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Chapter 1
SCIENCE OF
NUTURTION
It is the study of the nutrients in the food and the way in which
the body handle these nutrients. In other words it is the study
of nutrients in the food and their ingestion , digestion ,
transport , metabolism , interaction , storage and
excretion .
AIM OF STUDY CLINECAL NUTRITION
1) Understanding the food constitutes their function and the
requirements for nutrients by various age groups.
2) Understanding methods of food utilization in the body.
3) Understanding the relation between nutrition and human
health.
4) Understanding the importance of nutrition to the recovery
of the pt. from various diseases.
NUTRIENTS : ( these chemical substances obtained from
food promote growth and maintain life ).
PROCESSES IN THE FOOD UTILIZATION
1-Ingestion : The intake of food .
2-Digestion : The breakdown of foods into their constituent
nutrients .
3-Absorption : Transfer of nutrients from the gastrointestinal
tract into the circulation .
SCIENCE OF NUTURTION
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
gases.
6-Metabolism : Oxidation to create heat and energy as well
as formation of new cell.
7-Excretion : Undigested food wastes and certain body
wastes from the bowel , CO2 , from lungs , nitrogenous ,
mineral and other ( Wastes from kidney and skin ) .
RELEVANT DEFINITIONIONS
1- Health : Is defined by WHO. AS the stat of complete
physical, mental and social wellbeing and not merely the
absence of disease.
2- Nutrients : Are the constituents in the food that must be
supplied to the body in suitable amounts, these include,
carbohydrates, mineral ,proteins waters and vitamins.
3- Malnutrition : Is an impairment of health resulting from a
deficiency, excess or imbalance of nutrients, includes undernutrition and over nutrition.
4- Nutritional care : Is application of the science and art of
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.
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
number of calories needed to basic metabolic process of
person at rest and at least 12hr after taking food.
7- Enzyme : Chemical substances which act upon other
substances and speed up the specific chemical reaction but do
not itself become apart of final products.
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8- Deficiency disease : A disease due to lake of essential
substances in the diet or defective metabolism.
9- Obesity : Any abnormal fat in the body or abnormal
condition due to excessive deposits of fat in the body.
NUTRITIONAL PROBLEM
1. Low socioeconomic levels: ( Those are more prone to
dietary problem ).
2. Lack of knowledge: ( Is a further contributing factor ).
3. Increase incidence of dying baby from low wt. : ( Especially
babies who born to young women in teens who also poor ).
4. Anemia: ( Occurs frequently in all age and especially in
children 6 years ).
5. Increasing incidence of teeth problems: ( Decayed teeth,
missing teeth ).
6. Retarded growth and retarded bone development in
some children 1-3yrs of age.
7. Chronic illness: ( About 80% of elderly have some
chronic condition contributing factors include low income,
poor nutrition, and social isolation ).
NUTRITIONAL BALANCE
To achieve nutritional balance a good diet must fulfill the
following :
1. It must nourish the appropriate levels of all nutrients to
meet the physiologic and biochemical needs of the body at
all stages of the life cycle.
2. It must avoided excessive of calories, fats, sugar, salt and
alcohol.
A DAILY FOOD GUIDE
It includes 5 food groups, which are:
1. Vegetables – Fruit group
4 basic servings daily :
 One is 1/2 cup or atypical portion such as one orange,
half a medium grapefruit, a medium potato.
 One good vit. C source daily.
 One includes green vegetables.
 One includes unpeeled fruits and vegetables.
2. Bread – cereal group
4 basic servings daily.
3. Milk- cheese group:-
PROBLEM OF NUTRITIONAL EXCESSIVE
1. Excessive caloric intake leads to obesity, which is
associated with chronic disease such as DM, gallbladder
disease and cardiovascular disease.
2. Excessive intake of saturated fats, cholesterol is important
risk factors in the incidence of cardiovascular disease.
3. Excessive intake of sugars contributes to an increase in
dental caries.
4. Excessive intake of salt has been associated with
hypertension.
5. Excessive intake of some vitamins A and D are Known to
be toxic.
SCIENCE OF NUTURTION
 Children less than 9 year's
 Children 9-12 years
 Teen agars
 Adults
 Pregnant
 Nursing mothers
One serving is a cup of milk, whole, skim, low
dry milk.
2-3 servings
3 servings
4 servings
2 servings
3 servings
4 servings
fat, butter, non
4. Meat, fish, poultry and beans group:2 basic servings daily
 One servings is 2-3 ounces of lean, cooked meat,
poultry or fish.
 1 egg.
 1/2 to 2/3 cooked dry– beans, dray peas or lentils.
2

1/4 to1/2 cup nuts.
5. Fat, sweet, alcohol group:No basic servings suggested.
 Include butter, margarine, fats, oil, candy, sugars.
Good Nutrition
-Normal weight high, body from.
FACTORS INFLUANCING FOOD INTAKE
-Erect posture, arms and legs
straight, abdomen in chest up .
1) Physiological factors that determine food intake :
-Firm, strong muscle.
A. Hunger : Is physiologic sense has been defined as that
set of internal single that stimulate the consumption of
food .
B. Appetite: Commonly refers to the pleasurable
sensations provided by food the choices – made specific
food item.
C. Hedonic factors in food choice : The palatability of
food is a composite of taste, smell and temperature .
2) Environmental and behavioral factors influencing
food acceptance :
A. Role of culture : The ethnic group and a heritage
account – these patterns reflect the social organization
of he people including their economy, religion, belief and
attitudes.
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
drugs.
SCIENCE OF NUTURTION
-Firm, clear skin with good color,
pink mucus membranes .
-Well-formed jaw and teeth.
-Soft, glossy hair.
-Clear bright eyes, not sensitive to
light .
-Good appetite and digestion .
-Ability to concentrate .
Cooperative,interested, agreeable,
cheerful.
-Resistance to infection .
Poor nutrition
-Overweight, underweight, failure
to grow .
-Poor posture, chest forward,
rounded, shoulder, protruding
abdomen.
-Thin, flabby muscle, excessive
fat.
-Dry, pale skin, pale mucus
membranes .
-Poorly formed jaw with teeth
poorly aligned.
-Dull, dry hair .
-Dull eyes, sensitive to light,
puffiness under eye .
-Poor appetite, complaints of,
indigestion diarrhea.
-Short attention span .
-Irritable, apathetic, depressed.
-Many
infection,
longer
convalescence of disease .
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Common Therapeutic Diets
Diet
Types of food / fluids
Clear liquid
Full liquid
Soft diet
Mechanical soft
Bland diet
General diet or
regular diet
Six
small
feeding
Diet altering
Fiber :
-High fiber
Consists of fluid that are liquids at body temperature,
it is given as the first meal after surgery .
Consists of any food and drinks that are liquid at room
temperature , may provide adequate calories cereals
it is given as post op. surgery
Easy to – digest food, omit rough grains, nuts, spicy or
fatty food, dried fruits, raw vegetables, adequate
nutrients 2,000 - 00522 kcal, used in transition room
full liquid to regular diet
For Pt with difficulty chewing and swallowing
Removal of food knows stomach irritant as caffeine
dinks, citrus fruits, food with spices
Permit all foods
Foods, which are the sources of nutrients in the
body, have the following function :1. Provide energy for the body
2. Build and repair tissues
3. Regulate body process
There are six types of nutrients:
1. Carbohydrates
2. Fats
3. Proteins
4. Minerals salt
5. Water
6. Vitamins
Variety of foods from any type of diet divided into six
fairly equal portion: used for post op. Pt, anorexia,
poor appetite, Pt with reduced stomach capacity
Fiber is not digested and form fecal material.
