms, tetany

Purple swollen tongue

Potassium

Severe hypertension

Seborrhea of the skin in the nasolabial folds, scrotum, or vulva Capillary overgrowth around the corneas

Personality changes Arrhythmias Zinc

Delayed wound healing Hair loss Skin lesions Eye lesions Nasolabial seborrhea Pressure ulcers

Adapted from: Halsted C, et al. Preoperative nutritional assessment. In Quigley E, Sorrell M, eds. The gastrointestinal surgical patient: preoperative and postoperative care. Baltimore: Williams & Wilkins, 1994; pp. 27–49.


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TABLE B-5

955

Calculation of Adult Energy Requirements

For adults, body mass index is a useful guide. BMI  Weight (kg)/Height 2 (m) [Where 1 kg  2.2 lb; 1 in  2.54 cm] or [Weight (lb)  705/Height (in)]. Basal metabolic rate (BMR) or basal energy expenditure (BEE) is energy expenditure at rest. It involves energy required to maintain minimal physiological functioning (i.e., heart beating, breathing). Various methods are used to determine BEE and energy needs. Resting energy expenditure (REE) includes specific dynamic action for digestion and absorption (slightly above basal) and is considered relatively equivalent to BEE in a clinical context. Factors affecting energy requirements and BMR include the following: 1. Age. Infants need more energy per square meter of body surface than any other age group. BMR declines after maturity. 2. 3. 4. 5. 6. 7.

Body Size. Total BMR relates to body size; large persons require more energy for basal needs and for activity. Body Composition. Lean tissue is more active than adipose tissue. Climate. A damp or hot climate often decreases BMR, and a cold climate increases BMR slightly. Hormones. Thyroxine increases BMR; sex hormones and adrenaline alter BMR mildly; low zinc intake may lower BMR. Fever. BMR increases by 7% for each degree above normal in Fahrenheit; 10% for each degree Centigrade. Growth. BMR increases during anabolism in pregnancy, childhood, teen years, and the anabolic phase of wound healing.

REE can be from normal to below normal in mild starvation, such as that which occurs in the hospital setting. Unplanned weight loss can affect morbidity and mortality. Problematic % weight change in adults is considered to be: 2% in 1 week, 5% in 1 month, 7.5% in 3 months,  20% in any period of time. 40% is incompatible with life. Indirect calorimetry is useful for the critically ill where the calculation of energy expenditure is measured by gas exchange (VO2 and VCO2 represent intracellular metabolism). However, note that the energy needs of critically ill or injured adults are lower than previously thought; estimates are based on body mass index (BMI) if indirect calorimetry is not available. Overfeeding can cause fluid overload, increased CO2 production, and hepatic aberrations. Defer weight repletion until a patient’s critical episode subsides; needs generally normalize again in 3–6 weeks. Feeding programs should support a patient being within 10–15 pounds of desirable BMI range. Use these guidelines: For Adults Overweight BMI 30

Sedentary (kcal/kg)

Moderate

Active (kcal/kg)

Critically Ill (kcal/kg)

20–25

30

35

15–20

Normal weight BMI 20–29

30

35

40

20–25

Underweight BMI 15–19

30

40

45–50

30–35 (continued)


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TABLE B-5

Calculation of Adult Energy Requirements (continued) Mifflin – St. Jeor Equation Sheet Weight^

Pounds 85 90 95 100 105 110 115 120 125 130 135 140 145 150 155 160 165 170 175 180 185 190 195 200 205 210 215 220 225

Height

Age

Kilograms

MSJ*

Feet and Inches

Inches

Centimeters

MSJ*

Years

MSJ*

38.64 40.91 43.18 45.45 47.73 50.00 52.27 54.55 56.82 59.09 61.36 63.64 65.91 68.18 70.45 72.73 75.00 77.27 79.55 81.82 84.09 86.36 88.64 90.91 93.18 95.45 97.73 100.00 102.27

386.36 409.09 431.82 454.55 477.27 500.00 522.73 545.45 568.18 590.91 613.64 636.36 659.09 681.82 704.55 727.27 750.00 772.73 795.45 818.18 840.91 863.64 886.36 909.09 931.82 954.55 977.27 1000.00 1022.73

4’ 9” 4’ 10” 4’ 11” 5’ 5’ 1” 5’ 2” 5’ 3” 5’ 4” 5’ 5” 5’ 6” 5’ 7” 5’ 8” 5’ 9” 5’ 10” 5’ 11” 6’ 6’ 1” 6’ 2” 6’ 3”

57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75

144.78 147.32 149.86 152.4 154.94 157.48 160.02 162.56 165.1 167.64 170.18 172.72 175.26 177.8 180.34 182.88 185.42 187.96 190.5

904.88 920.75 936.63 952.50 968.38 984.25 1000.13 1016.00 1031.88 1047.75 1063.63 1079.50 1095.38 1111.25 1127.13 1143.00 1158.88 1174.75 1190.63

70 72 74 76 78 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103

350 360 370 380 390 400 405 410 415 420 425 430 435 440 445 450 455 460 465 470 475 480 485 490 495 500 505 510 515

*REE for males  (MSJ weight  MSJ Height  MSJ age)  5 *REE for females  (MSJ weight  MSJ Height  MSJ age)  161 ^Always use actual body weight. Activity factor is 1.2 if confined to bed; 1.3 if ambulatory.

Body Mass Index (BMI) Weight (lb) Height 5’0” 5’1” 5’2” 5’3” 5’4” 5’5” 5’6” 5’7” 5’8” 5’9” 5’10” 5’11” 6’0” 6’1” 6’2” 6’3” 6’4”

100 20 19 18 18 17 17 16 16 15 15 14 14 14 13 13 12 12

105 21 20 19 19 18 17 17 16 16 16 15 15 14 14 13 13 13

110 21 21 20 19 19 18 18 17 17 16 16 15 15 15 14 14 13

115 22 22 21 20 20 19 19 18 17 17 17 16 16 15 15 14 14

120 23 23 22 21 21 20 19 19 18 18 17 17 16 16 15 15 15

125 24 24 23 22 21 21 20 20 19 18 18 17 17 16 16 16 15

130 25 25 24 23 22 22 21 20 20 19 19 18 18 17 17 16 16

135 26 26 25 24 23 22 22 21 21 20 19 19 18 18 17 17 16

140 27 26 26 25 24 23 23 22 21 21 20 20 19 18 18 17 17

145 28 27 27 26 25 24 23 23 22 21 21 20 20 19 19 18 18

150 29 28 27 27 26 25 24 23 23 22 22 21 20 20 19 19 18

155 30 29 28 27 27 26 25 24 24 23 22 22 21 20 20 19 19

160 31 30 29 28 27 27 26 25 24 24 23 22 22 21 21 20 19

165 32 31 30 29 28 27 27 26 25 24 24 23 22 22 21 21 20

170 33 32 31 30 29 28 27 27 26 25 24 24 23 22 22 21 21

175 34 33 32 31 30 29 28 27 27 26 25 24 24 23 22 22 21

180 35 34 33 32 31 30 29 28 27 27 26 25 24 24 23 22 22

185 36 35 34 33 32 31 30 29 28 27 27 26 25 24 24 23 23

190 37 36 35 34 33 32 31 30 29 28 27 26 26 25 24 24 23

195 38 37 36 35 33 32 31 31 30 29 28 27 26 26 25 24 24

200 39 38 37 35 34 33 32 31 30 30 29 28 27 26 26 25 24

205 40 39 37 36 35 34 33 32 31 30 29 29 28 27 26 26 25


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TABLE B-6

957

Calculations of Adult Protein Requirements

It requires 6.25 g of dietary protein to equal 1 g of nitrogen. Therefore, estimated nitrogen requirements  6.25  estimated protein needs in grams. If energy is not provided in adequate amounts, protein tissues become a substrate. Extra protein intake may be needed to compensate for excess protein loss in specific patient populations such as those with burn injuries, open wounds, and protein-losing enteropathy or nephropathy. Lower protein intake may be necessary in patients with chronic renal insufficiency who are not treated by dialysis and certain patients with hepatic encephalopathy. The following table provides an estimate for protein needs in adults. Clinical Condition

Daily Protein Requirement (g/kg body weight)

Normal

0.8

Metabolic stress (illness/injury)

1.0–1.5

Acute renal failure (undialyzed)

0.8–1.0

Hemodialysis

1.2–1.4

Peritoneal dialysis

1.3–1.5

Adapted from the American Gastroenterological Association. Medical position statement: parenteral nutrition. Gastroenterol. 121:966, 2001.

TABLE B-7

Pediatric Nutrition Assessment

Date of Birth _______________ Hx of LBW or other birth problems __________ Present Illness: _____________________ Medical History: _________________ Social History: __________________ Family Medical Hx: ______________________ Height (Length): ______(cm) Height for Age: _______(%ile) % Height for Age: ________ Interpretation: _______ Current weight: _______(kg) Weight for Age: _______(%ile) % Weight for Height: ______ Interpretation: _________ Ideal Weight for Height: _______(kg) Ideal Height for Age: ____(cm) Weight change? (days, weeks, or months) __________ Head circumference: ______(cm) ______(%ile) ______ (For children 3 years old, use the growth chart.) Review of Systems for Nutritional Deficiencies: General: _________________________________________________ Skin: ____________________ Hair: __________ Nails: ____________ Head: ________________ Eyes: _____________ Mouth: ____________ GI/Abdomen: ____________ Cardiac: ____________ Extremities: ____________ Neurological: __________ Musculoskeletal: _____________________ Laboratory Test Results: _____________________________________________________________________ Child allergic to any food or drinks? Yes / No If yes, allergic to what? _____________ Rash or eczema? Yes / No Does the child avoid any specific foods such as milk or meats? Yes / No If yes, which ones? ____________________ Does the child take any vitamins, minerals, or food supplements? Yes / No If yes, which? ___________ With fluoride Yes / No If not taking a vitamin, does the water supply contain fluoride? Yes / No Using formula? ________ How much given and how much water is added? ________ Put to bed with a bottle? Yes / No What type of milk? _____________ # ounces/day? ______ Other beverages during the day? Iced tea Soda Diet soda

Kool-aid

Juice

Water

Other _______

If eating foods, at what age were solids introduced into the diet? __________ How many meals are eaten during the day? ___ How many snacks are eaten during the day? ________________ What types? ________________ Does the child usually eat the food that is prepared for the family? Yes / No Does the child chew on any of the following: Dirt Clay Paint chips Woodwork Ice Plaster Newspaper How old is the house? Are there lead pipes? Yes / No Has the water been tested for lead? Yes / No Estimated energy needs: _____________ Protein needs: ___________ Fluid needs: ________________ Patient Age

Energy Requirements

Fluid

Infants, up to 6 months Infants, 6 months to 1 year Children

108 kcal/kg 98 kcal/kg Requirements increase to 102 kcal/kg from 1–3 years of age. Requirements gradually decrease with age to 70 kcal/kg at age 10. 45–55 kcal/kg male; 40–47 kcal/kg female

1–10 kg  100 cc/kg body weight 11–20 kg  1000 cc plus 50 cc/kg body weight 10 kg 21 kg  1500 cc plus 20 cc/kg body weight 20 kg

Adolescents

— Can use 30 cc/kg body weight; increase with fever, illness, diseases

Dietitian Comments: Calculations: Estimated energy needs: ___kcal/kg Estimated protein needs: ___g/kg Estimated fluid needs: __ml/kg Signed: __________________________________ RD Date: _______________ Adapted from: University of California, Los Angeles Nutrition Department. Pediatric Nutrition Assessment Checklist. Accessed April 8, 2010 at http://apps.medsch.ucla.edu/ nutrition/chklst2.htm.


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TABLE B-8

Interpretation of Lab Values

Many lab tests can provide useful information on patients’ nutritional status along with information on their medical status. Age-specific criteria should be used to evaluate data. Common tests include the following. Allergy Antibody Assessment Allergy blood and skin testing C-reactive protein

Thyroxine (T4) Thyroid-stimulating hormone (TSH) Triiodothyronine (T3)

Helicobacter pylori Antibodies Test

Gastrointestinal System and Stool Tests

Immunoglobulins: IgG, IgM, IgA, IgD, and IgE; specific IgE for molds, IgG for spices and herbs

Bacterial overgrowth of small intestine breath test

Rheumatoid factor (RF)

Comprehensive digestive stool analysis Gastric analysis

Blood Chemistry and Renal Tests

Lactose intolerance breath test

Albumin

Parasitology assessment

Blood urea nitrogen (BUN)

Serum gastrin

Creatinine clearance Glomerular filtration rate (GFR)

Hepatic System

Nitrogen balance

Albumin, gamma-globulin, A-G ratio

Serum creatinine

Alanine aminotransferase (ALT)

Serum proteins, total protein

Aspartate aminotransferase (AST) Alkaline phosphatase (ALP)

Cardiopulmonary System

Ammonia

Arterial blood gases

Bilirubin

Cardiac enzymes

Gamma-glutamyl transpeptidase (GGT)

Creatine kinase

Hepatitis virus

Homocysteine

Prothrombin time (PT)

Lactate dehydrogenase, aspartate transaminase (AST)

Partial thromboplastin time (PTT)

Lipid profile: Cholesterol, lipoproteins, triglycerides

Total protein Urobilinogen

Celiac Assessment IgA-antitissue transglutaminase (tTG)

Musculoskeletal System

IgA-antiendomysial antibodies (IgA-EMA)

Alkaline phosphatase (ALP)

IgA-antigliadin antibodies (IgA-AGA)

Acid phosphatase Creatine phosphokinase (CPK)

Coagulation Tests

Enzymes, isoenzymes

Bleeding or coagulation time

Lactate dehydrogenase (LDH)

International normalized ratio (INR) Prothrombin time (PT)

Pancreatic Tests Serum amylase

Endocrine System Aldosterone Antidiuretic hormone

Serum lipase Red Cell Indices

Blood glucose

Carbon dioxide

C-peptide

Mean cell volume (MCV)

Calcium

Mean cell hemoglobin (MCH)

Calcitonin

MCH concentration

Glucose tolerance test (GTT)

Reticulocyte cell count

Insulin

Serum ferritin

Parathormone (PTH)

Serum iron and total iron-binding capacity

Phosphorus

Sodium, potassium, chlorine (continued)


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TABLE B-8

959

Interpretation of Lab Values (continued)

Vitamin and Mineral Assessment

Urinary System

Calcium

Physical observation: Color, clarity, odor

Zinc

Microscopic examination: Cells, casts, crystals, bacteria, yeast

Vitamin A

Urine volume

Vitamin C

Chemical tests: Specific gravity, pH, protein, glucose, ketones, blood, bilirubin, urobilinogen, nitrite, leukocyte esterase

Vitamin B6 Vitamin B12 Folate

Value

Normal Range

Purpose or Comment

Increased In

Decreased In

Since PT and INR evaluate the ability of blood to clot properly, they can be used to assess both bleeding and clotting tendencies. One common use is to monitor the effectiveness of blood thinning drugs such as warfarin (Coumadin). Anticoagulant drugs must be carefully monitored to maintain a balance between preventing clots and causing excessive bleeding.

A prolonged or increased prothrombin time means that blood is taking too long to form a clot.

Too much anticoagulation (warfarin, for example). Barbiturates, oral contraceptives, hormonereplacement therapy (HRT), and vitamin K (either in a multivitamin or liquid nutrition supplement) can decrease PT.

Hematology: Coagulation Tests and Bleeding Time Prothrombin time (PT), international normalized ratio (INR)

11–16 seconds control; 70–110% of control value Patients on anticoagulant drugs should have an INR of 2.0–3.0 for basic “blood thinning” needs. For some patients who have a high risk of clot formation, the INR needs to be higher—about 2.5–3.5.

Antibiotics, aspirin, and cimetidine can increase the PT/INR.

Beef and pork liver, green tea, broccoli, chickpeas, kale, turnip greens, and soybean products contain large amounts of vitamin K and can alter PT results if consumed in large amounts.

Hematology: Blood Cell Values Erythrocyte count (red blood cells [RBC])

4.5–6.2 million/mm3 in males; 4.2– 5.4 million/mm3 in females

Made in bone marrow; production controlled by erythropoietin.

Polycythemia, dehydration, severe diarrhea

Erythrocyte sedimentation rate

0–15 mm/hour in males; 0–25 mm/ hour in females

Sedimentation rate measures how quickly RBCs (erythrocytes) settle in a test tube in 1 hour. Often used with C-reactive protein (CRP) for testing of inflammation.

Inflammation, pneumonia, appendicitis, pelvic inflammatory disease, lymphoma, multiple myeloma, lupus, rheumatoid arthritis (RA), osteomyelitis, temporal arteritis

Ferritin

20–300 mg/mL in males; 20–120 mg/ mL in females

Chief iron storage protein in the body. Reflects reticuloendothelial iron storage. Usually 23% of total iron stores.

Hemochromatosis, leukemias, anemias other than iron deficiency, Hodgkin’s disease, liver diseases

Iron deficiency anemia

Folate, serum

0.3 g/dL (7 nmol/L)

Important for DNA functioning

Blind loop syndrome

Pregnancy, lactation, macrocytic anemia, intestinal malabsorption syndrome, alcoholism, use of goat’s milk in childhood, use of anticonvulsants, cycloserine, methotrexate, and oral contraceptives

Anemias such as vitamin B12, iron, folic acid, and protein; chronic infections; hemorrhage

(continued)


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TABLE B-8

Interpretation of Lab Values (continued)

Value

Normal Range

Purpose or Comment

Increased In

Decreased In

Iron, serum

75–175 mg/dL in males; 65–165 mg/ dL in females; 40–100 mg/dL in children up to 2 years old; 50–120 mg/dL in children 2 years.

Iron found in blood, largely in hemoglobin

Hemochromatosis, acute or chronic liver disease, hemolytic anemia, leukemia, lead poisoning, thalassemia, vitamin B12 or folate deficiency, dehydration, small bowel surgery

50 g/dL (9 mmol/L) may indicate iron deficiency anemia or blood loss.

Iron-binding capacity, total (TIBC)

240–450 mg/dL

Measure of the capacity of serum transferrin. 18–59% transferrin saturation is normal. As serum iron decreases, TIBC goes up, at least initially.

Iron deficiency, blood loss, later in pregnancy, oral contraceptive use, hepatitis, low serum iron, gastrectomy

High serum iron, renal disease, hemochromatosis, pernicious anemia, cancer, thalassemia, hemolytic diseases, small bowel surgery, sepsis, liver disease; may be low in malnutrition

Hematocrit (% packed cell volume)

40–54% in males; 37–47% in females; 33–35% in children; 37–49% in 12- to 18-year-old males; 36–46% in 12- to 18-year-old females

Cell volume % of RBCs in whole blood. Elevated when iron level is low.

Polycythemia

Anemias, prolonged dietary deficiency of protein and iron, sepsis, small bowel surgery, gastrectomy, renal or liver disease, blood loss

Hemoglobin, whole blood

14–17 g/dL in males; 12–15 g/dL in females; 10 g/ dL in babies 6–23 months old; 11 in children 2–5 years old; 11.5–15.5 g/dL in children 6–12 years old; 13.0–16.0 g/ dL in 12- to 18-year-old males; 12.0–16.0 g/dL in 12- to 18-year-old females

Oxygen carrier from lung to tissues. Binds CO2 on return to the lung.

Polycythemia, dehydration, hemolysis, sickle cell anemia, recent blood transfusions, chronic obstructive pulmonary disease (COPD), heart failure, high altitude, burns, dehydration

Anemias, prolonged dietary deficiency of iron, excessive bleeding, cancer, lupus, overhydration, Hodgkin’s disease, malnutrition, renal or liver disease, pregnancy, lead poisoning, sepsis, small bowel surgery, gastrectomy

Mean corpuscular hemoglobin (MCH)

26–32 pg; concentration is 32–36%

High concentration of individual RBCs (Hgb/RBC)

Macrocytic anemia

Hemoglobin deficiency, hypochromic anemia

Mean corpuscular volume (MCV)

80–94 cu/ m

Individual RBC size

High MCV or macrocytosis: folate, vitamin B12 deficiency. Alcoholic or liver disease, blood loss, hypothyroidism, small bowel surgery

Low MCV or microcytosis: iron, copper, pyridoxine deficiency.

Transferrin (siderophilin)

170–370 mg/dL (1.7–3.7 g/L)

Glycoprotein in blood plasma that transports iron to liver and spleen for storage and to bone marrow for hemoglobin synthesis

Iron deficiency, acute hepatitis, oral contraceptive use, pregnancy, chronic blood loss, dehydration, gastrectomy

Chronic diseases, pregnancy, cancer, end-stage renal disease (ESRD) or chronic renal disease, malnutrition or poor dietary intake, sickle cell disease, viral hepatitis, thalassemia

Thalassemia, anemia of chronic disease, cancer, blood loss Acute or chronic inflammation, chronic liver disease, lupus, zinc deficiency, sickle cell anemia, pernicious anemia with vitamin B12 or folate deficiency, chronic infection and inflammatory diseases, malnutrition, burns, iron overload, nephrotic syndrome, sepsis, small bowel surgery (continued)


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TABLE B-8

961

Interpretation of Lab Values (continued)

Value

Normal Range

Purpose or Comment

Increased In

Decreased In

White blood cells (WBC), leukocytes

4.8–11.8 thousand/mm3

Highly variable lab value; protect against disease or infection

Metabolic acidosis, acute hemorrhage, acute bacterial infections, leukemias, burns, gangrene, exercise, stress, eclampsia

Chemotherapy, ABT. Neutropenia is often seen in deficiency states. Some viral conditions, cachexia, anaphylactic shock, bone marrow suppression, pernicious or aplastic anemia, diuretic use

Hematology and Lymphatic System: Differential Lymphocytes

Total lymphocyte count (TLC)  normal, 12,000/ mm3; deficient, 900/mm3; 24–44% total WBC count

Made in thymus and lymph nodes; produce antibodies

Infectious mononucleosis, mumps, German measles, convalescence from acute infections

Infections, malnutrition

Leukocytes: basophils

0–1.5% total WBC count

They release substances that cause smooth muscle contraction, vasoconstriction, and an increased permeability of small blood vessels. Basophils are stimulated by allergens.

Postsplenectomy, chronic myelogenous leukemia, polycythemia, Hodgkin’s disease, chicken pox

Hyperthyroidism, acute infections,pregnancy, anaphylaxis

Leukocytes: eosinophils

0.5–4% total WBC count

Eosinophils are stimulated by parasites and some bacteria. They release substances that cause vasoconstriction, smooth muscle contraction, and an increased permeability of small blood vessels. Related to allergies.

Allergies, parasitic infections, pernicious anemia, ulcerative colitis, Hodgkin’s disease

Use of -blockers, corticosteroids; stress, and bacterial and viral infections including trichinosis

Leukocytes: monocytes

4–8% total WBC count

Phagocytosis. Produced in bone marrow.

Monocytic leukemia, lipid storage disease, protozoan infection, chronic ulcerative colitis

Leukocytes: neutrophils

60–65% total WBC count

Phagocytosis

Wound sepsis in burns, bacterial infections, inflammation, cancer, traumas, stress, diabetes, acute gout

Folate or vitamin B12 deficiency, sickle cell anemia, steroid therapy, postsurgical status

Platelets (thrombocytes)

125,000–300,000 mm3

Largely polysaccharides and phospholipids. Role in coagulation.

Malignancy, polycythemia vera, splenectomy, iron deficiency anemia, cirrhosis, chronic pancreatitis

Thrombocytopenic purpura

General Serum Values and Enzymes Amylase

60–180 Somogyi units/dL

Pancreatic enzyme for hydrolysis of starch and glycogen

Increased in perforated peptic ulcer, acute pancreatitis, mumps, cholecystitis, renal insufficiency, alcohol poisoning, partial gastrectomy

Decreased in hepatitis, severe burns, pancreatic disease, advanced cystic fibrosis, toxemia of pregnancy, hepatitis

Bicarbonate

22–28 mEq/L

Acid–base balance

Metabolic alkalosis, large intake of sodium bicarbonate, excessive vomiting, potassium deficiency, respiratory acidosis, emphysema

Diabetic acidosis, starvation, chronic diarrhea, renal insufficiency, respiratory alkalosis (hyperventilation), fistula drainage

(continued)


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TABLE B-8

Interpretation of Lab Values (continued)

Value

Normal Range

Purpose or Comment

Increased In

Decreased In

Bilirubin

Direct: 0.3 mg/dL; total: 1 mg/dL

Hemoglobin is converted to bilirubin when RBCs are destroyed.

Hepatitis, jaundice, biliary obstruction, drug toxicity, hemolytic disease, prolonged fasting

Seasonal affective disorder

Calcium

9–11 mg/dL (2.3–2.8 mmol/L); 3.9–5.4 mg/dL serum ionized

50% is protein bound, so protein intake affects serum calcium level more than dietary calcium. Regulated by parathormone (PTH) and thyrocalcitonin. Coma above 13 mg/ dL; death below 7 mg/dL.

Hyperparathyroidism, renal calculi, vitamin D excess, osteolytic disease, milkalkali syndrome, immobilization, tuberculosis, Addison’s disease, antibiotic therapy, cancer

Steatorrhea, renal failure, malabsorption, vitamin D deficiency, hypoparathyroidism, sprue, celiac disease, overhydration, hypoalbumenia, hyperphosphatemia

Ceruloplasmin

27–37 mg/dL

Form of copper found in the bloodstream

Leukemias, anemias, cirrhosis of the liver, hypo/hyperthyroidism, collagen diseases, pregnancy

Wilson’s disease, severe copper deficiency, nephrosis, leukemia remission, prolonged total parenteral nutrition (TPN) without copper, cystic fibrosis

Copper

70–140 g/dL in males; 80–155 g/ dL in females

Found bound to albumin or as ceruloplasmin

Leukemias, anemias, cirrhosis of the liver, hypo/ hyperthyroidism, collagen diseases, pregnancy

Wilson’s disease, severe copper deficiency, nephrosis, leukemia remission, prolonged TPN without copper, cystic fibrosis

Creatine phosphokinase (CPK)

0–145 IU/L

Catalyst for phosphorylation of creatine by adenosine triphosphate (ATP). Mostly found in skeletal and cardiac muscle. Increases 2–4 hours after myocardial infarction (MI), returning to normal after 3 days.

Hepatic or uremic coma, striated muscle disease, muscular dystrophy, MI, cerebrovascular accident (CVA), trauma, alcoholic liver disease, encephalitis

D-xylose,

30–40 mg/dL

This test measures the intestines’ ability to absorb D-xylose—a simple sugar—as an indicator of whether nutrients are being properly absorbed.

5–40 IU/L

GGT participates in the transfer of amino acids across the cellular membrane and in glutathione metabolism.

25-g dose

Gamma-glutamyl transpeptidase (GGT)

Used to detect diseases of the liver, bile ducts, and kidney and to differentiate liver or bile duct (hepatobiliary) disorders from bone disease.

Xylose malabsorption

Coronary heart failure (CHF), MI, cholecystitis, liver disease, alcoholism, hepatic biliary disease, pancreatitis, nephritic syndrome

Lactic acid dehydrogenase (LDH)

200–680 IU/mL

Catalyzes conversion between pyruvate and lactic acid in glycolytic cycle. Has 5 isoenzymes. Increases 8–10 hours after MI, returning to normal after 7–14 days.

Untreated pernicious anemia, acute MI, heart failure, malignancy, alcoholic liver damage, cardiovascular surgery, hepatitis, pulmonary embolus, leukemia, cancer, renal failure, hemolytic or megaloblastic anemia, muscular dystrophy, nephrotic syndrome

Lipase

0.2–1.5 IU/mL

Synthesized by the pancreas

Pancreatic disease, acute pancreatitis, perforated ulcer, pancreatic duct obstruction, biliary tract infection, renal insufficiency

Radiation therapy

(continued)


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APPENDIX B • DIETETIC PROCESS, FORMS, AND COUNSELING TIPS

TABLE B-8

963

Interpretation of Lab Values (continued)

Value

Normal Range

Purpose or Comment

Increased In

Decreased In

Phenylalanine, serum

3 mg/dL

An amino acid of importance in phenylketonuria (PKU) patients

Levels might be high in PKU

Severe protein deficiency and malnutrition

Phosphatase, acid

0.5–2 Bodansky units

A blood test that measures prostatic acid phosphatase (an enzyme found primarily in men in the prostate gland and semen) to determine the health of the prostate gland

Prostate dysfunction results in the release of prostatic acid phosphatase into the blood.

Phosphatase, alkaline (ALP)

2–4.5 Bodansky units (30–135 IU/L); children  3 that of adults

ALP is an enzyme found in all tissues. Tissues with particularly high concentrations of ALP include the liver, bile ducts, placenta, and bone. Indirect test for calcium, phosphorus, vitamin D nutriture. Used to determine the presence of liver or bone cell disorders.

Anemia, Paget’s disease, biliary obstruction, leukemia, hyperparathyroidism, rickets, bone disease, healing fracture

Malnutrition, protein deficiency

Sulfate, inorganic

0.5–1.5 mg/dL

Usual sulfur intake is 0.6–1.6 grams on a mixed diet containing 100 grams of protein.

Supplemental overdose; high sulfate intake from water supply

Protein deficiency; injury to the bones, cartilage, or tendons

Transaminase: aspartate aminotransferase (AST)

5–40 IU/mL

Found in the liver, muscle, and the brain. Functional measure of vitamin B6 nutriture. Released in tissue injury. Formerly SGOT (serum glutamic oxaloacetic transaminase).

Hepatic cancer, shock/ trauma, cirrhosis, neoplastic disease, MI

Uncontrolled diabetes mellitus; Beriberi

Transaminase: alanine aminotransferase (ALT)

4–36 IU/L

Found in the liver. Generally parallels AST levels. Functional measure of vitamin B6 nutriture. Formerly SGPT (serum glutamic pyruvic transaminase).

Hepatitis, cirrhosis, trauma, hepatic cancer, shock, mononucleosis

Wilson’s disease

Glucose, fasting serum

70–110 mg/dL (3.9–6.1 mmol/L)

Principle fuel for cellular function, particularly for the brain and RBCs.

DM, hyperthyroidism pancreatitis, MI, hyperfunction of endocrine, stress, CHF infection, surgery, CVA, hepatic dysfunction, cancer, Cushing’s syndrome, burns, steroids, chromium deficiency

Postprandial hypoglycemia, sepsis, cancer, malnutrition, hypothyroid, gastrectomy, liver damage or disease, Addison’s disease

Glucose tolerance test (GTT)

2-hour post load glucose 200 mg/dL

Test done when blood glucose levels are 120 mg/dL.

Diabetes, hyperthyroidism, pancreatic cancer, Cushing’s syndrome, acromegaly, pheochromocytoma.

Hypoglycemia, hypothyroidism, malabsorption, malnutrition, insulinoma, hypopituitarism

Glycosylated hemoglobin–HbA1 C

4–7% (nondiabetic); good, 9%; fair, 9–12%; poor, 12%

May reflect poor glucose control over the past 2–4 months

Poor blood sugar control, newly diagnosed diabetes, pregnancy

Low RBC (chronic blood loss, hemolytic anemia), chronic renal failure (CRF), sickle cell anemia

3.5–5 g/dL (35–50 g/L); 3.2–5.1 g/dL in infants up to 1 year old; 3.2–5.7 in children aged 1–2 years; 3.5–5.8 for ages 2 years to adult. Albumin is usually 40% of proteins.

Nonspecific protein nutriture measure. Mostly synthesized in the liver. Transports fatty acids, thyroxin, bilirubin, and many drugs. Albumin–globulin ratio (A:G) is 1.2–1.9; low in renal or liver diseases.

Dehydration, multiple myeloma

Decreased with inflammation and severity of illness, acute stress, starvation, malabsorption of protein, cirrhosis, nephritis with edema, liver disease, malnutrition

Glucose Control

Protein Factors Albumin

(continued)


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TABLE B-8

Interpretation of Lab Values (continued)

Value

Normal Range

Purpose or Comment

Increased In

Decreased In

C-reactive protein (CRP)

0

Elevated in inflammation

Systemic inflammation, obesity, diabetes, heart disease, arthritis, smoking

Vitamin C supplements may lower an elevated CRP. Marathon runners may have very low levels.

Creatinine

0.6–1.2 mg/dL

A basic creatine anhydride, nitrogenous end product of skeletal muscle metabolism. Indirect measure of renal filtration rate.

Hyperthyroidism, CHF, diabetic acidosis, dehydration, muscle disease, some cancers, nephritis, urinary obstruction

Overhydration, multiple sclerosis (MS), pregnancy, eclampsia, increased age, severe wasting

Creatinine–height index (CHI)

CHI  (measured 24-hour creatine excretion  100)/predicted 24-hour creatine excretion

Estimates skeletal muscle mass.

High doses of creatine supplementation

Marasmus, malnutrition

Globulin

2.3–3.5 g/dL

5 fractions; transport antibodies

Infections, leukemia, dehydration, shock, tuberculosis (TB), chronic alcoholism, Hodgkin’s disease

Malnutrition, immunological deficiency

Nitrogen balance

Goal of 1–4 g/24 hours urinary urea nitrogen (UUN)

Nitrogen balance is the result of nitrogen intake (from the diet) and nitrogen losses, which consist of nitrogen recovered in urine and feces and miscellaneous losses.

