Nutrition Essentials For Nursing Practice 9th Edition - Susan Dudek

Nutrition Essentials
for Nursing Practice
SUSAN G. DUDEK, RD, CDN, BS

Former Nutrition Instructor, Dietetic Technology Program
Erie Community College
Williamsville, New York
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Ninth edition
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Library of Congress Cataloging-in-Publication Data
Names: Dudek, Susan G., author.

Title: Nutrition essentials for nursing practice / Susan G. Dudek, RD, CDN, BS, Former Nutrition
Instructor, Dietetic Technology Program, Erie Community College Williamsville, New York.
Description: Ninth edition. | Philadelphia, PA : Wolters Kluwer, [2022] | Includes bibliographical
references and index.
Identifiers: LCCN 2021014575 | ISBN 9781975161125 (hardback) | ISBN 9781975161125
Subjects: LCSH: Diet therapy. | Nutrition. | Nursing. | BISAC: MEDICAL / Nursing / Nutrition
Classification: LCC RM216 .D8627 2022 | DDC 615.8/54--dc23
LC record available at https://lccn.loc.gov/2021014575
Care has been taken to confirm the accuracy of the information presented and to describe generally
accepted practices. However, the author, editors, and publisher are not responsible for errors or
omissions or for any consequences from application of the information in this book and make no
warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the
contents of the publication. Application of this information in a particular situation remains the
professional responsibility of the practitioner; the clinical treatments described and recommended
may not be considered absolute and universal recommendations.
The author, editors, and publisher have exerted every effort to ensure that drug selection and
dosage set forth in this text are in accordance with the current recommendations and practice at the
time of publication. However, in view of ongoing research, changes in government regulations, and
the constant flow of information relating to drug therapy and drug reactions, the reader is urged to
check the package insert for each drug for any change in indications and dosage and for added
warnings and precautions. This is particularly important when the recommended agent is a new or
infrequently employed drug.
Some drugs and medical devices presented in this publication have Food and Drug Administration
(FDA) clearance for limited use in restricted research settings. It is the responsibility of the health
care provider to ascertain the FDA status of each drug or device planned for use in his or her clinical
practice.
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Dedicated to
All the people who on a personal or professional level made my initial
dream of writing a book into a nine-edition-long reality. It has been a
rewarding journey of teaching and learning, for which I am eternally
grateful.
Reviewers
Claire Creamer, PhD, APRN-CPNP-PC

Associate Professor
Rhode Island College
Providence, Rhode Island
Claudia Kelley, PhD, RD, RN, CCS, CDE
Instructor
Los Angeles Mission College
Sylmar, California
Susan Kessler, RD, CDN, CHES
Senior Adjunct Professor
Adelphi University
Garden City, New York
Candace Pierce, DNP, RN, CNE
Assistant Professor
Troy University
Montgomery, Alabama
Colleen Tracy Snell, RN, MS
Faculty
Anoka-Ramsey Community College
Champlin, Minnesota
Stephanie R. Stewart, MSN, RN-BC
Associate Professor of Nursing
Missouri Western State University
St. Joseph, Missouri
Chantal Wolfe, MS, RDN, CSG, LDN, CLC
Pennsylvania College of Technology
Williamsport, Pennsylvania
Preface
Like air and sleep, nutrition is a basic human need, essential for survival.
From curing hunger to reducing the risk of chronic disease, nutrition is ever
changing in response to technological advances and cultural shifts. Because
nutrition at its most basic level is food—for the mind, body, and soul—it is
a complex blend of science and art.
Although considered the realm of the dietitian, nutrition is a vital and
integral component of nursing care across the life cycle and along the
wellness–illness continuum. By virtue of their close contact with clients and
families, nurses are often on the frontline in facilitating nutrition. Nutrition
is woven into all steps of the nursing care process, from assessment and
nursing analysis to implementation and evaluation. This textbook seeks to
give student nurses an essential nutrition foundation to better serve
themselves and their clients.
NEW TO THIS EDITION

This ninth edition of Nutrition Essentials for Nursing Practice has been
reformatted to reflect the way students want to access information: quickly
and concisely. To improve clarity and succinctness, bullet points are used
where appropriate to present details. The depth of content is limited to what
the nurse needs to know in an effort to avoid overwhelming the reader with
unnecessary information. Some content has been reorganized to facilitate
these changes.
• Content is updated throughout and reflects available evidence-based
practice. In addition to the Dietary Guidelines for Americans 2020–
2025, new guidelines or consensus reports included are those on
nutrition therapy for adults with diabetes or prediabetes, guidelines
on the primary prevention of cardiovascular disease, guidelines for
the prevention and management of hypertension in adults, practice
guidelines for obesity, and guidelines on nutrition in cancer care.
• The Table of Contents has been expanded to include a heading
outline of each chapter.
• Concept Mastery Alerts clarify fundamental nursing concepts to
improve the reader’s understanding of potentially confusing topics, as
identified by Misconception Alerts in Lippincott’s Adaptive Learning
Powered by prepU. Data from thousands of actual students using this
program in courses across the United States identified common
misconceptions that are clarified in this feature.
• Chapter 1 shifts from “Nutrition in Health and Health Care” to
“Nutrition in Health.” This chapter begins with recommended intake
standards for nutrients and progresses to the relationship between
nutrition and health, the importance of healthy eating, the concept of
lifestyle medicine, and the future of nutrition research.
• The chapter entitled “Guidelines for Healthy Eating” is repositioned
from Chapter 8 in the eighth edition to Chapter 2 in the ninth. This
move improves the flow of content and provides the foundation for
the chapters on nutrients that follow.
• Throughout the book, the focus on healthy eating patterns, such as the
Mediterranean-style Eating Pattern and the DASH (Dietary
Approaches to Stop Hypertension) diet, reflects the direction of
nutrition guidelines and the widespread applicability of these patterns
across the continuum of health and disease.
• In Chapter 9, “Food and Supplement Labeling,” new content has
been included on cannabidiol and labeling regulations regarding
allergens, gluten, and country of origin.
• Adolescent pregnancy is moved from Chapter 13, “Nutrition for
Infants, Children, and Adolescents,” in the eighth edition to Chapter
12 in the ninth, “Healthy Eating for Healthy Babies.”
• Healthy eating patterns promoted for healthy aging, namely the
Mediterranean-Style Eating Pattern and the MIND diet, are added to
Chapter 14, “Nutrition for Older Adults.”
• The importance of consuming appropriate calories to attain and
maintain healthy weight is emphasized throughout the units on health
promotion and clinical practice (Chapters 9–24). This emphasis
reflects the current prevalence of obesity and its significance as a
major modifiable risk factor for chronic disease.
• Nursing analysis statements feature a nutrition problem, etiology of
the problem, and the signs and symptoms of the problem. Because the
priority in clinical nutrition is to prevent or treat malnutrition, risk of
malnutrition is repeatedly cited as a nutrition problem throughout the
unit on clinical nutrition.
• The Chapter Summary at the end of each chapter replaces the Key
Concepts of the eighth edition. The straightforward outline format
highlights the most salient information.
ORGANIZATION OF THE TEXT

The number of chapters has expanded from 22 to 24, by separating two
large chapters into smaller chapters. “Consumer Issues” has been divided
into “Food and Supplement Labeling” and “Consumer Interests and
Concerns.” A new separate chapter entitled “Enteral and Parenteral
Nutrition” has been split from “Hospital Nutrition: Defining Nutrition Risk
and Feeding Patients.” These smaller chapters in the ninth edition are more
cohesive and focused than their larger predecessors.
The chapters are organized into three units. Unit One is entitled
“Principles of Nutrition.” It flows from “Nutrition in Health” to
“Guidelines for Healthy Eating” followed by chapters covering the six
classes of nutrients—carbohydrates, protein, lipids, vitamins, water, and
minerals. The health promotion section of each of these nutrient chapters
explains why and how Americans are urged to shift their eating patterns to
reduce the risk of chronic disease. The final chapter in this unit, “Energy
Balance,” explains how calorie needs are estimated, how body weight is
evaluated, and strategies for balancing calorie intake with expenditure.
Unit Two, “Nutrition in Health Promotion,” begins with Chapter 9,
“Food and Supplement Labeling.” Other chapters in this unit examine
consumer interests, issues of food access, and cultural and religious
influences on food and nutrition. The nutritional needs and concerns
associated with the life cycle are presented in chapters devoted to pregnant
and lactating women, infants, children and adolescents, and older adults.
Unit Three, “Nutrition in Clinical Practice,” begins with “Hospital
Nutrition: Defining-Nutrition Risk and Feeding Clients,” which covers
nutrition screening, nutrition in the nursing process, oral diets, and oral
nutrition supplements. The chapter on enteral and parenteral nutrition
follows. The unit continues with nutrition for obesity and eating disorders,
critical illness, gastrointestinal disorders, diabetes, cardiovascular disorders,
renal disorders, cancer, and HIV/AIDS. Pathophysiology is tightly focused
as it pertains to nutrition.
FEATURES
This edition of Nutrition Essentials for Nursing Practice incorporates
popular features to facilitate learning and engage students.
• Unfolding Cases present relevant nutrition information—in real-life
scenarios—to provide an opportunity for students to apply theory to
practice. Questions regarding the scenarios offer critical thinking
opportunities for the student.
• Key Terms are defined in the margin for convenient reference.
• Concept Mastery Alerts clarify common misconceptions as
identified by Lippincott’s Adaptive Learning Powered by prepU.
• Nursing Process tables clearly present sample application of
nutrition concepts in the context of the nursing process.
• How Do You Respond? helps students identify potential questions
they may encounter and prepares them to think on their feet.
• Review Case Study along with the Study Questions challenge
students to apply what they have learned.
• Chapter Summaries outlines the most important information from
each chapter.
TEACHING AND LEARNING RESOURCES
To facilitate mastery of this textbook’s content, a comprehensive teaching
and learning package has been developed to assist faculty and students.
Lippincott® CoursePoint is an integrated, digital curriculum solution for

nursing education that provides a completely interactive and adaptive
experience geared to help students understand, retain, and apply their
course knowledge and be prepared for practice. The time-tested, easy-to-
use, and trusted solution includes engaging learning tools, case studies, and
in-depth reporting to meet students where they are in their learning,
combined with the most trusted nursing education content on the market to
help prepare students for practice. This easy-to-use digital learning solution
of Lippincott® CoursePoint, combined with unmatched support, gives
instructors and students everything they need or course and curriculum
success!
Lippincott® CoursePoint includes the following:
• Engaging course content provides a variety of learning tools to
engage students of all learning styles.
• Adaptive and personalized learning helps students learn the critical
thinking and clinical judgment skills needed to help them become
practice-ready nurses.
• Unparalleled reporting provides in-depth dashboards with several
data points to track student progress and help identify strengths and
weaknesses.
• Unmatched support includes training coaches, product trainers, and
nursing education consultants to help educators and students
implement CoursePoint with ease.
Resources for Instructors

Tools to assist you with teaching your course are available upon adoption of
this textbook at https://thePoint.lww.com/Dudek9e.
• A Test Generator lets you put together exclusive new tests from a
bank containing hundreds of questions to help you in assessing your
students’ understanding of the material. Test questions link to chapter
learning objectives.
• PowerPoint Presentations provide an easy way for you to integrate
the textbook with your students’ classroom experience, either via
slide shows or handouts. Multiple-choice and true/false questions are
integrated into the presentations to promote class participation and
allow you to use i-clicker technology.
• An Image Bank lets you use the photographs and illustrations from
this textbook in your PowerPoint slides or as you see fit in your
course.
• Answers to Unfolding and Review Case Studies
• QSEN Map
Resources for Students

An exciting set of free resources is available to help students review
material and become even more familiar with vital concepts. Students can
access all these resources at https://thePoint.lww.com/Dudek9e using the
codes printed on the front of their textbooks.
• Concepts in Action Animations bring physiologic and
pathophysiologic concepts to life.
• Answers to Unfolding and Review Case Studies from the text.
• Learning Objectives from the text.
• Spanish–English Audio Glossary.
I hope this textbook and teaching/learning resource package provide the
impetus to embrace nutrition on both a personal and a professional level.
Susan G. Dudek, RD, CDN, BS

Acknowledgments
When I wrote the first edition of this book, I never imagined that the
privilege would extend through nine editions. I am both humbled and
thankful for the opportunity to do what I love—write, create, teach, and
learn. It amazes me how much our understanding of nutrition evolves from
one edition to the next. This project has been professionally rewarding,
personally challenging, and rich with opportunities to grow.
• In large part, the success of this book rests with the dedicated and
creative professionals at Wolters Kluwer. I especially thank Jonathan
Joyce, Acquisitions Editor
• Rebecca J. Rist, Associate Development Editor
• Oliver Raj, Editorial Coordinator
• Stephen Druding, Design Manager
• Jennifer Clements, Art Director
I also appreciate the insightful comments and suggestions from the
reviewers of the eighth edition that helped shape a new and improved
edition.
And above all I thank my husband, Joe, who has been with me at every
step of every edition with support, encouragement, and patience. Love you
always.
Contents
UNIT Nutrition
ONE
Fundamentals
1 Nutrition in Health
Dietary Reference Intakes
From Nutrients to Food
Nutrition and Health
2 Guidelines for Healthy Eating

Dietary Guidelines for Americans
MyPlate
Recommendations from Health Agencies
Eating Behaviors Americans are Trying to Improve
Guidelines and Graphics in Other Countries
3 Carbohydrates
Carbohydrate Classifications
Sources of Carbohydrates
How the Body Handles Carbohydrates
Functions of Carbohydrates
Carbohydrates in Health Promotion
4 Protein
Protein Composition and Structure
Functions of Protein
How the Body Handles Protein
Sources of Protein
Protein in Health Promotion
5 Lipids
Triglycerides
Other Lipids
Functions of Fat in the Body
How the Body Handles Fat
Sources of Fat
Fat in Health Promotion
6 Vitamins
Understanding Vitamins
Vitamin Classifications Based on Solubility
Vitamins in Health Promotion
7 Water and Minerals

Water
Fluid and Electrolyte Balance
Understanding Minerals
Major Electrolytes
Major Minerals
Trace Minerals
Water and Minerals in Health Promotion
8 Energy Balance
State of Energy Balance
Estimating Total Calorie Requirements
Evaluating Weight Status
Energy Balance in Health Promotion
UNIT
TWO
Nutrition in Health Promotion
9 Food and Supplement Labeling
Food Labeling
Dietary Supplements
10 Consumer Interests and Concerns

Consumer Information and Misinformation
Consumer-Related Interests
Food Access
11 Cultural and Religious Influences on Food and

Nutrition
American Cuisine
The Effect of Culture
Cultural Subgroups in the United States
Traditional Diets
Food and Religion
12 Healthy Eating for Healthy Babies
Prepregnancy Nutrition
Nutrition and Lifestyle During Pregnancy
Nutrition for Lactation
13 Nutrition for Infants, Children, and Adolescents

Infancy (Birth to 1 Year)
Nutrition During Early Childhood (1–5 years)
Nutrition for Children (6–10 years) and Adolescents (11–18 years)
Overweight and Obesity
14 Nutrition for Older Adults

Aging and Older Adults
Nutritional Needs of Older Adults
Healthy Aging
Nutrition and Health Concerns of Older Adults
UNIT Nutrition in Clinical Practice

THREE
15 Hospital Nutrition: Identifying Nutrition Risk and

Feeding Clients
Malnutrition
Nutrition Assessment
Nutrition in the Nursing Process
Feeding Hospitalized Clients
16 Enteral and Parenteral Nutrition

Enteral Nutrition
Parenteral Nutrition
17 Nutrition for Obesity and Eating Disorders

Obesity
Management of Overweight and Obesity
Weight-Loss Therapies
Eating Disorders: Anorexia Nervosa, Bulimia Nervosa, Binge-Eating
Disorder, and Eating Disorders Not Otherwise Specified
18 Nutrition for Clients with Critical Illness

Stress Response
Nutrition Support
Burns
Acute Respiratory Distress Syndrome
19 Nutrition for Clients with Upper Gastrointestinal
Tract Disorders
Disorders That Affect Eating
Disorders of the Esophagus
Disorders of the Stomach
20 Nutrition for Clients with Disorders of the Lower

Gastrointestinal Tract and Accessory Organs
Altered Bowel Elimination
Malabsorption Disorders
Conditions of the Large Intestine
Disorders of the Accessory Gastrointestinal Organs
21 Nutrition for Clients with Diabetes Mellitus

Diabetes
Lifestyle Management
Acute Diabetes Complications
Sick-Day Management
Life-Cycle Considerations
22 Nutrition for Clients with Cardiovascular Disorders

Cardiovascular Health
Secondary Prevention of Cardiovascular Diseases
23 Nutrition for Clients with Kidney Disorders

Nutrition in Maintaining Kidney Health
Nephrotic Syndrome
Chronic Kidney Disease
Acute Kidney Injury
Kidney Stones
24 Nutrition for Clients with Cancer or HIV/AIDS

Cancer
HIV and AIDS
APPENDIX
Answers to Study Questions
INDEX
UNIT ONE
Nutrition Fundamentals
Chapter Nutrition in Health
1
Tyrone Green
Tyrone is a 46-year-old national account executive who
spends 4 out of 5 weekdays traveling on business. He was
recently diagnosed with prediabetes and hypertension,
which are two of the five diagnostic components of
metabolic syndrome, which increases the risk of diabetes
and cardiovascular disease. He blames his 25-pound
weight gain on eating out while traveling.
Learning Objectives
Upon completion of this chapter, you will be able to:
1 Describe the five sets of reference standards that make up the Dietary
Reference Intakes.
2 Explain what the Recommended Dietary Allowances represent.
3 Describe characteristics of eating patterns associated with positive health
outcomes.
4 Describe characteristics of eating patterns associated with detrimental health
outcomes.
5 Discuss diet quality in the United States.
6 Define the purpose of Healthy People 2030.
7 Name four modifiable lifestyle risk factors for chronic disease.
8 Describe the characteristics of lifestyle medicine.
9 State potential future benefits of nutrigenomics.
Food is a complex mix of essential and nonessential components in various ratios

and combinations. Essential nutrients, such as most vitamins, minerals, amino
acids, fatty acids, and water, must be obtained through food because the body
cannot make them. Plants provide fiber and a variety of nonnutrient compounds
that have health-enhancing biological properties in the body. These beneficial
nonnutrient compounds are known as phytonutrients.
When nutrition was a young science, the focus of healthy eating was to
consume enough of all essential nutrients to avoid deficiency diseases. Today,
nutrient deficiency diseases are generally rare in the United States except among
specific population subgroups such as seniors, alcoholics, fad dieters, and
hospitalized patients. In fact, several of the leading causes of death in the United
States are associated with dietary excesses—namely, heart disease, cancer, stroke,
and diabetes. Many other health problems, such as obesity, hypertension, and
hypercholesterolemia, are related, at least in part, to dietary excesses. Although
Americans in general are overconsuming some nutrients (e.g., saturated fat,
sodium, sugar), other nutrients that are important for maintaining health (e.g.,
calcium and vitamin D) are being under-consumed. The current focus of nutrition
is to reduce the risk of chronic diseases by improving overall dietary patterns.
Lifestyle medicine is a medical specialty devoted to preventing and treating
chronic disease through lifestyle changes.
Nutrients
chemical substances used by the body that are necessary for life and growth. Nutrient classes are
carbohydrates, proteins, fats, vitamins, minerals, water.
This chapter begins with nutrient recommendations. The relationship between

nutrition and health includes a discussion of characteristics of healthy and
detrimental eating patterns, diet quality in the United States, Healthy People 2030,
and the role of nutrition in chronic disease. Lifestyle medicine and nutritional
genomics are presented.
DIETARY REFERENCE INTAKES

Dietary Reference Intakes (DRIs) are a collection of dietary reference standards
that estimate nutrient intakes necessary to ensure that healthy populations meet
nutrient needs to maintain health and prevent deficiency diseases (Institute of
Medicine, 2006). For each essential nutrient, research studies were reviewed to
help establish standards of adequacy and toxicity based on age and sex. Each
reference value is viewed as an average daily intake over time, at least one week
for most nutrients.
Dietary Reference Intakes (DRIs)
a set of five nutrient-based reference values used to plan and evaluate diets.
The four original DRI nutrient-based standards are the Recommended Dietary
Allowances (RDAs), Estimated Average Requirement (EAR), Adequate Intake
(AI), and Tolerable Upper Intake Level (UL). Each of these reference values has a
specific purpose and represents a different level of intake (Fig. 1.1). Nutrients
have either an RDA or an AI; not all nutrients have an established UL (Table 1.1).
Additional reference sets that pertain to calories are Acceptable Macronutrient
Distribution Ranges (AMDR) and the Estimated Energy Requirement (EER).
Figure 1.1 ▲ Representation of Dietary Reference Intake along a continuum

of intake.
Table Standards Applied to Each

Nutrient for People Age 1
1.1 Year and Older
In 2019, the National Academies of Sciences, Engineering, and Medicine Food

and Nutrition Board (formerly known as the Institute of Medicine, Food and
Nutrition Board) created a new category of DRIs based on chronic disease risk,
called the Chronic Disease Risk Reduction Intakes (CDRR) (National
Academies of Sciences, Engineering, and Medicine, 2019). At this time, only
sodium has a CDRR.
Chronic Disease Risk Reduction Intake (CDRR)
the level of intake associated with chronic disease risk. Recommendation specifies “reduce intake if
above…” for sodium. For a nutrient that is inversely associated with disease risk, such as potassium, the
recommendation would be to “increase intake if lower than…”
Since consumers eat food and not nutrients, nutrient recommendations are not
suited to teaching people how to make healthy choices. Instead, nutrient
recommendations are used by dietitians who plan and evaluate menus for specific
populations such as senior citizens, schools, prisons, hospitals, assisted living
communities, and military feeding programs. Nutrient recommendations are also
used to assess the adequacy of an individual’s intake by comparing estimated
intake with estimated requirements. Keep in mind that obtaining a reliable
estimate of a person’s actual intake is difficult, due to reporting errors, flaws in
estimating portion sizes, and day-to-day variation in food intake. Unless a person
has participated in a nutrient requirement study, it is impossible to quantify exact
nutrient requirements for an individual.
Recommended Dietary Allowances

The Recommended Dietary Allowances (RDAs) represents the average daily
recommended intake level that is sufficient to meet the nutrient requirements of
97% of healthy individuals by life stage and sex.
Recommended Dietary Allowances (RDAs)
the average daily dietary intake level sufficient to meet the nutrient requirement of 97% to 98% of healthy
individuals in a particular life stage and gender group.
• RDAs exceed the requirements of almost all members of the group;

therefore, intakes below the RDA cannot be assessed as inadequate.
• RDAs are set high enough to account for daily variations in intake.
• RDAs are used as a starting point when health professionals estimate the
nutritional needs of people with health disorders and are individualized as
needed.
Estimated Average Requirement

Estimated Average Requirement (EAR) values are used to determine RDA
values; they are not used as a daily intake goal for individuals.
Estimated Average Requirement (EAR)
the nutrient intake estimated to meet the requirement of half of the healthy individuals in a specific group.
• The EAR of a nutrient is the average daily intake estimated to meet the
nutrient needs of half of the healthy people in a life stage or gender group.
• Average actually means estimated median.
• Since it is an average, the EAR falls below the requirements of half of
the specific group.
• The EAR is not based solely on the prevention of nutrient deficiencies:
• it considers reducing the risk of chronic disease, and
• accounts for the bioavailability of the nutrient—that is, how its
absorption is affected by other food components.
Adequate Intake
An Adequate Intake (AI) is set when an RDA cannot be determined due to lack
of sufficient data on requirements.
Adequate Intake (AI)
an intake level thought to meet or exceed the requirement of almost all members of a specific group. An
AI is set when there is insufficient data to define an RDA.
• AI is a recommended average daily intake level that is expected to meet or

exceed the needs of virtually all members of a specific group based on
observed or experimentally determined estimates of nutrient intake by
groups of healthy people.
• The primary purpose of the AI is to be a guide for an individual’s nutrient
intake.
• The difference between the RDA and the AI is that the RDA is expected to
meet the needs of almost all healthy people whereas it is not known what
percentage of people are covered with an AI.
Tolerable Upper Intake Level

The Tolerable Upper Intake Level (UL) is the highest level of average daily
nutrient intake that likely poses no risk of adverse health effects to almost all
individuals in the general population.
Tolerable Upper Intake Level (UL)
the highest average daily intake level of a nutrient that probably poses no danger to most individuals in the
group.
• It is not intended to be a recommended level of intake: There is no benefit

in consuming amounts greater than the RDA or AI.
• Not all nutrients have an established UL (Table 1.1).
Chronic Disease Risk Reduction Intake

Some essential nutrients are not only essential to life but are also linked to chronic
disease risk, such as an excess of sodium. The category of CDRR was formed for
the purpose of lowering chronic disease risk.
• The CDRR is based on evidence of the beneficial effect of lowering
sodium intake on cardiovascular disease risk, hypertension risk, systolic
blood pressure, and diastolic blood pressure (National Academies of
Sciences, Engineering, and Medicine, 2019).
• The recommendation is written as “Reduce intake if above_____ mg/day.”
• A CDRR for potassium was considered but not established due to lack of
evidence that a low potassium intake increases the risk of chronic disease.
Acceptable Macronutrient Distribution Ranges

The Acceptable Macronutrient Distribution Ranges (AMDRs) are broad
ranges for each macronutrient expressed as a percentage of total calories
consumed.
Acceptable Macronutrient Distribution Ranges (AMDRs)
an intake range for energy nutrients expressed as a percentage of total calories that is associated with a
reduced risk of chronic disease.
• These ranges are associated with reduced risk of chronic disease yet
provide adequate amounts of essential nutrients.
• Over time, intakes above or below this range may increase the risk of
chronic disease or deficiency, respectively.
• The AMDRs for adults are as follows:
Percentage Total Calories Consum

Carbohydrate 45–65
Protein 10–35
Fat 20–35
Essential fatty acids
Linoleic acid (n-6) 5–10
Alpha-linolenic acid (n-3) 0.6–1.2
Estimated Energy Requirements

The Estimated Energy Requirements (EERs) are the dietary calorie intake
predicted to maintain weight in healthy, normal-weight individuals based on age,
sex, weight, height, and level of physical activity.
Estimated Energy Requirements (EERs)
level of calorie intake estimated to maintain weight in normal-weight individuals based on age, sex, height,
weight, and activity.
• Exceeding EERs may produce weight gain.

• See Chapter 8 for more on determining energy needs.
FROM NUTRIENTS TO FOOD
Intake guidelines have often focused on nutrients more than food, such as limiting
the total amount of fat consumed without consideration of the source of the fat.
Such a narrow focus underestimates the complexity of food and the interactions
between its components and ignores the possibility that many constituents of food
and eating patterns may act synergistically to impact health (Jacobs & Orlich,
2014). For instance, populations that consume high amounts of fruit and
vegetables were observed to have lower rates of epithelial cancers, so researchers
speculated that beta carotene intake was protective; however, a study of giving
large doses of supplemental beta carotene to people at high risk of lung cancer
resulted in an increase in cancer and necessitated a premature halt to the study
(Bjelakovic et al., 2007). This is a glaring example of how although certain food
patterns may be associated with lower risk of disease, it is not known which
components of a food, in what proportion, acting singularly or synergistically with
other substances, are protective or detrimental to health. Thus, the health effects of
foods may not be simply and accurately reduced to the effects of single nutrients
(Jacobs & Orlich, 2014).
Focus on Total Diet

Researchers are increasingly focusing on the total diet—dietary patterns, nutrient
density, and overall diet quality—to study the link between diet and health
promotion/disease prevention (Millen, 2018).
Dietary Patterns
The 2020–2025 Dietary Guidelines for Americans (2020) defines dietary patterns
as “the combination of foods and beverages that constitutes an individual’s
complete dietary intake over time. This may be a description of a customary way
of eating or a description of a combination of foods recommended for
consumption” (U.S. Department of Agriculture [USDA] and U.S. Department of
Health and Human Services [USDHHS], 2020).
• Dietary patterns, commonly referred to as eating patterns, may be a better
predictor of disease risk than specific nutrients or food (Wrobleski et al.,
2018).
• A healthy eating pattern includes a variety of nutrient-dense foods across
food groups that provide adequate amounts of nutrients within the
appropriate calorie limits.
Healthy and detrimental eating patterns according to the 2020–2025 Dietary
Guidelines for Americans (USDA & USDHHS, 2020) are as follows:
• Eating patterns associated with positive health outcomes are characterized
by relatively high intakes of vegetables, fruits, legumes, whole grains, low-
or nonfat dairy, lean meats and poultry, seafood, nuts, and unsaturated
vegetable oils:
• Examples of eating patterns consistently mentioned as healthy are plant-
based eating patterns, the Mediterranean-Style Eating Pattern, and the
Dietary Approaches to Stop Hypertension (DASH) diet.
• Healthy eating patterns are presented in Chapters 2, 7, and 14 and are
repeatedly referred to throughout Unit 3.
• Eating patterns associated with detrimental health outcomes are higher in
the intake of red and processed meats, sugar-sweetened foods and
beverages, and refined grains.
Nutrient Density
Nutrient density refers to foods and beverages that provide vitamins, minerals, and
other beneficial substances relative to the number of calories with little or no
added sugars, saturated fat, and sodium.
• Nutrient-dense foods include vegetables, fruits, whole grains, seafood,
eggs, legumes, unsalted nuts and seeds, low-fat and fat-free dairy, and lean
meats and poultry when prepared with no or little added sugars, saturated
fat, and sodium.
Conversely, calorie density refers to the relative proportion of calories to nutrients
in a food.
• Examples of calorie dense items include sugar-sweetened beverages, baked
goods, full-fat fruited yogurt, and candy.
• Foods that are not in their most nutrient-dense form, such as whole milk
compared to fat-free milk and fried chicken compared to baked chicken,
have greater calorie density.
Overall Diet Quality

One way to measure diet quality is to use the Healthy Eating Index-2015 (HEI-
2015).
Healthy Eating Index-2015 (HEI-2015)
a density-based (e.g., amounts per 1000 calories) measure of diet quality based on conformance with the
2015 Dietary Guidelines for Americans. It is composed of food and nutrient characteristics that have
established relationships with health outcomes. Previous versions were based on previous editions of the
Dietary Guidelines for Americans.
• The HEI-2015 uses a scoring tool to measure diet quality to assess how
well a person’s intake aligns with key dietary recommendations in the
Dietary Guidelines for Americans—guidelines that are intended to help
prevent diet-related chronic diseases, such as heart disease, type 2 diabetes,
and cancer.
• There are 13 components that reflect different food groups and key
recommendations (Table 1.2). The components are divided into two
groupings:
• The Adequacy group represents foods that are encouraged.
• The Moderation group contains foods that should be limited.
• Most of the components are density-based (e.g., amounts per 1000
calories) and not absolute amounts.
• The HEI is revised with each new update of the Dietary Guidelines that
occurs every 5 years. HEI-2020 has not yet been published.
• Evidence supports the validity and reliability of the HEI-2015 (Reedy et
al., 2018).
Diet Quality in the United States

For Americans aged 2 and older, the average HEI-2015 score is 59 out of 100,
indicating typical eating patterns consumed by Americans do not align with the
Dietary Guidelines for Americans (USDA & USDHHS, 2020)
• Americans aged 60 and over have the highest diet quality with a score of
63
• Youth ages 14–18 have the lowest diet quality with a score of 51
• Americans fall short of nearly every component of diet quality measured
(Wilson et al., 2016).
The term poor is often used to describe the typical American Eating Pattern, with
poor referring to quality, not inadequate quantity, of food consumed. Compared to
the Healthy U.S.-Style dietary pattern (USDA & USDHHS, 2020),
• 80% of Americans consume eating patterns that are low in vegetables,
fruits, and dairy;
• more than 50% of the population is meeting or exceeding total grain and
total protein foods recommendations but are not meeting the
recommendations for the subgroups within each of these food groups (e.g.,
are not eating enough whole grains or seafood);
• average intakes of saturated fat, added sugars, and sodium exceed
recommended amounts; and
• calorie intake in excess of need contributes to the high prevalence of
overweight or obesity in adults (74%) and children (40%).
Table Components of the

Healthy Eating Index-
1.2 2015
Standard for Minimum Standard for Maximum

Component Score of 0 Score
Adequacy: food components that are encouraged
Total fruits No fruit ≥0.8 c equivalents/1000 cal
Whole No whole fruit ≥0.4 c equivalents/1000 cal
fruits
Total No vegetables ≥1.1 c equivalents/1000 cal
vegetables
Greens and No dark green vegetables or ≥0.2 equivalents/1000 cal
beans beans and peas
Whole No whole grains ≥1.5 oz equivalents/1000 cal
grains
Dairy No dairy ≥1.3 c equivalents/1000 cal
Total No protein foods ≥2.5 oz equivalents/1000 cal
protein
foods
Seafood No seafood or plant proteins ≥0.8 c equivalents/1000 cal
and plant
proteins
Fatty acids Poly- + mono-unsaturated Poly- + mono-unsaturated
fatty acids/saturated fatty fatty acids/saturated fatty
acids ≤1.2 acids ≥2.5
Moderation: food components that should be consumed sparingly
Refined ≥4.3 oz equivalents/1000 cal ≤1.8 oz equivalents/1000 cal
grains
Sodium ≥2.0 g/1000 cal ≤1.1 g/1000 cal
Added ≥26% of energy ≤6.5% of energy
sugars
Saturated ≥16% of energy ≤8% of energy
fats
Source: United States Department of Agriculture, Food and Nutrition Service. (2019). Healthy Eating Index
(HEI). https://www.fns.usda.gov/resource/healthy-eating-index-
hei#targetText=The%20Healthy%20Eating%20Index%20(HEI,the%20Dietary%20Guidelines%20for%20
Americans.&targetText=The%20HEI%20uses%20a%20scoring,range%20from%200%20to%20100
Think of Tyrone His typical intake while traveling is: two

sandwiches containing eggs, cheese, and bacon for breakfast; a
footlong assorted deli meat submarine sandwich on white roll
with a soft drink and bag of chips for lunch; and a dinner of steak,
French fries, and salad. He snacks on candy, soft drinks, and
granola bars in between meals.
How is Tyrone’s intake of Adequacy components listed in the HIE-2015?
How is Tyrone’s intake of Moderation components?
NUTRITION AND HEALTH
Across the lifespan, good nutrition supports all aspects of health: healthy
pregnancy outcomes; normal growth, development, and aging; healthy body
weight; lower risk of disease; and helping to treat acute and chronic disease
(DiMaria-Ghalili et al., 2014). Nutrition is intimately entwined with health.
The World Health Organization (WHO, 1946) defines health as “a state of
complete physical, mental, and social well-being, not merely the absence of
disease or infirmity.” In practice, health is defined subjectively and individually
along a continuum that is influenced by an individual’s perception of health. For
instance, a recent survey found that although 53% of respondents ranked their
health as very good or excellent, 61% of those respondents were overweight or
obese (International Food Information Council Foundation, 2019). Likewise, older
adults may consider themselves healthy despite having arthritis because they
consider it a normal part of aging, not a chronic disease.
Healthy People 2030

Healthy People is a program under the jurisdiction of the U.S. Department of
Health and Human Services (USDHHS) that focuses on improving the health and
well-being of all Americans. Updated every 10 years since its inception, Healthy
People sets public health goals and objectives and monitors the nation’s progress
toward meeting those objectives.
The newest edition, Healthy People 2030, has 355 core (measurable)
objectives with 10-year targets. The objectives are organized into 5 categories:
health conditions, healthy behaviors, populations, settings and systems, and social
determinants of health. Box 1.1. lists core objectives under the topics of Nutrition
and Healthy Eating and Overweight and Obesity. Two additional categories of
objectives differ from core objectives in that they lack either reliable baseline data
(developmental objectives) or are not yet associated with evidence-based
interventions (research objectives).
Healthy People 2030 Summary of Core

BOX
Objectives for Nutrition and Healthy Eating
1.1 and Overweight and Obesity
Nutrition and Healthy Eating Objectives—General

• Reduce household food insecurity and hunger
• Eliminate very low food security in children
• Increase fruit consumption by people aged 2 years and over
• Increase vegetable consumption by people aged 2 years and older
• Increase consumption of dark green vegetables, red and orange vegetables,
and beans and peas by people aged 2 years and over
• Increase whole grain consumption by people aged 2 years and over
• Reduce consumption of added sugars by people aged 2 years and over
• Reduce consumption of saturated fat by people aged 2 years and over
• Reduce consumption of sodium by people aged 2 years and over
• Increase calcium consumption by people aged 2 years and over
• Increase potassium consumption by people aged 2 years and over
• Increase vitamin D consumption by people aged 2 years and over
• Reduce iron deficiency in children aged 1 to 2 years
Adolescents
• Increase the proportion of students participating in the School Breakfast
Program.
Heart Disease and Stroke

• Reduce the proportion of adults with high blood pressure
• Reduce cholesterol in adults
Infants
• Increase the proportion of infants who are breastfed exclusively through age
6 months
• Increase the proportion of infants who are breastfed at 1 year

• Reduce the proportion of adults with obesity
• Increase the proportion of health care visits by adults with obesity that
include counseling on weight loss, nutrition, or physical activity
Women
• Increase the proportion of women of childbearing age who get enough folic
acid
• Reduce iron deficiency in females aged 12 to 49 years
Overweight and Obesity Objectives

Overweight and Obesity—General
• Reduce the proportion of children and adolescents with obesity
Diabetes
• Reduce the proportion of adults who don’t know they have prediabetes
Nutrition and Healthy Eatinga

• Reduce the proportion of adults with obesity
• Increase the proportion of health care visits by adults with obesity that
include counseling on weight loss, nutrition, or physical activity
• Reduce consumption of added sugars by people aged 2 years and over
Pregnancy and Childbirth

• Increase the proportion of women who had a healthy weight before
pregnancy.
These objectives appear under the broad topic of Nutrition and Healthy Eating and as a subtopic of
a
Overweight and Obesity topics.

