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Chapter 9
Nutrition
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Learning Objectives
• Explain the role of the gastrointestinal system in the digestion of
food.
• Describe how food is digested and absorbed.
• List the functions of each of the six classes of essential nutrients.
• Define macronutrient and micronutrient.
• Identify the food sources of proteins, carbohydrates, and fats.
• Identify the food sources of dietary fiber.
• List the possible health benefits of dietary fiber.
• Identify the food sources of each of the vitamins and minerals.
• Describe the changes in nutrient needs as an individual ages.
• Differentiate between anorexia nervosa, bulimia, and binge eating
disorder.
• Discuss the different types of nutritional support.
• Identify guidelines for the nutritional assessment.
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Anatomy and Physiology of the
Gastrointestinal System
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Gastrointestinal System
(GI tract or “gut”)
• The long, continuous tube that receives and transports
food, absorbs nutrients, and eliminates waste products
of digestion
• Primary organs
• Mouth, pharynx, esophagus, stomach, small intestine, and
large intestine
• Accessory organs
• Liver, gallbladder, and pancreas
• Roles in food digestion even though not part of digestive tract
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Digestion and Absorption
• 92% to 97% of diet digested and absorbed
• Water, simple sugars, vitamins, minerals, and
alcohol absorbed in their original form
• Lipids, proteins, and complex sugars must be
converted to simple forms before they are
absorbed
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Digestion and Absorption
• Hydrolysis
• Water splits complex molecules into smaller units
• Enzymes
• Govern the process of hydrolysis, along with bile and
hydrochloric acid
• Help break down food particles to their simplest form so
nutrients can be absorbed
• Found throughout intestinal tract, except in the large intestine
• Only water, salt, vitamins, and minerals are absorbed
in the colon
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Regulators of the
Gastrointestinal Tract
• Neural control
• Managed by autonomic nervous system and nerve
network in gut wall called the enteric nervous
system
• Autonomic system: sympathetic and parasympathetic
nerves
• Parasympathetic nerves stimulate digestive activity
• Sympathetic nerves inhibit activity
• Parasympathetic effect conveyed by vagus nerve: acid
stimulation in stomach in response to sight/smell of food
• Enteric nervous system receives information from receptors
in gastric mucosa that are sensitive to acidity of the
gastrointestinal tract and the feeling of fullness
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Regulators of the
Gastrointestinal Tract
• Hormone secretion
• Secreted into the gastrointestinal tract to help
regulate gastric pH, gastric motility, and appetite
• Stimulate the pancreas to secrete insulin and
enzymes
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Digestive Process: Mouth
• Teeth grind and crush food into small particles
• Food forms mass moistened and lubricated by
saliva
• A secretion containing an enzyme known as
amylase (ptyalin) digests any present starch
• Mass, or bolus, then passed to the pharynx
and through the esophagus by the process of
swallowing
• Peristalsis moves the food rapidly through the
esophagus into the stomach
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Digestive Process: Stomach
• The mass is mixed with gastric secretions
• Active chemical digestion is accomplished by the
secretion of gastric juice
• Produces average of 2000 to 2500 ml gastric juice
daily
• The juice contains hydrochloric acid, enzymes,
mucus, and the GI hormone gastrin
• Aids in digestion by converting the mass to a
semiliquid substance called chyme
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Digestive Process: Stomach
• Normally emptied in 1 to 4 hours
• Carbohydrates leave the stomach most rapidly,
followed by protein, and then fat
• Valves (sphincters) at entrance (cardiac
sphincter) and exit (pyloric sphincter) of the
stomach prevent backflow of food from
stomach into pharynx and from duodenum into
the stomach
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Digestive Process: Small Intestine
• Divided into the duodenum, the jejunum, and
the ileum
• Most digestion completed in duodenum;
jejunum and ileum function mostly in the
absorption of nutrients
• The remaining chyme is delivered to the large
intestine
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Digestive Process: Large Intestine
• Water and electrolytes are absorbed, leaving a
mass of wastes called feces
• Fecal mass is stored in the rectum, where it
triggers the defecation reflex