Severe liver disease

Nephrosis

Prealbumin (transthyretin)

16–35 mg/dL

Reflects the past 3 days of protein intake but is affected by inflammation

Renal failure, Hodgkin’s disease, pregnancy, dehydration

Acute catabolic states, hepatic disease, stress infection, surgery, low protein intake, malnutrition, hyperthyroidism, nephritic syndrome, overhydration, inflammation

Proteins, total serum

6–8 g/dL; 5.6–7.2 in infants to 1 year; 5.4–7.5 in children 1–2 years old; 5.3–8.0 in ages 2 years to adult

Amount of protein in the bloodstream. Reflects depletion of tissue proteins. Act as buffers in acid–base balance. Plasma proteins equal approximately 7% of total plasma volume.

Dehydration, shock

Hepatic disease, leukemia, malnutrition, infection, pregnancy, malabsorption, severe burns

Ascorbic acid (vitamin C)

0.2–2.0 mg/dL

Serum levels of vitamin C

Oxalate stones, diarrhea, high uric acid

Large doses of aspirin, barbiturates, stress, anemia, tetracycline, oral contraceptives, cigarette smoking, alcoholism, dialysis

Essential fatty acids (EFA) (triene to tetraene [T/T] ratio)

0.2 is normal; a ratio 0.4 in serum phospholipids indicates EFA deficiency in healthy people

Ratio 20:39/20:46 (T/T ratio) is measured. T/T ratios are assessed in RBCs, RBC phospholipids, and serum phospholipids.

Niacin: Nmethylnicotinamide

5.8 mol/d

For niacin assessment. Usual dietary intake is 16–33 mg/d.

Riboflavin: glutathione reductase, erythrocyte

1.2 IU/g hemoglobin

Dietary intake is related to CHO and total energy intake.

CHI values of 60–80% represent mild marasmus. CHIs of 40–59% represent moderate marasmus. CHIs of 40% represent severe marasmus.

Nutrient Values

EFA deficiency occurs in starvation, marasmus, and strict low-fat diets.

Large doses of nicotinic acid

Pregnancy, lactation, Hartnup disease, pellagra, schizophrenia Tetracycline or thiazide diuretic use, probenecid, oral contraceptives, sulfa drugs, pellagra, cheilosis, some forms of glossitis, vegetarians using no dairy products or supplements (continued)


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TABLE B-8

965

Interpretation of Lab Values (continued)

Value

Normal Range

Purpose or Comment

Increased In

Decreased In

Selenium: glutathione peroxidase

Serum enzyme levels

Works with vitamin E to protect RBCs as part of the enzyme.

Excessive lipid peroxidation

PCM, hypoproteinemia

Thiamin: transketolase activity, erythrocyte

1.20 g/mL/hr

Dietary requirements increase when CHO intake is high.

Use of baking soda in cooking, high CHO intake, infantile beriberi, dry or edematous (cardiac) beriberi, excessive intake of caffeic or tannic acids, pellagra, chronic alcoholism, lactic acidosis in metabolic disorders such as maple syrup urine disease (MSUD)

Vitamin B6: pyridoxal 5 phosphate, plasma

5 ng/mL (20 nmol/L)

Usual dietary intake is 2 milligrams, assuming 100 grams of protein is consumed.

Acute celiac disease, chronic alcoholism, pellagra, high protein intake, pregnancy, oral contraceptive use, isoniazid (INH) and other TB drug use, use of anticonvulsants, malarial drugs

Vitamin A: carotene; retinol, serum

48–200 mg/dL; 10–60 g/dL

Serum levels of carotenoids

Excessive intake, such as from carrots; postprandial hyperlipidemia; diabetes; hypothyroidism

High fever, liver disease, malabsorption syndrome

Retinol-binding protein

2.6–7.6 mg/dL

Used less often to determine status of retinol

May be high in renal failure

Protein deficiency

Serum vitamin A

125–150 IU/dL or 20–80 mg/dL

Hypervitaminosis A

Cirrhosis, infectious hepatitis, myxedema, night blindness, malabsorption, starvation, infections such as measles

Vitamin B12: serum B12

24.4–100 ng/dL (180 pmol/L)

Vitamin B12 is less well absorbed in the elderly and in persons who have less intrinsic factor or the ability to reabsorb in the intestines.

Leukemia such as acute myelogenous leukemia (AML) or CML, leukocytosis, polycythemia vera, liver metastasis, hepatitis, cirrhosis

Macrocytic anemia, iron or vitamin B6 deficiency, gastritis, dialysis, congenital intrinsic factor deficiency, pernicious anemia, tapeworm, ileal resection, strict vegetarian diets, pregnancy

Vitamin D: 1,25-HCC, blood

0.7–3.3 IU/dL

Indirect measures are available from serum alkaline phosphatase, calcium levels, and serum phosphorus.

Hypervitaminosis D

Rickets; osteomalacia; steroid therapy; fracture; poorly calcified teeth; drug therapy such as anticonvulsants, cholestyramine, and barbiturates

Vitamin E: alphatocopherol; plasma vitamin E

18 mol/g (41.8 mol/L); 0.5–2.0 mg/dL

Usual dietary intake is 14 milligrams of d-alphatocopherol

High vitamin E intake (this affects coagulation because it works against vitamin K)

High polyunsaturated fatty acid (PUFA) intake, premature infants, cystic fibrosis, hemolytic anemia

Vitamin K: INR or PT

PT, 10–15 seconds

Combined low levels of prothrombin activity, serum calcium, and serum carotene may indicate abnormal fat and fatsoluble vitamin absorption.

Menadione use, intravenous (IV) administration of vitamin K, parenchymal liver disease

PT is prolonged in salicylates, sulfa, and tetracycline use.

Large amounts are found in liver, skeletal muscle, and bone. Part of the insulin molecule. Usual intake is 10–15 mg/d.

Eating foods stored in galvanized containers. Excesses from supplements.

Wounds, geophagia, highcalcium or high-phytate diets, growth, stress, skin lesions, poor taste or olfactory acuity, upper respiratory infections, MI, oral contraceptive use, cancer, pregnancy, cirrhosis, sickle cell or pernicious anemias

Zinc: serum zinc

0.75–1.4 mg/mL or up to 79 g/dL in plasma; 100–140 g/dL in serum

Liver disease, fat malabsorption, prematurity, small bowel disorders.

(continued)


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TABLE B-8

Interpretation of Lab Values (continued)

Value

Normal Range

Purpose or Comment

Increased In

Decreased In

Chloride

95–105 mEq/L

Acid–base balance. Major anion. Follows sodium passively in its transport.

Eclampsia, metabolic acidosis, dehydration, pancreatitis, anemia, renal insufficiency, Cushing’s syndrome, head injury, hyperventilation, hyperlipidemia, hypoproteinemia

Diabetic acidosis, metabolic alkalosis, gastroenteritis, fever, potassium deficiency, excessive sweating, heart failure, hyponatremia, infection, diuretics, overhydration

Magnesium

1.8–3 mg/dL

Influences muscular activity. Coenzyme in CHO and protein metabolism.

Renal insufficiency, uncontrolled diabetes, Addison’s disease, hypothyroidism, ingestion of magnesium-containing antacids or salts

Malnutrition, potassiumdepleting diuretics, malabsorption, alcohol abuse, starvation, renal disease, acute pancreatitis, severe diarrhea, ulcerative colitis

Phosphorous phosphate (PO4)

2.3–4.7 mg/dL

Influenced by diet and absorption; regulated by kidneys.

Liver disease, bone tumors, hypervitaminosis D, endstage renal disease, renal insufficiency, hypoparathyroidism, diabetic ketoacidosis (DKA), Addison’s disease, childhood

Malnutrition, gout, hyperparathyroidism, osteomalacia, hyperinsulinism, hypovitaminosis D, alcoholism, overuse of phosphate-binding antacids, rapid refeeding after prolonged starvation

Potassium, serum

3.5–5.5 mEq/L (16–20 mg/dL)

Intracellular. Cellular metabolism; muscle protein synthesis. Enzymes.

Renal insufficiency or failure, overuse of potassium supplements, Addison’s disease, dehydration, acidosis, cell damage, poorly controlled diabetes

Decreased potassium intake, renal disease, burns, trauma, diuretics, steroids, vomiting, stress, diarrhea, crash diet, overhydration, malnutrition, estrogen, steroid therapy, cirrhosis, hemolysis, fistula drainage

Sodium, serum

136–145 mEq/L

Absorbed almost 100% from gastrointestinal (GI) tract. Major cation; extracellular ion. Controls osmotic pressure. Acid–base balance.

Vitamin K deficiency, vomiting, heart failure, hypervitaminosis, dehydration, diabetes insipidus, Cushing’s disease, primary aldosteronism, diarrhea, steroids

Decreased sodium intake, diuretic use, burns, diarrhea, vomiting, nephritis, diabetic acidosis, hyperglycemia, overhydration

Adults: Desirable: 120–199 mg/dL; borderline high: 200–239 mg/dL; high: 240 mg/dL

Fat-related compound; component of plaque. Need fasting sample. Usually 30% high-density lipoprotein (HDL) and 70% low-density lipoprotein (LDL).

High: 200 mg/dL. Hyperlipidemia, diabetes, MI, hypertension (HTN), high-cholesterol diet, nephrotic syndrome, hypothyroidism, pregnancy, cardiovascular disease (CVD)

Low: 160 mg/dL.

Electrolytes

Lipids Total serum cholesterol (TC)

Child: Desirable: 70–175 mg/dL; borderline: 170–199 mg/dL; high: 200 mg/dL

Low dietary fat ingestion, malnutrition, malabsorption or starvation, fever, acute infections, liver damage, steatorrhea, hyperthyroidism, cancer, pernicious anemia

High-density lipoprotein (HDL)

Males: 45 mg/dL; females: 55 mg/dL

Usually higher in females. Low levels may indicate risk for heart disease.

Vigorous exercise, weight reduction, liver disease, alcoholism

Starvation, obesity, liver disease, DM, smoking, hyperthyroidism

Low-density lipoprotein (LDL)

Desirable: 130 mg/ dL; borderline high: 130–159 mg/ dL; high: 160 mg/dL

May indicate cardiac risk when elevated.

Familial hyperlipidemia, diet high in saturated fat and cholesterol, hypothyroidism, MI, DM, nephrotic syndrome, pregnancy, hepatic disease

Nephritic syndrome

(continued)


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APPENDIX B • DIETETIC PROCESS, FORMS, AND COUNSELING TIPS

TABLE B-8

967

Interpretation of Lab Values (continued)

Value

Normal Range

Purpose or Comment

Increased In

Decreased In

Phospholipids

60–350 mg/dL

Measure of EFAs, indirect. Includes lecithin, sphingomyelins, cephalins, and plasmogens.

Triglycerides (TG)

Desirable: 10–190 mg/dL; borderline high: 200–400 mg/dL; high: 400–1000 mg/dL; very high: 1000 mg/dL

Neutral fats are the main transport form of fatty acids. Need fasting sample.

High-carbohydrate diet, alcohol abuse (secondary), hyperlipoproteinemias, nephrotic syndrome, CRF, MI, HTN, DM, respiratory distress, pancreatitis, hypothyroidism

Malnutrition, COPD, malabsorption, hyperthyroidism, hyperparathyroidism, brain infarct

pH, arterial, plasma

7.36–7.44

Hydrogen ion concentration. Enzymes work within narrow pH ranges.

Alkalosis (uncompensated), hyperventilation, pyloric obstruction, HCl losses, diuretic use

Acidosis (uncompensated), emphysema, diabetic acidosis, renal failure, vomiting, diarrhea, intestinal fistula

Osmolality, serum

270–280 mOsm/L

Maintaining normal serum level is desirable.

Elevated in dehydration

Low in overhydration

Respiratory quotient (RQ)

0.85 from mixed diet

1.0 from CHO; 0.80 from protein; 0.70 from fat

High-CHO diet

High-fat diet

Oxygen: partial pressure of oxygen (pO2)

80–100 mm Hg

Reflects hemoglobin concentration. Arterial blood is used.

Hyperoxia

Hypoxia (anemic, stagnant, chronic, anoxic)

Carbon dioxide: partial pressure of carbon dioxide (pCO2)

35–45 mm Hg; 24–30 mEq/L

Pulmonary problems, metabolic alkalosis due to ingestion of excess sodium bicarbonate, protracted vomiting with potassium deficiency, Cushing’s syndrome, heart failure with edema

Diabetic ketosis or ketoacidosis, starvation, renal insufficiency, persistent diarrhea, lactic acidosis, respiratory alkalosis, diarrhea

EFA deficiency

Osmolality and pH

Respiratory Factors

Renal Values Glomerular filtration rate (GFR)

110–150 mL/min in males; 105–132 mL/min in females

GFR reflects kidney function

Renal failure: 90 mL/min/ 1.73 m2 indicates renal decline

Urea clearance

40–65 mL/min standard; 60–100 mL/ min maximum

Part of the assessment of renal status

Uremia

Blood urea nitrogen (BUN) to creatinine ratio

10:1

Measure of impaired renal function.

Renal disease, excess protein intake, bleeding in small intestine, burns, high fever, steroid therapy, decreased renal blood flow, urinary tract obstruction

Low-protein intake, repeated dialysis without repletion, severe vomiting and diarrhea, hepatic insufficiency

BUN

8–18 mg/dL (3–6.5 mmol/L); slightly higher in males

Urea is the end product of protein metabolism. Varies directly with dietary intake. Formed in the liver from amino acids and other ammoniacontaining compounds.

Renal failure, azotemia, DM, burns, dehydration, shock, heart failure, infection, chronic gout, excessive protein intake, catabolism, GI bleed, MI, urinary obstruction, starvation, steroid therapy, trauma

Hepatic failure, malnutrition, malabsorption, overhydration, pregnancy, acromegaly, low-protein diet

(continued)


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TABLE B-8

Interpretation of Lab Values (continued)

Value

Normal Range

Purpose or Comment

Increased In

Decreased In

Uric acid

4.0–9.0 mg/dL in men; 2.8–8.8 mg/ dL in women

Metabolite from purine metabolism. Excreted by kidney. Serum level reflects balance between production and excretion.

Higher in winter, stress, gout, leukemia, hypoparathyroidism, total fasting, toxemia of pregnancy, elevated triglycerides, DKA, hypertension, hemolytic or sickle cell anemia, renal disease, alcoholism, multiple myeloma, polycythemia, use of vincristine or mercaptopurine

Acute hepatitis, Wilson’s disease, celiac disease, Fanconi’s syndrome, Hodgkin’s disease, use of allopurinol or large doses of Coumadin, folic acid anemia, burns, pregnancy, malabsorption, lead poisoning

Cushing’s syndrome, secondary hypoadrenalism

Pituitary, Cushing’s syndrome, primary adrenal insufficiency

Hormones Adrenocorticotropic hormone (ACTH)

5–95 pg/mL at 9 AM; 0–35 pg/mL at midnight

Cortisol

5–25 g/dL at 8 AM; 10 g/dL at 8 PM

Gastrin

0–200 pg/mL

Growth hormone (GH)

6 ng/mL in men; 10 ng/mL in women

Being administered in some medical conditions

Insulin

6–26 IU/mL, fasting

Serum levels are useful.

Untreated obese patients who have diabetes, metabolic syndrome, insulinoma

Severe diabetic acidosis with ketosis and weight loss

Iodine, total

8–15 mEq/L

Affects the activity of the thyroid gland; usual intake with 10 grams of NaCl is 1000 micrograms of iodine.

Hyperthyroidism

Cretinism, simple goiter, low-iodine diet or highgoitrogenic dietary intake

Protein-bound iodine (PBI)

3.6–8.8 mg/dL

Most iodine is protein-bound in the thyroid hormones.

Hyperthyroidism, thyroiditis, pregnancy, oral contraceptive use, hepatitis

Cretinism, simple goiter, low-iodine diet or highgoitrogenic dietary intake

Serotonin (5-HIAA)

0.05–0.20 g/mL

Neurotransmitter

Thyroxine (T4); triiodothyronine (T3)

T4: 4–12 g/100 mL; T3: 75–95 g/ 100 mL

Tests of thyroid function

Myasthenia gravis, nephrosis, pregnancy, preeclampsia, Graves’ disease, hyperthyroidism

Increased thyroid-stimulating hormone (TSH), decreased T4, T3 (hypothyroidism); malnutrition; hypothyroidism; nephrosis; cirrhosis; Simmonds’ disease

Thyroid-stimulating hormone (TSH)

0.2 U/L

Thyroid function tests (TSH, T4, T3)

Primary untreated hypothyroidism, post subtotal thyroidectomy

Hyperthyroidism

Lower in women

Extreme stress, elevated in patients with nighteating syndrome Zollinger–Ellison syndrome, pyloric obstruction, short bowel syndrome, pernicious anemia, atrophic gastritis

Depression

Stool Values Fat, fecal

7 g/24 hr

Nitrogen

2.5 g/d

Urinalysis

Normal is pale golden yellow

Fat malabsorption Abnormal color changes: orange  high level of bile; red  blood, porphyria, urates, or bile or ingestion of beets, blackberries, or food dyes; brown  blood; melanin may turn black on standing.

Dehydration: dark golden color

Overhydration: clear color (diluted)

(continued)


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APPENDIX B • DIETETIC PROCESS, FORMS, AND COUNSELING TIPS

TABLE B-8

969

Interpretation of Lab Values (continued)

Value

Normal Range

Purpose or Comment

Increased In

Acetone, ketones

0

Elevation indicates ketosis.

Diabetic ketoacidosis; starvation; fever; prolonged vomiting; high-protein, high-fat, or low-CHO diet; diarrhea; anorexia

Aldosterone

6–16 mg/24 h

Ammonia

20–70 mEq/L

Hepatic disease or coma, renal failure, severe heart failure, high-protein diet

Essential hypertension

Amylase

260–950 Somogyi units/24 h

Perforated peptic ulcer, acute pancreatitis, mumps, cholecystitis, renal insufficiency, alcohol poisoning

Hepatitis, pancreatic insufficiency, severe burns

Calcium, normal diet

250 mg/24 h

Hyperparathyroidism, high calcium or vitamin D in diet, immobilization, metastatic bone disease, multiple myeloma, renal tubular acidosis

Decreased levels may reflect poor intake. Hypoparathyroidism, rickets, renal failure, steatorrhea, osteomalacia

Cortisol, urinary free

10–100 g/dL

Elevated in stress

Adrenal insufficiency

Creatinine clearance

Males (20 years old): 90 mL/min/SA; females (20 years old): 84 mL/min/SA; decreases by 6 mL/ min/SA per decade

Pregnancy, childhood, exercise.

Ascites, dehydration, renal failure, heart failure, shock, cirrhosis

Epinephrine, norepinephrine

Epinephrine: 10 g/ 24 h; Norepinephrine 100 g/24 h

Stress

Estrogens

4–25 mg/24 h in males; 4–60 mg/ 24 h in females, higher in pregnancy

Hemoglobin, myoglobin

0

Any amount

5-Hydroxyindoleacetic acid

0

Serotonin excretion

(5-HIAA)

20–60 mg/24 h

Oxalate pH

4.6–8; average of 6 (dependent on diet)

Depends on time of sampling and food ingested

Alkaline: metabolic alkalemia, proteus infection, aged specimen, large amount of fruits and vegetables eaten

Protein (albumin)

30 mg/24 h (0 qualitative)

Amino acids in urine should be 0.4–1 g/L.

Nephrotic syndrome

Specific gravity

1.003–1.030

Ability to concentrate urine

High in antidiuretic hormone deficiency

Sugar

0

Blood loss, urinary tract injury

Calcium oxalate stones Acidic: high-protein intake

Low in renal tubular dysfunction

Hyperglycemia, ketosis, DKA Indicator of lean body mass turnover

3-Methyl histidine, urine

Decreased In

Urea

20–35 g/L

Uric acid

0.2–2.0 g/L

Vanillylmandelic acid (VMA)

6.8 mg/24 h

Metabolite of both epinephrine and norepinephrine

Volume

1000–1500 mL

Varies slightly between individuals

Increased levels may reflect loss of lean body mass.

Diabetes insipidus

The table provides estimated and sample normal values; normal ranges will vary by the techniques used by the laboratory completing the tests. Developed from: Pagana KD, Pagana TJ. Mosby’s manual of diagnostic and laboratory tests. 4th ed. Philadelphia: Mosby, 2009.

Dehydration


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TABLE B-9

Quick Reference: Food–Drug Interactions

Drugs

Effects and Precautions

Antibiotics

Drugs

Effects and Precautions

Cholesterol-Lowering Drugs

Cephalosporins, penicillin

Take on an empty stomach to speed absorption of the drugs.

Cholestyramine

Increases the excretion of folate and vitamins A, D, E, and K.

Erythromycin

Do not take with fruit juice or wine, which decrease the drug’s effectiveness.

Gemfibrozil

Avoid fatty foods, which decrease the drug’s efficacy in lowering cholesterol.

Sulfa drugs

Increase the risk of vitamin B12 deficiency.

Tetracycline

Dairy products reduce the drug’s effectiveness. Lowers vitamin C absorption.

Heartburn and Ulcer Medications Antacids

Interfere with the absorption of many minerals; for maximum benefit, take medication 1 hour after eating.

Cimetidine, famotidine, sucralfate

Avoid high-protein foods, caffeine, and other items that increase stomach acidity.

Anticonvulsants Dilantin, phenobarbital

Increases the risk of anemia and nerve problems due to a deficiency in folate and other B vitamins.

Hormone Preparations

Antidepressants Fluoxetine

Reduces appetite and can lead to excessive weight loss.

Lithium

A low-salt diet increases the risk of lithium toxicity; excessive salt reduces the drug’s efficacy.

Monoamine oxidase (MAO) inhibitors

Foods high in tyramine (e.g., aged cheeses, processed meats, legumes, wine, and beer) can bring on a hypertensive crisis.

Tricyclics

Many foods, particularly legumes, meat, fish, and foods high in vitamin C, reduce absorption of the drugs.

Antihypertensives, Heart Medications Angiotensinconverting enzyme (ACE) inhibitors

Take on an empty stomach to improve the absorption of the drugs.

Alpha-blockers

Take with liquid or food to avoid excessive drop in blood pressure.

Antiarrhythmic drugs

Avoid caffeine, which increases the risk of an irregular heartbeat.

Beta-blockers

Oral contraceptives

Salty foods increase fluid retention. Drugs reduce the absorption of folate, vitamin B6, and other nutrients; increase intake of foods high in these nutrients to avoid deficiencies.

Steroids

Salty foods increase fluid retention. Increase intake of foods high in calcium, vitamin K, potassium, and protein to avoid deficiencies.

Thyroid drugs

Iodine-rich foods may lower the drug’s efficacy.

Laxatives Mineral oils

Overuse can cause a deficiency of vitamins A, D, E, and K.

Painkillers Aspirin and stronger nonsteroidal antiinflammatory drugs

Always take with food to lower the risk of gastrointestinal irritation; avoid taking with alcohol, which increases the risk of bleeding. Frequent use of these drugs lowers the absorption of folate and vitamin C.

Take on an empty stomach; food, especially meat, increases the drug’s effects and can cause dizziness and low blood pressure.

Codeine

Increase fiber and water intake to avoid constipation.

Digitalis

Avoid taking with milk and high-fiber foods, which reduce absorption; increases potassium loss.

Sleeping Pills, Tranquilizers

Diuretics

Increases the risk of potassium deficiency.

Benzodiazepines

Potassium-sparing diuretics

Unless a doctor advises otherwise, do not take diuretics with potassium supplements or salt substitutes, which can cause potassium overload.

Weight Loss– Inducing Drugs

Thiazide diuretics

Increases the reaction to MSG.

Asthma Drugs Pseudoephedrine

Avoid caffeine, which increases feelings of anxiety and nervousness.

Theophylline

Charbroiled foods and a high-protein diet reduce absorption. Caffeine increases the risk of drug toxicity.

Never take with alcohol. Caffeine increases anxiety and reduce drug’s effectiveness.

Many drugs cause weight loss because of changes in appetite or other side effects.


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TABLE B-10

971

Sample Worksheet for Using Standardized Nutrition Terminology

Nutrition Care Process—Critical thinking worksheet to help determine the appropriate standardized language to document and support the NCP STEP ONE: NUTRITION ASSESSMENT Complete a comprehensive assessment of a patient using the established assessment standards/guidelines set by your facility or practice setting. Be sure to include “comparative standards:” anthropometrics, estimated needs, and nutrient intake as well as identify the reference standards used to analyze the calculated/numerical data such as the DRIs, BMI, and NCHS charts. STEP TWO: NUTRITION DIAGNOSIS (1) List all of the patient’s problems/issues:

(2) Cross off medical problems/medical diagnoses. (3) Cross off issues that do not have supporting evidence (of signs/symptoms). (4) Cross off issues where the root etiology (cause of) cannot be determined. (5) Place a “✓” by the issues you will be able to re-evaluate upon follow-up; be sure to have updated signs/symptoms data on the reassessment date. (6) Of the checked issues, circle those that are the most urgent nutrition problem(s) to resolve and the priority issue to start addressing. (7) Based on the problem(s) circled, choose the diagnosis that best suits the nutrition issue in its most detailed form. (8) Write P.E.S statement(s) with the appropriate “root” etiology and signs/symptoms:

P: _______________________________________related to E: ___________________________________________________ as evidenced by S/S:______________________________________________________________________________________***See examples STEP THREE: NUTRITION INTERVENTION (Direct interventions at the etiology. If a dietitian cannot change the etiology, then direct the interventions at reducing the signs/symptoms of the nutrition diagnosis). Nutrition Prescription: (Proper diet and regimen to meet the nutrient needs of what?) ________________________________________ Based upon scope of practice and clinical privilege established by your facility or practice setting, choose: 1) Recommended Interventions (other practitioner must do)

2) Interventions you can/will do on your own (actions)

• intervention term:

• intervention term:

goal of intervention: • intervention term: goal of intervention: • intervention term: goal of intervention:

goal of intervention: • intervention term: goal of intervention: • intervention term: goal of intervention:

Goal of intervention  why you chose that intervention/strategy  what the intervention is intended to do/accomplish STEP FOUR: MONITORING & EVALUATION (Directed at the signs/symptoms to monitor the success of intervention(s) and progress toward goal(s) 1) Indicate when/timeframe during which you plan to reassess: within ____________ days/weeks/months 2) List signs/symptoms from PES above and match to M&E Terms (unshaded) from Assess/M&E list (indicators) 3) Establish criteria for each M&E indicator (pt goals) • Signs/Symptoms: M&E term: Criteria-Pt will: • Signs/Symptoms: M&E term: Criteria-Pt will: • Signs/Symptoms: M&E term: Criteria-Pt will: Criteria  measurable patient-centered goals

Reassessment or follow-up encounter 1) Do you have the info/data needed to compare previous signs/symptoms to the current time? If no, you need to address this as an intervention recommendation, and check it at the next encounter. If yes, evaluate progress toward the M&E criteria on the left (pt goals). n Pt met goal/criteria n Pt did not meet goal/criteria 2) Based upon progress toward pt goals, evaluate progress toward the resolution of the nutrition problem from the PES: n Resolved (nutrition problem no longer exists) n Improvement shown (nutrition problem still exists) n Unresolved no improvement shown n No longer appropriate (change in condition) 3) If no improvement is shown, you may need to change intervention(s).

(continued)


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Sample Worksheet for Using Standardized Nutrition Terminology (continued) ***SAMPLE COMMON PES STATEMENTS

Diagnostic Label

Domain Code

Inadequate oral food/ beverage intake

NI-2.1

• Common Etiology • “as related to . . .”

Common Signs/Symptoms “as evidenced by . . .” [with M/E codes]

• • • •

• Poor po intake of 25% of meals [M&E  FH-1.3.2]

Decreased appetite Nausea Emesis Altered mental status

• Increased needs with advanced Ca • Increased needs due to wound healing, infection, multiple frax • Increased needs secondary to catabolic state • Comfort measures only (Hospice)

• Wt loss of 5% in 1–2 months [M&E – AD-1.1.4] • Poor po intake of 25% of meals [M&E – FH-1.3.2]

• Consumption of minimal comfort foods 10% needs [M&E – FH-1.2.1]

Inadequate intake from enteral/ parenteral nutrition

NI-2.3

• Current TF formula/rate • Increased needs sec to surgery • Infusion goal not reached due to intolerance of feeding

• Current nutrition regimen only meeting __% of est. needs [M&E – FH-1.2.1] • TF/TPN only meeting __% of est. needs [M&E – FH-1.4.1] • Wt loss of ___% in ___ weeks/months [M&E – AD-1.1.4] • Delayed wound healing [M&E – PD-1.1.8]

Excessive intake from enteral/parenteral nutrition

NI-2.4

Decreased needs due to ventilator

• Current nutrition regimen meeting 100% of est. needs [M&E – FH-1.2.1] • TF/TPN meeting 100% of est. needs [M&E – FH-1.4.1]

Increased nutrient needs (protein)

NI-5.1

• Increased nutrient demands (PRO) for: • Wound healing • Surgical wounds

• Prealb or alb of __g/L (decreased) [M&E – BD-1.11.1] • Loss of skin integrity (surgical wounds) [M&E – PD-1.1.8] • Loss of muscle mass [M&E – PD-1.1.4] • Stage __ pressure ulcer [M&E – PD-1.1.8] • Inadequate protein intake– consuming only __% pro needs [M&E – FH-1.6.2]

Malnutrition

NI-5.2

• • • • • •

• Decreased albumin of ____g/L [M&E – BD-1.11.1] • Decreased food intake, consuming only ___% meals [M&E – FH-1.3.2] • Pt refusing to eat [M&E – FH-1.3.2] • Wt loss of ___% in ___weeks/months [M&E – AD-1.1.4] • Evident temporal wasting [M/E – PD-1.1.6] • Evident minimal body fat / fat stores [M/E – PD-1.1.4] • Evident cachexia [M/E – PD-1.1.4] • Delayed wound healing [M/E – PD-1.1.8]

End-stage liver disease Short gut Small bowel transplant Mental illness Ascites ETOH dependency

Provided courtesy of Sherri Jones, MS, MBA, RD, LDN. UPMC Presbyterian Shadyside, Pittsburgh PA.


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TABLE B-11

973

Clinical Case Review and Audit

Assessment

3 Exceeds Very detailed

2-Met Goals Competent

1-Unsat. Large amt missing

Comments

3 Exceeds Very detailed

2-Met Goals Competent

1-Unsat. Large amt missing

Comments

3 Exceeds Very detailed

2-Met Goals Competent

1-Unsat. Large amt missing

Comments

3 Exceeds Very detailed

2-Met Goals Competent

1-Unsat. Large amt missing

Comments

3 Exceeds Very detailed

2-Met Goals Competent

1-Unsat. Large amt missing

Comments

Pathophysiology of disease/disorder Stage/phase (if applicable) Relevance of nutrition status in this disorder/disease Prognosis for this disease Up-to-date interpretation of evidence-based research General information noted- Ht, Wt Social background reviewed Past medical status/socioeconomic status Family history; genetics, if relevant Pertinent medical/surgical status reviewed/documented Medications and potential drug/nutrient interactions assessed/noted Laboratory values: skewed values and relevance noted Typical diet recall or diet Hx analyzed Correct calculations/anthropometrics used to estimate nutrition needs Nutrition Diagnoses 1–2 Nutrition diagnosis(es) identified & appropriate P.E.S statements: logical, able to be managed by an RD in this setting Nutrition Interventions Short- and long-term goals set with pt/significant other Recommendations based on etiologies of problems Food–nutrient delivery: Education: Counseling: Coordination of care: Monitoring and Evaluation Progress: day to day analysis – Intake Progress: day to day analysis – Clinical Progress: day to day analysis – Behavioral/Environmental Documented need for f/up; timeframe noted If education provided, pt/family understanding is documented Nutrition support – kilocalories, protein, fluid, recommendations proper Nutrition care plans updated in a timely manner Meal plan established if warranted Age-appropriate standards and assessment tools used if needed Discharge plan or needs discussed Communication and Documentation Organized; follows a comprehensible sequence Educational flow sheets documented accurately Uses correct grammar and terms Follow-up notes re-evaluate nutrition diagnoses, status, plans Evaluator:_____________________________ TOTAL POINTS:________________

Date:________________

Medical Record #___________________


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Tips for Adult Education and Counseling

The adult as a learner

During the process of maturation, a person moves from dependency toward increasing self-directedness but at different rates for different people and in different dimensions of life. Teachers have a responsibility to encourage and nurture this movement. Adults have a deep psychological need to be generally self-directing, but they may be dependent in certain temporary situations.

The learner’s experience

As people grow and develop, they accumulate an increasing reservoir of experience that becomes an increasingly rich resource for learning—for themselves and for others. Furthermore, people attach more meaning to lessons they gain from experience than those they acquire passively. Accordingly, the primary techniques in education are experiential ones— laboratory experiments, discussion, problem-solving cases, field experiences, case reports.

Readiness to learn

People become ready to learn something when they experience a need to learn it in order to cope more satisfyingly with reallife tasks and problems. The educator has a responsibility to create conditions and provide tools and procedures for helping learners discover their “need to know.” Learning programs should be organized around life-application categories and sequenced according to the learners’ readiness to learn. Key: Attend to learners’ developmental readiness.

Orientation to learning

Adult learners see education as a process of developing increased competence to achieve their full potential in life. They want to be able to apply whatever knowledge and skill they gain today to living more effectively tomorrow. Accordingly, learning experiences should be organized around competency-development categories. People are performance-centered in their orientation to learning.

