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Nutrition Powered By Docstoc
					Chapter 1                                                           4-Transportation : Movement of nutrients through the
                                                                    circulatory system to sites for their use.
                                                                    5-Respiration : Provision of oxygen to the tissues for the
                                                                    oxidation of food and removal of the waste and carbon dioxide
                                                                    with the circulatory system responsible for transport of these
                                                                    6-Metabolism : Oxidation to create heat and energy as well
NUTURTION                                                           as formation of new cell.
                                                                    7-Excretion : Undigested food wastes and certain body
                                                                    wastes from the bowel , CO2 , from lungs , nitrogenous ,
It is the study of the nutrients in the food and the way in which   mineral and other ( Wastes from kidney and skin ) .
the body handle these nutrients. In other words it is the study
of nutrients in the food and their ingestion , digestion ,          RELEVANT DEFINITIONIONS
transport , metabolism , interaction , storage and                  1- Health : Is defined by WHO. AS the stat of complete
excretion .                                                         physical, mental and social wellbeing and not merely the
                                                                    absence of disease.
                                                                    2- Nutrients : Are the constituents in the food that must be
AIM OF STUDY CLINECAL NUTRITION                                     supplied to the body in suitable amounts, these include,
 1) Understanding the food constitutes their function and the
                                                                    carbohydrates, mineral ,proteins waters and vitamins.
    requirements for nutrients by various age groups.
 2) Understanding methods of food utilization in the body.          3- Malnutrition : Is an impairment of health resulting from a
 3) Understanding the relation between nutrition and human          deficiency, excess or imbalance of nutrients, includes under-
    health.                                                         nutrition and over nutrition.
 4) Understanding the importance of nutrition to the recovery       4- Nutritional care : Is application of the science and art of
    of the pt. from various diseases.                               human nutrition in helping people select and obtain food for
                                                                    the primary purpose of nourishing their bodies in health or in
                                                                    disease through out the life cycle.
NUTRIENTS : ( these chemical substances obtained from
food promote growth and maintain life ).                            5- Calorie : The amount of heat needed to raise 1C
                                                                    centigrade. One gram of water.
                                                                    6- Basal metabolism : Is the minimal amount of energy or
PROCESSES IN THE FOOD UTILIZATION                                   number of calories needed to basic metabolic process of
1-Ingestion : The intake of food .                                  person at rest and at least 12hr after taking food.
2-Digestion : The breakdown of foods into their constituent         7- Enzyme : Chemical substances which act upon other
nutrients .                                                         substances and speed up the specific chemical reaction but do
3-Absorption : Transfer of nutrients from the gastrointestinal      not itself become apart of final products.
tract into the circulation .

8- Deficiency disease : A disease due to lake of essential        NUTRITIONAL BALANCE
substances in the diet or defective metabolism.                   To achieve nutritional balance a good diet must fulfill the
9- Obesity : Any abnormal fat in the body or abnormal             following :
condition due to excessive deposits of fat in the body.            1. It must nourish the appropriate levels of all nutrients to
                                                                       meet the physiologic and biochemical needs of the body at
NUTRITIONAL PROBLEM                                                    all stages of the life cycle.
1. Low socioeconomic levels: ( Those are more prone to             2. It must avoided excessive of calories, fats, sugar, salt and
   dietary problem ).                                                  alcohol.
2. Lack of knowledge: ( Is a further contributing factor ).
3. Increase incidence of dying baby from low wt. : ( Especially   A DAILY FOOD GUIDE
   babies who born to young women in teens who also poor ).       It includes 5 food groups, which are:
4. Anemia: ( Occurs frequently in all age and especially in        1. Vegetables – Fruit group
   children 6 years ).                                                4 basic servings daily :
5. Increasing incidence of teeth problems: ( Decayed teeth,           One is 1/2 cup or atypical portion such as one orange,
   missing teeth ).                                                      half a medium grapefruit, a medium potato.
6. Retarded growth and retarded bone development in                   One good vit. C source daily.
   some children 1-3yrs of age.                                       One includes green vegetables.
7. Chronic illness: ( About 80% of elderly have some                  One includes unpeeled fruits and vegetables.
   chronic condition contributing factors include low income,      2. Bread – cereal group
   poor nutrition, and social isolation ).                           4 basic servings daily.
                                                                   3. Milk- cheese group:-
PROBLEM OF NUTRITIONAL EXCESSIVE                                       Children less than 9 year's                 2-3 servings
1. Excessive caloric intake leads to obesity, which is                 Children 9-12 years                         3 servings
   associated with chronic disease such as DM, gallbladder             Teen agars                                  4 servings
   disease and cardiovascular disease.                                 Adults                                      2 servings
2. Excessive intake of saturated fats, cholesterol is important        Pregnant                                    3 servings
   risk factors in the incidence of cardiovascular disease.            Nursing mothers                             4 servings
3. Excessive intake of sugars contributes to an increase in       One serving is a cup of milk, whole, skim, low   fat, butter, non
   dental caries.                                                 dry milk.
4. Excessive intake of salt has been associated with               4. Meat, fish, poultry and beans group:-
   hypertension.                                                     2 basic servings daily
5. Excessive intake of some vitamins A and D are Known to             One servings is 2-3 ounces of lean, cooked meat,
   be toxic.                                                            poultry or fish.
                                                                      1 egg.
                                                                      1/2 to 2/3 cooked dry– beans, dray peas or lentils.

     1/4 to1/2 cup nuts.
5. Fat, sweet, alcohol group:-                                            Good Nutrition                          Poor nutrition
  No basic servings suggested.
                                                                  -Normal weight high, body from.        -Overweight, underweight, failure
   Include butter, margarine, fats, oil, candy, sugars.                                                 to grow .
                                                                  -Erect posture, arms and legs          -Poor posture, chest forward,
FACTORS INFLUANCING FOOD INTAKE                                   straight, abdomen in chest up .        rounded, shoulder, protruding
1) Physiological factors that determine food intake :             -Firm, strong muscle.                  -Thin, flabby muscle, excessive
  A. Hunger : Is physiologic sense has been defined as that                                              fat.
     set of internal single that stimulate the consumption of     -Firm, clear skin with good color,     -Dry, pale skin, pale mucus
     food .                                                       pink mucus membranes .                 membranes .
  B. Appetite: Commonly refers to the pleasurable                 -Well-formed jaw and teeth.            -Poorly formed jaw with teeth
                                                                                                         poorly aligned.
     sensations provided by food the choices – made specific
                                                                  -Soft, glossy hair.                    -Dull, dry hair .
     food item.                                                   -Clear bright eyes, not sensitive to   -Dull eyes, sensitive to light,
  C. Hedonic factors in food choice : The palatability of         light .                                puffiness under eye .
     food is a composite of taste, smell and temperature .        -Good appetite and digestion .         -Poor appetite, complaints of,
                                                                                                         indigestion diarrhea.
2) Environmental and behavioral factors influencing                                                      -Short attention span .
                                                                  -Ability to concentrate .
    food acceptance :                                             Cooperative,interested, agreeable,     -Irritable, apathetic, depressed.
  A. Role of culture : The ethnic group and a heritage            cheerful.
     account – these patterns reflect the social organization     -Resistance to infection .             -Many      infection,      longer
     of he people including their economy, religion, belief and                                          convalescence of disease .
  B. Economic influences on food intake : The income
     influences the Varity of foods from which people can
     choose. (Poor increase bread and cereal)
  C. Social values of food : The food served to guests is
     the best that one can afford and the table appointments
     are as beautiful as one can make them.
  D. Religious and Moral values attributed to foods :
     Certain food is forbidden by religious regulations.
  E. Age and sex influence food choices.
  F. Illness modifies food acceptance : Disease and

Common Therapeutic Diets
      Diet                       Types of food / fluids                        Foods, which are the sources of nutrients in the
                                                                               body, have the following function :-
Clear liquid        Consists of fluid that are liquids at body temperature,    1. Provide energy for the body
                    it is given as the first meal after surgery .
Full liquid         Consists of any food and drinks that are liquid at room
                                                                               2. Build and repair tissues
                    temperature , may provide adequate calories cereals        3. Regulate body process
                    it is given as post op. surgery
Soft diet           Easy to – digest food, omit rough grains, nuts, spicy or   There are six types of nutrients:
                    fatty food, dried fruits, raw vegetables, adequate         1. Carbohydrates
                    nutrients 2,000 - 00522 kcal, used in transition room
                    full liquid to regular diet
                                                                               2. Fats
Mechanical soft     For Pt with difficulty chewing and swallowing              3. Proteins
Bland diet          Removal of food knows stomach irritant as caffeine         4. Minerals salt
                    dinks, citrus fruits, food with spices                     5. Water
General diet or     Permit all foods                                           6. Vitamins
regular diet
Six        small    Variety of foods from any type of diet divided into six
feeding             fairly equal portion: used for post op. Pt, anorexia,
                    poor appetite, Pt with reduced stomach capacity
Diet altering       Fiber is not digested and form fecal material.
Fiber :
-High fiber         Used in constipation and no inflammatory disease of
                    colon e.g. ( fresh fruit and vegetables )

-Low fiber          Used during acute phase of chronic GI disease e.g.
                    Inflammation of bowel.