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
4
3-Polysacharides , E.g. starch, glycogen, cellulose, dextrin
and other.
Chapter 2
MONOSACCHARIDES ( C6 H12 O6 )
UTILZATION OF
NUTRIENTS
Carbohydrates
, fats , and proteins must be digested and
further metabolized before they can be utilized by his body.
Water, minerals salt, and vitamins can be utilized without
further breakdown .
A. CARBOHYDRATES C H O
SOURCES OF CARBOHYDRATES
1- Plants are the principle source of carbohydrates in the diets
some plants that contains high amount of carbohydrates are
vegetables and fruits.
2- Animal starch is stored in the liver of animals, including
man, as glycogen.
COMPOSTION OF CARBOHYDRATES
Sugars and starches are composed of carbon, hydrogen and
oxygen with general formula of ( CnH2nOn ) .
FUNCTION OF CARBOHYDRATES
1-furnish heat and energy ( 4C.\gram of carbohydrates )
2-spare protein from being used for energy.
3-supply bulk in the form of cellulose.
CLASSIFICATION
There are three principles form of carbohydrates:1-Monosaccharides , E.g. glucose, fructose and glactose.
2-Disaccharides , E.g. maltose, sucrose and lactose.
SCIENCE OF NUTURTION
There are three monosaccharide:
1. Glucose or dextrose : Is the form which circulates in
blood. It is also found in fruits and vegetables.
2. Fructose : Is the sweetest of all sugars. It is found in
the honey, fruits and vegetable.
3. Galactose : Is not found free in nature but occurs as a
result of the breakdown of lactose.
DISACCHARIDES (C12 H22 O11)
There are three disaccharides:
1. Sucrose or table sugar : Is found in molasses, maple
sugar, fruit and vegetables. It is also found in beet and
cane sugar.
2. Lactose : Is milk sugar. It remains in the intestines fairly
long and encourages the growth of favorable bacteria.
3. Maltose : Occurs as a result of the breakdown of
starch. It is also found in cereals and beer.
POLYSACCHAIDES (
)
There are several polysaccharides:
1. Starch : is encased in cellulose walls and must be
ground or cooked to release the starch. It is found in
creels, fruit and vegetables.
2. Cellulose : forms the framework of vegetables, the skin
of fruits and vegetables and the coverings of whole
grains. It is not digested but provides bulk.
3. Glycogen : is the form in which carbohydrates are
stored
in the animal glycogen can be converted to
glucose rapidly .
ROLE OF CARBOHYDRATES IN THE DIET
1-Carbohydrates provide the cheapest sources of energy.
2-Carbohydrates provide about 50% of calories in the Arabic
diet.
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B. FATS
SOURCES
There are 2 general sources of fat:1- Animal fats, e.g. Butter, cream, fat meat, bacon and lard.
2- Plant oils, e.g. olive oil, peanut oil and soy bean oil.
COMPOSTION
Fat are compounds of carbon, hydrogen and oxygen but the
oxygen is less in the proportion to carbon and hydrogen than it
is in carbohydrates. For this reason, fats yield more energy
than do carbohydrates.
FUNCTION OF FAT
1. Provides energy (9C. /gram)
2. Aids in digestion, absorption and utilization of other
nutrients.
3. Carries fat soluble vitamins and aids in their absorption and
utilization.
ROLE OF FATS IN THE DIET
Fats provide from 35-40% of calories in the diet. This is too
high and creates a serious health problem by contributing to
atherosclerosis.
N.B: ATHEROSCLEROSIS ( Fatty deposits of cholesterol on
the inner linings of arteries ) is caused by elevated blood
cholesterol level.
 Dietary factors can affect the blood cholesterol level in
three ways :
1. Food high in cholesterol raise the blood cholesterol
level slightly but generally the liver compensates for this
by producing less cholesterol.
2. Ingestion of fat containing highly unsaturated fatty
acids, e.g. those found in most vegetables oils, depress
the blood cholesterol level.
3. The most important factor in high blood cholesterol is
the total amount of fat ingested, because increased fat
metabolism causes increased amounts of cholesterol to
SCIENCE OF NUTURTION
be produced by the liver.
C. PROTEIN
SOURCES
When the word protein is mentioned most people immediately
think of meat, also they think that diets cannot be adequate in
protein if they don't include meat.
There are 2 general sources of protein:1-Animal protein : e.g. milk, eggs, cheese, meat, poultry and
fish.
2- Plant protein : e.g. peas, beans, nuts, cereals, soy beans
COMPOSTION
Proteins are complex compound which contain carbon,
hydrogen, oxygen, nitrogen, and some times other elements
such as sulfur and phosphorus. The protein molecules are
composed of amino acids which are Known as a building
blocks of protein.
That can not be manufactured by the body must be present in
the protein of the diet and are called essential amino acid.
It is a good idea to be able recognizes the name of essential
amino acid.
When you see them they are:-Histidine
-Phenylamine
-Leucine
-Threonine
-Lysine
-Tryptophan
-Valine-Isoleucine
-Methionine
FUNCTION
1. Building and repair tissue.
2. Form much of body from work and are a major component
of skin, hair, nails and matrix of teeth and bones.
3. Used in the manufacture of enzymes, hormone, antibiotics
and hemoglobin.
4. Proved energy, if it is not provided by carbohydrates or
fates.
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► proteins furnish 4 Kcal per gram. If the diet contains more
protein than is needed, the nitrogen will be removed from the
excess amino acids by the liver. The nitrogen is excreted in
the form of urea by the kidney if the diet does not contain
sufficient calories from carbohydrate and fat, the protein will be
used for energy rather than for building or replacing tissue.
► The protein need of the adult is based on body size . the
recommended allowance is 0.8 gram per kilogram.
CLASSIFICATION OF PROTIEN
Protein are classified either as a complete or incomplete
protein.
1. Complete protein
There are over 20 different amino acids : 10 of this cannot
synthesized be by a child and 9 cannot be synthesized by an
a adult. The amino acid which can not synthesized are known
as essential amino acid , because it is essential that these be
taken into the body daily .any food which contain all of
essential amino acid is called the a complete protein food .
Most animal protein such as eggs, milk, meet; poultry and fish
are complete protein.
2. Incomplete proteins
These lacks at list one of essential amino acid, plant protein
such as beans, peas, macaroni, grain, vegetables and nuts
are incomplete protein .
CLINICAL PROPLEMS
1) Negative protein balance : this means the body is
breaking down protein tissues faster than they are being
replaced, so the individual is less able to resist infection.
Negative protein balance can exist when individual dose not
eat enough protein containing food, many elderly person are
unable to chew well or don’t like milk.
►The nurse should be alert to the possibility of protein mal
nutrition in pt. With poor appetite.
SCIENCE OF NUTURTION
2) Protein-calorie malnutrition :
a) Kwashiorkor: Usually appears after the child is weaned
from the mothers breast.
S/S: edema of hands and feet, fail to grow, poor appetite and
the skin and hair change in texture and color.
b) Marasmus: Occurs in infants who are weaned very early
and who are fed diets that are low in calories as well as
protein.