• When anal sphincters relax, feces pass out of
the body through the anus
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Mechanisms of Absorption
• Absorption is accomplished by the combination
of the processes of diffusion and active
transport
• Diffusion
• Movement of particles from an area of higher concentration
to an area of lower concentration
• Active transport
• Requires the input of energy for the movement of particles
across a membrane against an energy gradient
• Requires a carrier protein
• Best-known carrier is the intrinsic factor, which is
responsible for the absorption of vitamin B12
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Mechanisms of Absorption
• Small intestine
• Primary organ of absorption
• 22 feet long and arranged in folds
• Surface of folds covered with fingerlike projections
called villi
• Absorb nutrients into the blood and lymph vessels that
support them
• Absorbs several hundred grams of carbohydrate,
100 g or more of fat, 50 to 100 g amino acids, 50 to
100 g of ions, and 7 to 8 L of water each day
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Nutrients: Carbohydrates
• Digestion begins in the mouth, where the
enzyme amylase is released
• In the stomach, amylase activity halted when it
comes into contact with hydrochloric acid
• If carbohydrates remain in the stomach long enough,
hydrochloric acid reduces most to their simplest
form
• Stomach generally empties into the small intestine before
this occurs, so most of the digestion of carbohydrates
occurs within the small intestine
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Nutrients: Carbohydrates
• In the small intestine, pancreatic amylase is
released to continue carbohydrate digestion
• Pass through the villi into the bloodstream, where
carbohydrates carried by the portal vein to the liver
• From the liver, most of the glucose is transported to
the tissues
• Some stored for later use in the liver in the form of
glycogen and in the muscle
• Some forms, particularly fiber, cannot be digested
by humans and are excreted unchanged in the
feces
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Nutrients: Protein
• Digestion does not begin until it reaches the
stomach
• Split into smaller molecules
• Most digestion occurs in the duodenum
• Almost all of the protein is absorbed by the time it
reaches the end of the jejunum
• Only 1% of ingested protein found in the feces
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Nutrients: Fat
• Digestion begins in the stomach
• Gastric lipase
• An enzyme, breaks down the triglycerides that make
up fat into fatty acids and glycerol
• Major portion of fat digestion takes place in the
small intestine
• Peristaltic action of small intestine, along with
bile secreted by the liver, breaks down the
larger fat globules into smaller particles
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Nutrients: Fluids,
Vitamins, and Minerals
• Absorbed through the intestinal mucosa
• Each day about 8 L of fluid from the body pass
back and forth across gut membrane to keep
the nutrients in solution
• Vitamins and water pass unchanged from the
small intestine into the blood by passive
diffusion
• Mineral absorption is a more active, complex
process that takes place in several stages
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Factors Affecting Digestion
• Psychological state
• Look, smell, and taste of food have effect on digestion
• Emotions such as fear, anger, and worry can inhibit peristalsis
and depress gastric secretions
• Bacterial action
• Needed to help form vitamin K, vitamin B12, thiamine, and
riboflavin
• Produce various gases, acids, and other toxic substances
• Food processing
• Cooked foods generally more digestible than raw foods
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Energy Expenditure
• Measurement of energy expenditure
• Basal metabolic rate (BMR)
• Factors that can cause the metabolic rate to vary
•
•
•
•
•
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Body size and composition
Periods of growth
Secretion of hormones
Temperature
Menstrual cycle
Pregnancy
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Energy Expenditure
• Energy measurements and calculations
• Calorie
• Standard unit for measuring energy
• Amount of heat energy needed to increase temperature of 1 g
of water at standard temperature by 1° C
• Measure of human energy expenditure
• Direct calorimetry
• Indirect calorimetry
• Doubly labeled water
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Carbohydrates
• Organic compounds consisting of carbon,
hydrogen, and oxygen
• All the sugars and starches that people eat and
most types of fibers
• Plants manufacture and store carbohydrates
as their chief source of energy
• Glucose main sugar in the blood and body’s
basic fuel; serves as primary source of energy