-Fiber restricted   Used before and after surgery on the large bowel or
                    rectum partial obstructive GI problem.

                SCIENCE OF NUTURTION
                                                                   3-Polysacharides , E.g. starch, glycogen, cellulose, dextrin
Chapter 2                                                          and other.

                                                                      MONOSACCHARIDES ( C6 H12 O6 )
                                                                   There are three monosaccharide:
                                                                      1. Glucose or dextrose : Is the form which circulates in
UTILZATION OF                                                            blood. It is also found in fruits and vegetables.
                                                                      2. Fructose : Is the sweetest of all sugars. It is found in
NUTRIENTS                                                                the honey, fruits and vegetable.
                                                                      3. Galactose : Is not found free in nature but occurs as a
Carbohydrates    , fats , and proteins must be digested and              result of the breakdown of lactose.
further metabolized before they can be utilized by his body.          DISACCHARIDES (C12 H22 O11)
Water, minerals salt, and vitamins can be utilized without         There are three disaccharides:
further breakdown .                                                   1. Sucrose or table sugar : Is found in molasses, maple
                                                                         sugar, fruit and vegetables. It is also found in beet and
                                                                         cane sugar.
  A. CARBOHYDRATES C H O                                              2. Lactose : Is milk sugar. It remains in the intestines fairly
SOURCES OF CARBOHYDRATES                                                 long and encourages the growth of favorable bacteria.
1- Plants are the principle source of carbohydrates in the diets      3. Maltose : Occurs as a result of the breakdown of
some plants that contains high amount of carbohydrates are               starch. It is also found in cereals and beer.
vegetables and fruits.                                                POLYSACCHAIDES (                           )
2- Animal starch is stored in the liver of animals, including      There are several polysaccharides:
man, as glycogen.                                                     1. Starch : is encased in cellulose walls and must be
COMPOSTION OF CARBOHYDRATES                                              ground or cooked to release the starch. It is found in
Sugars and starches are composed of carbon, hydrogen and                 creels, fruit and vegetables.
                                                                      2. Cellulose : forms the framework of vegetables, the skin
oxygen with general formula of ( CnH2nOn ) .
                                                                         of fruits and vegetables and the coverings of whole
FUNCTION OF CARBOHYDRATES                                                grains. It is not digested but provides bulk.
1-furnish heat and energy ( 4C.\gram of carbohydrates )               3. Glycogen : is the form in which carbohydrates are
2-spare protein from being used for energy.                              stored      in the animal glycogen can be converted to
3-supply bulk in the form of cellulose.                                  glucose rapidly .
                                                                   ROLE OF CARBOHYDRATES IN THE DIET
CLASSIFICATION                                                     1-Carbohydrates provide the cheapest sources of energy.
There are three principles form of carbohydrates:-                 2-Carbohydrates provide about 50% of calories in the Arabic
1-Monosaccharides , E.g. glucose, fructose and glactose.           diet.
2-Disaccharides , E.g. maltose, sucrose and lactose.
  B. FATS                                                                 be produced by the liver.
SOURCES                                                               C. PROTEIN
There are 2 general sources of fat:-                                SOURCES
1- Animal fats, e.g. Butter, cream, fat meat, bacon and lard.       When the word protein is mentioned most people immediately
2- Plant oils, e.g. olive oil, peanut oil and soy bean oil.         think of meat, also they think that diets cannot be adequate in
                                                                    protein if they don't include meat.
COMPOSTION                                                          There are 2 general sources of protein:-
Fat are compounds of carbon, hydrogen and oxygen but the            1-Animal protein : e.g. milk, eggs, cheese, meat, poultry and
oxygen is less in the proportion to carbon and hydrogen than it     fish.
is in carbohydrates. For this reason, fats yield more energy        2- Plant protein : e.g. peas, beans, nuts, cereals, soy beans
than do carbohydrates.
FUNCTION OF FAT                                                     Proteins are complex compound which contain carbon,
1. Provides energy (9C. /gram)                                      hydrogen, oxygen, nitrogen, and some times other elements
2. Aids in digestion, absorption and utilization of other           such as sulfur and phosphorus. The protein molecules are
   nutrients.                                                       composed of amino acids which are Known as a building
3. Carries fat soluble vitamins and aids in their absorption and    blocks of protein.
   utilization.                                                     That can not be manufactured by the body must be present in
ROLE OF FATS IN THE DIET                                            the protein of the diet and are called essential amino acid.
Fats provide from 35-40% of calories in the diet. This is too       It is a good idea to be able recognizes the name of essential
high and creates a serious health problem by contributing to        amino acid.
atherosclerosis.                                                    When you see them they are:-
N.B: ATHEROSCLEROSIS ( Fatty deposits of cholesterol on             -Histidine                    -Phenylamine
the inner linings of arteries ) is caused by elevated blood         -Leucine                     -Threonine
cholesterol level.                                                  -Lysine                      -Tryptophan
 Dietary factors can affect the blood cholesterol level in         -Valine-Isoleucine           -Methionine
   three ways :                                                     FUNCTION
   1. Food high in cholesterol raise the blood cholesterol          1. Building and repair tissue.
      level slightly but generally the liver compensates for this   2. Form much of body from work and are a major component
      by producing less cholesterol.                                   of skin, hair, nails and matrix of teeth and bones.
   2. Ingestion of fat containing highly unsaturated fatty          3. Used in the manufacture of enzymes, hormone, antibiotics
      acids, e.g. those found in most vegetables oils, depress         and hemoglobin.
      the blood cholesterol level.                                  4. Proved energy, if it is not provided by carbohydrates or
   3. The most important factor in high blood cholesterol is           fates.
      the total amount of fat ingested, because increased fat
      metabolism causes increased amounts of cholesterol to