Assumptions

1. All learners can think; critical and creative thinking are goals. 2. There needs to be a safe, risk-taking environment and sufficient time to learn. 3. The environment for learning should be rich and responsive. 4. Offer challenging problem-solving opportunities.

Chief assessment factors for learning

1. Socioeconomic factors 2. Cultural/religious beliefs and background 3. Age and sex of patient and significant others (SOs) 4. Birth order of patient and family involvement 5. Occupation 6. Medical status and medical history 7. Marital status; number and ages of children 8. Cognitive status; educational level 9. Readiness to learn and staging: precontemplation, contemplation, preparation, action, or maintenance 10. Emotional status (stress, acceptance of illness, chronic disease, or condition)

Health literacy and teaching tools

Low health literacy (the ability to read, understand, and act on health information) is a public health issue. One out of five American adults reads at the fifth-grade level or below, and the average American reads at the eighth to ninth grade level. Most consumers need help understanding healthcare information. Patients prefer medical information that is easy to read and understand. Easy-to-read healthcare materials are essential. Provide important information first.

Written materials

Print very clearly and avoid handwritten messages. Use large print; font size should be a minimum of 12 points. Double space text to avoid crowding. Avoid using all capital letters. Use headings to introduce the upcoming topic. Avoid abbreviations, and use black ink on light-colored paper. Information must be current and accurate. Provide important information first. Highlight the “need to know” versus the “nice to know.” Present information in a “how to” manner. Use a conversational style. Spell out numbers below 10. Limit syllables to —one or two per word. Keep sentences short, and use bullets when possible.

Educational tools

Newsletters and bulletin boards Demonstrations or role-playing Laboratory reports, flip charts Food recall or intake records with feedback Educational games and fun quizzes Group classes or supermarket tours Educational video and audio tapes (continued)


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975

Tips for Adult Education and Counseling (continued)

Visual aids

Visuals should be able to stand alone, without words. Use photographs and realistic images. Use culturally appropriate food models, empty packages of real foods, and measuring cups and spoons. Work with restaurant menus where needed. Share simple recipes.

Principles of learning

The recipient must value the information. Pace should be adequate for learner; take small steps. Environment should be conducive to learning (free of distractions and stress), and patient should be ready to learn (free from pain). Information must be meaningful, relevant, and organized. Material should be logical in sequence. Counselor must be truly interested in sharing the information. Adequate follow-up should be available for the reinforcement of facts and principles. For adult learners, information that is useful in the present is more meaningful than facts learned for the “future.” Adults tend to prefer problem-solving information (survival skills) over learning facts.

Principles of teaching

The counselor must first listen to the patient. Involve the patient in setting mutual objectives. Small segments of information should be presented in understandable language in small, manageable “sound bytes.” An organized plan should be used to teach. Clear objectives should be established, with timelines and short- and long-term outcomes. Feedback should be used with each step. Be prepared to receive evaluation (peer review) from the patient; improve as needed. Good eye contact should be maintained with the patient. Be aware, however, that direct or prolonged eye contact can be seen as rude or threatening by some cultures; know your client. Appropriate teaching tools or audiovisual aids should be used as appropriate. Using a sixth- to eighth-grade reading level is suggested, preferably with an easy layout, visual appeal, and illustrations. Questions must be allowed for clarification. Praise and positive reinforcement should be offered to the learner. Carl Rogers emphasizes the use of “unconditional positive regard” for all persons.

Counseling tips

Knowledge does not automatically ensure compliance. Behavioral change takes time and encouragement. Trial and error will be common for the patient in learning new behaviors. An increase in self-esteem comes with an improvement in behavior. The counselor should appropriately foster independence. Empathy is an important part of humanistic care. The counselor serves as an intervention specialist. The “patient-centered” approach to counseling is effective. Assess the stage of change and motivation level of client. Evaluate past experiences with dietary changes and anticipated challenges. Goal-setting requires the patient to recognize the need for change, establish a goal, monitor goal-related activity, and use self-reward for goal attainment. Identify challenges, obstacles, coping strategies, and skills. Help the client to anticipate lapses and relapses.

Patient assessment of chronic illness care (PACIC tool)

Patient-centered model of behavioral counseling using the 5 As: Assess: Beliefs, behavior, and knowledge. Advise: Provide specific information about health risks and benefits of change. Agree: Collaboratively set goals based on the patient’s interest and confidence in their ability to change behavior. Assist: Identify personal barriers, strategies, problem-solving techniques, and social/environmental support. Arrange: Specify a plan for follow-up (e.g., visits, phone calls, mailed reminders).

Counseling in hospice care

Attempt to reduce fears related to eating. Recognize stages of terminal illness: fear of abandonment, finding a natural and realistic approach, building bridges, and ownership of the experience. Pain management is most important for quality of life. Respect the individual’s cultural beliefs and needs. Identify a patient advocate who will address concerns as care progresses. Help maintain self-esteem and dignity. Comfort foods can be important to patient satisfaction; address these needs on a meal-to-meal basis. Listen for hidden messages from the patient; communicate with other healthcare team members.


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TABLE B-13

Health-Promotion Intervention Models

Because increasing evidence suggests that health-promotion interventions that are based on social and behavioral science theories are more effective than those lacking a theoretical base, five models are described here (Glanz and Bishop, 2010.) Behavioral Ecological Model (BEM)

Sources of Interlocked Contingencies

G en

er

ic

SOCIAL/CULTURAL LEVEL Nationality Culture Specific

lI na io e

c en lu nf

Sp

ec

INDIVIDUAL LEVEL Normative Group Physical

c

ct ire

D

LOCAL LEVEL Clinical Services Built and Social Environment

ifi

Bi

COMMUNITY LEVEL Policies Laws Media

Figure B-4 Behavioral Ecological Model (BEM). (Image courtesy of Hovell et al [2002].)

Behavioral Ecological Model (BEM) Principle

Processes

Application

Environment influences behavior

Consequences are produced by the behavior

Control or change risky environment

Hierarchy of interacting reinforcement contingencies

Interaction is key

Interaction among both physical and social contingencies explain and ultimately control health behavior.

Hovell MF, Wahlgren DR, Gehrman C. The Behavioral Ecological Model: Integrating public health and behavioral science. In DiClemente RJ, Crosby R, Kegler M, (eds.). New and Emerging Theories in Health Promotion Practice & Research. Jossey-Bass Inc., San Francisco, California, 2002.

(continued)


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977

Health-Promotion Intervention Models (continued)

Health Belief Model Perceptions and modifying factors.

Age, race, ethnicity etc. Peers, personality, social pressure etc. Prior contact or knowledge about the disease

Demographic, Sociopsycho and Structural Variables

Assessments Cost / benefit analysis

Likelihood of action

Perceived seriousness and susceptibility

“How dangerous is it?”

Perceived threat

“Will I get it?” Cue to action Media campagns, lay advice, reminders from G.P., magazines, articles, etc.

Figure B-5 Health Belief Model (HBM). (Image courtesy of Glanz et al (2002).)

Health Belief Model Concept

Definition

Application

Perceived susceptibility

One’s opinion of chances of getting a condition.

Define population(s) at risk, risk levels. Personalize risk based on a person’s features or behavior. Heighten perceived susceptibility if too low.

Perceived severity

One’s opinion of how serious a condition and its sequelae are.

Specify consequences of the risk and the condition.

Perceived benefits

One’s opinion of the efficacy of the advised action to reduce risk or the seriousness of impact.

Define action to take: how, where, when; clarify the positive effects to be expected.

Perceived barriers

One’s opinion of the tangible and psychological costs of the advised action.

Identify and reduce barriers through reassurance, incentives, and assistance.

Cues to action

Strategies to activate readiness.

Provide how-to information; promote awareness, reminders.

Self-efficacy

Confidence in one’s ability to take action.

Provide training, guidance in performing action.

Glanz K, Bishop DB. The role of behavioral science theory in development and implementation of public health interventions. Annu Rev Public Health. 31:399, 2010. Glanz, K., Rimer, BK, Lewis, FM. Health Behavior and Health Education. Theory, Research and Practice. San Francisco: Wiley & Sons., 2002.

(continued)


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Health-Promotion Intervention Models (continued)

Motivational Interviewing

Risk Road Blocks Revelance

Reward Reinforcement

Figure B-6 Key Words for Motivational Interviewing.

Motivational Interviewing (MI) Concept

Definition

Application

Motivation to change comes from the client, not the counselor

Direct persuasion is not an effective method for achieving change. Client must articulate and resolve his or her own ambivalence.

Counseling style is a quiet, eliciting one. Partnership is the goal, not an expert—recipient relationship.

Resolution of ambivalence

Directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.

Compared with nondirective counseling, it is more focused and goal-directed. Readiness to change is a fluctuating product of personal interaction.

Rollnick S., & Miller, W.R. What is motivational interviewing? Behavioural and Cognitive Psychotherapy, 23: 325, 1995.

Social Cognitive Theory

Figure B-7 Self-Efficacy as part of Social Cognitive Theory. Social Cognitive Theory Principle

Processes

Application

Human functioning is self-regulated

Cognitive, vicarious, and self-reflective processes

Human adaptation to change

Dynamic interplay of personal, behavioral, and environmental influences

Self as organizing, proactive, self-reflective

People are not reactive organisms shepherded by environmental forces or concealed inner impulses

People watch and learn from others

Interactive learning

Confidence comes from practice

Self-efficacy is the belief in the ability to succeed in specific situations

Positive approaches to goals, tasks, and challenges.

Those who believe they can perform well are more likely to view difficult tasks as something to be mastered rather than something to be avoided.

Bandura, A. Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice Hall, 1986.

(continued)


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TABLE B-13

979

Health-Promotion Intervention Models (continued)

Transtheoretical Model (TTM) PROGRESS

Precontemplation

Contemplation

Preparation

Action

Maintenance

RELAPSE

Figure B-8 Transtheoretical Model (TTM). (Image courtesy of Prochaska and DiClemente (1982).) TTM Stage

Definition

Helping Processes

Precontemplation

Individual has the problem (whether he/she recognizes it or not) and has no intention of changing.

Consciousness raising (information and knowledge) Dramatic relief (role-playing) Environmental reevaluation (how problem affects physical environment)

Contemplation

Individual recognizes the problem and is seriously thinking about changing.

Self-reevaluation (assessing one’s feelings regarding behavior)

Preparation for action

Individual recognizes the problem and intends to change the behavior within the next month. Some behavior change efforts may be reported but the defined behavior change criterion has not been reached consistently.

Self-liberation (commitment or belief in the ability to change)

Action

Individual has enacted consistent behavior change for less than six months.

Reinforcement management (overt and covert rewards) Helping relationships (social support, self-help groups) Counterconditioning (alternatives for behavior) Stimulus control (avoid high-risk cues)

Maintenance

Individual maintains new behavior for six months or more.

Support and encouragement

Prochaska JO, DiClemente CC. Trans-theoretical therapy – toward a more integrative model of change. Psychotherapy: Theory, Research & Practice. 19(3):276, 1982.


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TABLE B-14

Sample Monitoring and Evaluation Audits for Patient Education

This patient education audit identifies the ability of the patient to demonstrate or verbalize how he or she will or has changed behaviors after nutritional instructions. Any Patient 1. Patient is able to personalize the MyPyramid food guidance system. 2. Patient is able to explain the importance of his or her diet for his or her health. 3. Patient is able to plan ____ day’s menus and snacks from his/her dietary pattern. 4. Patient is able to incorporate desirable economic/ethnic food choices into his/her prescribed diet. 5. Patient has been following _____ diet at home for a period of time and is able to describe the elements of this diet with accuracy. 6. Patient expresses recognition of a need to lose/gain weight. 7. Patient is able to describe specific food allergies and food ingredients to avoid. 8. Patient is able to describe the reasons for following _______ diet (e.g., improve appearance, increase energy, reduce chances for complications, improve quality of life). 9. Patient is able to describe the impact of appropriate activity or exercise on health and nutritional well-being. Cardiac Diet

12. Patient is able to describe 1–2 items to carry in case of episodes of low blood glucose. 13. Patient is able to define when to call his or her health provider (e.g., when glucose is above/below normal ___ times). 14. Patient is able to discuss proper foot care, the need for eye exams, and the need for foot exams. Dumping Syndrome Diet 1. Patient is able to verbalize the effects of diet on dumping syndrome. 2. Patient is able to explain the guidelines to be followed to prevent dumping syndrome (e.g., beverages are served 30 minutes before or after meals; concentrated sweets are omitted or severely limited). Gliadin-Free/Gluten-Restricted Diet 1. Patient is able to examine food labels and to name ingredients that must be avoided. 2. Patient is able to list products that must be avoided in diet. 3. Patient is able to plan menus that can be used at home. 4. Patient is able to adapt recipes for use at home.

1. Patient is able to name three beverages that are high in caffeine. 2. Patient is able to describe modifications in his or her diet that will be needed to prevent further coronary complications: saturated versus polyand monounsaturated fats, sodium and potassium, fiber, and use of the DASH diet. 3. Patient is able to categorize correctly into the proper food pyramid lists. 4. Patient is able to plan menus for home use that include appropriate modifications. 5. Patient is able to name snack foods that can be included in dietary plan.

High-Fiber Diet

Diabetes Diet

1. Patient is able to name foods or beverages that must be avoided. 2. Patient is able to plan menus that are nutritionally complete for calcium but are lactose restricted. 3. Patient demonstrates awareness that he or she can tolerate up to ___ milliliters of lactose per day at this time. 4. Patient is able to discuss the difference between lactose intolerance and milk allergy.

1. Patient is able to explain the relationship of diet with complications of diabetes. 2. Patient is able to name foods that contain CHO. 3. Patient is able to preplan meals for _____ weeks. 4. Patient is able to verbalize a simple definition of diabetes. 5. Patient is able to describe the role of medications related to food intake. 6. Patient is able to explain the rationale for following a prudent diet to prevent complications such as heart disease. 7. Patient is able to explain how proper spacing of meals affects his/her disorder. 8. Patient is able to describe symptoms of ketoacidosis and insulin shock and can name foods to take or avoid for each condition. 9. After looking at several food labels, patient is able to point out ingredients that mean carbohydrate. 10. Patient is able to describe techniques for managing special events (travel, parties, restaurants, holiday meals, weekends). 11. Patient is able to describe his or her personal exercise prescription as ___ minutes of activity ___ times per week.

1. Patient is able to verbalize foods that can be used to increase fiber in his or her diet, to desired level of ___ grams daily. 2. Patient is able to explain the role of fiber in his or her particular disorder. 3. Patient is able to describe the purpose of adequate fluids in the dietary regimen and is able to consume ___ milliliters daily. Lactose Intolerance Diet

Low-Cholesterol and Dyslipidemia Diets 1. Patient is able to describe simple definitions for cholesterol and saturated, polyunsaturated, and monounsaturated fats. 2. Patient is able to identify foods that have high cholesterol content. 3. Patient is able to name vegetable oils that may be used in the diet. 4. Patient is able to describe three cooking methods that are acceptable for the dietary regimen. 5. Patient is able to name foods that are good sources of monounsaturated fats.

(continued)


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APPENDIX B • DIETETIC PROCESS, FORMS, AND COUNSELING TIPS

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Sample Monitoring and Evaluation Audits for Patient Education (continued)

Low-Fat Diet

Sodium Restrictions

1. Patient is able to name foods that he or she must omit for the low-fat diet. 2. Patient is able to explain the role of fat in his or her condition. 3. Patient is able to note grams of fat from a given food label.

1. Patient is able to name foods that are naturally high in sodium. 2. Patient is able to name foods that have been processed or prepared with an excess of sodium. 3. Patient is able to explain the difference between “salt” and “sodium” in foods. 4. Patient is able to list seasonings that can be used at home in place of salt and salt-containing seasonings. 5. Patient is able to plan menus for home that will be low in sodium. 6. Patient is able to identify salt substitutes that he or she can use for his or her condition. 7. Patient is able to discuss how other minerals (potassium, calcium, magnesium) play a role in the specific condition.

Mineral-Altered Diets (Iron, Potassium, Calcium, Sodium) 1. Patient is able to name foods that are high/low in minerals. 2. Patient is able to accurately select menu choices for days that include/exclude foods that are high in mineral. 3. Patient is able to plan menus for home that are high/low in minerals. Pregnancy Diet 1. Patient is able to describe nutritional changes to her diet in order to have a healthy baby. 2. Patient is able to describe why breastfeeding is an important consideration. Protein-Altered Diets 1. Patient can identify foods that contain protein of high biological value. 2. Patient can name foods to include/omit in diet to increase/decrease the protein content of meals and snacks. Renal Diets 1. Patient is able to describe restrictions that are needed in regard to protein, sodium, potassium, fluid, calories, and phosphorus. 2. Patient is able to plan menus that are balanced for the restricted nutrients. 3. Patient is able to name “free” foods that he or she can eat as desired. 4. Patient is able to discuss how foods, nutrients, and prescribed medications may interact.

Vegetarian Diet 1. Patient is able to identify correctly two or more complementary protein foods. 2. Patient is able to plan menus that provide adequate protein and vitamin B12, zinc, and so on for age and gender. Weight Management Diet 1. Patient is able to verbalize his or her primary motivation for losing weight and current readiness for a change in behaviors. 2. Patient is able to describe his or her realistic goal for weight loss—either short term or long term, including a timetable. 3. Patient is able to list foods that are low in energy and may be eaten as snacks. 4. Patient is able to categorize foods into the proper pyramid food categories. 5. Patient is able to demonstrate a proper technique for recording food intake at home. 6. Patient has demonstrated weight loss over a certain timeframe.


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Acuity Ranking for Dietitian Services and Concept Map Over 100 dietitians, clinical nutrition managers, and specialists were surveyed for this acuity ranking for dietitian services, and a summary is given below. Levels of consensus on acuity are indicated for the medical diagnoses and conditions in this text. Where strong consensus was available, this table provides the acuity ranking for the nutritional involvement needed from a registered dietitian (RD). The survey asked the quesTABLE C-1

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tions listed in Table C-1. Table C-2 summarizes the rankings given by participants to the nutrition acuity by condition or disease. Concept maps are useful for organizing data to prepare assessments or case reviews. Figure C-1 can be used or adapted as a teaching tool for skill development. Figure C-2 provides an example of a process chart for considering all aspects of data for a comprehensive functional nutrition plan.

Nutrition Acuity and Medical Diagnosis–Related Survey Questions

Rate your opinion about the level of dietitian involvement (over time, not just per visit) for the following diagnoses on a 1 to 5 rating scale where 1  Little involvement; minimal, can be delegated to others 4  Extensive involvement needed over time 2  Some roles in oversight of nutrition care 5  Unable to determine; no opinion or experience 3  Moderate involvement needed over time

TABLE C-2

Acuity for Dietitian Roles in Medical Diagnoses

Minimal Role of Dietitian–1 NORMAL LIFE-CYCLE CONDITIONS Pregnancy, normal Lactation Infant, normal (birth up to 6 months) Infant, normal (6–12 months) (1–2) DIETARY PRACTICES AND MISCELLANEOUS CONDITIONS Periodontal disease (1–2) Temporomandibular joint (TMJ) dysfunction Skin disorders (acne, rosacea, eczema, psoriasis) Ménière’s syndrome

Some Roles of Dietitian–2

Moderate Role of Dietitian–3

Child, normal (1–2) Teenager, normal Adult male, normal

Pregnancy, high risk

Extended Role of Dietitian–4

Adult female, normal Elderly male, normal Elderly female, normal

Complementary medicine and herbal/ botanical counseling Cultural food pattern, advisement and planning Vegetarian diet advisement or planning

Pressure ulcer, stages 1 or 2 (2–3)

Pressure ulcer, stages 3 or 4 or multiple

Vitamin deficiency prevention or counseling Food allergy, multiple or complex (3–4)

Religious dietary patterns, advisement/ planning Dental difficulties (caries, wired jaw, mouth pain, xerostomia) (2–3) Vision and self-feeding problems (low vision or chewing problems) (1–2) blindness, coordination Food allergy, simple (2–3) Foodborne illness, prevention or counseling (continued)

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TABLE C-2

Acuity for Dietitian Roles in Medical Diagnoses (continued)

Minimal Role of Dietitian–1

Some Roles of Dietitian–2

Moderate Role of Dietitian–3

Extended Role of Dietitian–4

Attention deficit disorders

Abetalipoproteinemia (variable)

Bronchopulmonary dysplasia (3–4)

Failure to thrive, pediatric

Autism spectrum disorders (1–2)

Biliary atresia (2–3)

Cerebral palsy

Inborn errors of carbohydrate metabolism

Adrenoleukodystrophy (variable)

Congenital heart disease

Cleft palate

Hirschsprung’s disease (congenital megacolon)

Leukodystrophies (variable)

Cystinosis and Fanconi’s syndrome (variable)

Homocystinuria (3–4)

HIV infection and AIDS, pediatric

Otitis media

Down syndrome

Maple syrup urine disease (MSUD) (3–4)

Low birth weight or premature infant (3–4)

Fetal alcohol syndrome (1–2)

Medium-chain acyl-CoA dehydrogenase deficiency (MCADD)

Necrotizing enterocolitis

Large for gestational age infant (variable)

Myelomeningocele (variable)

Phenylketonuria (PKU)

Obesity, childhood (prevention, treatment) (3–4)

Tyrosinemia (variable)

Prader–Willi syndrome (3–4)

Urea cycle disorders (variable)

PEDIATRICS: BIRTH DEFECTS, GENETIC, ACQUIRED DISORDERS

Rickets, nutritional Spina bifida and neural tube defects Wilson’s disease (hepatolenticular degeneration) NEUROLOGICAL AND PSYCHIATRIC CONDITIONS Neurological Disorders Migraine headache, prevention or counseling

Epilepsy or seizure disorders

Amyotrophic lateral sclerosis

Brain trauma

Trigeminal neuralgia (1–2)

Multiple sclerosis

Cerebral aneurysm

Coma

Myasthenia gravis and neuromuscular junction disorders

Guillain-Barré syndrome

Parkinson’s disease

Huntington’s chorea (variable)

Tardive dyskinesia

Spinal cord injury Stroke (cerebrovascular accident)

Eating Disorders

Anorexia nervosa Binge eating disorder (3–4) Bulimia (3–4) Other disordered eating patterns (3–4)

Psychiatric Disorders Bipolar disorder (1–2)

Alzheimer’s disease or other dementias

Depression with numerous medications (1–2) Schizophrenia and psychoses (1–2) Substance use disorders (continued)


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APPENDIX C • ACUITY RANKING FOR DIETITIAN SERVICES AND CONCEPT MAP

TABLE C-2

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Acuity for Dietitian Roles in Medical Diagnoses (continued)

Minimal Role of Dietitian–1

Some Roles of Dietitian–2

Moderate Role of Dietitian–3

Extended Role of Dietitian–4

Cor pulmonale (variable)

Chronic obstructive pulmonary diseases (emphysema or chronic bronchitis)

Chylothorax

PULMONARY DISORDERS Asthma

Bronchiectasis

Interstitial lung disease (1–2)

Cystic fibrosis

Bronchitis, acute

Sarcoidosis

Respiratory distress syndrome (3–4)

Pneumonia (1–2)

Sleep apnea

Transplantation, lung (3–4)

Pulmonary embolism (1–2)

Thoracic empyema

Respiratory failure and ventilator dependency

Tuberculosis CARDIOVASCULAR DISORDERS Angina pectoris

Peripheral artery disease

Atherosclerosis, coronary heart disease, and dyslipidemias

Cardiac cachexia

Arteritis

Cardiomyopathies

Heart transplantation or heart– lung transplantation

Pericarditis and cardiac tamponade

Heart failure

Thrombophlebitis

Hypertension Myocardial infarction

GASTROINTESTINAL DISORDERS Upper GI Dyspepsia or indigestion (1–2)

Esophageal varices (2–3)

Dysphagia (3–4)

Hiatal hernia, esophagitis, and gastroesophageal reflux (GERD) (2–3)

Esophageal stricture or spasm, achalasia, or Zenker’s diverticulum

Gastric retention or gastroparesis (2–3)

Esophageal trauma (3–4)

Peptic ulcer

Gastritis and gastroenteritis Giant hypertrophic gastritis (Ménétrier’s disease) Gastrectomy and/or vagotomy (3–4) Vomiting, pernicious

Lower GI Lactose malabsorption (lactase deficiency) (variable)

Diarrhea, dysentery, and traveler’s diarrhea

Fat malabsorption syndrome

Tropical sprue

Constipation (1–2)

Diverticular diseases (2–3)

Megacolon, acquired

Celiac disease

Fecal incontinence

Peritonitis

Irritable bowel disease

Crohn’s disease (3–4)

Hemorrhoids, hemorrhoidectomy

Colostomy (2–3)

Carcinoid syndrome

Ulcerative colitis

Ileostomy

Short bowel syndrome

Intestinal lymphangiectasia (variable)

Intestinal fistula

Whipple’s disease (intestinal lipodystrophy) (3–4)

Intestinal transplantation

Proctitis

(continued)


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TABLE C-2

Acuity for Dietitian Roles in Medical Diagnoses (continued)

Minimal Role of Dietitian–1

Some Roles of Dietitian–2

Moderate Role of Dietitian–3

Extended Role of Dietitian–4

Ascites and chylous ascites

Alcoholic liver disease

Liver transplantation

Hepatitis

Hepatic cirrhosis

Pancreatic insufficiency (2–3)

Hepatic encephalopathy, failure or coma (3–4)

Gallbladder disease, surgical or nonsurgical

Pancreatitis, acute (3–4)

Biliary cirrhosis

Pancreatitis, chronic

Cholestatic liver disease (2–3)

Zollinger–Ellison syndrome (variable)

Adrenocortical insufficiency, chronic

Pregnancy-induced

Metabolic syndrome (3–4)

Type 1 diabetes

Hypertension and preeclampsia

Prediabetes (3–4)

Pancreatic transplantation

Addison’s disease (variable)

Syndrome of inappropriate antidiuretic hormone (SIADH)

Diabetic gastroparesis (3–4)

Type 2 diabetes mellitus, adults

Diabetic ketoacidosis (3–4)

Type 2 diabetes mellitus, children and teens Gestational diabetes

HEPATIC, PANCREATIC, AND BILIARY DISORDERS Jaundice

ENDOCRINE DISORDERS

Cushing’s syndrome (variable) Acromegaly (variable)

Parathyroid disorders

Hyperosmolar hyperglycemic state (3–4)

Hyperaldosteronism (variable)

(altered calcium)

Hypoglycemia, iatrogenic

Hypopituitarism (variable)

Hyperinsulinism and spontaneous hypoglycemia (3–4)

Pheochromocytoma (variable)

Diabetes insipidus

Hyperthyroidism Hypothyroidism WEIGHT MANAGEMENT, UNDERNUTRITION, AND MALNUTRITION

Underweight or unintentional weight loss (3–4)

Overweight or uncomplicated obesity

Protein–calorie malnutrition, mild (3–4)

Obesity, medical (with comorbidities) Protein–calorie malnutrition, moderate or severe Energy malnutrition Refeeding syndrome

MUSCULOSKELETAL AND COLLAGEN DISORDERS Ankylosing spondylitis (variable)

Immobilization, extended

Myofascial pain syndromes: fibromyalgia or polymyalgia rheumatica

Muscular dystrophy

Osteomyelitis, acute (1–2)

Osteoarthritis and degenerative joint disease

Paget’s disease (osteitis deformans) (variable)

Osteopenia and osteomalacia

Polyarteritis nodosa (variable)

Osteoporosis

Rheumatoid arthritis

Systemic lupus erythematosus

Rhabdomyolysis (variable)

Ruptured intervertebral disc Scleroderma (systemic sclerosis) (1–2) (continued)


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TABLE C-2

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Acuity for Dietitian Roles in Medical Diagnoses (continued)

Minimal Role of Dietitian–1

Some Roles of Dietitian–2

Moderate Role of Dietitian–3

Extended Role of Dietitian–4

Breast cancer

Brain tumor

Bone marrow transplantation

Choriocarcinoma

Esophageal cancer (3–4)

Leukemia, chronic

Gastric carcinoma (3–4)

Lung cancer

Hepatic carcinoma

Myeloma (simple or multiple) (2–3)

Intestinal carcinoma (3–4)

Prostate cancer

Leukemia, acute

HEMATOLOGY: ANEMIAS AND BLOOD DISORDERS Aplastic anemia

Anemia, hemolytic from vitamin E deficiency (2–3)

Anemia from parasitic infestation

Anemia, iron deficiency

Anemia, sickle cell

Anemia, nutritional (folic acid, copper, etc.)

Anemia, sideroblastic

Anemia, pernicious or vitamin B12 deficiency

Polycythemia vera (Osler’s disease)

Hemochromatosis (iron overloading)

Thalassemia (Cooley’s anemia)

Hemorrhage, acute or chronic

Thrombocytic purpura CANCER

Lymphoma, Hodgkin’s disease Lymphoma, non-Hodgkin’s Oral cancer (3–4) Osteosarcoma (2–3) Pancreatic carcinoma Radiation colitis or enteritis (3–4) Wilms’ tumor (embryoma of kidney) SURGICAL DISORDERS Appendectomy

Surgery, general

Bowel surgery

Cesarean delivery

Sodium imbalances: hyponatremia or hypernatremia

Open heart surgery

Hysterectomy, abdominal

Potassium imbalances: hypokalemia or hyperkalemia

Pancreatic surgery (3–4)

Pelvic exenteration

Calcium imbalances: hypocalcemia or hypercalcemia

Spinal surgery (1–2)

Magnesium imbalances: hypomagnesemia or hypermagnesemia

Total hip arthroplasty

Phosphate imbalances: hypophosphatemia or hyperphosphatemia

Tonsillectomy and adenoidectomy

Amputation, one or more limbs

Gastric bypass surgery

Parathyroidectomy (continued)


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NUTRITION AND DIAGNOSIS-RELATED CARE

TABLE C-2

Acuity for Dietitian Roles in Medical Diagnoses (continued)

Minimal Role of Dietitian–1

Some Roles of Dietitian–2

Moderate Role of Dietitian–3

Extended Role of Dietitian–4

Candidiasis

Bacterial endocarditis

AIDS and HIV infection, adult (3–4)

Burns, major thermal injury

Chronic fatigue syndrome (1–2)

Burns, minor thermal injury

Sepsis or septicemia

Multiple organ dysfunction

Fever 102F

Encephalitis or Reye’s syndrome

Trauma, major

Herpes simplex 1 or 2

Fracture, hip or long bone

Herpes zoster (shingles)

Trauma, minor

AIDS, INFECTIONS, BURNS, IMMUNOLOGY, AND TRAUMA

Infection, general Influenza (flu, respiratory) Intestinal parasites Meningitis Mononucleosis Pelvic inflammatory disease Poliomyelitis Rheumatic fever Toxic shock syndrome Trichinosis Typhoid fever RENAL DISORDERS Pyelonephritis

Inborn errors: polycystic kidney disease

Inborn errors: vitamin D–resistant rickets (3–4)

Chronic kidney disease

Urolithiasis (renal stones) (1–2)

Glomerulonephritis, acute

Inborn errors: Hartnup disease (variable)

Hemodialysis

Glomerulonephritis, chronic

Nephrosclerosis (2–3)

Peritoneal renal dialysis

Nephritis (Bright’s disease) (2–3)

Renal failure, acute

Renal transplantation

Nephrotic syndrome (2–3) ENTERAL–PARENTERAL NUTRITION

Tube feeding, initiation, monitoring, or home Parenteral nutrition, initiation, monitoring, or home

Thanks to Matthew Dallas, MS, RD, for summarizing this table.


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APPENDIX C • ACUITY RANKING FOR DIETITIAN SERVICES AND CONCEPT MAP

989

Current Appetite Level

Client’s Initials: _____ Client’s Age: _____ Client’s Gender: _____

Current ht/wt Current Diet Order

Diagnosis/Reason for Nutrition Assessment

Previous ht/wt

Nutrition Support

UBW/%UBW

A

Dietary Supplements

Anthropometric Data % Weight Change

B Biochemical Data

C Clinical/Client History

IBW/%IBW

Food/Nutrition History Data

D Dietary

BMI Physical Examination

Social /Personal/ Family History Current Intake

Diabetic Exchanges Normal Lab Values

Abnormal Lab Values

Medical Hx/Tx

Activity/Restrictions

Signs/Symptoms

Medications

Total kcal & Protein

Nutrient Needs

Total kcal

Protein

Fluid

Standard

Standard

Standard

Figure C-1 Concept Map. Used with permission from Molaison, E.F., Taylor, K., Erickson, D., and Connell, C.L. (2009). Perception of concept mapping as a learning tool by dietetic internship students and preceptors. Journal of Allied Health, 38, e-97–e-103.


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NUTRITION AND DIAGNOSIS-RELATED CARE

Lifestyle A In ller to ge le n ra s nc & es

•Food •Culture •Environment •Movement •Nature •Relationships

Ne

•Sleep •Stress •Spirituality •Sunlight •Supplements •Traditions

ga &

tiv e Be Tho lie ugh fs ts

Systems Signs & Symptoms

Core Imbalances

Nutrition Physical

Assessment Diagnosis Intervention Monitoring Evaluation

s

Nutrition Care Process

•Circulatory •Nervous •Digestive •Reproductive •Endocrine •Respiratory •Immune •Skeletal •Integumentary •Urinary •Lymph •Musculoskeletal

ens

hog

gen

Pat

etic

•Digestion •Detoxification •Energy Metabolism •Inflammation •Neuro-Endocrine-Immune •Nutritional Status •Oxidative stress •Structural Integrity

Epi

990

Metabolic Pathways

Biomarkers

•Anabolic / Catabolic •Nutrient Cofactors •Cellular Respiration •Eicosanoid Series •Methionine Pathway •Biotransformation •Steroidogenic Pathway •Urea Cycle

•Anthropometrics •Fatty Acids •Genomics-SNPs •Glucose/Insulin •Organic acids •Protein/Amino Acids •Vitamins & Minerals Toxins

Figure C-2 Integrative & Functional Medical Nutrition Therapy (IFMNT) Process Guide. (© 2010 Copyright. Used with permission from M. Swift, D. Noland & E. Redmond.)