Source: U.S. Department of Health and Human Services. (2020, August 18). Healthy People 2030.
Building a healthier future for all. https://health.gov/healthypeople/objectives-and-data/browse-
objectives.
Chronic Disease
Changes in lifestyle over the last 50 years—an abundant, cheap food supply,
increasing mechanization of daily life, sedentary occupations, and sedentary
screen time—have been reflected in changes in disease patterns. Acute infectious
diseases have been replaced by chronic diseases related to lifestyle as major
causes of death. Preventable chronic disease is a major challenge to global health.
• Noncommunicable diseases account for 71% of all deaths worldwide
(World Health Organization, 2018).
• In the United States, chronic diseases are responsible for 7 of the top 10
causes of death (Box 1.2) and are the leading causes of disability (CDC,
2019).
BOX Ten Leading Causes of Death in the

1.2 United Statesa (Data for 2018)
1. Heart disease
2. Cancer
3. Accidents (unintentional injuries)
4. Chronic lower respiratory diseases
5. Cerebrovascular diseases
6. Alzheimer’s disease
7. Diabetes mellitus
8. Influenza and pneumonia
9. Nephritis, nephrotic syndrome, and nephrosis
10. Suicide
includes people of all origins, sex, age groups.
a
Source: Centers for Disease Control and Prevention. (2020, October 30). Leading causes of death.
https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm.
• Today, 60% of American adults have one or more diet-related chronic

diseases (USDA & USDHHS, 2020), and 4 out of 10 adults have two or
more chronic health conditions (Centers for Disease Control and
Prevention [CDC], 2019). (See Table 1.3.)
Table Facts about Nutrition-

Related Health Conditions
1.3 in the United States
Health
Conditions Statistics
Overweight
• About 74% of adults are overweight or have obesity.
and obesity
• Adults ages 40–59 have the highest rate of obesity (43%)
of any age group with adults 60 years and older having a
41% rate of obesity.
• About 40% of children and adolescents are overweight or
have obesity; the rate of obesity increases throughout
childhood and teen years.
CVD and risk
• Heart disease is the leading cause of death.
factors:
• About 18.2 million adults have coronary artery disease,
• Coronary the most common type of heart disease.
artery • Stroke is the 5th leading cause of death.
disease
• Hypertension, high LDL cholesterol, and high total
• Hypertension cholesterol are major risk factors in heart disease and
• High LDL stroke.
and total • Rates of hypertension and high total cholesterol are
blood higher in adults with obesity than those who are at a
cholesterol healthy weight.
• Stroke • About 45% of adults have hypertension.a
• More Black adults (54%) than White adults (46%) have
hypertension.
• More adults ages 60 and older (75%) than adults ages 40–
59 (55%) have hypertension.
• Nearly 4% of adolescents have hypertension.b
• More than 11% of adults have high total cholesterol, ≥240
mg/dL.
• More women (12%) than men (10%) have high total
cholesterol, ≥240 mg/dL.
• 7% of children and adolescents have high total
cholesterol, ≥200 mg/dL.
Diabetes
• Almost 11% of Americans have type 1 or type 2 diabetes.
• Almost 35% of American adults have prediabetes, and
people 65 years and older have the highest rate (48%)
compared to other age groups.
• Almost 90% of adults with diabetes also are overweight
or have obesity.
• About 210,000 children and adolescents have diabetes,
including 187,000 with type 1 diabetes.
• About 6%–9% of pregnant women develop gestational
diabetes.
Cancerc • Colorectal cancer in men and breast cancer in women are
• Breast among the most common types of cancer.
Cancer • About 250,520 women will be diagnosed with breast
• Colorectal cancer this year.
Cancer • Close to 5% of men and women will be diagnosed with
colorectal cancer at some point during their lifetime.
• More than 1.3 million people are living with colorectal
cancer.
• The incidence and mortality rates are highest among those
ages 65 and older for every cancer type.
Bone Health
• More women (17%) than men (5%) have osteoporosis.
and Muscle
• 20% of older adults have reduced muscle strength.
Strength
• Adults over 80 years, non-Hispanic Asians, and women
are at the highest risk for reduced bone mass and muscle
strength.
a
For adults, hypertension is defined as systolic blood pressure (SBP) > 130 mm Hg and/or a diastolic blood
pressure (DBP) > 90 mm Hg.
b
For children, hypertension was defined using the 2017 American Academy of Pediatrics (AAP) Clinical
Practice Guideline.
c
The types of cancer included here are not a complete list of all diet- and physical activity–related cancers.
• Children and adolescents also have chronic diseases, such as type 2

diabetes and hypertension.
• Almost half of premature deaths in the United States are related to tobacco
use, lack of physical activity, and poor diet (United Health Foundation,
2018).
• Box 1.3 features modifiable risk factors for chronic disease.
BOX Modifiable Risk Factors for Chronic Disease

1.3
Poor Nutrition
• Fewer than 1 in 10 U.S. adults and adolescents eat enough fruit and
vegetables.
• 6 in 10 young people and 5 in 10 adults consume a sugary drink on a given
day.
• 9 out of 10 Americans aged 2 and older consume more than the
recommended amount of sodium.
• U.S. diets are high in added sugars, sodium, and saturated fats.
Tobacco Use
• Tobacco use is the leading cause of preventable disease, disability, and death
in the United States.
• About 34 million U.S. adults smoke cigarettes, and 58 million nonsmokers
are exposed to secondhand smoke.
• Every day, about 2000 young people under age 18 smoke their first cigarette
and >300 become daily cigarette smokers.
• Cigarette smoking causes >480,000 deaths annually, including 41,000 deaths
from secondhand smoke. For every American who dies because of smoking,
at least 30 are living with a serious smoking-related illness.
• Smoking causes cancer, heart disease, stroke, lung disease, type 2 diabetes,
and other chronic health conditions.
Excessive Alcohol
• Excessive alcohol use is responsible for 88,000 deaths in the United States
each year, including 1 in 10 total deaths among working-age adults.
• In 2010, excessive alcohol use cost the U.S. economy $249 billion, or $2.05 a
drink.
• Binge drinking is responsible for over half the deaths related to excessive
alcohol use.
• 9 in 10 adults who binge drink do not have an alcohol use disorder.
Physical Inactivity
• Only 1 in 4 U.S. adults and 1 in 5 high school students meet the
recommended physical activity guidelines.
• About 31 million adults aged 50 or older are inactive, meaning that they get
no physical activity beyond that of daily living.
• Low levels of physical activity can contribute to heart disease, type 2
diabetes, some kinds of cancer, and obesity.
Source: Centers for Disease Control and Prevention. (2019). National Center for Chronic Disease
Prevention and Health Promotion. About chronic diseases.
https://www.cdc.gov/chronicdisease/about/index.htm
Consider Tyrone. From what we know about Tyrone, what

modifiable risk factors for chronic disease does he have? What
questions would you ask to further identify modifiable risk
factors?
Lifestyle Medicine
According to the American College of Lifestyle Medicine, “lifestyle medicine is
the use of evidence-based lifestyle therapeutic approaches, such as a plant-
predominant dietary lifestyle, regular physical activity, adequate sleep, stress
management, avoiding use of risky substances, and pursuing other non-drug
modalities to treat, reverse, and prevent chronic disease” (American College of
Lifestyle Medicine [ACLM], 2019).
• Advocating for healthy lifestyles started when physicians began to see
lifestyle as a critical tool in caring for patients but also healthy people (Yeh
& Kong, 2013).
• The focus on food and lifestyle choices to prevent and treat chronic
diseases, such as obesity, type 2 diabetes, cardiovascular disease, and many
types of cancer, has become an increasingly popular medical paradigm
(Retelny, 2017).
• Hippocrates’ quote, “Let food be thy medicine and medicine be thy food,”
supports the present-day trend to view food as medicine based on the
premise that good health depends on a healthy diet.
• Characteristics of lifestyle medicine differ from those of traditional
medicine (Battersby et al., 2011):
• Patients are an active partner in their own care and not a passive
recipient.
• Patients are required to make major changes.
• Treatment is always long-term.
• Medications are used as an adjunct to therapeutic lifestyle changes.
• Motivation and compliance are emphasized.
• The goal is primary, secondary, or tertiary prevention.
• Lifestyle medicine involves a multidisciplinary team approach that
includes allied health professionals.
• The patient’s home and community environment are assessed as
contributing factors.
Remember Tyrone. Tyrone considers himself more interested in

“natural” remedies than in conventional medicine. He asks you to
explain lifestyle medicine and wants to know whether he is a good
candidate. How would you respond?
Future Directions
Nutrition has the potential to help individuals live healthier, more productive lives
and reduce the worldwide strain of chronic disease. The importance of nutrition as
part of the solution to societal, environmental, and economic challenges facing the
world has just begun to be fully recognized (Ohlhorst et al., 2013). Some of the
questions driving nutrition research are featured in Box 1.4. New technology and
scientific discoveries are deepening our understanding of how nutrients and eating
patterns affect health and disease.
BOX Some Questions Driving Nutrition Research

1.4
• How do an individual’s genes determine how the body handles specific

nutrients?
• What role does a person’s microbiota have in an individual’s response to diet
and food components? What is its role in disease prevention and progression?
• How does food intake affect a person’s microbiota?
• How does an individual’s genome affect responses to diet and food?
• How does diet during critical periods of development “program” long-term
health and well-being? For instance, how does undernutrition during fetal life
increase the risk of diabetes in adulthood?
• How can obesity be prevented? Can obesity be cured?
• How does nutrition influence the initiation of disease and its progression?
• What are the nutritional needs of aging adults?
• What are the biochemical and behavior bases for food choices? How can we
most effectively measure, monitor, and evaluate dietary change?
• How can we get people to change their eating behaviors?
Source: Ohlhorst, S., Russell, R., Bier, D., Klurfeld, D., Li, Z., Mein, J., Milner, J., Ross, A., Stover, P., &
Konopka, E. (2013). Nutrition research to affect food and a health life span. American Journal of
Clinical Nutrition, 98, 620–625.
• Technology will enable researchers to expand and update nutrition

databases to include more food items and substances in food previously
not quantified, such as lycopene, resveratrol, and other phytonutrients,
which will provide a more accurate and complete picture of food
composition.
• Bioinformatics will enable researchers to make connections between
intake and health that were not previously possible.
• Nutrigenomics has the potential to redefine the role of nutrition in health
and disease risk in individuals.
Database
a comprehensive collection of related information organized for convenient access.
Bioinformatics
an interdisciplinary field that uses computer science and information technology to develop and improve
techniques that make it easier to acquire, store, organize, retrieve, and use complex biological data.
Nutrigenomics
Nutrigenomics is the study of the interaction between nutrients and other
bioactive compounds with the human genome at the molecular level.
Nutrigenomics
the study of the interaction between bioactive food components and genes and how that interaction impacts
health and disease
• Mapping the sequence of the human genome allows researchers to

examine the relationship between a person’s genetic makeup, response to
diet, and health outcomes.
• Hundreds of links between genes, diet, and health outcomes have already
been identified. Obesity is one area of particular interest. For instance,
• It has been revealed that a variation in fat mass and an obesity-
associated gene (FTO) is associated with susceptibility to obesity
(Merritt et al., 2018).
• Research findings suggest that a high protein intake may protect against
the obesity effects of certain FTO genotypes (Merritt et al., 2018).
• Further studies are needed to identify the mechanism of this gene–diet
interaction, as well as explore the possibility of incorporating a high-
protein diet in personalized weight loss plans.
• Nutrigenomics has the potential to produce major nutrition breakthroughs
in the prevention of chronic disease and to identify new biomarkers that
will more accurately assess a person’s health and nutritional status.
Additional benefits may include the following:
Biomarker
a measurable biological molecule found in blood, other body fluids, or tissues that is a sign of a normal or
abnormal process or of a condition or disease.
• individualized dietary advice and customized dietary guidelines based

on genetic background;
• the development of healthier foods, such as functional foods, to provide
specific health benefits based on genetic background beyond basic
nutrition;
• a reduction in health disparities that are related, at least in part, to the
interaction between diet and genes;
• reduced health care costs and improved quality of life (Singh & Sharma,
2019). For instance, it is possible that certain components of food when
matched with individual genotypes could take the place of more
expensive drugs in the treatment of certain disorders.
• Genetic mutations only partially predict disease risk because most chronic
diseases (e.g., cardiovascular disease, diabetes, and cancer) are
multigenetic and multifactorial (Camp & Trujillo, 2014). For instance,
tobacco use impacts the risk of chronic disease.
• It is not yet known whether knowledge gained from nutrigenomics will
have practical application in the everyday life of consumers (Camp &
Trujillo, 2014).
Genomics
an area of genetics that studies the sequencing and analysis of an organism’s genome.
Recall Tyrone. He is admitted to the hospital for chest pain.

Although screening did not find him to be at nutritional risk, he is
counseled on the importance of eating healthier. He and his wife
have many questions about how to implement a healthy eating
pattern.
• Do you feel competent to reinforce the written and verbal instructions

they’ve been given?
• How will you assure the patient that he can improve his eating pattern?
• What benefits could he realize with improved eating and exercise?
How Do You Respond?
Both of my parents had type 2 diabetes so I know
I’m doomed. Why should I eat healthier to reduce
my risk if it’s in the genes? A healthy eating pattern and
physical activity have been found to be effective in preventing
or delaying the onset of diabetes among individuals with
prediabetes, although eating healthier is not guaranteed to
prevent type 2 diabetes. There are other potential health
benefits to adopting a healthy eating pattern and increasing
physical activity: improvements in weight status, blood
pressure, low high-density lipoprotein cholesterol, and high
triglyceride levels as well as possible reduced risk of certain
cancers. There is not a downside to adopting healthier lifestyle
behaviors, even though the benefits cannot be guaranteed.
REVIEW CASE STUDY
Kyla is 25 years old, overweight, and convinced a paleo diet will help her achieve
her ideal weight. She eats only meat, fish, vegetables, nuts, and seeds. Fruit is
acceptable to eat on a paleo diet, but Kyla avoids them because they are “high in
sugar.” She does not consume any dairy products, legumes, or grains in any form.
She has lost weight but is concerned her diet may not be balanced or healthy for
the long term.
• Using Table 1.2, what food components are missing from Kyla’s diet?
• Is it possible for Kyla to eat too many calories despite the restrictiveness of her
diet?
• Can a multivitamin adequately replace the nutrient and food components
missing in Kyla’s diet?
• When someone needs to lose weight for health benefits, is it okay to eat
according to a less-than-healthy diet for the sake of weight loss, or should a
healthy diet that provides all the adequate components always be the priority?
• There are no long-term clinical studies about the benefits and potential risks of
the paleo diet. What would you say to Kyla about the efficacy and safety of her
diet choice?
STUDY QUESTIONS
1 Recommended Dietary Allowances represent

a. the average amount of a nutrient considered adequate to meet the needs of
almost all healthy people.
b. the minimum amount of a nutrient necessary to avoid deficiency disease.
c. the optimal amount of a nutrient to prevent chronic disease.
d. the highest amount of a nutrient that appears safe for most healthy people.
2 The typical American dietary pattern is
a. low in refined grains.
b. low in whole grains.
c. high in fruit.
d. high in dairy products.
3 Which statement is accurate regarding characteristics of a healthy eating
pattern?
a. The only healthy eating pattern is a vegetarian one.
b. Healthy eating patterns eliminate foods that are high in saturated fat, added
sugar, and sodium (fried foods, desserts, snack chips, etc.).
c. Healthy eating patterns may reduce the risk of several chronic diseases:
cardiovascular disease, type 2 diabetes, and certain cancers.
d. Most young and middle-aged adults consume a healthy eating pattern.
4 Detrimental health outcomes are linked to excessive intakes of all of the
following except
a. Saturated fat.
b. Carbohydrates.
c. Added sugars.
d. Sodium.
5 Which statement regarding the characteristics of lifestyle medicine is not true?
a. Medications are not used in conjunction with lifestyle medicine.
b. Patients are expected to be active participants in their care.
c. Patients are required to make major lifestyle changes.
d. Treatment is always long-term.
CHAPTER SUMMARY NUTRITION IN

HEALTH
More than ever before, studies link dietary patterns, including nutrient density
and diet quality, to health promotion and the prevention of disease.

The DRIs are the set of accepted reference standards of estimated nutrient
needs and intake recommendations for healthy people to maintain health and
prevent deficiency diseases. The DRIs are primarily for professional use
because they deal with nutrients, not food.
List of Dietary Reference Intakes

• Recommended Dietary Allowances (RDAs): amounts of nutrients
considered adequate to meet the needs of almost all healthy people.
• Adequate Intake (AI): similar to RDA, but it is not known what percentage
of people meet their nutritional needs by consuming the AI.
• Tolerable Upper Intake Level (UL): the highest intake of a nutrient over
time that poses no risk.
• Chronic Disease Risk and Reduction Intake (CDRR): the level of a
nutrient above or below which risk of chronic disease increases.
• Acceptable Macronutrient Distribution Ranges (AMDRs): the range of
intake of each macronutrient, expressed as a percentage of total calories,
associated with reduced risk of chronic disease.
From Nutrients to Food

The total diet approach to healthy eating encompasses eating patterns, nutrient
density, and diet quality.
• Dietary patterns: the amount, proportions, variety, or combinations of
different foods and beverages in diets, and the frequency with which they are
usually eaten. Examples of healthy eating patterns are plant-based eating
patterns, the Mediterranean-Style Eating Pattern, and the DASH diet.
• Nutrient density: the relative proportion of nutrients compared to calories in
a food or serving
• Overall diet quality: the HEI-2015 is a numerical measure of diet quality
based on food groups and key recommendations made in the Dietary
Guidelines for Americans.
• Diet quality in the United States: the typical American Eating Pattern is
low in fruits, vegetables, whole grains, dairy, and seafood and provides
excessive saturated fat, added sugars, and sodium. An excessive intake of
calories contributes to the high prevalence of overweight and obesity in
children and adults.
Nutrition and Health
Nutrition plays a vital role in all aspects of health: growth, development, and
health maintenance.
• Healthy People 2030 is a comprehensive blueprint for monitoring the
nation’s progress toward becoming healthier. Nutrition and Healthy Eating
and Overweight and Obesity are among the topics with specific core
objectives.
• Chronic disease is responsible for 7 of the top 10 causes of death in the
United States. Modifiable risk factors for chronic disease include poor diet,
tobacco use, excessive alcohol intake, and physical in activity.
• Lifestyle medicine uses evidence-based lifestyle therapeutic approaches,
such as a plant based eating pattern, regular physical activity, adequate sleep,
stress management, avoiding the use of risky substances, and pursuing other
non-drug modalities to treat, reverse, and prevent chronic disease.
• Future directions: new technology and scientific discoveries are deepening
our understanding of how nutrients and eating patterns affect health and
disease. Nutrigenomics studies the interaction between genes, diet, and
health. It has the potential to revolutionize advances in individualized
nutrition interventions.
Figure sources: shutterstock.com/Lightspring and shutterstock.com/Elenadesign
Student Resources on
For additional learning materials,

activate the code in the front of this book
at https://thePoint.lww.com/activate
Websites
Dietary guidelines for Americans 2020–2025 at https://www.dietaryguidelines.gov/
Healthy Eating Index (HEI) at https://www.fns.usda.gov/resource/healthy-eating-index-hei
Healthy People 2030 at https://www.healthypeople.gov
United Health Foundation (a private, not-for-profit foundation dedicated to improving health and health care)
at https://www.unitedhealthfoundation.org
References
American College of Lifestyle Medicine. (2019). Mission/vision. Available at
https://www.lifestylemedicine.org/ACLM/About/Mission_Vision/ACLM/About/Mission_Vision.aspx?
hkey=0c26bcd1-f424-416a-9055-2e3af80777f6
Battersby, M., Egger, G., & Litt, J. (2011). Introduction to lifestyle medicine. In: Egger, C., Binns, A., and
Rossner, S., [eds]. Lifestyle medicine: Managing diseases of lifestyle in the 21st century. McGraw-Hill.
Bjelakovic, G., Nikolova, D., Gluud, L., Simonetti, R., & Gluud, C. (2007). Mortality in randomized trials of
antioxidant supplements for primary and secondary prevention: Systematic review and meta-analysis.
JAMA, 297(8), 842–857. https://doi.org/10.1001/jama.297.8.842
Camp, K., & Trujillo, E. (2014). Position of the Academy of Nutrition and Dietetics: Nutritional genomics.
Journal of the Academy of Nutrition and Dietetics, 114(2), 299–312.
https://doi.org/10.1016/j.jand.2013.12.001
Centers for Disease Control and Prevention. (2019). National Center for Chronic Disease Prevention and
Health Promotion (NCCDPHP). Chronic diseases in America.
https://www.cdc.gov/chronicdisease/resources/infographic/chronic-diseases.htm
DiMaria-Ghalili, R., Mirtallo, J., Tobin, B., Hark, L., Van Horn, L., & Palmer, C. (2014). Challenges and
opportunities for nutrition education and training in the health care professions: Intraprofessional and
interprofessional call to action. American Journal of Clinical Nutrition, 99(5), 1184S–1193S.
https://doi.org/10.3945/ajcn.113.073536
Institute of Medicine. (2006). Dietary reference intakes: The essential guide to nutrient requirements. The
National Academies Press. www.nap.edu
International Food Information Council Foundation. (2019). 2019 food & health survey.
https://foodinsight.org/wp-content/uploads/2019/05/IFIC-Foundation-2019-Food-and-Health-Report-
FINAL.pdf
Jacobs, D., & Orlich, M. (2014). Diet pattern and longevity: Do simple rules suffice? A commentary.
American Journal of Clinical Nutrition, 100(Suppl. 1), 313S–319S.
Merritt, D., Jamnik, J., & El-Sohemy, A. (2018). FTO genotype, dietary protein intake, and body weight in a
multiethnic population of young adults: A cross-sectional study. Genes and Nutrition, 13, 4.
https://doi.org/10.1186/s12263-018-0593-7
Millen, B. (2018). Nutrition research advances and practice innovations. The future is very bright. Journal of
the Academy of Nutrition and Dietetics, 118(9), 1587–1590. https://doi.org/10.1016/j.jand.2018.05.018
National Academies of Sciences, Engineering, and Medicine. (2019). Consensus study report highlights.
Dietary reference intakes for sodium and potassium.
https://www.nap.edu/resource/25353/030519DRISodiumPotassium.pdf
Ohlhorst, S., Russell, R., Bier, D., Klurfeld, D., Li, Z., Mein, J., Milner, J., Ross, A., Stover, P., & Konopka, E.
(2013). Nutrition research to affect food and a healthy life span. The Journal of Nutrition, 143(8), 1349–
1354. https://doi.org/10.3945/jn.113.180638
Reedy, J., Lerman, J., Krebs-Smith, S., Kirkpatrick, S., Pannucci, T., Wilson, M., Subar, A., Kahle, L., &
Tooze, J. (2018). Evaluation of the healthy eating index-2015. Journal of the Academy of Nutrition and
Dietetics, 118(9), 1622–1633. https://doi.org/10.1016/j.jand.2018.05.019
Retelny, V. (2017). Using food as lifestyle medicine. Today’s Dietitian, 19, 36.
https://www.todaysdietitian.com/newarchives/1217p36.shtml
Singh, R., & Sharma, L. (2019). Nutrigenomics: A combination of nutrition and genomics: A new concept.
International Journal of Physiology, Nutrition and Physical Education, 4(1), 417–421.
https://www.researchgate.net/profile/Richa_Singh25/publication/334603656_Nutrigenomics_A_combinati
on_of_nutrition_and_genomics_A_new_concept/links/5d35596992851cd0467b4e9d/Nutrigenomics-A-
combination-of-nutrition-and-genomics-A-new-concept.pdf
U.S. Department of Agriculture & U.S. Department of Health and Human Services. (2020). Dietary
guidelines for Americans, 2020–2025. 9th ed. https://www.dietaryguidelines.gov
United Health Foundation. (2018). American’s health rankings. Annual report 2018.
https://assets.americashealthrankings.org/app/uploads/2018ahrannual_020419.pdf
United States Department of Agriculture, Food and Nutrition Service. (2019). Healthy eating index (HEI).
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hei#targetText=The%20Healthy%20Eating%20Index%20(HEI,the%20Dietary%20Guidelines%20for%20
Americans.&targetText=The%20HEI%20uses%20a%20scoring,range%20from%200%20to%20100
Wilson, M., Reedy, J., & Krebs-Smith, S. (2016). American diet quality: Where it is, where it is heading, and
what it could be. Journal of the Academy of Nutrition and Diet, 116(2), 302–310.
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room/fact-sheets/detail/noncommunicable-diseases
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by the International Health Conference, New York, June 19–22, 1946; signed on July 22, 1946 by the
representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered
into force on April 7, 1948. http://whqlibdoc.who.int/hist/official_records/constitution.pdf
Wrobleski, M., Parker, E., Hurley, K., Oberlander, S., Merry, B., & Black, M. (2018). Comparison of the HEI
and HEI-2010 diet quality measures in association with chronic disease risk among low-income African
American urban youth in Baltimore, Maryland. Journal of American College of Nutrition, 37(3), 201–208.
https://doi.org/10.1080/07315724.2017.1376297
Yeh, B. I., & Kong, I. D. (2013). The advent of lifestyle medicine. Journal of Lifestyle Medicine, 3(1), 1–8.
Chapter Guidelines for Healthy
2 Eating
Aurea Espada
Aurea is 30 years old and has battled ulcerative colitis
for more than 10 years. Medication helps keep her in
remission, but she still has diarrhea that is sometimes
bloody when she is stressed or eats too much fiber.
She avoids fruits, vegetables, and whole grains to
keep her gut calm. She worries that her diet lacks
healthy foods and that it may place her at greater risk
of chronic disease.
Learning Objectives
1 Discuss the four broad dietary guidelines and the key recommendations
for each.
2 Explain how the Healthy U.S.-Style Eating Pattern differs from the
typical American eating pattern.
3 List four underlying principles inherent in healthy eating.
4 Give examples of nutrient-dense foods.
5 Describe the MyPlate graphic.
6 List the nutritional attributes and potential health benefits associated with
each of the MyPlate food groups.
7 Compare the nutrition recommendations from the American Heart
Association, the American Cancer Society, and the American Institute
for Cancer Research.
Healthy eating guidelines translate the science of nutrient needs into

evidence-based public health recommendations for eating patterns to meet
those needs. A healthy eating pattern provides adequate amounts of all
essential nutrients, helps people attain and maintain a healthy body weight,
promotes overall health, and reduces the risk of chronic disease. Following
are the prominent characteristics of healthy eating patterns:
Variety in
• the color of fruits and vegetables
• the selections within each group
• methods of cooking
Balance
• inclusion of all food groups in reasonable proportions
Moderation
• limited amounts of saturated fat, added sugars, and sodium
• moderate amounts of alcohol and coffee, if adults so choose
Appropriate for the individual
• calorically, culturally, personally, and economically
No prohibition on any foods
This chapter discusses tools and resources for planning a healthy diet,
including the Dietary Guidelines for Americans, MyPlate, and diet and
lifestyle recommendations from leading health agencies. Guidelines and
graphics from other countries are also introduced.
DIETARY GUIDELINES FOR
AMERICANS
The Dietary Guidelines for Americans (DGA) have been published once
every 5 years since 1980 jointly by the U.S. Department of Agriculture
(USDA) and the U.S. Department of Health and Human Services
(USDHHS). The report contains evidence-based advice on foods and
beverages to consume to promote health, reduce the risk of chronic disease,
and meet nutrient needs (USDA & USDHHS, 2020). The DGA are
designed to meet the Recommended Dietary Allowances (RDA) and
Adequate Intakes (AI) for essential nutrients while also staying within the
Acceptable Macronutrient Distribution Ranges for carbohydrates, protein,
and fat (USDA & USDHHS, 2020). The DGA serve as the basis of federal
food, nutrition, and health policies and programs (USDA & USDHHS,
2020). They are intended to help all people shift to better food and beverage
choices to achieve healthier eating patterns.
There are four broad guidelines with key recommendations for each
(Box 2.1). Reflecting how the science of nutrition has evolved, the focus of
the 2020–2025 DGA is
• to recognize the major public health problem caused by diet-related
chronic diseases such as heart disease, type 2 diabetes, obesity, and
some types of cancer,
• on dietary patterns, not individual nutrients or foods, and
• to provide guidance throughout the lifespan from infancy through
older adulthood.
BOX Dietary Guidelines for Americans 2020–2025

2.1
The Guidelines
Make every bite count with the Dietary Guidelines for Americans.
Here’s how:
1. Follow a healthy dietary pattern at every life stage.
At every life stage—infancy, toddlerhood, childhood, adolescence,
adulthood, pregnancy, lactation, and older adulthood—it is never too
early or too late to eat healthfully.
• For about the first 6 months of life, exclusively feed infants
human milk. Continue to feed infants human milk through at least
the first year of life and longer if desired. Feed infants iron-
fortified infant formula during the first year of life when human
milk is unavailable. Provide infants with supplemental vitamin D
beginning soon after birth.
• At about 6 months, introduce infants to nutrient-dense
complementary foods. Introduce infants to potentially allergenic
foods along with other complementary foods. Encourage infant and
toddlers to consume a variety of foods from all food groups.
Include foods rich in iron and zinc, particularly for infants fed
human milk.
• From 12 months through older adulthood, follow a healthy
dietary pattern across the lifespan to meet nutrient needs, help
achieve a healthy body weight, and reduce the risk of chronic
disease.
2. Customize and enjoy nutrient-dense food and beverage choices to
reflect personal preferences, cultural traditions, and budgetary
considerations.
A healthy dietary pattern can benefit all individuals regardless of age,
race, or ethnicity, or current health status. The Dietary Guidelines
provides a framework intended to be customized to individual needs
and preferences as well as the foodways of the diverse cultures in the
United States.
3. Focus on meeting food group needs with nutrient-dense foods and
beverages, and stay within calorie limits.
An underlying premise of the Dietary Guidelines is that nutritional
needs should be met primarily from foods and beverages—
specifically, nutrient-dense foods and beverages. Nutrient-dense
foods provide vitamins, minerals, and other health-promoting
components and have no or little added sugars, saturated fat, and
sodium. A healthy dietary pattern consists of nutrient-dense forms of
foods and beverages across all food groups, in recommended
amounts, and within calorie limits.
The core elements that make up a healthy dietary pattern include the
following:
• Vegetables of all types—dark green; red and orangebeans, peas,
and lentils; starchy; and other vegetables
• Fruits, especially whole fruit
• Grains, at least half of which are whole grain
• Dairy, including fat-free or low-fat milk, yogurt, andcheese and/or
lactose-free versions and fortified soy beveragesand yogurt as
alternatives
• Protein foods, including lean meats, poultry, and eggs;seafood;
beans, peas, and lentils; and nuts, seeds, andsoy products
• Oils, including vegetables oils and oils in food, such asseafood and
nuts
4. Limit foods and beverages higher in added sugars, saturated fat,
and sodium and limit alcoholic beverages.
At every life stage, meeting food group recommendations—even with
nutrient-dense choices—requires most of a person’s daily calorie
needs and sodium limits. A healthy dietary pattern doesn’t have much
room for extra added sugars, saturated fat, or sodium—or for
alcoholic beverages. A small amount of added sugars, saturated fat,
or sodium can be added to nutrient-dense foods and beverages to help
meet food group recommendations, but foods and beverages high in
these components should be limited. Limits are as follows:
• Added sugars—Less than 10% of calories per daystarting at age 2.
Avoid foods and beverages with addedsugars for those younger
than age 2.
• Saturated fat—Less than 10% of calories per day startingat age 2.
• Sodium—Less than 2300 mg/day—and even less forchildren
younger than age 14.
• Alcoholic beverages—Adults of legal drinking age can choose not
to drink or to drink in moderation by limiting intake to 2 drinks or
less in a day for men and 1 drink or less in a day for women, when
alcohol is consumed. Drinking less is better for health than
drinking more. There are some adults who should not drink
alcohol, such as women who are pregnant.
Source: U.S. Department of Agriculture & U.S. Department of Health and Human Services.
(2020, December).. Dietary guidelines for Americans, 2020–2025.
https://www.dietaryguidelines.gov.
Recommended Eating Patterns

Three different healthy eating patterns are featured in the DGA to illustrate
how the guidelines translate into types and amounts of foods. There are 12
different calorie levels within each style, ranging from 1000 to 3200
calories in 200-calorie increments. This wide range of calorie levels is
intended to meet the needs of individuals across the lifespan. Each style
lists recommended daily amounts of food within each food group for each
calorie level. Patterns meet the standards for almost all nutrients while
staying within limits for added sugars, saturated fat, and sodium. However,
vitamin D, vitamin E, and choline may be marginal or below the RDA or AI
standard for many or all age/sex groups (USDA & USDHHS, 2020). Table
2.1 compares each of the styles at 1600- and 2000-calorie levels. The styles
are summarized in the following sections.
Table 1600- and 2000-Calorie

Patterns for Ages 2 and Older
2.1 for the Healthy U.S.-Style
Eating Pattern, the Healthy
Mediterranean-Style Eating
Pattern, and the Healthy
Vegetarian Eating Pattern
Healthy U.S.-Style Eating Pattern
The Healthy U.S.-Style Eating Pattern is based on the types and proportions
of foods Americans typically consume in nutrient-dense forms and
appropriate amounts.
• Because this pattern is designed as a healthier version of the typical
American eating pattern, it is higher in fruits, vegetables, dairy,
whole grains, and seafood than what the typical American
consumes. It is also more restricted in the number of calories
remaining for other uses, previously known as discretionary
calories.
• It aligns closely with the Dietary Approaches to Stop Hypertension
(DASH) diet (see Chapter 7).
Healthy Mediterranean-Style Eating Pattern

There is no single defined standard Mediterranean diet; this eating pattern is
based on the food intakes of people who display positive health outcomes
related to a Mediterranean-type diet. The traditional Mediterranean diet is
higher in unsaturated fat and lower in saturated fat compared to the typical
American diet.
Compared to the U.S.-Style Eating Pattern featured in the DGA, the
Mediterranean-Style Eating Pattern
• provides slightly higher amounts of protein foods overall and
significantly higher amounts of seafood/week.
• is higher in fruits.
• contains less dairy so the pattern is lower in calcium and vitamin D.
Healthy Vegetarian Eating Pattern

The Healthy Vegetarian Eating Pattern is a modified version of the Healthy
U.S.-Style Eating Pattern and is similar to the eating patterns reported by
self-identified vegetarians. Dairy and eggs are included because they are
consumed by the majority of vegetarians studied. Compared to the Healthy
U.S.-Style Eating Pattern, the Healthy Vegetarian Eating Pattern
• excludes meat, poultry, and seafood,
• lists the subgroups of protein foods as eggs; beans, peas, lentils; soy
products; and nuts and seeds. The amount of beans, peas, and lentils
recommended under protein foods is in addition to the amount
recommended from the vegetable group,
• includes higher amounts of legumes, soy products, and nuts and
seeds, and
• at some calorie levels, provides slightly higher amounts of whole
grains and calories for other uses.
The Underlying Principles of Healthy Eating