► proteins furnish 4 Kcal per gram. If the diet contains more          2) Protein-calorie malnutrition :
protein than is needed, the nitrogen will be removed from the        a) Kwashiorkor: Usually appears after the child is weaned
excess amino acids by the liver. The nitrogen is excreted in         from the mothers breast.
the form of urea by the kidney if the diet does not contain          S/S: edema of hands and feet, fail to grow, poor appetite and
sufficient calories from carbohydrate and fat, the protein will be   the skin and hair change in texture and color.
used for energy rather than for building or replacing tissue.        b) Marasmus: Occurs in infants who are weaned very early
► The protein need of the adult is based on body size . the          and who are fed diets that are low in calories as well as
recommended allowance is 0.8 gram per kilogram.                      protein.
                                                                     S/S: emaciated appearance, brain cell have had less
CLASSIFICATION OF PROTIEN                                            opportunity to develop ( mental retardation ).
Protein are classified either as a complete or incomplete
protein.                                                             SOME FALLACY AND FACTS :
   1. Complete protein                                               1. Athletes need more protein than nonetheless ….. (Fallacy)
There are over 20 different amino acids : 10 of this cannot          ►The protein requirement of the adult depends on the body
synthesized be by a child and 9 cannot be synthesized by an          size and not one the amount of exercise ….. (Fact)
a adult. The amino acid which can not synthesized are known          2. Older people need less protein than young adult …..
as essential amino acid , because it is essential that these be          (Fallacy)
taken into the body daily .any food which contain all of             ►The need for replacing the protein of tissues continues
essential amino acid is called the a complete protein food .         throughout life.
Most animal protein such as eggs, milk, meet; poultry and fish       ►Older people need the same amount of protein as the young
are complete protein.                                                adult of the same size ….. (Fact).
                                                                     3. Gelatin is an excellent source of protein ….. (Fallacy)
   2. Incomplete proteins
                                                                     ►Dry gelatin is about 90% protein ….. (Fact)
These lacks at list one of essential amino acid, plant protein
                                                                     4- Protein food should not be eaten in the same meal as
such as beans, peas, macaroni, grain, vegetables and nuts
                                                                     starches ….. (Fallacy).
are incomplete protein .
                                                                     ►There is no reason to separate protein foods and starches,
CLINICAL PROPLEMS                                                    many conmen foods contain both proteins, carbohydrates the
  1) Negative protein balance : this means the body is               digestive tract digests protein, carbohydrates and fat
breaking down protein tissues faster than they are being             components of the diet at the same time ….. (Fact)
replaced, so the individual is less able to resist infection.          D. WATER
Negative protein balance can exist when individual dose not
eat enough protein containing food, many elderly person are
                                                                     AMOUNT : Water makes up about 60% of body weight.
unable to chew well or don’t like milk.                              FUNCTION
►The nurse should be alert to the possibility of protein mal         1- Serves as a solvent for material.
nutrition in pt. With poor appetite.                                 2- Transport materials via the blood and lymph.
                                                                     3- Necessary for digestion.
                                                                     4- Necessary for removal of body waste products through
urine and feces.                                                 Causes for negative water balance:
5- Helps regulation of body temperature by evaporating           1- Insufficient intake of fluid.
perspiration which helps cool the body.                          2- Excessive loss of fluid:-
SOURCES                                                             -Diarrhea
1- Drinking water.                                                  -Profuse sweating.
2- Other liquids, such as milk or fruit juices.                     -High body temperatures.
3- Many foods are mainly water.                                     -Some disease e.g. Diabetes mellitus, Diabetes insipid us .
4- Water produce by metabolism of food .
                                                                 Effect on the body of the negative water balance:
FLUID COMPARTMENT OF THE BODY                                    1-plasma shows the first effect o dehydration with the
There are two major fluid compartments in the body:-              Possibility of shock.
1- Intracellular fluid ----- 45%                                 2-interstitial or tissue fluid is the next to show a decrease.
2- Extra cellular fluid ---- 15%                                 3-Finally, intracellular fluid decrease and this creates an
 Is found both as interstitial fluid and as plasma:-             intense thirst and interference with enzyme.
        ► Interstitial fluid about ---- 11%
        ► Plasma about ---- 4%
                                                                   E. VITAMINS
WATER BALANCE                                                    CHARACTERISTIC OF VITAMINS
Water balance occurs when intake loss :                          1- Organic compound not structurally related.
► Water intake:                                                  2- Essential for life.
   1- Fluid                              1500ml                  3- Needed in small amounts.
   2- Food                               700ml                   4- Not manufactured by the body, must be taken in through
   3- Metabolism                         200ml                   food some vitamins are manufactured by bacteria in the
                                         2400ml                  intestines an exception to this is one form of vitamins D.
► Water loss:-                                                   Natural vitamins D is found by ultraviolet light ( sun light )
   1- Large intestine (Feces)             200ml                  irradiation of cholesterol compound in the skin.
   2- Lung                                350ml                  General resources:
   3- Skin                                                       1-NO one food supplies all of the vitamins but with balanced
             * Insensible                 350ml                  diet there would be no deficiency.
             * Perspiration               100ml                  2- Protective food is diary products, eggs and fruits.
   4- Urine                               1400ml
                                                                 GENARAL FUNCTION :
                                          2400ml                 1-Regulates body process by acting as coenzymes which
Negative water balance or dehydration :                          make possible the activities of enzymes.
This occurs when intake is insufficient to provide for losses.   2-Aids in structure, i.e. the eye requires Vit. A.
Fluid depends not only on water but also on salt.

TYPES OF VITAMINS                                                  VITAMIN (D) :
     There are 2 major types of vitamins:-                         SOURCES
    1. Fat soluble vitamin (A, D, E, K).                           Foods are not good sources of vitamin D, except when they
A) These are not easily lost by ordinary cooking methods and       are fortified
do not easily dissolve in water, since these are absorbed with
fat, any condition such as gall bladder disease which interferes   FUNCTION
with fat absorption, could cause a deficiency of these vitamins.   1-aids in the absorption of calcium and phosphorus from GIT .
B) These are stored by the body and deficiencies are not           2- promote the mineralization of bones and teeth .
prevalent .                                                        3-regulates the normal level of calcium in the blood
    2. Water soluble vitamins (vit. B complex and vit. C)          DEFICIENCY OF VITAMIN D
These do dissolve out in water.                                    1. Rictets it seen in the children
In general these are not stored by the body.                       2. Osteomalacia: it seen in adult women and who had several
Deficiencies are more prevalent for water soluble vitamins.           pregnancy.
N.B : ► water- soluble (C, B1, B2, B6, B12) .                      3. Osteodystrophy: it occur in sever renal failure because the
      ► Fat- soluble (A, D, K, E) .                                   kidney is unable to convert vitamin D to its active form.
                                                                   Recommended daily allowances : 400 units for children and
      FAT SOLUBLE VITAMINS                                         adolescents.
SOURCES                                                            VITAMIN (K) :
Cheese, Butter, Eggs, Milk, Fish liver oils, Yellow vegetables     It is known as the antihemorrhagic vitamin .
(carrot, sweet potatoes) green leafy vegetables (spinach).         Small amounts of vitamin K are stored in the liver, heart, skin ,
                                                                   muscle and kidney.
 1. For the normal structure of the bone and teeth .               SOURCES
 2. Maintain of the epithelium or outer layer of skin and          pork liver, green leafy vegetable and bacteria in the intestine.
    mucous membrane of nose , mouth , GIT, eyes, URS.              FUNCTION
 3. Formation of the visual purple which make eye adapt to         Needed for the formation of prothrombin and substance
    dim light .                                                    necessary for blood clotting.
DEFICIENCY OF VITAMIN A                                            DEFICIENCY OF VITAMIN K
 1. slow growth poor teeth and gums .                              1-hemorrhagic disease especially in newborn and infants
 2. skin changes and infection (dry and scaly)                     2-slow blood clotting
 3. night blindness(nyctalopia)                                    Recommended daily allowances : It is not established.
Recommended daily allowances:                                      Dicumarol is vitamin K antagonist, it contract the effect of
For adult : 0.8-1.6mg or 5000iu-8000iu                             vitamin K in formation of prothrombin and prevents blood
For child :   0.4-1.0mg or 1500-5000 unit.                         clotting , It is effective in treating circulatory disease .