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PantoThiaRibothenic Biotin Cholineg Life Stage Vit A Vit C Vit D Vit E Vit K min flavin Niacin Vit B 6 Folate Vit B 12 Group (µg/d)a (mg/d) d (µg/d) f (µg/d) Acid (mg/d) (µg/d) (mg/d) (mg/d) (µg/d)b,c (µg/d) (mg/d) (mg/d) (mg/d)e (mg/d) Infants 0–6 mo 400* 40* 5* 4* 2.0* 0.2* 0.3* 2* 0.1* 65* 0.4* 1.7* 5* 125* 7–12 mo 500* 50* 5* 5* 2.5* 0.3* 0.4* 4* 0.3* 80* 0.5* 1.8* 6* 150* Children 5* 30* 2* 8* 200* 300 15 6 0.5 0.5 6 0.5 150 0.9 1–3 y 4–8 y 5* 55* 3* 12* 250* 400 25 7 0.6 0.6 8 0.6 200 1.2 Males 5* 60* 4* 20* 375* 600 45 11 0.9 0.9 12 1.0 300 1.8 9–13 y 14–18 y 5* 75* 5* 25* 550* 900 75 15 1.2 1.3 16 1.3 400 2.4 19–30 y 5* 120* 5* 30* 550* 900 90 15 1.2 1.3 16 1.3 400 2.4 31–50 y 5* 120* 5* 30* 550* 900 90 15 1.2 1.3 16 1.3 400 2.4 51–70 y 10* 120* 2.4i 5* 30* 550* 900 90 15 1.2 1.3 16 1.7 400 > 70 y 15* 120* 2.4i 5* 30* 550* 900 90 15 1.2 1.3 16 1.7 400 Females 5* 60* 4* 20* 375* 600 45 11 0.9 0.9 12 1.0 300 1.8 9–13 y 14–18 y 5* 75* 400i 5* 25* 400* 700 65 15 1.0 1.0 14 1.2 2.4 19–30 y 5* 90* 400i 5* 30* 425* 700 75 15 1.1 1.1 14 1.3 2.4 31–50 y 90* 400i 5* 30* 425* 700 75 15 1.1 1.1 14 1.3 2.4 h 51–70 y 10* 90* 2.4 5* 30* 425* 700 75 15 1.1 1.1 14 1.5 400 > 70 y 15* 90* 2.4h 5* 30* 425* 700 75 15 1.1 1.1 14 1.5 400 Pregnancy 14–18 y 5* 75* 600j 6* 30* 450* 750 80 15 1.4 1.4 18 1.9 2.6 19–30 y 5* 90* 600j 6* 30* 450* 770 85 15 1.4 1.4 18 1.9 2.6 j 31–50 y 5* 90* 600 6* 30* 450* 770 85 15 1.4 1.4 18 1.9 2.6 Lactation 14–18 y 5* 75* 7* 35* 550* 1,200 115 19 1.4 1.6 17 2.0 500 2.8 19–30 y 5* 90* 7* 35* 550* 1,300 120 19 1.4 1.6 17 2.0 500 2.8 31–50 y 5* 90* 7* 35* 550* 1,300 120 19 1.4 1.6 17 2.0 500 2.8 NOTE: This table (taken from the DRI reports, see www.na p.edu) presents Recommended Dietary Allowances (RDA s) in bold type and Adequate Intakes (AIs) in ordinary type followed by an asterisk (*). RDAs and AIs may both be used as goals for individual intake. RDAs are set to meet the needs of almost all (97 to 98 percent) individuals in a group. For healthy breastfed infants, the AI is the mean intake. The AI for other life stage and gender groups is believed to cover needs of all individuals in the group, but lack of data or uncertainty in the data prevent being able to specify with confidence the percentage of individuals covered by this intake. a As retinol activity equivalents (RAEs). 1 RAE = 1 μg retinol, 12 μg β-carotene, 24 μg α-carotene, or 24 μg β-cryptoxanthin. The RAE for dietary provitamin A carotenoids is twofold greater than retinol equivalents (RE), whereas the RAE for preformed vitamin A is the same as RE. b As cholecalciferol. 1 µg cholecalciferol = 40 IU vitamin D. c In the absence of adequate exposure to sunlight. d As α-tocopherol. α-Tocopherol includes RRR-α-tocopherol, the only form of α-tocopherol that occurs naturally in foods, and the 2R-stereoisomeric forms of α-tocopherol (RRR-, RSR-, RRS-, and RSS-α-tocopherol) that occur in fortified foods and supplements. It does not include the 2S-stereoisomeric forms of α-tocopherol (SRR-, SSR-, SRS-, and SSS-α-tocopherol), also found in fortified foods and supplements. e As niacin equivalents (NE). 1 mg of niacin = 60 mg of tryptophan; 0–6 months = preformed niacin (not NE). f As dietary folate equivalents (DFE). 1 DFE = 1 µg food folate = 0.6 µg of folic acid from fortified food or as a supplement consumed with food = 0.5 µg of a supplement taken on an empty stomach. g Although AIs have been set for choline, there are few data to assess whether a dietary supply of choline is needed at all stages of the life cycle, and it may be that the choline requirement can be met by endogenous synthesis at some of these stages. h Because 10 to 30 percent of older people may malabsorb food-bound B12, it is advisable for those older than 50 years to meet their RDA mainly by consuming foods fortified with B12 or a supplement containing B12. i In view of evidence linking folate intake with neural tube defects in the fetus, it is recommended that all women capable of becoming pregnant consume 400 µg from supplements or fortified foods in addition to intake of food folate from a varied diet. jk It is assumed that women will continue consuming 400 µg from supplements or fortified food until their pregnancy is confirmed and they enter prenatal care, which ordinarily occurs after the end of the periconceptional period—the critical time for formation of the neural tube. Copyright 2004 by the National Academy of Sciences. All rights reserved.

Dietary Reference Intakes (DRIs): Recommended Intakes for Individuals, Vitamins Food and Nutrition Board, Institute of Medicine, National Academies

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Copyright 2004 by the National Academy of Sciences. All rights reserved.

SOURCES: Dietary Reference Intakes for Calcium, Phosphorous, Magnesium, Vitamin D, and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline (1998); Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000); Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc (2001); and Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate (2004). These reports may be accessed via http://www.nap.edu.

Life Stage Calcium Chromium Copper Fluoride Iodine Iron Magnesium Manganese Molybdenum Phosphorus Selenium Zinc Potassium Sodium Chloride (mg/d) (µg/d) (mg/d) (µg/d) (mg/d) (g/d) (g/d) Group (mg/d) (µg/d) (µg/d) (mg/d) (µg/d) (mg/d) (mg/d) (g/d) Infants 210* 0.01* 30* 0–6 mo 0.2* 200* 110* 0.27* 0.003* 2* 100* 15* 2* 0.4* 0.12* 0.18* 7–12 mo 270* 5.5* 220* 0.5* 130* 75* 0.6* 3* 275* 20* 0.7* 0.37* 0.57* 11 3 Children 500* 11* 0.7* 1.2* 3.0* 1.0* 1.5* 340 90 7 80 17 460 20 3 1–3 y 4–8 y 800* 15* 1* 1.5* 3.8* 1.2* 1.9* 440 90 10 130 22 500 30 5 Males 1,300* 25* 2* 1.9* 4.5* 1.5* 2.3* 700 120 8 240 34 1,250 40 8 9–13 y 14–18 y 1,300* 35* 3* 2.2* 4.7* 1.5* 2.3* 890 150 11 410 43 1,250 55 11 19–30 y 1,000* 35* 4* 2.3* 4.7* 1.5* 2.3* 900 150 8 400 45 700 55 11 31–50 y 1,000* 35* 4* 2.3* 4.7* 1.5* 2.3* 900 150 8 420 45 700 55 11 51–70 y 1,200* 30* 4* 2.3* 4.7* 1.3* 2.0* 900 150 8 420 45 700 55 11 > 70 y 1,200* 30* 4* 2.3* 4.7* 1.2* 1.8* 900 150 8 420 45 700 55 11 Females 1,300* 21* 2* 1.6* 4.5* 1.5* 2.3* 700 120 8 240 34 1,250 40 8 9–13 y 14–18 y 1,300* 24* 3* 1.6* 4.7* 1.5* 2.3* 890 150 15 360 43 1,250 55 9 19–30 y 1,000* 25* 3* 1.8* 4.7* 1.5* 2.3* 900 150 18 310 45 700 55 8 31–50 y 1,000* 25* 3* 1.8* 4.7* 1.5* 2.3* 900 150 18 320 45 700 55 8 51–70 y 1,200* 20* 3* 1.8* 4.7* 1.3* 2.0* 900 150 8 320 45 700 55 8 > 70 y 1,200* 20* 3* 1.8* 4.7* 1.2* 1.8* 900 150 8 320 45 700 55 8 Pregnancy 14–18 y 1,300* 29* 3* 2.0* 4.7* 1.5* 2.3* 1,000 220 27 400 50 1,250 60 13 19–30 y 1,000* 30* 3* 2.0* 4.7* 1.5* 2.3* 1,000 220 27 350 50 700 60 11 31–50 y 1,000* 30* 3* 2.0* 4.7* 1.5* 2.3* 1,000 220 27 360 50 700 60 11 Lactation 14–18 y 1,300* 44* 3* 2.6* 5.1* 1.5* 2.3* 1,300 290 10 360 50 1,250 70 14 19–30 y 1,000* 45* 3* 2.6* 5.1* 1.5* 2.3* 1,300 290 9 310 50 700 70 12 31–50 y 1,000* 45* 3* 2.6* 5.1* 1.5* 2.3* 1,300 290 9 320 50 700 70 12 NOTE: This table presents Recommended Dietary Allowances (RDAs) in bold type and Adequate Intakes (AIs) in ordinary type followed by an asterisk (*). RDAs and AIs may both be used as goals for individual intake. RDAs are set to meet the needs of almost all (97 to 98 percent) individuals in a group. For healthy breastfed infants, the AI is the mean intake. The AI for other life stage and gender groups is believed to cover needs of all individuals in the group, but lack of data or uncertainty in the data prevent being able to specify with confidence the percentage of individuals covered by this intake.

Dietary Reference Intakes (DRIs): Recommended Intakes for Individuals, Elements Food and Nutrition Board, Institute of Medicine, National Academies

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SOURCES: Dietary Reference Intakes for Calcium, Phosphorous, Magnesium, Vitamin D, and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline (1998); Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000); and Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc (2001). These reports may be accessed via http://www.nap.edu.

Biotin Choline CaroteVitamin C Vitamin B6 Folate Vitamin E Life Stage Vitamin A Vitamin K Thiamin RiboNiacin Vitamin B 12 Pantothenic Vitamin D Group (µg/d)b flavin (mg/d)d noidse Acid (g/d) (mg/d) (mg/d) (mg/d)c,d (μg/d)d (μg/d) Infants 600 ND f 25 ND ND ND ND ND ND ND ND ND ND ND ND 0−6 mo 600 ND 25 ND ND ND ND ND ND ND ND ND ND ND ND 7−12 mo Children 600 400 50 200 ND ND ND 10 30 300 ND ND ND 1.0 ND 1−3 y 900 650 50 300 ND ND ND 15 40 400 ND ND ND 1.0 ND 4−8 y Males, Females 1,700 1,200 50 600 ND ND ND 20 60 600 ND ND ND 2.0 ND 9−13 y 2,800 1,800 50 800 ND ND ND 30 80 800 ND ND ND 3.0 ND 14−18 y 3,000 2,000 50 1,000 ND ND ND 35 100 1,000 ND ND ND 3.5 ND 19−70 y > 70 y 3,000 2,000 50 1,000 ND ND ND 35 100 1,000 ND ND ND 3.5 ND Pregnancy 14–18 y 2,800 1,800 50 800 ND ND ND 30 80 800 ND ND ND 3.0 ND 3,000 2,000 50 1,000 ND ND ND 35 100 1,000 ND ND ND 3.5 ND 19−50 y Lactation 14–18 y 2,800 1,800 50 800 ND ND ND 30 80 800 ND ND ND 3.0 ND 3,000 2,000 50 1,000 ND ND ND 35 100 1,000 ND ND ND 3.5 ND 19−50 y a UL = The maximum level of daily nutrient intake that is likely to pose no risk of adverse effects. Unless otherwise specified, the UL represents total intake from food, water, and supplements. Due to lack of suitable data, ULs could not be established for vitamin K, thiamin, riboflavin, vitamin B12, pantothenic acid, biotin, carotenoids. In the absence of ULs, extra caution may be warranted in consuming levels above recommended intakes. b As preformed vitamin A only. c As α-tocopherol; applies to any form of supplemental α-tocopherol. d The ULs for vitamin E, niacin, and folate apply to synthetic forms obtained from supplements, fortified foods, or a combination of the two. e β-Carotene supplements are advised only to serve as a provitamin A source for individuals at risk of vitamin A deficiency. f ND = Not determinable due to lack of data of adverse effects in this age group and concern with regard to lack of ability to handle excess amounts. Source of intake should be from food only to prevent high levels of intake.

Dietary Reference Intakes (DRIs): Tolerable Upper Intake Levels (UL a), Vitamins Food and Nutrition Board, Institute of Medicine, National Academies

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ND ND

3 6

11 17 20 20

17 20

17 20

ND ND

ND ND ND ND

ND ND

ND ND

Boron (mg/d)

NDf ND

Arsenicb

2.5 2.5

2.5 2.5

2.5 2.5 2.5 2.5

2.5 2.5

ND ND

Calcium (g/d)

ND ND

ND ND

ND ND ND ND

ND ND

ND ND

Chromium

8,000 10,000

8,000 10,000

5,000 8,000 10,000 10,000

1,000 3,000

ND ND

Copper (µg/d)

10 10

10 10

10 10 10 10

1.3 2.2

0.7 0.9

Fluoride (mg/d)

900 1,100

900 1,100

600 900 1,100 1,100

200 300

ND ND

Iodine (µg/d)

45 45

45 45

40 45 45 45

40 40

40 40

Iron (mg/d)

350 350

350 350

350 350 350 350

65 110

ND ND

Magnesium (mg/d)c

9 11

9 11

6 9 11 11

2 3

ND ND

Manganese (mg/d)

1,700 2,000

1,700 2,000

1,100 1,700 2,000 2,000

300 600

ND ND

Molybdenum (µg/d)

1.0 1.0

1.0 1.0

0.6 1.0 1.0 1.0

0.2 0.3

ND ND

Nickel (mg/d)

4 4

3.5 3.5

4 4 4 3

3 3

ND ND

Phosphorus (g/d)

ND ND

ND ND

ND ND ND ND

ND ND

ND ND

Potassium

400 400

400 400

280 400 400 400

90 150

45 60

Selenium (µg/d)

ND ND

ND ND

ND ND ND ND

ND ND

ND ND

Silicond

ND ND

ND ND

ND ND ND ND

ND ND

ND ND

Sulfate

ND ND

ND ND

ND ND 1.8 1.8

ND ND

ND ND

Vanadium (mg/d)e

34 40

34 40

23 34 40 40

7 12

4 5

Zinc (mg/d)

3.6 3.6

3.6 3.6

2.3 2.3 2.3 2.3

3.4 3.6 3.6 3.6

2.3 2.9

ND ND

Chloride (g/d)

2.2 2.3 2.3 2.3

1.5 1.9

ND ND

Sodium (g/d)

Copyright 2004 by the National Academy of Sciences. All rights reserved.

SOURCES: Dietary Reference Intakes for Calcium, Phosphorous, Magnesium, Vitamin D, and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline (1998); Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000); Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc (2001); and Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate (2004). These reports may be accessed via http://www.nap.edu.

UL = The maximum level of daily nutrient intake that is likely to pose no risk of adverse effects. Unless otherwise specified, the UL represents total intake from food, water, and supplements. Due to lack of suitable data, ULs could not be established for arsenic, chromium, silicon, potassium, and sulfate. In the absence of ULs, extra caution may be warranted in consuming levels above recommended intakes. b Although the UL was not determined for arsenic, there is no justification for adding arsenic to food or supplements. c The ULs for magnesium represent intake from a pharmacological agent only and do not include intake from food and water. d Although silicon has not been shown to cause adverse effects in humans, there is no justification for adding silicon to supplements. e Although vanadium in food has not been shown to cause adverse effects in humans, there is no justification for adding vanadium to food and vanadium supplements should be used with caution. The UL is based on adverse effects in laboratory animals and this data could be used to set a UL for adults but not children and adolescents. f ND = Not determinable due to lack of data of adverse effects in this age group and concern with regard to lack of ability to handle excess amounts. Source of intake should be from food only to prevent high levels of intake.

a

Life Stage Group Infants 0−6 mo 7−12 mo Children 1−3 y 4−8 y Males, Females 9−13 y 14−18 y 19−70 y >70 y Pregnancy 14–18 y 19−50 y Lactation 14–18 y 19−50 y

Dietary Reference Intakes (DRIs): Tolerable Upper Intake Levels (UL a), Elements Food and Nutrition Board, Institute of Medicine, National Academies

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996

NUTRITION AND DIAGNOSIS-RELATED CARE

Dietary Reference Intakes (DRIs): Estimated Energy Requirements (EER) for Men and Women 30 Years of Agea Food and Nutrition Board, Institute of Medicine, National Academies Weight for BMIc Weight for BMI EER, Mend (kcal/day) EER, Womend (kcal/day) 2 2 Height of 18.5 kg/m of 24.99 kg/m BMI of BMI of BMI of 24.99 BMI of (m [in]) PALb (kg [lb]) (kg [lb]) 18.5 kg/m2 24.99 kg/m2 18.5 kg/m2 kg/m2 1.50 (59) Sedentary 41.6 (92) 56.2 (124) 1,848 2,080 1,625 1,762 Low active 2,009 2,267 1,803 1,956 Active 2,215 2,506 2,025 2,198 Very active 2,554 2,898 2,291 2,489 1.65 (65) Sedentary Low active Active Very active

50.4 (111)

68.0 (150)

2,068 2,254 2,490 2,880

2,349 2,566 2,842 3,296

1,816 2,016 2,267 2,567

1,982 2,202 2,477 2,807

1.80 (71) Sedentary 59.9 (132) 81.0 (178) 2,301 2,635 2,015 2,211 Low active 2,513 2,884 2,239 2,459 Active 2,782 3,200 2,519 2,769 Very active 3,225 3,720 2,855 3,141 a For each year below 30, add 7 kcal/day for women and 10 kcal /day for men. For each year above 30, subtract 7 kcal/day for women and 10 kcal/day for men. b PAL = physical activity level. c BMI = body mass index. d Derived from the following regression equations based on doubly labeled water data: Adult man: EER = 662 – 9.53 × age (y) + PA × (15.91 × wt [kg] + 539.6 × ht [m]) Adult woman: EER = 354 – 6.91 × age (y) + PA × (9.36 × wt [kg] + 726 × ht [m]) Where PA refers to coefficient for PAL PAL = total energy expenditure ÷ basal energy expenditure PA = 1.0 if PAL ≥ 1.0 < 1.4 (sedentary) PA = 1.12 if PAL ≥ 1.4 < 1.6 (low active) PA = 1.27 if PAL ≥ 1.6 < 1.9 (active) PA = 1.45 if PAL ≥ 1.9 < 2.5 (very active)

Dietary Reference Intakes (DRIs): Acceptable Macronutrient Distribution Ranges Food and Nutrition Board, Institute of Medicine, National Academies Range (percent of energy) Macronutrient Children, 1–3 y Children, 4–18 y Adults Fat 30–40 25–35 20–35 n-6 polyunsaturated fatty acidsa (linoleic acid) 5–10 5–10 5–10 0.6–1.2 0.6–1.2 0.6–1.2 n-3 polyunsaturated fatty acidsa (α-linolenic acid) Carbohydrate 45–65 45–65 45–65 Protein 5–20 10–30 10–35 a Approximately 10% of the total can come from longer-chain n-3 or n-6 fatty acids.

SOURCE: Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (2002).


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APPENDIX D • DIETARY REFERENCE INTAKES

Dietary Reference Intakes (DRIs): Recommended Intakes for Individuals, Macronutrients Food and Nutrition Board, Institute of Medicine, National Academies Total Total Linoleic α-Linolenic Acid Acid Proteinb Life Stage Group Water a Carbohydrate Fiber Fat (g/d) (g/d) (g/d) (g/d) (g/d) (g/d) (L/d) Infants 0–6 mo 0.7* 60* ND 31* 4.4* 0.5* 9.1* 7–12 mo 0.8* 95* ND 30* 4.6* 0.5* 13.5 Children 1–3 y 1.3* 19* ND 7* 0.7* 130 13 4–8 y 1.7* 25* ND 10* 0.9* 130 19 Males 9–13 y 2.4* 31* ND 12* 1.2* 130 34 14–18 y 3.3* 38* ND 16* 1.6* 130 52 19–30 y 3.7* 38* ND 17* 1.6* 130 56 31–50 y 3.7* 38* ND 17* 1.6* 130 56 51–70 y 3.7* 30* ND 14* 1.6* 130 56 > 70 y 3.7* 30* ND 14* 1.6* 130 56 Females 9–13 y 2.1* 26* ND 10* 1.0* 130 34 14–18 y 2.3* 26* ND 11* 1.1* 130 46 19–30 y 2.7* 25* ND 12* 1.1* 130 46 31–50 y 2.7* 25* ND 12* 1.1* 130 46 51–70 y 2.7* 21* ND 11* 1.1* 130 46 > 70 y 2.7* 21* ND 11* 1.1* 130 46 Pregnancy 14–18 y 3.0* 28* ND 13* 1.4* 175 71 19–30 y 3.0* 28* ND 13* 1.4* 175 71 31–50 y 3.0* 28* ND 13* 1.4* 175 71 Lactation 14–18 y 3.8* 29* ND 13* 1.3* 210 71 19–30 y 3.8* 29* ND 13* 1.3* 210 71 31–50 y 3.8* 29* ND 13* 1.3* 210 71 NOTE: This table presents Recommended Dietary Allowances (RDAs) in bold type and Adequate Intakes (AIs) in ordinary type followed by an asterisk (*). RDAs and AIs may both be used as goals for individual intake. RDAs are set to meet the needs of almost all (97 to 98 percent) individuals in a group. For healthy infants fed human milk, the AI is the mean intake. The AI for other life stage and gender groups is believed to cover the needs of all individuals in the group, but lack of data or uncertainty in the data prevent being able to specify with confidence the percentage of individuals covered by this intake. a Total water includes all water contained in food, beverages, and drinking water. b Based on 0.8 g/kg body weight for the reference body weight. Dietary Reference Intakes (DRIs): Additional Macronutrient Recommendations Food and Nutrition Board, Institute of Medicine, National Academies Macronutrient Recommendation Dietary cholesterol As low as possible while consuming a nutritionally adequate diet Trans fatty acids As low as possible while consuming a nutritionally adequate diet Saturated fatty acids As low as possible while consuming a nutritionally adequate diet Added sugars Limit to no more than 25% of total energy SOURCE: Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (2002).

997


11 15

27 44 46 46 46 46

28 38 38 38 38 38

50 50 50

60 60 60

100 100 100 100 100 100

100 100 100 100 100 100

135 135 135

160 160 160

10

Protein (g/d)

100 100

CHO (g/d)

880 900 900

530 550 550

420 485 500 500 500 500

445 630 625 625 625 625

210 275

Vit A (μg/d)a

96 100 100

66 70 70

39 56 60 60 60 60

39 63 75 75 75 75

13 22

Vit C (mg/d)

16 16 16

12 12 12

9 12 12 12 12 12

9 12 12 12 12 12

5 6

Vit E (mg/d)b

1.2 1.2 1.2

1.2 1.2 1.2

0.7 0.9 0.9 0.9 0.9 0.9

0.7 1.0 1.0 1.0 1.0 1.0

0.4 0.5

Thiamin (mg/d)

1.3 1.3 1.3

1.2 1.2 1.2

0.8 0.9 0.9 0.9 0.9 0.9

0.8 1.1 1.1 1.1 1.1 1.1

0.4 0.5

Riboflavin (mg/d)

13 13 13

14 14 14

9 11 11 11 11 11

9 12 12 12 12 12

5 6

Niacin (mg/d)c

1.7 1.7 1.7

1.6 1.6 1.6

0.8 1.0 1.1 1.1 1.3 1.3

0.8 1.1 1.1 1.1 1.4 1.4

0.4 0.5

Vit B 6 (mg/d)

450 450 450

520 520 520

250 330 320 320 320 320

250 330 320 320 320 320

120 160

Folate (μg/d)a

2.4 2.4 2.4

2.2 2.2 2.2

1.5 2.0 2.0 2.0 2.0 2.0

1.5 2.0 2.0 2.0 2.0 2.0

0.7 1.0

Vit B 12 (μg/d)

209 209 209

160 160 160

785 800 800 985 1,000 1,000

73 95 95 95 95 95

73 95 95 95 95 95

65 65

Iodine (μg/d)

540 685 700 700 700 700

540 685 700 700 700 700

260 340

Copper (μg/d)

7 6.5 6.5

23 22 22

5.7 7.9 8.1 8.1 5 5

5.9 7.7 6 6 6 6

3.0 4.1

6.9

Iron (mg/d)

300 255 265

335 290 300

200 300 255 265 265 265

200 340 330 350 350 350

65 110

Magnesium (mg/d)

35 36 36

40 40 40

26 33 34 34 34 34

26 33 34 34 34 34

13 17

Molybdenum (μg/d)

1,055 580 580

1,055 580 580

1,055 1,055 580 580 580 580

1,055 1,055 580 580 580 580

380 405

Phosphorus (mg/d)

59 59 59

49 49 49

35 45 45 45 45 45

35 45 45 45 45 45

17 23

Selenium (μg/d)

10.9 10.4 10.4

10.5 9.5 9.5

7.0 7.3 6.8 6.8 6.8 6.8

7.0 8.5 9.4 9.4 9.4 9.4

2.5 4.0

2.5

Zinc (mg/d)

Copyright 2002 by the National Academy of Sciences. All rights reserved.

SOURCES: Dietary Reference Intakes for Calcium, Phosphorous, Magnesium, Vitamin D, and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline (1998); Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000); Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc (2001), and Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (2002). These reports may be accessed via www.nap.edu.

a

As retinol activity equivalents (RAEs). 1 RAE = 1 μg retinol, 12 μg β-carotene, 24 μg α-carotene, or 24 μg β-cryptoxanthin. The RAE for dietary provitamin A carotenoids is two-fold greater than retinol equivalents (RE), whereas the RAE for preformed vitamin A is the same as RE. b As α-tocopherol. α-Tocopherol includes RRR-α-tocopherol, the only form of α-tocopherol that occurs naturally in foods, and the 2R-stereoisomeric forms of α-tocopherol (RRR-, RSR-, RRS-, and RSS-α-tocopherol) that occur in fortified foods and supplements. It does not include the 2S-stereoisomeric forms of α-tocopherol (SRR-, SSR-, SRS-, and SSS-α-tocopherol), also found in fortified foods and supplements. c As niacin equivalents (NE). 1 mg of niacin = 60 mg of tryptophan. d As dietary folate equivalents (DFE). 1 DFE = 1 µg food folate = 0.6 µg of folic acid from fortified food or as a supplement consumed with food = 0.5 µg of a supplement taken on an empty stomach.

NOTE: This table presents Estimated Average Requirements (EARs), which serve two purposes: for assessing a dequacy of population intakes, and as the basis for calculating Recommended Dietary Allowances (RDAs) for individuals for those nutrients. EARs have not been established for vitamin D, vitamin K, pantothenic acid, biotin, choline, calcium, chromium, fluoride, manganese, or other nutrients not yet evaluated via the DRI process.

Infants 7–12 mo Children 1–3 y 4–8 y Males 9–13 y 14–18 y 19–30 y 31–50 y 51–70 y > 70 y Females 9–13 y 14–18 y 19–30 y 31–50 y 51–70 y > 70 y Pregnancy 14–18 y 19–30 y 31–50 y Lactation 14–18 y 19–30 y 31–50 y

Life Stage Group

Dietary Reference Intakes (DRIs): Estimated Average Requirements for Groups Food and Nutrition Board, Institute of Medicine, National Academies

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I

N

D

E

X

Note: Italicized f ’s and t’s refer to figures and tables A1c levels, 523t Abacavir, 834t Abatacept, 681t Abducens nerve, 221t Abetalipoproteinemia, 144–145 Absorption, 384 Acanthocytosis, 144–145 Acarbose, 401, 543 Accidents, 44t Accolate, 296t Accutane (isotretinoin), 112 Acesulfame potassium (Sunette), 533t Acetaldehyde, 174 Acetaminophen, 381, 679t Acetylcholine, 224t, 227 Acetylcholine receptors (AChRs), 251 Achalasia, 390–391 Achondrosplasia, 45t Achromycin V (tetracycline), 486t Acid-base balance, 860t Aciphex (rabeprazole), 409t, 512 Acne, 110, 112 Acquired autoimmune hemolytic anemia, 705t Acquired immunity, 820t Acquired immunodeficiency syndrome (AIDS), 829–837 clinical indicators, 831–832t clinical staging, 830t drugs and side effects, 833, 834–836 nutritional guidelines for, 831t, 833 nutritional objectives for, 832–833 patient education, 833–837 supplements, 833 ACR16, 245 Acrobose (Precose), 547t Acrodermatitis enteropathica, 112 Acromegaly, 573–574 Actigall (ursodiol), 152, 517 Actinomycin D, 787 Actonel (risedronate), 670t, 673 Actos (pioglitazone), 547t Acute anemia, 689t Acute gastritis, 402 Acute glomerulonephritis, 879 Acute leukemia, 793t Acute lymphocytic leukemia, 793t Acute myelogenous leukemia, 793t Acute necrotizing ulcerative gingivitis, 103 Acute pyelonephritis, 894 Acute renal failure (ARF), 864 Acute respiratory distress syndrome (ARDS), 317 Acute stress disorder, 222t Acyclovir, 283, 755t, 835t Adalimumab (Humira), 332t, 681t Adderall (amphetamine), 147t Adderol, 356

Addiction, 287–289 Addison’s disease, 582–584 Adefovir, 834t Adenocarcinoma, 732t Adenoidectomy, 811t Adenoma, 732t Adipex (phentermine), 617t Adjustment disorder, 222t Admixture, 899t Adolescents, 33–37 body mass index for, 605t drug effects, 36 eating behavior, 34 food safety tips, 36 growth and development of, 33–34 HIV infection in, 177–179 nutritional guidelines for, 36–38 nutritional objectives for, 35 pregnancy in, 36t recommended intakes, 35t sports nutrition, 38 supplements, 36 type 1 diabetes in, 521t type 2 diabetes in, 521t, 549–551 Adrenal cortex, 570t, 585–586 Adrenal gland disorders. See also Endocrine disorders Addison’s disease, 582–584 adrenocortical insufficiency, 582–584 hyperaldosteronism, 585–586 pheochromocytoma, 586–588 Adrenalin, 570t Adrenergic system blockers, 361t Adrenocortical insufficiency, 582–584 Adrenocorticotropic hormone, 569t, 571 Adriamycin (doxorubicin), 774, 835t Adrucil (5-fluorouracil), 512 Adults, 44–56 disorders and related genes, 45–46t drugs and side effects, 49, 52t food and nutrition, 48–49 functional foods, 50–51t leading causes of death, 44t nutritional guidelines for, 49–53 nutritional objectives for, 47 nutrition-related concerns for women, 48t single gene disorders in, 141t supplements, 49 ADV (adefovir), 834t Advair, 296t Advil (ibuprofen), 408, 657, 660t AeroBid (flunisolide), 296t African American diet, 85 African diet, 85 Age-related macular degeneration (AMD), 106–108 Aging. See Elderly Agoraphobia, 223t

Agrylin (anagrelide), 727, 729 Albuterol, 296t Alcohol consumption addiction, 288t bone health and, 665t breast cancer and, 784 calories, 51 dietary guideline for, 4t headaches and, 247t heart disease and, 338t pregnancy and, 8 Alcoholic liver disease, 474–477 Alcoholism, 287 Aldosterone, 583, 860t Aldosterone blockers, 361t Aldosteronism, 45t Alendronate (Fosamax), 52t, 670t, 844 Alendronic acid, 669 Aleve (naproxen), 657 Alfalfa, 71t Alfence (rabeprazole), 409t Alferon N, 486t Alimentum, 20 Alitame, 533t Alkeran (melphalan), 798 Alkylating agents, 744t allergens, 125t Allergic pneumonia, 314t Allergies, 122–127 allergens, 125t clinical indicators, 124 education, 131 food processing concerns, 126t gastrointestinal, 122–123 in infants, 21t nutritional guidelines for, 124–125 nutritional objectives for, 124 patient education, 126–127 prevalence of, 122 supplements, 126 symptoms, 122 Allicin, 736t Allium, 736t, 768 Allopregnanolone, 229 Allopurinol (Aloprim), 646 Allyl sulfides, 735t, 736t, 790t Aloe vera, 71t, 534t Aloprim (allopurinol), 646 Alpha carotene, 790t Alpha linolenic acid, 338t, 433 Alpha lipoic acid, 71t, 534t 5-Alpha reductase, 52t Alpha thalassemia, 720 Alpha-1-antitrypsin deficiency, 45t Alpha-adrenergic blockers, 616t Alpha-carotene, 499t Alpha-glucosidase deficiency, 176t Alpha-glucosidase inhibitors, 547t