S/S: emaciated appearance, brain cell have had less
opportunity to develop ( mental retardation ).
SOME FALLACY AND FACTS :
1. Athletes need more protein than nonetheless ….. (Fallacy)
►The protein requirement of the adult depends on the body
size and not one the amount of exercise ….. (Fact)
2. Older people need less protein than young adult …..
(Fallacy)
►The need for replacing the protein of tissues continues
throughout life.
►Older people need the same amount of protein as the young
adult of the same size ….. (Fact).
3. Gelatin is an excellent source of protein ….. (Fallacy)
►Dry gelatin is about 90% protein ….. (Fact)
4- Protein food should not be eaten in the same meal as
starches ….. (Fallacy).
►There is no reason to separate protein foods and starches,
many conmen foods contain both proteins, carbohydrates the
digestive tract digests protein, carbohydrates and fat
components of the diet at the same time ….. (Fact)
D. WATER
AMOUNT : Water makes up about 60% of body weight.
FUNCTION
1- Serves as a solvent for material.
2- Transport materials via the blood and lymph.
3- Necessary for digestion.
4- Necessary for removal of body waste products through
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urine and feces.
5- Helps regulation of body temperature by evaporating
perspiration which helps cool the body.
SOURCES
1- Drinking water.
2- Other liquids, such as milk or fruit juices.
3- Many foods are mainly water.
4- Water produce by metabolism of food .
FLUID COMPARTMENT OF THE BODY
There are two major fluid compartments in the body:1- Intracellular fluid ----- 45%
2- Extra cellular fluid ---- 15%
Is found both as interstitial fluid and as plasma:► Interstitial fluid about ---- 11%
► Plasma about ---- 4%
Causes for negative water balance:
1- Insufficient intake of fluid.
2- Excessive loss of fluid:-Vomiting
-Diarrhea
-Profuse sweating.
-High body temperatures.
-Some disease e.g. Diabetes mellitus, Diabetes insipid us .
Effect on the body of the negative water balance:
1-plasma shows the first effect o dehydration with the
Possibility of shock.
2-interstitial or tissue fluid is the next to show a decrease.
3-Finally, intracellular fluid decrease and this creates an
intense thirst and interference with enzyme.
E. VITAMINS
WATER BALANCE
CHARACTERISTIC OF VITAMINS
Water balance occurs when intake loss :
► Water intake:
1- Fluid
1500ml
2- Food
700ml
3- Metabolism
200ml
2400ml
► Water loss:1- Large intestine (Feces)
200ml
2- Lung
350ml
3- Skin
* Insensible
350ml
* Perspiration
100ml
4- Urine
1400ml
2400ml
Negative water balance or dehydration :
This occurs when intake is insufficient to provide for losses.
Fluid depends not only on water but also on salt.
1- Organic compound not structurally related.
2- Essential for life.
3- Needed in small amounts.
4- Not manufactured by the body, must be taken in through
food some vitamins are manufactured by bacteria in the
intestines an exception to this is one form of vitamins D.
Natural vitamins D is found by ultraviolet light ( sun light )
irradiation of cholesterol compound in the skin.
General resources:
1-NO one food supplies all of the vitamins but with balanced
diet there would be no deficiency.
2- Protective food is diary products, eggs and fruits.
SCIENCE OF NUTURTION
GENARAL FUNCTION :
1-Regulates body process by acting as coenzymes which
make possible the activities of enzymes.
2-Aids in structure, i.e. the eye requires Vit. A.
8
TYPES OF VITAMINS
VITAMIN (D) :
There are 2 major types of vitamins:1. Fat soluble vitamin (A, D, E, K).
A) These are not easily lost by ordinary cooking methods and
do not easily dissolve in water, since these are absorbed with
fat, any condition such as gall bladder disease which interferes
with fat absorption, could cause a deficiency of these vitamins.
B) These are stored by the body and deficiencies are not
prevalent .
2. Water soluble vitamins (vit. B complex and vit. C)
These do dissolve out in water.
In general these are not stored by the body.
Deficiencies are more prevalent for water soluble vitamins.
N.B : ► water- soluble (C, B1, B2, B6, B12) .
► Fat- soluble (A, D, K, E) .
SOURCES
FAT SOLUBLE VITAMINS
VITAMIN (A) :
Foods are not good sources of vitamin D, except when they
are fortified
FUNCTION
1-aids in the absorption of calcium and phosphorus from GIT .
2- promote the mineralization of bones and teeth .
3-regulates the normal level of calcium in the blood
DEFICIENCY OF VITAMIN D
1. Rictets it seen in the children
2. Osteomalacia: it seen in adult women and who had several
pregnancy.
3. Osteodystrophy: it occur in sever renal failure because the
kidney is unable to convert vitamin D to its active form.
Recommended daily allowances : 400 units for children and
adolescents.
SOURCES
VITAMIN (K) :
Cheese, Butter, Eggs, Milk, Fish liver oils, Yellow vegetables
(carrot, sweet potatoes) green leafy vegetables (spinach).
It is known as the antihemorrhagic vitamin .
Small amounts of vitamin K are stored in the liver, heart, skin ,
muscle and kidney.
FUNCTION
1. For the normal structure of the bone and teeth .
2. Maintain of the epithelium or outer layer of skin and
mucous membrane of nose , mouth , GIT, eyes, URS.
3. Formation of the visual purple which make eye adapt to
dim light .
DEFICIENCY OF VITAMIN A
1. slow growth poor teeth and gums .
2. skin changes and infection (dry and scaly)
3. night blindness(nyctalopia)
Recommended daily allowances:
For adult : 0.8-1.6mg or 5000iu-8000iu
For child :
0.4-1.0mg or 1500-5000 unit.
SCIENCE OF NUTURTION
SOURCES
pork liver, green leafy vegetable and bacteria in the intestine.
FUNCTION
Needed for the formation of prothrombin and substance
necessary for blood clotting.
DEFICIENCY OF VITAMIN K
1-hemorrhagic disease especially in newborn and infants
2-slow blood clotting
Recommended daily allowances : It is not established.
Dicumarol is vitamin K antagonist, it contract the effect of
vitamin K in formation of prothrombin and prevents blood
clotting , It is effective in treating circulatory disease .
9
VITAMIN (E) :
DEFICIENCY OF VITAMIN C
SOURCES
1.
2.
3.
4.
It s widely distributed in food, with vegetable oils , margarines ,
nuts, dark green vegetable.
FUNCTION
prevent the oxidation (antioxidant) of vitamin A in the intestinal
tract .
DEFICIENCY OF VITAMIN E
Deficiency only providing in premature new infant –
irritability, edema and hemolytic anemia (hemolysis of red
blood cell)
Recommended daily allowances :
Male: 15 IU
Female: 12 IU
WATER SOLUBLE VITAMINS
VITAMIN (C) : ( Ascorbic Acid )
SOURCES
Oranges, grapefruit, limes and lemons. Tossed salad, fresh
tomatoes .
PROPERITIES OF VITAMIN C :
1.
2.
3.
Vitamin C is highly soluble in water. So avoid soaking
vegetable in large amounts of water cooking in smallest
amounts of water.
The oxidation of ascorbic acids increase rapidly as
temperature is increased :So store fruits and vegetable in
a cool place, and use the shorting time in cooking.