Certain underlying principles are inherent to healthy eating: Choose
nutrient-dense foods and beverages; meet nutrient needs through food and
beverages, not through supplements; use portion control to avoid exceeding
calorie limits; and focus on variety to ensure nutritional adequacy.
Nutrient-Dense Foods
Nutrient-dense foods and beverages provide vitamins, minerals, and other beneficial substances
relative to the number of calories with little or no added sugars, saturated fat, and sodium.
Choose Nutrient Dense Foods and Beverages

At each calorie level, the amount of food recommended in each eating
pattern is based on the assumption that all foods are chosen in their most
nutrient-dense form. Figure 2.1 compares the calories in nutrient dense and
non-nutrient-dense forms of various foods. Note that although whole milk is
not made with added fat, it is not the leanest possible variety of milk;
therefore, it is not as nutrient dense as fat-free milk. As such, eating patterns
are based on the assumption that fat-free milk will be chosen.
Figure 2.1 ▲ Examples of calories in food choices that are nutrient
dense and calories in nutrient-dense forms of these foods. (Source: U.S.
Department of Agriculture, Agricultural Research Service. [2019].
FoodData Central. fdc.nal.usda.gov).
• Eating nutrient-dense food, helps achieve nutrient requirements

without exceeding calorie needs.
• The following foods and beverages are considered nutrient dense if
they are prepared with little or no added solid fats, sugar, refined
starches, or sodium: vegetables, fruits, whole grains, eggs, beans,
peas, lentils, nuts, fat-free and low-fat dairy products, and lean
proteins.
• If all food choices are nutrient dense, then a small number of
calories will remain in the overall calorie limit of the eating pattern.
• These calories are referred to “limit on calories for other uses.”
• If the limits for added sugars, saturated fat, and alcohol
recommended by the DGA are not exceeded and the intake of
carbohydrates, protein, and fat is within Acceptable
Macronutrient Distribution Ranges, these calories can be used for
• added sugars (e.g., a soft drink), added refined starches (e.g.,
white bread), solid fats (e.g., butter), or alcohol,
• foods that are not the most nutrient-dense in a group, such as
2% milk instead of fat-free milk, and
• eating more than the recommended amount of food in a food
group (e.g., larger portion of seafood).
Meet Nutrient Needs through Foods and Beverages

People are urged to meet their nutrient needs through nutrient-dense foods
and beverages, not through supplements, to the greatest extent possible.
• Foods and beverages provide complex mixtures of many nutrient
and non-nutrient components that cannot be replicated in pill form,
such as the wide variety of phytonutrients in fruits and vegetables
that are not found in multivitamin supplements.
• However, sometimes, fortified foods or supplements are necessary
to meet certain nutrient needs, such as the use of calcium- and
vitamin D–fortified orange juice by people who cannot or will not
consume adequate amounts of dairy products.
Use Portion Control

Just as the quality of foods chosen influences total calorie intake, so does
the quantity.
• Eating patterns specify daily or weekly amounts from each food
group or subgroup, respectively, in “ounce-equivalents” or “cup-
equivalents.”
• Total oils recommended per day are in grams.
• Although these measures are more specific than the previously
used term of serving, which consumers often confuse with
portion, it is still a matter of estimating how much food is
consumed.
• Often, portion sizes exceed serving sizes; using common objects is
an easy way to convey the concept of serving sizes (Box 2.2).
• Strategies to help downsize portion sizes include
• using smaller dinnerware at home, and
• using a tall slender glass instead of a short wide one.
Serving Size
the amount of food listed on the Nutrition Facts label that refers to the amount customarily
consumed, for example, 1 cup of cooked spaghetti pasta.
Portion Size
the amount of food usually consumed at one time (e.g., 3 cups of spaghetti served as a restaurant
entrée).
BOX Everyday Items to Help Estimate

2.2 Recommended Serving Sizes
This Amount . . .
1 cup raw vegetables

½ cup vegetables
1 medium piece of fruit or 1 cup of berries
½ cup canned fruit
1 cup dry cereal
½ cup cooked pasta
2–3 oz of meat, fish, or poultry
2 tbsp peanut butter or 2 tbsp hummus
¼ cup of nuts
1 oz of cheese
1 teaspoon butter or oil
Looks Like . . .
1 baseball
1 computer mouse
1 tennis ball
1 computer mouse
1 baseball
1 computer mouse
1 deck of cards
1 pingpong ball
1 golf ball
4 dice
About the size of a penny
Source: Move, V. A. (n.d.). Serving sizes. Nutrition Handouts N21 version 5.0.
https://www.move.va.gov/download/NewHandouts/Nutrition/N21_ServingSizes.pdf
Focus on Variety
Choosing a variety of foods from within each food group helps ensure that
the more than 40 known essential nutrients are consumed in adequate
amounts based on the rationale that some nutrients (e.g., iron, calcium,
vitamin C, and vitamin A) are concentrated in a few foods.
• Cultural and personal preferences can be incorporated into healthy
eating patterns.
• All foods, such as fresh, canned, dried, frozen, and 100% juices, can
be included in healthy eating patterns when consumed in nutrient
dense forms.
• Variety is promoted by dividing some groups into subgroups:
• The vegetable group contains five subgroups with recommended
cup-equivalents per week specified:
• dark green
• red and orange
• legumes
• starchy
• other
• Grains are divided into refined and whole grain categories.
• At least half of all grains consumed should be whole grains.
• Women of childbearing age who consume all their grains in the
form of whole grains should be sure to choose some whole
grains that are fortified with folic acid, such as some breakfast
cereals.
• There are three protein food subgroups for the Healthy U.S.-Style
and Mediterranean-Style Eating Patterns:
• meats, poultry, eggs
• seafood
• nuts, seeds, and soy products
• The Healthy Vegetarian Eating Pattern also includes beans, peas,
and lentils as a protein food subgroup.
MYPLATE
MyPlate is the graphic illustration of the DGA that was created to help
consumers achieve healthy eating patterns. It features a place setting with
one half of the dinner plate devoted to fruits and vegetables, one fourth to
protein foods, and the one fourth to grains. Dairy is shown to accompany
the plate (Fig. 2.2) (USDA, n.d.). MyPlate encompasses the same
underlying principles as the DGA and promotes the following main points:
• Every bite counts—focus on variety, amount, and nutrition.
• Choose foods and beverages with less added sugars, saturated fat,
and sodium.
• Small changes matter, and the benefits of healthy eating accumulate
over time.
The serving sizes, nutritional attributes, and health benefits associated

with each food group are listed in Table 2.2. Additional guidance on oils,
added sugars, saturated fat, sodium, and alcohol are outlined in Table 2.3.
Table MyPlate Food Groups:

Serving Sizes, Nutrition
2.2 Attributes, Health
Table MyPlate: Additional
Key Topics and
2.3 Points
Key Topic Key Points

Use oils: They are not a food group but provide
unsaturated fat and vitamin E.
• Oils are derived from plants, such as olive oil,
canola oil, and corn oil.
• Three plant oils are high in saturated fat and
should be limited: coconut oil, palm oil, and
palm kernel oil.
• Oil-containing foods include mayonnaise, salad
dressings, soft margarine.
• Using unsaturated fat in place of saturated fat can
lower the risk of heart disease and increase high
density lipoprotein (HDL) cholesterol.
Key Topic Key Points
Added sugars: Syrups and sugars added to food or
beverages during processing or preparation.
• Children under the age of 2 should avoid all
foods with added sugar
• People aged 2 and older should limit added
sugars
Saturated fat: Fat that is solid at room temperature,
such as butter, milk fat, and fat in and around meat.
• Replace foods high in saturated fat with those
higher in unsaturated fat, such as vegetable oils,
fish, nuts, avocado.
Sodium: Pervasive in the food supply as a
seasoning and in preservatives.
• People aged 14 and older should limit their
sodium intake to 2300 mg/day.
• Limiting sodium intake may lower the risk of
hypertension and heart disease.
Alcohol People who do not drink should not start drinking.
Pregnant women and people with certain health
conditions should not drink.
Adults who choose to drink should do so in
moderation: 1 drink or less for women and 2 drinks
or less for men.
Source: U.S. Department of Agriculture. (n.d.) More key topics.

https://www.myplate.gov/eat-healthy/more-key-topics
Figure 2.2 ▲ MyPlate graphic. (Source: MyPlate, U.S. Department of
Agriculture. What’s on your plate?. myplate. gov. MyPlate.gov is based on
the Dietary Guidelines for Americans, 2020–2025)
Fruit
Slightly less than one quarter of MyPlate is depicted as fruit.
• Generally, slightly fewer servings of fruit than vegetables are
recommended per day in all the three styles of eating patterns.
• Fresh fruits provide more calories than vegetables and virtually all
the calories in fruit are from natural sugars.
• Canned and frozen fruit with added sugar are higher in
carbohydrates and calories.
Vegetables
Recommended amounts (based on age, sex, and level of physical activity)
are specified for the total amount of vegetables per day and total amounts
for each vegetable subgroup per week to be consumed.
• Vegetables are naturally low in calories; their calories come mostly
from starch, with someincomplete protein.
• Vegetables are generally higher in vitamins and minerals than fruits.
Grains
All foods made from wheat, rice, corn, barley, oats, or other grains are grain
products.
• Grains are used primarily for flour, pasta, and breakfast cereals.
• Grains provide calories from starch and incomplete protein.
• Whole grains are made from the intact grain kernel: bran,
endosperm, and germ.
• Refined grains contain only the endosperm; fiber, iron,
phytochemicals, and many B vitamins are lost when the bran and
germ are removed. Enrichment and fortification add back some of
these nutrients to enriched grains.
Protein Foods
This group contains both animal (meat, poultry, seafood, eggs) and plant
(nuts, seeds, beans, peas, lentils) protein sources.
• Calories come from protein and fat (animal proteins, nuts, seeds)
and carbohydrate (beans, peas, lentils, and nuts).
• The fat and saturated fat content of meat and poultry choices vary
with the specific selection; choices should be lean or low fat to help
avoid excessive calorie and saturated fat intake.
• A variety of protein foods should be consumed to improve nutrient
intake and health benefits, including at least 8 oz of seafood/week.
Dairy
The dairy group is comprised of dairy items that provide calcium: milk,
yogurt, natural cheese, and fortified soy milk and yogurt.
• Items like butter, cream cheese, and cream have little or no calcium;
therefore, they are notconsidered part of this group.
• Calories in dairy products come from carbohydrates (lactose, the
natural sugar) and protein. Fat content varies: Low-fat and fat-free
choices such as low-fat cheese and fat-free milk provide little to no
calories from fat.
Recall Aurea. She may be able to achieve variety in fruits

and vegetables. For instance, certain items in the vegetable
subgroups of dark green (raw chopped spinach), red
(tomato), orange (carrot juice), and other (zucchini) are low
in fiber. However, Aurea may not be able to tolerate legumes
or many whole grains. How do you respond to Aurea’s
frustration about having to adhere to a restrictive eating
pattern?
MyPlate
The website MyPlate.gov provides a wealth of information under the
headings of Eat Healthy, Life Stages, Resources, Professionals, and
MyPlate Kitchen.
Users can obtain:
• details about each of the food groups, what counts as a cup or ounce
equivalent for individual foods, and the nutritional value and health
benefits of each group,
• a calorie-appropriate plan based on the individual’s age, sex, height,
weight, and activity level,
• age- and lifecycle-specific information and resources for women
during pregnancy and lactation and older adults,
• activity ideas and mealtime tips for families,
• ideas for healthy eating on a budget,
• MyPlate videos and MyPlate app,
• MyPlate tools, such as quizzes,
• recipes, recipe videos, and recipe resources, and
• MyPlate graphics in multiple languages (Fig. 2.3).
Figure 2.3 ▲ MyPlate graphic in Spanish. (Source: MyPlate, U.S.
Department of Agriculture. What’s on your plate?. myplate. gov.
MyPlate.gov is based on the Dietary Guidelines for Americans, 2020–2025)
Think of Aurea. Aurea wants to add probiotics to her diet to

see if they help. The American Gastroenterology
Association’s clinical practice guidelines for the
management of mild to moderate ulcerative colitis do not
make a recommendation regarding the use of probiotics due
to insufficient evidence regarding their benefits (Ko et al.,
2019). How would you respond to Aurea? What foods
contain probiotics?
When providing an explanation of MyPlate, the nurse should note

that it is a graphic of a place setting with a quarter of the plate
devoted to grains and one half devoted to fruits and vegetables.
MyPlate covers all aspects of the diet and reflects a philosophy that
nutrient needs should be met through food as much as possible.
RECOMMENDATIONS FROM
HEALTH AGENCIES
Many health agencies publish guidelines or recommendations for healthy

eating, including the American College of Cardiology/American Heart
Association (Arnett et al., 2019), the American Cancer Society (Kushi et
al., 2012), and the American Institute for Cancer Research (World Cancer
Research Fund & American Institute for Cancer Research, 2007) (Table
2.4). The recommendations of these agencies are similar to each other and
to those of the DGA. Common themes are attaining or maintaining healthy
weight, being physically active, choosing a nutrient-dense varied eating
pattern, limiting certain foods and dietary components, and drinking alcohol
in moderation, if at all.
Table A Summary Comparison of

Nutrition and Physical Activity
2.4 Recommendations from the
American College of
Cardiology/American Heart
Association, the American
Cancer Society, and the
American Institute for Cancer
Research
EATING BEHAVIORS AMERICANS
ARE TRYING TO IMPROVE
There is some evidence to indicate that people are at least trying to improve
their eating patterns, although they fall short of current recommendations.
The 2019 Food and Health Survey of the International Food Information
Council (2019) shows that the top five ways in which people say their diets
have changed over the past 10 years is
• limiting sugar intake,
• eating more fruits and vegetables,
• eating less carbohydrate,
• eating healthier protein sources, and
• eating better and healthier in general.
GUIDELINES AND GRAPHICS IN

OTHER COUNTRIES
Cultural differences in symbolism and other cultural norms influence the

shape of food guides in other countries. Similar to MyPlate, a circle or
dinner plate with each section depicting relative proportion to the total diet
is used in many countries, including Canada (Fig. 2.4), the United
Kingdom, and Mexico. In the Republic of Korea, the back wheel of a
bicycle is used to depict the food groups. China employs a pagoda shape to
depict the food groups, while the Bahamas uses a more unique goatskin
drum, divided into different food groups. Despite the differences in the
shape of the graphics, guidelines generally contain several consistent
concepts:
• Eat a variety of foods.
• Limit added sugar and salt.
• Be physically active.
• Attain and maintain healthy weight.
Figure 2.4 ▲ Canada’s food guide. Eat well. Live well. (© Her Majesty
the Queen in Right of Canada, as represented by the Minister of Health,
2019. Reprinted with permission)
How Do You Respond?

Which foods are “good?” Which foods are
“bad”? Instead of thinking of individual foods as good
or bad, consider how a food fits within the context of the
total intake. For instance, broccoli is among the best plant
foods available, yet if someone ate only broccoli all day
long, it would not be “good” because broccoli does not
supply adequate amounts of all essential nutrients for
health. What matters is how often a particular food is
eaten, the amount eaten, and the overall calorie and
nutrient balance.
If most of a person’s intake is of nutrient-dense foods, small amounts

of less nutritious choices can fit into the eating pattern without wreaking
havoc as long as total calorie intake is appropriate. The keys to fitting in
less-than-healthy foods are to eat them infrequently, in small amounts,
and in the context of an otherwise healthy eating pattern.
How can I eat whole grains if I don’t like whole wheat
bread? Just as there are no good or bad foods, there is no one particular
food you must eat to be healthy or one particular food you must never eat
to be healthy. White whole wheat bread or whole wheat versions of
bagels, pita bread, or tortillas for sandwiches and wraps may be eaten.
Whole grains like quinoa, brown rice, bulgur, or barley can be eaten as a
side dish or as part of a grain bowl that can be a substitute for a
sandwich. Whole grains can also be consumed as cereals (e.g., oatmeal,
shredded wheat), as side dishes (e.g., quinoa, brown rice), as ingredients
in other dishes (e.g., wild rice or sorghum added to soup), and even as
snacks (e.g., popcorn).
REVIEW CASE STUDY
Andrew wants to eat healthier, so he went online to learn about MyPlate. He

was overwhelmed by all the information on MyPlate.gov and became
disenchanted by recommendations in cups and ounces—concepts that are
unfamiliar to him. Andrew is clearly interested in changing his food habits,
but he is stuck on the idea that he won’t be able to make any changes unless
he weighs and measures his food. He is wondering if eating healthier is
worth the trouble.
• How would you encourage Andrew to approach the goal of eating

healthier?
• How would you use MyPlate to help Andrew make better choices
without overwhelming him?
• What would you tell him about weighing and measuring foods?
• How would you respond to these questions or statements from Andrew?
• “I only like fruit juice and not whole fruits. Is it okay to consume all
my fruit servings as juice?”
• “I don’t like fat-free milk. Can I drink 2% milk instead?”
• “I noticed on my MyPlate plan that I should eat less than 2300 mg of
sodium each day. I eat out a lot, so I don’t have the option of
calculating sodium intake from food labels for everything I eat.”
• “I like craft beers. Where does alcohol fit into MyPlate?”
STUDY QUESTIONS
1 Which of the following is not part of the four DGA?

a. Attain and maintain a healthy body weight throughout life.
b. Focus on meeting food group needs with nutrient-dense foods and
beverages and stay within calorie limits.
c. Customize and enjoy nutrient-dense foods and beverage choices.
d. Follow a healthy dietary pattern at every life stage.
2 The DGA recommend that Americans do all of the following except
a. limit saturated fat intake to less than 10% of total calories starting at
age 2.
b. limit sodium to less than 2300 mg/day for people 14 and older.
c. limit total fat intake to less than 30% of calories beginning at age 2.
d. limit added sugars to less than 10% of total calories beginning at age 2.
3 “Moderate” alcohol consumption is
a. three to 4 drinks per week for women and 6 to 8 drinks per week for
men.
b. up to 1 drink per day for both men and women.
c. up to 1 drink per day for women and up to 2 drinks per day for men.
d. up to 2 drinks per day for women and up to 3 drinks per day for men.
4 The nurse knows that the client understands their instructions about grain
equivalents when the client verbalizes that one grain equivalent is equal
to
a. one slice of bread.
b. two cups of ready-to-eat cereal.
c. one cup of cooked pasta.
d. one cup of cooked rice.
5 A client states that there is no way they can eat all the vegetables
recommended in their MyPlate plan. What is the nurse’s best response?
a. “If you can’t eat all the vegetables, then make up for the difference by
eating more fruit.”
b. “Be sure to take a daily multivitamin to provide the nutrients that may
be missing from your diet.”
c. “Set a goal of eating larger quantities of the vegetable servings that
you currently eat, and gradually increase the servings and variety as
you become more skillful in adding vegetables to your diet.”
d. “No one can. The recommendations are only a guide. Just eat what you
can.”
6 The nurse knows that the client understands their instructions about
estimating portion sizes when the client verbalizes that one cup of dry
cereal looks like
a. one baseball.
b. one computer mouse.
c. one ping-pong ball.
d. one tennis ball.
7 Which of the following food items is not nutrient dense?
a. Sweetened applesauce
b. Whole wheat bread
c. Plain shredded wheat
d. Plain low-fat yogurt with fruit
8 Compared to a Healthy U.S.-Style Eating Pattern, a Mediterranean-Style
Eating Pattern is generally
a. higher in vegetables and whole grains.
b. higher in seafood and lower in dairy.
c. higher in oils and dairy.
d. lower in protein foods and fruits.
CHAPTER SUMMARY Guidelines for

Healthy Eating
Guidelines for healthy eating, put forth by the government and health
organizations, are intended to help the public choose healthy eating
patterns.
Dietary Guidelines for

Americans
Revised every 5 years, the DGA provide evidence-based advice across
the lifespan on food and beverages to consume to promote health, reduce
the risk of chronic disease, and meet nutrient needs:
• Follow a healthy dietary pattern at every life stage.
• Customize and enjoy nutrient-dense food and beverage choices to
reflect personal preferences, cultural traditions, and budgetary
considerations.
• Focus on meeting food group needs with nutrient-dense foods and
beverages, and stay within calorie limits.
• Limit foods and beverages higher in added sugars, saturated fat, and
sodium, and limit alcoholic beverages.
The DGA feature healthy food patterns with three different eating pattern
styles to illustrate how the guidelines and recommendations translate into
food across 12 different calorie levels, from 1000 to 3200 calories:
• Healthy U.S.-Style Pattern
• Healthy Mediterranean-Style Pattern
• Healthy Vegetarian Pattern
The underlying principles of healthy eating are to
• choose nutrient-dense foods and beverages,
• meet nutrient needs through foods and beverages not through
supplements,
• use portion control, and
• focus on variety.
MyPlate
MyPlate is a graphic illustration of the DGA. It features a dinner plate
with one half devoted to fruits and vegetables, one fourth to protein, and
one fourth to grains. Dairy is alongside the plate.
• Whole fruits that are fresh, frozen, canned, or dried are emphasized.
• The vegetable group is divided into subgroups with weekly
recommended amounts specified for each group to ensure variety.
• At least half of grain servings should be whole grain.
• Within the protein group, lean sources of meat and poultry are
recommended, as are two weekly servings of seafood. Nuts, seeds, soy
products, and legumes are healthy plant sources of protein with
recommended amounts per week specified.
• The dairy group features low-fat or fat-free milk, yogurt, and soy milk.
• Additional points are to use oils and limit added sugars, saturated fat,
sodium, and alcohol.
The website MyPlate.gov provides a myriad of online resources about
healthy eating for all lifecycle stages.
Recommendations from Health

Agencies
Many health agencies publish healthy eating recommendations or
guidelines for the prevention of chronic disease. Recommendations made
by the American Heart Association, the American Cancer Society, and
the American Institute for Cancer Research are remarkably consistent:
• Attain and maintain a healthy weight.
• Eat a variety of foods, with an emphasis on fruits and vegetables,
whole grains, and healthy proteins.
• Eat less saturated fat, sodium, and added sugars.
• Drink alcohol in moderation, if at all.
Eating Behaviors Americans

Are Trying to Improve
The typical American diet is far from ideal, yet many Americans
surveyed say they are trying to
• limit sugar intake,

• eat more fruits and vegetables,
• eat less carbohydrate,
• eat healthier protein sources, and
• eat better and healthier in general.
Guidelines and Graphics in

Other Countries
Many countries use a circle or dinner plate to illustrate their dietary
guidelines for healthy eating; however, there is still variety around the
globe, such as a pagoda (China), bicycle wheel (Korea), and a goatskin
drum (Bahamas). Global recurrent concepts are to
• be physically active,
• limit salt and added sugar,
• eat a variety of foods, and
• attain and maintain a healthy weight.
Figure sources: shutterstock.com/P Kyriakos and shutterstock.com/Valentyn Volkov.

activate the code in the front of this
book at
https://thePoint.lww.com/activate
Websites
American Cancer Society Guideline for Diet and Physical Activity for Cancer Prevention at
http://www.cancer.org/healthy/eathealthygetactive/acsguidelinesonnutritionphysicalactivityforcan
cerprevention/index
The American Heart Association Diet and Lifestyle Recommendations at
https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/nutrition-basics/aha-diet-and-
lifestyle-recommendations
American Institute for Cancer Research’s cancer prevention recommendations at
https://www.aicr.org/reduce-your-cancer-risk/recommendations-for-cancer-prevention/
Dietary Guidelines for Americans 2020–2025 at
https://www.dietaryguidelines.gov/sites/default/files/2020-
12/Dietary_Guidelines_for_Americans_2020-2025.pdf
Food and Agriculture Organization of the United Nations’ food-based dietary guidelines at
http://www.fao.org/nutrition/education/food-dietary-guidelines/regions/en/. Choose from the
drop-down menu “Browse by countries” to select a particular country.
International Food Information Council’s 2019 Food and Health Survey at
https://foodinsight.org/2019-food-and-health-survey/
MyPlate at https://www.myplate.gov/
References
Arnett, D. K., Blumenthal, R. S., Albert, M. A., Buroker, A. B., Goldberger, Z. D., Hahn, E. J.,
Himmelfarb, C. D., Khera, A., Lloyd-Jones, D., McEvoy, J. W., Michos, E. D., Miedema, M. D.,
Muñoz, D., Smith, S. C. Jr., Virani, S. S., Williams, K. A. Sr., Yeboah, J., & Ziaeian, B. (2019).
2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: A report of the
American College of Cardiology/American Heart Association Task Force on Clinical Practice
Guidelines. Circulation, 140, e596–e646. https://doi.org/10.1161/CIR.0000000000000678
International Food Information Council. (2019, May 22). 2019 food and health survey.
https://foodinsight.org/2019-food-and-health-survey/
Ko, C. W., Singh, S., Feuerstein, J. D., Falck-Ytter, C., Falck-Ytter, Y., Cross, R. K., & American
Gastroenterological Association Institute Clinical Guidelines Committee. (2019). AGA clinical
practice guidelines on the management of mild-to-moderate ulcerative colitis. Gastroenterology,
156(3), 748–764. https://doi.org/10.1053/j.gastro.2018.12.009
Kushi, L., Doyle, C., McCullough, M., Rock, C. L., Demark-Wahnefried, W., Bandera, E. V.,
Gapstur, S., Patel, A., Andrews, K., Gansler, T., & American Cancer Society 2010 Nutrition and
Physical Activity Guidelines Advisory Committee. (2012). American Cancer Society guidelines
on nutrition and physical activity for cancer prevention: Reducing the risk of cancer with healthy
food choices and physical activity. CA: A Cancer Journal for Clinicians, 62(1), 30–67.
https://doi.org/10.3322/caac.20140
U.S. Department of Agriculture. (n.d.). MyPlate. https://www.myplate.gov
U.S. Department of Agriculture & U.S. Department of Health and Human Services. and U.S.
Department of Agriculture. (2020, December). Dietary guidelines for Americans 2020–2025.
World Cancer Research Fund & American Institute for Cancer Research. (2007). Food, nutrition,
physical activity, and the prevention of cancer: A global perspective. American Institute for
Cancer Research.
Chapter Carbohydrates
3
Krista Larson
Krista is a 24-year-old graduate student who
complains of chronic constipation. She has used
laxatives for years in an effort to control her weight,
and eliminates as many carbohydrates from her diet
as she can. She recently tried to stop using laxatives
but is unable to have a bowel movement on her own.
Learning Objectives
1 Explain how carbohydrates are classified.

2 Identify sources of carbohydrates.
3 Debate the usefulness of using glycemic load to make food choices.
4 Describe the functions of carbohydrates.
5 Modify a menu to replace low-fiber foods with higher-fiber foods.
6 Discuss the recommendations regarding carbohydrate intake in the
Dietary Guidelines for Americans.
7 Suggest ways to increase whole grain intake.
8 Discuss the benefits and disadvantages of using sugar alternatives.
Sugar and starch come to mind when people hear the word carbs, but
carbohydrates are so much more than just table sugar and bread. Foods
containing carbohydrates can be empty calories, nutritional powerhouses, or
something in between. Globally, carbohydrates provide the majority of
calories in almost all human diets.
This chapter describes what carbohydrates are, where they are found in
the diet, and how they are handled in the body. Recommendations regarding
intake and the role of carbohydrates in health are presented.
CARBOHYDRATE CLASSIFICATIONS
Carbohydrates (CHO) are composed of the elements carbon, hydrogen,

and oxygen arranged into basic sugar molecules. They are classified as
either simple sugars or complex carbohydrates (Fig. 3.1). Simple sugars
contain only one (mono-) or two (di-) sugar (saccharide) molecules; they
vary in sweetness and sources. Complex carbohydrates, of which starch is
the most common, is made of long chains of many (poly) sugar (saccharide)
molecules.
Figure 3.1 ▲ Carbohydrate classifications.
Carbohydrates (CHO)
a class of energy-yielding nutrients that contain only carbon, hydrogen, and oxygen, hence the
common abbreviation of CHO.
Simple Sugars
a classification of carbohydrates that includes monosaccharides and disaccharides; commonly
referred to as sugars.
Complex Carbohydrates
a group name for starch, glycogen, and fiber; composed of long chains of glucose molecules.
Starch
the storage form of glucose in plants.
Monosaccharides
Monosaccharides are the simplest form of carbohydrate. They cannot be
digested into smaller molecules and thus are absorbed as they are. Hexoses,
sugar molecules containing six carbon atoms, are the only monosaccharides
that are abundant in food and nutritionally significant.
Monosaccharide
single (mono) molecules of sugar (saccharide); the most common monosaccharides in foods are
hexoses that contain six carbon atoms.
Glucose
Glucose, also known as dextrose, is the simple sugar of greatest distinction,
which
• circulates through the blood to provide energy for body cells,
• is a component of all disaccharides, and is virtually the sole
constituent of complex carbohydrates,
• is the sugar to which the body converts all other digestible
carbohydrates, and
• is naturally found in fruit, vegetables, honey, corn syrup, and
cornstarch.
Fructose
Fructose, also known as fruit sugar or levulose
• is the sweetest of all simple sugars,
• is naturally found in fruit, honey, and some vegetables, and
• comprises 42% to 55% of high-fructose corn syrup (HFCS).
Galactose
Galactose does not occur in appreciable amounts in foods. It is significant
only as it combines with glucose to form lactose.
Disaccharides
Disaccharides are double sugars made from one glucose molecule and one
other monosaccharide.
Disaccharide
“double sugar” composed of two (di) monosaccharides (e.g., sucrose, maltose, lactose).
Sucrose
Sucrose is the most familiar of all sugars and what comes to mind when the
word sugar is used. It is
• composed of 50% glucose and 50% fructose,
• extracted from sugarcane and sugar beets and processed into its
many forms, such as white, brown, powdered, turbinado, raw, and
Baker’s Special, and
• found naturally in maple syrup, bananas, dates, pineapple, peas, and
sweet potato.
Lactose
Also known as milk sugar, lactose is the only animal source of carbohydrate
in the diet, and
• is composed of 50% glucose and 50% galactose,
• is the least sweet of all sugars,
• enhances the absorption of calcium when consumed at the same
time, and
• is often used by the pharmaceutical industry as filler in pills.
Maltose
Also known as malt sugar, maltose is not found freely in food. It is
• composed of two glucose molecules,
• produced through the process of malting (e.g., malted milk),
• used primarily as a flavoring and coloring agent in the manufacture
of beer, and
• an intermediate in the digestion of starch.
Table Fiber Content of

3.1 Fiber-rich Foods
Complex Carbohydrates
Complex carbohydrates, also known as polysaccharides, are composed of
hundreds to thousands of glucose molecules linked together. Despite being
made of sugar, polysaccharides do not taste sweet because their molecules
are too large to fit on the tongue’s taste bud receptors that sense sweetness.
Starch, glycogen, and fiber are types of polysaccharides.
Polysaccharides
carbohydrates consisting of many (poly) sugar molecules.
Glycogen
storage form of glucose in animals and humans.
Starch
Plants synthesize glucose through the process of photosynthesis, and they
use that glucose for energy. Glucose not used by the plant for immediate
energy is stored in the form of starch in seeds, roots, or stems.
• Starch provides the majority of calories in grains, such as wheat,
rice, corn, barley, millet, sorghum, oats, and rye. Other sources
include legumes and starchy vegetables (e.g., potatoes, plantains,
and parsnips).
• The majority of starch in grains comes from the endosperm, or the
middle portion of the kernel, which is a component of both refined
and whole grains.
• Cooking makes starch more digestible and slightly sweeter.
Glycogen
Glycogen is the animal (including human) version of starch. It is stored
carbohydrate available for energy as needed. Humans have a limited supply
of glycogen stored in the liver and muscles.
• There is virtually no dietary source of glycogen because any
glycogen stored in animal tissue is quickly converted to lactic acid
at the time of slaughter.
• The only exception is the miniscule amounts of glycogen in
shellfish, such as scallops and oysters, which is why they taste
slightly sweet compared to other fish.
Fiber
Fiber is a group name for non-digestible carbohydrates linked to an array of
potential health benefits, including a lower risk of cardiovascular disease,
stroke, hypertension, certain gastrointestinal conditions, obesity, type 2
diabetes, and some types of cancer (Box 3.1). Historically referred to as
“roughage” or “bulk,” fiber only occurs naturally in plants as a component
of plant cell walls or intercellular structure. An estimated 85% of fiber in
the U.S. food supply comes from grain products, vegetables, legumes, nuts,
soy, and fruit (Dahl & Stewart, 2015). Table 3.1 lists the fiber content of
selected fiber-rich foods. Almost all sources of fiber provide a mix of
different types of fiber. No universal definition of fiber exists, and there are
a number of ways it can be classified.
BOX Potential Health Benefits Linked to Fiber

3.1
• A high fiber intake may improve serum lipid levels, lower blood
pressure, and lower inflammatory marker levels, which may explain
the link between fiber and lower risk of cardiovascular disease (CVD)
(International Food Information Council, 2019).
• Observational data suggest a 15% to 30% lower risk in all-cause and
CVD mortality, incidence of congenital heart disease, stroke incidence
and mortality, type 2 diabetes, and colorectal cancer when comparing
higher with lower intakes of dietary fiber (Reynolds et al., 2019).
• A high fiber intake is associated with a reduced risk of mortality from
all cancers (Kim & Je, 2016).
• Observational studies show that populations with higher intakes of
fiber often have lower body weight and that obese people tend to have
lower intakes of fiber (Dahl & Stewart, 2015).
• Fiber promotes gastrointestinal health by increasing stool bulk to
improve laxation (IFIC, 2019).
• A high fiber intake contributes to the maintenance of a healthy gut
microbiota associated with increased diversity and functions, such as
the production of short-chain fatty acids, which help maintain a
functional immune system (Makki et al., 2018).
• Fiber has commonly been classified as either soluble or insoluble.