VITAMIN (E) :                                                         DEFICIENCY OF VITAMIN C
SOURCES                                                               1.Sore of mouth and bleeding from gums.
It s widely distributed in food, with vegetable oils , margarines ,   2.Weak walled capillaries.
nuts, dark green vegetable.                                           3.Poor wound healing.
                                                                      4.Scurvy: Is characterized by easy bruising and
FUNCTION                                                                hemorrhaging of skin, loosing of the teeth, bleeding of the
prevent the oxidation (antioxidant) of vitamin A in the intestinal      gums and disruption of the cartilages of that support the
tract .                                                                 skeleton.
DEFICIENCY OF VITAMIN E                                               Recommended daily allowances : Adult : 60mg.
       Deficiency only providing in premature new infant –
irritability, edema and hemolytic anemia (hemolysis of red            VITAMIN (B) COMPLEX :
blood cell)                                                             1. VITAMIN (B1) : ( Thiamin )
Recommended daily allowances :                                        SOURCES
  Male: 15 IU        Female: 12 IU                                    Meat especially pork and liver, dry beans, peas, peanuts, eggs
                                                                      and milk.
VITAMIN (C) : ( Ascorbic Acid )                                       1. Maintain health nerves, a good mental out look, a normal
SOURCES                                                                  appetite and good digestion.
Oranges, grapefruit, limes and lemons. Tossed salad, fresh            2. Breakdown of glucose to energy.
tomatoes .
                                                                      DEFICIENCY OF VITAMIN B1
PROPERITIES OF VITAMIN C :                                            1. Fatigue and poor appetite.
1.   Vitamin C is highly soluble in water. So avoid soaking           2. Neuritis of legs.
     vegetable in large amounts of water cooking in smallest          3. Beriberi, some times called Rice-eater disease the S&S is:
     amounts of water.                                                   polyneuritis, edema and heart disease.
2.   The oxidation of ascorbic acids increase rapidly as              Recommended daily allowances: 0.5mg per 1000kcal.
     temperature is increased :So store fruits and vegetable in
     a cool place, and use the shorting time in cooking.
                                                                           2. VITAMIN (B2) : ( Riboflavin )
3.   Ascorbic acid is destroyed in presence of alkali : So, do
     not use baking soda .
                                                                      Meat, poultry, fish, dark green leafy vegetables and grain
FUNCTION                                                              breads
1.   It is essential for building the connective tissue .
2.   It improves the absorption of iron in the intestine.
                                                                      1. It is necessary of breaking down glucose to release energy.
3.   It is required for formation of hormones such as thyroxin
                                                                      2. It is essential for healthy skin and for good vision in bright
     and adrenaline.
4.   Necessary for blood, teeth and bones.
DEFICIENCY OF VITAMIN B2                                          Absorption and storage :
► Cheilosis : S&S :                                               The absorption of vitamin B12 is much more complex than
  A. Cracking of skin at the corners of the lips and scaliness    other B-complex vitamin:
     around the ears.                                             The stomach produces a substance called intrinsic factor,
  B. Redness and burning as well as it changing of the eyes       vitamin B12 is attached to intrinsic factor and is carried to the
     and extreme sensitivity to the strong light.                 ileum from which it is absorbed. In the absence of intrinsic
Recommended daily allowances:                                     factor vitamin B12 can not be absorbed.
Men : 1.6mg            Women : 1.2mg                              The liver stores most of vitamin B12. One adequate diet, the
                                                                  storage in the adult may be sufficient to provide body needs
  3. VITAMIN (B6) : Three forms of Vit. B6                        for as much as 3 to 5years.
  ( Pyridoxal, Pyridoxine and pyridoxamine )                      DEFICIENCY OF VITAMIN B12
SOURCES                                                           1. Pernicious anemia it is a genetic defect with an absence of
Meat, especially organ meat, whole-green cereal, soybeans,           intrinsic factor, so Vitamin B12 in the diet can not be
peanuts, milk and green vegetables.                                  absorbed, ( the red blood cells are large and reduced in
                                                                     numbers ) the pt. is complaining of sore mouth, poor
                                                                     appetite and gastrointestinal disturbances.
1. Essential for synthesis and break down of amino acids.
                                                                  2. The nervous system is affected so that the individual
2. Essential for production of antibodies, formation of heme in
                                                                     shows poor coordination in walking.
   hemoglobin .
                                                                  Recommended daily allowances :
DEFICIENCY OF VITAMIN B6                                          FOR : Adult :                            3mcg.
1. Gastrointestinal upset .                                              Infant :                          0.5mcg / 1.5mcg.
2. Irritability, nervousness and convulsions.                            Children :                        2-3mcg.
Recommended daily allowances :                                           During pregnancy and lactating : 4mcg.
Men : 2mg                Women : 2.2mg
                                                                    F. MINERAL ELEMANT
   4. VITAMIN (B12)                                               OVER 20 different minerals can be found in the human body.
SOURCES                                                           Thirteen are essential for life, most of minerals are present in a
Milk, eggs, cheese, meat, fish and poultry supply                 small amounts and the total amount in the body is about 4%
► Plant food supply no vitamin B12                                of body weight.
FUNCTION                                                          GENERAL FUNCTION OF MINERALS
1. Required for the maturation of the red blood cells in the      1. Regulate body process e.g. potassium is necessary for
   born marrow.                                                      proper functioning of nerves and muscles.
2. required for synthesis of protein.                             2. Aid in forming structure, e.g. calcium is necessary for
3. Required for metabolism of nervous tissue.                        formation of bone.

TYPES OF MINERALS                                                    2. PHOSPHORS
a) Macronutrients: these are major elements that occur in the   FOOD SOURCES
   largest amount:-                                             Milk, meat, poultry, fish, eggs, yolk and nuts are rich sources.
Calcium------------99% in bone and teeth.
Phosphours --------80-90% in bones and teeth.                   FUNCTION
Potassium---------- Fluid inside cells.                         1.   It is essential for building bones and teeth.
Sulfur--------------- Associated with protein.                  2.   Regulate the absorption and transport of fats.
Chlorine----------- Fluid outside cells.                        3.   Acid-base balance.
Sodium------------- Fluid outside cells.                        4.   It is essential component of ATP, DNA and RNA
Magnesium--------- 60% in bones and teeth.
b) Micronutrients: These are found in very small amounts.            3. MAGNESIUM
Manganese, Copper, Iodine, Fluorine, Zinc.                      About 60% of the body magnesium is found in the bones and
   1. CALCIUM :                                                 FUNCTION
FOOD SOURCES                                                    1. It regulates nervous irritability and muscle contraction.
Any kind of milk, fish whole, skim, yogurt, hard cheeses and    2. It activates many enzymes including those involved in
butter, turnip green and collards, fruits (oranges)                energy metabolism.
► N.B. : Meat and Cereal foods are poor of calcium.             Most absorption occurs from the upper gastrointestinal tract.
                                                                Recommended daily allowances : Adult : 300-350mg / day.
1. It gives the rigidity to the skeleton.
2. It required for complex process of blood coagulation.             4. SODIUM, POTASSIUM AND CHLOINE
3. It regulates the passage of materials into and out of the    These mineral are collectivity termed electrolytes because
   cells.                                                       they are dissolved in water and able to conduct electricity.
4. It controls the transmission of nerve messages.              Sodium and Chlorine are the chief minerals in the blood
5. It aids in the absorption of vitamin B12                     plasma and extra cellular fluid while potassium is the chief
                                                                intracellular mineral.
DEFICIENCY OF CALCIUM                                           ► These are necessary for acid-base and fluid balance
1. Rickets
2. Bone pain and susceptibility to fracture.                    DEFICIENCY OF SODIUM CHLORID
3. Osteoporosis .                                               Headache, muscle cramps and vomiting.
4. Periodontal,(changes of the structures of the gums) .        DEFICIENCY OF POTASSIUM
Recommended daily allowances:                                   Weakness of muscles including skeleton muscle, heart and
The calcium allowance for school children and adult             respiratory muscles.
throughout life is 800mg.
During period of rapid growth in teenagers, during pregnancy
and lactation is 1200mg .
   5. IRON                                                           PERCENTAGE OF NUTRIENTS IN THE BODY
The content of iron in the adult body is only 3 to 5 gm, most of            Nutrient                                Percentage
iron is present in hemoglobin .                                      1-   CHOs                                    Less than 1 %
FOOD SOURCES                                                         2-   LIPIDS                                  ~ 20%
Meat, eggs yolk, beans, spinach, dark green vegetables,              3-   PROTIEN                                 ~ 20%
legumes and nuts .                                                   4-   VITAMINS                                ~ very few
                                                                     5-   MINERALS                                ~ 4%
FUNCTION                                                             6-   WATER                                   ~ 65%
It is forms hemoglobin.
                                                                     Human body contain 300 – 350mg CHO as blood glucose and
Iron is use very economically by the body. When the red blood        glycogen
cells are destroyed after their life span of about 120 days, the     However these percentages vary from individual to another
hemoglobin is break down. The iron that is released is used          e.g. Alean person has lower fat than obese one and e.g. a
over and over again.                                                 baby has more water relative to it is weight than adult .
Small amounts of iron are lost daily in perspiration, in the
sloughing of the cells from the skin and mucosal membranes,          Energy yielding nutrient :
in the hair and nail clippings and through excretion in the urine.   - CHO                  4 Kcal.
These losses account for 0.5 to 1 mg iron / day. Menstrual           - Protein              4 Kcal.
losses are about 15 to 30 mg / month.                                - Lipid                9 Kcal.
                                                                     Thus, the energy content of food depends on the amount of
Daily allowances :                                                   CHO, fat and protein that food contains.
The allowances for the well-nourished woman is 18 mg iron
per day, whereas that healthy man is 10 mg. Infants and              Example : Calculate the Kcal in a slice of bread with 1
children need liberal intakes of iron take care of expanding         teaspoon of butter
blood circulation as grow .                                                    (15 gm CHO, 2 gm Protein and 5 gm Fat)