Ascorbic acid is destroyed in presence of alkali : So, do
not use baking soda .
FUNCTION
1.
2.
3.
4.
It is essential for building the connective tissue .
It improves the absorption of iron in the intestine.
It is required for formation of hormones such as thyroxin
and adrenaline.
Necessary for blood, teeth and bones.
SCIENCE OF NUTURTION
Sore of mouth and bleeding from gums.
Weak walled capillaries.
Poor wound healing.
Scurvy: Is characterized by easy bruising and
hemorrhaging of skin, loosing of the teeth, bleeding of the
gums and disruption of the cartilages of that support the
skeleton.
Recommended daily allowances : Adult : 60mg.
VITAMIN (B) COMPLEX :
1. VITAMIN (B1) : ( Thiamin )
SOURCES
Meat especially pork and liver, dry beans, peas, peanuts, eggs
and milk.
FUNCTION
1. Maintain health nerves, a good mental out look, a normal
appetite and good digestion.
2. Breakdown of glucose to energy.
DEFICIENCY OF VITAMIN B1
1. Fatigue and poor appetite.
2. Neuritis of legs.
3. Beriberi, some times called Rice-eater disease the S&S is:
polyneuritis, edema and heart disease.
Recommended daily allowances: 0.5mg per 1000kcal.
2. VITAMIN (B2) : ( Riboflavin )
SOURCES
Meat, poultry, fish, dark green leafy vegetables and grain
breads
FUNCTION
1. It is necessary of breaking down glucose to release energy.
2. It is essential for healthy skin and for good vision in bright
light.
10
DEFICIENCY OF VITAMIN B2
► Cheilosis : S&S :
A. Cracking of skin at the corners of the lips and scaliness
around the ears.
B. Redness and burning as well as it changing of the eyes
and extreme sensitivity to the strong light.
Recommended daily allowances:
Men : 1.6mg
Women : 1.2mg
3. VITAMIN (B6) : Three forms of Vit. B6
( Pyridoxal, Pyridoxine and pyridoxamine )
SOURCES
Meat, especially organ meat, whole-green cereal, soybeans,
peanuts, milk and green vegetables.
FUNCTION
1. Essential for synthesis and break down of amino acids.
2. Essential for production of antibodies, formation of heme in
hemoglobin .
DEFICIENCY OF VITAMIN B6
1. Gastrointestinal upset .
2. Irritability, nervousness and convulsions.
Recommended daily allowances :
Men : 2mg
Women : 2.2mg
4. VITAMIN (B12)
Absorption and storage :
The absorption of vitamin B12 is much more complex than
other B-complex vitamin:
The stomach produces a substance called intrinsic factor,
vitamin B12 is attached to intrinsic factor and is carried to the
ileum from which it is absorbed. In the absence of intrinsic
factor vitamin B12 can not be absorbed.
The liver stores most of vitamin B12. One adequate diet, the
storage in the adult may be sufficient to provide body needs
for as much as 3 to 5years.
DEFICIENCY OF VITAMIN B12
1. Pernicious anemia it is a genetic defect with an absence of
intrinsic factor, so Vitamin B12 in the diet can not be
absorbed, ( the red blood cells are large and reduced in
numbers ) the pt. is complaining of sore mouth, poor
appetite and gastrointestinal disturbances.
2. The nervous system is affected so that the individual
shows poor coordination in walking.
Recommended daily allowances :
FOR : Adult :
3mcg.
Infant :
0.5mcg / 1.5mcg.
Children :
2-3mcg.
During pregnancy and lactating : 4mcg.
F. MINERAL ELEMANT
Milk, eggs, cheese, meat, fish and poultry supply
► Plant food supply no vitamin B12
OVER 20 different minerals can be found in the human body.
Thirteen are essential for life, most of minerals are present in a
small amounts and the total amount in the body is about 4%
of body weight.
FUNCTION
GENERAL FUNCTION OF MINERALS
1. Required for the maturation of the red blood cells in the
born marrow.
2. required for synthesis of protein.
3. Required for metabolism of nervous tissue.
1. Regulate body process e.g. potassium is necessary for
proper functioning of nerves and muscles.
2. Aid in forming structure, e.g. calcium is necessary for
formation of bone.
SOURCES
SCIENCE OF NUTURTION
11
2. PHOSPHORS
TYPES OF MINERALS
a) Macronutrients: these are major elements that occur in the
largest amount:Calcium------------99% in bone and teeth.
Phosphours --------80-90% in bones and teeth.
Potassium---------- Fluid inside cells.
Sulfur--------------- Associated with protein.
Chlorine----------- Fluid outside cells.
Sodium------------- Fluid outside cells.
Magnesium--------- 60% in bones and teeth.
b) Micronutrients: These are found in very small amounts.
Manganese, Copper, Iodine, Fluorine, Zinc.
1. CALCIUM :
FOOD SOURCES
Any kind of milk, fish whole, skim, yogurt, hard cheeses and
butter, turnip green and collards, fruits (oranges)
► N.B. : Meat and Cereal foods are poor of calcium.
FUNCTION
1. It gives the rigidity to the skeleton.
2. It required for complex process of blood coagulation.
3. It regulates the passage of materials into and out of the
cells.
4. It controls the transmission of nerve messages.
5. It aids in the absorption of vitamin B12
DEFICIENCY OF CALCIUM
1. Rickets
2. Bone pain and susceptibility to fracture.
3. Osteoporosis .
4. Periodontal,(changes of the structures of the gums) .
Recommended daily allowances:
The calcium allowance for school children and adult
throughout life is 800mg.
During period of rapid growth in teenagers, during pregnancy
and lactation is 1200mg .
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FOOD SOURCES
Milk, meat, poultry, fish, eggs, yolk and nuts are rich sources.
FUNCTION
1.
2.
3.
4.
It is essential for building bones and teeth.
Regulate the absorption and transport of fats.
Acid-base balance.
It is essential component of ATP, DNA and RNA
3. MAGNESIUM
About 60% of the body magnesium is found in the bones and
teeth.
FUNCTION
1. It regulates nervous irritability and muscle contraction.
2. It activates many enzymes including those involved in
energy metabolism.
Most absorption occurs from the upper gastrointestinal tract.
Recommended daily allowances : Adult : 300-350mg / day.
4. SODIUM, POTASSIUM AND CHLOINE
These mineral are collectivity termed electrolytes because
they are dissolved in water and able to conduct electricity.
Sodium and Chlorine are the chief minerals in the blood
plasma and extra cellular fluid while potassium is the chief
intracellular mineral.
► These are necessary for acid-base and fluid balance
DEFICIENCY OF SODIUM CHLORID
Headache, muscle cramps and vomiting.
DEFICIENCY OF POTASSIUM
Weakness of muscles including skeleton muscle, heart and
respiratory muscles.
12
5. IRON
The content of iron in the adult body is only 3 to 5 gm, most of
iron is present in hemoglobin .
FOOD SOURCES
Meat, eggs yolk, beans, spinach, dark green vegetables,
legumes and nuts .
FUNCTION
PERCENTAGE OF NUTRIENTS IN THE BODY
123456-
Nutrient
CHOs
LIPIDS
PROTIEN
VITAMINS
MINERALS
WATER
Percentage
Less than 1 %
~ 20%
~ 20%
~ very few
~ 4%
~ 65%
It is forms hemoglobin.