999


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INDEX

Alphanate, 723 Alport syndrome, 862–863 Alprazolam (Xanax), 284t, 616t Aluminum hydroxide, 396–397, 409t Aluminum-containing binders, 872t Alupent (metaproterenol), 296t Alzheimer’s disease, 45t, 227–231 AM80, 250 Amantadine (Symmetrel), 255t Amaryl (glimepiride), 547t Amica, 71t Amiloride (Midamor), 486t Amino acids, 520 in breast milk, 13t for healthy vision, 108t nutritional relevance, 224t in pregnancy, 7 Aminosalicylates, 436 Aminosalicylic acid, 332t 5-Aminosalicylic acid, 436, 467 Amitiza (lubiprostone), 420t Amitriptyline (Elavil), 284t, 616t, 657 Amnestic disorder, 222t Amoxapine (Asendin), 284t Amoxicillin, 895 Amoxil, 895 Amphetamines, 147t, 288t Amphogel, 409t Amphotericin, 755t Amphotericin-B, 835t Ampicillins, 486t Amputations, 524t, 808t, 809t Amylin (Symlin), 547t Amyotrophic lateral sclerosis (ALS), 45t, 232–234 Anabolic steroids, 258, 288t, 836t, 841t Anadrol-50, 616t Anafranil, 283t, 284t Anagrelide, 727, 729 Anakinra (Kineret), 681t Analgesics, 235, 258, 364t, 376, 496t, 510t, 679t, 683, 755t, 804, 841t Anastrozole (Arimidex), 784 Ancylostoma duodenale, 845t Andersen disease, 176t Androderm, 616t Androgens, 570t, 616t Androstenedione, 40, 42t, 79t Anemia, 687–690. See also Hematologic disorders aplastic, 696–698 assessment factors, 687 in cancer patients, 739t of chronic disease, 690–692 Cooley’s, 720 copper deficiency, 698–700 Diamond-Blackfan, 692–693 Fanconi’s, 696–698 folic acid deficiency, 701–704 glucose-6-phosphate dehydrogenase deficiency, 705t hemolytic, 705–706 iron deficiency, 89t iron tests, 689t iron-deficiency, 706–709 Mediterranean, 720 megaloblastic, 713–714 in neonates, 692–694

parasitic, 710–712 pernicious, 713–714 of prematurity, 692–694 of renal diseases, 694–696 sickle cell, 719 sideroblastic, 715–716 signs and symptoms, 689t spherocytic, 705t Vitamin B12 deficiency, 713–714 Anencephaly, 194 Anesthesia, 804 Anethol, 433, 644 Angina pectoris, 343–345 Angioplasty, 378 Angiotensin, 860t Angiotensin II receptor antagonists, 371t Angiotensin II receptor blockers (ARBs), 886 Angiotensin receptor blockers, 361t Angiotensin-converting enzyme inhibitors (ACEI), 361t, 371t, 872t, 886 Ankylosing spondylitis, 643–644 Anorexia, 739t Anorexia athletica (compulsive exercising), 274t Anorexia nervosa, 266–268, 581 Antabuse (disulfiram), 476 Antacids, 391, 394, 396, 398, 402, 409t, 841t Anthocyanidins, 500t Anthocyanins, 734t, 790t Antiangiogenesis, 732t Antiangiogenic agent, 744t Antianxiety agents, 616t Antibiotic lock technique, 804 Antibiotic ointments, 841t Antibiotics, 152, 154, 160, 193, 296t, 310t, 402, 423, 429, 432, 442t, 459t, 486t, 491t, 498t oral, 841t Antibodies, 732t Anticholinergics, 255t, 296t Anticoagulant therapy, 356 Anticoagulants, 366, 374, 379 Anticonvulsants, 30, 174, 235, 239, 265, 276, 616t Antidepressants, 230t, 255t, 268, 616t, 755t, 835t, 872t Antidiarrheals, 401, 423–424, 429, 432, 459t Antidiuretic hormone, 571 Antiemetic agents, 9, 411, 559, 744t Antiepileptic drugs, 268 Antiestrogen therapy, 784 Antifungals, 835t Antihemophilic factor, 723 Antihistamines, 126, 616t, 727, 755t Anti-hyperglycemics, 547t Antihypertensive agents, 486t, 586, 685 Anti-inflammatory drugs, 230t, 486t, 660t, 683, 685 Anti-inflammatory factors, 13t Antimalarials, 651 Antimetabolites, 744t Antimicrobial factors, 13t Antineoplastic agents, 745t, 835t Antioxidants, 185, 225t, 337t, 339t, 476, 499–500t, 534t, 733, 790t, 835t Antiplatelet drugs, 379 Antiproliferative agents, 893t Antipsychotics, 149, 230t, 276, 283t, 616t

Antithymocyte globulin, 755t Anti-tumor necrosis factor alpha, 431, 432–433 Antiviral agents, 255t, 442t, 486t, 755t Anturane (sulfinpyrazone), 646 Anusol, 466 Anxiety disorders, 222t APalpha, 229 Apigenin, 499t, 734t Aplastic anemia, 696–698 Apokyn (apomorphine hydrochloride), 255t Apolipoprotein B deficiency, 144–145 Apolipoprotein E, 227, 338t Appendectomy, 809t Appetite stimulants, 836t Apresoline (hydralazine), 376 Aptivus, 834t, 835t AquaMEPHYTON (phytonadione), 486t Arachidonic acid, 186 Aralen (chloroquine), 651 Arctic root, 77t Aredia (pamidronate), 673 Arginase, 214t Arginine, 214t, 824t Arginine vasopressin, 571 Argininosuccinate lyase, 214t Argininosuccinate synthetase, 214t Argininosuccinic aciduria, 214t Aricept, 168 Aricept (donepezil), 230t Arimidex (anastrozole), 784 Aripiprazole (Abilify), 283t Aristolochic acid, 79t Arnica, 113 Aromatic amino acid, 483 Arrhythmias, 373 Arsenic trioxide (Trisenox), 798 Artane (trihexyphenidyl), 255t Artemisinin, 712t Arterial vascular disease, 525t Arteritis, 345–347 Arthritis, 638 Ascariasis, 845t Ascites, 477–479 Asendin (amoxapine), 284t Ashwagandha, 746t Asian diet, 85 Aspart (Novolog), 533t Aspartame, 533t Aspartate, 224t Asperger’s disorder, 148 Aspiration pneumonia, 314t Aspirin, 338t, 366, 374, 381, 679t, 697, 727 Astaxanthin, 499t Asthma, 293–296 Astragalus, 80t, 746t Astralgus, 736t Atamet, 255t Atazanavir, 834t Atenolol (Tenormin), 486t, 616t Atherogenic dyslipidemia, 540 Atherosclerosis, 347–351 Athletes, 38–43 children and adolescent athletes, 38 drugs and side effects, 40–42 female, 38 food safety tips, 43 meal planning, 41t


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nutritional guidelines, 40, 42t nutritional objectives for, 39–40 proteins for, 40t supplements, 42, 42t Ativan (lorazepam), 284t Atomoxetine (Strattera), 31, 147t Atonic constipation, 418–419 Atopic dermatitis, 110–111, 112 Atorvastatin, 350t, 886 Atripla, 834t Atrophic gastritis, 401 Atrovent, 296t, 302 Attention-deficit disorders, 145–147, 222t Attention-deficit hyperactivity disorder (ADHD) disorders, 145–147 Autism, 148 Autism spectrum disorder (ASD), 148–150 Autistic disorder, 222t Autoimmune inner-ear disease, 128–129 Autoimmune kidney diseases, 879–881 Autoimmune thyroiditis, 589 Autonomic neuropathy, 524t Avandia (rosiglitazone), 547t Avastin (bevacizumab), 744t, 762 Avenanthramides, 735t Aventyl, 284t, 616t Avlimil, 71t Avonex, 250 Axid (nizatidine), 409t Ayuverda, 71t Azathioprine (Imuran), 250, 312, 329t, 364t, 436, 486t, 496t, 510t, 644, 651, 680t, 755t Azilect (rasagiline), 255t Azithromycin, 310t Azmacort (triamcinolone), 296t B cells, 821t Baclofen, 160, 250, 265 Bacterial diarrheas, 421 Bacterial pneumonia, 314t Bactrim, 486t, 836t, 895 Bad breath, 98t Baking ingredients, 491t Baldness, 52t Ban lan gen, 747t Baraclude (Entecavir), 486t Barberry, 71t Bariatric surgery, 812–815 Barrett’s esophagus, 395 Basal cell carcinoma, 732t Basiliximab, 893t Bassen-Kornzweig syndrome, 144–145 Beans, 491t, 535t Becker muscular dystrophy, 653t Beclomethasone, 755t Bee pollen, 126 Belatacept, 893t Belimumab (Benlysta), 650 Belladonna, 79t Benacol (sterol), 615 Benadryl (diphenhydramine), 616t Benazepril (Lotensin), 886 Benefiber, 235, 420t, 424 Benemid (probenecid), 646 Benlysta (belimumab), 650 Benzo-alpha-pyrones, 735t Benzodiazepines, 284t, 616t

Benzoyl peroxide, 110 Benztropine (Cogentin), 255t Beta thalassemia, 720 Beta-adrenergic blockers, 616t Beta-agonists, 296t Beta-blockers, 356, 361t, 371t, 394, 476, 486t Beta-carotene, 499t, 734t, 736t, 760, 790t Beta-cryptoxanthin, 790t Beta-galactosidofructose, 486t Betaine, 149, 181, 194, 784 Betaine-tHcy methyltransferase (BHMT), 194 Betaseron, 250 Beta-sitosterol, 736t Bevacizumab (Avastin), 744t, 762 Beverages, 492t Bexxar, 744t Bezafibrate, 513 Bezoar formation, 397–399 Biaxin (clarithromycin), 315 Bicytopenia, 698 Bifidobacterium infantis, 444 Bifidus infantis, 193 Bigorexia, 274t Biguanides, 547t Bilberry, 72t, 534t Bile acid sequestrant, 350t Bile salt replacements, 459t Bile salts, 498t Biliary atresia, 150–152 Biliary cirrhosis, 512–514 Biliary disorders, 471–473 Bilirubin, 500t Binge eating disorder, 222t, 269–270 Biochanin A, 736t Bioflavonoids, 736t Biogenic amine, 224t Biogenic monoamines, 224t Biological response modifiers, 681t Biotherapy, 732t Biotin, 119t, 534t Bipolar disorders, 222t, 273–276, 279t Bisacodyl, 417, 420t Bismuth subsalicylate, 409t Bisoprolol, 616t Bisphosphonates, 310t, 670t, 752, 755t, 798, 844 Bitter melon, 72t, 534t Bitter orange, 80t Black cohosh, 72t, 746t Bladder cancer, 772–773 Bleeding disorders, 722–724 Bleomycin, 764t, 835t Blindness, 106–108 Blocadren (timolol), 486t Blood clotting factors, 722t Blood formation, nutritional factors in, 689t Blood glucose, 526t Blood lipids, 526t Blood pressure, 367–369, 526t, 540, 860t, 880 Blood urea nitrogen (BUN), 694 Body dysmorphic disorder, 222t, 274t Body mass index (BMI), 604–605t for adolescents, 605t for children, 198, 605t mortality and, 605t for older adults, 605t for pregnant women, 604t underweight and, 622

1001

Body weight in amputees, 808t calculation of, 604t, 606t Bone cancer, 751–752 Bone disorders, 641–642 Bone marrow transplantation, 753–756 Boniva (ibandronate), 670t Borage, 80t Borage oil, 72t Boron, 665t Bortezomib (Velcade), 798, 893t Bosentan, 306 Boswellia, 72t Botanicals. See Complementary nutrition Botulinum toxin, 195, 246 Bowel surgery, 816–818 Bradycardia, 373 Brain. See also Neurological disorders cranial nerves, 221t nutrients for brain health, 225–226t parts and functions, 220t trauma, 234–236 tumor, 756–758 Brainstem, 220 Branched-chain amino acids (BCAAs), 483 Brancher enzyme deficiency, 176t Breads, 359t Breast cancer, 46t, 782–785. See also Cancer Breast milk, 12 food antigens in, 17 for infants with cerebral palsy, 159 nutrient content of, 13t premature, 186 storage of, 18 Breastfeeding, 12–18. See also Pregnancy from 0-6 months, 19–20 from 6-12 months, 22 benefits of, 14 common problems in, 15t drugs and, 17 food and nutritional recommendations for, 16–17 food safety and, 18 HIV-infected mothers, 178 nutritional objectives for, 14–16 promotion of, 14 recommended intakes in, 16t supplements, 17 Brewer’s yeast, 72t Broken jaw, 99–100 Broken tooth, 98t Bromelain, 72t, 661t, 746t Bromocriptine (Parlodel), 255t, 289, 574 Bronchiectasis, 297–298 Bronchitis, 298–299, 300 Bronchodilators, 154, 296t, 298, 299, 302, 310t, 413 Bronchopulmonary dysplasia, 152–154 Bruxism, 105 B-type natriuretic peptide (BNP), 305, 357 Buckthorn bark, 72t Buddhism, dietary practices of, 91 Budesonide, 296t, 432, 436, 513 Buerger’s disease, 346, 378 Bulimia nervosa, 6, 270–273 Bulking agents, 420t, 444, 451 Bumetanide, 486t Bumex, 486t


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INDEX

Buphenyl (sodium phenylbutyrate), 215 Bupleurum, 72t Buprenorphine, 289 Bupropion, 284t Burdock, 72t Burns, 838–841 Busulfan, 727, 755t, 794t Butcher’s broom, 72t Butyrophenone (Haldol), 283t Byetta (exenatide), 547t C93, 787 Cachexia, 630, 739t Caffeic acid, 734t Caffeine, 42t, 247t, 280, 288t, 665t Calan (verapamil), 345 Calcet, 669t Calciferol, 595–596 Calcijex (calcitriol), 872t Calcineurin inhibitors, 893t Calcitonin, 570t Calcitonin-salmon (Miacalcin), 670t Calcitriol, 111, 208–209, 670t, 872t Calcium anti-cancer roles, 735t bone health and, 665t depression and, 278 in foods, 53t, 735t health claims, 55t imbalance, 806t for infants, 19 for oral tissue and dental care, 97t in post-transplant nutrition, 495t recommended intakes for children, 29t sources of, 341–342t supplements, 669t Calcium carbonate, 779 Calcium channel blockers, 345, 356, 371t, 391 Calcium glucarate, 747t Calcium glycerophosphate (Prelief), 397 Calcium oxalate stone, 882–883, 884t Calcium polycarbophil (FiberCon), 420t Calcium supplements, 459t Calcium-containing binders, 872t Calendula, 72t, 113 Calories adding to diet, 302t in post-transplant nutrition, 495t Caltrate 600, 669t Campath-1 H, 744t Campesterol, 736t Camptosar (irinotecan), 744t Cancer assessment factors, 731 bladder, 772–773 bone, 751–752 brain tumor, 756–758 breast, 782–785 as cause of death, 44t choriocarcinoma, 786–787 clinical indicators, 742t colorectal, 759–762 complementary nutrition, 745 definitions, 732t dietary fats and, 55t drugs and chemotherapy agents, 744–745t enteral nutrition for, 738t esophageal, 763–766

food safety tips, 745 gastric, 767–769 head and neck, 763–766 kidney, 772–773 leukemia, 791–794 liver, 769–771 lymphomas, 795–796 myeloma, 797–798 nutrition support therapy for, 738t nutritional guidelines for, 742–743 nutritional objectives for, 742t pancreatic, 777–779 patient education, 745, 750t prevention, 733 prostate, 788–790 risk factors, 737t risk reduction, 733 selenium and, 56t side effects of treatment, 739–741 skin, 780–782 thyroid, 763–766 treatment guidelines, 738–750 urinary tract, 772–773 Canker sores, 98t Cannabidiol, 500t Cannabinoids, 250, 500t Canthaxanthin, 499t Capoten (captopril), 886 Capsaicin, 72t, 247, 433, 644, 736t, 746t Capsicum, 72t Captopril (Capoten), 886 Carafate (sucralfate), 409t Carbamazepine, 241t, 265, 268, 616t Carbamoylphosphate synthetase, 214t Carbatrol (carbamazepine), 241t Carbazochrome, 466 Carbidopa, 255t Carbohydrates dietary guideline for, 3t heart disease and, 338t malabsorption, 155–157 metabolic disorders, 155–157 in post-transplant nutrition, 495t recommended intakes, 48–49 recommended intakes for children, 29t Carcinogens, 733 Carcinoid syndrome, 412–413 Carcinoma, 732t Cardiac cachexia, 352–354 Cardiac glycosides, 361t Cardiac neuropathy, 524t Cardiac tamponade, 375–377 Cardiomyopathies, 354–356 Cardiorenal syndrome, 866 Cardiovascular agents, 616t Cardiovascular disorders, 336–343 angina pectoris, 343–345 arteritis, 345–347 assessment factors, 335 atherosclerosis, 347–351 cardiac cachexia, 352–354 cardiac tamponade, 375–377 cardiomyopathies, 354–356 coronary artery disease, 347–351 diabetes and, 525t dietary recommendations for, 337t dyslipidemia, 347–351 factors in, 338–339t

heart failure, 357–362 heart valve diseases, 365–367 herbs and botanical products for, 340t hypertension, 367–371 lipids and, 336 myocardial infarction, 372–375 pericarditis, 375–377 peripheral artery disease, 377–379 thrombophlebitis, 379–381 Cardizem (diltiazem), 345 Cardura (doxazosin), 616t Carmustine, 755t, 798 Carnitine, 860t, 872t Carotenoids, 110, 499t Carvedilol, 616t Cascara, 72t Catabolic illness, 525t Cataract, 106–108 Catatonic disorder, 222t Catechin, 499t, 734t, 735t Catecholamines, 587t Catechol-O-methyltransferase (COMT) inhibitors, 255t Cat’s claw, 746t Cayenne, 73t CD20 antibody, 681t Ceftriaxone, 233, 895 Celebrex (celecoxib), 660t Celecoxib, 660t, 679t Celexa, 616t Celiac disease, 414–415 Central nervous system (CNS), 220 Cephalosporins, 315 Cephulac, 420t, 486t Cerebellum, 220 Cerebral aneurysm, 236–238 Cerebral palsy, 155t, 158–160 Cerebrovascular accident (CVA), 259–263 Cerebrum, 220 Cerebyx (fosphenytoin), 241t Cerefolin, 229 Cerivastatin, 350t, 676 Ceruloplasmin, 698 Cervical radiculopathy, 683 Cesarian delivery, 809t Cetuximab, 744t Cevimeline (Evoxac), 681t Chamomile, 73t, 113, 746t Chaparral, 79t, 538 Chasteberry, 73t Cheese, 247t Chemical pneumonia, 314t Chemotherapy, 332t, 616t, 732t, 739t, 755t Chemotherapy agents, 744t Chewing problems, 107, 108–109 Chicoric acid, 500t Childhood disintegrative disorder, 222t Children body mass index for, 605t clinical indicators, 28 constipation in, 418–419 daily estimated calories, 30t dietary recommendations for, 32t drugs and side effects, 30–31 eating behavior, 27 energy requirements/expenditures, 142t failure to thrive, 169–171 food and nutrition, 29–30


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food safety tips, 32 HIV infection in, 177–179 immunocompetence of, 822t infectious diseases, 28 lead poisoning, 32t malnutrition in, 27–28 measles, 32t normal growth rates, 164t nutritional guidelines for, 29–30, 31 nutritional objectives for, 28–29 obesity in, 27, 197–201 clinical indicators, 198t complications, 198t drugs and side effects, 200 food safety tips, 201t genetic markers, 198t nutritional guidelines for, 200–201 nutritional objectives for, 199–200 patient education, 200–201 weight loss diets for, 199t weight loss program for, 201t pediatric disorders, 137–143 anthropometric, 138t behavioral, 138–139t clinical, 139–140t developmental disabilities, 140t eating/feeding skills, 140t genetic/metabolic, 140t nutritional risks, 143t physical activity, 32t, 142t recommended intakes, 29t refeeding, 635 sports nutrition, 38 supplements, 31 type 1 diabetes in, 521t, 523t type 2 diabetes in, 521t, 523t, 549–551 Chili powder, 746t Chinese asparagus, 73t Chinese diet, 85 Chinese herbal medicine, 746t Chinese PC-SPES, 746t Chitosan, 73t Chlorambucil, 727, 794t Chloramphenicol, 716 Chlordiazepoxide (Librium), 284t, 616t Chloride, 63t, 340 Chloride channel activators, 420t Chlorogenic acid, 500t, 734t Chloroquine (Aralen), 651 Chlorothiazide, 486t Chlorpromazine (Thorazine), 283t Chocolate, 247t, 288t Cholac syrup, 491t Cholangiolitic hepatitis, 512–514 Cholecalciferol, 208–209 Cholecystitis, 516–517 Cholecystokinin, 569t Cholelithiasis, 516–517 Cholestasis, 514–516 Cholesterol, 55t Cholesterol spinach, 73t Cholestyramine, 152, 350t, 424, 459t, 491t, 515 Choline, 121, 181, 226t, 784 deficiency of, 119t toxicity of, 121 Cholinesterase inhibitors, 230t Cholylsarcosine, 429 Chondroitin, 73t, 660t

Choriocarcinoma, 786–787 Christianity, dietary practices of, 94 Chromium, 97t, 340t, 534t Chromium picolinate, 73t, 581, 615 Chronic anemia, 689t Chronic gastritis, 401, 402 Chronic glomerulonephritis, 879 Chronic heart failure (CHF), 353 Chronic kidney disease (CKD), 864–873. See also Renal disorders acute renal failure, 864 chronic renal failure, 865 clinical indicators, 866t drugs and side effects, 872t fluid restriction, 873t hypertension and, 368 nutritional guidelines for, 869 nutritional objectives for, 868–869 patient education, 869–873 protein-energy malnutrition in, 866–868t stages and symptoms of, 865t supplements, 869 Chronic leukemias, 793t Chronic lymphocytic leukemia, 793t Chronic myelogenous leukemia, 793t Chronic obstructive pulmonary disease (COPD), 300–303 Chronic pancreatitis, 501–506 Chronic pyelonephritis, 894 Chronulac (lactulose), 420t, 486t, 491t Chrysanthemum, 73t Church of Jesus of Latter Day Saints, 94 Chylothorax, 304–305 Chylous ascites, 477–479 Cialis (tadalafil), 52t Cidofovir, 835t Cimetidine (Tagamet), 283, 409t, 459t Cinacalcet (Sensipar), 598, 872t Cinnamic acid, 500t Cinnamon, 73t, 534t Ciprofloxacin, 424, 436, 455, 895 Circadian rhythm disorder, 222t, 285–286 Cirrhosis, 44t, 512–514 Cisplatin, 764t Citracal, 669t Citrate stones, 884t Citric acid, 500t Citrucel (methylcellulose), 420t Citrulline, 215 Citrullinemia, 214t Clarithromycin (Biaxin), 315 Cleft lip and cleft palate, 161–162 Clofibrate, 350t Clomipramine, 149, 284t Clonazepam (Klonopin), 160, 241t, 284t Clonidine, 149, 459t Clorazepate (Tranxene), 284t Closed enteral system, 899t Closed fractures, 842 Clostridium difficile infection, 422 Clotrimazole (Mycelex), 755t, 835t Cloves, 644, 746t Clozapine, 264, 283t Clozaril, 264, 283t, 616t Club drugs, 288t CNS lymphoma, 757t Cobalamin, 181 Cocaine, 288t

1003

Coenzyme Q10, 73t, 229, 230t, 262, 340t, 350, 357, 362, 676, 736t, 886 Cogentin (benztropine), 255t Cognex (tacrine), 230t Colchicine (Colcrys), 646 Colcrys (colchicine), 646 Colectomy, 816 Colesevelam, 350, 350t Colestipol, 350t, 515 Coleus, 73t Colic, 21t Colitis, 741t Collagen-IV nephropathies, 862–863 Colon, loss of, 456t Colorectal cancer, 759–762 Colostomy, 450–452 Coma, 238–239, 900–901t Combivent, 296t Combivir, 834t Comfrey, 79t Comminuted fractures, 842 Common cold, 826t Complementary nutrition, 70–83 for allergies, 126 for cancer patients, 746–749t clinical indicators, 82t drugs and side effects, 83–84 food safety tips, 83 for foodborne illnesses, 135 guidelines for, 82t hazardous products in, 79–81t for heart disease, 340t herbs, botanicals, and supplements in, 71–81t for infants, 22 nutritional objectives for, 82 patient education, 83 for rheumatic disorders, 639 supplements, 83 Compound fracture, 842 Compression fractures, 842–843 Compulsive exercising, 274t Comtan (entacapone), 255t Concerta (methylphenidate), 147t Condiments, 492t Conduct disorder, 222t Cone flower, 73t Congenial hyperinsulinism, 567–569 Congenital glucose-galactose malabsorption, 155, 157 Congenital heart disease (CHD), 163–164. See also Cardiovascular disorders drugs and side effects, 164 genetic markers, 163 incidence of, 163 medications for, 159t nutritional guidelines for, 164 nutritional objectives for, 163–164 supplements, 164 Congenital hypothyroidism, 592 Congenital megacolon, 175–177 Congenital muscular dystrophy, 653t Congenital renal glycosuria, 155 Conivaptan, 580 Conn’s syndrome, 585 Constipation, 418–420. See also Gastrointestinal disorders cancer and, 739t


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1004

INDEX

Constipation (continued ) fecal incontinence and, 463t in infants, 21t Constulose (lactulose), 491t Continent ileostomy, 453 Continuous positive airway pressure (CPAP), 324 Conversion disorder, 222t Cooley’s anemia, 720 Coordination problems, 106–107, 108 Copegus (ribavirin), 481 Copper, 19, 97t, 294t, 338t, 665t deficiency of, 698–700, 712t food sources, 700t Copper deficiency anemia, 698–700 Copper sulfate, 700t Cor pulmonale, 305–306 Corgard (nadolol), 345, 486t Cori disease, 176t Corn syrup, 532t Coronary artery bypass graft (CABG), 809t Coronary artery disease (CAD), 347–351, 525t Coronary heart disease (CHD), 55t, 56t Coronary occlusion, 372–375 Cortef, 572 Corticosteroids, 30, 152, 217, 258, 296t, 329t, 364t, 417, 432, 436, 442t, 454, 476, 486t, 496t, 510t, 572, 616t, 674, 680t, 697, 729, 744t, 755t, 796, 835t, 893t Corticotropin-releasing hormone, 225t Cortisol, 572, 583 Cortisone, 572 Cotazym (pancreatic enzyme), 508 Cotrim, 895 Coumadin, 317, 318, 356, 374, 381 Coumarins, 735t Coumestans, 734t Coviracil, 834t Cozaar (losartan), 886 Cranberry, 73t Cranial arteritis, 346 Cranial nerves, 221t Craniopharyngiomas, 757t Craniotomy, 810t C-reactive protein, 338t, 688 Creatinine index, 867 Creon (pancreatic enzyme), 508 CREST syndrome, 684 Crestor (rosuvastatin), 886 Cretinism, 592 Crixivan, 835t Crohn’s disease, 430–433, 760 Cromolyn (Intal), 296t Cultural food patterns, 84–87 African/African American, 85 Asian, 85 drugs and side effects, 86–87 Hispanic/Latino, 85 Hmong, 85 Indian/Pakistani, 86 Mediterranean diet, 86 Middle Eastern, 86 Native American, 86 nutritional objectives, 85 patient education, 87 religious food practices, 86 supplements, 87 Cuprimine (D-penicillamine), 217, 486t

Curative therapy, 732t Curcumin, 73t, 433, 500t, 644 Curry, 73t Cushing’s syndrome, 575–576 Cyanidin, 500t Cyclic vomiting syndrome, 274t Cyclizine, 411 Cyclobenzaprine (Flexeril), 657 Cyclooxygenase-2 (COX-2) inhibitors, 660t, 679t, 719 Cyclophosphamide, 312, 651, 697, 727, 744t, 755t, 774, 784, 787, 798, 886 Cyclosporine, 126, 329t, 364t, 436, 442t, 496t, 510t, 538t, 644, 646, 680t, 755t, 893t Cymbalta (duloxetine), 284t, 657 Cyproheptadine HCl (Periactin), 631 Cystagon (cysteamine), 166 Cystathionine-beta-synthase (CBS), 180 Cysteamine (Cystagon), 166 Cystic fibrosis, 46t, 307–310 Cystine stones, 882, 884t Cystinosis, 165–166 Cystitis, 894 Cytochrome P450, 110 Cytokines, 13t, 225t, 821t, 838 Cytotec (misoprostol), 660t Cytotoxic T cells, 821t Cytovene, 835t Cytoxan (cyclophosphamide), 312, 651, 755t, 774, 784 Da qing ye, 73t Daclizumab, 893t Da-huang, 77t Daidzein, 499t, 736t Dairy products, 303t, 338t, 359t, 491t Dalmane (flurazepam), 284t Dandelion, 73t Danshen, 340t Dantrium (Dantrolene), 160 Dantrolene (dantrium), 160 Darunavir, 834t Darvon (propoxyphene), 283 Dasatinib (Sprycel), 794t DASH diet, 342t, 354, 357, 366, 369, 374 Dawn phenomenon, 522t Daytrana (methylphenidate), 147t D-cycloserine, 149 Death, leading causes of, 44t Debrancher enzyme deficiency, 176t Decanoate, 836t Declomycin (demeclocycline), 580 Deferoxamine, 486t, 726 Degenerative joint disease, 658–661 Dehydration, 915t Dehydroepiandrosterone, 746t Delavirdine, 834t Delayed gastric emptying (DGE), 558 Deli, 492t Delphinidin, 500t Deltasone, 296t Deltasone (prednisone), 657 Delusional disorder, 222t Demeclocycline (Declomycin), 580 Dementia, 56t, 227–231 Demerol (meperidine), 844 Dental abscess, 98t Dental caries, 56t, 99–100, 739t

Dental problems, 96–101 nutrients for, 97t symptoms, 98–99t treatment of, 98–99t Depacon, 241t Depakene, 241t, 616t Depakote, 241t, 616t Depen (D-penicillamine), 217, 486t Depersonalization disorder, 223t Deplin (L-methylfolate), 168, 277, 704 Depo-Provera, 616t Depression, 277–280 Depressive disorders, 223t Dermatitis herpetiformis, 111, 112, 415 Desamino-8-arginine vasopressin (DDAVP), 722 Desferal (deferoxamine), 486t Desipramine, 149, 284t, 289 Desoxyn (methamphetamine), 147t Desserts, 303t DETERMINE checklist, 60t Devil’s claw, 73t Dexamethasone, 154 Dexedrine, 31 Dexedrine (dextroamphetamine), 147t Dexferrum, 695 Dexmethylphenidate, 147t Dextroamphetamine, 31, 147t Dextrose, 532t Diabeta (glyburide), 547t Diabetes insipidus, 577–578 Diabetes mellitus, 44t, 520–526. See also Endocrine disorders assessment factors, 519–520 assessment in, 519–520 as cause of death, 338t complications of, 522–525t etiologic classification of, 521t evaluation for, 522t exercise guidelines for, 536t gestational, 523t, 552–555 herbs and supplements, 534t management of, 526t prediabetes, 542–544 pregnancy and, 523t type 1, 414, 520, 528–536 in children, 521t, 523t clinical indicators, 529 drugs and side effects, 531 medical nutrition therapy for, 529–531 patient education, 531–536 warning signs, 519 type 2, 520 in adults, 544–549 in children, 521t, 523t in children and teens, 549–551 clinical indicators, 545t, 550t drugs and side effects, 547–548, 551 medical nutrition therapy for, 545t, 546–547, 550–551 medications for, 547t patient education, 548–549, 551 risk factors, 519 supplements, 548, 551 type 3, 227 Diabetic gastroparesis, 558–559 Diabetic ketoacidosis (DKA), 522t, 560–562 Diabetic retinopathy, 106


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INDEX

Diallyl sulfide, 433, 644 Dialysis, 874–878 Diamond-Blackfan anemia, 692–693 Diarrhea, 421–424. See also Gastrointestinal disorders bacterial, 421 Bristol stool scale, 422t in cancer patients, 740t Clostridium difficile infection, 422 drugs and side effects, 423–424 early childhood, 421–422 fecal incontinence and, 463t in infants, 21t nutritional guidelines for, 423 nutritional objectives for, 423 traveler’s diarrhea, 422 types of, 421t Diazepam (Valium), 284t Diazoside, 568 Didanosine, 834t Diet African/African American, 85 Asian, 85 Hispanic/Latino, 85 Hmong, 85 Indian/Pakistani, 86 Mediterranean diet, 86 Middle Eastern, 86 religious food practices, 86 Eastern, 91–92 Middle Eastern, 95–96 Western, 93–95 vegetarian, 88–90 Dietary fats, 55t in breast milk, 13t in diet, 302t dietary guideline for, 3t health claims, 55t in post-transplant nutrition, 495t recommended intakes for children, 29t Dietary fiber bone health and, 665t breast cancer and, 784 cardiovascular disease, 349 in common foods, 465t constipation and, 235 health claims, 55t, 56t heart disease and, 337t, 338t insoluble, 736t myocardial infarction and, 374 recommended intakes, 49 recommended intakes for children, 29t soluble, 736t in vegetarian diet, 89t Dietary guidelines, 3–5t American, 3–4t for athletes, 41t Canadian, 4t Chinese, 4t MyPyramid, 35 South African, 5t Diethylpropion (Tenuate), 617t Digestion, 384 Digitalis, 350, 361t, 586 Digoxin, 350, 356, 366 Dihydrochalcones, 734t Dilantin (phenytoin), 235, 239, 241t, 376 Dilated congestive cardiomyopathy, 354–355