DEFICIENCY OF IRON                                                   15 gm CHO times 4Kcal / gm      = 60 kcal
Iron deficiency anemia.                                              2 gm Protein times 4Kcal / gm   = 8 Kcal
                                                                     5 gm Fat times 9 Kcal /gm       = 45 Kcal
                                                                           Total                     = 113 Kcal

Chapter 3                                                           CHEMICAL DIGESTION
                                                                  General                                     Site of
                                                                                    Enzymes      making                    substrate        product
                                                                 substance                                    action
                                                                                     Salivary    Salivary                Starch(cooked)
                                                                                                              mouth                         Maltose
                                                                                     amylase      gland                     Glycogen

FOOD                                                                                Pancreatic
                                                                                                               Small     Starch(cooked)

                                                                                     amylase                 intestine      Glycogen

DIGESTION                                                                            Maltase
                                                                                                                            Maltose        2glucose

Is the sum of all the changes food undergoes in the alimentary                                     Small       Small                       1glucose
                                                                                     sucrose                                sucrose
canal.                                                                                           intestine   intestine                     2fructose
The purpose of digestion is to convert food into substance                                         Small       Small
which can be absorbed in the intestinal tract, e.g.                                  Lactase                                Lactose        1galactos
                                                                                                 intestine   intestine
monosaccharide from carbohydrate , amino acid from protein                                                                                 Fatty acid
                                                                                                               Small     Bile emulsified

and glycerol and fatty acid from fats.                                                lipase     Pancreas
                                                                                                             intestine         fats
This achieved by mechanical and chemical means                                                                                              glycerol
                                                                                     pepsin      stomach     stomach        Proteins         s and
    MECHANICAL DIGESTION                                                                                                                  peptones

1. chewing which breaks food into smaller pieces and mixes                           Trypsin     Pancreas
                                                                                                             intestine                       acid
   it with saliva.                                                                                                         peptones
2. Churning stomach and intestinal contents so that food                            peptidase
                                                                                                   Small       Small
                                                                                                 intestine   intestine                       acid
   becomes well mixed with digestive juices.
3. Peristalsis which move food through tract .



    ENERGY                                                             2. VOLUNTARY WORK :
Energy of the body is drive principally from oxidation of food .    The energy requirements depend on the type of activity and
                                                                    increase with the intensity of the work.
MEASUREMENT OF ENERGY                                               Examples of calories required per hour for each pound of the
The large calorie (Cal or C) is the unit used for measuring the     body weight.
heat energy produced by food when oxidized in the body.             -Bicycling              1.7 C       -Eating meals     0.7 C
NEED FOR ENERGY                                                     -Swimming               4.5 C       -Typing           1C
Energy is necessary for the work performed by the body.             -Dancing                2.4 C       -Running          4.0 C
There are two types of work performed by the body,                  -Walking rapidly        2.2 C
involuntary and voluntary .                                         Total energy required includes the requirement for energy both
                                                                    the voluntary and involuntary work of the body .
This is the work done by the body in a fasting state and at rest.   ► Voluntary work : Muscular work is the greatest factor
Energy is needed for vital life process, e.g. breathing, heart      influencing total energy requirements.
beat and circulation of blood, kidney function and all chemical     Mental work requires minimal amount energy
reactions which are constantly taking place in the body .           ► Involuntary work : The requirement for involuntary work
                                                                    vary according to the general factors affecting basal metabolic
General factors affecting basal metabolism rate :                   rate i.e., surface area, sex and age. Also affecting energy
1-Surface area:                                                     requirement for involuntary work are other previously
The greater the surface area the more heat will be given off        mentioned factors which increase anabolism or catabolism.
and the basal metabolism will be higher.                            ► Other factors can also increase total energy
A tall thin person has a greater surface area then a short fat      requirement :
person with the same weight and will consequently have a            1-Stimulant drugs, e.g., Caffeine, nicotine.
higher basal metabolic rate.                                        2-Fall in outside temperature.
2-Sex:                                                              3-Pregnancy., A rise occurs in the last trimester.
The meal has a higher basal metabolic rate than does the            4-Lactation.
female .                                                            5-Specific dynamic action of foods. All foods increase
3-Age:                                                              metabolism but protein foods increase metabolism much more
Basal metabolism is highest in periods of active growth. It is      than do carbohydrates and fats.
highest during the first and the second years of life and           ► Normal daily calorie requirement :
decreases with age.                                                 The normal daily calorie requirements depend on sex, weigh,
The calories necessary for basal metabolism in 14 hr period in      activity and age. The following figures represent the
average 25 year old person are listed:-                             approximate the number of calories necessary to maintain
Male                    1650 C                                      present weight in a moderately active male and female aged
Female                  1400 C                                      25 years .
                                                                    - Male : Weight 154 pound                  3080 C

- Female : Weight 125 pound               2125 C
► A factor can be used to roughly determine this figure:
* Male :                  20 C. per pound of body weight.
* Female :                17 C. per pound of body weight.
► N.B: Calorie needs decrease with age for 2 reasons:
    a. Basal metabolism is decreased.
    b. Activity is also decreased .

Obesity is an increase in weight above normal due to a greater
intake of calories from food than expenditure of calories in
► The most common cause for this condition is eating more
food than is necessary.
► A second cause could be alack of exercise or utilization of
►     Endocrine     disorders,   e.g.   hypothyroidism    and
hypopituitarism can cause a weight gain .

Underweight is a condition caused by an insufficient intake of
calories to meet energy requirements.
► The most common cause is insufficient intake of calories in
food to meet energy requirement .
► A second cause could b over activity or utilization of too
many calories.
►      Endocrine disorders, e.g. hyperthyroidism and
hypopituitarism can cause loss of weight.

Chapter 4                                                               HEALTHY EATING DURING ADOLESCENCE
                                                                  Healthy eating during adolescence is important as necessary
                                                                  body changes during this time affect an individual's nutritional
                                                                  and dietary need.
                                                                  Adolescents are becoming more independent and making
                                                                  many food decisions on other own. Many adolescents
                                                                  experience a growth spurt and an increase in appetite and
NUTRITION                                                         need healthy foods to meet their growth needs. Adolescents
                                                                  tend to eat more meals away from home than younger
      A.     DIET FOR ADOLESCENT                                  children. They are also heavily influence by their peers. Meal
                                                                  convenience is important to many adolescents and they may
      WHAT IS HEALTHY EATING ??                                  be eating too much of the wrongs kinds of foods ( i.e., soft
Eating health is an important part of a health lifestyle and is   drinks, fast food, processed foods).
some thing that should be incorporated at a young age and         Further, a common concern of many adolescents is dieting.
continued throughout your life. The following are some general    Girls may feel an unhealthy pressure from peers to be thin and
guidelines any dietary changes with your physician or medical     to limit what they eat. Both boys and girls may diet to ( make
provider.                                                         weight ) for a particular sporting or social event.
 Eat three meals a day, with health snacks.                       The following are some helpful consideration for
 Increase fiber in the diet and decrease the use of salt.            variety and meal choice :
 Drink a lot of water.                                              Encourage exploration about healthy nutrition.
 Eat balanced meals.                                                Meal planning at home should be actively participated in
 Try to choose baked or broiled foods over fried foods.                by all household members.
 Wash and decrease, if necessary, your sugar intake.                Experiment with foods outside your own culture.
 Eat fruit or vegetables for a snack.                               Have several nutritious snack foods readily available.
 For children over 5yr use low – fat diatry products.               Avoid overabundance of unhealthy or (junk) Foods in the
 Decrease the use of butter and heavy gravies.                         home.
 Eat more chicken and fish.                                            B.     DIET FOR ELDERLY PEOPLE
      MAKING-HEALTHY FOOD CHOICES                                      ELDERLY DIET AND FIBER
The food guide pyramid, designed by the United state              As the body ages, the gastrointestinal tract changes and
department of agriculture ( USDA ) and the US department of       people tend to develop more problems with constipation. A
health and human services, is a good guideline to help you eat    high-fiber diet can prevent that but many elderly people,
a heart healthy diet.                                             especially those with dentures; do not want to eat the seed-
This guide can help you choose to eat a variety of foods while    filled or crunchy food that is typically high in fiber.
encouraging the right amount of calories and fat.                 They instead go for soft, slippery food that is easily chewed
                                                                  but is often high in fat.