Iron is use very economically by the body. When the red blood
cells are destroyed after their life span of about 120 days, the
hemoglobin is break down. The iron that is released is used
over and over again.
Small amounts of iron are lost daily in perspiration, in the
sloughing of the cells from the skin and mucosal membranes,
in the hair and nail clippings and through excretion in the urine.
These losses account for 0.5 to 1 mg iron / day. Menstrual
losses are about 15 to 30 mg / month.
Daily allowances :
The allowances for the well-nourished woman is 18 mg iron
per day, whereas that healthy man is 10 mg. Infants and
children need liberal intakes of iron take care of expanding
blood circulation as grow .
DEFICIENCY OF IRON
Iron deficiency anemia.
Human body contain 300 – 350mg CHO as blood glucose and
glycogen
However these percentages vary from individual to another
e.g. Alean person has lower fat than obese one and e.g. a
baby has more water relative to it is weight than adult .
Energy yielding nutrient :
- CHO
4 Kcal.
- Protein
4 Kcal.
- Lipid
9 Kcal.
Thus, the energy content of food depends on the amount of
CHO, fat and protein that food contains.
Example : Calculate the Kcal in a slice of bread with 1
teaspoon of butter
(15 gm CHO, 2 gm Protein and 5 gm Fat)
15 gm CHO times 4Kcal / gm
2 gm Protein times 4Kcal / gm
5 gm Fat times 9 Kcal /gm
Total
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= 60 kcal
= 8 Kcal
= 45 Kcal
= 113 Kcal
13
Chapter 3
 CHEMICAL DIGESTION
Is the sum of all the changes food undergoes in the alimentary
canal.
The purpose of digestion is to convert food into substance
which can be absorbed in the intestinal tract, e.g.
monosaccharide from carbohydrate , amino acid from protein
and glycerol and fatty acid from fats.
This achieved by mechanical and chemical means
 MECHANICAL DIGESTION
1. chewing which breaks food into smaller pieces and mixes
it with saliva.
2. Churning stomach and intestinal contents so that food
becomes well mixed with digestive juices.
3. Peristalsis which move food through tract .
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fats
DIGESTION
Protein
FOOD
carbohydrates
General
substance
Enzymes
Organ
making
enzyme
Site of
action
substrate
product
Salivary
amylase
Salivary
gland
mouth
Starch(cooked)
Glycogen
Maltose
Pancreatic
amylase
Pancreas
Small
intestine
Starch(cooked)
Glycogen
Maltose
Maltase
Small
intestine
Small
intestine
Maltose
2glucose
sucrose
Small
intestine
Small
intestine
sucrose
1glucose
2fructose
Lactase
Small
intestine
Small
intestine
Lactose
1glucose
1galactos
e
lipase
Pancreas
Small
intestine
Bile emulsified
fats
Fatty acid
and
glycerol
pepsin
stomach
stomach
Proteins
Protease
s and
peptones
Trypsin
Pancreas
Small
intestine
Protein
Proteases
peptones
Amino
acid
peptidase
Small
intestine
Small
intestine
peptides
Amino
acid
14
FATE OF CARBOHYDRATE IN THE BODY
FATE OF FATS IN THE BODY
FATE OF PROTEINS IN THE BODY
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15
 ENERGY
Energy of the body is drive principally from oxidation of food .
MEASUREMENT OF ENERGY
The large calorie (Cal or C) is the unit used for measuring the
heat energy produced by food when oxidized in the body.
NEED FOR ENERGY
Energy is necessary for the work performed by the body.
There are two types of work performed by the body,
involuntary and voluntary .
1. INVOLUNTARY WORK : ( BASAL METABOLISM )
This is the work done by the body in a fasting state and at rest.
Energy is needed for vital life process, e.g. breathing, heart
beat and circulation of blood, kidney function and all chemical
reactions which are constantly taking place in the body .
General factors affecting basal metabolism rate :
1-Surface area:
The greater the surface area the more heat will be given off
and the basal metabolism will be higher.
A tall thin person has a greater surface area then a short fat
person with the same weight and will consequently have a
higher basal metabolic rate.
2-Sex:
The meal has a higher basal metabolic rate than does the
female .
3-Age:
Basal metabolism is highest in periods of active growth. It is
highest during the first and the second years of life and
decreases with age.
The calories necessary for basal metabolism in 14 hr period in
average 25 year old person are listed:Male
1650 C
Female
1400 C
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2. VOLUNTARY WORK :
The energy requirements depend on the type of activity and
increase with the intensity of the work.
Examples of calories required per hour for each pound of the
body weight.
-Bicycling
1.7 C
-Eating meals
0.7 C
-Swimming
4.5 C
-Typing
1C
-Dancing
2.4 C
-Running
4.0 C
-Walking rapidly
2.2 C
Total energy required includes the requirement for energy both
the voluntary and involuntary work of the body .
► Voluntary work : Muscular work is the greatest factor
influencing total energy requirements.
Mental work requires minimal amount energy
► Involuntary work : The requirement for involuntary work
vary according to the general factors affecting basal metabolic
rate i.e., surface area, sex and age. Also affecting energy
requirement for involuntary work are other previously
mentioned factors which increase anabolism or catabolism.
► Other factors can also increase total energy
requirement :
1-Stimulant drugs, e.g., Caffeine, nicotine.
2-Fall in outside temperature.
3-Pregnancy., A rise occurs in the last trimester.
4-Lactation.
5-Specific dynamic action of foods. All foods increase
metabolism but protein foods increase metabolism much more
than do carbohydrates and fats.
► Normal daily calorie requirement :
The normal daily calorie requirements depend on sex, weigh,
activity and age. The following figures represent the
approximate the number of calories necessary to maintain
present weight in a moderately active male and female aged
25 years .
- Male : Weight 154 pound
3080 C
16
- 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 .
EXCESSES AND DEFICIENCIES OF CALORIES
1. OVER WEIGHT ( OBESITY ) :
Obesity is an increase in weight above normal due to a greater
intake of calories from food than expenditure of calories in
energy.
► 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
calories.
►
Endocrine
disorders,
e.g.
hypothyroidism
and
hypopituitarism can cause a weight gain .
2. UNDERWEIGHT ( UNDERNOURISHMENT )
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.
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17
Chapter 4
 HEALTHY EATING DURING ADOLESCENCE
DIET AND
NUTRITION
A.
DIET FOR ADOLESCENT
 WHAT IS HEALTHY EATING ??
Eating health is an important part of a health lifestyle and is
some thing that should be incorporated at a young age and
continued throughout your life. The following are some general
guidelines any dietary changes with your physician or medical
provider.
 Eat three meals a day, with health snacks.
 Increase fiber in the diet and decrease the use of salt.
 Drink a lot of water.
 Eat balanced meals.
 Try to choose baked or broiled foods over fried foods.
 Wash and decrease, if necessary, your sugar intake.
 Eat fruit or vegetables for a snack.
 For children over 5yr use low – fat diatry products.
 Decrease the use of butter and heavy gravies.
 Eat more chicken and fish.
 MAKING-HEALTHY FOOD CHOICES
The food guide pyramid, designed by the United state
department of agriculture ( USDA ) and the US department of
health and human services, is a good guideline to help you eat
a heart healthy diet.