• Soluble fibers dissolve in water to a gel-like substance (are
viscous) and are easily digested (fermentable) by bacteria in the
colon.
• Sources include oatmeal, legumes, lentils, and citrus fruit.
• Soluble fiber is credited with slowing gastric emptying time to
promote a feeling of fullness, delaying and blunting the rise in
postprandial serum glucose, and lowering serum cholesterol by
promoting its excretion.
• Insoluble fibers do not form gels, and they are not readily
fermentable.
• Insoluble fibers absorb water to add bulk to stools, and thereby
promote laxation.
• Whole grains, bran, and the skins and seeds of fruit and
vegetables provide insoluble fiber.
• The National Academy of Sciences recommends phasing out the
terms soluble and insoluble and replacing them with terms that
describe their physiochemical properties of viscosity and
fermentability (Institute of Medicine, 2001). This means the term
soluble fiber would be replaced by viscous fiber and insoluble
fiber by non-fermentable fiber.
• Another way to classify fiber is by its source.
• Dietary fiber is the intact and naturally occurring fiber in plants.
• Functional fiber is fiber that has been isolated or extracted from
plants and then added to food. For example, inulin is added to
some yogurt.
• Total fiber is the sum of dietary fiber and functional fiber.
Recall Krista. Her restricted carbohydrate intake provides

negligible fiber, because fiber occurs naturally only in plant
sources of carbohydrates.
• What other nutrients may be lacking in her eating
pattern due to her restricted intake of grains, fruit,
vegetables, and legumes?
• What would you teach Krista about the role of carbohydrates and
fiber in health?
• What does she need to know about increasing her fiber intake?
It is commonly assumed that fiber does not provide any calories because it
is not truly digested by human enzymes and may actually trap
macronutrients eaten at the same time, preventing them from being
absorbed. Yet fibers that are soluble/viscous are fermented by bacteria in
the colon to produce carbon dioxide, methane, hydrogen, and short-chain
fatty acids, which serve as a source of energy (calories) for the mucosal
lining of the colon. Although the exact energy value available to humans
from the blend of fibers in food is unknown, it is estimated that the
fermentation of fiber in the average human gut yields between 1.5 and 2.5
cal/g (Institute of Medicine, 2005).
Dietary Fiber
carbohydrates and lignin that are natural and intact components of plants that cannot be digested
by human enzymes.
Soluble Fiber/Viscous Fiber

non-digestible carbohydrates that tend to form a thick, gel-like compound in the stomach that may
then be fermented by bacteria in the colon.
Insoluble Fiber/Non-Fermentable Fiber

non-digestible carbohydrates that cannot be broken down by bacteria in the colon but absorb
water.
Functional Fiber
as proposed by the Food and Nutrition Board, functional fiber consists of extracted or isolated
non-digestible carbohydrates that have beneficial physiologic effects in humans.
Total Fiber
total fiber = dietary fiber + functional fiber.
SOURCES OF CARBOHYDRATES
Table 3.2 summarizes the amount of carbohydrate and fiber in servings of

various foods. Americans consume approximately 50% of their total daily
calorie intake in the form of carbohydrates, including starch from grains,
legumes, and some vegetables; naturally occurring sugars in milk, fruit, and
vegetables; and added sugars in items containing sugars and syrups added
during processing, food preparation, or at the table (e.g., sugar in coffee).
Added Sugars
caloric sugars and syrups added to foods during processing or preparation, or consumed
separately; do not include sugars naturally present in foods, such as fructose in fruit and lactose in
milk.
Sources of
Table Carbohydrates: Average
3.2 Amount of Carbohydrate
and Fiber per Serving
HOW THE BODY HANDLES
CARBOHYDRATES
Digestion and Absorption

Carbohydrates are digested more quickly and completely than protein and
fat. Normally, most starches and all sugars are digested within 1 to 4 hours
after eating. Monosaccharides are the simplest form of carbohydrates and
are the end product of disaccharide and polysaccharide digestion.
• Cooked starch begins to undergo digestion in the mouth by the
action of salivary amylase, but the overall effect is small because
food is not held in the mouth for very long (Fig. 3.2).
• The stomach churns and mixes its contents, but its acidic medium
halts any residual effect of swallowed amylase.
• The principal site of carbohydrate digestion is the small intestine.
Pancreatic amylase, secreted into the intestine by way of the
pancreatic duct, reduces polysaccharides to shorter glucose chains
and maltose.
• Disaccharidase enzymes (maltase, sucrase, and lactase) within the
brush border of the intestine split maltose, sucrose, and lactose, into
monosaccharides.
• Monosaccharides, whether consumed as monosaccharides or
resulting from the digestion of other carbohydrates, are absorbed
through intestinal mucosa cells and travel to the liver via the portal
vein.
• Small amounts of starch that have not been fully digested pass into
the colon and are excreted in the stools.
• Fibers, which are non-digestible, advance to the large intestine.
• Non-fermentable fibers attract water, which softens stools and
promotes laxation.
• Viscous fibers are fermented by gut microbiota, which yields
water, methane, hydrogen, and short-chain fatty acids: These fatty
acids are used by the colon for energy or are absorbed and
metabolized by liver cells.
Typically, two-thirds of the body’s glycogen is stored in the muscle,

where it is available only for use in the muscle, and the remaining
one third is stored in the liver, where it is available for all body cells.
Figure 3.2 ▲ Carbohydrate digestion.

Metabolism
Fructose and galactose are converted to glucose in the liver. The liver
releases glucose into the bloodstream, where its level is held fairly constant
by hormones.
• A rise in blood glucose concentration after eating causes the
pancreas to secrete insulin, which moves glucose out of the
bloodstream and into the cells.
• Most cells take only as much glucose as they need for immediate
energy needs.
• Liver and muscle cells take up extra glucose molecules during
times of plenty and join them together to form glycogen.
• One-third of the body’s total glycogen reserve is in the liver
and can be released into circulation for all body cells to use
• Two-thirds is in muscle, which is available only for use by
muscles.
• Unlike fat, glycogen storage is limited and may provide only
enough calories for about a half-day of moderate activity.
• The movement of glucose out of the bloodstream and into cells
eventually causes glucose levels to return to normal.
• Blood glucose concentration begins to drop as the body uses the
energy from the last meal.
• Even a slight fall in blood glucose stimulates the pancreas to
release glucagon, which causes the liver to release glucose from
its supply of glycogen. The result is that blood glucose levels
increase to normal.
Glycemic Response
It was commonly believed that sugars produce a greater increase in blood
glucose levels, or glycemic response, than complex carbohydrates because
they are rapidly and completely absorbed. This assumption proved to be too
simplistic, as illustrated by the lower glycemic index of cola (sugar)
compared to that of baked potatoes (complex carbohydrate) (Table 3.3). A
food’s glycemic response is actually influenced by many variables,
including the amounts of fat, fiber, and acid in the food; the degree of
processing; the method of preparation; the amount eaten; the degree of
ripeness (for fruit and vegetables); and whether other foods are eaten at the
same time.
Glycemic Index and

Table Glycemic Load of Selected
Foods, as Determined in
3.3 People with Normal
Glucose Tolerance
Glycemic Index Glycemic
Item (Glucose = 100) Load/Serving
Pretzels (Canada) 83 ± 9 16
Puffed rice cakes, caramel 82 ± 10 18
flavored
Corn flakes 77 19
Boiled white rice (Canada) 72 ± 9 30
Whole meal (whole wheat) 72 ± 6 8
bread (Canada)
Clover honey 69 ± 8 15
Mars Bar 68 ± 12 27
Brown rice (Canada) 50 ± 8 24
Coca-Cola 63 16
Sweet corn, boiled 60 11
White spaghetti (Canada) 50 ± 8 24
V8 100% vegetable juice 43 ± 4 4
Whole milk 41 ± 2 5
Orange, raw (Canada) 40 ± 3 4
All-bran cereal 38 8
Glycemic Index Glycemic
Item (Glucose = 100) Load/Serving
Chocolate cake with 38 ± 3 20
chocolate frosting
Fat-free milk 32 4
Note. All items are U.S. formulations unless otherwise indicated.
Source: Atkinson, F., Foster-Powell, K., & Brand-Miller, J. (2008). International tables of glycemic
index and glycemic load values: 2008. Diabetes Care, 32(12), 2281–2283.
https://doi.org/10.2337/dc08-1239.
On a scale of 0 to 100, GI ranks carbohydrates based on how quickly
they raise blood glucose levels after eating.
• A food’s GI is determined by comparing the impact on blood
glucose after a food sample of 50 g of carbohydrate (minus the
fiber) is eaten to the impact of 50 g of pure glucose or white bread
over a 2-hour period: For instance, a boiled potato with a GI of 78
elicits 78% of the blood glucose response as an equivalent amount
of pure glucose.
• The amount of carbohydrate contained in a typical portion of food
also influences the glycemic response, so the concept of glycemic
load (GL) was created; it combines portion size and GI into one
value.
• The carbohydrate content of a serving is multiplied by the food’s
GI, then divided by 100.
• For example, the GI of beets is 64, but because they have only 13
g of carbohydrate per cup, the GL is only 8.3. (13 g × 64 ÷ 100 =
8.3)
• In general, a GL > 20 is considered high, and 10 or less is
considered low.
• In a practical sense, GL is not a reliable tool for choosing a healthy
diet, and claims that a low-GI diet promotes significant weight loss
or helps control appetite are unfounded.
• Soft drinks, candy, sugars, and high-fat foods may have a low to
moderate GI, but these foods are not nutritious and eating them
does not promote weight loss.
• In addition, a food’s actual impact on glucose levels is difficult to
predict, due to the many factors influencing GL.
• GI may help people with diabetes fine-tune optimal meal planning
(see Chapter 21), and athletes can use the GI to choose optimal fuels
for before, during, and after exercise.
Glycemic Response
the effect a food has on the blood glucose concentration: how quickly the glucose level rises, how
high it goes, and how long it takes to return to normal.
Glycemic Index (GI)

a numeric measure of the glycemic response of a 50 g carbohydrate serving of a food sample. The
higher the number, the higher the glycemic response.
Glycemic Load (GL)

a formula that combines portion size and GI into one number to evaluate the impact on blood
glucose levels.
FUNCTIONS OF CARBOHYDRATES
Glucose metabolism is a dynamic state of balance between burning glucose

for energy (catabolism) and using glucose to build other compounds
(anabolism). This process is a continuous response to the supply of glucose
from food and the demand for glucose for energy needs.
Glucose for Energy

The primary function of carbohydrates is to provide energy for cells.
• Glucose is burned more efficiently and more completely than either
protein or fat, and it does not leave an end product that the body
must excrete.
• Although muscles use a mixture of fat and glucose for energy, the
brain is normally totally dependent on glucose for energy.
• All digestible carbohydrates—namely, simple sugars and complex
carbohydrates—provide 4 cal/g. Depending on the extent to which
fibers are fermented in the colon into short-chain fatty acids and
metabolized, fibers provide 1.5 to 2.5 cal/g.
Protein Sparing
Consuming adequate carbohydrate to meet energy needs has the effect of
“sparing protein” from being used for energy, leaving it available to do the
special functions that only protein can perform, such as replenishing
enzymes, hormones, antibodies, and blood cells. An adequate carbohydrate
intake is especially important whenever protein needs are increased, such as
for wound healing and during pregnancy and lactation.
Preventing Ketosis
Fat normally supplies about half of the body’s energy requirement at rest.
Yet, glucose fragments are needed to efficiently and completely burn fat for
energy.
• Fat oxidation prematurely stops at the intermediate step of ketone-
body formation without adequate glucose.
• Ketone bodies are normally produced in small quantities.
• They can be used by muscles and other tissues for energy.
• An increased production of ketone bodies and their accumulation in
the bloodstream can cause nausea, fatigue, loss of appetite, and
ketoacidosis.
• Dehydration and sodium depletion may follow as the body tries to
excrete ketones in the urine.
Ketone Bodies
intermediate, acidic compounds formed from the incomplete breakdown of fat when adequate
glucose is not available.
Using Glucose to Make Other Compounds

After energy needs are met, excess glucose can be
• converted to other essential carbohydrates, such as ribose, a
component of ribonucleic acid and deoxyribonucleic acid;
• broken down to provide a carbon stem that the body can use to make
nonessential amino acids, if nitrogen and other necessary
components are available.
Using Glucose to Make Fat

After energy needs are met, glycogen stores are saturated, and other specific
compounds are made. Any glucose remaining at this point is converted by
liver cells to triglycerides and stored in the body’s fat tissue. The body does
this by combining acetate molecules to form fatty acids, which then are
combined with glycerol to make triglycerides. Although it sounds easy for
excess carbohydrates to be converted to fat, it is not a primary pathway; the
body prefers to make body fat from dietary fat, not from carbohydrates.
Total Carbohydrate
The Recommended Dietary Allowance for total carbohydrate (starch,
natural sugar, added sugar) is set at 130 g for both adults and children,
based on the average minimum amount of glucose that is needed to fuel the
brain and assuming total calorie intake is adequate (Institute of Medicine,
2005). Yet at this level, total calorie needs are not met unless protein and fat
intakes exceed levels considered healthy.
• A more useful guideline for determining appropriate carbohydrate
intake is the Acceptable Macronutrient Distribution Range
(AMDR), which recommends carbohydrates provide 45% to 65% of
total calories consumed (Institute of Medicine, 2005).
• As illustrated in Figure 3.3 the carbohydrate content using AMDR
standards is significantly higher than the minimum of 130 g/day.
• Table 3.4 estimates the Carbohydrate Content of a 2000-calorie
Healthy U.S.-Style Eating Pattern.
Table Carbohydrate Content of

the 2000-Calorie Healthy
3.4 U.S.-Style Eating Pattern
Figure 3.3 ▲ Amount of total carbohydrates appropriate at various
caloric levels based on the Acceptable Macronutrient Distribution
Range of 45% to 65% of total calories. The dotted line represents the
Recommended Dietary Allowance for carbohydrate based on the
average minimum amount needed.
Fiber
An Adequate Intake (AI) for total fiber is set at 14 g/1000 calories, or
approximately 25 g/day for women and 38 g/day for men (Institute of
Medicine, 2005). Fiber is not an essential nutrient that must be consumed
through food in order to prevent a deficiency disease; the recommendation
is based on intake levels that have been observed to protect against
coronary heart disease based on epidemiologic and clinical data. Most
Americans eat about half the amount of fiber recommended, most of which
comes from vegetables (International Food Information Council [IFIC],
2019).
CARBOHYDRATES IN HEALTH
PROMOTION
Americans, on average, consume an appropriate percentage of their calories

from carbohydrates but are urged to make healthier choices, namely, to use
whole grains in place of refined grains (especially refined grains that are
high in saturated fat, added sugars, or sodium) and to limit added sugars.
For instance, the American College of Cardiology and the American Heart
Association (AHA) recommend a healthy diet that emphasizes whole grains
and minimizes the intake of refined carbohydrates and sugar-sweetened
beverages (SSB) (Arnett et al., 2019).
Increase Whole Grains

Americans are urged to eat whole grains for at least half of their total grain
servings. Yet according to the 2020–2025 Dietary Guidelines for
Americans, 98% of Americans aged 1 and older consume less than the
recommended amounts of whole grains (U.S. Department of Agriculture
[USDA] & U.S. Department of Health and Human Services [USDHHS],
2020). Low intakes of whole grain (and also fruit and vegetables)
negatively effects fiber intake. Fiber is identified as a shortfall nutrient in
the typical American eating pattern and a dietary component of public
health concern because underconsumption is associated with health
concerns (USDA & USDHHS, 2020).
Grains are classified as “whole” or “refined,” which means not whole
(Box 3.2). Whole grains consist of the entire kernel of a grain bran, germ,
and endosperm (Fig. 3.4). They may be eaten whole as a complete food
(e.g., oatmeal, brown rice, popcorn) or milled into flour to be used as an
ingredient in bread, cereal, pasta, and baked goods. Even when whole
grains are ground, cracked, or flaked, they must have the same proportion
of the original three parts: bran, endosperm, and germ.
Figure 3.4 ▲ Whole wheat. The components of the whole wheat kernel
are the bran, the germ, and the endosperm.
• Whole grains vary widely in their fiber content, providing slightly

more than a half gram (e.g., brown rice) to around 3 g per serving
(bulgur wheat). Whole grain cereals also vary in fiber content. Some
bran cereals provide >10 g per serving, but they are not truly
“whole” grain because they are only one part of the complete grain
kernel.
• Although whole grains may be best known for their fiber content,
the health benefits are probably due to the “whole package” of
healthful components, including essential fatty acids, antioxidants,
vitamins, minerals, and phytonutrients.
• Just as there is not one “healthiest” vegetable, there is not one
healthiest whole grain. Each whole grain (e.g., oats, quinoa, wheat,
barley, rye) has a slightly different nutrient profile.
• People who choose whole grains for all of their grain choices are
urged to choose some whole grains that are fortified with folic acid
because the content of folic acid is naturally lower in whole grains
than in fortified refined grains. This is especially true for women
who are capable of becoming pregnant, because folic acid helps
lower the risk of neural tube defects.
BOX Sources of Whole and Not Whole Grains

3.2
Whole Grains
• Original Cream of Wheat, puffed wheat, refined ready-to-eat wheat
cereals
• Products containing enriched white or wheat flour, even if “whole
grain”, “whole wheat”, or “multigrain” are also listed, such as white,
wheat, or multigrain breads, pasta, tortillas, and crackers
• Oat bran
• White rice, Rice Krispies, cream of rice, puffed rice, rice bran
• Cornstarch, grits, degerminated corn meal, white hominy, corn flakes
Not Whole Grains

(Missing one or more of the 3 components of a whole grain)
• Whole wheat grains, including varieties of spelt, emmer, farro,
einkorn, bulgur, cracked wheat, and wheat berries
• Products made with whole wheat flour, such as 100% whole wheat
bread, whole wheat pasta, shredded wheat, Wheaties, whole wheat
tortillas, whole wheat crackers
• Whole oats, oatmeal (steel-cut, old-fashioned, quick, and instant), Oat
flour
• Brown rice Whole grain rice may also be black, purple, or red
• Corn, popcorn, whole corn meal
• Whole-grain barley, whole rye, teff, triticale, millet, amarantha,
buckwheata, sorghuma, quinoaa, wild ricea
a
Considered whole grains but are technically not cereals, but rather
pseudocereals.
“Refined” grains are not whole because they are missing the bran and
germ. They are rich in starch but have significantly lesser amounts of fiber,
vitamin B6, vitamin E, trace minerals, unsaturated fat, and most of the
phytonutrients found in whole grains. Refined flour in the United States is
enriched to add back some B vitamins (thiamin, riboflavin, and niacin) and
iron to levels higher than found prior to processing. Enriched flour is also
required to be fortified with folic acid, a mandate designed to reduce the
risk of neural tube defects.
• Other substances that are lost (other minerals, fiber, and
phytonutrients) are not replaced by enrichment: For instance, fiber
content is low—from 0 to 1 g per serving.
• Examples of refined grains include white flour, white bread, white
rice, flour tortillas, and grits.
• Some refined grain products have added sugar such as: sweetened
ready-to-eat cereals, muffins, and pancakes.
Whole Grains
contain the entire grain, or seed, which is the endosperm, bran, and germ.
Phytonutrients
are bioactive, nonnutrient plant compounds associated with a reduced risk of chronic diseases.
Also known as phytochemicals.
Refined Grains
consist of only the endosperm (middle part) of the grain and therefore do not contain the bran and
germ portions.
enriched
adding back certain nutrients (to specific levels) that were lost during processing.
Fortified
adding nutrients that are not naturally present in the food or were present in insignificant amounts.
Identifying Whole Grains

At a quick glance, it is not always easy to distinguish between whole grain,
“made with whole grain,” and completely refined grains, especially with
regard to bread and pasta.
• Labels that state a product is “100% whole wheat” or “100% whole
grain” are whole grains.
• “Whole wheat” or “whole (grain)” should be the first ingredient
on the list or the second ingredient after water.
• Enriched or refined flour should not appear on the ingredient list
(Fig. 3.5).
• Breads, ready-to-eat cereals, and pastas labeled “made with whole
grain” are not whole grains. They contain whole grains but also
refined flour.
• Items containing “enriched flour” are refined.
• Just seeing “wheat” on the label does not mean “whole wheat,”
such as in the case of breads identified as “honey wheat,” “white
wheat,” or “made with 100% wheat flour.”
• With the exception of gluten-free breads, all bread contains wheat
(e.g., rye bread contains rye and wheat flour) because it contains
sufficient gluten to allow bread to rise.
• Tips for eating more whole grains appear in Box 3.3.
Figure 3.5 ▲ A comparison of ingredient lists to identify whole grains
in bread.
BOX Tips for Increasing Whole Grain Intake

3.3
Substitute
• whole wheat bread or rolls for white bread or rolls
• brown rice for white rice
• whole wheat pasta or pasta that is part whole wheat, part white flour
for white pasta
• whole wheat pita for white pita
• whole wheat tortillas for flour tortillas
• whole wheat English muffins for white English muffins
• whole grain for refined cereals
• whole wheat flour or oats for half of the white flour in pancakes,
waffles, or muffins
• whole wheat bread or cracker crumbs for white crumbs as a coating or
breading for meat, fish, and poultry
• whole corn meal for refined corn meal in corn cakes, corn bread, and
corn muffins
Add
• barley, brown rice, or bulgur to soups, stews, bread stuffing, and
casseroles
• handful of oats or whole grain cereal to yogurt
Snack on
• ready-to-eat whole grain cereal, such as shredded wheat or toasted oat
cereal
• whole grain baked tortilla chips
• whole grain crackers
• popcorn
Decrease
• desserts and sweet snacks made with refined flour:
• cakes, cookies, and pastries (which are also high in added sugars, solid fats, or both and a
source of excess calories)
Think of Krista. She has increased her intake of grains,

fruit, vegetables, and legumes but admits she doesn’t like
whole wheat bread or whole grains in any form.
• What other specific strategies should she try to increase her fiber intake?
Limit Added Sugars

Sugar has many functional roles in foods, including taste, physical
properties, antimicrobial purposes, and chemical properties. Sugar adds
flavor and interest. Few would question the value brown sugar adds to a
bowl of hot oatmeal. Besides its sweet taste, sugar has important functions,
such as promoting tenderness in cakes, inhibiting the growth of mold in
jams and jellies, and retaining moisture in cookies. However, added sugars
are considered empty calories because they provide calories with few or no
nutrients. The 2020–2025 Dietary Guidelines for Americans recommend
added sugars be limited to <10% of total calories/day starting at age 2
(USDA & USDHHS, 2020). Foods and beverages with added sugars should
be avoided for those younger than age 2. The rational for limiting added
sugars is to help ensure an adequate intake of nutrients while keeping
calorie intake at an appropriate level.
The average added sugar intake in the United States accounts for almost
270 calories or more than 13% of total calories per day (USDA &
USDHHS, 2020). The biggest source of added sugars (24%) in the
American population aged 1 and older is diet with SSB: soft drinks, fruit
drinks, and sport and energy drinks (Fig. 3.6). A large body of evidence
shows a strong link between SSB intake and weight gain (Malik et al.,
2013) and risk of type 2 diabetes (Malik et al., 2010). SSB have also been
linked to coronary heart disease (Malik & Hu, 2019). SSB are thought to
promote weight gain because people do not compensate for their liquid
calories by eating less at subsequent meals. Suggestions for limiting added
sugar intake are in Box 3.4.
Figure 3.6 ▲ Top sources and average intakes of added sugars: U.S.
Population ages 1 and older. (Source: U.S. Department of Agriculture &
U.S. Department of Health and Human Services. (2020). Dietary guidelines
for Americans 2020–2025.
12/Dietary_Guidelines_for_Americans_2020-2025.pdf)
Ways to Limit Added Sugars

BOX
3.4
Cut Back On or Eliminate Sugar-Sweetened

Beverages
• choose beverages with no added sugars: water or flavored water.
• consume SSB less often
• reduce portion size
Limit Sweetened Grain-based and Dairy-based

Items
• smaller portions less often:
• breakfast cereals and bars
• sweetened yogurt
• sweetened milks
• candy
• cookies
• brownies
• doughnuts
• sweet rolls
• pastries
• cakes
• ice cream
• other frozen desserts
• pudding
Rely on Natural Sugars in Fruit to Satisfy a

“Sweet Tooth”
• Fruit also boosts vitamin, mineral, phytonutrient, and fiber intake
Read Labels
• “Nutrition Facts” labels (see Chapter 9) list the amount of total sugars
and added sugars.
• The Daily Value (DV) for added sugars is 50 g (10% of the calories the
2000 calorie standard used for DV). If total calories consumed are
<2000, the percentage of the DV listed on the food label will
underestimate the actual percent of calories from added sugar.
• Look for these sources of added sugar on the ingredient list:
• agave sugar
• brown sugar
• cane juice
• corn syrup
• corn syrup solids
• dextrose
• fructose
• glucose
• HFCS
• honey
• invert sugar
• lactose
• maltose/malt
• sugar
• maple syrup
• molasses
• nectars
• raw sugar
• sucrose
• sugar
• sugarcane juice
• white granulated sugar
Consider Sugar Alternatives: Sugar Alcohols or

Nonnutritive Sweeteners
• Products containing sugar alcohols (e.g., dietetic candy) are lower in
calories from sugar but not necessarily lower in total calories.
• Some sugar alcohols can cause diarrhea when eaten in large amounts.
• Remember: artificially sweetened low-calorie or calorie-free
beverages can reduce calorie and added sugar intake, but their
effectiveness as a long-term weight-loss strategy is not certain.
The high-intensity sweeteners approved for use in the United States
• are safe for the general population when consumed under the intended
conditions of use.
The AHA’s recommendation to limit added sugar intake is even more

restrictive based on a large body of evidence showing diets high in added
sugars are linked to risk factors for cardiovascular disease, obesity,
dyslipidemia, high blood pressure, and chronic inflammation (Johnson et
al., 2009). As previously stated, a high intake of added sugars can displace
nutrient-containing foods and contribute to excess calorie intake. The AHA
recommends that added sugars should contribute no more than half of a
person’s daily discretional calorie allowance:
• For most American women, that is a maximum of 100 calories per
day (25 g or 6 tsp).
• For most American men, the limit for added sugar intake is 150
calories per day (38 g or 9 tsp).
High-Fructose Corn Syrup

HFCS is an added sugar that generates a lot of controversy. It is a
commercial sweetener made from enzymatically treated corn syrup. It is
“high” in fructose compared to the corn syrup from which is it derived,
which is essentially 100% glucose. HFCS is composed of glucose and
either 42% or 55% fructose, making it similar in composition to sucrose,
which is 50% glucose and 50% fructose. The primary differences between
sucrose and the common forms of HFCS are that
• HFCS contains water;
• fructose and glucose molecules in HFCS are not joined by a
chemical bond as they are in sucrose (U. S. Food and Drug
Administration, 2018).
HFCS is widely used in food and beverages, not only because it
provides the same sweetness as white sugar, but also because it has other
desirable functional properties, such as enhancing spice and fruit flavors. A
review of short-term randomized controlled trials, cross-sectional studies,
and review articles consistently found little evidence that HFCS differs
uniquely from sucrose and other nutritive sweeteners in metabolic effects
(e.g., levels of circulating glucose, insulin, postprandial triglycerides),
subjective effects (e.g., hunger, satiety, calorie intake at subsequent meals),
and adverse effects (e.g., risk of weight gain) (Fitch & Keim, 2012).
Sugar Alternatives
One way to reduce sugar intake and not forsake sweetened foods is to
consume sugar alternatives, such as polyols and nonnutritive sweeteners
(NNS), in place of regular sugar.
Polyols
sugar alcohols produced from the fermentation or hydrogenation of monosaccharides or
disaccharides. Most originate from sucrose or glucose and maltose in starches.
Nonnutritive Sweeteners (NNS)

synthetically made sweeteners that provide minimal or no carbohydrate and calories. They are
also known as artificial sweeteners.
Polyols
Polyols, or sugar alcohols, are used as sweeteners but are not true sugars or
alcohols. They are derived from hydrogenated sugars and starches (Table
3.5).
• Although polyols occur naturally in some fruit, vegetables, and
fermented foods (e.g., wine and soy sauce), the majority of polyols
in the food supply are commercially synthesized.
• With the exception of xylitol, polyols are all less sweet than sucrose,
so they are often combined with NNS in sugarless foods.
• Sugar alcohols are approved for use in a variety of products:
candies, chewing gum, jams and jellies, baked goods, and frozen
confections.
• Polyols are not sold as an ingredient for use at home.
• Foods containing polyols and no added sugars can be labeled as
sugar-free.
Polyols offer some advantages to sugar.
• They are not fermented by mouth bacteria, and thus do not cause
dental caries.
• Since polyols are non-cariogenic, they are often used in items
held in the mouth, such as chewing gum and breath mints.
• They are considered low-calorie sweeteners because they are
incompletely absorbed.
• Their calorie value generally ranges from 1.6 to 3.0 cal/g.
• They are generally slowly and incompletely absorbed and/or
metabolized differently than true sugars, so they produce a smaller
effect on blood glucose levels and insulin response, making them
attractive to people with diabetes.
• Polyols that are not fully absorbed in the small intestine enter the
large intestine where they function as a prebiotic.
• They are fermented into short-chain fatty acids, which foster the
growth of colonic bacteria.
The disadvantage of polyols is that, because they are incompletely
digested and absorbed, they can lead to GI side effects such as diarrhea,
abdominal pain, and gas. Therefore, it is recommended that sorbitol intake
not exceed 50 g/day, and mannitol intake be limited to 20 g/day. Likewise,
only limited amounts of xylitol are allowed in foods marketed for special
diets (Brown, 2019). There is little research on the benefits of sugar
alcohols for people with diabetes (Evert et al., 2019).
Consider Krista. She wondered if eating several pieces of

dietetic chocolate candy sweetened with sugar alcohols
every day would help prevent constipation. She was shocked
to discover that five pieces of sugarless dark chocolate
contains almost 200 calories, mostly from fat, and quickly
ruled out candy as an option. She asks if she can chew
several pieces of gum containing xylitol every day to
improve laxation without consuming calories. How do you
respond?
Table
Polyols
3.5
NNS are also known as intense sweeteners, artificial sweeteners, or sugar
substitutes. They are hundreds to thousands of times sweeter than sugar and
are virtually calorie-free because so little is needed. Sometimes
combinations of NNS are used in a food to produce a synergistically
sweeter taste, decrease the amount of sweetener needed, and minimize
aftertaste. They have different functional properties, which influences how
they are used in foods. Questions about their safety and efficacy are
common.
• NNS approved by the U.S. Food and Drug Administration (FDA)
for use in the United States are featured in Table 3.6. When
consumed at levels within the Acceptable Daily Intake (ADI), all
FDA-approved NNS are safe for use by the general public,
including pregnant and lactating women.
• Although it is difficult to determine the intake of food additives,
including NNS, the FDA has determined that estimated daily
intake would not exceed ADI limits even among high users (U.S.
Food and Drug Administration, 2014).
• Evidence suggests that used judiciously, NNS could promote a
decrease in added sugar intake and a decrease in calorie intake and
potential loss of weight (Gardner et al., 2012).
• These potential benefits can only be realized if there is not a
compensatory increase in calories from other sources.
• For instance, it has been proposed that NNS may lower‐
awareness of calorie intake. Further research is needed.
• NNS appeal to people with diabetes because they do not raise blood
glucose levels.
• Again, there is not enough evidence to determine if sugar
substitute use definitely leads to long-term decrease in body
weight or cardiometabolic risk factors, including improved
glycemic control (Evert et al., 2019).
• Nutrition therapy for people with diabetes stresses replacing SSB
with water as much as possible, and if NNS are used to lower
calorie and carbohydrate intake, counseling should include how to
avoid compensating by eating calories from other sources (Evert
et al., 2019).
Table Approved for Use in the
3.6 United States by the Food
and Drug Administration
Acceptable Daily Intake (ADI)
the estimated amount of a food additive that a person can safely consume every day over a
lifetime without risk.
Dental Caries
Limiting added sugars is also one of the strategies to help reduce the risk of
dental caries. Sugars—whether added or natural—and starches that stay on
the teeth provide substrates oral bacteria feed on. This creates an acid that
erodes tooth enamel. Although whole-grain crackers and orange juice are
more nutritious than caramels and soft drinks, their potential damage to
teeth is similar. The frequency of carbohydrate intake, the amount
consumed, and the duration of time between eating and brushing teeth may
be more important than whether or not they are “sticky sugars.”
Anti-cavity strategies are
• eat a well-balanced diet—oral health is dependent on good nutrition;
• limit added sugars, especially SSB;
• limit in-between meal snacking, especially items that can remain on
the surface of the teeth (e.g., candy, pretzels, and chips);
• avoid high-sugar items that stay in the mouth for a long time: hard
candy, suckers, and cough drops;
• brush promptly after eating;
• chew gum sweetened with sugar alcohols (e.g., sorbitol, mannitol,
and xylitol) or with NNS after eating. This may reduce the risk of
cavities by stimulating production of saliva, which helps to rinse the
teeth and neutralize plaque acids. Unlike sucrose and other nutritive
sweeteners, sugar alcohols and NNS are not fermented by bacteria
in the mouth, so they do not promote cavities
• use fluoridated toothpaste.
How Do You Respond?