Cooked or baked vegetables, fresh fruit and high-fiber                                         FOOD TO INCLUDE FOR OPTIMUM HEALTH
breakfast cereals are some denture-friendly ways to get fiber                            FRUIT
in the diet. Beans and black-eyed peas are also nutritious and                           In particular those high in vitamin C, like blackberries,
inexpensive.                                                                             strawberries, raspberries, blackcurrants, citrus fruit, kiwi fruit,
                                                                                         peaches, mango, cantaloupe melon and apples.
It is important to drink lost of fluids, despite the risk of a leak.                     VEGETABLES
The elderly have decreased thirst and often do not get enough
                                                                                         In particular vegetables high in vitamin A (beta carotene) and
fluid in their diet as a result. Getting plenty of fluid helps
                                                                                         vitamin C. Carrots, squash, sweet potato, tomatoes, spinach,
prevent constipation. The fiber nutritionists recommend is
                                                                                         kale, collard greens, broccoli, cabbage, Brussels sprouts,
more effective in decreasing constipation when fluids are
                                                                                         onions leeks and avocado.
taken generously. Milk, tea, coffee, soda, ice cream and soup
all count as fluids.
                                                                                         OILY FISH
        ELDERLY DIET SHOULD BE COMBINED WITH                                            Rich in omega-3 essential fatty acids and high in vitamin E,
         EXERCISE                                                                        like salmon, mackerel, sardines, herring, tuna and trout. Also
Get more physical, not less. The amount of exercise needed                               white fish in place of red meat.
depends on the person, but in general people need to step up
their activity as they get older. Elderly people often do the                            NUTS AND SEEDS
opposite because of bad knees or arthritis.                                              Rich in omega-3 essential fatty acid and high in vitamin E.
Instead of becoming guarded, they need to walk, bicycle,                                 Unsalted nuts, like walnuts, cashews, Brazil nuts and almonds
swim, garden and find other ways to stay on the move.                                    and seeds like poppy seeds, sunflower, flax seeds and
        ELDERLY PEOPLE AND CALORIE NEEDS                                                seeds.
As we age our calorie needs decrease due to a drop in muscle
strength from taking less physical activity. However, vitamin                            PROTEIN
and mineral needs may stay the same or even increase if the                              Eggs, white fish, milk, cheese, yogurt, lean meat, chicken and
body absorbs them less efficiently.                                                      beans.





                                                                                         PULSES AND GRAINS FOR FIBER


    Age group
                                                                                         Including, brown rice, whole wheat bread, wheat germ, whole
             Male                                                                        wheat cereals, whole wheat crackers.

                     1230   1715   1970       2220     2755     2550     2350     2100

            Female   1165   1545   1740       1845     2110     1940     1900     1810

► Note: These are average values only. Heavier or more
active people may need more.
                SCIENCE OF NUTURTION
       C.     DIET FOR INFANCY                                         retained as it is not destroyed by heating which happens in
► Infancy : is a period of rapid growth. During the first year         case of cows milk.
of life, the infant grows and develops far more rapidly than at            3. Anti-infection properties:-
any other time in life.                                                Breast milk is a very hygienic method of feeding as the milk
This is evident from the fact that the totally helpless newly born     goes straight from the mother's breast to the child's mouth,
child, who is completely dependent on the mother or the                reducing the chances of contamination and infection which are
caretaker, develops a fair degree of physical and mental               plenty in case of artificially fed infants. Breast milk contains
abilities by the first birthday. The child develops the ability of     antistaphylococcal factor which prevents the growth of bacteria
speech and is able to express himself. He attains a fairly good        in the infants intestines the gastric juice of breast fed infants is
motion development and starts walking and holding objects.             more acidic and this destroys any microorganism that may
By this time he also develops a strong emotional and                   enter the stomach.
psychological relationship with his near and dear ones.                    4. Source of natural immunity:-
                                                                       The secretion from the mother's breast for the first 2 to 3 days
      DIET AND FEEDING PATTERN                                        is a thick yellowish liquid known as colostrums. This
To meet the high nutritional requirements of an infants, good          colostrums contains certain antibodies, which develop natural
nutrition throughout infancy is very important. The first food for     immunity in the child, thus protecting him from various
the infants is mother milk. It is nature's gift for the child and is   infectious diseases. Besides providing antibodies, colostrums
the best Suited for the infant's growth and development.               is also rich in certain nutrients and should nerve be discarded
Fortunately even a poorly nourished mother is able to nurse            but fed to the newborn.
her child satisfactorily at least during the first few months of           5. Anti-allergic properties:-
life.                                                                  Cow's milk contains lactglobulin and serum bovine which may
      ADVANTAGES OF BREAST FEEDING                                    cause allergy in some infants. As these are not present in
   1. Natural method of feeding :                                      mother's milk, there is no danger of allergy with breast milk.
Breast feeding is a simple and a natural method of feeding                 6. Psychological advantages:-
which eliminates the need for preparation of a feed and                Breast feeding is most conducive for a health, happy and
sterilization of bottles. It is very convenient for both the mother    emotional relationship between the mother and her newly born
and child as the milk is available at all times and at right           baby.
temperature with no worries about the quantity.
   2. Nutritionally tailor made for the body :
                                                                                          DO YOU KNOW ????
                                                                         - As per documented evidence, infants grow well on
Breast milk provides almost all the nutrients to the infants that
                                                                       exclusive breast feeding for the first 4 to 6 months of life.
are adequate enough to meet his requirement. It has adequate
                                                                         - During this period, the baby does not even need water
amount of fat which is highly emulsified and is therefore better
                                                                       supplements, as breast milk provides enough water even for
digested. Lactose present in breast milk provides natural
                                                                       the hot summer months.
sweetness and also helps in calcium and iron absorption. Low
                                                                         - In fact water supplements may be unhygienic and also the
amount of protein in mothers milk reduced pressure on infants
                                                                       sucking of breast by reduced thereby diminishing the breast
kidneys to extreme extra nitrogen. Vitamin C content is
milk output.                                                           2. Help parents and child care providers to foster food
When introducing new foods the following points to be                     attitudes and eating practices which promote health.
kept in mind :                                                         3. Further the development of programs and policies which
 Only one food be introduced at a time .                                 advance nutritional health for the preschool population.
 Consistency of foods as per child's age i.e. for very young
                                                                       1) PROVIDING  A               HEALTHY          DIET       FOR
   infants, liquid to semi solid and then to solid with advancing
   age of child.                                                          PRESCHOOLERS
 Food is given in small quantities in the beginning and the           1- Provide a healthful variety of foods recommended food
   amount gradually increased as child develops a likes for            guide and in amounts appropriate to the needs of the
   the food.                                                           individual preschooler.
 Never force feed a child. If the child dislikes a particular         2- Apply the principle of moderation in selecting foods outlined
   food, remove it from his/her diet and reintroduce it a later        in the nutrition.
   age. If the disliking persists then think of a substitute for it.   3- Ensure a gradual transition from the milk-predominant
 Don’t give spicy foods and also avoid fried ones.                    infants diet to family foods.
 Include variety to make food more appealing.                         4- help preschoolers determine the quantity of food they can
 As child grows older, attract his/her attention by giving            eat. Allow self-selection of amounts when possible or offer
   consideration to color, flavor, texture and shape of food.          child-sized portions with the opportunity for seconds.
 To inculcate good eating habits in a child, parents should           5- Recognize the need of most preschoolers to eat small
   not show personal prejudices and dislike towards any                amount of food frequently throughout the day. On a daily
   foods                                                               basis, this requirement most commonly means three meals
 It is not always necessary to cook separately for the child,         with a snack between meals. Snacks should contribute to both
   as the family meals can be easily modified in consistency,          nutritional and dental health.
   spicing, etc, for the amount needed for to feed the child.          6- Recognize the need for routine and structure in the daily
                                                                       eating pattern of preschoolers and plan accordingly.
                                                                       7- take measures to encourage healthy body weight and
   NUTRITION FOR PRESCHOOLERS                                          promote a positive self-image in preschoolers.
 Recommendations to health and child care professionals                8- Encourage physical activity and set limits on sedentary
► Child care is a shared responsibility. Everyone who cares            activities, especially television viewing.
for children has an important role in promoting their nutritional      9- Consult appropriate health professionals when deviations in
health.                                                                normal growth and development are suspected or when
► The nutritional of young children begins with the attention          unusual food patterns persist.
paid by parents and caregivers to providing a healthy diet and         10- Protect preschoolers against hazards associated with
food experiences which foster healthy eating patterns. To              food, such as choking and food-borne illness.
promote nutritional health during preschool years, health and          11- Recognize that routine administration of vitamin-minerals
child care professionals can do the following :                        supplements is not advised and that the preschoolers
1. Enable parents and child care providers a healthy diet to           physician should be consulted before any vitamin-minerals
    preschool children.                                                supplement is used.
2) FOSTERING POSITIVE FOOD ATTITUDES AND                           support the growth, development and health of preschoolers.
   EATING PRACTICES                                                2- Award high priority to good nutritional care in the
Parents and child care providers should be supported in their      development and ongoing delivery of quality child care
efforts to:                                                        services. In supervised child care settings, standards should
1- Establish a positive feeding relationship which sets            be established where they do not exist for evaluating the
reasonable limits while supporting the development of the          nutritional quality of the food served and promoting mealtimes
preschooler's food preference and food choice skills.              and snack times as opportunities to instill positive attitudes
2- Make available and offer a variety of nutritious foods within   toward food and healthy eating practices.
the framework of the family's cultural heritage, lifestyle and     3- Direct nutrition programs to preschoolers and their parents.
resources.                                                         Consider especially those disadvantage families most
3- Identify and respond to cues from the preschooler that          vulnerable to inadequate nutrition whether due to economic,
indicate when the child is hunger and satisfied, with and          social or environmental deprivation or physical and mental
understanding that fluctuations in appetite are normal at this     handicap. Strategies using self-help and mutual aid and
age.                                                               comment-based models should be pursued.
4- Encourage self-feeding and support increasing                   4- Design and delivery innovative nutrition education programs
independence in eating.                                            that enable child care providers, in both supervised and
5- Respect the individual food preference of preschoolers          informal child care settings, to promote the nutritional health of
while encouraging them to experience and enjoy eating              children in their care.
deferent foods.                                                    5- Consider, in health assessment of preschoolers, the many
6- Appreciate the strong influence parents and caregivers          factors in the family, community and society which act as
have as role models in instilling healthy food practices.          opportunities for or barriers against healthy eating during
7- Avoid using food in emotion-laden contexts such as to           preschool years.
control or manage the preschooler's behavior.                      6- Incorporate nutritional health during preschool years as an
8- Provide opportunities for the preschooler to learn about the    integral component of health promotion and disease
nature of food and to value its role in achieving health.          prevention programs delivered nationally and regionally.
9- Provide the preschooler with opportunities to discuss claims    7- Support efforts by health professionals to identify those
promoting foods and to acquire decision-making skills related      children aged 2 years and over at risk for the major diet-
to food selection at home and in the marketplace.                  related chronic disease so that age-appropriate action may be
                                                                   taken to decrease risk in later life.
3) DEVELOPING PROGRAMS AND POLICIES TO                             8- Promote more research on nutrition-related issues of
   PROMOTE NUTRITIONAL HEALTH                                      preschoolers. Specific topics in need of research and
Health and child care professional involved in designing and       development are:
delivering programs and developing policy related to the health        ► Parameters of an optimum diet during childhood to
of preschoolers should:                                                support normal growth and development and prevent
1- Recognize that accessible, affordable, personally                   development of chronic disease
acceptable and nutritionally adequate food is essential to             ► estimates of energy and nutrient requirements of