This guide can help you choose to eat a variety of foods while
encouraging the right amount of calories and fat.
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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
need healthy foods to meet their growth needs. Adolescents
tend to eat more meals away from home than younger
children. They are also heavily influence by their peers. Meal
convenience is important to many adolescents and they may
be eating too much of the wrongs kinds of foods ( i.e., soft
drinks, fast food, processed foods).
Further, a common concern of many adolescents is dieting.
Girls may feel an unhealthy pressure from peers to be thin and
to limit what they eat. Both boys and girls may diet to ( make
weight ) for a particular sporting or social event.
 The following are some helpful consideration for
variety and meal choice :
 Encourage exploration about healthy nutrition.
 Meal planning at home should be actively participated in
by all household members.
 Experiment with foods outside your own culture.
 Have several nutritious snack foods readily available.
 Avoid overabundance of unhealthy or (junk) Foods in the
home.
B.
DIET FOR ELDERLY PEOPLE
 ELDERLY DIET AND FIBER
As the body ages, the gastrointestinal tract changes and
people tend to develop more problems with constipation. A
high-fiber diet can prevent that but many elderly people,
especially those with dentures; do not want to eat the seedfilled or crunchy food that is typically high in fiber.
They instead go for soft, slippery food that is easily chewed
but is often high in fat.
18
Cooked or baked vegetables, fresh fruit and high-fiber
breakfast cereals are some denture-friendly ways to get fiber
in the diet. Beans and black-eyed peas are also nutritious and
inexpensive.
 ELDERLY DIET AND FLUIDS
It is important to drink lost of fluids, despite the risk of a leak.
The elderly have decreased thirst and often do not get enough
fluid in their diet as a result. Getting plenty of fluid helps
prevent constipation. The fiber nutritionists recommend is
more effective in decreasing constipation when fluids are
taken generously. Milk, tea, coffee, soda, ice cream and soup
all count as fluids.
 ELDERLY DIET SHOULD BE COMBINED WITH
EXERCISE
Get more physical, not less. The amount of exercise needed
depends on the person, but in general people need to step up
their activity as they get older. Elderly people often do the
opposite because of bad knees or arthritis.
Instead of becoming guarded, they need to walk, bicycle,
swim, garden and find other ways to stay on the move.
 ELDERLY PEOPLE AND CALORIE NEEDS
1-3
4-6
7-10
11-14
15-18
19-59
60-74
75+
As we age our calorie needs decrease due to a drop in muscle
strength from taking less physical activity. However, vitamin
and mineral needs may stay the same or even increase if the
body absorbs them less efficiently.
Male
1230
1715
1970
2220
2755
2550
2350
2100
Female
1165
1545
1740
1845
2110
1940
1900
1810
Calorie
needs
Age group
 FOOD TO INCLUDE FOR OPTIMUM HEALTH
FRUIT
In particular those high in vitamin C, like blackberries,
strawberries, raspberries, blackcurrants, citrus fruit, kiwi fruit,
peaches, mango, cantaloupe melon and apples.
VEGETABLES
In particular vegetables high in vitamin A (beta carotene) and
vitamin C. Carrots, squash, sweet potato, tomatoes, spinach,
kale, collard greens, broccoli, cabbage, Brussels sprouts,
onions leeks and avocado.
OILY FISH
Rich in omega-3 essential fatty acids and high in vitamin E,
like salmon, mackerel, sardines, herring, tuna and trout. Also
white fish in place of red meat.
NUTS AND SEEDS
Rich in omega-3 essential fatty acid and high in vitamin E.
Unsalted nuts, like walnuts, cashews, Brazil nuts and almonds
and seeds like poppy seeds, sunflower, flax seeds and
pumpkin
seeds.
PROTEIN
Eggs, white fish, milk, cheese, yogurt, lean meat, chicken and
beans.
PULSES AND GRAINS FOR FIBER
Including, brown rice, whole wheat bread, wheat germ, whole
wheat cereals, whole wheat crackers.
► Note: These are average values only. Heavier or more
active people may need more.
SCIENCE OF NUTURTION
19
C.
DIET FOR INFANCY
► Infancy : is a period of rapid growth. During the first year
of life, the infant grows and develops far more rapidly than at
any other time in life.
This is evident from the fact that the totally helpless newly born
child, who is completely dependent on the mother or the
caretaker, develops a fair degree of physical and mental
abilities by the first birthday. The child develops the ability of
speech and is able to express himself. He attains a fairly good
motion development and starts walking and holding objects.
By this time he also develops a strong emotional and
psychological relationship with his near and dear ones.
 DIET AND FEEDING PATTERN
To meet the high nutritional requirements of an infants, good
nutrition throughout infancy is very important. The first food for
the infants is mother milk. It is nature's gift for the child and is
the best Suited for the infant's growth and development.
Fortunately even a poorly nourished mother is able to nurse
her child satisfactorily at least during the first few months of
life.
 ADVANTAGES OF BREAST FEEDING
1. Natural method of feeding :
Breast feeding is a simple and a natural method of feeding
which eliminates the need for preparation of a feed and
sterilization of bottles. It is very convenient for both the mother
and child as the milk is available at all times and at right
temperature with no worries about the quantity.
2. Nutritionally tailor made for the body :
Breast milk provides almost all the nutrients to the infants that
are adequate enough to meet his requirement. It has adequate
amount of fat which is highly emulsified and is therefore better
digested. Lactose present in breast milk provides natural
sweetness and also helps in calcium and iron absorption. Low
amount of protein in mothers milk reduced pressure on infants
kidneys to extreme extra nitrogen. Vitamin C content is
SCIENCE OF NUTURTION
retained as it is not destroyed by heating which happens in
case of cows milk.
3. Anti-infection properties:Breast milk is a very hygienic method of feeding as the milk
goes straight from the mother's breast to the child's mouth,
reducing the chances of contamination and infection which are
plenty in case of artificially fed infants. Breast milk contains
antistaphylococcal factor which prevents the growth of bacteria
in the infants intestines the gastric juice of breast fed infants is
more acidic and this destroys any microorganism that may
enter the stomach.
4. Source of natural immunity:The secretion from the mother's breast for the first 2 to 3 days
is a thick yellowish liquid known as colostrums. This
colostrums contains certain antibodies, which develop natural
immunity in the child, thus protecting him from various
infectious diseases. Besides providing antibodies, colostrums
is also rich in certain nutrients and should nerve be discarded
but fed to the newborn.
5. Anti-allergic properties:Cow's milk contains lactglobulin and serum bovine which may
cause allergy in some infants. As these are not present in
mother's milk, there is no danger of allergy with breast milk.
6. Psychological advantages:Breast feeding is most conducive for a health, happy and
emotional relationship between the mother and her newly born
baby.
DO YOU KNOW ????
- As per documented evidence, infants grow well on
exclusive breast feeding for the first 4 to 6 months of life.
- During this period, the baby does not even need water
supplements, as breast milk provides enough water even for
the hot summer months.
- In fact water supplements may be unhygienic and also the
sucking of breast by reduced thereby diminishing the breast
20
milk output.
When introducing new foods the following points to be
kept in mind :
 Only one food be introduced at a time .
 Consistency of foods as per child's age i.e. for very young
infants, liquid to semi solid and then to solid with advancing
age of child.