Aren’t carbohydrates fattening? At 4 cal/g,
carbohydrates are no more fattening than protein and are
less than half as fattening as fat at 9 cal/g. Whether or not
a food is “fattening” has more to do with frequency of
intake and total calories provided than whether the
calories are in the form of carbohydrates, protein, or fat.
Is “white” whole wheat bread as nutritious as
whole wheat? Whole “white” wheat flour is made from
albino wheat that is white in color, not the characteristic
brown color of whole wheat. It is a whole grain, so it is
nutritionally comparable to whole wheat. Many people
prefer not only its lighter color but also its milder flavor.
#x201C;Light” or “diet” breads are high in
fiber. Can I use them in place of whole grain
breads? “Light breads” usually have processed fiber
from peas or other foods substituted for some starch. The
result is a lower-calorie, higher-fiber bread that may help
to prevent constipation but lacks the unique “package” of
vitamins, minerals, and phytonutrients found in whole
grains.
REVIEW CASE STUDY
Amanda is convinced that white flour and white sugar cause her to overeat,
resulting in an extra 30 pounds of weight she is carrying around. To control
her impulse to overeat, she has decided to eliminate all foods made with
white flour and white sugar from her diet. Her total calorie needs are
estimated to be 2000 per day. Yesterday, she ate the foods listed in the box.
She asks if you think this is a healthy eating plan.
What foods did she eat yesterday that contained carbohydrates? Estimate
• how many grams of carbohydrate she ate.
• How does her intake compare with the amount of total carbohydrate
recommended for someone needing 2000 cal/day?
• Are all of the sources of carbohydrate she chose the “healthiest” in
their food group?
• What items is she consuming that contain added sugar?
• What sources of fiber did she consume? Estimate how many grams of
fiber she ate.
• How does her fiber intake compare with the AI amount recommended
for women?
• What would you tell her about her fiber intake?
• What would you tell her about her idea to forsake white flour and white
sugar to manage her weight?
• What are the benefits and potential problems with her proposed diet?
• What suggestions would you make about her intake?
Breakfast: 2 scrambled eggs and 2 sausage links; 1 cup orange juice; tea
with agave nectar
Snack: 2 oz of honey-roasted peanuts and a diet soft drink
Lunch: tossed salad with 1 hard cooked egg, 3 oz of sliced turkey, 2 oz
of sliced cheese, 3 tbsp of honey mustard dressing; 1 can diet soft
drink; 1 cup of diet gelatin
Snack: 2 oz of cheese curds and a diet soft drink
Dinner: 6 oz of fried chicken; 1 cup of white rice; ½ cup corn; ½ cup
diet pudding with whipped cream; 1 can diet soft drink
Snack: 5 chicken wings with ¼ cup bleu cheese dressing
STUDY QUESTIONS
1 The nurse knows their explanation of glycemic index was effective when
the client says?
a. “Choosing foods that have a low GI is an effective way to eat
healthier.”
b. “Low-GI foods promote weight loss because they do not stimulate the
release of insulin.”
c. “GI could help me choose the best foods to eat before, during, and
after training.”
d. “GI is a term used to describe the amount of refined sugar in a food.”
2 Which of the following recommendations would be most effective for
someone wanting to eat more fiber?
a. Eat legumes more regularly.
b. Eat raw vegetables in place of cooked vegetables.
c. Use potatoes in place of white rice.
d. Eat fruit for dessert in place of ice cream.
3 A client asks why sugar should be limited in the diet. What is the best
response?
a. “A high-sugar intake causes dental caries if you don’t brush your teeth
shortly after eating.”
b. “Sugar provides more calories per gram than starch, protein, or fat.”
c. “There is a direct correlation between sugar intake and increased
hunger.”
d. “Foods high in sugar generally provide few nutrients other than
calories and may make it hard to consume a diet that has enough of all
the essential nutrients.”
4 Compared to refined grains, whole grains have more
a. Folic acid
b. Vitamin A
c. Vitamin C
d. Phytonutrients
5 The nurse knows their instructions about choosing whole grains in place
of refined grains are understood by the client when they verbalize that
they will substitute
a. Rice Krispies for puffed rice
b. Bulgur for barley
c. Shredded wheat cereal for puffed wheat cereal
d. Quick oats for old-fashioned oats
6 Which might a client who has eaten too many dietetic candies sweetened
with sorbitol experience?
a. Diarrhea
b. Heartburn
c. Vomiting
d. Low blood glucose
7 The client wants to eat fewer calories and lose weight by substituting
regularly sweetened foods with those that are sweetened with sugar
alternatives. Which would be the most effective at lowering calorie
intake?
a. Sugar-free cookies for regular cookies
b. Sugar-free for regular chocolate candy
c. Sugar-free soft drinks for regular soft drinks
d. Sugar-free ice cream for regular ice cream
8 A client is on a low-calorie diet that recommends they test their urine for
ketones to tell how well they are adhering to the guidelines of the diet.
What does the presence of ketones signify about their intake?
a. It is too low in carbohydrates.
b. It is too high in fat.
c. It is too high in carbohydrates.
d. It is too high in protein.
CHAPTER SUMMARY CARBOHYDR
ATES
Carbohydrates are almost exclusively found in plants and provide the
major source of energy in almost all human diets.
Carbohydrate Classifications
Monosaccharides are composed of one sugar molecule.
• Glucose (or dextrose) is a component of almost all carbohydrates, and
is the sugar found in blood.
• Fructose, the sweetest of all natural sugars, is found in fruit, honey,
and HFCS.
Disaccharides are composed of one glucose molecule and one other
monosaccharide.
• Sucrose comes in many forms: table sugar, white sugar, brown sugar,
granulated sugar, powdered sugar, raw sugar, and turbinado sugar.
• Lactose is the only animal source of carbohydrate. It is found in dairy
products, and is the least sweet sugar.
• Maltose is an intermediate in starch digestion. It occurs in malted food
products and is used to color beer.
Polysaccharides are made up of many glucose molecules. They do not
taste sweet.
• Starch provides the majority of calories in grains. It is found in the
endosperm portion of whole and refined grains.
• Fiber, the non-digestible part of plants, is commonly classified as
either water soluble (or viscous and fermentable) or water insoluble
(not viscous and not fermentable).
Natural sugars and starches are found in fruit, vegetables, grains, dairy,
and legumes.
Added sugars are found in snacks and sweets, cereals, and sweetened
yogurt. SSB are the biggest source of added sugars in the American diet.
How the Body Handles

Carbohydrates
Digestion: The majority of carbohydrate digestion occurs in the small
intestine. Disaccharides and starches are digested into
monosaccharides. Fiber is not digested, but some types can be
fermented by gut microbiota in the large intestine into water, gas, and
short-chain fatty acids.
Absorption: Monosaccharides are absorbed through intestinal mucosal
cells and transported to the liver through the portal vein.
Metabolism: In the liver, fructose and galactose are converted to glucose.
The liver releases glucose into the bloodstream.
Glycemic response: The glycemic response is the effect a food has on the
blood glucose concentration—how quickly the glucose level rises,
how high it goes, and how long it takes to return to normal. It is hard
to predict in practice.
Functions of Carbohydrates
• provide energy
• spare protein
• prevent ketosis
• produce specific body compounds: nonessential amino acids
• converts and stores remaining glucose as fat

The typical American diet provides an appropriate percentage of calories
from carbohydrates but is too high in added sugars and low in fiber.
• Carbohydrates should provide 45% to 65% of total calories.
• Added sugars should contribute ≤10% of total calories.
• Women should consume approximately 25 g fiber per day and men
about 38 g.
Carbohydrates in Health
Promotion.
Americans are urged to make healthier carbohydrate choices:
• half or more of grain choices should be whole grain
• limit added sugars to <10% of calories/day starting at age 2. Added
sugars in food and beverages should be avoided by those younger than
age 2.
Sugar Alternatives
Polyols (sugar alcohols):
• provide fewer calories than sugar because they are incompletely
digested and absorbed
• large amounts can cause osmotic diarrhea and cramping
• are not fermentable by mouth bacteria, so they do not contribute to
tooth decay
NNS (intense sweeteners, artificial sweeteners, or sugar substitutes):
• provide negligible or no calories
• are hundreds to thousands of times sweeter than sugar
• use is approved and regulated by the FDA
• it is unknown if their use helps people to reduce their calorie intake
and better manage weight
Consuming a healthy diet that is limited in added sugars and in snacks
that contain fermentable carbohydrates may help reduce the risk of dental
caries.
Figure sources: shutterstock.com/Tatjana Baibakova, shutterstock.com/Evan Lorne, and

shutterstock.com/Mirror-Images
book at
Websites
Learn about grains at https://wholegrainscouncil.org/
References
Academy of Nutrition and Dietetics & American Diabetes Association. (2019). Choose your foods:
Food lists for weight management. American Diabetes Association & Academy of Nutrition and
Dietetics.
Arnett, D. K., Blumenthal, R. S., Albert, M. A., Buroker A. B., Goldberger, Z. D., Hahn, E. J.,
Dahl, W., & Stewart, M. (2015). Position of the Academy of Nutrition and Dietetics: Health
implications of dietary fiber. Journal of the Academy of Nutrition and Dietetics, 115(11), 1861–
1870. https://doi: 10.1016/j.jand.2015.09.00
Evert, A., Dennison, M., Gardner, C., Garvey, W., Lau, K., MacLeod, J., Mitri, J., Pereira, R.,
Rawlings, K., Robinsion, S., Saslow, L., Uelmen, S., Urbanski, P., & Yancy, W. (2019). Nutrition
therapy for adults with diabetes or prediabetes: A consensus report. Diabetes Care, 42(5), 731–
754. https://doi.org/10.2337/dci19-0014
Fitch, C., & Keim, K. (2012). Position of the Academy of Nutrition and Dietetics: Use of nutritive
and nonnutritive sweeteners. Journal of the Academy of Nutrition and Dietetics, 112(5), 739–758.
Gardner, C., Wylie-Rosett, J., Gidding, S. S., Steffen, L. M., Johnson, R. K., Reader, D., Lichtenstein,
A. H., American Heart Association Nutrition Committee of the Council on Nutrition, Physical
Activity and Metabolism, Council on Arteriosclerosis, Thrombosis and Vascular Biology,
Council on Cardiovascular Disease in the Young, & American Diabetes Association. (2012).
Nonnutritive sweeteners: Current use and health perspectives—A scientific statement from the
American Heart Association and the American Diabetes Association. Diabetes Care, 35(8),
1798–1808. https://doi.org/10.2337/dc12-9002
Institute of Medicine. (2001). Dietary reference intakes: Proposed definition of dietary fiber. The
National Academies Press.
Institute of Medicine. (2005). Dietary reference intakes for energy, carbohydrates, fiber, fat, fatty
acids, cholesterol, protein, and amino acids (macronutrients). The National Academies Press.
International Food Information Council Foundation. (2019). Fiber. https://foodinsight.org/wp-
content/uploads/2019/07/IFIC-Foundation-Fiber-Fact-Sheet-for-HPs.pdf
Johnson, R., Appel, L., Brands, M., Brands, M., Howard, B., Lefevre, M., Lustig, R., Sacks, F.,
Steffen, L., Wylie-Rosett, J., & on behalf of the American Heart Association Committee of the
Council on Nutrition, Physical Activity, and Metabolism and the Council on Epidemiology and
Prevention. (2009). Dietary sugars intake and cardiovascular health: A scientific statement from
the American Heart Association. Circulation, 120(11), 1011–1020.
https://doi.org/10.1161/CIRCULATIONAHA.109.192627
Kim, Y., & Je, Y. (2016). Dietary fibre intake and mortality from cardiovascular disease and all
cancers: A meta-analysis of prospective cohort studies. Archives Cardiovascular Disease, 109(1),
39–54. https://doi.org/10.1016/j.acvd.2015.09.005
Makki, K., Deehan, E., Walter, J., & Backhed, F. (2018). The impact of dietary fiber on gut
microbiota in host health and disease. Cell Host & Microbe, 23(6), 705–715.
https://doi.org/10.1016/j.chom.2018.05.012
Malik, V., & Hu, B. (2019). Sugar-sweetened beverages and cardiometabolic health: An update of the
evidence. Nutrients, 11(8), 1840. https://doi.org/10.3390/nu11081840
Malik, V., Pan, A., Willett, W., & Hu, F. (2013). Sugar-sweetened beverages and weight gain in
children and adults: A systematic review and meta-analysis. American Journal of Clinical
Nutrition, 98(4), 1084–1102. https://doi.org/10.3945/ajcn.113.058362
Malik, V., Popkin, B., Bray, G., Despres, J.-P., Willett, W., & Hu, F. (2010). Sugar-sweetened
beverages and risk of metabolic syndrome and type 2 diabetes: A meta-analysis. Diabetes Care,
33(11), 2477–2483. https://doi.org/10.2337/dc10-1079
Reynolds, A., Mann, J., Cummings, J., MDiet, N., MDiet, E., & Morenga, L. (2019). Carbohydrate
quality and human health: A series of systematic reviews and meta-analyses. Lancet, 393(10170),
434–445. https://doi.org/10.1016/S0140-6736(18)31809-9
guidelines for Americans 2020–2025. https://www.dietaryguidelines.gov/sites/default/files/2020-
U. S. Food and Drug Administration. (2014). High-intensity sweeteners.
https://www.fda.gov/food/food-additives-petitions/high-intensity-sweeteners
U. S. Food and Drug Administration. (2018). High fructose corn syrup questions and answers.
https://www.fda.gov/food/food-additives-petitions/high-fructose-corn-syrup-questions-and-
answers
Chapter Protein
4
Robert Santos
Three years ago, Robert, a 50-year-old farmer,
learned he has alpha-gal allergy. This allergy
originates from a lone star tick bite that, in turn,
causes a delayed anaphylactic reaction after eating
meat. Robert must avoid beef, pork, lamb, rabbit,
venison, and buffalo meats. Prior to the tick bite, his
usual weight was 185 pounds (84 kg), which was
within the healthy range for his height. However, after
years of restricting the variety of protein foods he
eats, Robert is now underweight and continues to lose
weight. He does not like seafood and is tired of eating
poultry.
Learning Objectives
1 Explain the difference between essential and nonessential amino acids.

2 Discuss the functions of protein.
3 Give examples of conditions where people are in a positive nitrogen
balance.
4 Name sources of complete and incomplete protein.
5 Calculate an individual’s protein requirement.
6 Discuss how Americans should shift their protein food choices to
improve their eating pattern.
7 Give examples of conditions that increase a person’s protein requirement.
8 Name sources of lean protein foods.
9 Name sources of the nutrients that are most likely to be deficient in a
vegetarian diet.
10Describe nitrogen balance and how it is determined.
In Greek, protein means “to take first place,” and truly life could not exist
without protein. Protein is a component of every living cell: plant, animal,
and microorganism. In adults, protein accounts for 20% of total weight.
Dietary protein seems relatively immune to the controversy over optimal
intake that surrounds both carbohydrates and fat.
This chapter discusses the composition of protein, its functions, and
how it is handled in the body. Sources, Dietary Reference Intakes, and the
role of protein in health promotion are presented.
PROTEIN COMPOSITION AND

STRUCTURE
Proteins are composed of chains of amino acids that can be from several
dozen to several hundred amino acids in length. Just as the 26 letters of the
alphabet can be used to form an infinite number of words, so can amino
acids be joined in different amounts, proportions, and sequences to form a
great variety of proteins.
Amino Acids
All amino acids have a carbon atom core with four bonding sites:
• one hydrogen atom
• one amino group (NH2)
• one acid group (COOH) (see Fig. 4.1)
• one side group (R group) contains atoms that give each amino
acid its own distinct identity
• some side groups contain
• sulfur
• some are acidic
• some are basic
• differences in side groups account for differences in amino acids:
• size
• shape
• electrical charge
Figure 4.1 ▲ Generic amino acid structure.
There are 20 common amino acids that make up proteins.

• Nine amino acids are classified as essential or indispensable.
• They cannot be made by the body and so must be supplied
through the diet (Box 4.1).
• Eleven amino acids are classified as nonessential or dispensable.
• They can be made by cells, as needed, through the process of
transamination.
• Some dispensable amino acids may become indispensable when
metabolic need is great and endogenous synthesis is not adequate.
• Note that the terms essential and nonessential refer to whether the
amino acid must be supplied by the diet, not to their relative
importance: All 20 amino acids must be available for the body to
make proteins.
Amino Acids
BOX
4.1
Essential Nonessential Conditionallya Essential

(Indispensable) (Dispensable) (Indispensable)
Histidine Alanine Arginine
Isoleucine Asparagine Cysteine
Leucine Aspartic acid Glutamine
Lysine Glutamic acid Glycine
Methionine Serine Proline
Phenylalanine Tyrosine
Threonine
Tryptophan
Valine
Under most normal conditions, the body can synthesize adequate amounts of these amino acids.
a
A dietary source is necessary only when metabolic demands exceed endogenous synthesis.
Protein Structure
A protein’s primary structure is determined by the types and amounts of
amino acids and the unique sequence in which they are joined. Proteins also
vary in shape. They may be straight, folded, coiled along one dimension, or
a three-dimensional shape resembling a sphere. Larger proteins are created
when two or more three-dimensional polypeptides combine. A protein’s
shape determines its function.
FUNCTIONS OF PROTEIN
Protein is the major structural and functional component of every living
cell. Every tissue and fluid in the body contains some protein, except for
bile and urine. In fact, the body may contain as many as 10,000 to 50,000
different proteins that vary in size, shape, and function.
Like carbohydrates, protein provides 4 cal/g. Protein is not the body’s
preferred fuel but is a source of energy when consumed in excess or when
calorie intake from carbohydrates and fat is inadequate. Using protein for
energy is a physiologic waste because amino acids used for energy are not
available to be used for protein’s specific functions (Box 4.2).
BOX Functions of Protein

4.2
Body structure and framework

• >40% of protein in the body is found in each skeletal muscle and approximately 15% is
found in the skin and the blood.
• Proteins also form tendons, membranes, organs, and bones.
Enzymes
• Enzymes are proteins that facilitate specific chemical reactions in the body without
undergoing change themselves.
• Some enzymes (e.g., digestive enzymes) break down larger molecules into smaller ones.
• Other enzymes (e.g., enzymes involved in protein synthesis) combine molecules to form
larger compounds.
Body secretions and fluids that are made from amino acids include
• Neurotransmitters such as serotonin and acetylcholine
• Antibodies
• Peptide hormones such as insulin, thyroxine, and epinephrine
• Breast milk
• Mucus
• Sperm
• Histamine
Fluid balance
• Proteins help to regulate fluid balance because they attract water, which creates osmotic
pressure.
Circulating proteins, such as albumin, maintain the proper balance of fluid among the
• intravascular, intracellular, and interstitial compartments of the body. A symptom of a
low albumin level is edema.
Acid–base balance
• Because amino acids contain both an acid (COOH) and a base (NH2), they can act as either
acids or bases, depending on the pH of the surrounding fluid.
• The ability to buffer or neutralize excess acids and bases enables proteins to maintain normal
blood pH, which protects body proteins from being denatured.
Transport molecules
• Globular proteins transport other substances through the blood. For instance, lipoproteins
transport fats, cholesterol, and fat-soluble vitamins; hemoglobin transports oxygen; and
albumin transports free fatty acids and many drugs.
Other compounds that contain amino acids

• Opsin, the light-sensitive visual pigment in the eye
• Thrombin, a protein necessary for normal blood clotting
Some amino acids have specific functions within the body

• Tryptophan is a precursor of the vitamin niacin, and is also a component of serotonin.
• Tyrosine is the precursor of melanin, the pigment that colors hair and skin, and is
incorporated into the thyroid hormone.
Intravascular
within blood vessels.
Intracellular
within cells.
Interstitial
between cells.
Edema
the swelling of body tissues secondary to the accumulation of excessive fluid.
Denatured
an irreversible process in which the structure of a protein is disrupted, leading to partial or
complete loss of function.
Globular
spherical.
HOW THE BODY HANDLES PROTEIN

Protein digestibility varies among protein sources:
• 90% to 99% for animal proteins
• over 90% for soy and legumes
• 70% to 90% for other plant proteins
Protein Digestibility
how well a protein is digested to make amino acids available for protein synthesis.
Chemical digestion of protein begins in the stomach. Hydrochloric acid

denatures protein to make the peptide bonds more susceptible to the actions
of enzymes (Fig. 4.2). Hydrochloric acid also converts pepsinogen to the
active enzyme pepsin, which begins the process of breaking down proteins
into smaller polypeptides and some amino acids.
Figure 4.2 ▲ Protein digestion.
The majority of protein digestion occurs in the small intestine.

• Pancreatic proteases reduce polypeptides to
• shorter chains,
• tripeptides,
• dipeptides, and
• amino acids.
• Enzymes trypsin and chymotrypsin break peptide bonds between
specific amino acids.
• Carboxypeptidase breaks off amino acids from the acid end
(carboxyl) of polypeptides and dipeptides.
• Enzymes located on the surface of the cells that line the small
intestine complete the process of digestion:
Aminopeptidase splits amino acids from the amino ends of short
• peptides.
• Dipeptidase reduces dipeptides to amino acids.
Amino acids, and sometimes a few dipeptides or larger peptides, are
absorbed through the mucosa of the small intestine by active transport with
the aid of vitamin B6. Intestinal cells release amino acids into the
bloodstream for transport to the liver via the portal vein.
Metabolism
The liver acts as a clearing house for the amino acids it receives. It uses the
amino acids it needs, releases those needed elsewhere, and handles the
extra. The liver
• retains amino acids to make
• liver cells
• nonessential amino acids
• plasma proteins such as heparin, prothrombin, and albumin
• regulates the release of amino acids into the bloodstream,
• removes excess amino acids from the circulation,
• synthesizes specific enzymes to degrade excess amino acids,
• removes the nitrogen from amino acids so that they can be burned
for energy,
• converts certain amino acids to glucose, if necessary,
• forms urea from the nitrogenous wastes when protein and calories
are excessively consumed, and
• converts protein to fatty acids that form triglycerides for storage in
adipose tissue.
Protein Synthesis
Protein synthesis (anabolism) is a complicated but efficient process that
quickly assembles amino acids provided through food or released from the
breakdown of existing body proteins into proteins the body needs, such as
those required for growth and development or lost through normal wear and
tear. The body prioritizes muscle protein synthesis. Cells in the liver, heart,
and diaphragm are replenished even during short-term periods of
catabolism.
Part of what makes every individual unique are the minute differences
in body proteins. These variations are caused by amino acid sequencing
determined by genetics. Genetic codes created at conception hold the
instructions for making all of the body’s proteins. Cell function and life
itself depend on the precise replication of these codes. Some important
concepts related to protein synthesis are protein turnover and metabolic
pool.
Protein Turnover
Protein turnover is a continuous process that occurs within each cell as
proteins are broken down due to normal wear and tear, and replenished.
Body proteins vary in their rate of turnover. For example, red blood cells
are replaced every 60 to 90 days, gastrointestinal cells are replaced every 2
to 3 days, and enzymes used in the digestion of food are continuously
replenished.
Metabolic Pool
Although protein is not actually stored in the body (glucose and fat are), a
supply of each amino acid exists in a “metabolic pool” of free amino acids
within cells and circulating in the blood. This pool consists of recycled
amino acids from food and body proteins that have broken down. The pool
is in a constant state of flux because it is constantly accepting amino acids
as they become available or donating them when they are needed.
Protein Catabolism
Normally, the body uses very little protein for energy as long as intake and
storage of carbohydrate and fat are adequate. If insufficient carbohydrate
and fat are available for energy use (when calorie intake is inadequate),
dietary and body proteins are sacrificed to provide amino acids that can be
burned for energy. Over time, loss of lean body tissue occurs that, if severe,
can lead to decreased muscle strength, altered immune function, altered
organ function, and ultimately death. To “spare” protein—both dietary and
body proteins—from being burned for calories, an adequate supply of
energy from carbohydrate and fat is needed.
Nitrogen Balance
Nitrogen balance reflects the state of balance between protein breakdown
(catabolism) and protein synthesis (anabolism). It is determined by
comparing nitrogen intake with nitrogen excretion over a specific period of
time, usually 24 hours.
• Calculate total nitrogen intake for a 24-hour period:
• Measure protein intake in grams over a 24-hour period.
• Divide grams of protein consumed by 6.25 because protein is
16% nitrogen.
• Calculate nitrogen excretion in a 24-hour period:
• Analyze a 24-hour urine sample for grams of urinary urea
nitrogen (UUN).
• Add a coefficient of 4 to account for the estimated daily nitrogen
loss in feces, hair, nails, and skin.
Comparing grams of nitrogen excretion to grams of nitrogen intake will
reveal the state of nitrogen balance, as illustrated in Box 4.3.
• A neutral nitrogen balance (or state of equilibrium) exists when
nitrogen intake equals nitrogen excretion. This indicates that protein
synthesis is occurring at the same rate as protein breakdown.
• Healthy adults are in neutral nitrogen balance.
• Nitrogen balance is positive when protein synthesis exceeds protein
breakdown.
• This is the case during growth, pregnancy, or recovery from
injury.
• A negative nitrogen balance indicates that protein catabolism is
occurring at a faster rate than protein synthesis.
• This occurs during starvation or the catabolic phase after injury.
BOX Calculating Nitrogen Balance

4.3
Mary is a 25-year-old woman who was admitted to the hospital with

multiple fractures and traumatic injuries from a car accident. A
nutritional intake study indicated a 24-hour protein intake of 64 g. A 24-
hour UUN collection result was 19.8 g.
1. Determine nitrogen intake by dividing grams of protein intake by
6.25:
64 g ÷ 6.25 = 10.24 g of nitrogen
2. Determine total nitrogen output by adding a coefficient of 4 to the
UUN:
19.8 g + 4 g = 23.8 g of nitrogen
3. Calculate nitrogen balance by subtracting nitrogen output from
nitrogen intake:
10.24 g − 23.8 g = −13.56 g in 24 hours
4. Interpret the results.
A negative number indicates that protein breakdown is exceeding protein
synthesis. Mary is in a catabolic state.
SOURCES OF PROTEIN
Table 4.1 features protein sources and the average protein content per
serving. The quality of dietary proteins differs based on their essential
amino acid composition. Terms that refer to protein quality are complete
and incomplete.
• Complete proteins provide all nine essential amino acids in adequate
amounts and proportions needed by the body for protein synthesis.
• All animal sources of protein—meat, poultry, seafood, eggs, milk
—are complete proteins, with the exception of gelatin.
• Incomplete proteins also provide all the essential amino acids, but
one or more are present in insufficient quantities to support protein
synthesis.
• These amino acids are considered “limiting” in that they limit the
process of protein synthesis. All plant proteins and gelatin are
incomplete proteins.
• Different sources of incomplete proteins differ in their limiting
amino acids.
• For instance, grains are typically low in lysine and isoleucine.
Legumes are low in methionine and cysteine.
• Two incomplete proteins that have different limiting amino acids are
known as complementary proteins because together they form the
equivalent of a complete protein.
• Likewise, a complete protein combined with any incomplete
protein is complementary.
• Examples of foods that contain complementary proteins appear in
Box 4.4
• It is not necessary to eat complementary proteins at the same meal;
what is important is eating a variety of proteins over the course of a
day and consuming adequate calories.
• Protein quality is not important for most Americans because the
amounts of protein and calories consumed over the course of a
day are more than adequate. Quality becomes a crucial concern
when protein needs are increased or protein intake is marginal.
Table Sources of Protein and

Average Protein
4.1 Content per Servinga
Vegetables
Non-starchy vegetables: 2 g of protein per
serving
• ½ c cooked broccoli, cabbage, carrots,
cauliflower, eggplant, green beans, green
peas, mushrooms, spinach, tomatoes
• 1 c of raw carrots, peppers
shutterstock.com/Gilles
Starchy vegetables: 3 g protein per serving Lougassi
• ½ c cooked corn, yam, sweet potato,
parsnips, green peas, succotash, potato
• 1 c cooked winter squash, french fries (oven
baked)
Grains
Grain products: 3 g protein per serving
• 1 slice bread
• 1 oz ready-to-eat cereals
• ½ c cooked pasta, rice, oats, barley, bulgur,
grits
shutterstock.com/Billion
Photos
Proteins
Both animal and plant proteins: approximately
7 g protein per serving
• 1 oz beef, pork, lamb, veal, poultry, seafood,
deli meats
• 1 egg
• 1 oz cheese shutterstock.com/Billion
• ½ c black, garbanzo, kidney, lima, navy, Photos
pinto, white, black-eyed peas, lentils
• ½ c tofu
• 1 tbsp nut “butters”
• 1 oz “beef” or “sausage” crumbles
(meatless)
• ⅓ c hummus
Dairy
Milk and yogurt choices: 8 g of protein per
serving
• 1 c milk—fat-free, low-fat, 2%, or whole
• 6 oz yogurt
shutterstock.com/New Africa
a
Based on American Diabetes Association, Academy of Nutrition and Dietetics. (2019). Choose your
foods: Food lists for diabetes. American Diabetes Association & Academy of Nutrition.
BOX Sources of Foods with Complementary

4.4 Proteins
Two Incomplete Proteins A Complete Protein Combined with an

Incomplete Protein
Black beans and rice Bread pudding
Bean tacos Rice pudding
Pea soup with toast Corn pudding
Lentils and rice curry Cereal and milk
Falafel (ground chickpea Macaroni and cheese
patties) sandwich French toast
Peanut butter sandwich Cheese sandwich
Pasta e fagioli (white beans Vegetable quiche
and pasta soup) Cheese enchilada
Hummus with crackers
Tofu lasagna
Two kinds of beans (e.g., black beans and kidney beans) do not
create a complete, or complementary, protein because they have the
same incomplete proteins. Consuming one of those kinds of beans
with a different incomplete or complete protein (e.g., rice or cheese)
would create a complete protein.
Protein has both a Recommended Dietary Allowance (RDA) and an

Acceptable Macronutrient Distribution Range (AMDR).
Recommended Dietary Allowance and Mean U.S.

Protein Intake
The RDA for protein for healthy adults age 19 years and older is 0.8 g/kg,
and is derived from the absolute minimum requirement needed to maintain
nitrogen balance, plus an additional factor to account for individual
variations and the mixed quality of proteins typically consumed (National
Research Council, 2005). The RDA is also based on the assumption that
calorie intake is adequate.
• For reference, the RDA for an adult male weighing 154 pounds is
0.8 g/kg, which translates to 56 g protein/day.
• For reference, the RDA of an adult female weighing 127 pounds
would need 46 g/day.
• To calculate a healthy adult’s RDA for protein
determine weight in kilograms by dividing weight in pounds by
• 2.2.
• multiply the weight in kilograms by 0.8 to determine total grams
of protein needed per day.
• The RDA for protein is higher for people younger than 19 years (in
grams per kilogram of body weight) and for pregnant or lactating
women, to support growth and development (Table 4.2).
• A growing body of evidence suggests older adults may need more
than the current RDA to help preserve muscle mass and function
(Traylor et al., 2018).
• The RDA is intended for healthy people only.
• Health impairments that require tissue repair increase a person’s
protein requirement (Box 4.5).
• Conversely, protein restriction is appropriate for people with
severe liver disease (because the liver metabolizes amino acids),
and for those who are unable to adequately excrete nitrogenous
wastes from protein metabolism, due to impaired kidney function.
BOX Conditions That Increase the Need for

4.5 Protein
When Calorie Intake is Inadequate Resulting in Protein

Being Used for Energy
• Very-low-calorie weight-loss diets
• Starvation
• PEM
When the Body Needs to Heal Itself

• Hypermetabolic conditions such as thermal injuries, sepsis, major
infection, and major trauma
• Post-surgically
• Acute inflammation such as inflammatory bowel disease
• Skin breakdown
• Multiple fractures
• Hepatitis
When Excessive Protein Losses Need Replacement

• Long-term peritoneal or hemodialysis dialysis
• Protein-losing renal diseases
• Malabsorption syndromes such as protein-losing enteropathy and short
bowel syndrome
When Periods of Normal Tissue Growth Occur

• Pregnancy
• Lactation
• Infancy through adolescence
Table Recommended Dietary

Allowance for Protein
4.2 by Age and Life Stage
By Age Gram Protein/kg Body Weight

For men and women:
7–12 months 1.2
1–3 years 1.05
4–13 years 0.95
14–18 years 0.85
≥19 years 0.8
By life stage
Pregnancy 1.1
Lactation 1.3
According to the National Health and Nutrition Examination Survey
2015 to 2016 data, the mean protein intake for adult men and women age 20
years and older is 97 and 70 g, respectively. This amount is well above the
RDA (U.S. Department of Agriculture, Agricultural Research Service,
2018a). It represents an average of 16% of total calories for both men and
women age 20 and older (U.S. Department of Agriculture, Agricultural
Research Service, 2018b). Table 4.3 estimates the protein content of a 2000-
calorie Healthy U.S.-Style Eating Pattern.
Table Protein of the 2000-

Calorie Healthy U.S.-
4.3 Style Eating Pattern
Think of Robert. What is Robert’s RDA for protein at a

healthy weight of 84 kg? His protein and calorie intakes are
inadequate, as determined by food records and weight loss.
He agrees to try in-between meal snacks. What snacks
would you specifically suggest?
Acceptable Macronutrient Distribution Range

The AMDR for protein for adults is 10% to 35% of total calories (National
Research Council, 2005). However, the AMDR is not a useful tool for
assessing protein adequacy, because it is based on intake levels that are
associated with a reduced risk of chronic disease while providing adequate
intake of essential nutrients. The AMDR ranges established for
carbohydrate and fat are supported by evidence, but for protein, evidence is
lacking. For instance, a Tolerable Upper Intake Limit has not been
established for protein. The AMDR for protein was set, in part, to
complement the ranges for carbohydrate and fat, and was not due to
compelling evidence indicating a range based on risk of chronic disease.
Protein Deficiency
Protein deficiency usually occurs in conjunction with calorie deficiency.
Protein–energy malnutrition (PEM), sometimes referred to as protein–
energy undernutrition, is a calorie deficit due to a deficiency of all
macronutrients—carbohydrates, protein, and fat. Accompanying
deficiencies of micronutrients are common. It can occur simply from poor
intake, or secondary to conditions or drugs that alter nutrient intake (e.g.,
anorexia nervosa), absorption (e.g., pancreatic insufficiency), utilization
(e.g., cancer), or requirements (e.g., trauma).
• In developed countries, PEM is common among seniors, especially
institutionalized seniors (Morely, 2018), hospitalized patients, and
people with certain diseases.
• Children worldwide are most often affected by PEM. Globally,
malnutrition affects almost half of the 5.6 million children who die
before their fifth birthday each year (Black et al., 2013).
• Marasmus and Kwashiorkor are the two common forms of PEM
in children (Table 4.4).).
Macronutrients
nutrients required by the body in large amounts (gram quantities); namely, carbohydrate, protein,
and fat.
Micronutrients
nutrients required by the body in small amounts (microgram or milligram quantities); namely,
vitamins and minerals.
Kwashiorkor
a type of PEM resulting from a deficiency of protein or infections.
Marasmus
a type of PEM resulting from severe deficiency or impaired absorption of calories, protein,
vitamins, and minerals.
Table Comparison between

Kwashiorkor and
4.4 Marasmus
Kwashiorkor Marasmus
Intake • More deficient in protein
than calories • Inadequate calorie and
• Tends to be confined protein intake
to areas of the world
where staple foods
(e.g., yams,
cassavas, green
bananas) are low in
protein and high in
carbohydrates
Cause
• Premature • Severe prolonged starvation
abandonment of may occur in children from
breastfeeding chronic or recurring
• Acute illness or infections with marginal
infections that cause food intake; in adults from
loss of appetite developed countries, may
while increasing occur secondary to chronic
nutrient illness.
requirements and • More common than
losses. Kwashiorkor
• Stressors in children
in developing
countries may be
measles or
gastroenteritis and
often occurs during
weaning
• Less common than
marasmus
Onset • Rapid, acute; may • Slow, chronic; may take
develop in a matter months or years to develop
of weeks
Edema • Characterized by • Absent
peripheral edema
due to low serum
albumin
Appearance • May look plump due • “Skin and bones” due to
to ascites severe muscle loss and
• Abdomen protrudes virtually no body fat
due to weakened
abdominal muscles
Weight loss • Children present • Severe
with poor weight
gain or weight loss
Other
• Skin lesions; • Dry, thin skin that easily
clinical shedding skin wrinkles
symptoms
• Hair loss, loss of • Hair is sparse; easy
that may be
present hair color, easy pluckability
pluckability • No fatty liver
• Enlarged fatty liver • Hypothermia
• Loss of appetite • Increased susceptibility to
• Apathy and lethargy infections
• Increased
susceptibility to
infections
Signs and Symptoms of Protein–energy Malnutrition

PEM affects all body organs and many body systems.
• Apathy and irritability are common.
• Work capacity is impaired.
• Temporary lactose deficiency can develop.
• Diarrhea is common and can be aggravated by a deficiency of
lactase and other disaccharidases.
• Muscle and fat wasting are common.
• An impaired immune system increases the risk of infection.
• Infection in the intestinal tract impairs nutrient digestion and
absorption.
• Wound healing is impaired. In senior patients, risk of hip fractures
and pressure ulcers also increases.
• With acute or chronic severe PEM
cardiac output decreases, blood pressure falls, and respiratory rate
• decreases,
• body temperature falls,
• anemia occurs from a decreased production of hemoglobin,
• diminished levels of serum albumin leads to edema,
• jaundice and petechiae can develop, and
• liver, kidney, or heart failure may occur.
Treatment
Treatment is determined by the severity of PEM. Mild or moderate PEM
can be treated with a balanced diet, preferably oral.
• Liquid supplements are useful if solid food intake is inadequate.
• Lactose is restricted if diarrhea persists.
• Multivitamin supplements are given.
In severe PEM or chronic starvation, the following apply:
• Nutrition therapy begins with correcting fluid and electrolyte
imbalances to help raise the blood pressure and increase the heart
rate.
• Infections are treated.
• In children with diarrhea, feeding may be delayed for 24 to 48 hours
to avoid worsening diarrhea.
• It is usually not necessary to delay feeding in adults.
• Oral or enteral feedings (e.g., nasogastric tube feedings) begin with
small amounts to avoid overwhelming the absorptive capacity of the
small intestine (Morley, 2018).
• Intake progresses as tolerated.
• Multivitamin supplements at about twice the RDA are given until
recovery is complete.
Protein Excess
There are no proven risks from eating an excess of protein. A Tolerable
Upper Intake Level has not been established, but this does not mean that
there is no potential for adverse effects from a high protein intake from food
or supplements (National Research Council, 2005). Data are limited on the
adverse effects of high levels of amino acid intake from supplements, so
caution is advised in taking any single amino acid in amounts significantly
higher than what is found in food (National Research Council, 2005).
PROTEIN IN HEALTH PROMOTION
The Dietary Guidelines for Americans (DGA) 2020–2025 urge people to

consume a healthy eating pattern that includes a variety of protein foods in
nutrient-dense forms. This means meat and poultry should be consumed
fresh, frozen, or canned forms instead of processed products and that
choices be lean or low fat (Box 4.6) (U.S. Department of Agriculture
[USDA] & U.S. Department of Health and Human Services [USDHHS] ,
2020). This advice is consistent with guidelines from other health agencies.
BOX Lean Animal and Plant Protein Choices

4.6
Animal
• Beef: USDA Choice or Select grades trimmed of fat: 90% or higher
lean ground beef, roast (chuck, round, rump, sirloin), steak (cubed,
flank, porterhouse, T-bone), tenderloin
• Beef jerky
• Lean pork choices: pork loin, tenderloin, center loin, ham, and
Canadian bacon
• Skinless poultry: chicken, Cornish hen, turkey, well-drained domestic
duck or goose; lean ground turkey or chicken
• Veal: culet without breading, loin chop, roast
• Any of the following processed items in varieties that provide 3 g of
fat or less per oz: sausage, hot dogs, deli meat, cheese
• Fish: fresh or frozen; canned salmon, sardines, tuna (in water or oil,
drained)
• Shellfish: clams, oysters, crab, lobster, scallops, shrimp
• Game: buffalo, ostrich, rabbit, venison
• Egg substitutes or egg whites
• Goat: chop, leg, loin
• Organ meats: heart, kidney, liver
Plant
• Beans, peas, and lentils
• Edamame
• Light tofu
• Meatless crumbles, soy-based bacon strips, meatless burger, meatless
chicken tenders, meatless hotdog, meatless deli slices
Source: American Diabetes Association, Academy of Nutrition and Dietetics. (2019). Choose
your food: Food lists for weight management. American Diabetes Association & Academy of
Nutrition.
• The American College of Cardiology/American Heart Association

recommendations for the primary prevention of cardiovascular
disease suggests that adults consume lean vegetable or animal
protein and fish, and minimize the intake of red and processed meats
(Arnett et al., 2019).
• The American Cancer Society recommends limiting processed meat
and red meat (Kushi et al., 2012).
• The American Institute for Cancer Research advises consumers to
limit consumption of red meats (e.g., beef, pork, and lamb) to
moderate amounts and to eat little, if any, processed meat, such as:
ham, bacon, salami, hot dogs, and sausages. (American Institute for
Cancer Research, 2020).
Protein Food Group
Dietary Reference Intakes for protein refer to protein (the nutrient); protein
foods (the group) refer to a set of foods that provide significant protein as
well as fat and/or carbohydrates and micronutrients. Subgroups within the
protein food group include: meats, poultry, eggs; seafood; nuts, seeds, and
soy products; and beans, peas, and lentils.
Intake of Protein Foods