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Carbohydrates
• Classified according to the number of simple
sugars or saccharides
• Monosaccharides
• 1 saccharide
• Disaccharides
• 2 saccharides
• Oligosaccharides
• 3 to 10 monosaccharides
• Polysaccharides
• 10 to 10,000 or more molecules
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Carbohydrates
• Metabolism
• Converted to glucose for immediate use by the body’s
cells and to glycogen for storage
• Serum glucose level maintained at normal through the
regular intake of nutrients, storage or breakdown of
glycogen, glucogenesis, and gluconeogenesis
• Normal blood glucose levels: 70 to 100 mg/100 ml
under fasting conditions
• After a meal, blood glucose level may rise to
130 mg/100 ml but returns to normal within 2 to 3 hours
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Carbohydrates
• Dietary fiber
• A group of polysaccharides that act differently from
other carbohydrates
• Found only in plant foods and are resistant to
human digestive enzymes
• Major digestive role is to help form a soft, firm stool
and to aid in the process of elimination
• Types
• Insoluble
• Soluble
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Carbohydrates
• Functions of carbohydrates
•
•
•
•
•
Major source of energy to body tissues
Sole source of energy for the brain
Maintain functional integrity of nerve tissue
Spare fats from being used for metabolism
Precursors (basic building blocks) for other
physiologic substances
• Recommended Dietary Allowance
• Carbohydrates should comprise 45% to 65%
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Lipids
• Include fats, oils, waxes, and related
compounds
• May be solid or liquid forms
• Insoluble in water
• Contain carbon, hydrogen, and oxygen
• Triglycerides: most common fat found in foods
of both animal and plant origin
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Lipids
• Saturated fatty acids
• Loaded with all the hydrogen atoms they can carry
• Solid at room temperature
• Unsaturated fatty acids
• Do not have all the hydrogen atoms they can carry
• Liquid at room temperature
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Lipid Transport and Storage
• Most are absorbed into the lymphatic system
through the intestinal mucosa
• The exception is certain fatty acids that are
absorbed directly into the portal blood
• For fat to be digested, it must be emulsified, or
pulled into suspension with digestive juices
• Bile (secretion of liver) needed to emulsify fat
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Lipid Transport and Storage
• Once emulsified, fats can be broken down and
absorbed
• Lipoproteins
• Protein that transports lipids in the bloodstream
• Chylomicrons, high-density lipoproteins (HDLs),
low-density lipoproteins (LDLs), and very-lowdensity lipoproteins (VLDLs)
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Lipid Metabolism
• A source of energy for most body tissues except the
brain, blood cells, skin, and renal medulla
• Lipolysis
• Fat cells release glycerol and free fatty acids
• Liver converts it to triglycerides or glucose
• Free fatty acids bind to albumin for transportation in the
blood and interstitial tissue
• Most lipids carried to liver for conversion to energy or
for the synthesis of new triglycerides
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Recommended Dietary Allowance
• 20% to 35% of the adult diet should be
composed of fats
• Unsaturated fats rather than saturated fats
minimize the risk of heart disease
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Food Sources of Fat
• Saturated fats
• Animal products: beef, dairy products, and eggs
• Unsaturated fats
• Vegetable oils, including corn oil, cottonseed oil,
and safflower oil
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Lipid Function
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•
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•
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Store energy
Maintain healthy skin and hair
Carry fat-soluble vitamins
Supply essential fatty acids
Promote satiety
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Proteins
• Basic structure of a chain of amino acids that
can form many different configurations and
combine with other substances
• Contains carbon, hydrogen, oxygen, nitrogen,
sulfur: sometimes metals, acids, lipids,
polysaccharides
• Simple proteins
• Made of only amino acids
• Conjugated proteins
• Made of amino acids in combination with other
substances
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Proteins
• Amino acids
• Nine essential: must be obtained from the diet
• Body can manufacture enough of the other amino
acids from the essential amino acids
• Complete protein
• Contains all 9 essential amino acids in sufficient quantity
and ratio for the body’s needs
• Incomplete proteins
• Lack one or more of the essential amino acids