 Food is given in small quantities in the beginning and the
amount gradually increased as child develops a likes for
the food.
 Never force feed a child. If the child dislikes a particular
food, remove it from his/her diet and reintroduce it a later
age. If the disliking persists then think of a substitute for it.
 Don’t give spicy foods and also avoid fried ones.
 Include variety to make food more appealing.
 As child grows older, attract his/her attention by giving
consideration to color, flavor, texture and shape of food.
 To inculcate good eating habits in a child, parents should
not show personal prejudices and dislike towards any
foods
 It is not always necessary to cook separately for the child,
as the family meals can be easily modified in consistency,
spicing, etc, for the amount needed for to feed the child.
NUTRITION FOR PRESCHOOLERS
Recommendations to health and child care professionals
► Child care is a shared responsibility. Everyone who cares
for children has an important role in promoting their nutritional
health.
► The nutritional of young children begins with the attention
paid by parents and caregivers to providing a healthy diet and
food experiences which foster healthy eating patterns. To
promote nutritional health during preschool years, health and
child care professionals can do the following :
1. Enable parents and child care providers a healthy diet to
preschool children.
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2. Help parents and child care providers to foster food
attitudes and eating practices which promote health.
3. Further the development of programs and policies which
advance nutritional health for the preschool population.
1) PROVIDING
A
PRESCHOOLERS
HEALTHY
DIET
FOR
1- Provide a healthful variety of foods recommended food
guide and in amounts appropriate to the needs of the
individual preschooler.
2- Apply the principle of moderation in selecting foods outlined
in the nutrition.
3- Ensure a gradual transition from the milk-predominant
infants diet to family foods.
4- help preschoolers determine the quantity of food they can
eat. Allow self-selection of amounts when possible or offer
child-sized portions with the opportunity for seconds.
5- Recognize the need of most preschoolers to eat small
amount of food frequently throughout the day. On a daily
basis, this requirement most commonly means three meals
with a snack between meals. Snacks should contribute to both
nutritional and dental health.
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
promote a positive self-image in preschoolers.
8- Encourage physical activity and set limits on sedentary
activities, especially television viewing.
9- Consult appropriate health professionals when deviations in
normal growth and development are suspected or when
unusual food patterns persist.
10- Protect preschoolers against hazards associated with
food, such as choking and food-borne illness.
11- Recognize that routine administration of vitamin-minerals
supplements is not advised and that the preschoolers
physician should be consulted before any vitamin-minerals
supplement is used.
21
2) FOSTERING POSITIVE FOOD ATTITUDES AND
EATING PRACTICES
Parents and child care providers should be supported in their
efforts to:
1- Establish a positive feeding relationship which sets
reasonable limits while supporting the development of the
preschooler's food preference and food choice skills.
2- Make available and offer a variety of nutritious foods within
the framework of the family's cultural heritage, lifestyle and
resources.
3- Identify and respond to cues from the preschooler that
indicate when the child is hunger and satisfied, with and
understanding that fluctuations in appetite are normal at this
age.
4- Encourage self-feeding and support increasing
independence in eating.
5- Respect the individual food preference of preschoolers
while encouraging them to experience and enjoy eating
deferent foods.
6- Appreciate the strong influence parents and caregivers
have as role models in instilling healthy food practices.
7- Avoid using food in emotion-laden contexts such as to
control or manage the preschooler's behavior.
8- Provide opportunities for the preschooler to learn about the
nature of food and to value its role in achieving health.
9- Provide the preschooler with opportunities to discuss claims
promoting foods and to acquire decision-making skills related
to food selection at home and in the marketplace.
3) DEVELOPING PROGRAMS AND POLICIES TO
PROMOTE NUTRITIONAL HEALTH
Health and child care professional involved in designing and
delivering programs and developing policy related to the health
of preschoolers should:
1- Recognize that accessible, affordable, personally
acceptable and nutritionally adequate food is essential to
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support the growth, development and health of preschoolers.
2- Award high priority to good nutritional care in the
development and ongoing delivery of quality child care
services. In supervised child care settings, standards should
be established where they do not exist for evaluating the
nutritional quality of the food served and promoting mealtimes
and snack times as opportunities to instill positive attitudes
toward food and healthy eating practices.
3- Direct nutrition programs to preschoolers and their parents.
Consider especially those disadvantage families most
vulnerable to inadequate nutrition whether due to economic,
social or environmental deprivation or physical and mental
handicap. Strategies using self-help and mutual aid and
comment-based models should be pursued.
4- Design and delivery innovative nutrition education programs
that enable child care providers, in both supervised and
informal child care settings, to promote the nutritional health of
children in their care.
5- Consider, in health assessment of preschoolers, the many
factors in the family, community and society which act as
opportunities for or barriers against healthy eating during
preschool years.
6- Incorporate nutritional health during preschool years as an
integral component of health promotion and disease
prevention programs delivered nationally and regionally.
7- Support efforts by health professionals to identify those
children aged 2 years and over at risk for the major dietrelated chronic disease so that age-appropriate action may be
taken to decrease risk in later life.
8- Promote more research on nutrition-related issues of
preschoolers. Specific topics in need of research and
development are:
► Parameters of an optimum diet during childhood to
support normal growth and development and prevent
development of chronic disease
► estimates of energy and nutrient requirements of
22
children aged one through five years to further substantiate
the recommended nutrient intakes for Canadians.
► Identification of risk factors in early childhood related to
the development of major chronic disease such as
cardiovascular.
► Nutritional assessments of preschoolers living in poverty
and development of appropriate intervention strategies.
► Development of screening tools for nutritional
assessment of preschool populations.
► Development of appropriate growth standards and
standards for health body weights for preschool children.
► Development of effective nutrition education techniques
for promoting nutrition during preschool.
Chapter 5
TOTAL PARENTERAL
NUTRITION ( TPN )
INDICATIONS FOR TOTAL PARENTERAL
NUTRITION ( TPN )
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
syndrome.
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
SCIENCE OF NUTURTION
23
administration of parenteral nutrition. The roles of various
members of the nutrition support team are described as well
as indications for use of nutrition support.
► Some patients are unable to eat; therefore nutritional
support is an important part of their care. The decision for how
the nutritional needs of the patients will be met is determined
by the physician. Although feeding by the gastrointestinal tract
is preferred, certain individuals cannot be supported in this
way.
► A centrally placed catheter is essential for TPN to be
infused into the patient. These catheters are usually divided
into the nontunneled catheters, tunneled catheters and the
implanted ports.
NON-TUNNELED CATHETER
1- They are usually placed in the subclavian, jugular or femoral
for a short term therapy of < 8 weeks. These catheters are
rarely used for home TPN.
2- Insertion of these catheters should be done with sterile
technique but can be done at the patient's bedside.
3- Once the catheter is inserted, a stat portable chest X-ray
should be taken. This assures the physician of correct
placement of the catheter and the absence of insertion
complications. The tip of the catheter must be in the superior
or inferior vena cava to infuse TPN through the catheter.
4- Single lumen a catheter is recommended because of the
decreased risk of infection although multiple lumen catheters
can be used. If multiple lumen catheters are used, the lumen
used to administration TPN must be a lumen where no other
solutions could have contaminated the lumen.
TUNNELED CATHETER
1-These catheters are more commonly known as Hickman's,
Groshongs, Broviac, etc., which are brand names for these
catheters.