While Americans eat enough of the nutrient protein and come close to the
target amounts for the protein food group, many people do not meet
recommendations for specific protein subgroups (USDA & USDHHS,
2020):
• Approximately 75% of Americans meet or exceed the
recommendation for meats, poultry, and eggs.
• Almost 90% do not meet the recommendation for seafood.
• More than 50% do not meet the recommendation for nuts, seeds,
and soy products.
• 48% of protein foods consumed are eaten as part of a mixed dish,
such as sandwiches, burgers, and tacos. The protein in mixed dishes
may have higher amounts of saturated fat than protein foods
consumed as a separate food (e.g., a chicken breast or fillet of fish)
and mixed dishes may have other ingredients that are not in nutrient-
dense form.
Seafood
Seafood is known for providing the omega-3 fatty acids eicosapentaenoic
acid (EPA) and docosahexaenoic acid (DHA) yet it contains an array of
other nutrients including protein, selenium, iron, zinc, iodine, vitamin B12,
and vitamin D. Healthy eating patterns that include a focus on fish are
recommended to lower atherosclerotic cardiovascular disease (Arnet et al.,
2019). It is not completely known whether health benefits are solely due to
fish oil intake or if other nutrients contribute to its benefits (Gribble et al.,
2016).
The healthy U.S. style eating patterns intended for adults (total daily
calorie intake from 1600 to 3200) recommend Americans consume at least
eight ounces of seafood/week (USDA & USDHHS, 2020). A variety of
seafood is recommended to limit exposure to methylmercury, which is
present in varying amounts in nearly all fish.
Methylmercury
Mercury, a neurotoxin, is a heavy metal that occurs naturally in the environment and is released
into the air through industrial pollution. It changes to methylmercury when it falls from the air
into the water. As a fat-soluble element, it accumulates in the fat tissue of large predatory fish.
Pregnant and lactating women and children younger than age 8 years are vulnerable to the toxic
effects of mercury because it can damage the developing brain and spinal cord.
• Most fish have minute amounts of methylmercury that are not

harmful to humans; large predatory fish with long lifespans have
more.
• Evidence suggests the benefits of consuming moderate amounts of
fish on cardiovascular health very likely outweigh the risk of any
potential harm related to mercury exposure (Rimm et al., 2018).
• Still, to minimize potential risk from methylmercury, it is
recommended that people choose seafood that is high in EPA and
DHA and lower in methylmercury: salmon, anchovies, herring,
shad, sardines, Pacific oysters, and Atlantic and Pacific mackerel
(Fig. 4.3).
• People who eat more than the recommended 8 oz of seafood per
week are encouraged to choose a mix of seafood that is relatively
low in methylmercury.
• Because fish provides vital nutrients for developing fetuses and
infants, especially fatty acids, pregnant and lactating women are
urged to eat 8 to 12 oz of a variety of seafood per week, from
choices that are lower in mercury a week (FDA & Environmental
Protection Agency [EPA], 2019). See Chapter 12 for additional
recommendations regarding seafood intake during pregnancy.
Figure 4.3 ▲ Recommended fish choices based on mercury content.
(Source: United States Food and Drug Administration. (2019). Advice
about eating Fish. https://www.fda.gov/food/consumers/advice-about-
eating-fish)
Vegetarian Diets
A healthy vegetarian-style eating pattern is one of three eating patterns
featured in the Dietary Guidelines for Americans 2020-2025 (USDA &
USDHHS 2020). The health benefits of a plant-based diet may come from
eating less of certain substances (such as saturated fat), eating more of
others (such as fiber, antioxidants, and phytonutrients), or a combination of
the two. Plant-based foods are also low in calorie density.
Vegetarianism is a general term assigned to plant-based eating patterns
that restrict animal foods (e.g., meat, poultry, seafood, dairy, and eggs) and
products made with them.
• Restrictions range from total elimination of all animal products to
simply excluding one or more types of animal proteins (Box 4.7).
• Each defined category of vegetarianism has different characteristics,
and individuals differ in how strictly they adhere to the eating
pattern. For instance, some vegans do not eat refried beans that
contain lard because lard is an animal product, but other vegans do
not avoid animal products so conscientiously.
• Nationally, 3.3% of American adults describe themselves as
vegetarians and about half of the vegetarians are also vegan
(Vegetarian Resource Group, 2016).
• Properly planned vegan, lacto-vegetarian, and lacto-ovo vegetarian
eating patterns are healthful and are nutritionally adequate during all
phases of the life cycle, including pregnancy, lactation, infancy,
childhood, and adolescence, older adulthood, and for athletes
(Melina et al., 2016).
• Vegetarian diets improve several modifiable risk factors for heart
disease, including abdominal obesity, blood pressure, serum lipids,
and blood glucose as well as lowered C-reactive protein (Melina et
al., 2016).
• Vegetarian eating patterns can provide health benefits in the
prevention and treatment of certain health conditions: ischemic heart
disease, type 2 diabetes, and certain cancers.
• Compared to meat eaters, vegetarians eat less total fat, saturated fat,
and cholesterol, and more fiber (Ha & de Souza, 2015), as well as
more micronutrients and phytonutrients.
• Although the cardiometabolic benefits of vegetarian diets are widely
attributed to the absence of red meat, reciprocal increases in the
intake of healthy foods, such as legumes, vegetables, fruit, and
grains, are also significant (Ha & de Souza, 2015).
BOX Types of Vegetarian Diets

4.7
The basis of all vegetarian diets is the exclusion of meat, fish, and
poultry. Additional traits vary with the type of vegetarian diet.
• Vegan: also excludes eggs, dairy products, and may exclude honey
• Raw vegan: a strictly uncooked food eating pattern based on fruit,
vegetables, nuts, seeds, legumes, and sprouted grains. Uncooked food
ranges from 75% to 100% of total food consumed.
• Lacto-ovo vegetarian: includes dairy products and eggs.
• Lacto-vegetarian: excludes eggs but includes dairy products.
• Ovo-vegetarian: excludes dairy products but includes eggs.
• Other eating patterns that restrict the types of protein consumed are
loosely defined.
• Pesco-vegetarian: excludes all animal products except fish
• Semi-vegetarian: does not eat red meat
• Flexitarian: eats chicken and fish, occasionally eats red meat
Recall Robert. Is it appropriate to recommend vegetarian

resources that feature nonmeat recipes and meal patterns to
him even though he is not a vegetarian?
However, vegetarian eating patterns are not automatically healthier than

nonvegetarian patterns.
• Poorly planned vegetarian eating patterns may lack certain essential
nutrients, which endangers health.
• Fat and cholesterol intake can be excessive if whole milk, whole-
milk cheeses, eggs, and high-fat desserts are used extensively.
• Actual food choices made over time determine whether a vegetarian
eating pattern is healthy or detrimental to health.
• Tips for vegetarians appear in Box 4.8.
BOX Tips for Following a Vegetarian Diet

4.8
• Eat a variety of foods that provide protein, including whole grains,
vegetables, legumes, nuts, seeds, and, if desired, dairy products and
eggs.
• Consider meatless versions of familiar favorites, such as vegetable pizza, vegetable lasagna,
vegetable stir-fry, vegetable lo mein, and vegetable kabobs.
• Experiment with meat substitutes made from vegetables.
• For variety, try soy sausage patties or links, veggie burgers, quinoa chili, or scrambled tofu.
• Include legumes.
• Try vegetarian chili, three-bean salad, navy bean soup, hummus, lentil stew, bean burritos, or
black bean burgers.
• Substitute soy milk in place of cow’s milk
• such as in french toast, rice pudding, and smoothies.
• Experiment with tofu
• such as in place of eggs (e.g., scrambled “eggs”) or ricotta cheese (e.g., lasagna).
• Include nuts.
• Snack on unsalted nuts, or add to salads or main dishes.
• Eat enough calories.
• Adequate calories are necessary to avoid using amino acids for energy, which could lead to a
shortage of amino acids for protein synthesis.
• Consume a rich source of vitamin C at every meal.
• Eating a good source of vitamin C at every meal helps to maximize iron absorption from
plants.
• Try citrus fruits and juices, tomatoes, kiwi, red and green peppers,
broccoli, brussels sprouts, cantaloupe, and strawberries.
• Include foods that supply plant omega-3 fat
• such as flaxseeds, tofu, chia seeds, walnuts, and canola and soybean oils.
• Don’t go overboard on high-fat cheese as a meat substitute.
• Full-fat cheese has more saturated fat and calories than many meats.
• Experiment with ethnic cuisines.
• Many Asian, Middle Eastern, and Indian restaurants offer a variety of meatless dishes.
• Choose vitamin B12-fortified foods, or take a vitamin B12 supplement
daily.
• Supplement nutrients that are lacking from food.
• See Table 4.5 for sources of other nutrients of concern.
Nutrients of Concern
The concerns that vegetarian eating patterns are deficient in total protein or
provide poor overall protein quality are unfounded.
• Most vegetarian eating patterns, even vegan ones, meet or exceed
the RDA for protein. Box 4.9 illustrates how a vegan menu can
exceed the RDA for the average adult.
• Eating a variety of plant proteins and adequate calories ensures that
the supply of essential amino acids is adequate.
• Iron, zinc, calcium, vitamin D, omega-3 fatty acids, and iodine are
nutrients of concern, not because they cannot be obtained in
sufficient quantities from plants, but because they may not be
adequately consumed, depending on an individual’s food choices.
• Vitamin B12 is of concern because it does not occur naturally in
plants. Table 4.5 lists vegetarian sources of these nutrients of
concern.
BOX
Protein Content of a Sample Vegan Menu
4.9
Food Item g Protein*
Breakfast
1 cup oatmeal 6
With 2 tbsp walnuts 1
1 cup soymilk 8
Banana
Lunch
Black bean burger 10
On whole wheat bun 6
Condiments as desired
Side salad with dressing 2
Fresh orange
Food Item g Protein*
Dinner 12
4 oz tofu 6
Stir fried with 1½1 cup vegetables 4
Served over 1 cup brown rice
Fresh watermelon
Snack
1 cup soy yogurt 10
With 2 tbsp almonds 2
Total grams protein/day 67
*Estimates based on averages listed in Table 4.1.

Note. The RDA for reference man is 56 g/day and for reference woman 46 g/day.
Table Sources of Nutrients of

Concern in Vegan
4.5 Eating Patterns
Vegetarian
Nutrient Sources Comments
Vegetarian
Iron Iron-fortified bread Vegetarians generally consume as
and cereals much or more iron than meat
Baked potato eaters but their iron stores are
with skin lower (Melina et al., 2016).
Kidney beans, KIt is recommended that vegetarians
black-eyed consume good sources of iron
peas, such as iron-fortified breads and
chickpeas, and cereals, legumes, lentils, and
lentils raisins, with a source of vitamin C
KCooked soybeans because vitamin C enhances the
KTofu, tahini bioavailability of iron from plants.
KVeggie “meats”
KDried apricots,
prunes, and
raisins
KCooking in a cast
iron pan,
especially with
acidic foods
such as
tomatoes
Zinc Whole grains Compared to meat eaters, adult
KLegumes vegetarians consume similar or
KZinc-fortified somewhat lower amounts of zinc
cereals and have serum levels that are
KSoybean lower but within normal range
products (Melina et al., 2016)
KSeeds KOvert zinc deficiency is not evident
KNuts in American vegetarians.
Vegetarian
Calcium Bok choy Calcium recommendations are met or
KBroccoli exceeded by lacto-ovo vegetarians.
KChinese/Napa Calcium intake among vegans
cabbage varies widely and may be less than
KCollard greens recommended (Melina et al.,
KKale 2016)
KTurnip greens KBeet greens, spinach, and Swiss
KCalcium-fortified chard are also high in calcium, but
orange juice their oxalate content greatly
KCalcium-set tofu impairs calcium absorption, so
KCalcium-fortified they are not considered good
plant milks, sources.
breakfast KCalcium supplements are
cereals recommended for people who do
not meet their calcium requirement
through food.
Vitamin Sunlight Supplements may be necessary depending
D KFortified milk on the quality of sunlight exposure
KFortified ready- and adequacy of vitamin D–fortified
to-eat cereals food choices.
KFortified fruit
juices
KFortified soy
milk
KFortified
nondairy milk
products
Vegetarian
Omega- Fortified foods, Diets that exclude fish do not contain
3 fatty such as a direct source of omega-3 fatty
acids breakfast acids EPA and DHA.
cereals, soy KThe body can convert small amounts
milk, and of alpha-linolenic acid into DHA
yogurt and EPA.
KSources of alpha- KAdequate DHA and EPA is
linolenic acid especially important during
are the pregnancy, infancy, and in seniors.
following: KLow-dose microalgae-based DHA
KGround flaxseed supplements are available
and flaxseed oil
KChia seeds
KWalnuts and
walnut oil
KCanola oil
KSoybean oil
Vegetarian
VitaminFortified soy milk, Vitamin B12 is naturally present only
B12 breakfast cereals, in foods derived from animals
and veggie burgers KSeaweed, algae, spirulina, tempeh,
miso, beer, and other fermented
foods cannot be relied up as
adequate or practical sources of
B12 (Melina et al., 2016)
KVegans must regularly consume B12-
fortified foods or supplements
containing B12 to avoid deficiency.
KSupplemental vitamin B12 through
food or pills is recommended for
all people over the age of 50 years
regardless of the type of diet they
consume because absorption
decreases with age.
KVitamin B12 deficiency during
pregnancy and lactation may lead
to severe developmental problems
in the fetus and infant.
Iodine Iodized salt Vegans who do not consume iodized
KSea vegetables salt or sea vegetables may be at
risk for iodine deficiency (Melina
et al., 2016)
KSea salt, kosher salt, and salt-based
seasonings are generally not
iodized, nor is iodized salt used in
processed foods.
KVegan women of childbearing age
should consume a iodine
supplement of 150 mcg/day
(Melina et al., 2016)
Think of Robert. Robert’s intake of heme iron is low
because he does not eat red meat.
What other nutrients may he consume in inadequate
amounts?
Would he benefit from a multivitamin with minerals?
Protein for Muscle Building

High-protein diets and protein supplements are popular among athletes
based on the rationale that muscle is protein tissue; thus eating more protein
makes more muscle. Building muscle is not simply a matter of increasing
protein intake, even though protein recommendations for athletes are higher
than for nonathletes. Both resistance training and an adequate overall intake
are necessary to increase muscle mass.
Resistance training, also called weight or strength training, is exercise
that causes muscle to contract against an external force for the purpose of
increasing strength, tone, mass, or endurance. Resistance training causes
microscopic tears in muscle tissue (catabolism), which the body quickly
repairs to regenerate and strengthen muscle (anabolism). Although an
adequate protein is important, so is an adequate intake of overall calories—
energy to fuel the activity as well as repair the tissue.
• Athletes need to consume adequate calories timed to meet energy
needs during high-intensity and/or long-duration training (Thomas
et al., 2016).
• Recommendations for protein intake typically range from 1.2 to 2.0
g protein/kg/day (Thomas et al., 2016). This amount of protein can
generally be met through food alone, without the need for protein or
amino acid supplements.
• An even distribution of protein intake after exercise and throughout
the day may optimize muscle protein synthesis (Thomas et al.,
2016).
• Vitamin and mineral supplements are unnecessary for athletes who
consume adequate calories from a variety of nutrient-dense foods
(Thomas et al., 2016).
• The use of sports supplements is a personal choice, and is
controversial (Thomas et al., 2016).
Consider Robert. Robert wants to know if whey protein

powder or amino acid supplements would be beneficial.
How would you respond?
How Do You Respond?

Is ground turkey a low-fat alternative to ground
beef? Not necessarily. Ground turkey may contain skin,
dark meat, and fat, which makes it a higher-fat product
than 95% lean ground beef. Ground turkey breast and
chicken breast are both made only from white meat and
are lower in fat (approximately 3 g/3 oz cooked) than all
varieties of ground beef (5.5–15 g fat/3 oz cooked).
Are amino acid supplements a good idea to
boost protein intake or sports performance?
Amino acid supplements often provide only one or few
particular amino acids, unlike the natural array of amino
acids found in food. An imbalance of amino acids is not
beneficial: an excess of one amino acid can interfere with
the absorption of other amino acids, and cause them to
become the limiting amino acid for protein synthesis. An
abnormally high serum concentration of an amino acid
raises the possibility of toxicity. Caution is advised in
using any single amino acid at levels other than what is
supplied by food.
REVIEW CASE STUDY
Emily does not eat meat, eggs, or milk for ethical reasons, although she will
still eat baked goods that may contain milk or eggs. Over the last 6 months,
she has gained 15 pounds. Emily admits that she expected to see weight
loss instead of gain.
She needs 2000 cal/day according to MyPlate, and a typical daily intake
for Emily is shown on the right.
• What kind of vegetarian is Emily? What sources of protein is she

consuming? Is she consuming enough protein?
• How does her daily intake compare to MyPlate recommendations for a
2000-calorie diet? What suggestions would you make to her to
improve the quality of her diet?
• Is Emily at risk of any nutrient deficiencies?
• If so, what would you recommend she do to ensure nutritional
adequacy?
• What would you tell Emily about her weight gain? What food would you
recommend limiting to promote weigt loss? What could she substitute for
those foods?
Breakfast: a glazed donut and a smoothie made with soy milk, tofu, and
fresh fruit
Snack: potato chips and soda
Lunch: peanut butter sandwich, soy yogurt, oatmeal cookies, and a soft
drink
Snack: candy bar
Dinner: stir-fried vegetables over rice, bread w/margarine, glass of soy
milk, apple pie
Snack: buttered popcorn
STUDY QUESTIONS
1 What is the RDA for protein for a healthy adult who weighs 165 pounds?
a. 40 g
b. 60 g
b. 75 g
d. 132 g
2 The client asks what foods are rich in protein and are less expensive than
meat. Which foods would the nurse recommend they eat more of?
a. Breads and cereals
b. Fish and shellfish
c. Fruit and vegetables
d. Beans, peas, and lentils
3 Which of the following is a lean source of protein?
a. Eggs
b. Turkey breast without skin
c. 80% lean ground beef
d. Prime beef rib roast
4 Which statement indicates the client understands vegetarian diets?
a. “Vegetarian diets are not adequate during pregnancy and lactation.”
b. “Vegetarians may need to take a vitamin B12 supplement and other
nutrients, depending on their actual food selection.”
c. “Vegetarian diets are always healthier than nonvegetarian diets.”
d. “Vegetarians usually do not consume enough protein.”
5 A client who is in a positive nitrogen balance is most likely to be
a. Pregnant.
b. Starving.
c. A healthy adult.
d. Losing weight.
6 What should the nurse tell a client who likes fish but refuses to eat it
because of fear of mercury poisoning?
a. “You are justified to be concerned. To be safe, use fish oil supplements
instead.”
b. “You can eat as much fish as you want because most fish are not
contaminated with even small amounts of mercury.”
c. “The benefits of eating 8 oz/week of a variety of fish outweigh any
potential risks from mercury.”
d. “As a compromise, eat 4 oz of fish per week instead of 8 oz.”
7 The nurse knows that instructions have been effective when the client
verbalizes that a source of complete, high-quality protein is found in
a. Peanut butter
b. Black-eyed peas
c. Corn
d. Cottage cheese
8 To move toward healthier eating patterns, Americans should
a. Eat more seafood
b. Eat more total protein
c. Eat more mixed protein dishes, such as sandwiches, in place of eating
protein as a separate food
d. Replace seafood with poultry
CHAPTER SUMMARY PROTEIN

Protein is a component of every living cell. It provides the structure and
framework of the body. Amino acids are components of enzymes,
hormones, neurotransmitters, and antibodies. Proteins play a role in fluid
balance and acid–base balance, and are used to transport substances
through the blood. Protein provides 4 cal/g.
Protein Composition and

Structure
Amino acids are the building blocks of protein.
• They are composed of carbon, hydrogen, oxygen, and nitrogen atoms.

• Amino acids are joined in different amounts, proportions, and
sequences to form the thousands of different proteins in the body.
• Nine are essential and must be supplied through the diet.
• The remaining 11 are considered nonessential only because they can
be made if nitrogen is available.
Functions Of Protein
Amino acids or proteins are involved in or components of
• body structure and framework: muscle, skin, blood, tendons, organs,

and bones,
• enzymes,
• other body secretions and fluids: neurotransmitters, antibodies, and
peptide fluid balance,
• acid–base balance,
• transport molecules,
• fueling the body (protein provides 4 cal/g).
How the Body Handles Protein

• The small intestine is the principal site of protein digestion.
• Amino acids and some dipeptides are absorbed through the portal
bloodstream.
• Amino acids consumed in excess are burned for energy or converted
to fat and stored.
• Healthy adults are in nitrogen balance, which means that protein
synthesis is occurring at the same rate as protein breakdown.
Sources of Protein
Complete proteins contain all essential amino acids in adequate amounts
and proportions to support protein synthesis:
• meat, poultry, seafood, eggs
• milk, yogurt, cheese
Incomplete proteins contain insufficient quantities of one or more
essential amino acids:
• grains and products made with grains
• legumes and lentils
• nuts and seeds
• vegetables
• gelatin

• The RDA for protein is 0.8 g/kg/day for adults.
• Protein should provide 10% to 35% of total calories consumed.
• Protein need is higher during growth, pregnancy, lactation, recovery
from injury, or when calorie intake is inadequate.
• Protein is restricted in certain liver and kidney diseases.
• Protein deficiency is rare in the United States except among
hospitalized patients and certain others.
Protein in Health Promotion
• Americans eat enough protein foods but are urged to make more
nutrient dense selections, such as avoiding fatty and processed meats.
• Americans are urged to eat 8 oz or more/week of a variety of seafood
that is low in methylmercury.
• Vegetarian diets exclude animal products. Most vegetarian diets meet
or exceed the RDA for protein. Pure vegans who do not have reliable
sources of vitamin B12 and vitamin D need supplements.
• Resistance exercise helps build muscle mass. Adequate calories and
protein are necessary. The use of sports food and supplements should
be carefully considered.
Figure sources: shutterstock.com/Ekaterina Markelova and shutterstock.com/Elena Veselova

book at
Websites
Soyfoods Association of North America at www.soyfoods.org
Vegan Health at www.veganhealth.org
The Vegan Society at www.vegansociety.com
Vegetarian Nutrition Dietetic Practice Group’s at www.vegetariannutrition.net
Vegetarian Resource Group at www.vrg.org
Vegetarian-Nutrition Info at https://vegetarian-nutrition.info/
VegWeb at www.vegweb.com
References
American Institute for Cancer Research. (2020). Cancer prevention recommendations.
https://www.aicr.org/reduce-your-cancer-risk/recommendations-for-cancer-prevention/index.html
Muñoz, D., Smith, S. C. Jr., Virani, S. S., Williams, K. A., Sr., Yeboah, J., & Ziaeian, B. (2019).
ACC/AHA guideline on the primary prevention of cardiovascular disease: A report of the
Guidelines. Journal of American College of Cardiology, 74, e177–e232.
https://doi.org/10.1016/j.jacc.2019.03.010
Gribble, M., Karimi, R., Feingold, B., Nyland, J., O’Hara, T., Gladyshev, M., & Chen, C. Y. (2016).
Mercury, selenium and fish oils in marine food webs and implications for human health. Journal
of the Marine Biological Association of the United Kingdom, 96(1), 43–59.
https://doi.org/10.1017/S0025315415001356
Ha, V., & de Souza, R. (2015). “Fleshing out” the benefits of adopting a vegetarian diet. Journal of
the American Heart Association, 4, e002654. https://doi.org/10.1161/JAHA.115.002654
Gapstur, S., Patel, A. V., Andrews, K., Gansler, T., & American Cancer Society 2010 Nutrition
and Physical Activity Guidelines Advisory Committee. (2012). American Cancer Society
Guidelines on nutrition and physical activity for cancer prevention: Reducing the risk of cancer
with healthy food choices and physical activity. CA: A Cancer Journal for Clinicians, 62, 30–67.
Melina, V., Craig, W., & Levin, S. (2016). Position of the Academy of Nutrition and Dietetics:
Vegetarian diets. Journal of the Academy of Nutrition and Dietetics, 116, 1970–1980.
Morley, J. (2018). Protein-energy undernutrition. Merck Manual Professional Version.
https://www.merckmanuals.com/professional/nutritional-disorders/undernutrition/protein-energy-
undernutrition-PEM?query=Undernutrition
National Research Council. (2005). Dietary reference intakes for energy, carbohydrate, fiber, fat,
fatty acids, cholesterol, protein, and amino acids (macronutrients). The National Academies
Press.
Thomas, D., Erdman, K., & Burke, L. M. (2016). Position of the Academy of Nutrition and Dietetics,
Dietitians of Canada, and the American College of Sports Medicine: Nutrition and athletic
performance. Journal of the Academy of Nutrition and Dietetics, 116, 501–528.
Traylor, D., Gorissen, S., & Phillips, S. (2018). Perspective: Protein requirements and optimal intakes
in aging: Are we ready to recommend more than the Recommended Daily Allowance. Advances
in Nutrition, 9, 171–182. https://doi.org/10.1093/advances/nmy003
U.S. Department of Agriculture, Agricultural Research Service. (2018a). Nutrient intakes from food
and beverages: Mean amounts consumed per individual, by gender and age. What we eat in
America, NHANES 2015–2016. www.ars.usda.gov/nea/bhnrc/fsrg
U.S. Department of Agriculture, Agricultural Research Service. (2018b). Energy intakes: Percentages
of energy from protein, carbohydrate, fat, and alcohol, by gender and age. What we eat in
guidelines for Americans 2020–2025. https://www.dietaryguidelines.gov/sites/default/files/2020-
Vegetarian Resource Group. (2016). How many adults in the United States are vegetarian and vegan?
How many adults eat vegetarian and vegan meals when eating out?
https://www.vrg.org/nutshell/Polls/2016_adults_veg.htm
Chapter Lipids
5
Dylan Masters
Dylan is a 5-year-old boy who has up to 20 seizures a
day due to epilepsy. He is a candidate for a ketogenic
diet because antiseizure medications have failed to
control his seizures. Although there are several
different levels of the diet, it is characterized as a
high-fat, adequate-protein, very-low-carbohydrate
diet. Dylan’s classic ketogenic diet will provide 1200
calories, 120 g of fat, 18 g of protein, and 12 g of
carbohydrate. The family has undergone extensive
counseling and agreed to try the diet for at least 12
weeks; they understand the risks and that all foods
must be carefully prepared and weighed on a gram
scale. Dylan will be under close medical and
nutritional supervision and will start the diet in the
hospital, where he will be closely monitored by a
neurologist and registered dietitian. Lab work will be
used to identify metabolic abnormalities and evaluate
serum nutrient levels.
Learning Objectives
1 List sources of saturated, monounsaturated, and polyunsaturated fatty

acids and discuss how they impact health.
2 List sources of dietary cholesterol.
3 Name sources of synthetic trans fats.
4 Explain the functions of fat in the body.
5 Discuss the digestion and absorption of fat.
6 Give examples of foods that provide omega-3 fatty acids.
7 Discuss strategies for making healthier food choices based on fat.
Fat has many vital functions in food and improves the overall palatability of
the diet. It absorbs the flavors and aromas of ingredients to improve overall
taste. It adds juiciness to meats and mouthfeel to milk. Fat is the ingredient
that makes cakes tender, ice cream creamy, and pie crusts flaky. Nothing
can duplicate the unique properties of fats in foods.
However, the amount and quality of fat in the typical American diet has
been the subject of study and debate for decades. “Avoid too much fat”
appeared in the first edition of the Dietary Guidelines for Americans
published in 1980 (the 1980 DGA can be found with a quick Google
search). Since then, studies have shown that the relationship between fat
and health is far more complex than that statement implies. Current
recommendations put forth by many American and international health and
government agencies recommend emphasizing or limiting specific sources
of fat rather than addressing total fat intake.
There are three classes of lipids, which are referred to as fat throughout
the rest of this chapter and book: triglycerides (fats and oils), which account
for 98% of the fat in food; phospholipids (e.g., lecithin); and sterols (e.g.,
cholesterol). This chapter describes the classes of fats, their dietary sources,
and how they are handled in the body. The functions of fat and
recommendations regarding intake are presented.
Lipids
a group of water-insoluble, energy-yielding organic compounds composed of carbon, hydrogen,
and oxygen atoms.
TRIGLYCERIDES
Chemically, triglycerides are made of the same elements as carbohydrates

—namely, carbon, hydrogen, and oxygen. There are proportionately more
carbon and hydrogen atoms to oxygen atoms, so triglycerides yield more
calories per gram than carbohydrates. Structurally, triglycerides are
composed of a three-carbon atom glycerol backbone with three fatty acids
attached (Fig. 5.1). An individual triglyceride molecule may contain one,
two, or three different types of fatty acids.
Glycerol
a three-carbon atom chain that serves as the backbone of triglycerides.
Fatty Acids
organic compounds composed of a chain of carbon atoms to which hydrogen atoms are attached.
An acid group (COOH) is attached at one end, and a methyl group (CH3) at the other end.
Triglycerides
a class of lipids composed of a glycerol molecule as its backbone with three fatty acids attached.
Sterols
one of three main classes of lipids, which include cholesterol, bile acids, sex hormones, the
adrenocortical hormones, and vitamin D.
Figure 5.1 ▲ Generic triglyceride molecule.
Fatty Acids
Fatty acids are basically chains of carbon atoms with hydrogen atoms
attached (Fig. 5.2). At one end of the chain is a methyl group (CH3), and at
the other end is an acid group (COOH).
Figure 5.2 ▲ Fatty acid configurations.
• Fatty acids attach to glycerol molecules in various ratios and

combinations to form a variety of triglycerides within a single food
fat.
• The types and proportions of fatty acids present influence the
sensory and functional properties of the food fat. For instance, butter
tastes and acts differently from corn oil, which tastes and acts
differently from lard.
Fatty Acid Chain Length

Fatty acids vary in the length of their carbon chain. Almost all naturally
occurring fatty acids have an even number of carbon atoms in their chain,
generally between 4 and 24.
• Long-chain fatty acids (containing more than 12 carbon atoms)
predominate in meat, fish, and vegetable oils and are the most
common length fatty acid in the diet.
• Smaller amounts of medium-chain (8–12 carbon atoms) and short-
chain (up to 6 carbon atoms) fatty acids are found primarily in dairy
products.
Fatty Acid Saturation

Fatty acid saturation refers to the types of bonds between carbon atoms.
Based on degree of saturation, fatty acids differ in their function, major
sources, and impact on health (Table 5.1).
Types of Fatty Acids,

Table Their Functions,
5.1 Sources, and Impact on
Health
Types of Fatty
Acids and Common Food
Functions Sources Impact on Health
Types of Fatty
Saturated fatty
• Animal fats— • As a category, saturated
acids (SFA) beef, pork, fat is associated with a
Functions:
poultry, veal, egg higher risk of total and
• Provide yolks, dairy cause-specific death
structure to cell products (the fat (Arnett et al., 2019).
membranes in milk does not Although not all
• Facilitate appear as a solid saturated fatty acids may
normal function due to the negatively impact health,
of proteins process of “good” and “bad”
homogenization). saturated fatty acids
• The only share the same food
vegetable oils sources, so foods high in
that are saturated saturated fat should be
are palm oil, limited.
palm kernel oil, • Reducing saturated fat
and coconut oil. intake by replacing it
• Products with unsaturated fats,
containing palm, particularly PUFA,
palm kernel, or lowers the incidence of
coconut oils or cardiovascular disease
any oil that is (CVD) in adults and
fully reduces serum total and
hydrogenated low-density cholesterol
• The body makes in all adults and some
more than children (Dietary
enough saturated Guidelines Advisory
fats to meet its Committee, 2020).
need
Types of Fatty
Monounsaturated
• Olives, olive oil, • When substituted for
fatty acids
canola oil, saturated fatty acids,
(MUFA)
avocado, peanut plant sources of MUFA
Functions: oil, and most but not animal sources
• Key nuts. may lower mortality risk
components of • Meat fat contains (Guasch-Ferre et al.,
membrane moderate 2019).
lipids, amounts of
especially monounsaturated
nervous tissue fats, providing
myelin approximately
50% of MUFAs
in a typical
American eating
pattern (National
Research
Council, 2005).
Polyunsaturated fatty acids (PUFA)
n-3 fatty acids: Components of phospholipids that form the structures of
cell membranes
Types of Fatty
Alpha linolenic
• Soybean, • May provide modest
acid (ALA)
flaxseed, and protection against CVD
Function: canola oils. although the evidence is
• Precursor of • Other sources not as strong as the
EPA and DHA include walnuts association of fish oils
and chia and and CVD (Rajaram,
hemp seeds. 2014).
• Grass-fed cows
produce beef
with ALA but in
very low
amounts.
Types of Fatty
Eicosapentaenoic
• Fatty fish, • n-3 fatty acids are best
acid (EPA) and especially known for their heart
docosahexaenoic
salmon, anchovy, health benefits, which
acid (DHA)
sardines, tuna, are attributed to their
Functions:
herring, and antiinflammatory,
• EPA is mackerel. anticlotting, and anti-
precursor for n- • Food products arrhythmic effects.
3 eicosanoids. fortified with • Evidence supports
• Eicosanoids EPA and/or DHA recommendations to
made from n-3 are available, consume seafood,
tend to have such as soy especially species that
anti- milks, cooking are higher in n-3 fatty
inflammatory, oils, margarine- acids, 1–2 times per
antiarrhythmic, like spreads, week for cardiovascular
and anticlotting breakfast cereals, benefits, including lower
effects. baked goods, risk of cardiac death,
• DHA is a infant formulas, coronary heart disease,
structural and baby food and ischemic stroke,
component of and juices. especially when seafood
red blood cell replaces the intake of
membranes and less healthy foods
is abundant in (Rimm et al., 2018).
retinal tissue,
neuron cells, the
liver, and testes.
Types of Fatty
n-6 fatty acids • Linolenic acid: • Epidemiologic evidence
Functions: Soybean shows aninverse
• LA is a (“vegetable oil”), relationship between n-6
precursor of corn oil, fatty acid intake and
arachidonic acid safflower oil, CVD, coronary artery
and other n-6 poultry, nuts, disease (CAD), diabetes,
fatty acids seeds and CVD mortality and
• Components of • Arachidonic generally supports lower
membrane lipids acid: Found in cardiometabolic disease
• Play a role in small amounts in risk with higher intakes
cell signaling meat, poultry, of n-6 PUFA (Maki et
pathways and eggs al., 2018).
• Play a role in
maintaining
normal skin cell
function
• Precursor of
eicosanoids,
including
prostaglandins
• Involved in
regulation of
genes for
proteins that
regulate fatty
acid synthesis
• When all the carbon atoms have four single bonds, the fatty acid is
“saturated” with hydrogen atoms.
• Saturated fatty acids are straight-line molecules that can pack
tightly together; thus, they are solid at room temperature and
referred to as “solid fat.”
• An “unsaturated” fatty acid does not have all the hydrogen atoms it
can potentially hold; therefore, one (monounsaturated) or more
(polyunsaturated) double bonds form between carbon atoms in the
chain.
• Because of the double bond, unsaturated fatty acids are
physically kinked and unable to pack together tightly; they are
liquid at room temperature and are referred to as “oils.”
Saturated Fatty Acids (SFAs)
fatty acids in which all the carbon atoms are bonded to as many hydrogen atoms as they can hold,
so no double bonds exist between carbon atoms.
Unsaturated Fatty Acids

fatty acids that are not completely saturated with hydrogen atoms, so one or more double bonds
form between the carbon atoms.
Further Unsaturated Fatty Acid Classification Based on the

First Double Bond
Unsaturated fatty acids can be classified according to the ___location of their
double bonds along the carbon chain. The most common method of
identifying the bond is to count the number of carbon atoms from the
methyl (CH3) end, as denoted by the term n or omega.
• Omega-3 fatty acids (n-3) are polyunsaturated fatty acids
(PUFA) with the first double-bond three carbons from the methyl
end. Several n-3 fatty acids exist, but the majority of research
focuses on three: alpha-linolenic acid (ALA) found in certain plants
and the two “fish oils” eicosapentaenoic acid (EPA) and
docosahexaenoic acid (DHA).
• Omega-6 fatty acids (n-6) are PUFA that have the first double-
bond 6 carbons from the methyl end. The two major n-6 fatty acids
are linoleic acid (LA) and arachidonic acid (ARA).
• Omega-9 (n-9) fatty acids are monounsaturated fatty acids
(MUFA) with the only double-bond 9 carbon atoms from the methyl
end.
Omega-3 (n-3) Fatty Acid
an unsaturated fatty acid the endmost double bond of which occurs three carbon atoms from the
methyl end of its carbon chain.
Polyunsaturated Fatty Acids (PUFA)

fatty acids that have two or more double bonds between carbon atoms.
Fish Oils
a common term for the long-chain, polyunsaturated omega-3 fatty acids EPA and DHA found in
the fat of fish, primarily in cold-water fish.
Omega-6 (n-6) Fatty Acid

an unsaturated fatty acid the endmost double bond of which occurs six carbon atoms from the
methyl end of its carbon chain.
Monounsaturated Fatty Acids (MUFA)

fatty acids that have only one double bond between two carbon atoms.
Essential Fatty Acids