children aged one through five years to further substantiate     Chapter 5
the recommended nutrient intakes for Canadians.
► Identification of risk factors in early childhood related to
the development of major chronic disease such as
► Nutritional assessments of preschoolers living in poverty
and development of appropriate intervention strategies.          TOTAL PARENTERAL
► Development of screening tools for nutritional                 NUTRITION ( TPN )
assessment of preschool populations.
► Development of appropriate growth standards and
standards for health body weights for preschool children.
                                                                 INDICATIONS FOR TOTAL PARENTERAL
► Development of effective nutrition education techniques        NUTRITION ( TPN )
for promoting nutrition during preschool.                        The decision to start pt. on TPN can be a difficult one to make.
                                                                 It is widely felt that to outweigh the risks of placing a central
                                                                 line, the pt. should require TPN for at least one week .

                                                                 When the gastrointestinal tract is not functioning
                                                                 properly :
                                                                 1. Inadequate absorption resulting from short bowel
                                                                 2. Gastrointestinal fistula.
                                                                 3. Bowel obstruction.
                                                                 4. Prolonged bowel rest need for pancreatitis, ileus, etc.
                                                                 5. Sever malnutrition, significant weight loss and/or
                                                                    hypoproteinemia when enteral therapy is not possible.
                                                                 6. Other disease states or conditions in which oral or enteral
                                                                    feeding are not an option.
                                                                 Benefit of therapy is uncertain or questionable
                                                                 1. Terminal Cancer Patient.
                                                                 2. AIDS Patient.
                                                                 ► The purpose of this handbook is to provide a brief outline
                                                                 of policies, procedures, prescribing information and care of
                                                                 individuals receiving parenteral nutrition therapy at the
                                                                 University of low Hospital and Clinics (UI Hospital and Clinics).
                                                                 It is intended to help physicians, nurses, students and other
                                                                 related    health   care     professionals   understand      the
administration of parenteral nutrition. The roles of various       2- They are placed in patients that need more of a long term
members of the nutrition support team are described as well        therapy. They are placed either in the procedure room in the
as indications for use of nutrition support.                       clinic or in the operation room.
► Some patients are unable to eat; therefore nutritional           3- These catheters are made of silicone. They are placed most
support is an important part of their care. The decision for how   commonly in the chest area. The catheter is tunneled under
the nutritional needs of the patients will be met is determined    the skin and enters a large vein and then is threaded into the
by the physician. Although feeding by the gastrointestinal tract   superior vena cava.
is preferred, certain individuals cannot be supported in this
way.                                                               IMPLANTED PORTS
► A centrally placed catheter is essential for TPN to be           1- These catheters are placed in the procedure room of the
infused into the patient. These catheters are usually divided      clinic or in the operating room. It is used for more intermittent
into the nontunneled catheters, tunneled catheters and the         therapies but can be used for TPN infusion both in the hospital
implanted ports.                                                   and in the home setting.
                                                                   2- The septum of these catheters is sutured under the skin in
NON-TUNNELED CATHETER                                              the subcutaneous tissue. The silicone catheter that attaches to
1- They are usually placed in the subclavian, jugular or femoral   the septum is then threaded into a major vein.
for a short term therapy of < 8 weeks. These catheters are
rarely used for home TPN.                                          CENTRAL LINE IS INDICATED FOR
2- Insertion of these catheters should be done with sterile        INFUSION OF
technique but can be done at the patient's bedside.
3- Once the catheter is inserted, a stat portable chest X-ray      ( TPN )
should be taken. This assures the physician of correct             INFUSION
placement of the catheter and the absence of insertion             1. The amino acids and dextrose solution with additives is
complications. The tip of the catheter must be in the superior        mixed in a one bag per day system at the UT Hospital and
or inferior vena cava to infuse TPN through the catheter.             Clinics. The fat emulsions are a separate solution, which
4- Single lumen a catheter is recommended because of the              are added to the intravenous tubing at the designated
decreased risk of infection although multiple lumen catheters         connection.
can be used. If multiple lumen catheters are used, the lumen       2. Starting and weaning the TPN should be done gradually.
used to administration TPN must be a lumen where no other             The starting rate should be no more than 50cc / hr for 4-6
solutions could have contaminated the lumen.                          hr. The rate can be increased 25% every 4-6 hr. Weaning
                                                                      is accomplished by decreasing the rate by 25% every 4-6
TUNNELED CATHETER                                                     hr.
                                                                   3. Blood glucose monitoring is recommended every 6hr after
1-These catheters are more commonly known as Hickman's,
                                                                      TPN initiation.
Groshongs, Broviac, etc., which are brand names for these