Diltiazem, 345 Dimenhydrinate (Dramamine), 559 Diovan (valsartan), 886 Diphenhydramine, 616t Dipsogenic diabetes insipidus, 577 Dipyridamole, 181 Direct renin inhibitors, 371t Disability Rating Scale, 238 Discolored teeth, 98t Disease-modifying antirheumatic drugs (DMARDs), 680t Disopyramide (Norpace), 345 Disruptive behavior, 223t Dissociative disorders, 223t Dissociative identity disorder, 223t Distal colitis, 434 Distal muscular dystrophy, 653t Disulfiram (Antabuse), 476 Diuretic-antihypertensives, 371t Diuretics, 152, 154, 329t, 356, 361t, 364t, 366, 371t, 376, 478, 486t, 496t, 498t, 510t, 538t, 596, 886 Diuril (chlorothiazide), 486t Divalproex sodium, 241t Diverticular diseases, 425–426 Diverticulitis, 425–426 Diverticulosis, 426 Docosahexaenoic acid (DHA), 362, 378 Docusate, 695 Docusate sodium, 417, 420t Domperidone, 404, 559, 744t Donepezil (Aricept), 230t Dong quai, 73t Dopamine, 224t, 287, 587t Dopamine agonists, 255t Dopamine antagonists, 404 Dopamine receptor antagonists, 263 Down syndrome, 166–167 Doxazosin (Cardura), 616t Doxepin (sinequan), 284t, 616t Doxercalciferol (Hectorol), 598, 872t Doxil, 512 Doxorubicin, 512, 774, 784, 798, 835t Doxycycline, 467 D-penicillamine, 217 DPP-4 inhibitors, 547t Dramamine (dimenhydrinate), 559 Dronabinol (Marinol), 631, 836t Droxia (hydroxyurea), 719 DSM-IV, 222t Duchenne muscular dystrophy, 653t Duchenne/Becker muscular syndrome, 45t Dulcolax (bisacodyl), 417 Duloxetine (Cymbalta), 284t, 657 Duphalac (lactulose), 491t Dyrenium (triamterene), 486t Dysentery, 421t, 422 Dysgeusia, 740t Dyslipidemia, 347–351, 525t, 540, 875 Dyspepsia, 397–399 Dysphagia, 386–390. See also Gastrointestinal disorders cancer and, 740t causes of, 387t clinical indicators, 387t drugs and side effects, 390 evaluation of, 387t nutritional guidelines for, 388

1005

nutritional objectives for, 388 patient education, 390 supplements, 390 Dysthymia, 277 Dysthymic disorder, 223t Earache, 128 Early childhood caries (ECC), 99–100 Early childhood diarrhea, 421–422 Eastern Orthodox Christian, dietary practices of, 94 Eating disorder, 223t anorexia athletica, 274t anorexia nervosa, 266–268 bigorexia, 274t binge, 269–270 body dysmorphic disorder, 274t bulimia nervosa, 270–273 compulsive exercising, 274t cyclic vomiting syndrome, 274t eating disorders not otherwise specified (ED-NOS), 274t muscle dysmorphic disorder, 274t night eating syndrome, 274t nocturnal sleep-related eating disorder, 274t orthorexia nervosa, 274t pica, 274t rumination syndrome, 274t Eating disorders not otherwise specified (ED-NOS), 274t Echinacea, 74t, 661t, 736t, 746t, 808t Ecstasy, 288t Eczema, 110–111 Edema, 740t, 880 Edentulism, 99, 101 Efavirenz, 834t Effexor (venlafaxine), 284t Eggs allergy to, 125t, 127t heart disease and, 338t Eicosapentaenoic acid (EPA), 362 Elavil (amitriptyline), 284t, 616t, 657 Eldepryl (selegiline), 230t, 255t Elderly, 58–66 clinical indicators, 59t diabetes in, 523t drug effects in, 63, 64t drugs and side effects, 58 food safety tips, 66 immunocompetence of, 822t medical nutrition therapy for, 58–59 nutrition assessment for, 60t nutritional education for, 64–66 nutritional guidelines for, 61 nutritional objectives for, 59–61 patient education for, 66 physiological characteristics of, 58 recommended intakes for, 62–63t stature for, 66t supplements, 63–64 weight table for, 65t Elderly Dietary Index (EDI), 336 Electrolytes, 63t, 806–807t, 915t Eleuthero, 746t Ellagic acid, 433, 500t, 644 Ellagitannins, 500t Emery-Dreyfus muscular dystrophy, 653t


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1006

INDEX

Emitasol, 559 Emollient laxatives, 420t Emphysema, 300 Emtricitabine, 834t Emtriva, 834t Enalapril (Vasotec), 886 Enbrel (etanercept), 332t, 681t Encephalomalacia, 705–706 Encopresis, 418–419 Endemic goiter, 592 Endocannabinoids, 225t Endocrine disorders, 519–527 acromegaly, 573–574 Addison’s disease, 582–584 adrenocortical insufficiency, 582–584 assessment factors, 519–520 Cushing’s syndrome, 575–576 diabetes. see Diabetes mellitus diabetes insipidus, 577–578 diabetic gastroparesis, 558–559 diabetic ketoacidosis, 560–563 hyperaldosteronism, 585–586 hypercalcemia, 596–598 hyperinsulinism, 567–569 hyperosmolar hyperglycemic state, 563–564 hyperparathyroidism, 596–598 hyperthyroidism, 589–591 hypocalcemia, 595–596 hypoglycemia, 565–566 hypoparathyroidism, 595–596 hypopituitarism, 571–573 hypothyroidism, 591–594 metabolic syndrome, 539–541 pheochromocytoma, 586–588 polycystic ovarian syndrome, 580–582 prediabetes, 542–544 pre-eclampsia, 556–557 spontaneous hypoglycemia, 567–569 syndrome of inappropriate antidiuretic hormone, 579–580 Endocrine system cancers, 732t End-of-life care, 900–901t End-stage renal disease, 524t Enemas, 466 Energy, 3t Energy requirements, 608t in athletes, 38 in children, 29t, 142t in infants, 142t protein-energy malnutrition, 626–631 Enfuvirtide, 835t Entacapone (Comtan), 255t Entamoeba histolytica, 845t Entecavir (baraclude), 486t Enteral nutrition, 902–911. See also Parenteral nutrition assessment factors, 897 checklist, 910t clinical indicators, 904–905t clinical practice guidelines, 905t for coma patients, 900–901t complications, 908t consequences of not feeding in, 904t contraindications, 908t delivery methods, 908t for dialysis patients, 877t disadvantages of, 903 drugs and side effects, 907

feeding site selection, 908t fluid needs in, 908t formula selection, 908t formulas, 906t indications and contraindications, 738t, 850 issues in, 908t overview, 898–901 patient education, 910–911 terminology, 899t Enteric fever, 828t Enteric nervous system stem cells (ENSSCs), 448 Enterobius vermicularis, 845t Enteropathy-associated T-cell lymphoma (EATL), 795 Entocort (budesonide), 432 Entry inhibitors, 835t Eosinophilic esophagitis, 122, 395 Eosinophilic gastroenteritis, 122 Ephedra, 42t, 80t, 272, 283, 295, 302, 356, 615, 808t Ephedrine, 42t Epicatechin, 499t Epidermolysis bullosa, 111, 112 Epidural hemorrhages, 237 Epigallocatechin, 499t Epigallocatechin gallate (ECGC), 735t Epilepsy, 240–242 Epinephrine, 126, 224t, 296t, 570t, 587t Epithelioma, 732t Epivir (lamivudine), 486t, 834t Eplerenone, 586 Epoetin, 872t Epzicom, 834t Equal (aspartame), 533t Equilactin, 420t Erectile dysfunction, 52t Ergocalciferol, 595–596 Eriodictyol, 499t, 736t Erlotinib (Tarceva), 779 Erucic acid, 185 Erythremia, 726–728 Erythroblastosis fetalis, 692 Erythrocyte sedimentation rate, 338t Erythromycin, 404, 559 Erythropoietin, 688, 860t Erythropoietin stimulating agents (ESAs), 695 Escherichia coli, 851 Esidrix, 486t Eskalith, 616t Esomeprazole (Nexium), 397, 398, 402, 406, 409t, 512 Esophageal cancer, 763–766 Esophageal spasm, 390–391 Esophageal stricture, 390–391 Esophageal trauma, 392–393 Esophageal varices, 393–394 Esophagitis, 395–397, 740t Essential fatty acids (EFAs), 9, 110–111, 225t Essential oils, 534t Essiac, 746t Estimated energy requirement (EER), 605t Estrogen, 5, 338t, 370, 517, 570t, 572, 784 Etanercept (Enbrel), 332t, 681t Ethambutol, 332t, 376 Ethionamide, 332t Ethopropazine, 255t Ethosuximide (Zarontin), 241t

Etoposide, 787 Eucalyptus, 74t Eugenol, 433, 500t, 644 Eurixor, 81t Eustachian tube, 202 Evening primrose oil, 74t, 534t, 661t, 746t Evista (raloxifene), 670t Exanta (ximelagatran), 381 Exelon (rivastigmine), 230t Exenatide (Byetta), 547t Exercise breastfeeding and, 17 carbohydrate ingestion and, 38 for diabetic patients, 536t heart disease and, 338t Expectorants, 296t, 298 Facial nerve, 221t Factitious disorder, 223t Failure to thrive (FTT), 169–171, 280 Falcarinol, 746t Familial adenomatous polyposis (FAP), 46t Familial hemolytic jaundice, 705t Family meals, 49 Famotidine (Pepcid), 409t Fanconi anemia, 45t Fanconi-Bickel syndrome, 176t Fanconi’s anemia, 696–698 Fanconi’s syndrome, 165–166 Fascioscapulohumeral muscular dystrophy, 653t Fasting, 95–96 Fat malabsorption syndrome, 427–430 Fatigue, 740t Fats in breast milk, 13t in diet, 302t dietary guideline for, 3t health claims, 55t in post-transplant nutrition, 495t recommended intakes for children, 29t Fatty acid oxidation disorders, 172–173 Fatty acid synthase, 786 Fatty acids, 638–639 Febrile conditions, 825–829 Febuxostat (Uloric), 646 Fecal incontinence, 463–465 Felbamate, 241t Felbatol, 241t Feldene (piroxicam), 660t Felty’s syndrome, 677t Female athlete triad, 38 Fenfluramine-phentermine, 366 Fenofibrate, 350t Fenugreek, 74t, 340t, 534t Fermented foods, 247t, 492t Ferritin, 689t, 707 Ferulic acid, 734t Fetal alcohol syndrome, 173–175 Feverfew, 74t, 113, 247 Fiber bone health and, 665t breast cancer and, 784 cardiovascular disease, 349 in common foods, 465t constipation and, 235 health claims, 55t, 56t heart disease and, 337t, 338t


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INDEX

insoluble, 736t myocardial infarction and, 374 recommended intakes, 49 recommended intakes for children, 29t soluble, 736t in vegetarian diet, 89t Fiberall, 420t FiberCon (calcium polycarbophil), 420t Fiber-Lax, 420t Fibric acids, 350t Fibromyalgia, 656–657 Filgrastim (Neupogen), 755t Finasteride (Proscar), 52t Fish, 492t allergy to, 125t, 127t sodium content, 359t FK506 (tacrolimus), 364t, 442, 510t FK5-6 (tacrolimus), 496t, 538t, 893t Flagyl (metronidazole), 283 Flavanones, 499t, 734t, 736t Flavoglycosides, 500t Flavones, 294t, 499t, 734t Flavonoids, 294t, 338t, 349, 737t, 771 Flavonolignans, 500t Flavonols, 499t, 734t, 735t Flaxseed, 74t, 746t Fleet Mineral Oil, 420t Fleet Phospho-Soda, 420t Flexeril (cyclobenzaprine), 657 Florinef (fludrocortisone), 583 Flovent (fluticasone), 296t Floxin (ofloxacin), 895 Flu, 826t Flucytosine, 744t, 835t Fludarabine, 755t Fludrocortisone (Florinef), 583 Fluid overload, 915t Flunisolide, 296t Fluoride, 97t Fluoroquinolone, 895 Fluorouracil, 46t, 512, 744t, 762, 768, 784 Fluoxetine, 149, 272, 279, 284t, 616t Flurazepam (Dalmane), 284t Fluticasone (Flovent), 296t Fluvastatin, 350t, 886 Fluvoxamine (Luvox), 283t, 616t Focal segmental glomerulosclerosis, 880 Focalin (dexmethylphenidate), 147t Folate deficiency of, 712t dementia and, 229 drug interactions, 195 health claims, 55t for healthy vision, 108t for oral tissue and dental care, 97t recommended intakes, 341t recommended intakes for children, 29t schizophrenia and, 281 Folate antagonists, 744t Folic acid, 56t, 119t, 121, 181, 226t, 229, 338t, 661t, 665t, 701–704, 735t, 760 Folic acid deficiency anemia, 701–704 Folinic acid, 149 Folk remedy oils, 74t Follicle-stimulating hormone (FSH), 571 Food additives, allergy to, 125t Food Allergen Labeling and Consumer Protection Act (FALCPA), 123

Food allergies/intolerances, 122–127 allergens, 125t clinical indicators, 124 education, 131 food processing concerns, 126t food safety tips, 131t gastrointestinal, 122–123 nutritional guidelines for, 124–125 nutritional objectives for, 124 patient education, 126–127 prevalence of, 122 supplements, 126 symptoms, 122 Food labeling terms, 55t Food protein-induced enterocolitis syndrome (FPIES), 122–123 Food scale, 612t Foodborne illnesses, 130–136 clinical indicators, 130t drugs and side effects, 134–135 food handling/safety guidelines, 134t, 135 nutritional objectives for, 131 outbreaks, 130 pathogens, 132–133t refrigerator food storage, 135t symptoms, 132–133t Food-dependent exercise-induced anaphylaxis (FDEIA), 123 Food-induced anaphylaxis, 123 Foods fruits, 54t functional, 50–51t labeling terms, 55t oxygen radical absorbance capacity (ORAC), 503–505t vegetables, 54t Foradil, 296t Forbes disease, 176t Forebrain, 220t Formiminoglutamic acid, 701 Formula-fed infants, 20 Formulation, 899t Forskolin, 73t, 74t Forteo, 670t Fosamax (alendronate), 52t, 670t Fosamprenavir, 834t Foscarnet, 835t Foscavir, 835t Fosfree, 669t Fosphenytoin (Cerebyx), 241t Fosrenol (lanthanum carbonate), 872t Fractures, 842–844 Fragile X syndrome, 45t, 148 Frankincense, 660t Frondanol A5, 762 Frontal lobe, 220t, 234 Frontotemporal dementia, 45t Frozen foods, 492t Fructose, 532t Fructose intolerance, 155 Fructose-1,6-disphosphatase deficiency, 45t Fructosemia, 157 Fruits eating tips, 53t fiber content, 465t headaches and, 247t health claims, 55t nutrients in, 54–55

1007

Fumarylacetoacetate hydrolase (FAH), 212 Functional foods, 49, 734–737t Furadantin (nitrofurantoin), 895 Furosemide (Lasix), 478, 486t, 886 Fusion inhibitors, 835t Fuzeon, 835t Gabapentin (Neurontin), 241t, 616t Gabitril (tiagabine), 241t Galactosemia, 155, 156 Galantamine, 230t Gallate esters, 499t Gallbladder cancer, 516 Gallbladder disorders, 473, 516–518, 915t Gallic acid, 500t, 735t Gallocatechin, 499t Gallotannins, 500t Gallstones, 516 Gamma aminobutyric acid, 224t Gamma linolenic acid, 74t, 295, 534t, 661t, 746t Ganciclovir, 835t Gantrisin (sulfisoxazole), 895 Garcinia, 615 Garlic, 74t, 340t, 534t, 661t, 747t, 808t Gastrectomy, 399–401 Gastric bypass surgery, 812–815 Gastric cancer, 767–769 Gastric mucosa, 569t Gastric residual volume, 907 Gastric retention, 403–405 Gastrin, 569t Gastrinoma, 511–512 Gastritis, 401–403 Gastroduodenostomy, 399 Gastroenteritis, 401–403 Gastroesophageal reflux disease (GERD), 395–397 Gastrointestinal agents, 409t Gastrointestinal cancers, 732t Gastrointestinal disorders, 383–385 achalasia, 390–391 assessment factors, 383 carcinoid syndrome, 412–413 celiac disease, 414–417 conditions that may cause fear of eating, 384t constipation, 418–420 Crohn’s disease, 430–433 diarrhea, 421–424 diverticular diseases, 425–427 dysentery, 421–424 dysphagia, 386–390 esophageal stricture/spasm, 390–391 esophageal trauma, 392–393 esophageal varices, 393–394 esophagitis, 395–397 fat malabsorption syndrome, 427–430 fecal incontinence, 463–465 gastric retention, 403–405 gastritis, 401–403 gastroenteritis, 401–403 gastroesophageal reflux disease, 395–397 gastroparesis, 403–405 giant hypertrophic gastritis, 405–406 hemorrhoids, 466–467 hiatal hernia, 395–397 intestinal fuels for, 385t intestinal lymphangiectasia, 439–440


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1008

INDEX

Gastrointestinal disorders (continued ) irritable bowel syndrome, 443–445 lactose maldigestion, 445–447 malabsorption, 384t malnutrition and, 384t mechanical function, 384t megacolon, 447–449 Ménétrier’s disease, 405–406 peptic ulcer disease, 407–410 peritonitis, 454–455 proctitis, 467–468 short bowel syndrome, 456–459 traveler’s diarrhea, 421–424 tropical sprue, 460–461 ulcerative colitis, 434–436 vomiting, pernicious, 410–412 Whipple’s disease, 461–462 Zenker’s diverticulum, 390–391 Gastrointestinal neuropathy, 524t Gastrointestinal stromal tumor (GIST), 767 Gastrojejunostomy, 399 Gastroparesis, 403–405 Gaviscon, 409t GBL, 288t Gelusil, 409t Gemcitabine (Gemzar), 784 Gemfibrozil, 350, 350t Gemzar (gemcitabine), 784 Generalized anxiety disorder, 223t Genetic disorders abetalipoproteinemia, 144–145 assessment factors, 137–142t attention-deficit disorders, 145–147 autism spectrum disorder, 148–150 biliary atresia, 150–152 bronchopulmonary dysplasia, 152–154 carbohydrate metabolic disorders, 155–157 cerebral palsy, 158–160 congenital heart disease, 163–164 congenital megacolon, 175–177 cystinosis, 165–166 Down syndrome, 167–168 Fanconi’s syndrome, 165–166 fatty acid oxidation disorders, 172–173 fetal alcohol syndrome, 173–175 Hirschsprung’s disease, 175–177 HIV infection, pediatric, 177–179 homocystinuria, 180–182 infant macrosomia, 182–183 intrauterine growth restriction, 210–211 leukodystrophies, 184–185 maple syrup urine disease, 189–191 myelomeningocele, 194–196 necrotizing enterocolitis, 192–193 neural-tube defects, 194–196 orofacial clefts, 161–162 phenylketonuria, 203–204 Prader-Willi syndrome, 206–207 small for gestational age, 210–211 spina bifida, 194–196 tyrosinemia, 212–213 urea cycle disorders, 214–216 Wilson’s disease, 216–218 Genetically modified foods, 123 Gengraf (cyclosporine), 893t Genistein, 499t, 736t Genitourinary tract disturbances, 524t

Gentamicin, 895 Geodon (ziprasidone), 283t Germander, 80t Germinomas, 757t Gestational diabetes, 523t, 552–555 Gestational diabetes insipidus, 577 GHB, 288t Ghrelin, 206–207 Giant cell arteritis, 346 Giant hypertrophic gastritis, 405–406 Giardia, 845t Giardia intestinalis, 460 Gigantism, 573 Ginger, 10t, 74t, 398, 410, 411, 644, 661t, 747t Gingerol, 433, 644, 747t Gingivitis, 103–104 Gingko biloba, 74t, 229, 272, 283, 534t, 661t Ginkgo, 808t Ginkgo biloba, 747t Ginkgolides, 735t Ginseng, 42t, 75t, 229, 230t, 283, 661t, 808t Ginseng, American, 534t, 747t Ginseng, Asian, 747t Glandular extracts, 81t Glargine (Lantus), 533t Glasgow Coma Scale, 238, 855t Glasgow Outcome Scale, 238 Glaucoma, 106 Gleevec, 755t, 768, 794t Glehnia, 75t Gliadins, 417 Glimepiride (Amaryl), 547t Glioblastoma multiforme, 757 Gliomas, 757t Glipizide (Glucotrol), 547t Glomerular diseases, 879–881 Glomerular filtration rate (GFR), 865t, 867t Glomerulonephritis, 879 Glomerulosclerosis, 879–880 Glossopharyngeal nerve, 221t Glucagon, 566, 569t Glucarate, 747t Glucocorticoids, 570t, 583–584 Gluconeogenesis, 565–566 Glucosamine sulfate, 75t, 660t, 661 Glucose, 532t, 860t Glucose transporter type 1 (Glut1) deficiency syndrome, 155, 157 Glucose-6-phosphate dehydrogenase deficiency anemia, 705t Glucosinolates, 735t Glucotrol (glipizide), 547t Glutamate, 224t Glutamine, 153, 458, 903 Glutathione, 310t, 734t Gluten, 247t Glyburide, 547t Glycemic index, 535t Glycemic load, 338t, 535t Glycine, 224t Glycitein, 499t Glycogen, 38, 622 Glycogen storage disorders (GSDs), 155, 157, 176t Glycogen synthase kinase-3 (GSK-3), 227 Glycogenolysis, 565–566 Glycolax, 420t Glycomacropeptide, 204

Glycyrrhizin, 735t Glyset (miglitol), 547t Goiter, 592 Gold sodium thiomalate (Ridaura), 680t Goldenseal, 80t Gonadocorticoids, 570t Gonadotropin-releasing hormone (GnRH), 569t Gonadotropins, 569t Gonads, 570t Gotu kola, 75t Gout, 645–647 Graft-versus-host disease, 740t Graft-versus-host disease prophylaxis, 755t Grains, 359t, 416t, 491t, 535t Granisetron, 744t Grapefruit, 340t Graves’ disease, 589 Green coffee bean extract, 370 Green tea, 75t, 370, 615, 655, 747t, 760 Growth factors, 13t Growth hormone, 58, 152, 310, 459t, 571, 841t, 872t Growth hormone deficiency, 45t Guar gum, 534t Guggul, 75t, 340t Gugulipid, 340t Guillain-Barré syndrome, 242–243 Gum disease, 98t Gut immunity, 821t Gut-associated lymphoid tissue (GALT), 123 Gymnema sylvestre, 534t Gynecological cancer, 732t H2-receptor antagonists, 409t, 498t Haemophilus influenzae, 315 Halal, 95 Halcion (triazolam), 284t Haldol, 283t, 616t Haloperidol, 149, 616t Hang time, 899t Haram, 95 Harris-Benedict equation, 606t, 824t, 838 Hartnup disorder, 887–888 Hashimoto’s thyroiditis, 591–592 Hawthorn, 75t, 340t Head and neck cancer, 763–766 Health claims, 55–56t Healthcare-associated pneumonia, 314t Hearing loss, 107, 109 Heart disease, 44t dietary recommendations for, 337t factors in, 338–339t herbs and botanical products for, 340t Heart failure, 357–362 Heart transplantation, 363–365 Heart valve diseases, 365–367 Heart valve replacement, 809t Heart-lung transplantation, 363–365 Hectorol (doxercalciferol), 598, 872t Hedagenin, 734t Helicobacter pylori, 11, 18, 406, 407–410, 767 Helper T cells, 821t Hematochromatosis, 724–726 Hematologic disorders anemia. see Anemia assessment factors, 687 hemochromatosis, 724–726


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hemophilia, 722–724 hemorrhage, 722–724 iron overload, 724–726 leukemia, 791–794 myeloma, 797–798 thalassemias, 720–721 thrombocytopenia, 728–729 Hematopoietic stem-cell transplantation, 753–756 Hemianopia, 106 Hemochromatosis, 45t Hemoglobin, 688, 689t, 707 Hemolytic anemia, 705–706 Hemolytic disease of the newborn, 692 Hemophilia, 722–724 Hemorrhage, 722–724 Hemorrhagic gastritis, 401 Hemorrhoidectomy, 816 Hemorrhoids, 466–467 Heparin, 318 Hepatic cirrhosis, 483–486 Hepatic coma, 488 Hepatic encephalopathy, 487–492 Hepatic failure, 487–490 Hepatitis, 479–482 Hepatitis A virus, 479, 480t Hepatitis B virus, 479, 480t Hepatitis C virus, 480, 480t Hepatitis D virus, 480, 480t Hepatitis E virus, 480, 480t Hepatobiliary disorders, 471–473 alcoholic liver disease, 474–477 ascites, 477–479 biliary cirrhosis, 512–514 cholestasis, 514–516 chylous ascites, 477–479 cirrhosis, 483–486 gallbladder disorders, 516–518 hepatic coma, 487–492 hepatic encephalopathy, 487–492 hepatic failure, 487–492 hepatitis, 479–482 pancreatic cancer, 777–779 pancreatic insufficiency, 507–508 pancreatitis, acute, 497–501 pancreatitis, chronic, 501–506 Zollinger-Ellison syndrome, 511–512 Hepatocellular carcinoma, 769–771 Hepatolenticular degeneration, 216–218 Hepcidin, 688 Hepsera (adefovir), 834t Herbs and supplements. See Complementary nutrition Herceptin (trastuzumab), 784 Hereditary hematochromatosis, 724 Hereditary nonspherocytic hemolytic anemia, 705t Heroin, 288t Herpes simplex, 826t Herpes zoster, 826t Hers disease, 176t Hesperetin, 499t, 736t Hiatal hernia, 395–397 High-calorie diet, 302 High-density lipoprotein cholesterol (HDL-C), 338t Highly active antiretroviral therapy (HAART), 177, 179

High-protein diet, 302 Hindbrain, 220t Hinduism, dietary practices of, 91 Hip replacement, 810t Hirschsprung’s disease, 175–177 Hirschsprung’s-associated enterocolitis, 171t Hispanic diet, 85 Histamine, 123, 224t, 247t Histidine, 701 HIV infection, pediatric, 177–179 Hivid (zalcitabine), 834t HLA-DR gene expression, 151 HMG-CoA reductase, 348 Hmong food, 85 Hodgkin’s lymphoma, 795–796 Homocysteine, 338t, 513 Homocystinuria, 45t, 180–182 Honey, 532t Hookworms, 845t Hormonal therapy, 732t Hormones, 13t Horse chestnut, 75t, 80t Horseradish, 75t Huang lian, 75t Humalog (lispro), 533t, 559 Human chorionic gonadotropin (hCG), 569t Human growth hormone, 569t Human immunodeficiency virus (HIV) infection, 829–837 clinical staging, 830t Humira (adalimumab), 332t, 681t Humulin R, 533t Huntington’s disease, 45t, 244–245 Huperzine A, 229 Hydergine, 230t Hydralazine, 376 Hydrea (hydroxyurea), 719 Hydrochlorothiazide, 486t, 591, 645 Hydrocortisone, 329t, 364t, 572 HydroDIURIL, 486t Hydroxychloroquine, 651, 680t Hydroxycinnamic acids, 734t Hydroxycitric acid, 74t 4-Hydroxyphenylpyruvate dioxygenase (HPD), 212 Hydroxyurea, 719 Hyperaldosteronism, 585–586 Hyperammonemia, 214t Hyperargininemia, 214t Hypercalcemia, 596–598, 806t, 807t, 915t Hypercholesterolemia, 45t Hyperchromia, 689t Hyperemesis, 10t Hyperglycemia, 183, 193, 522t, 796, 803, 915t Hyperinsulinism, 567–569 Hyperkalemia, 806t, 807t, 915t Hyperkinesis, 145 Hypermagnesemia, 806t, 807t, 915t Hypernatremia, 806t, 915t Hyperosmolar hyperglycemic state, 563–564 Hyperosmolar laxatives, 420t Hyperoxaluria, 429 Hyperparathyroidism, 596–598 Hyperphagia, 206–207 Hyperphosphatemia, 807t, 915t Hypertension, 55t, 337t, 367–371, 525t, 556–557 Hyperthyroidism, 589–591

1009

Hyperuricemia, 645 Hypervitaminosis, 9 Hypocalcemia, 595–596, 806t, 807t, 915t Hypochromia, 689t Hypoglossal nerve, 221t Hypoglycemia, 183, 522t, 565–566, 915t Hypokalemia, 806t, 915t Hypomagnesemia, 806t, 807t, 915t Hyponatremia, 580, 806t, 915t Hypoparathyroidism, 595–596 Hypopharynx, 764t Hypophosphatemia, 807t, 915t Hypophosphatemic rickets, 887–888 Hypopituitarism, 571–572 Hypostatic pneumonia, 314t Hypothalamic lesions, 234 Hypothalamus, 220t, 569t Hypothermia, 65 Hypothyroidism, 591–594 Hysterectomy, abdominal, 810t Hytrin (terazosin), 616t Ibandronate (Boniva), 670t, 844 Ibuprofen, 230t, 255t, 408, 657, 660t, 679t, 719 Ice cream, 247t Idarubicin, 798 Ideal body weight, 606t Ileal pouch rectal anastomosis (IPRA), 467 Ileoanal anastomosis, 452–454 Ileostomy, 452–454 Ileum, loss of, 456t Imatinib, 768, 794t Imdur (isosorbide), 345 Imidazoquinazoline, 729 Imipramine (Tofranil), 31, 284t, 289, 616t Immobilization, 647–648 Immune system, 820 assessment factors, 819 cells of, 820–821t gut immunity, 821t innate and acquired immunity, 820t nutrition and, 820 Immunity, nutritional and host factors in, 823–824t Immunocompromised persons, 822t Immunosuppressants, 329t, 364t, 442t, 496t, 510t, 538t, 755t Imodium (loperamide), 447 Impulse control disorders, 223t Imuran (azathioprine), 250, 312, 329t, 364t, 486t, 496t, 510t, 651 Incomplete fracture, 842 Incretin mimetics, 547t Inderal (propranolol), 486t, 616t Indeterminate colitis, 434 Indian diet, 86 Indian snakeroot, 283 Indigestion, 397–399 Indinavir, 835t Indirect calorimetry, 824t Indirubin, 76t Indocin (indomethacin), 660t Indoles, 735t, 790t Indomethacin (Indocin), 660t Induction therapy, 442t Infant macrosomia, 182–183 Infantile nephropathic cystinosis, 165–166


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Infants ages 0-6 months, 19–21 breastfeeding, 19–20 food and nutrition, 20 food safety tips, 21 nutrition education, 21 nutritional objectives for, 19–20 recommended intakes, 20 solid foods, 20 supplements, 21 ages 6-12 months, 22–26 breastfeeding, 22 clinical indicators, 23 complementary nutrition for, 22 drugs and side effects, 25 feeding, 24t food and nutrition, 23–24 food safety tips, 26 nutritional guidelines for, 25–26 supplements, 25–26 anemia in, 692–694 clinical indicators, 19 energy requirements/expenditures, 142t failure to thrive, 169–171 feeding problems, 21 formula-fed, 20 growth monitoring, 19 HIV infection, 177–179 HIV infection in, 177–179 immunocompetence of, 821t large for gestational age, 182–183 low birth weight, 186–189 normal growth rates, 164t pediatric disorders, 137–143 anthropometric, 138t behavioral, 138–139t clinical, 139–140t developmental disabilities, 140t eating/feeding skills, 140t genetic/metabolic, 140t nutritional risks, 143t premature, 186–189 small for gestational age, 210–211 Infections, 825–829 Infectious arthritis, 638 Infective endocarditis, 164 Infertility, 48t, 52t Inflammation, 638–639 Inflammatory bowel diseases Crohn’s disease, 430–433 ulcerative colitis, 434–436 Infliximab (Remicade), 332t, 436, 674, 681t Influenza, 44t, 826t Innate immunity, 820t Inositol, 153, 734t Insomnia, 285 Insulin, 9, 183, 193, 230t, 235, 356, 476, 486t, 496t, 498t, 510t, 531, 533t, 538t, 562, 569t, 616t, 779, 804, 841t, 872t Insulin-like growth factor 1 (IGF-1), 573 Intal (cromolyn), 296t Integrase inhibitors, 835t Integrative nutrition. See Complementary nutrition Interferon, 250, 312, 481, 744t, 773 Interferon-alpha, 486t, 798, 841t Interferon-gamma, 841t Interleukin-1, 838