The ___location of the first double bond is significant because it determines if
the fatty acid is essential. Essential does not refer to importance but rather
to whether it must be consumed through food because it cannot be
synthesized in the body.
• The body is unable to synthesize fatty acids with double bonds
closer than n-9, so one n-6 fatty acid (LA) and one n-3 fatty acid
(ALA) are deemed essential.
• Although the body cannot make essential fatty acids, it does
store them, making cases of deficiencies of either n-3 or n-6 fatty
acids virtually nonexistent in the United States.
• MUFAs are n-9 fatty acids and thus are not essential.
• Saturated fatty acids do have double bonds, so none are essential.
Linoleic Acid (n-6)

LA accounts for 80% to 90% of total dietary PUFA intake (Micha et al.,
2014).
• The richest source of LA in the typical American diet is soybean oil
(often labeled as vegetable oil) because it used extensively in
processed foods.
• The body can make other n-6 fatty acids, such as ARA, from LA.
However, if a deficiency of LA develops, ARA becomes
“conditionally essential” because the body is unable to synthesize it
without a supply of LA.
Essential Fatty Acids
fatty acids that cannot be synthesized in the body and thus must be consumed through food.
Alpha-Linolenic Acid (n-3 from plants)

ALA is the most prominent n-3 fatty acid in most Western diets because
average seafood intake (source of EPA and DHA) is low.
• The richest sources of ALA are soybean and canola oils.
• Humans can convert ALA into the n-3 fatty acids EPA and DHA to
only a very limited extent, so the only practical way to increase the
levels of these fatty acids in the body is to consume seafood or take
n-3 fatty acid supplements (National Institutes of Health, Office of
Dietary Supplements, 2019).
Trans Fatty Acids

The term trans refers to the placement of the hydrogen atoms in relation to
double carbon bonds. Almost all double bonds in nature exist in the cis
position; trans bonds are rare in nature (Fig. 5.3).
Figure 5.3 ▲ Trans and cis fatty acid configurations.
• Only small amounts of trans fats occur naturally in some animal

foods, such as beef, lamb, and dairy products.
• Synthetic sources of trans fats were once widespread in the food
supply from partially hydrogenated oils (e.g., stick margarine and
shortening) and processed foods containing them (e.g., crackers,
doughnuts, frozen french fries).
• The process of light or partial hydrogenation of oils extends
stability (e.g., longer shelf life because fewer double bonds lower
the risk of rancidity) and functionality (e.g., crispier french fries,
creamier frosting), so partially hydrogenated oils permeated the
food supply.
• It eventually became evident that synthetic trans fats are
detrimental to health, because they increase low-density
lipoprotein (LDL)–cholesterol and increase the risk of
cardiovascular disease (CVD).
• Based on extensive research and public input, the U.S. Food &
Drug Administration (FDA) withdrew partially hydrogenated oils
status as Generally Recognized as Safe (GRAS) (Food & Drug
Administration [FDA], 2018).
• In place of partially hydrogenated fats, food manufacturers are using
palm oil, fully hydrogenated palm oil, or a blend of oils. The result
is that trans fatty acids are eliminated, but saturated fat content
increases.
• Trans fatty acid content is listed on the Nutrition Facts label. There
is no %Daily Value, because it is recommended that trans fat intake
be as close to zero as possible.
Partial or Light Hydrogenation
some, but not all, unsaturated fatty acids are converted to saturated fatty acids. Some of the
unsaturated fatty acids are changed from a cis to a trans configuration.
Rancidity
the chemical change that occurs when fats are oxidized, which causes an offensive taste and smell
and the loss of fat-soluble vitamins A and E.
Low-Density Lipoprotein (LDL) Cholesterol

the major class of atherogenic lipoproteins that carry cholesterol from the liver to the tissues.
Generally Recognized as Safe (GRAS)

compounds exempt from the definition of “food additive” because they are GRAS, based on “a
reasonable certainty of no harm from a product under the intended conditions of use.”
Food Fats
All food fats contain a mixture of saturated, monounsaturated, and PUFA
(Fig. 5.4). When used to characterize fat in food, unsaturated and saturated
are not absolute terms; rather, they are relative descriptions that indicate
which kinds of fatty acids are present in the largest proportion. For instance,
olive oil is classified as monounsaturated fat, because 73% of its fatty acids
are MUFA. Of its remaining fatty acids, 10% are PUFA and 14% are
saturated.
Figure 5.4 ▲ Fatty acid profile of selected animal fats and vegetable
oils. (Source: Maki, K., Eren, F., Cassens, M., Dicklin, M. R., & Davisdon,
M. H. [2018]. n-6 polyunsaturated fatty acids and cardiometabolic health:
Current evidence, controversies, and research gaps. Advances in Nutrition,
9, 688–700. https://doi.org/10.1093/advances/nmy038; Garavaglia, J.,
Markowski, M., Oliveira, A., & Marcadenti, A. [2016]. Grapeseed oil
compounds: Biological and chemical actions for health. Nutrition and
Metabolic Insights, 9, 59–64; Flax Council of Canada (n.d.). A focus on
fatty acids. https://flaxcouncil.ca/resources/nutrition/general-nutrition-
information/a-focus-on-fatty-acids.)
Note. Expressed as percentages. Numbers may not total 100 due to the
presence of other fatty acids, such as naturally present trans fatty acids in
butter.
OTHER LIPIDS
Phospholipids and cholesterol are two other types of lipids.
Phospholipids
Like triglycerides, phospholipids have a glycerol backbone with fatty acids
attached. What makes them different from triglycerides is that a phosphate
group replaces one of the fatty acids. Although phospholipids occur
naturally in almost all foods, they make up a very small percentage of total
fat intake.
• Phospholipids are both fat soluble (because of the fatty acids) and
water soluble (because of the phosphate group), which is a unique
feature that enables them to act as emulsifiers.
• As emulsifiers, they surround fats and keep them suspended in
blood and other body fluids.
• As a component of all cell membranes, phospholipids provide
structure and help to transport fat-soluble substances across cell
membranes.
• Phospholipids are also precursors of prostaglandins.
• Lecithin is the best-known phospholipid.
Phospholipids
a group of compound lipids that is similar to triglycerides in that they contain a glycerol molecule
and two fatty acids. In place of the third fatty acid, phospholipids have a phosphate group and a
molecule of choline or another nitrogen-containing compound.
Emulsifier
a stabilizing compound that helps to keep both parts of an emulsion (oil and water mixture) from
separating.
Cholesterol
Cholesterol is a sterol, a waxy substance whose carbon, hydrogen, and
oxygen molecules are arranged in a ring.
Cholesterol is found in all cell membranes and in myelin. Brain and
• nerve cells are especially rich in cholesterol.
• The body makes cholesterol from acetyl-coenzyme A (acetyl-CoA),
which can originate from carbohydrates, protein, fat, or alcohol.
Eating an excess of calories, regardless of the source, can increase
cholesterol synthesis.
• All body cells are capable of making enough cholesterol to meet
their needs, so cholesterol is not an essential nutrient. In fact, daily
endogenous cholesterol synthesis is approximately two to three
times more than average cholesterol intake.
• Although cholesterol is made from acetyl-CoA, the body cannot
break down cholesterol into CoA molecules to yield energy, so
cholesterol does not provide calories.
• The body synthesizes bile acids, steroid hormones, and vitamin D
from cholesterol.
• Dietary cholesterol is found exclusively in animals, with organ
meats and egg yolks the richest sources. Meats, shrimp, lobster, and
full-fat dairy products provide moderate amounts.
• The cholesterol in food is just cholesterol; descriptions of “good”
and “bad” cholesterol refer to the lipoprotein packages that move
cholesterol through the blood (see Chapter 22). You cannot eat more
“good” cholesterol, but you can make lifestyle changes, such as
quitting smoking, exercising, and losing weight if overweight, that
increase the amount of “good” cholesterol in the blood.
FUNCTIONS OF FAT IN THE BODY
The primary function of fat is to fuel the body. At rest, fat provides about
60% of the body’s calorie needs. All fat—whether saturated, unsaturated,
cis, or trans—provides 9 cal/g, which is more than double the amount of
calories as an equivalent amount of either carbohydrate or protein.
Although fat is an important energy source, it cannot meet all of the body’s
energy needs, because certain cells, such as brain cells and cells of the
central nervous system, normally rely solely on glucose for energy.
Fat has other important functions in the body. Fat deposits insulate and
cushion internal organs to protect them from mechanical injury. Fat under
the skin helps to regulate body temperature by serving as a layer of
insulation against the cold. And dietary fat facilitates the absorption of the
fat-soluble vitamins A, D, E, and K when consumed at the same meal.
Table 5.1 lists the functions of fatty acids by type.
HOW THE BODY HANDLES FAT

A minimal amount of chemical digestion of fat occurs in the mouth and
stomach through the action of lingual lipase and gastric lipases, respectively
(Fig. 5.5).
Figure 5.5 ▲ Fat digestion.
• Fat entering the duodenum stimulates the release of the hormone

cholecystokinin, which, in turn, stimulates the gallbladder to release
bile.
• Bile, an emulsifier produced in the liver from bile salts, cholesterol,
phospholipids, bilirubin, and electrolytes, prepares fat for digestion
by suspending the hydrophobic molecules in the watery intestinal
fluid. Emulsified fat particles have enlarged surface areas on which
digestive enzymes can work.
• Most fat digestion occurs in the small intestine. Pancreatic lipase,
the most important and powerful lipase, splits off one fatty acid at a
time from the triglyceride molecule, working from the outside in
until two free fatty acids and a monoglyceride remain.
Usually, the process stops at this point, but sometimes, digestion
• continues and the monoglyceride splits into a free fatty acid and a
glyceride molecule.
• The end products of digestion—mostly monoglycerides with free
fatty acids and little glycerol—are absorbed into intestinal cells. It is
normal for a small amount of fat (4–5 g) to escape digestion and be
excreted in the feces.
• The digestion of phospholipids is similar, with the end products
being two free fatty acids and a phospholipid fragment.
• Cholesterol does not undergo digestion; it is absorbed as is.
Absorption
• About 95% of consumed fat is absorbed, mostly in the duodenum
and jejunum.
• Small fat particles, such as short- and medium-chain fatty acids and
glycerol, are absorbed directly through the mucosal cells into
capillaries. They bind with albumin and are transported to the liver
via the portal vein.
• The absorption of larger fat particles—namely, monoglycerides and
long-chain fatty acids—is more complex. Although they are
insoluble in water, monoglycerides and long-chain fatty acids
dissolve into micelles, which deliver fat to the intestinal cells. Once
inside the intestinal cells, the monoglycerides and long-chain fatty
acids combine to form triglycerides. The reformed triglycerides,
along with phospholipids and cholesterol, become encased in
protein to form chylomicrons and enter circulation via the
lymphatic system.
• Once in the bloodstream, lipoprotein particles circulate, delivering
dietary lipids to various organs for oxidation, metabolism, or to store
in adipose tissue.
• Their job done, most of the released bile salts are reabsorbed in the
terminal ileum, transported back to the liver, and recycled
(enterohepatic circulation). Some bile salts become bound to fiber in
the intestine and are excreted in the feces.
Micelles
fat particles encircled by bile salts to facilitate their diffusion into intestinal cells.
Chylomicrons
lipoproteins that transport absorbed lipids from intestinal cells through the lymph and eventually
into the bloodstream.
Monoglyceride
a glyceride molecule with only one fatty acid attached.
Fat Catabolism
Whether from the most recent meal or from storage, triglycerides that are
needed for energy are split into glycerol and fatty acids by lipoprotein
lipase, and are released into the bloodstream to be picked up by cells.
• The catabolism of fatty acids increases when carbohydrate intake is
inadequate (e.g., while on a very-low-calorie or low-carbohydrate
diet) or unavailable (e.g., in the case of uncontrolled diabetes).
Without adequate glucose, the breakdown of fatty acids is
incomplete, and ketones are formed. Eventually, ketosis and acidosis
may result.
• Since fatty acids break down into two-carbon molecules, not three-
carbon molecules, they cannot be reassembled to make glucose.
Only the glycerol component of triglycerides can be used to make
glucose, making fat an inefficient choice of fuel for glucose-
dependent brain cells, nerve cells, and red blood cells. Fortunately,
most body cells can use fatty acids for energy.
Recall Dylan. It is well known that starvation causes a

decrease in seizure activity, although the mechanism of
action is not known. Starvation causes acidosis, ketosis,
dehydration, and hypoglycemia. The ketogenic diet provides
calories and carbohydrate at levels that mimic a starved state
in which the primary fuel is fat. Dylan’s blood work
confirms a low pH related to ketoacids. What does that
finding indicate in terms of dietary compliance?
Fat Anabolism
Most newly absorbed fatty acids recombine with glycerol to form
triglycerides that end up stored in adipose tissue. Fat stored in adipose cells
represents the body’s largest and most efficient energy reserve; most other
body cells are able to store only minute amounts of fat.
• Unlike glycogen, which can be stored only in limited amounts and is
accompanied by water, adipose cells have a virtually limitless
capacity to store fat, and carry very little additional weight as
intracellular water.
• Fat reserves can last up to 2 months in people of normal weight.
• Each pound of body fat provides 3500 calories.
SOURCES OF FAT
Food categories that provide naturally occurring fat are protein foods, dairy,
and oils (Table 5.2). Vegetables and grains naturally provide little or no fat;
however, some items within each group may have added fat, such as fried
or creamed vegetables and granola cereals and biscuits. Fruit is naturally fat
free, with the exception of avocado, coconut, and olives. Within all calorie
levels of MyPlate meal patterns and across all food groups, the amount of
food recommended is based on the assumption that all foods chosen are in
their most nutrient-dense form: vegetables, fruits, whole grains, seafood,
eggs, beans, peas, lentils, unsalted nuts and seeds, fat-free and low-fat dairy
products, and lean meats and poultry—all prepared with no or little
saturated fat.
Think of Dylan. A typical ketogenic meal consists mostly
of fats (e.g., 5 tbsp heavy whipping cream) with
approximately an ounce of protein (e.g., chicken) and a
small amount of carbohydrate (e.g., <½ cup green beans).
What serving suggestions would you make to help make the
high-fat diet more palatable?
Table Sources of Fat:

Average Fat Content
5.2 per Serving
Protein
Lean proteins provide 2 g fat per oz
• Lean cuts of beef, pork veal, ham
• Skinless poultry
• Ninety percent lean or higher ground beef,
chicken, or turkey
• Fish and shellfish
• Game: buffalo, ostrich, rabbit, venison
shutterstock.com/Hurst Photo
• Organ meats: heart, kidney, liver
• Veal: cutlet, loin chop, roast
• Egg substitutes, egg whites
• Processed deli meats with 3 g or fat or
less per oz
Medium-fat proteins provide 5 g fat per oz

• Beef trimmed of visible fat, 85% or lower
lean ground beef, USDA Prime cuts of
beef
• Cheeses with 4–7 g fat/oz, such as feta
and mozzarella
Protein
• Egg
• Fried fish
• Poultry with skin; fried chicken
High-fat proteins provide 8 g fat per choice

• 1 oz regular cheese
• 2 slices pork bacon or 3 slices turkey
bacon
• Turkey or chicken hot dogs
• 1 oz of certain processed deli meats, such
as bologna, hard salami, pastrami
• 1 oz certain sausages, such as bratwurst,
chorizo, Italian, Knockwurst, Polish,
smoked, summer
Plant-based proteins vary in fat content from

very little in legumes to 8 g in a tablespoon
of nut spreads such as peanut butter, almond
butter, and soy nut butter
Protein
Milk, yogurt, and milk substitutes
Milk, yogurt, and milk substitute choices
vary in fat content
• 0–3 g fat in fat-free or low-fat (1% fat)
choices: 1 cup milk or 2/3 cup plain
yogurt
• 5 g fat in 2% choices: 1 cup milk, 2/3 cup
plain yogurt, 1 cup regular-fat plain soy
milk, 1 cup flavored coconut milk
• 8 g fat in whole-milk choices: 1 cup milk
or 1 cup plain yogurt
shutterstock.com/Modernista
Magazine
Oils and fats
1 serving provides 5 g fat
• 1 tsp oil, such as canola, olive, corn,
soybean, flaxseed, or coconut
• 1 tsp solid fat, such as stick or tub
margarine, stick butter, regular
mayonnaise, lard, or shortening shutterstock.com/Photo Art
Lucas
• 1 tbsp salad dressing, such as regular
Italian
• 6 almonds or cashews
• 2 tbsp avocado
• 1 tbsp pumpkin, sesame, or sunflower
seeds
• 2 tbsp half and half, whipped cream, or
regular sour cream
Note. Based on American Diabetes Association, Academy of Nutrition and Dietetics. (2019). Choose
your foods. Food lists for diabetes. American Diabetes Association & Academy of Nutrition.
Sources: shutterstock.com/Hurst Photo; shutterstock.com/Modernista Magazine;
shutterstock.com/Photo/Photo Art Lucas
Fats that the body can synthesize—namely, saturated fatty acids, MUFAs,
and cholesterol—do not need to be consumed through food. Trans fats
provide no known health benefits, and so they are not essential. Neither an
Adequate Intake (AI) nor a Recommended Dietary Allowance (RDA)
exists for any of these fats. Box 5.1 outlines the DRI for adults for total fat
and specific types of fat.
Hydrogenation
a process of adding hydrogen atoms to unsaturated vegetable oils (usually corn, soybean,
cottonseed, safflower, or canola oil), which reduces the number of double bonds; the number of
saturated and monounsaturated bonds increases as the number of polyunsaturated bonds
decreases.
Cis Fats
unsaturated fatty acids whose hydrogen atoms occur on the same side of the double bond.
Trans Fats
unsaturated fatty acids that have at least one double bond the hydrogen atoms of which are on the
opposite sides of the double bond; trans means “across” in Latin.
Adequate Intake (AI)

an intake level thought to meet or exceed the requirement of almost all members of a life stage
and gender group; AI is set when there are insufficient data to define an RDA.
Recommended Dietary Allowance (RDA)

the average daily dietary intake level sufficient to meet the nutrient requirements of 97% to 98%
of healthy people in a particular life stage and gender group.
BOX Dietary Reference Intakes for Adults for

5.1 Total Fat and Specific Types of Fat
Total Fat
• AMDR 20% to 35% of total calories
• No RDA, AI, or Tolerable Upper Intake Level (UL)
Saturated Fatty Acids, Cholesterol, and Trans Fat

• No RDA or AI because a dietary source is not required
• No UL because any incremental increase in intake increases the risk of
coronary heart disease
Monounsaturated Fatty Acids

• No RDA or AI because a dietary source is not required
• Evidence is insufficient to set a UL
Alpha-Linolenic Acid (n-3 Fatty Acid)

• AMDR 0.6% to 1.2% of total calories
• AI: 1.1 g/day for women; 1.6 g/day for men
• Evidence insufficient to set a UL
Linoleic Acid (n-6 Fatty Acid)

• AMDR 5% to 10% of total calories
• AI: 11 to 12 g/day for women; 14 to 17 g/day for men
• Evidence insufficient to set a UL
Total Fat Recommendation and Average Intake

An Acceptable Macronutrient Distribution Range (AMDR) for total fat
intake is estimated to be 20% to 35% of the total calories for adults (Fig.
5.6). There is insufficient data to define a level of total fat intake at which
the risk of deficiency or prevention of chronic disease occurs, so there is not
an AI or RDA for total fat (National Research Council, 2005).
Acceptable Macronutrient Distribution Range (AMDR)
an intake range as a percentage of total calories for energy nutrients.
Tolerable Upper Intake Level (UL)

the highest average daily intake level of a nutrient likely to pose no danger to most individuals in
the group.
Figure 5.6 ▲ Amount of total fat appropriate at various calorie levels

based on AMDR of 20% to 35% of total calories.
Unlike carbohydrate and protein, Americans consume more than the
AMDR for fat. The National Health and Nutrition Examination Survey
2015 to 2016 data show that 36% of total calories consumed by males and
females age 20 and older come from fat, with 12% of total calorie intake
from saturated fat (USDA & Agricultural Research Service [ARS], 2018).
As total fat intake increases, the amount of saturated fat increases;
therefore, limiting total fat intake to 35% of total calories or less may help
limit saturated fat intake.
Figure 5.7 ▲ Top sources and average intakes of saturated fat: U.S.
population ages 1 and older. (Source: U.S. Department of Agriculture,
U.S. Department of Health and Human Services. [2020]. Dietary
Guidelines for Americans 2020–2025. https://www.dietaryguidelines.gov;
What We Eat in America, NHANES, 2013–2016, ages 1 and older, 2 days
intake data, weighted).
Consider Dylan. His 1200 calorie eating pattern provides

18 g of protein, 12 g of carbohydrate, and 120 g of fat.
• What are the percentages of calories from protein,
carbohydrate, and fat?
• How do these percentages compare to the AMDR for
each of these macronutrients?
• What nutrients are deficient in the diet due to the
severe restriction on carbohydrates?
FAT IN HEALTH PROMOTION
In general, health is “promoted” when total fat intake and the types of fat
consumed are appropriate based on calorie needs. Exactly what
“appropriate” is in terms of individual fatty acids is not entirely clear.
Dietary advice on fat intake generally centers specifically on saturated fat
content and broadly on healthy eating patterns.
Limit Saturated Fat

The Dietary Guidelines for Americans 2020–2025 recommend limiting
saturated fat intake to less than 10% of total calories for all people age 2
and older and replacing saturated fat with unsaturated fats, particularly
polyunsaturated fats (U.S. Department of Agriculture [USDA] & U.S.
Department of Health and Human Services [USDHHS], 2020). Making this
shift lowers the incidence of CVD in adults and reduces serum total and
low-density cholesterol in all adults and some children (Dietary Guidelines
Advisory Committee, 2020).
• Even with nutrient-dense food choices, approximately 5% of the
calories in the Healthy U.S.-Style Eating Pattern comes from
saturated fat present in lean meat, poultry, eggs, nuts, seeds, grains,
and oils, leaving little room for higher saturated fat choices (USDA
& USDHHS, 2020).
• Foods highest in saturated fat include fatty meats; full-fat milk,
yogurt, cheese, and ice cream; and butter. The tropical oils coconut
oil, palm kernel oil, and palm oil are also high in saturated fat.
• The top food sources of saturated fat among Americans ages 1 and
older are sand wiches, such as tacos, burgers, and chicken
sandwiches (Fig. 5.7).
• The most effective way to limit saturated fats is to eat less animal
fats and processed foods containing hydrogenated oils. Strategies for
making healthier food choices based on fat appear in Box 5.2.
Healthy Eating Patterns

With the exception of quantifying limits on saturated fat, most intake
recommendations from leading health organizations emphasize healthy
eating patterns and types of food rather than specific types of fat. For
instance, the American College of Cardiology/American Heart Association
guidelines to reduce the risk of atherosclerotic cardiovascular disease
(ASCVD) recommend an eating pattern that emphasizes vegetables, fruits,
legumes, nuts, whole grains, and fish to decrease ASCVD risk factors
(Arnett et al., 2019). Additional fat-related intake recommendations state
that
• replacing saturated fat with monounsaturated and polyunsaturated
fats can help lower ASCVD risk (see Box 5.2), and
• reducing cholesterol intake can be beneficial to decrease ASCVD
risk, and
• within the context of a healthy eating pattern, it is reasonable to
minimize the intake of processed meats (e.g., sausage, hot dogs,
salami, cured bacon, salted and cured meats, and canned meats) and
avoid the intake of trans fats (e.g., foods containing partially
hydrogenated oils).
BOX Strategies for Making Healthier Food

5.2 Choices Regarding Fat
Make better protein choices

• Keep portion sizes of protein to the amount recommended for your
appropriate calorie level. 5½ oz-equivalents are recommended per day
for a 2000-calorie eating pattern. Limit the intake of red meat (beef,
pork, veal, lamb) to 3 to 4 times per week or 12 to 18 oz total per
week.
• Minimize processed meat intake: bacon (regular and turkey), hot dogs,
corned beef, pepperoni, salami, beef jerky, bologna, canned meats, etc.
Eat 8 oz of fish per week; best choices regarding mercury content
include salmon, sardines, herring, freshwater trout, and Atlantic
mackerel (see Fig. 4.3 for more choices). If you eat more than 8 oz of
fish per week, choose a variety of seafood.
• Choose lean cuts of meat that are labeled as “round,” “loin,” or
“sirloin.”
• “Select” grades of beef have less fat marbled through than “Choice”
grades.
• Choose ground beef that is at least 90% lean. This is indicated on the
label.
• Trim all visible fat from meat before cooking and drain fat after
cooking.
• Remove poultry skin.
• Bake, broil, grill, stew, or roast meats, poultry, and seafood. Avoid
frying and breading meat or poultry.
• Eat more plant-based meals: bean burritos, black beans and rice,
meatless chili, vegetable stir-fry with tofu, and lentil soup.
• Choose unsalted nuts or seeds as a snack, on salads, or in main dishes
to replace meat or poultry. Keep portions small because nuts and seeds
are high in calories.
• Replace deli meats with leftover chicken or turkey; use canned tuna or
salmon, hummus, or nut butters for sandwiches.
Choose low-fat or fat-free dairy items.
• fat-free or low-fat milk and yogurt
• cheese with 3 g or less per serving
• sherbet, reduced-fat ice cream, and nonfat ice cream
Limit solid fats used in food preparation.
• Use nonstick spray, olive oil, or canola oil in place of margarine or
butter to sauté foods and “butter” pans.
• Use imitation butter spray to season vegetables and hot-air popcorn.
• Use oils—especially soybean, canola, corn, or olive—instead of butter
or shortening for cooking and baking.
Use oils as a healthier option to solid fat.
• Use soft margarine (liquid or tub) in place of butter or stick margarine.
• Look for margarine that contains no more than 2 g saturated fat per
tablespoon and has liquid vegetable oil as the first ingredient.
• Look for processed foods made with non-hydrogenated oil other than
coconut oil, palm oil, or palm kernel oil.
• Eat nuts and nut butters that are rich in unsaturated fats: peanuts,
walnuts, almonds, hazelnuts, pecans
• Walnuts also contain ALA.
• Cashews and macadamia nuts are higher in saturated fats.
• Sprinkle ground flaxseed, chia seeds, or hemp seed (1–2 tbsp/day)
over cereal or yogurt.
• Use ground flaxseed as a fat substitute in many recipes: 3 tbsp of ground flaxseed can replace
1 tbsp of fat or oil.
Replace fatty foods with fruit and vegetables.

• Eat fruit for dessert instead of baked goods or full-fat ice cream.
• Snack on raw vegetables or fresh fruit instead of snack chips.
Consider the following foods as “treats” to be used only on occasion and
in small portions.
• Baked goods: cakes, cookies, pies, doughnuts, muffins, etc.
• candy
• Full-fat dairy: whole milk, sour cream, cheese, and ice cream
• pizza and fast food
• Fatty meats: ribs, Prime rib, fried chicken, etc.
• Processed meats: bacon (regular and turkey), hot dogs, corned beef,
pepperoni, salami, beef jerky, bologna, canned meats, etc.
Recall Dylan. The most common adverse side effect of the

ketogenic diet is constipation related to the very low
carbohydrate intake. Children are closely monitored for
other potential side effects, such as kidney stones,
hyperlipidemias, dyslipidemias, hypoglycemia, pancreatitis,
and cardiomyopathy. How do the potential risks of the diet
compare to the risk of uncontrolled seizures, severe adverse
side effects from medication, or the possible option of brain
surgery?
When providing instruction about what constitutes a “good” fat,

nurses should emphasize soybean oil, flaxseed, walnuts, and salmon.
Whole wheat bread for sandwiches is a healthy choice, but processed
meat (like bologna) should be limited in the diet.
How Do You Respond?
Is coconut oil healthy? Coconut oil is being touted as
a healthy fat that helps promote weight loss, control
diabetes, and reverse Alzheimer’s disease (Gordon,
2019). Unfortunately, studies showing weight loss
benefits were small and not well designed. Likewise,
studies on its beneficial effects in managing diabetes were
done on animals and may not be applicable to humans,
and as of yet, there is no scientific evidence supporting
the value of coconut oil in the treatment of Alzheimer’s.
Eighty-two percent of the fatty acids in coconut oil are
saturated, and saturated fats may raise cholesterol and
increase the risk for CVD, so coconut oil intake should be
limited.
What is flaxseed? Flaxseed is derived from the flax
plant and is the same plant used to make linen. It is a
nutritional powerhouse that provides essential fatty acids,
fiber, and lignans. Specifically, 57% of its fat is from
ALA, the essential n-3 fatty acid that is only found in
plants. The fiber in flaxseed is predominately soluble,
which helps to lower cholesterol levels and improves
glucose levels in people with diabetes. Flaxseed contains
100 to 800 times more lignans than other grains. Lignans
are a group of plant estrogens, and they may help to
reduce the risk of breast and prostate cancers. Although
flaxseed oil and flaxseed oil pills provide the benefits of
ALA, they lack the fiber found in the whole grain, and the
lignan content is variable. Humans are unable to digest
the tough outer coating, so flaxseeds must be eaten
ground, not whole. They are prone to rancidity because
they are high in polyunsaturated fat. Ground flaxseed
should be refrigerated and used within a few weeks.
REVIEW CASE STUDY
Michael is a 40-year-old man who lost about 25 pounds 10 years ago by

reducing his fat intake. He has slowly regained the weight and now wants to
go back to a low-fat diet to manage his weight. (A sample of his usual
intake is in the box on the right.)
• What foods and beverages did Michael eat that contain fat?
• What sources of saturated fat did he eat? What sources of unsaturated
fat? What sources of n-3 fats? What sources of cholesterol?
• What specific suggestions would you make for him to eat less fat
and/or improve the type of fat he eats?
• What would you tell Michael about cutting fat intake to lose weight?
• What would you suggest he do to “eat healthier”?
Breakfast: 3 cups of coffee with sugar and nondairy creamer

On the way to work: A bagel with low-fat cream cheese and jelly
Snack before lunch: Low-fat coffee cake; more coffee with sugar and
nondairy creamer
Lunch: Usually a burger, a large order of french fries, and a diet soda
from the fast-food restaurant near his office
Snack before dinner: A glass of wine with cheese and crackers
Dinner: Meat, potato, and vegetable; often double portions of meat; a
salad with Italian dressing; bread and butter; sherbet for dessert
Snack: A bowl of cornflakes with 2% milk and sugar
STUDY QUESTIONS
1 The client asks if the cholesterol in shrimp is the “good” or “bad” type.
What is the nurse’s best response?
a. “All cholesterol is bad cholesterol.”
b. “Bad and good refer to how cholesterol is packaged for transport
through the blood. The cholesterol in food is unpackaged and neither
bad nor good.”
c. “Good cholesterol is found in plants, and bad cholesterol is found in
animal sources.”
d. “Shrimp has good cholesterol because it is low in saturated fat; foods
high in cholesterol and saturated fat are a source of bad cholesterol.”
2 When developing a teaching plan for a client who needs to limit saturated
fat, which of the following foods would the nurse suggest the client
limit?
a. Seafood and poultry
b. Nuts and seeds
c. Olive oil and canola oil
d. Prime cuts of red meat and whole milk
3 What is the primary function of fat?
a. Facilitate protein metabolism
b. Provide energy
c. Promote the absorption of fat-soluble vitamins
d. Facilitate carbohydrate metabolism
4 The nurse knows that instructions have been effective when the client
verbalizes that an ingredient that provides synthetic trans fats is
a. Fully hydrogenated oil
b. Partially hydrogenated oil
c. Palm oil
d. Palm kernel oil
5 A client asks why lowering saturated fat intake is necessary for lowering
serum cholesterol levels. What is the nurse’s best response?
a. “Replacing saturated fats with unsaturated fats helps lower LDL (the
‘bad’ cholesterol) and the risk of cardiovascular disease.”
b. “Sources of saturated fat also provide monounsaturated fat, and both
should be limited to control blood cholesterol levels.”
c. “Saturated fat is high in calories, and excess calories from any source
increase the risk of high blood cholesterol levels.”
d. “Saturated fats make blood more likely to clot, increasing the risk of
heart attack.”
6 Which of the following is the best source of polyunsaturated fats?
a. Soybean oil
b. Corn oil
c. Vegetable oil
d. Olive oil
7 Which statement indicates the client understands how to choose low-fat
foods from MyPlate?
a. “All items within a food group have approximately the same amount
of fat so my fat intake isn’t affected by the specific foods I choose
from any group.”
b. “You don’t have to consciously select low-fat items because the
calories for other uses will account for higher-fat choices.”
c. “All fats are bad fats. It is best to eliminate as much fat from your diet
as possible.”
d. “Within each food group, the foods lowest in fat should be chosen
most often.”
8 Which of the following is the top source of saturated fat intake among
Americans?
a. Desserts and sweet snacks
b. Pizza
c. Sandwiches
d. Chips, crackers, and savory snacks
CHAPTER SUMMARY LIPIDS
Ninety-eight percent of lipids consumed in the diet are triglycerides,
which are composed of one glyceride molecule and three fatty acids.
Phospholipids and sterols are the other two types of dietary lipids.
Fatty Acids
Saturation refers to each carbon atom in the fatty-acid chain having four
single bonds.
• Saturated fatty acids have four single bonds and are “saturated” with
hydrogen.
• They are “solid” fats—solid at room temperature.
• Monounsaturated fatty acids have one double bond between carbon
atoms; polyunsaturated fatty acids have more than one double bond.
• They are liquid at room temperature and are considered “oils.”
Double bond position is identified by counting the number of carbon
atoms from the methyl (CH3) end, as denoted by the term n or omega.
• Monounsaturated fats (n-9) can be made by the body, so they are not
essential in the diet (like saturated fats).
• One n-3 and one n-6 PUFA are deemed essential because they cannot
be made in the body.
Artificial trans fatty acids are created from the partial hydrogenation of
oils.
• They have no function in the body and their impact on health is
negative, so they are no longer considered GRAS and are being
removed from the food supply.
All food fats are a mixture of saturated and unsaturated fatty acids.
Sources of fat are classified according to the type of fatty acid present to the
largest degree.
Other Lipids
• Phospholipids occur naturally in almost all foods but in very small
amounts. They are similar in structure to triglycerides but have only
two fatty acids plus a phosphate group.
• They act as emulsifiers to keep fat (e.g., cholesterol) suspended in
water (e.g., blood)
• Cholesterol is a sterol found in all animal tissues. It does not supply
calories. The body makes cholesterol from an excess of calories from
any source, so it is not an essential nutrient. “Good” cholesterol and
“bad” cholesterol refer to how it is packaged in the blood, not its
dietary sources.
Functions of Fat in the Body
The primary function of fat is to supply energy. It provides 9 cal/g. Fat
also insulates and cushions internal organs, helps regulate body
temperature, and facilitates the absorption of fat-soluble vitamins.
Individual fatty acids have other specific functions.
How the Body Handles Fat
Fat digestion occurs mostly in the small intestine.
• Short- and medium-chain fatty acids and glycerol are absorbed
through mucosal cells into capillaries leading to the portal vein.
• Larger fat molecules—namely, cholesterol, phospholipids, and
reformed triglycerides made from monoglycerides and long-chain
fatty acids—are absorbed in chylomicrons and transported through the
lymph system.
• Not all body cells can use fat for energy. The complete oxidation of
fatty acids requires adequate glucose.
• Ketones are formed when catabolism is incomplete.
• Fat consumed in excess of need is stored in adipose tissue.
Sources of Fat
Fat is naturally found in protein foods, dairy, and the category of oils.
Grains and vegetables may have fat added during preparation. Fruits are
considered fat free with the exception of olive, avocado, and coconut.