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Protein Metabolism and Synthesis
• Deamination
• Protein is broken down in the small intestine to the
constituent amino acids
• Protein synthesis
• Controlled by DNA in the cells
• DNA: provides the form to link up the exact
combination of amino acids needed to form a
particular protein
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Protein Deficiency
• The body cannot store protein, so it needs to
be eaten each day
• If protein intake is inadequate, nitrogen will be
conserved by the kidneys, causing the urine
nitrogen to be low
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Evaluation of Protein Quality
• Should include both the quantity and the
quality of the protein consumed
• Eating a mixture of foods in a meal, if the
quantity is sufficient, tends to provide all of the
essential amino acids
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Functions of Proteins
• Furnish building blocks (amino acids) to build
and repair tissue
• Serve as an energy source
• Help form enzymes, hormones, and other body
fluids and secretions
• Assist in the transport of fats, fat-soluble
vitamins, and other substances
• Help maintain osmolarity of body fluids
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Recommended Dietary Allowance
• Should contribute 10% to 35% of the
macronutrients in the adult diet
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Vitamins
• Fat soluble
• Vitamins A, D, E, and K
• Usually absorbed in the body with other lipids
• Water soluble
• B-complex group (thiamine, riboflavin, niacin, B6,
folate, B12, pantothenic acid, and biotin) and vitamin
C (ascorbic acid)
• Readily excreted from the body
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Minerals
• Enzyme regulation, maintain acid-base
balance and osmotic pressure, and maintain
nerve and muscular irritability
• Macrominerals
• Calcium, phosphorus, magnesium, sulfur, sodium,
chloride, potassium
• Microminerals or trace elements
• Iron, zinc, iodine
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Minerals
• Ultratrace elements
• Selenium, chromium, copper, manganese,
molybdenum, boron, cobalt
• Ionized forms
• Sodium, potassium
• Constituents of organic compounds
• Phospholipids, hemoglobin
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Water
• Largest component of the body and tissues;
essential to all body life processes
• Intake of water is controlled by thirst
• Also ingested through food
• The body cannot store water
• Essential that all living things replenish water daily
to maintain health and efficiency
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Water
• The longest that people can live without water
is approximately 4 days
• Adults generally should take in about 2500 ml,
or 2 to 3 quarts, per day
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Age-Related Changes
• Energy
• Normal decline in metabolism and common
decrease in physical activity, lower energy needs
with age
• Often reduce the kilocalories taken in per day
• Can result in inadequate intake of essential nutrients
• Psychosocial factors also may lead to poor nutrition
in the older person
• Depression, cognitive impairment, and loneliness
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Nutritional Care of the Older Adult
• Dietary planning
• Meals need to be appealing, taking into
consideration individual likes and dislikes, and
should be tasteful and filling
• Nutrition programs
• Community-based programs, administered by public
and private agencies, provide hot, nutritious meals
to older adults
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Nutritional Care of the Older Adult
• Nutritional needs during prolonged illness
• Increased nutritional needs during illness
• Nasogastric tube feedings or parenteral nutrition
may be required
• Nutritional care in institutional settings
• Periodic reassessment of nutritional status is critical
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MyPyramid
• Based on recommendations from the 2005 USDA
Dietary Guidelines for Americans
• Includes figure climbing the steps of the pyramid to
emphasize exercise in addition to nutrition
• Colored bands on the pyramid represent the
recommended proportions of vegetables (green),
grains (orange), fruits (red), milk products (blue), meats
and beans (purple), and oils (yellow)
• Personalized pyramid
• www.mypyramid.gov
• Enter age, gender, and activity level
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Figure 9-1A
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Food Labeling
• People have expressed an increased need to
be informed about what they are eating
• Many more foods are now labeled so that the
average person can make determinations
about the quality and quantity of the nutrients
consumed