Interleukin-1 inhibitor, 681t Interleukin-2, 744t, 773 Interstitial cystitis, 894 Interstitial lung disease, 311–313 Intestinal fistula, 437–438 Intestinal flora modifiers, 429, 461 Intestinal lipodystrophy, 461–462 Intestinal lymphangiectasia, 439–440 Intestinal parasite infections, 845t Intestinal transplantation, 440–442 Intracerebral hemorrhage, 237 Intracranial hemorrhage, 237 Intrauterine growth restriction (IUGR), 210–211 Intravenous fat emulsion, 899t Intron A, 486t Inulin, 771 Invirase, 835t Iodine, 8 Ionamin (phentermine), 617t Ireton-Jones formula, 824t, 838 Irinotecan (Camptosar), 744t Iron, 706–709 bone health and, 665t for brain health, 225t deficiency of, 712t for dialysis patients, 872t heart disease and, 339t infection and, 829t for oral tissue and dental care, 97t overload, 724 for pregnant women, 9 recommended intakes for children, 29t Iron deficiency, 19, 36t Iron deficiency anemia, 89t Iron dextran, 695 Iron sucrose (Venofer), 695 Iron-deficiency anemia, 706–709 Irritable bowel syndrome, 443–445 Isatis root, 747t Iscador, 748t Ischemia, 347–348 Isentress, 835t Islet cell transplantation, 537–539 Isocarboxazid (Marplan), 284t, 616t Isoflavone phytoestrogens, 499t Isoflavones, 736t Isoniazid, 332t, 376 Isordil (isosurbide), 345 Isorhamnetin, 499t, 734t Isosorbide dinitrate, 391 Isosurbide, 345 Isothiocyanates, 790t Isotretinoin, 9 Isotretinoin (Accutane), 112 Isoxsuprine (Vasodilan), 379 Jainism, dietary practices of, 91 Januvia (sitagliptin), 547t Jasmonates, 735t Jejunostomy, 559 Jejunum, loss of, 456t Judaism, dietary practices of, 93–94 Juniper, 76t Juvenile rheumatic arthritis, 677t Kaempferol, 499t, 734t Kaletra, 835t

Kaolin, 413, 423–424 Kaopectate, 401, 413, 423–424 Karela, 76t Kasai procedure, 151 Kashrut, 93 Kava, 76t, 80t, 283, 661t, 808t Kelp, 80t Keppra (levetiracetam), 241t Ketamine, 288t Ketek (telithromycin), 315 Ketoconazole, 835t Ketones, 561 Ketoprofen, 679t Kidney, 860t Kidney cancer, 772–773 Kidney diseases, 44t Kidney Early Evaluation Program (KEEP), 866 Kidney stones, 882–884 Kineret (anakinra), 681t Klonopin (clonazepam), 160, 241t, 284t Kock pouch, 453 Kombucha tea, 80t Konsyl, 420t Kosher, 93 Kristalose, 420t, 486t Kudzu, 76t Kuvan, 205 Kwashiorkor, 626 Kyushin, 76t Lactation, 12–18, 523t. See also Breastfeeding Lactobacillus, 96 Lactobacillus acidophilus, 193 Lactose intolerance, 155 Lactose maldigestion, 445–447 Lactulose, 420t, 491t Lamictal (lamotrigine), 241t Lamivudine, 486t, 834t Lamotrigine, 276 Lamotrigine (Lamictal), 241t Lanoxin, 350 Lansoprazole (Prevacid), 397, 398, 402, 406, 409t, 512 Lanthanum carbonate (Fosrenol), 872t Lantus (glargine), 533t Laparoscopic Roux-en-Y gastric bypass (LRYGB), 813 Lap-band adjustable gastric banding, 813 Large for gestational age (LGA), 182–183 Large intestine, 384 L-arginine, 310t, 340t Larynx, 764t Lasix (furosemide), 478, 486t, 886 Latino diet, 85 Laxatives, 217, 230t, 235, 258, 417, 420t, 466, 486t, 491t, 804 Lead poisoning, 23, 32t Learning disorders, 223t Leflunomide, 644, 680t Lenalidomide, 798 Lente, 533t Leucovorin, 762 Leukemia, 46t, 791–794 Leukeran (chlorambucil), 794t Leukocytes, 820–821t Leukodystrophies, 184–185 Leukotriene modifiers, 296t Levalbuterol, 296t


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Levetiracetam (Keppra), 241t Levodopa, 255t Levothyroxine, 572 Lexiva, 834t Librium (chlordiazepoxide), 284t, 616t Licorice, 76t, 410, 476, 747t Life expectancy, 44, 58 Life stage-specific assessments, 2 Lignan, 500t, 735t Limb-girdle muscular dystrophy, 653t Limonene, 736t Limonoids, 736t Linoleic acid, 734t Lioresal, 250 Liotrix, 592 Lipid-lowering drugs, 872t Lipids in breast milk, 13t cardiovascular disorders and, 336 Lipitor (atorvastatin), 886 Lipoic acid, 500t, 748t Lisdexamfetamine dimesylate, 147t Lispro (Humalog), 533t, 559 Listeria, 18 Lithane, 276 Lithium, 230t, 276, 594, 616t Lithobid, 276, 616t Lithotabs, 276 Live glycogen phosphorylase deficiency, 176t Liver cancer, 769–771 Liver disease, 44t alcoholic, 474–477 ascites, 477–479 biliary cirrhosis, 512–514 cholestasis, 514–516 chylous ascites, 477–479 cirrhosis, 483–486 hepatic coma, 487–492 hepatic encephalopathy, 487–492 hepatic failure, 487–492 hepatitis, 479–482 liver cancer, 769–771 Liver phosphorylase deficiency, 176t Liver transplantation, 493–496 L-methylfolate, 229, 279 Lobelia, 81t Lomotil, 424, 451, 454 Long-bone structure, 842 Long-chain 3-hydroxyacyl-Coa dehydrogenase (LCHAD) deficiency, 172 Loop diuretics, 361t, 486t Loose teeth, 99t Loperamide, 401, 447 Lopid (gemfibrozil), 350 Lopinavir, 835t Lopressor (metoprolol), 486t, 616t Lorazepam (Ativan), 284t Lorelco (probucol), 350 Lorenzo’s oil, 185 Losartan (Cozaar), 886 Lotensin (benazepril), 886 Lou Gehrig’s disease, 232–234 Lovastatin, 185, 350t Low birth weight (LBW), 6, 36t, 186–189, 202 Low vision, 106–108 Low-density lipoprotein cholesterol (LDL-C), 30, 337t, 338t Low-sodium diet, 359t

Lubiprostone (Amitiza), 420t Lubricant laxatives, 420t Lumbarradiculopathy, 683 Luminal (phenobarbital), 241t Lung cancer, 774–776 Lung transplantation, 327–329 Lupus, 649–651 Lutein, 108t, 109, 499t, 735t, 790t Luteinizing hormone (LH), 571 Luteolin, 499t, 734t Luvox (fluvoxamine), 283t, 616t Lycium, 76t Lycopene, 232, 499t, 736t, 790t Lymphocytes, 821t Lymphogranuloma venereum, 467 Lymphomas, 795–796 Lynch syndrome, 46t Lyrica (pregabalin), 657 Lysergic acid diethylamide (LSD), 288t Ma huang, 42t, 272, 283, 295, 302, 615, 808t Maalox (aluminum hydroxide), 396–397 Macrobiotic diet, 748t Macrocytic anemia, 689t Macrodantin (nitrofurantoin), 895 Macroglossia, 405–406 Macronutrients, 63t, 142t, 823t Macrosomia, 182–183 Madopar, 255t Magaldrate (Riopan), 409t Magnesium, 97t, 232, 294t, 342t, 495t, 534t, 661t, 665t, 806t Magnesium carbonate, 872t Magnesium hydroxide, 409t Malabsorption, 740t Malaria, 710–712 Malignant of fulminant multiple sclerosis, 249t Malnutrition, 601–608 assessment factors, 601 biochemical changes in, 631t in children, 27–28 consequences of not feeding in, 632t drugs and side effects, 631 effects on body systems, 627t gastrointestinal disorders, 384t indicators of, 628t nutritional guidelines for, 630–631 protein-energy, 626–631 in pulmonary disorders, 291–292 refeeding syndrome, 633–635 types of, 601 universal screening tool, 629–630t Malnutrition-inflammation complex syndrome, 865 Maltose, 532t Maltose intolerance, 157 Malvidin, 500t Manganese, 665t Maple syrup urine disease, 189–191 Marasmic kwashiorkor, 626 Marasmus, 626 Maraviroc, 835t Marfan syndrome, 45t Marijuana, 288t Marinol (dronabinol), 631, 744t Marjoram, 748t Marplan (isocarboxazid), 284t, 616t

1011

Mashbooh, 95 Matairesinol, 735t Matrix extracellular phosphoglycoprotein (MEPE), 664 Maturity-onset diabetes of the young (MODY), 521t Maxamaid XPHEN, 212 Maxaquin (fluoroquinolone), 895 McArdle disease, 176t Meadowsweet, 76t Measles, 32t Meat, 303t, 359t, 492t Meat substitutes, 303t Meclizine, 411 Mediterranean anemia, 720 Mediterranean diet, 49, 86, 339t, 374, 640t, 784, 877t Medium0-chain triglycerides, 145 Medium-chain acyl-CoA dehydrogenase deficiency (MCAD), 172–173 Medium-chain triglycerides (MCTs), 429t Medrol, 296t Medroxyprogesterone acetate, 616t Medulla, 586–588 Medullar oblongata, 220t Medullary thyroid carcinoma, 46t Medulloblastomas, 757t Megace, 52t, 631, 836t Megacolon, 448–449 Megaloblastic anemia, 689t, 713–714 Megestrol acetate, 52t, 631, 784, 836t Meglitinides, 547t Melatonin, 76t, 371t, 500t, 570t, 615, 748t Mellaril (thioridazine HCl), 616t Melphalan (Alkeran), 798 Memantine (Namenda), 230t Ménétrier’s disease, 405–406 Ménière’s syndrome, 128–129 Meningiomas, 757, 757t Meningitis, 827t Meningoceles, 194 Menopause, 48t, 52t Mental disorder, 223t Mental health disorders, 222–224t Meperidine, 844 Mephyton (phytonadione), 486t 6-Mercaptoguanine, 436 Meridia (sibutramine), 617t Mesalamine, 436 Metabolic bone disease, 915t Metabolic disorders, 45t Metabolic syndrome, 339t, 344t, 539–541. See also Obesity clinical indicators, 539–540t diagnostic criteria for, 539 drugs and side effects, 541 elevated glucose, 540 nutritional objectives for, 540 patient education, 541 proinflammatory state, 540 prothrombic state, 540 supplements, 541 Metadate (methylphenidate), 147t Metafolin, 703–704 Metal chelating agents, 486t Metamucil (laxative), 235, 340t, 417, 436, 444, 451, 454, 466 Metaprel (metaproterenol), 296t


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INDEX

Metaproterenol, 296t Metformin, 195, 543 Methadone, 793 Methamphetamines, 147t, 288t Methicillin-resistant Staphylococcus aureus (MRSA) infection, 828t Methimazole (Tapazole), 590 Methionine, 339t Methotrexate, 195, 323, 644, 651, 681t, 744t, 755t, 762, 764t, 784, 787, 796 Methylcellulose, 420t, 444 Methylcobalamin, 149 5-10-Methylene-tetrahydrofolate reductase (MTHFR), 180–181, 281–282 Methylphenidate, 31, 147t Methylprednisolone, 296t, 436, 476, 680t Methylprednisone, 154, 312 Methylselenol, 760 Methyltetrahydrofolate, 229, 703 5-10-Methyltetrahydrofolate-homocysteine methyltransferase (MTR), 181 5-10-Methyltetrahydrofolate-homocysteine methyltransferase reductase (MTRR), 181 Metoclopramide, 404, 559, 744t, 804, 841t Metoprolol (Lopressor), 486t, 616t Metronidazole, 283, 436 Mexiletine (Mexitil), 374 Mexitil, 374 Miacalcin (calcitonin), 670t Microalbuminuria, 524t Microcytic anemia, 689t Micronase (glyburide), 547t Micronutrients, 823t dietary guideline for, 3t Micropreemies, 186 Midamor (amiloride), 486t Midazolam (Versed), 284t Midbrain, 220t Middle Eastern food, 86 Mifflin-St. Jeor equation, 838 Miglitol (Glyset), 547t Migraine, 245–247 Milk, 536t allergy to, 125t, 127t Milk of magnesia, 409t, 420t Milk powder, 303t Milk thistle, 76t, 476, 748t Mineralocorticoids, 570t Minerals, 459t, 823t in breast milk, 13t for dialysis patients, 877t Mini Nutrition Assessment (MNA), 60t Minimal enteral feeding, 20 Minipress (prazosin), 616t Minocycline, 245 Minoxidil (Rogaine), 52t Mint, 76t Miralax, 420t Mirapex (pramipexole), 255t Mirtazapine (Remeron), 616t Misoprostol (Cytotec), 660t Mistletoe, 81t, 748t Mitochondrial disorders, 46t Mitomycin C, 768 Mitral stenosis, 365 Mitral valve prolapse, 365 Mixed connective tissue disease, 638

Moban, 616t Modular enteral feeding, 899t Molasses, 532t Monoamine oxidase inhibitors (MAOIs), 283, 284t, 616t Monoclonal antibodies, 744t, 893t Mononucleosis, 827t Monosodium glutamate (MSG), 85 allergy to, 125t Monounsaturated fats, 338t, 736t Mood stabilizers, 230t, 276, 616t Mormons, dietary practices of, 94 Morphine, 374, 844 Motherwort, 76t Motilium (domperidone), 559 Motrin (ibuprofen), 408, 657, 660t Mouth ulcers, 99, 101 Mucolytics, 310t Mucositis, 740t Mulberry, 748t Multichamber bag, 899t Multiple organ dysfunction syndrome (MODS), 847–850 Multiple pregnancy, 6 Multiple sclerosis, 248–250 Muromonab (Orthoclone OKT3), 496t Muscle dysmorphic disorder, 274t Muscle glucagon phosphorylase deficiency, 176t Muscle glycogen, 38 Muscle relaxants, 683 Muscle wasting, 741t Muscular disorders, 45t Muscular dystrophy, 652–655 Musculoskeletal disorders ankylosing spondylitis, 643–644 assessment factors, 633–635 bone disorders, 641–642 degenerative joint disease, 658–661 fibromyalgia, 656–657 gout, 645–647 immobilization, 647–649 lupus, 651 muscular dystrophy, 652–655 myofascial pain syndromes, 656–657 osteoarthritis, 656–657 osteomalacia, 664–666 osteomyelitis, 662–663 osteopenia, 666–671 osteoporosis, 666–671 Paget’s disease, 672–673 polyarteritis nodosa, 673–674 polymyalgia rheumatica, 656–657 rhabdomyolysis, 675–676 rheumatic disorders, 638–640 rheumatoid arthritis, 677–682 ruptured disc, 683–684 scleroderma, 684–686 Mushrooms, 76t Muslims, dietary practices of, 95 Mustard, allergy to, 125t Mustard seed, 748t Myambutol, 332t Myasthenia gravis, 251–252 Mycelex (clotrimazole), 755t Mycobacterium tuberculosis, 330 Mycophenolate mofetil, 496t Myeloma, 797–798

Myelomeningocele, 194 Myelosuppressive agents, 727, 729 Mylanta, 409t Myocardial infarction (MI), 372–375 Myofascial pain syndromes, 656–657 Myotonic dystrophy, 653t MyPyramid Food Guidance System, 35, 61 Myricetin, 499t, 734t, 736t Mysoline (primidone), 241t Myxedema, 592 Nabumetone (Relafen), 660t N-acetylcysteine, 229, 500t N-acetylglutamate synthetase deficiency, 214t N-acetyl-L-cysteine, 76t Nadolol, 345, 476 Nadolol (Corgard), 486t Naloxone, 289 Naltrexone, 149, 289, 476 Namenda (memantine), 230t Nandrolone, 836t Naprosyn (naproxen), 657, 660t Naproxen (Naprosyn), 657, 660t, 679t Nardil (phenelzine), 284t, 616t Naringenin, 499t, 736t Nasal cavity, 764t Nasopharynx, 764t Native American diet, 86 Naturacil, 417 Nausea, 741t Navane (thiothixene), 283t, 616t Necator americanus, 845t Necrotizing enterocolitis, 186, 192–193 Nedocromil (Tilade), 296t Neevo, 9 Nefazodone (Serzone), 616t Nelfinavir, 835t Neomycin, 491t Neonatal hepatitis, 150–152 Neoplastic disorders, 46t Neoral (cyclosporine), 893t Neotame, 533t Nephrogenic diabetes insipidus, 577 Nephrolithiasis, 884t Nephropathy, 524t Nephrotic syndrome, 885–886 Nesiritide, 164 Neupogen (filgrastim), 755t Neural-tube defects, 55t, 194–196 Neuroblastoma, 757t Neurogenic diabetes insipidus, 577 Neurological disorders, 45t Alzheimer’s disease, 227–231 amyotrophic lateral sclerosis, 232–234 assessment factors, 219t brain trauma, 234–236 cerebral aneurysm, 236–238 cerebrovascular accident, 259–263 coma, 238–239 dementia, 227–231 epilepsy, 240–242 Guillain-Barré syndrome, 242–243 Huntington’s disease, 244–245 migraine, 245–247 multiple sclerosis, 248–250 myasthenia gravis, 251–252 neuromuscular junction disorders, 251–252 Parkinson’s disease, 253–255


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persistent vegetative state, 238–239 seizure disorders, 240–242 spinal cord injury, 256–259 stroke, 259–263 tardive dyskinesia, 263–264 trigeminal neuralgia, 265–266 Neuromuscular junction disorders, 251–252 Neurontin (gabapentin), 241t, 616t Neuro-psychiatric disorders, 219–226 Neurotransmitter, 587t Neutropenia, 740t Neutrophils, 821t Nevirapine, 834t Nexium (esomeprazole), 397, 398, 402, 406, 409t, 512 Niacin for brain health, 226t deficiency of, 119t, 121 drug interactions, 262 for healthy vision, 108t for heart disease, 340t heart disease and, 339t lipoprotein metabolism and, 350t recommended intakes for children, 29t sources of, 121 toxicity of, 121 Nicardipine, 345 Nickel dermatitis, 111, 112 Nicotinamide adenine dinucleotide (NAD), 249, 566 Nicotine, 280, 288t Nicotinic acid. See Niacin Nifedipine, 345, 391 Night eating syndrome, 274t, 611t Nilotinib (Tasigna), 794t Nimodipine, 237 Nitisone (Orfadin), 212 Nitoman (tetrabenazine), 263 Nitrofurantoin, 895 Nitroglycerin, 391 Nizatidine (Axid), 409t Nocturnal sleep-related eating disorder, 274t Non-Hodgkin’s lymphoma, 795–796 Noni juice, 748t Nonsmall cell lung cancer (NSCLC), 46t, 774 Non-steroidal anti-inflammatory drugs (NSAIDs), 247, 323, 376, 638, 657, 660t, 679t Nonucleoside reverse transcriptase inhibitors (NNRTIs), 834t Noradrenalin, 570t Noradrenaline, 224t Noraldex (tamoxifen), 784 Norepinephrine, 570t, 587t Norfloxacin (Noroxin), 895 Normochromia, 689t Normocytic anemia, 689t Noroxin (norfloxacin), 895 Norpace (disopyramide), 345 Norpramin, 284t Nortriptyline, 284t, 616t Norvir, 835t Novolin R, 533t Novolog (aspart), 533t NPH, 533t Nucleoside reverse transcriptase inhibitors (NRTIs), 834t Nummular eczematous dermatitis, 111

Nutramigen, 20 NutraSweet (aspartame), 533t Nutrition screening and assessment factors, 1–2 Nutrition support process, 899t Nutrition support service, 899t Nutrition support teams, 904 Nutritional guidelines for acquired immunodeficiency syndrome (AIDS), 831t, 833 for adolescents, 36–38 for adults, 49–53 for allergies, 124–125 athletes, 40, 42t for cancer, 742–743 for childhood obesity, 200–201 for children, 29–30, 31 for chronic kidney disease (CKD), 869 for congenital heart disease (CHD), 164 for diarrhea, 423 for dysphagia, 388 for elderly, 61 for food allergies/intolerances, 124–125 for infants, 25–26 for malnutrition, 630–631 for obesity, 614–615 for osteoporosis, 668–669 for overweight, 614–615 for pregnancy, 9–11 for rheumatoid arthritis, 679 sports nutrition, 40, 42t for stroke, 261–262 Nuts, 337t, 339t allergy to, 125t, 127t headaches and, 247t seeds, 491t Nydrazid (isoniazid), 376 Nytol (diphenhydramine), 616t Obesity, 609–620. See also Metabolic syndrome body mass index and, 198 colorectal cancer and, 760 diet program comparisons, 620t drugs and side effects, 615 heart disease and, 339t medications that cause weight gain, 616t nutritional guidelines for, 614–615 nutritional objectives for, 612–614 patient education, 615–619 supplements, 615 weight management counseling, 610 Obesity, childhood, 197–201 clinical indicators, 198t complications, 198t drugs and side effects, 200 food safety tips, 201t genetic markers, 198t nutritional guidelines for, 200–201 nutritional objectives for, 199–200 patient education, 200–201 weight loss diets for, 199t weight loss program for, 201t Obsessive-compulsive disorder, 223t Obstructive jaundice, 512–514 Obstructive sleep apnea, 324–325 Occipital lobe, 220t Octreotide (Sandostatin), 134, 304, 437–438, 498t, 574

1013

Oculomotor nerve, 221t Oculopharyngeal muscular dystrophy, 653t Odoroside, 748t Ofloxacin, 895 Oils, 491t Olanzapine (Zyprexa), 149, 264, 283t, 616t Oleandrin, 748t Oleanic acid, 734t Oleic acid, 185 Olfactory nerve, 221t Oligosaccharides, 737t, 771 Oliguria, 880 Olive leaf extract, 370 Olive oil, 246 Olsalazine, 436 Omega-3 fatty acids, 56t, 89t, 108t, 126, 185, 186, 225t, 229, 230t, 246, 294t, 295, 296t, 337t, 339t, 340t, 356, 413, 643, 660t, 736t, 760, 794, 803, 877t Omega-6 fatty acids, 108t, 225t, 229, 294t, 736t Omeprazole (Prilosec), 397, 398, 402, 406, 409t, 459t, 512 Oncaspar (pegaspargase), 794t Oncovin, 787, 796, 798 Ondansetron, 744t Oolong tea, 370 Open fracture, 842 Opiates, 498t Opioids, 657 Oppositional defiant disorder, 223t Optic nerve, 221t Oral allergy syndrome, 123 Oral cavity, 764t Oral contraceptives, 370, 517 Oral disorders, 96–101 dental problems, 96–101 gingivitis, 103–104 periodental disease, 103–104 temporomandibular joint dysfunction, 104–105 Oral health, 339t Orapred, 296t Orasone (prednisone), 657 Oregano, 76t Oregon grape root, 76t Orfadin (nitisinone), 212 Organ extracts, 81t Orlistat, 429–430 Orlistat (Xenical), 617t Ornithine transcarbamylase (OTC), 214t Orofacial clefts, 161–162 Oropharynx, 764t Orthoclone OKT3 (muromonab), 496t Orthorexia nervosa, 274t Os-Cal 500, 669t Osler-Vasquez disease, 726–728 Osmolality, 899t Osmotic laxatives, 420t Osteitis deformans, 672–673 Osteoarthritis, 658–661 Osteoblasts, 641 Osteocalcin, 641 Osteomalacia, 664–666 Osteomyelitis, 662–663 Osteopenia, 666 Osteoporosis, 666–671. See also Musculoskeletal disorders calcium and, 55t


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INDEX

Osteoporosis (continued ) calcium supplements for, 669t clinical indicators, 668t drugs and side effects, 669 medications for, 670t nutritional guidelines for, 668–669 nutritional objectives for, 668 pathogenesis of, 103 patient education, 670–671 prevention of, 642t related genes, 45t risk factors, 667t Osteoprotegerin, 673 Osteosarcoma, 751–752 Ostomy colostomy, 450–452 ileostomy, 452–454 Otitis media, 202–203 Ovarian cancer, 46t Ovaries, 570t Overnutrition, 602, 603t, 822t Overweight, 198, 609–620. See also Malnutrition; Metabolic syndrome; Underweight diet program comparisons, 620t drugs and side effects, 615 medications that cause weight gain, 616t nutritional guidelines for, 614–615 nutritional objectives for, 612–614 patient education, 615–619 prevalence of, 609 supplements, 615 weight management counseling, 610t Oxalic acid, 500t Oxaliplatin, 762 Oxandrin, 631, 836t Oxandrolone, 258, 631, 836t Oxazepam (Serax), 284t Oxcarbazepine (Trileptal), 241t Oxygen radical absorbance capacity (ORAC), 503–505t Oxymetholone, 616t Oxytocin, 569t Paget’s disease, 672–673 Pain, 741t Pain disorder, 223t Painkillers, 498t Pakistani diet, 86 Pamelor, 284t, 616t Pamidronate (Aredia), 673, 798 Panax ginseng, 747t Pancreas, 569t Pancreatic cancer, 777–779 Pancreatic disorders, 471–473 Pancreatic enzyme, 459t, 498t, 508, 510t, 538t, 779, 836t Pancreatic insufficiency, 507–508 Pancreatic surgery, 810t Pancreatic transplantation, 509–510 Pancreatin, 779 Pancreatitis, acute, 497–501 Pancreatitis, chronic, 501–506 Pancrelipase, 310t, 779 Panic disorder, 223t Pantoprazole (Protonix), 409t, 512 Pantothenic acid, 121 deficiency of, 119t toxicity of, 121

Papaverine, 237 Para-amino benzoic acid (PABA), 701 Paracicaltol (Zemplar), 872t Paranasal sinuses, 764t Paraplegia, 257t Parasitic anemia, 710–712 Parathyroid glands, 570t, 594 Parathyroid hormone (PTH), 357, 570t, 594 Parathyroidectomy, 811t Parenteral nutrition, 911–916. See also Enteral nutrition assessment factors, 897 in brain trauma, 234 central, 899t, 911–912 in chylothorax patients, 304 clinical indicators, 912t clinical practice guidelines, 905t for coma patients, 900–901t complications, 915t for dialysis patients, 875 drugs and side effects, 915–916 guidelines, 913–914 infusion safety, 916 overview, 898–901 patient education, 916 peripheral, 899t, 911 of preterm infants, 188t standardized, 899t supplements, 915–916 terminology, 899t Paricalcitol (Zemplar), 598 Pariet (rabeprazole), 409t Parietal lobe, 220t Parkinson’s disease, 45t, 253–255 Parlodel (bromocriptine), 255t, 289, 574 Parnate (tranylcypromine), 284t, 616t Parotid gland, 764t Paroxetine (Paxil), 284t, 616t Parsley, 76t Passion flower, 81t Paxil (paroxetine), 284t, 616t Peanuts allergy to, 125t, 127t headaches and, 247t Peas, 491t Pediatric constipation, 418–419 Pediatric disorders, 137–143 abetalipoproteinemia, 144–145 anthropometric, 138t assessment factors, 137–142t attention-deficit disorders, 145–147 autism spectrum disorder, 148–150 behavioral, 138–139t biliary atresia, 150–152 bronchopulmonary dysplasia, 152–154 carbohydrate metabolic disorders, 155–157 cerebral palsy, 158–160 clinical, 139–140t congenital heart disease, 163–164 congenital megacolon, 175–177 cystinosis, 165–166 developmental disabilities, 140t Down syndrome, 167–168 eating/feeding skills, 140t Fanconi’s syndrome, 165–166 fatty acid oxidation disorders, 172–173 fetal alcohol syndrome, 173–175 genetic/metabolic, 140t

Hirschsprung’s disease, 175–177 HIV infection, pediatric, 177–179 homocystinuria, 180–182 infant macrosomia, 182–183 intrauterine growth restriction, 210–211 leukodystrophies, 184–185 maple syrup urine disease, 189–191 myelomeningocele, 194–196 necrotizing enterocolitis, 192–193 neural-tube defects, 194–196 nutritional risks, 143t obesity, 197–201 orofacial clefts, 161–162 otitis media, 202–203 phenylketonuria, 203–204 Prader-Willi syndrome, 206–207 rickets, 208–209 small for gestational age, 210–211 spina bifida, 194–196 tyrosinemia, 212–213 urea cycle disorders, 214–216 Wilson’s disease, 216–218 Pegaspargase (Oncaspar), 794t Pegasys, 481 Peginterferon-alpha, 836t Pegvisomant, 574 Pelargonidin, 500t Pelvic exenteration, 811t Pelvic floor dysfunction, 463t Pelvic inflammatory disease, 827t Penicillamine, 486t Penicillin, 895 Pennyroyal oil, 81t Pentoxifylline (Trental), 379, 685 Peonidin, 500t Pepcid (famotidine), 409t Peppermint, 77t Peppermint oil, 444 Peptic ulcer disease, 407–410 Peptides, 459t Pepto-Bismol, 408 Percutaneous automated discectomy, 683 Periactin, 631 Periarteritis nodosa, 346 Pericarditis, 375–377 Peridex, 103 Perimenopause, 48t Perimolysis, 273t Periodontal disease, 103–104 Periodontoclasia, 103 Peripheral artery disease (PAD), 377–379 Peripheral vascular disease (PVD), 377–379 Peritoneal dialysis, 875 Peritonitis, 454–455 Pernicious anemia, 713–714 Peroxisome biogenesis disorders, 184–185 Perphenazine (Trilafon), 616t Persistent vegetative state, 238–239, 900–901t Personality disorders, 223t Pervasive developmental disorders (PDDs), 148, 223t Petunidin, 500t Phenelzine, 284t, 616t Phenobarbital, 152, 241t Phenolic acids, 500t, 734t, 735t, 736t Phenoptin, 205 Phentermine, 617t Phenylalanine, 204, 225t


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Phenylalanine hydroxylase, 204 Phenylketonuria, 126, 203–205 Phenylpropanolamine, 615 Phenytoin, 195, 235, 239, 241t Phenytoin (Dilantin), 376 Pheochromocytoma, 586–588 Phosphate binders, 872t Phosphatidylserine, 56t Phosphorus, 598t for bone health, 665t for dialysis patients, 877t in diet, 869 for oral tissue and dental care, 97t in post-transplant nutrition, 495t Phytates, 736t Phytic acid, 500t Phytochemicals, 433, 639, 640t, 734–737t Phytoestrogen, 734t, 786, 790 Phytonadione, 486t Phytosterols, 49, 339t, 736t Pica, 10t, 148, 274t, 707 Pickled foods, 492t Pickwickian syndrome, 619t Pilocarpine, 764t Pilocarpine hydroxide (Salagen), 681t Pine bark extract, 748t Pineal gland, 570t Pineal gland tumors, 757t Pinworm, 845t Pioglitazone (Actos), 547t Piroxicam (Feldene), 660t Pituitary gland, 569t. See also Endocrine disorders acromegaly, 573–574 anterior, 573–574, 575–576 Cushing’s syndrome, 575–576 diabetes insipidus, 577–578 hypopituitarism, 571–572 posterior, 577–578 syndrome of inappropriate antidiuretic hormone, 579–580 Pituitary hormone deficiency, 45t Placenta, 569t Plant stanols, 735t Plant sterols, 49, 56t Plaquenil (hydroxychloroquine), 651 Plasma lipoprotein, 339t Plasma volume and osmolality, 860t Pneumocystis carinii pneumonia, 314t Pneumonia, 44t, 313–315 Poke root, 81t Pokeweed, 748t Policosanols, 77t Poliomyelitis, 827t Polyarteritis nodosa, 673–674 Polycillin (ampicillin), 486t Polycystic kidney disease (PKD), 46t, 889–890 Polycystic ovarian syndrome (PCOS), 34, 580–582 Polycythemia vera, 726–728 Polyendocrine deficiency syndrome, 583 Polyethylene glycol 3350, 420t Polymyalgia rheumatica, 346, 656–657 Polyphenols, 49, 734t, 735t, 771 Polyunsaturated fatty acids (PUFA), 349, 640t Pompe disease, 176t Pons, 220t Poplar, 77t

Porphyria cutanea tarda (PCT), 725 Porphyrias, 724–725 Portal hypertension, 483 Postmenopause, 48t Postpartum depression, 277, 280 Posture (calcium supplement), 669t Posture-Vitamin D, 669t Potassium, 63t for dialysis patients, 877t in diet, 869 dietary guideline for, 4t imbalance, 806t for oral tissue and dental care, 97t in post-transplant nutrition, 495t recommended intakes, 340 in salt, salt substitutes and herbal seasonings, 370t sources of, 341t Potassium-sparing diuretics, 486t Poultry, 492t Prader-Willi syndrome, 206–207, 305 Pramipexole (Mirapex), 255t Prandin (repaglinide), 547t Pravachol (fluvastatin), 886 Pravastatin, 350t Prazosin (Minipress), 616t Prealbumin, 867t Prebiotics, 385t, 420t, 425, 442t, 451, 454, 459t, 491–492t, 736t, 771 Preconception, 523t Precose (Acrobose), 547t Prediabetes, 542–544 Prednisone, 258, 312, 323, 329t, 364t, 376, 436, 442t, 451, 486t, 496t, 510t, 657, 680t, 729, 744t, 835t, 893t Preeclampsia, 10t Pre-eclampsia, 556–557 Pregabalin (Lyrica), 657 Pregestimil, 20 Pregnancy, 5–11 adolescent, 36t body mass index and, 604t clinical indicators, 7t deficiency of micronutrients in, 6 diabetes and, 523t drugs in, 9 early, 6 food and nutrition in, 8–9 food safety in, 11 hypertension in, 525t intervention, 7–8 multiple, 6, 10t nutrition care process steps, 7t nutritional guidelines for, 9–11 prenatal risk assessments, 6t preterm births, 11t recommendations for pregnant women, 8t spacing of, 6 supplements, 9 tissue growth in, 5 weight gain in, 5, 17 Pregnancy-induced hypertension, 556–557 Prehypertension, 44 Prelief (calcium glycerophosphate), 397 Prelone, 296t Prematurity, 186–189 Premenstrual dysphoric disorder (PMDD), 48t, 223t