                                                                    and number of lumens of the central venous catheter.
1- Potassium             50-80mEq/ day.                          CATHETER AND ( TPN )
2- Sodium                60-120mEq/day.                          1. Sepsis should be assessed by taking patients temperature
3- Calcium               8-20mEq/ day (160-400mg)                   at least twice/day.
4- Magnesium             10-30mEq/ day (120-360mg)               2. Local infection needs to be assessed during every dressing
5- Chloride              100-120mEq/ day.                           change.
6- Phosphate             12-30mmol/ day (463-927 mg)             3. The patient should be weighed and intake and out-put
                                                                    monitored to assess for fluid imbalance.
DRESSING CHANGE                                                  4. Blood sugars should be obtained to assess the patient for
1- Central venous dressing should be changed at least once a        hypo/hyperglycemia.
week or more frequently based on pt. condition/ need.            5. Resistance to flushing may be corrected with the use of
2- Initial dressing change should be completed within 48hrs         Urokinase instilled into the catheter.
after placement of catheter.                                     6. Thrombosis should be suspected if the patient complains of
3- Medical aseptic technique is absolutely essential in the         pain or swelling in the extremity or surrounding area on
management of parenteral nutrition therapy administration and       side where the catheter is located. Leakage at catheter
catheter care.                                                      insertion site may also occur. Venogram is needed to
                                                                    confirm a thrombosis.
1. The parenteral nutrition tubing should be treated as a        STANDARD TPN SOLUTION
   closed system. Only after consideration for alternative       1- Recommended for general use since it can fulfill most
   entries into the system are explored, should the parenteral   patients nutritional requirements and be cost effective.
   nutrition catheter lumen be accessed for other uses.          2- Final concentration is 4.25% amino acids and 25%
2. TPN should always be given via an infusion pump.              dextrose.
3. The pharmacist may be consulted regarding drug                3- Calorie: nitrogen ratio is 125:1 this is a 1Kcal/cc solution.
   compatibility for simultaneous administration of 2 or more
   drugs through a single lumen of the catheter.                 ADDITIVES
4. Avoid the use of stopcocks and/ or the administration of      1- Electrolytes are included when ordering the standard TPN
   blood products into the lumen designated for parenteral       solution. It is possible to order an electrolyte-free solution and
   nutrition.                                                    then order the more appropriate electrolytes for the patient.
                                                                 Compatibility can be a problem when adding certain
HEPARIN FLUSH                                                    electrolytes together. A pharmacist should be contracted if this
1. When parenteral nutrition infusion is being cycled, a         need arises.
   heparin flush is needed to maintain potency of central
   venous catheter when solution is not infusing.
2. Dosage, volume and frequency is determined by type, size
                                                                   it reduces vein thrombosis.
                                               Electrolyte Free
                                                                   6- Lipids
                                 Electrolyte                          a) Used as a calorie source and to prevent fatty acid
 A.   Sodium ( mEq/L )                35              0                  deficiency.
 B.   Potassium                       30              0
                                                                      b) Fat emulsions are available vas a 10% product which is
 C.   Calcium                          5              0
 D.   Magnesium                        5              0                  1.1 Kcal/cc and a 20% product which is 2.0Kcal/cc.
 E.   Chloride                      47-50           17-20             c) A three-in-one (3-in-1) mixture in which the fat emulsion is
 F.   Phosphate                      14.3             0                  mixed in with the TPN is not available at the UI hospitals
 G.   Acetate                       67-74           37-44                and clinics .
                                                                   7- Medications should not beaded routinely to the TPN
2- Vitamins                                                        unless it is necessary and they are compatible with the TPN .
a) Standard multivitamin additive is MVI-12 ands should be
added every day .
      1.    vitamin C ( ascorbic acid )           100 mg
                                                                   SOLUTION FOR RENAL FAILURE
      2.    Vitamin A ( retinol )                3300 I.U.         1- Patients with renal failure need a balance of both essential
      3.    Vitamin D( ergocalciferol )          200 I.U.          and nonessential amino acids.
      4.    Vitamin B1 ( thiamine)                 3 mg            2- Nephramine:-
      5.    Vitamin B2 ( riboflavin)              3.6 mg
                                                                      a. Contains only essential amino acids.
      6.    Vitamin B6 ( pyridozine HCL)           4 mg
      7.    Niacinamide.                          40 mg               b. Recommended only to decrease net urea synthesis for
      8.    Pantothenic acid                      15 mg                   short periods of time.
      9.    Vitamin E                             10 I.U.             c. Close monitoring of serum ammonia levels is important.
      10.   Biotin                                60 mcg           3- In order to restrict fluid, it is possible to increase the
      11.   folic Acid                           400 mcg
                                                                   concentration of dextrose and fat emulsion.
      12.   Vitamin B12                           5 mcg
b) Vitamin K 10mg needs to be added every week .
                                                                   SOLUTION FOR LIVER FAILURE
3- Trace elements                                                  1. Patients with chronic liver disease are usually
  a- Zinc               5mg                                           malnourished. They are prone to complications such as
  b- Copper             1 mg                                          gastrointestinal bleeding and infection that compromise
  c- Manganese          0.5 mg                                        nutritional status.
  d- Chromium           1-0 mcg                                    2. Standard TPN should be used if the patient doses not have
  e- Selected patients may require zinc and selenium                  hepatic encephalopathy.
  supplementation .                                                3. Hepatamine can be used with patients with hepatic
4- Insulin can be added to the TPN bag if needed to minimize          encephalopathy. It is a liver-specific amino acid mixture.
5- Heparin is not routinely used at the UI hospital and clinic s   SOLUTION FOR THE CATABOLIC
in the TPN bags as there is no strong evidence to support that     PATIENT
1- Metabolic response to injury, burn or sepsis generates a          the patient if the bowel is capable of handling the delivery and
neuron endocrine response that induces hyper metabolism,             absorption of nutrients. If the patient is willing and able to eat,
proteolysis, insulin resistance with hyperglycemia and a             feeding can be accomplished by mouth; however, if this is not
depletion of lean body mass.                                         possible a feeding tube could be placed into the GI tract
2- Ina catabolic state nutritional support is extremely important.
Patients should be fed within 48-72 hrs of insult to optimize the
patient's metabolic state.
3- Nutritional requirements should be calculated. The optimal
portion requirement of a critically ill patient is 1.5 to 2.0 gm/                     **********************
4- Nitrogen balance.

ROLE OF             NUTRITION           SUPPORT           TEAM
PHYSICIAN : The physician on a nutrition support team will :
1. Indicate whether the patient needs to have parenteral
   nutrition therapy.
2. Assess the patient and order appropriate nutrition and
   electrolytes needed for the patient after evaluating lab
3. Evaluate the patient for potential line infections .

NURSE : The nurse as a member of the nutritional support
team will :
1. Be a resource per so for patients, staff and local health
   care providers regarding parenteral nutrition therapy and
   central venous catheters.
2. Monitor quality care for parenterals nutrition therapy and
   central venous catheters.
3. Participate in the discharge planning and patient education
   of home parenteral nutrition therapy patients.
4. Follow-up with home parenteral nutrition therapy patients
   after discharge from the hospital.

Complete or partial enteral feeding should be considered for

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