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National Guidelines for Diet Planning
• Many guidelines are available on proper
nutrition to maintain health and prevent
disease
• Surgeon General’s Report on Nutrition and
Health can be used as a basis for dietary
planning (Table 9-14)
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Figure 9-2
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Vegetarian Diets
• Many vegetarians eat all foods except red
meat, although some exclude poultry and fish
as well
• Lactovegetarian diet
• Includes milk, cheese, and other dairy products but
excludes meat, fish, poultry, and eggs
• Lacto-ovo-vegetarian diet
• Includes dairy products and eggs but excludes meat, fish,
and poultry
• Vegan
• Consumes no foods of animal origin
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Nursing Assessment of
Nutritional Status
• Dietary history
• Physical, psychological, social, and medical data that may
affect nutritional status
• Anthropometric data
• Height, weight (including weight patterns), and body
composition
• Laboratory data
• Serum albumin, total lymphocyte count (TLC),
creatinine/height index, nitrogen balance, mean corpuscular
volume (MCV), and transferrin saturation
• Physical examination data
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Figure 9-3
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Weight Management and
Eating Disorders
• Most adults maintain a constant weight but
must eat and exercise consistently on a daily
basis
• Overweight: obese if weight is 20% or more
above ideal body weight
• Underweight: weight is 15% to 20% or more
below accepted weight standards
• Eating disorders fairly common among teenage
girls and young women, and may persist into
adulthood
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Anorexia Nervosa
• An eating disorder characterized by selfimposed starvation
• Generally girls in their midteens, although
young adult women and men sometimes
develop the disorder
• Become obsessed with weight loss; distorted
body image
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Bulimia
• Characterized by periods of binge eating
followed by purging
• May alternate with periods of fasting
• Occurs more frequently than anorexia nervosa;
also seen most often in young women
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Binge-Eating Disorder
• The intake of excessive calories at least twice
a week for 6 months
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Nutritional Support with
Supplemental Feedings
• Sometimes a person’s nutritional needs cannot
be met by oral feeding and a nutritional
supplement is required
• Liquid or powdered milk, powdered whole eggs, and
powdered egg albumin as concentrated protein
sources
• Examples: Ensure, Compleat, Sustacal, Criticare
HN, Pulmocare, Trauma Cal, Travasorb HN, and
Travasorb Renal
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Enteral Tube Feedings
• Bypass the mouth and deliver nutrients directly
into the stomach or small intestine through
inserted tubes
• Tubes can be inserted into the stomach,
duodenum, or jejunum through the nose or
through the abdominal wall
• Complications
• Nausea or vomiting, diarrhea, gastrointestinal
bleeding, aspiration pneumonia, hyperkalemia,
hyponatremia, hyperglycemia, or nutritional
deficiency
• Dumping syndrome
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Figure 9-4
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Parenteral Nutrition
• Peripheral parenteral nutrition
• Intravenous therapy
• May be composed of dextrose (5%-10%), amino
acids, vitamins, minerals, and electrolytes
• At most it supplies 1800 kcal/day
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Parenteral Nutrition
• Total parenteral nutrition
• Used for patients who are unable to obtain
adequate nutrition enterally or with PPN
• Can supply up to 4000 kcal/day
• Complications: pulmonary complications, injury to
the veins and arteries surrounding the TPN catheter
site, air embolism, infection, electrolyte imbalance,
mineral deficiency, hyperglycemia, and, if treatment
is ended suddenly, rebound hypoglycemia
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Transitional Feeding
• Nutrition changed from one method to another
• Important that it be done gradually
• Nutritional recovery syndrome my occur if given food too
quickly
• Moderate in carbohydrates, low in sodium, lactose
free, and supplemented with phosphorus and
potassium
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Transitional Feeding
• Parenteral to oral or enteral feeding
• Continue the parenteral feeding; as patient is able to
tolerate the oral or enteral feedings, parenteral
feedings can be tapered off
• Enteral to oral feedings
• Change the enteral feeding from a continuous drip
to an intermittent feeding; allows patient to get
hungry
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