1015

Premenstrual syndrome (PMS), 48t Prescription medications, addiction to, 288t Pressure ulcers, 114–118 clinical indicators, 115t drugs and side effects, 116 Medicare costs, 114 nutritional objectives for, 116 patient education, 116–118 skin changes with aging, 115t stages, 115t supplements, 116 Preterm infants, nutrient needs of, 188t Prevacid (lansoprazole), 397, 398, 402, 406, 409t, 512 Preveon (adefovir), 834t Prezista (darunavir), 834t Prilosec (omeprazole), 397, 398, 402, 406, 409t, 512 Primary adrenal insufficiency, 583 Primary biliary cirrhosis, 513 Primary hyperparathyroidism, 596 Primary-progressive multiple sclerosis (PPMS), 249t Primidone (Mysoline), 241t Proanthocyanidins, 499t, 734t Probenecid (Benemid), 646 Probiotics, 77t, 126, 193, 385t, 420t, 425, 433, 442t, 451, 454, 455, 459t, 461, 491–492t, 737t, 748t Probucol (Lorelco), 350 Procainamide, 374, 376 Procanbid, 376 Procardia (nifedipine), 345 Processed meats, 247t Proctitis, 122, 467–468 Proctocolitis, 122 Procyanidins, 734t, 735t Product recalls, 126t Progestational agents, 616t Progesterone, 5, 570t, 572 Prograf (tacrolimus), 364t, 442t, 496t, 510t, 538t, 893t Progressive-relapsing multiple sclerosis (PRMS), 249t Prolactin, 569t Promethazine (Phenergan), 744t Promotility agents, 841t Pronestyl, 376 Propafenone (Rythmol), 374 Propoxyphene (Darvon), 283 Propranolol, 394, 476 Propranolol (Inderal), 486t, 616t Propylthiouracil, 590 Proscar (finasteride), 52t Prostaglandin, 442t, 860t Prostate, 52t Prostate cancer, 788–790 Protease inhibitors, 737t, 834–835t Proteasome inhibitors, 893t Protein-energy malnutrition, 626–631. See also Malnutrition Proteins adding to diet, 303t for athletes, 40t body storage of, 622 bone health and, 665t for dialysis patients, 877t dietary guideline for, 3t


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INDEX

Proteins (continued ) for healthy vision, 108t in post-transplant nutrition, 495t recommended intakes for children, 29t requirements in infants, 20 vegetarian diet and, 89t Protestants, dietary practices of, 94 Proton pump inhibitors (PPIs), 396, 397, 402, 409t, 455, 478, 512 Protonix (pantoprazole), 409t, 512 Proventil (albuterol), 296t Provera, 616t Prozac (fluoxetine), 279, 283t, 284t, 616t Psoriasis, 111, 112, 113 Psychiatric disorders addiction, 287–289 anorexia nervosa, 266–269 assessment factors, 219t binge eating disorder, 269–270 bipolar disorders, 273–276 bulimia nervosa, 270–273 circadian rhythm disorder, 285–286 depression, 277–280 DSM-IV classification of, 222–224t schizophrenia, 281–284 sleep disorders, 285–286 substance use disorders, 287–289 Psyllium, 77t, 283, 340t, 420t, 424, 436, 451, 454, 466 Pterostilbene, 500t Public health achievements, 2 essential services, 2 Pulmicort (budesonide), 296t Pulmonary disorders, 291–292 assessment factors, 291 asthma, 293–296 bronchiectasis, 297–298 bronchitis, acute, 298–299 chronic obstructive pulmonary disease, 300–303 chylothorax, 304–305 cor pulmonale, 305–306 cystic fibrosis, 307–310 interstitial lung disease, 311–313 malnutrition in, 291–292 pneumonia, 313–315 pulmonary embolism, 315–317 respiratory distress syndrome, 317–319 respiratory failure, 319–321 sarcoidosis, 322–324 sleep apnea, 324–326 thoracic empyema, 324–326 tuberculosis, 330–333 Pulmonary embolism (PE), 315–317 Pulmozyme, 310t Punicalagin, 736t Pycnogenol, 748t Pyelonephritis, 894–896 Pygeum, 790 Pyorrhea alveolaris, 103 Pyrazinamide, 332t, 376 Quadriplegia, 257t Quercetin, 49, 295, 339t, 499t, 734t, 748t Questran (cholestyramine), 424 Quetiapine (Seroquel), 264, 283t Quinolones, 895 Qvar (beclomethasone HFA), 296t

Rabeprazole, 409t, 512 Radiation enteritis, 741t Radiation therapy, 741t Rajasic foods, 86 Raloxifene (Evista), 670t Raltegravir, 835t Ranitidine (Zantac), 409t Rapamycin, 773 Rasagiline (Azilect), 255t Raynaud’s syndrome, 378 Razadyne (galantamine), 230t Reader disorder, 223t Rebetol (ribavirin), 481 Rebif, 250 Rebound hyperglycemia, 522t Recombinant human erythropoietin, 872t Rectal cancer, 760 Rectum, 384 Red blood cells (RBCs), 688, 715–716 Red clover, 77t Red yeast rice, 80t Reed-Sternberg’s cells, 795 Refeeding syndrome, 633–635 Reflux, 21t Refsum’s disease, 184 Reglan, 235, 559, 744t, 804 Regurgitation, 21t Reishe mushroom, 748t Relafen (nabumetone), 660t Relapsing-remitting multiple sclerosis (RRMS), 249t Religious dietary practices, 86 Eastern, 91–92 Middle Eastern, 95–96 Western, 93–95 Remeron (mirtazapine), 616t Remicade (infliximab), 332t, 436, 681t Remifemin, 746t Reminyl (galantamine), 230t Renagel (sevelamer), 872t Renal cell cancer (RCC), 772 Renal disorders, 859–861 Alport syndrome, 862–864 anemia of, 694–696 assessment factors, 859 autoimmune kidney diseases, 879–881 chronic kidney disease, 864–873 collagen-IV nephropathies, 862–864 glomerulonephritis, 875–878, 879–881 Hartnup disorder, 887–888 hypophosphatemic rickets, 887–888 kidney stones, 882–884 nephrotic syndrome, 885–886 nutritional interventions for, 860–861 polycystic kidney disease, 889–890 renal failure, 864–873 symptoms, 859 thin glomerular basement membrane nephropathy, 862–864 urinary tract infection, 894–896 Renal metabolic disorders, 887–888 Renal transplantation, 891–893 Renin, 860t Repaglinide (Prandin), 547t Repertaxin, 784 Reproductive disorders, 46t Requip (ropinirole), 255t Rescriptor (delavirdine), 834t Reserpine, 263

Respiratory distress syndrome (RDS), 292, 317–319 Respiratory failure, 319–321 Respiratory quotient, 292t Resting metabolic rates (RMR), 606t Restoril (temazepam), 284t Restrictive cardiomyopathy, 354 Resveratrol, 500t, 737t, 771, 790t Retacrit (epoetin zeta), 872t Retin A (retinoic acid), 112 Retinitis pigmentosa, 144 Retinoblastoma, 46t Retinoic acid, 112, 433 Retinoids, 736t Retinopathy, 524t Retrovir, 834t Rett syndrome, 45t, 148 Reyataz (atazanavir), 834t Rhabdomyolysis, 675–676, 813 Rheumatic arthritis, 671t Rheumatic disorders, 638–640 Rheumatic fever, 828t Rheumatoid arthritis, 677–682. See also Musculoskeletal disorders clinical indicators, 678t drugs and side effects, 679 juvenile, 677t medications for, 679–681t nutritional guidelines for, 679 nutritional objectives for, 679 patient education, 682 supplements, 682 variant forms of, 677t Rheumatoid vasculitis, 677t Rheumatrex (methotrexate), 651, 681t, 762 Rhodiola, 77t Rhubarb, 77t Ribavirin, 481, 486t Riboflavin deficiency of, 119t, 712t for healthy vision, 108t for migraine headache, 247 recommended intakes for children, 29t sources of, 121 toxicity of, 121 Rice, 85 allergy to, 125t Rice bran oil, 77t Rickets, 89t, 208–209 Ridaura (gold sodium thiomalate), 680t Rifadin, 332t Rifampin, 332t, 376 Rifaximin, 424, 491t Riluzole, 233, 245 Rimactane, 332t Riopan (magaldrate), 409t Risedronate, 669, 670t, 673, 844 Risperdal (risperidone), 264, 283t, 616t Risperidone (Risperdal), 149, 264, 283t, 616t Ritalin (methylphenidate), 31, 147t Ritonavir, 835t Rituxan, 744t Rituximab, 681t, 719, 729, 744t, 893t Rivaroxaban, 317 Rivastigmine (Exelon), 230t Rocaltrol (calcitriol), 872t Rofecoxib, 719 Roferon-A, 486t Rogaine (minoxidil), 52t


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INDEX

Rohypnol, 288t Roman Catholics, dietary practices of, 94 Ropinirole (Requip), 255t Rosacea, 111, 112 Rosemary, 77t, 748t Rosiglitazone (Avandia), 547t Rosmarinic acid, 500t Rosuvastatin, 676, 886 Roundworms, 845t Roux-en-Y gastric bypass (RYGB), 813 Royal jelly, 77t Rumination disorder, 223t Rumination syndrome, 274t Ruptured disc, 683–684 Rutin, 499t Rythmol (propafenone), 374 S-5-adenosyl-methionine, 284t Sabril (vigabatrin), 241t Saccharin, 533t S-adenosylmethionine (SAMe), 661t, 702 Salagen (pilocarpine hydroxide), 681t Salbumol, 296t Salicylates, 338t Salicylic acid, 113, 500t Salivary gland, 764t S-allylcysteine, 736t Salmonella, 135 Salt substitutes, 361t, 370t Sandimmune (cyclosporine), 755t, 893t Sandostatin (octreotide), 134, 304, 574 Saponins, 78t, 734t Saquinavir, 835t Sarcoidosis, 322–323 Sarcopenia, 602t Sassafras, 81t Sattvic foods, 86 Saturated fatty acids (SFA), 338t, 349 Saw palmetto, 77t, 749t, 790 Scabies, 113 Schisandra, 77t Schizoaffective disorder, 224t Schizophrenia, 281–284 Schmidt’s syndrome, 583 Schwannoma, 757t Scleroderma, 684–686 Scleroderma renal crisis, 684 Sclerotherapy, 466 Sea cucumber extract, 762 Seasonal affective disorder, 224t Secoisolariciresinol, 735t Secondary hyperparathyroidism, 596 Secondary-progressive multiple sclerosis (SPMS), 249t Secretin, 569t Seeds, 339t Seizure disorders, 240–242 Selective costimulation modulator, 681t Selective serotonin 5-hydroxytryptamine-3 (5-HT3), 411 Selective serotonin reuptake inhibitors (SSRIs), 279, 283t, 284t, 616t, 669 Selegiline (Eldepryl), 230t, 255t Selenium, 56t, 108t, 225t, 294t, 712t, 734t, 735t, 760 Self-feeding problems, 106–109 Selzentry, 835t Senaglinide (Starlix), 547t Senna, 77t

Sensipar (cinacalcet), 598, 872t Separation anxiety disorder, 224t Sepsis, 850–854 Septra, 486t, 836t, 895 Serax (oxazepam), 284t Serevent (salmeterol xinafoate), 296t Serlect, 616t Seronegative arthritis, 638 Seroquel (quetiapine), 264, 283t Serotonin, 224t Serpalan (reserpine), 263 Serpasil (reserpine), 263 Sertraline, 272 Sertraline (Zoloft), 284t, 616t Serum ferritin, 689t Serum iron, 689t Serutan, 420t Serzone (nefazodone), 616t Sevelamer (Renagel), 872t Seventh-Day Adventists, dietary practices of, 94 Sexual maturation, 34 Sfforon, 749t Shared psychotic disorder, 224t Shark cartilage, 749t Shark oil, 749t Sheep sorrel, 77t Shell fish, allergy to, 125t, 127t Shepherd’s purse, 78t Shiitake mushroom, 749t Shingles, 826t Short bowel syndrome, 456–459, 816 Siberian ginseng, 746t Sibutramine, 270, 617t Sickle cell anemia, 719 Sideroblastic anemia, 715–716 Sikhism, dietary practices of, 91 Sildenafil, 306 Sildenafil citrate (Viagra), 52t Silicon, 665t Silymarin, 500t, 736t, 748t Simple fractures, 842 Simvastatin, 886 Sinemet, 245, 250, 255t Sinequan (Doxepin), 284t, 616t Single-nucleotide polymorphisms (SNPs), 44, 415t Singulair, 296t Sirolimus, 755t, 893t Sitagliptin (Januvia), 547t Sjögren’s syndrome, 677t Skeletal disorders, 45t Skin disorders, 110–113 Skullcap, 81t, 749t Sleep apnea, 324–325, 619t Sleep disorders, 224t, 285–286 Slippery elm, 78t Slow Food movement, 52 Small bowel surgery, 816–818 Small for gestational age (SGA), 210–211 Small intestinal mucosa, 569t Small intestine, 384 Small-cell lung cancer (SCLC), 774 Smilax, 42t Smoking, 36t, 52t, 339t Smoking cessation, 619t Snacks, 302t, 492t, 536t Snakeroot, 283 SNAP, 60t

1017

Sodium for asthma, 294t bone health and, 665t for dialysis patients, 877t dietary guideline for, 4t dietary recommendations for, 63t health claims, 55t for healthy vision, 108t imbalance, 806t low-sodium diet, 359t in post-transplant nutrition, 495t recommended intakes, 340 reduction, 368 restriction, 354, 356 in salt, salt substitutes and herbal seasonings, 370t in typical food items, 359t Sodium bicarbonate, 103, 166 Sodium fluoride, 670t Sodium levothyroxine, 592 Sodium phenylbutyrate, 215 Solu-Cortef, 442t, 496t, 510t, 893t Somatostatin analogs, 478 Somatotropin, 572, 573 Somatuline Depot, 574 Somogyi effect, 522t Sorbitol, 423 Sour orange, 760 Soy allergy to, 125t, 127t formulas, 20 isoflavones, 749t protein, 49, 56t, 337t, 339t Spastic constipation, 418–419 Speech disorder, 224t Spherocytic anemia, 705t Sphingomyelin, 735t Spices, 492t, 640t allergy to, 125t Spina bifida, 194 Spina bifida cystica, 194 Spina bifida occulta, 194 Spinach, 73t Spinal accessory nerve, 221t Spinal arthritis, 643–644 Spinal cord, 220t Spinal cord injury, 256–259 Spinal surgery, 811t Spirulina, 78t, 749t Splenda (sucralose), 533t Splenorenal shunting, 484–485 Spondyloarthropathies, 643 Spondylosis, 638 Spontaneous hypoglycemia, 567–569 Sports nutrition, 38–43 children and adolescent athletes, 38 drugs and side effects, 40–42 female athletes, 38 food safety tips, 43 meal planning, 41t nutritional guidelines, 40, 42t objectives, 39–40 protein, 40t supplements, 42, 42t Sprycel (dasatinib), 794t Squalene, 736t St. John’s wort, 78t, 250, 272, 295, 661t, 749t, 794, 808t Stains, 109


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1018

INDEX

Stanols, 337t, 339t, 615, 735t Staphylococcus aureus, 662, 828t Starch, 85, 416t Starlix (senaglinide), 547t Starvation, 602t Statins, 230t, 337t, 350, 350t, 361t, 364t, 366, 379, 670t, 676, 886 Stature, calculation of, 66t Stavudine, 834t Steroids, 40, 288t, 616t, 660t Sterol esters, 56t Sterols, 337t, 339t, 615, 736t Stigmasterol, 736t Stilbenes, 737t Stilbenoids, 500t Stillingia, 78t Stimulant laxatives, 420t Stomach acid protector, 409t Stomatitis, 740t Stool softeners, 420t Strattera (atomoxetine), 31, 147t Streptococcus, 851 Streptococcus mutans, 96 Streptomycin, 332t Streptozotocin (Zanosar), 512 Stress fractures, 842 Stroke, 259–263 as cause of death, 44t clinical indicators, 260t diabetes and, 525t drugs and side effects, 262 nutritional guidelines for, 261–262 nutritional objectives for, 261 prevention of, 261–262 supplements, 262 symptoms, 260t Struvite stones, 882, 884t Subarachnoid hemorrhages, 237 Subclinical hypothyroidinism, 592 Subdural hemorrhages, 237 Subjective Global Assessment (SGA), 60t Suboxone, 289 Substance use disorders, 287–289 Substance-related disorders, 224t Subutex, 289 Sucralfate, 402, 409t Sucralose, 533t Sucrose, 532t Sucrose intolerance, 155, 157 Sudden infant death syndrome (SIDS), 172 Sugar, 532t Sugar alcohols, 56t, 532t Suicide, 44t Sulfasalazine, 195, 436, 644, 681t Sulfinpyrazone (Anturane), 646 Sulfisoxazole (Gantrisin), 895 Sulfites, 247t allergy to, 125t Sulfonylureas, 547t, 616t Sulforaphane, 407, 640t, 734t, 760, 790t Sulphadoxine-pyrimethamine, 712t Sunburn, 113 Sunette (acesulfame potassium), 533t Sunitinib (Sutent), 769, 773 Supertasters, 44 Surfak (docusate sodium), 417 Surgery, 800–811 amputations, 808t

assessment factors, 799 bariatric, 812–815 bowel, 816–818 clinical indicators, 801t colostomy, 450–452 drugs and side effects, 804 electrolyte imbalances in, 806–807t gastrectomy, 399–401 gastric bypass, 812–815 herbal medications, 808t ileostomy, 452–454 immunity concerns in, 822t nutritional objectives, 809–811t nutritional support in, 802–804 patient education, 805 postoperative concerns in, 802, 803–804 postsurgical status, 799 preoperative concerns in, 801–803 presurgical status, 799 small intestine after, 803t types of, 809–811t vagotomy, 399–401 Surmontil (trimipramine), 616t Sutent (sunitinib), 773 Sweet ’N Low (saccharin), 533t Sweeteners, 126, 532–533t Sweets, 302t, 532t, 536t Symlin (amylin), 547t Symmetrel (amantadine), 255t Synbiotics, 385t, 459t Syndrome of inappropriate antidiuretic hormone (SIADH), 579–580 Synthroid, 593 Syprine (trientine), 486t Systemic inflammation response syndrome (SIRS), 848, 850–854, 903 Systemic sclerosis, 684–686 T cells, 821t Tachycardia, 373 Tacrine (Cognex), 230t Tacrolimus, 329t, 364t, 442t, 496t, 510t, 538t, 646, 755t, 893t Tadalafil (Cialis), 52t Tagamet (cimetidine), 283, 409t Takayasu’s arteritis, 346 Tamasic foods, 86 Tamoxifen (Noraldex), 784 Tangeritin, 499t Tanner stages, 33–34 Tannins, 78t, 735t, 771 Tansy, 113 Tapazole (methimazole), 590 Tarceva, 774, 779 Tardive dyskinesia (TD), 263–264 Tartrazine, allergy to, 125t Tarui disease, 176t Tarvil, 263 Tasigna (nilotinib), 794t Tasmar (tolcapone), 255t Taste, 44 Tay-Sachs disease, 45t T-cell prolymphocytic leukemia, 793t Tea tree oil, 78t Tegaserod (Zelnorm), 420t Tegretol (carbamazepine), 241t, 265, 616t Telithromycin (Ketek), 315 Temazepam (Restoril), 284t

Temporal lobe, 220t Temporomandibular joint (TMJ) disorder, 104–105 Tenofovir DF, 834t Tenormin (atenolol), 486t, 616t Tenuate (diethylpropion), 617t Terazosin (Hytrin), 616t Teriparatide, 670t Terminally ill patients, 238t Terpenes, 734t, 735t, 736t Terpenoids, 499t Testes, 570t Testoderm, 616t Testosterone, 570t, 572, 616t Tetrabenazine, 245, 263 Tetracycline, 112, 461, 486t Tetrahydrobiopterin, 204, 205 Tetranectin, 538t Tetrathiomolybdate, 217 TF constipation, 418–419 Thalamus, 220t Thalassemias, 720–721 Thalidomide, 798 Theaflavin, 499t Thearubigins, 499t Theo-Dur, 302 Theophylline, 296t, 299 Thermal injury, 838–841 Thiamin deficiency of, 119t for healthy vision, 108t recommended intakes for children, 29t toxicity of, 121 Thiazide, 306, 350 Thiazide diuretics, 361t, 370, 486t, 886 Thiazolidinediones, 547t, 616t Thin glomerular basement membrane nephropathy (TBMN), 862–863 6-Thioguanine, 436 Thiols, 734t, 735t Thionamides, 590–591 Thiopurine toxicity, 46t Thioridazine HCl (Mellaril), 616t Thiothixene (Navane), 283t, 616t Thitoic acid, 534t Thoracic empyema, 326–327 Thorazine (chlorpromazine), 283t Thrombocytopenia, 45t, 192 Thrombocytopenia purpura, 728–729 Thrombolytics, 381 Thrombophilia, 45t Thrombophlebitis, 379–381 Thymoglobulin, 538 Thymosin, 570t Thymus, 570t Thyrocalcitonin, 673 Thyroid cancer, 763–766 Thyroid crisis, 589 Thyroid gland, 570t hypercalcemia, 596–598 hyperparathyroidism, 596–598 hyperthyroidism, 589–591 hypocalcemia, 595–596 hypoparathyroidism, 595–596 hypothyroidism, 591–594 Thyroid hormones, 593–594 Thyroid storm, 589 Thyroid-stimulating hormone, 569t


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INDEX

Thyrotoxicosis, 589 Tiagabine (Gabitril), 241t Tilade (nedocromil), 296t Timolol (Blocadren), 486t Tinnitus, 128 Tipranavir, 834t, 835t Tissue transglutaminase (TTG), 415 Tobramycin, 310t Tocolytics, 9 Tofranil (imipramine), 31, 284t, 616t Tolcapone (Tasmar), 255t Tongue disorders, 99, 101 Tonsillectomy, 811t Toothache, 99t Topamax (topiramate), 241t, 270 Topical pain relievers, 660t Topiramate, 276 Topiramate (Topamax), 241t, 270 Total nutrient admixture, 899t Total-body irradiation, 755t Toxic shock syndrome, 828t Tramadol (Ultram), 660t Tranquilizers, 283t Trans fatty acids, 339t Transferrin, 689t Transplantation bone marrow, 753–756 heart-lung, 363–365 hematopoietic stem-cell, 753–756 intestinal, 440–442 islet cell, 537–539 liver, 493–496 lung, 327–329 pancreatic, 509–510 renal, 891–893 Transtheoretical Model for Stages of Change, 52 Transthyretin, 867t Tranxene (clorazepate), 284t Tranylcypromine (Parnate), 284t, 616t Trastuzumab (Herceptin), 784 Trauma, 822t, 854–856 Traumatic brain injury (TBI), 234–236 Traveler’s diarrhea, 421t, 422 Trecator-SC, 332t Trental (pentoxifylline), 379, 685 Triamcinolone (Azmacort), 296t Triamterene, 195 Triamterene (Dyrenium)_, 486t Triazolam (Halcion), 284t Tribulus, 42t Tribulus terrestris, 78t Trichinella spiralis, 845t Tricyclic antidepressants, 284t, 616t, 657 Trientine (Syprine), 486t Trigeminal nerve, 221t Trigeminal neuralgia, 265–266 Triglycerides, 339t Trihexyphenidyl (Artane), 255t Trilafon (perphenazine), 616t Trileptal (oxcarbazepine), 241t Trimethoprim (Trimpex), 895 Trimethoprim-sulfamethoxazole, 486t, 836t, 895 Trimipramine (Surmontil), 616t Trimox (amoxicillin), 895 Trimpex (trimetophrim), 895 Trinsicon, 714

Trisenox (arsenic trioxide), 798 Triterpene glycoside, 735t Trizivir, 834t Trochlear nerve, 221t Tropheryma whipplei, 461 Tropical sprue, 460–461 Trovafloxin, 895 Troxerutin, 466 Truvada, 834t Tryptophan, 42t, 78t, 225t, 283 Tube feeding, 100, 101 Tuberculosis, 330–333 Tumor necrosis factor alpha (TNF), 638, 643 Tumor necrosis factor (TNF), 838 Tumor necrosis factor (TNF) inhibitors, 681t Tums (calcium supplement), 669t Turkey tail mushroom, 749t Turmeric, 78t, 476, 534t, 644, 749t Twinrix, 481 Typhoid fever, 828t Tyramine, 247t TYREX, 212 TYROMEX-1, 212 TYROS, 212 Tyrosine, 204, 212–213, 225t Tyrosine aminotransferase (TAT), 212 Tyrosinemia, 212–213 Ubiquinone, 340t, 736t Ukrain, 78t ulcerative colitis, 434–436 Ulcerative colitis, 760 Uloric (febuxostat), 646 Ultralente, 533t Ultram (tramadol), 660t Undernutrition, 602–603t, 626–631, 822t. See also Malnutrition Underweight, 622–626. See also Malnutrition; Overweight body mass index and, 622 clinical indicators, 623t drugs and side effects, 624 nutritional guidelines for, 624 patient education, 624–625 strengthening tips, 623t Upper respiratory infections, 822t Urea cycle disorders, 213–216 Uremia, 880 Uric acid, 500t, 645–646 Uric acid stones, 882 Uricosuric drugs, 646 Uridine, 226t Urinary incontinence, 894 Urinary tract cancer, 772–773 Urinary tract infection, 894–896 Urolithiasis, 884t Urso, 517 Ursodeoxycholic acid, 310t, 491t, 514, 515, 517, 755t Ursodiol, 152, 517 Ursolic acid, 433, 644, 748t Vaccines, 522t Vagotomy, 399–401 Vagus nerve, 221t Valcyte, 836t Valdecoxib, 679t Valerian, 78t, 283, 661t, 749t, 808t

1019

Valganciclovir, 836t Valium (diazepam), 284t Valproate, 241t, 268 Valproic acid, 241t, 616t Valsartan (Diovan), 886 Vanadium, 79t, 534t Vanatrip (amitriptyline), 616t Vancomycin, 424 Vascular access device, 899t Vasodilan (isoxsuprine), 379 Vasopressin, 569t Vasotec (enalapril), 886 Vegan vegetarians, 10t Vegetables eating tips, 53t fiber content, 465t glycemic index, 535t headaches and, 247t health claims, 55t nutrients in, 54–55 Vegetarian diet, 88–90 Velcade (bortezomib), 798 Venlafaxine (Effexor), 284t Venofer, 695 Ventilator, 319–321 Ventolin (albuterol), 296t Verapamil, 345 Versed (midazolam), 284t Very long-chain fatty acid (VLCFA), 184–185 Very low birth weight (VLBW), 153 Vestibulocochlear nerve, 221t Viagra (sildenafil citrate), 52t Video-assisted thorascopy (VATS), 326 Videx (didanosine), 834t Vigabatrin (Sabril), 241t Vinblastine, 744t Vinca alkaloids, 744t Vincent’s disease, 103 Vincristine, 744t, 796, 835t Viracept, 835t Viral pneumonia, 314t Viramune (nevirapine), 834t Virazole (ribavirin), 486t Virchow triad, 315 Viread, 834t Vistide, 835t Vitamin A for asthma, 294t bone health and, 665t deficiency of, 119t, 120, 712t in functional foods, 735t for healthy vision, 108t for heart disease, 337t for oral tissue and dental care, 97t for pregnant women, 9 recommended intakes for children, 29t sources of, 499t toxicity of, 121 Vitamin B complex, 97t Vitamin B12 Alzheimer’s disease and, 227 for bone health, 665t for brain health, 226t deficiency anemia, 713–714 deficiency of, 89t, 119t, 121 for healthy vision, 108t for homocystinuria, 181–182 for pancreatic cancer, 779


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1020

INDEX

Vitamin B12 (continued ) schizophrenia and, 281 sources of, 121 Vitamin B6 Alzheimer’s disease and, 227 for bone health, 665t for brain health, 226t deficiency of, 119t, 121 for diabetic patients, 534t in functional foods, 735t for healthy vision, 108t metabolic disorder, 180 for sideroblastic anemia, 716 sources of, 121 toxicity of, 121 Vitamin C for asthma, 294t bone health and, 665t in cancer prevention, 736t deficiency of, 120t, 121, 712t in functional foods, 736t for healthy vision, 108t for heart disease, 337t, 339t, 340t recommended intakes for children, 29t role in brain, 226t side effects of, 423 sources of, 499t toxicity of, 121 Vitamin D bone health and, 665t for Crohn’s disease, 433 deficiency of, 89t, 119t, 121, 208–209 in diabetes management, 534t for dialysis patients, 872t for healthy vision, 108t for infants, 19 for oral tissue and dental care, 97t rheumatic disorders and, 640t role in brain, 226t supplementation for asthma, 294t for chronic obstructive pulmonary disease, 302 for dialysis patients, 876 toxicity of, 121 Vitamin D3, 208, 278, 669, 735t, 771, 850, 878t Vitamin E Alzheimer’s disease and, 229, 230t arthritis and, 661t for asthma, 294t for colorectal cancer, 760 deficiency of, 120t, 712t in functional foods, 735t, 736t for healthy vision, 108t

for heart disease, 337t, 339t, 340t side effects of, 356 sources of, 499t for stroke patients, 262 toxicity of, 121 Vitamin E-sensitive hemolytic anemia, 705t Vitamin K, 722–724 blood clotting and, 394, 804 bone health and, 665t for cirrhosis, 486t deficiency of, 120t, 121 food sources, 723t heart disease and, 339t for oral tissue and dental care, 97t toxicity of, 121 warfarin and, 350 Vitamins, 118–121 in breast milk, 13t deficiency of, 118–121 for dialysis patients, 877t immunutrition and, 823t Vitex, 79t Vomiting, 741t Vomiting, pernicious, 410–412 Von Gierke disease, 176t Von Willebrand disease, 722 Vyvanse (lisdexamfetamine dimesylate), 147t Warfarin, 317, 318, 356, 374, 381, 886 Waste excretion, 860t Water, 340 Weight, calculation of, 604t Weight gain. See also Body mass index (BMI) activity level or illness, 608t medications that cause, 616t in pregnancy, 7, 17 smoking cessation and, 619t Weight loss activity level or illness, 608t in cancer patients, 741t in malnutrition, 602t medications for, 617t unintentional, 622–626 Wellbutrin, 284t, 835t Wheat, allergy to, 125t, 127t Wheat grass, 81t, 749t Whipple’s disease, 461–462 White birch, 749t White willow, 79t Wild yams, 42t, 79t Willow bark, 79t Willow yam, 79t Wilm’s tumor, 46t, 772–773 Wilson’s disease, 216–218 Wired jaw, 99–100

Witch hazel, 79t Women medications, 52t nutrition-related concerns for, 48t Wymox (amoxicillin), 895 Xanax (alprazolam), 284t, 616t Xanthene oxidase inhibitors, 646 Xanthones, 500t Xenazine (tetrabenazine), 245 Xenical (orlistat), 617t Xerostomia, 101, 178, 273t, 740t Xifaxan (rifaximin), 424 Ximelagatran (Exanta), 381 X-linked adrenoleukodystrophy, 184 X-linked hypophosphatemic rickets (XLH), 887–888 X-linked sideroblastic anemia, 715–716 Yersinia enterocolitis, 851 Yew, 79t Yogurt, 536t Yohimbe, 42t, 81t, 283 Zalcitabine, 834t Zanosar (streptozotocin), 512 Zantac (ranitidine), 409t Zarontin (ethosuximide), 241t Zeaxanthin, 108t, 109, 499t, 735t, 790t Zeldox, 616t Zellweger’s syndrome, 184 Zelnorm (tegaserod), 420t Zemplar (paricalcitol), 598, 872t Zenker’s diverticulum, 390–391 Zerit, 834t Ziagen (abacavir), 834t Zidovudine, 834t Zinc, 19, 42t, 79t, 89t, 97t, 108t, 225t, 294t, 534t, 661t, 665t, 698, 712t, 736t Zinc acetate, 217 Ziprasidone (Geodon), 283t Zocor (simvastatin), 886 Zofrab, 559 Zoledronic acid, 773 Zoledronic acid (Zometa), 673, 798 Zollinger-Ellison syndrome, 511–512 Zoloft, 283t Zoloft (sertraline), 284t, 616t, 835t Zometa (zoledronic acid), 673, 798 Zonegran, 241t Zonisamide, 241t Zovirax, 835t Zyflo, 296t Zymenol, 420t Zyprexa (olanzapine), 149, 264, 283t, 616t

 
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