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2- They are placed in patients that need more of a long term
therapy. They are placed either in the procedure room in the
clinic or in the operation room.
3- These catheters are made of silicone. They are placed most
commonly in the chest area. The catheter is tunneled under
the skin and enters a large vein and then is threaded into the
superior vena cava.
IMPLANTED PORTS
1- These catheters are placed in the procedure room of the
clinic or in the operating room. It is used for more intermittent
therapies but can be used for TPN infusion both in the hospital
and in the home setting.
2- The septum of these catheters is sutured under the skin in
the subcutaneous tissue. The silicone catheter that attaches to
the septum is then threaded into a major vein.
CENTRAL LINE IS INDICATED FOR
INFUSION OF
( TPN )
INFUSION
1. The amino acids and dextrose solution with additives is
mixed in a one bag per day system at the UT Hospital and
Clinics. The fat emulsions are a separate solution, which
are added to the intravenous tubing at the designated
connection.
2. Starting and weaning the TPN should be done gradually.
The starting rate should be no more than 50cc / hr for 4-6
hr. The rate can be increased 25% every 4-6 hr. Weaning
is accomplished by decreasing the rate by 25% every 4-6
hr.
3. Blood glucose monitoring is recommended every 6hr after
TPN initiation.
24
and number of lumens of the central venous catheter.
SUGGESTED DAILY ELECTROLYTE INTAKE
1- Potassium
2- Sodium
3- Calcium
4- Magnesium
5- Chloride
6- Phosphate
50-80mEq/ day.
60-120mEq/day.
8-20mEq/ day (160-400mg)
10-30mEq/ day (120-360mg)
100-120mEq/ day.
12-30mmol/ day (463-927 mg)
DRESSING CHANGE
1- Central venous dressing should be changed at least once a
week or more frequently based on pt. condition/ need.
2- Initial dressing change should be completed within 48hrs
after placement of catheter.
3- Medical aseptic technique is absolutely essential in the
management of parenteral nutrition therapy administration and
catheter care.
ADMINISTRATION
1. The parenteral nutrition tubing should be treated as a
closed system. Only after consideration for alternative
entries into the system are explored, should the parenteral
nutrition catheter lumen be accessed for other uses.
2. TPN should always be given via an infusion pump.
3. The pharmacist may be consulted regarding drug
compatibility for simultaneous administration of 2 or more
drugs through a single lumen of the catheter.
4. Avoid the use of stopcocks and/ or the administration of
blood products into the lumen designated for parenteral
nutrition.
HEPARIN FLUSH
1. When parenteral nutrition infusion is being cycled, a
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
SCIENCE OF NUTURTION
COMPLICATION WITH CENTRAL VENOUS
CATHETER AND ( TPN )
1. Sepsis should be assessed by taking patients temperature
at least twice/day.
2. Local infection needs to be assessed during every dressing
change.
3. The patient should be weighed and intake and out-put
monitored to assess for fluid imbalance.
4. Blood sugars should be obtained to assess the patient for
hypo/hyperglycemia.
5. Resistance to flushing may be corrected with the use of
Urokinase instilled into the catheter.
6. Thrombosis should be suspected if the patient complains of
pain or swelling in the extremity or surrounding area on
side where the catheter is located. Leakage at catheter
insertion site may also occur. Venogram is needed to
confirm a thrombosis.
STANDARD TPN SOLUTION
1- Recommended for general use since it can fulfill most
patients nutritional requirements and be cost effective.
2- Final concentration is 4.25% amino acids and 25%
dextrose.
3- Calorie: nitrogen ratio is 125:1 this is a 1Kcal/cc solution.
ADDITIVES
1- Electrolytes are included when ordering the standard TPN
solution. It is possible to order an electrolyte-free solution and
then order the more appropriate electrolytes for the patient.
Compatibility can be a problem when adding certain
electrolytes together. A pharmacist should be contracted if this
need arises.
25
A.
B.
C.
D.
E.
F.
G.
Sodium ( mEq/L )
Potassium
Calcium
Magnesium
Chloride
Phosphate
Acetate
Standard
Electrolyte
35
30
5
5
47-50
14.3
67-74
Electrolyte Free
0
0
0
0
17-20
0
37-44
2- Vitamins
a) Standard multivitamin additive is MVI-12 ands should be
added every day .
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
vitamin C ( ascorbic acid )
Vitamin A ( retinol )
Vitamin D( ergocalciferol )
Vitamin B1 ( thiamine)
Vitamin B2 ( riboflavin)
Vitamin B6 ( pyridozine HCL)
Niacinamide.
Pantothenic acid
Vitamin E
Biotin
folic Acid
Vitamin B12
100 mg
3300 I.U.
200 I.U.
3 mg
3.6 mg
4 mg
40 mg
15 mg
10 I.U.
60 mcg
400 mcg
5 mcg
b) Vitamin K 10mg needs to be added every week .
3- Trace elements
a- Zinc
5mg
b- Copper
1 mg
c- Manganese
0.5 mg
d- Chromium
1-0 mcg
e- Selected patients may require zinc and selenium
supplementation .
4- Insulin can be added to the TPN bag if needed to minimize
hyperglycemia.
5- Heparin is not routinely used at the UI hospital and clinic s
in the TPN bags as there is no strong evidence to support that
SCIENCE OF NUTURTION
it reduces vein thrombosis.
6- Lipids
a) Used as a calorie source and to prevent fatty acid
deficiency.
b) Fat emulsions are available vas a 10% product which is
1.1 Kcal/cc and a 20% product which is 2.0Kcal/cc.
c) A three-in-one (3-in-1) mixture in which the fat emulsion is
mixed in with the TPN is not available at the UI hospitals
and clinics .
7- Medications should not beaded routinely to the TPN
unless it is necessary and they are compatible with the TPN .
SOLUTION FOR RENAL FAILURE
1- Patients with renal failure need a balance of both essential
and nonessential amino acids.
2- Nephramine:a. Contains only essential amino acids.
b. Recommended only to decrease net urea synthesis for
short periods of time.
c. Close monitoring of serum ammonia levels is important.
3- In order to restrict fluid, it is possible to increase the
concentration of dextrose and fat emulsion.
SOLUTION FOR LIVER FAILURE
1. Patients with chronic liver disease are usually
malnourished. They are prone to complications such as
gastrointestinal bleeding and infection that compromise
nutritional status.
2. Standard TPN should be used if the patient doses not have
hepatic encephalopathy.
3. Hepatamine can be used with patients with hepatic
encephalopathy. It is a liver-specific amino acid mixture.
SOLUTION FOR THE CATABOLIC
PATIENT
26
1- Metabolic response to injury, burn or sepsis generates a
neuron endocrine response that induces hyper metabolism,
proteolysis, insulin resistance with hyperglycemia and a
depletion of lean body mass.
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/
kg/day.
4- Nitrogen balance.
ROLE OF
MEMBERS
NUTRITION
SUPPORT
the patient if the bowel is capable of handling the delivery and
absorption of nutrients. If the patient is willing and able to eat,
feeding can be accomplished by mouth; however, if this is not
possible a feeding tube could be placed into the GI tract
**********************
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
values.
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.
ENTERAL NUTRITION
Complete or partial enteral feeding should be considered for
SCIENCE OF NUTURTION
27