• The AMDR for total fat intake is 20% to 35% of total calorie intake.
• Americans exceed this on average.
• AI are established for ALA (n-3 fatty acid) and LA (n-6).
• Dietary reference intakes do not exist for total fat, saturated fat,
monounsaturated fat, cholesterol, and trans fatty acids.
Fat in Health Promotion
Americans are urged to consume an eating pattern that emphasizes the
intake of vegetables, fruits, legumes, nuts, whole grains, and fish to
lower the risk of heart disease. Other fat-related recommendations are to
• replace saturated fat with polyunsaturated and monounsaturated fats,
• reduce cholesterol intake,
• minimize the intake of processed meats, and
• avoid trans fats.
Figure sources: shutterstock.com/JPC-PROD and shuterstock.com/stockfour

book at
Websites
American Heart Association at www.heart.org
Calorie Control Council’s glossary of fat replacers at www.caloriecontrol.org/articles-and-
video/feature-articles/glossary-of-fat-replacers
Dietary Guidelines for Americans, 2020–2025 at www.dietaryguidelines.gov
Institute of Shortening and Edible Oils at www.iseo.org
International Food Information Council at www.foodinsight.org
National Heart, Lung, and Blood Institute at www.nhlbi.nih.gov
References
Arnett, D. K., Blumenthal, R. S., Albert, M. A., Buroker A. B., Goldberger, Z. D., Hahn, E. J.,
Dietary Guidelines Advisory Committee. (2020). Scientific report of the 2020 Dietary Guidelines
Advisory Committee: Advisory Report to the Secretary of Agriculture and the Secretary of
Health and Human Services. U.S. Department of Agriculture, Agricultural Research Service,
Washington, DC. https://www.dietaryguidelines.gov/2020-advisory-committee-report
Gorden, B. (2019). The facts about coconut oil. https://www.eatright.org/food/nutrition/nutrition-
facts-and-food-labels/the-facts-about-coconut-oil
Guasch-Ferre, M., Zong, G., Wilett, W., Zock, P. L., Wanders, A. J., Hu, F. B., & Sun, Q. (2019).
Associations of monounsaturated fatty acids from plant and animal source with total and cause-
specific mortality in two U.S. prospective cohort studies. Circulation Research, 124, 1266–1275.
https://doi.org/10.1161/CIRCRESAHA.118.313996
Micha, R., Khatibzadeh, S., Shi, P., Fahimi, S., Lim, S., Andrews, K. G., Engell, R. E., Powles, J.,
Ezzati, M., & Mozaffarian, D. (2014). Global, regional, and national consumption levels of
dietary fats and oils in 1990 and 2010: A systematic analysis including 266 country-specific
nutrition surveys. British Medical Journal, 348, g2272. https://doi.org/10.1136/bmj.g2272
National Institutes of Health, Office of Dietary Supplements. (2019). Omega-3 fatty acids: Fact sheet
for professionals. https://ods.od.nih.gov/factsheets/Omega3FattyAcids-HealthProfessional/
Press.
Rajaram, S. (2014). Health benefits of plant-derived alpha-linolenic acid. American Journal of
Clinical Nutrition, 100(suppl 1), 443S–448S. https://doi.org/10.3945/ajcn.113.071514
Rimm, E., Appel, L., Chiuve, S., Djoussé, L., Engler, M. B., Kris-Etherton, P. M., Mozaffarian, D.,
Siscovick, D. S., Lichtenstein, A. H. and On behalf of the American Heart Association Nutrition
Committee of the Council on Lifestyle and Cardiometabolic Health; Council on Epidemiology
and Prevention; Council on Cardiovascular Disease in the Young; Council on Cardiovascular and
Stroke Nursing; and Council on Clinical Cardiology. (2018). Seafood long-chain n-3
polyunsaturated fatty acid and cardiovascular disease: A science advisory from the American
Heart Association. Circulation, 138, e35–e47. https://doi.org/10.1161/CIR.0000000000000574
U.S. Department of Agriculture, Agricultural Research Service. (2018). Percentages of energy from
protein, carbohydrate, fat, and alcohol, by gender and age, in the United States, 2015–2016.
https://www.ars.usda.gov/ARSUserFiles/80400530/pdf/1516/Table_5_EIN_GEN_15.pdf
U.S. Department of Agriculture & U.S. Department of Health and Human Services. (2020,
December). Dietary guidelines for Americans 2020–2025. www.dietaryguidelines.gov
U.S. Food & Drug Administration. (2018). Final determination regarding partially hydrogenated oils
(removing trans fat). https://www.fda.gov/food/food-additives-petitions/final-determination-
regarding-partially-hydrogenated-oils-removing-trans-fat
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become pregnant, breastfeeding mothers, and young children.
https://www.fda.gov/food/consumers/advice-about-eating-fish
Chapter Vitamins
6
Marcus Skinner
Marcus is a 4-year-old boy with autism spectrum
disorder who has communication impairments and
social difficulties and exhibits repetitive behavior. His
treatment includes medical nutrition therapy, speech-
language therapy, occupational therapy, and physical
therapy. Marcus does not eat a well-balanced eating
pattern for several reasons: A feature of his
compulsive behavior is that he only accepts a limited
variety of foods, he is unable to eat when
overstimulated at mealtime, and he has poor fine
motor coordination that impairs his ability to feed
himself. He is on a gluten-free/casein-free diet
because these peptides are believed to cause a variety
of effects in the neurotransmitter systems of the brain.
Eliminating all foods containing gluten (foods
containing wheat, barley, oats, and rye) and casein
(the major protein in milk and other dairy products
and used as an additive in other foods such as soy
products) is theorized to improve social and cognitive
behaviors and speech in some children with autism,
although there is a lack of scientific evidence of
benefit.
Learning Objectives
1 Compare and contrast fat- and water-soluble vitamins.

2 Describe general functions and uses of vitamins.
3 Judge when vitamin supplements may be necessary.
4 Give examples of food sources for individual vitamins.
5 Discuss how Americans can shift their food choices to improve their
intake of shortfall vitamins.
6 Identify characteristics to look for when choosing a vitamin supplement.
In 1913, thiamin was discovered as the first vitamin, the “vital amine”
necessary to prevent the deficiency disease beriberi. Today, 13 vitamins
have been identified as important for human nutrition; vitamin deficiency
diseases are generally rare in the United States, and vitamin research
focuses on whether consuming various vitamins above the minimum basic
requirement can reduce the risk of heart disease, cancer, vision disorders,
cognitive decline in seniors, and other chronic diseases.
This chapter describes vitamins and their uses. Generalizations about
fat- and water-soluble vitamins are presented. The unique features of each
vitamin are covered individually, and criteria for selecting a vitamin
supplement are discussed.
UNDERSTANDING VITAMINS
Vitamins are organic compounds made of carbon, hydrogen, oxygen, and
sometimes nitrogen or other elements. They differ in their chemistry,
biochemistry, function, and availability in foods. Vitamins facilitate
biochemical reactions within cells to help regulate body processes such as
growth and metabolism. They are essential to life. Unlike the organic
compounds covered previously in this unit (carbohydrates, protein, and fat),
vitamins
• are individual molecules, not long chains of molecules linked
together,
• do not provide energy but are needed for the metabolism of energy,
and
• are needed in microgram or milligram quantities (not gram
quantities), so they are called micronutrients.
Micronutrients
nutrients that are needed in very small amounts.
Chemical Substances
Vitamins are extremely complex chemical substances that differ widely in
their structures. Because vitamins are defined chemically, the body cannot
distinguish between natural vitamins extracted from food and synthetic
vitamins produced in a laboratory. However, the absorption rates of natural
and synthetic vitamins sometimes differ because of different chemical
forms of the same vitamin (e.g., synthetic folic acid is better absorbed than
natural folate in foods) or because the synthetic vitamins are “free,” not
“bound” to other components in food (e.g., synthetic vitamin B12 is not
bound to small peptides as natural vitamin B12 is).
Susceptible to Destruction
As organic substances, vitamins in food are susceptible to destruction and
subsequent loss of function. Individual vitamins differ in their vulnerability
to heat, light, oxidation, acid, and alkalis:
Oxidation
a chemical reaction in which a substance combines with oxygen; oxidation reactions involve the
loss of electrons in an atom.
• Thiamin is heat sensitive and is easily destroyed by high

temperatures and long cooking times.
• Riboflavin is resistant to heat, acid, and oxidation but is quickly
destroyed by light. That is why riboflavin-rich milk is sold in
opaque, not transparent, containers.
• From 50% to 90% of folate in foods may be lost during preparation,
processing, and storage.
• Vitamin C is destroyed by heat, air, and alkalis.
Multiple Forms
Many vitamins exist in more than one active form. Different forms perform
different functions in the body. For instance, vitamin A exists as retinol
(important for reproduction), retinal (needed for vision), and retinoic acid
(acts as a hormone to regulate growth). Some vitamins have provitamins,
an inactive form found in food that the body converts to the active form.
Beta carotene is a provitamin of vitamin A. Dietary Reference Intakes
(DRIs) take into account the biologic activity of vitamins as they exist in
different forms.
Provitamins
precursors of vitamins.
Essentiality
Vitamins are essential in the diet because the body cannot make them with a
few exceptions. The body can make vitamin A, vitamin D, and niacin if the
appropriate precursors are available. Microorganisms in the gastrointestinal
(GI) tract synthesize vitamin K and vitamin B12 but not in amounts
sufficient to meet the body’s needs.
Coenzymes
Many enzymes cannot function without a coenzyme, and many coenzymes
are vitamins. All B vitamins work as coenzymes to facilitate thousands of
chemical conversions. Thiamin, riboflavin, niacin, and biotin participate in
enzymatic reactions that extract energy from glucose, amino acids, and fat.
Folacin facilitates both amino acid metabolism and nucleic acid synthesis.
Protein synthesis and cell division are impaired without adequate folacin.
An adequate and continuous supply of B vitamins in every cell is vital for
normal metabolism.
Enzymes
proteins produced by cells that catalyze chemical reactions within the body without undergoing
change themselves.
Coenzymes
organic molecules that activate an enzyme.
Antioxidants
Free radicals are produced continuously in cells as they burn oxygen
during normal metabolism. Ultraviolet radiation, air pollution, ozone, the
metabolism of food, and smoking can also generate free radicals in the
body. The problem with free radicals is that they oxidize body cells and
deoxyribonucleic acid (DNA) in their quest to become stable by gaining an
electron. These structurally and functionally damaged oxidized cells are
believed to contribute to aging and various health problems such as cancer,
heart disease, and cataracts. Polyunsaturated fatty acids (PUFAs) in cell
membranes are particularly vulnerable to damage by free radicals.
Free Radicals
highly unstable, highly reactive molecular fragments with one or more unpaired electrons.
Antioxidants protect body cells from being oxidized (destroyed) by
free radicals by undergoing oxidation themselves, which renders free
radicals harmless.
Antioxidants
substances that donate electrons to free radicals to prevent oxidation.
• Vitamins and other substances in fruits, vegetables, and other plant-

based food provide dozens, if not hundreds, of antioxidants.
• Vitamins that function as major antioxidants are vitamin C, vitamin
E, folate, and the provitamin beta carotene.
• Each has a slightly different role, so one cannot completely
substitute for another.
• For instance, water-soluble vitamin C works within cells to
disable free radicals, and fat-soluble vitamin E functions within
fat tissue.
• Whether high doses of individual antioxidants offer the same health
benefits as the package of substances found in food sources is an
area of ongoing research.
Food Additives
Some vitamins are used as food additives in certain foods to boost their
nutritional content: vitamin C–enriched fruit drinks, vitamin D–fortified
milk, and enriched flour. Other foods have certain vitamins added to them
to help preserve quality: vitamin C is added to frozen fish to help prevent
rancidity and to luncheon meats to stabilize the red color. Vitamin E helps
slow rancidity in vegetable oils, and beta carotene adds color to margarine.
Food Additives
substances added intentionally or unintentionally to food that affect its character.
Enrich
to add nutrients back that were lost during processing; for example, white flour is enriched with
certain B vitamins lost when the bran and germ layers are removed.
Medications
In megadoses, vitamins function like drugs, not nutrients. Large doses of
niacin are used to lower cholesterol, low-density lipoprotein (LDL)
cholesterol, and triglycerides in people with hyperlipidemia who do not
respond to diet and exercise. Tretinoin (retinoic acid, a form of vitamin A)
is used as a topical treatment for acne vulgaris. Gram quantities of vitamin
C promote healing in patients with impaired bone and wound healing.
Megadoses
amounts at least 10 times greater than the Recommended Dietary Allowance (RDA).
VITAMIN CLASSIFICATIONS BASED

ON SOLUBILITY
Vitamins are classified according to their solubility. Vitamins A, D, E, and

K are fat soluble. Vitamin C and the B vitamins (thiamin, riboflavin, niacin,
folate, B6, B12, biotin, and pantothenic acid) are water soluble. Solubility
determines vitamin absorption, transportation, storage, and excretion (Table
6.1).
Table Group Characteristics

of Fat-Soluble and
6.1 Water-Soluble Vitamins
Characteristic Fat-Soluble Vitamins Water-Soluble Vitamins

Sources The fat and oil portion The watery portion of
of foods foods
Characteristic Fat-Soluble Vitamins Water-Soluble Vitamins
Absorption With fat encased in Directly into the
chylomicrons that enter bloodstream
the lymphatic system
before circulating in the
bloodstream
Conditions that impair
fat absorption increase
the risk of fat-soluble
vitamin deficiencies
Transportation Attach to protein Move freely through the
through the carriers because fat is watery environment of
blood not soluble in watery blood and within cells
blood
When Are stored—primarily Are excreted in the urine,
consumed in in the liver and adipose although some tissues may
excess of need tissue hold limited amounts of
certain vitamins
Safety of Can be toxic; this Are generally considered
consuming applies primarily to nontoxic, although side
high intakes vitamins A and D; large effects can occur from
through doses of vitamins E and consuming very large doses
supplements K are considered of vitamin B6 over a
relatively nontoxic prolonged period
Frequency of Generally do not have Generally must be
intake to be consumed daily consumed daily because
because the body can there is no reserve in
retrieve them from storage
storage as needed
Fat-Soluble Vitamins
Table 6.2 highlights recommended intakes, sources, functions, deficiency
symptoms, and toxicity symptoms of each fat-soluble vitamin. Additional
features of individual fat-soluble vitamins follow.
Table Summary of Fat-

6.2 Soluble Vitamins
Vitamin and Deficiency/Toxicity

Sources Functions Signs and Symptoms
Vitamin A The formation of Deficiency
Adult RDA: visual purple, Slow recovery of vision
Men: 900 mcg which enables after flashes of bright
Women: 700 mcg the eye to adapt light at night is the
to dim light first ocular symptom,
• Retinol: beef,
Normal growth and which can progress
liver, milk, butter,
cheese, cream, development of to xerophthalmia and
bones and teeth blindness
egg yolk,
The formation and Bone growth ceases;
fortified milk,
maintenance of bone shape changes;
margarine, and
ready-to-eat mucosal enamel-forming cells
epithelium to in the teeth
cereals
maintain healthy malfunction; teeth
• Beta carotene:
functioning of crack and tend to
“greens” (turnip,
skin and decay
dandelion, beet, membranes, hair, Skin becomes dry, scaly,
collard, mustard), gums, and rough, and cracked;
spinach, kale,
various glands keratinization or
broccoli, carrots,
Important role in hyperkeratosis
peaches, immune function develops; mucous
pumpkin, red
membrane cells
peppers, sweet
flatten and harden:
potatoes, winter eyes become dry
squash, mango, (xerosis); irreversible
apricots,
drying and hardening
cantaloupe
of the cornea can
result in blindness
Decreased saliva
secretion →
difficulty chewing,
swallowing →
anorexia
Decreased mucous
secretion of the
stomach and
intestines →
impaired digestion
and absorption →
diarrhea, increased
excretion of nutrients
Impaired immune
system functioning
→ increased
susceptibility to
respiratory, urinary
tract, and vaginal
infections increases
Toxicity
Headaches, vomiting,
double vision, hair
loss, bone
abnormalities, liver
damage, which may
be reversible or fatal
Can cause birth defects
during pregnancy
Vitamin D Maintains serum Deficiency
Adult RDA: calcium
Up to age 70 years: concentrations by
600 IU/day 70
Sources the following:
Functions Signs and Symptoms
years and older: Stimulating GI
800 IU/day absorption Rickets (in infants and
UL: 4000 IU/day Stimulating the children)
Sunlight on the skin release of Retarded bone growth
calcium from the Bone malformations
• Fatty fish (bowed legs)
bones
(salmon, tuna, Enlargement of ends of
sardines, Stimulating calcium
absorption from long bones (knock-
swordfish), cod knees)
the kidneys
liver oil, egg Deformities of the ribs
Other roles include
yolks, beef liver; (bowed with beads
fortified foods: cell growth,
neuromuscular or knobs)
milk (dairy and Delayed closing of the
and immune
nondairy), ready- fontanel → rapid
to-eat cereals, function, and
reducing enlargement of the
orange juice, and head
inflammation
infant formula Decreased serum
Most tissues and
cells have calcium and/or
vitamin D phosphorus
receptors (e.g., in Malformed teeth;
the skin, decayed teeth
pancreas, colon, Protrusion of the
kidney, abdomen related to
parathyroid and relaxation of the
pituitary glands, abdominal muscles
ovaries, and Increased secretion of
lymphocytes), parathyroid hormone
which suggests Osteomalacia (in adults)
vitamin D has Softening of the bones
many diverse → deformities, pain,
roles and easy fracture
Decreased serum
calcium and/or
phosphorus,
increased alkaline
phosphatase
Involuntary muscle
twitching and
spasms
Toxicity
Kidney stones,
irreversible kidney
damage, muscle and
bone weakness,
excessive bleeding,
loss of appetite,
headache, excessive
thirst, calcification of
soft tissues (blood
vessels, kidneys,
heart, lungs), death
Vitamin E Acts as an Deficiency
Adult RDA: 15 mg antioxidant to Increased red blood cell
protect vitamin A hemolysis
• Vegetable oils,
margarine, salad and In infants, anemia,
polyunsaturated edema, and skin
dressing, other
fatty acids from lesions
foods made with
being destroyed Toxicity
vegetable oil,
nuts, seeds, Protects cell Relatively nontoxic
membranes High doses enhance
wheat germ,
Also involved in action of
dark-green
vegetables, whole inhibiting cell anticoagulant
division, medications
grains, fortified
enhancing
cereals
immune system
functioning,
regulating gene
expression,
inhibiting platelet
aggregation, and
promoting blood
vessel dilation
Vitamin K Coenzyme for Deficiency
Adult AI: reactions Hemorrhaging
Men: 120 mcg involved in blood Toxicity
Women: 90 mcg clotting and bone No symptoms have been
Menaquinone: metabolism observed from
meat, dairy excessive intake of
products, eggs; vitamin K.
synthesized by
intestinal
microbiota
Phylloquinone:
brussels sprouts,
broccoli,
cauliflower,
Swiss chard,
spinach, loose
leaf lettuce,
carrots, green
beans,
asparagus
Vitamin A
Two forms of vitamin A are available in the diet:
• Preformed vitamin A
• It exists as an alcohol (retinol), aldehyde (retinaldehyde), or acid
(retinoic acid).
• It is found only in animal sources such as liver, whole milk, and
fish.
• Low-fat milk, skim milk, margarine, and ready-to-eat cereals
are fortified with vitamin A.
• Provitamin A carotenoids
• Beta carotene, alpha carotene, and cryptoxanthin can be
converted to retinol.
• Other carotenoids (e.g., lycopene, lutein, and zeaxanthin) do not
have vitamin A activity.
Fortified
to fortify is to add nutrients to a food that were either not originally present or were present in
insignificant amounts; for instance, many brands of orange juice are fortified with vitamin D.
Carotenoids
natural plant pigments found in deep-yellow and orange fruits and vegetables and most dark-
green leafy vegetables. Well-known carotenoids that cannot be converted to vitamin A in the body
are zeaxanthin, lutein, and lycopene.
The body can store up to a year supply of vitamin A, 90% of which is in the
liver. It may take 1 to 2 years for deficiency symptoms to appear because
they do not develop until body stores are exhausted.
• Vitamin A deficiency is rare in the United States. Premature infants,
infants with malabsorption disorders, and people with cystic fibrosis
are the groups most at risk.
• In sub-Saharan Africa and South Asia, vitamin A deficiency affects
approximately one third of children living in low- and middle-
income settings (Stevens et al., 2015), causing a range of vision
problems, including permanent blindness.
• Vitamin A deficiency is also linked to an increased risk of
mortality from measles and diarrhea in children.
Only preformed vitamin A, the form found in animal foods, fortified
foods, and supplements, is toxic in high doses.
Preformed Vitamin A
the active form of vitamin A.
• Chronic excessive vitamin A intake can cause central nervous

system changes, bone and skin changes, and liver abnormalities that
range from reversible to fatal.
• Toxicity is usually caused by consuming too much vitamin A from
supplements.
• At high doses during pregnancy (three to four times the
recommended intake), vitamin A is teratogenic.
• Supplementation is not recommended during the first trimester of
pregnancy unless there is specific evidence of vitamin A
deficiency.
Beta carotene is nontoxic because the body makes vitamin A from it only as
needed and the conversion is not rapid enough to cause hypervitaminosis A.
• Carotene is stored primarily in adipose tissue and may accumulate
under the skin to the extent that it causes the skin color to turn
yellowish orange, a harmless and reversible condition known as
carotenodermia.
• The Tolerable Upper Intake Level (UL) for vitamin A does not
apply to vitamin A derived from carotenoids.
Beta carotene is a major antioxidant in the body, which prompted
researchers to study whether it can prevent heart disease and cancer. A
landmark trial designed to test whether beta carotene supplements could
decrease cancer incidence in people at high risk was prematurely halted
when results showed a surprising increase in lung cancer incidence and
deaths in smokers and male asbestos workers (Omenn et al., 1996; The
Alpha Tocopherol, Beta Carotene Cancer Prevention Study Group, 1994).
Vitamin D
Vitamin D is unique in that the body has the potential to make all it needs if
exposure to ultraviolet rays from sunlight is optimal and liver and kidney
functions are normal. Because vitamin D can be endogenously synthesized,
it is not an essential nutrient in the diet.
Essential Nutrient
A nutrient that must be supplied by the diet because it is not synthesized in the body. Essentiality
does not refer to importance but to the need for a dietary source.
• Vitamin D also known as calciferol, exists in two forms:

• Vitamin D3 or cholecalciferol, which is derived from animal foods
in the diet and synthesis in the skin
• Vitamin D2 or ergocalciferol, which is found in plant foods in the
diet
• Vitamin D naturally occurs in very few foods; fortified foods are the
major dietary source (Box 6.1).
• Vitamin D from sunlight or food is inert and requires two
hydroxylation reactions to become active.
• The first reaction occurs in the liver where vitamin D is converted
to 25-hydroxyvitamin D [25(OH)D], also known as calcidiol.
• The second reaction occurs primarily in the kidney where
25(OH)D is converted to the biologically active form of vitamin
D, 1,25(OH)2D, also known as calcitriol. This conversion is
tightly regulated by parathyroid hormone in response to serum
calcium and phosphorus levels.
• Because vitamin D is synthesized in one part of the body (skin) and
stimulates functional activity elsewhere (e.g., GI tract, bones, and
kidneys), it is actually a prohormone.
BOX Vitamin D Content of Selected Items

6.1
IUs of
Vitamin D
1 tbsp cod liver oil 1360
3 oz swordfish 566
3 oz Atlantic salmon 447
3 oz canned tuna in water, drained 154
1 cup fortified orange juice 137
IUs of
Vitamin D
1 cup nonfat, reduced fat, and whole milk fortified with 115–124
vitamin D
1 tbsp fortified margarine 60
1 large egg yolk 41
Source: USDA National Nutrient Database for Standard Reference Release 28.
https://ods.od.nih.gov/pubs/usdandb/VitaminD-Content.pdf.
The RDA for vitamin D is based on the assumption of minimal or no sun

exposure.
• The basis for determining the RDA for vitamin D is its cause-and-
effect relationship with bone health only.
• The Institute of Medicine (IOM) maintains that evidence linking
vitamin D with extra-skeletal outcomes (e.g., cancer, cardiovascular
disease, diabetes, and autoimmune disorders) is inconsistent,
inconclusive, and insufficient to use in determining vitamin D
requirements (Food and Nutrition Board, Institute of Medicine
[IOM], 2011).
• The current UL for vitamin D is set at 4000 IU/day for ages 9 years
and older.
• Factors considered in determining the UL included
hypercalcemia, hypercalciuria, and vascular and soft-tissue
calcification.
• Vitamin D toxicity from overexposure to the sun does not occur
because the body limits the amount it produces.
Although it is possible for the body to make all the vitamin D it needs, a
dietary source is considered necessary because few people meet those
conditions.
• Cloud cover, time of day, dark skin pigmentation, air pollution, and
the use of sunscreen are the factors that affect ultraviolet (UV)
radiation exposure and vitamin D synthesis in the skin (Food and
Nutrition Board, IOM, 2011).
• Season also impacts vitamin D synthesis.
• During the winter months, people living in latitudes above 37° do
not receive enough UVB radiation, preventing most or all
endogenous synthesis of previtamin D (Fig. 6.1).
• Although it is difficult to determine how much sun exposure is
adequate, some experts suggest 5 to 30 minutes of sun exposure
between 10 a.m. and 3 p.m. at least twice a week to the face, arms,
legs, or back without sunscreen is sufficient (Holick, 2007).
Overt deficiency of vitamin D causes poor calcium absorption, leading to a
calcium deficit in the blood, which the body corrects by releasing calcium
from bone.
• The result is rickets in children, a condition characterized by
abnormal bone shape and structure.
• In adults, vitamin D deficiency can result in osteomalacia, a
softening of the bones.
Rickets
vitamin D deficiency disease in children; most prominently characterized by bowed legs.
Osteomalacia
adult rickets characterized by inadequate bone mineralization due to the lack of vitamin D.
Food fortification, particularly milk, has virtually eradicated these two

deficiency diseases in the United States (Pfotenhauer & Shubrook, 2017).
However, many Americans may have inadequate serum concentrations of
vitamin D.
Because the major source of vitamin D for children and adults is
sunlight exposure, the major cause of vitamin D inadequacy or deficiency is
inadequate sun exposure (Nair & Maseeh, 2012).
• Senior persons are particularly at risk for vitamin D deficiency
because of various factors: inadequate intake, limited sun exposure,
reduced skin thickness, and impaired activation by the liver and
kidneys.
• Other groups at risk of vitamin D deficiency include breastfed
infants who do not receive vitamin D supplements, people with fat
malabsorption or inflammatory bowel conditions, and people who
are obese or have had gastric bypass surgery (National Institutes of
Health, Office of Dietary Supplements, 2019a).
• Certain medications, such as anticonvulsants, glucocorticoids, and
highly active antiretroviral therapy can interfere with vitamin D
metabolism.
Recall Marcus. His gluten-free/casein-free diet restricts

many types of grain and milk products, and some children
following this diet have developed amino acid deficiencies,
which is essentially a form of protein malnutrition. Marcus
has difficulty chewing meat, which further limits his intake
of protein. What foods can provide protein within the
context of his dietary restrictions? Which vitamins may he
be under consuming given his restricted intake of grains,
milk, and meats? Will vitamin supplements compensate for
the lack of variety in his intake?
Vitamin E
Vitamin E is a group name that describes a group of at least eight
structurally related, naturally occurring compounds.
• Alpha tocopherol is considered the most biologically active form of
vitamin E, although other forms also have important roles in
maintaining health.
• As a group, vitamin E functions as the primary fat-soluble
antioxidant in the body, protecting PUFAs and other lipid molecules,
such as LDL cholesterol, from oxidative damage. By doing so, it
helps to maintain the integrity of PUFA-rich cell membranes,
protects red blood cells against hemolysis, and protects vitamin A
from oxidation.
The need for vitamin E increases as the intake of PUFA increases.
• Fortunately, vitamin E and PUFA share many of the same food
sources, particularly nuts, seeds, fortified cereals, vegetable oils, and
products made from oil such as margarine, salad dressings, and
other prepared foods.
• Not all oils are rich in alpha tocopherol, the active form of vitamin
E.
• Sunflower oil, canola oil, and olive oil all have higher amounts of
the active form of vitamin E than does soybean oil, the most
commonly used oil in food processing.
It is noteworthy that deficiency symptoms have never been reported in
healthy people eating a low–vitamin E diet. Mean intake in the United
States is somewhat less than recommended (U.S. Department of Agriculture
[USDA], Agricultural Research Service [ARS], 2018).
• Total fat intake, thus vitamin E intake, may be underreported.
• It is difficult to estimate the amount of fat used in food preparation
(e.g., frying).
• Vitamin E content cannot be determined when the ingredient list of
a food states “may contain one or more of the following oils”
because vitamin E content differs among oils.
Vitamin E deficiency is rare and more likely to occur secondary to fat
malabsorption syndromes, such as cystic fibrosis and short bowel
syndrome, than from an inadequate intake.
• Premature infants who have not benefited from the transfer of
vitamin E from mother to fetus in the last weeks of pregnancy are at
risk for red blood cell hemolysis.
• The breaking of their red blood cell membranes is caused by
oxidation; vitamin E corrects red blood cell hemolysis by
preventing oxidation.
• Prolonged vitamin E deficiency symptoms include peripheral
neuropathy, ataxia, and impaired vision and speech.
Large amounts of vitamin E are relatively nontoxic as evidenced by a UL
that is 66 times higher than the RDA.
Excessive vitamin E can interfere with vitamin K action (blood
•
clotting) by decreasing platelet aggregation.
• Large doses may also potentiate the effects of blood-thinning drugs,
increasing the risk of hemorrhage.
Vitamin K
Vitamin K occurs naturally in two forms. Phylloquinone is found in plants,
and menaquinones, the animal form, is found in modest amounts in meat,
dairy products, and eggs. It is the form of vitamin K synthesized in the
intestinal tract by microbiota. It is not known how much vitamin K
produced by microbiota are absorbed. A UL has not been set because no
adverse effects are associated with vitamin K intake from food or
supplements. Vitamin K is a coenzyme essential for the synthesis of
prothrombin and at least 6 of the other 13 proteins needed for normal blood
clotting.
• Without adequate vitamin K, life is threatened.
• Even a small wound can cause someone deficient in vitamin K to
bleed to death.
• Vitamin K also activates at least three proteins involved in building
and maintaining bone.
Newborns are prone to vitamin K deficiency for a few reasons.
• Vitamin K transport across the placenta is low.
• Breast milk is low in vitamin K.
• Newborns have sterile GI tracts that cannot synthesize vitamin K.
• To prevent hemorrhagic disease, a single intramuscular dose of
vitamin K is given prophylactically at birth.
Clinically significant vitamin K deficiency is defined as vitamin K–
responsive hypoprothrombinemia and is characterized by an increase in
prothrombin time.
• Vitamin K deficiency does not occur from inadequate intake but
may occur secondary to malabsorption syndromes.
• The use of certain medications that interfere with vitamin K
metabolism or synthesis, such as anticoagulants and antibiotics, can
cause vitamin K deficiency.
• Anticoagulants, such as warfarin (Coumadin), interfere with hepatic
synthesis of vitamin K–dependent clotting factors.
• People who take warfarin do not need to avoid vitamin K, but
they should try to maintain a consistent intake so that the effect on
coagulation time is as constant and as predictable as possible.
• Antibiotics kill the intestinal bacteria that synthesize vitamin K.
Water-Soluble Vitamins
Table 6.1 summarizes the group characteristics of water-soluble vitamins.
Table 6.3 highlights sources, functions, deficiency symptoms, and toxicity
symptoms of each water-soluble vitamin. Additional features of individual
water-soluble vitamins are summarized in the following sections.
Figure 6.1 ▲ Americans living north of 37° latitude (shaded area) are
at great risk for vitamin D deficiency because of low or absent UVB
sunlight from late October to late April. (Source: Wickham, R. [2012].
Cholecalciferol and cancer: Is it a Big D3-eal? Journal of the Advanced
Practitioner in Oncology, 3(4), 249–257.
https://doi.org/10.6004/jadpro.2012.3.4.6)
Table Summary of
Water-Soluble
6.3 Vitamins

Thiamin (vitamin Coenzyme in energy Deficiency
B1) metabolism Beriberi
Adult RDA Promotes normal Mental confusion,
Men: 1.2 mg appetite and decrease in short-
Women: 1.1 mg nervous system term memory
• Whole grain and functioning Fatigue, apathy
enriched breads Peripheral paralysis
and cereals, liver, Muscle weakness and
nuts, wheat germ, wasting
pork, dried peas Painful calf muscles
and beans Anorexia, weight loss
Edema
Enlarged heart
Cardiac and renal
complications can be
fatal
Toxicity
No toxicity symptoms
reported
Riboflavin Coenzyme in energy Deficiency
(vitamin B2) metabolism Dermatitis
Adult RDA Aids in the Cheilosis
Men: 1.3 mg conversion of Glossitis
Women: 1.1 mg tryptophan into Photophobia
• Milk and other niacin Reddening of the cornea
dairy products; Toxicity
whole-grain and No toxicity symptoms
enriched breads reported
and cereals; liver,
eggs, meat,
spinach
Niacin (vitamin B3) Coenzyme in energy Deficiency
Adult RDA metabolism Pellagra: 4 Ds
Men: 16 mg Promotes normal Dermatitis (bilateral and
Women: 14 mg nervous system symmetrical) and
All protein foods, functioning glossitis
whole grain and Diarrhea
enriched breads Dementia, irritability,
and cereals mental confusion →
psychosis
Death, if untreated
Toxicity (from
supplements/drugs)
Flushing, liver damage,
gastric ulcers, low
blood pressure,
diarrhea, nausea,
vomiting
Vitamin B6 Coenzyme in >100 Deficiency
Adult RDA enzyme Microcytic anemia,
Men: 1.3–1.7 mg reactions, mostly dermatitis, cheilosis,
Women: 1.3–1.5 mg concerned with glossitis, abnormal
• Fish, beef liver protein brain wave pattern,
and other organ metabolism convulsions,
meats, potatoes, Involved in the depression and
other starchy metabolism of confusion, weakened
vegetables, non- carbohydrates immune system
citrus fruits, and lipids functioning
fortified cereals, Plays a role in Toxicity
beef, and poultry gluconeogenesis, Depression, fatigue,
immune system irritability,
functioning, headaches; sensory
hemoglobin neuropathy
formation, and characteristic
the synthesis of
neurotransmitters
Folate Coenzyme in DNA Deficiency
Adult RDA: 400 synthesis; Glossitis, diarrhea,
mcg therefore, vital macrocytic anemia,
• Liver, okra, for new cell depression, mental
spinach, synthesis and the confusion, fainting,
asparagus, dried transmission of fatigue
peas and beans, inherited Toxicity
seeds, orange characteristics Too much can mask
juice; breads, Coenzyme in vitamin B12
cereals, and other homocysteine deficiency
grains are metabolism
fortified with
folic acid
Vitamin B12 Coenzyme in the Deficiency
Adult RDA: 2.4 synthesis of new GI changes: glossitis,
mcg cells anorexia, indigestion,
Animal products: Activates folate recurring diarrhea or
meat, fish, Maintains myelin constipation, and
poultry, sheath around weight loss
shellfish, milk, nerve cells Macrocytic anemia:
dairy products, Helps metabolize pallor, dyspnea,
eggs some fatty acids weakness, fatigue,
• Some fortified and amino acids and palpitations
foods Coenzyme in Neurologic changes:
homocysteine paresthesia of the
metabolism hands and feet,
decreased sense of
position, poor muscle
coordination, poor
memory, irritability,
depression, paranoia,
delirium, and
hallucinations
Toxicity
No toxicity symptoms
reported
Pantothenic acid Part of coenzyme A Deficiency
Adult AI: 5 mg used in energy Rare; general failure of
Widespread in foods metabolism all body systems
• Meat, poultry, Toxicity
fish, whole-grain No toxicity symptoms
cereals, and dried reported, although
peas and beans large doses may
are among best cause diarrhea
sources
Biotin Coenzyme in energy Deficiency
Adult AI: 30 mcg metabolism, fatty Rare; anorexia, fatigue,
Widespread in foods acid synthesis, depression, dry skin,
Eggs, liver, milk, amino acid heart abnormalities
and dark-green metabolism, and Toxicity
vegetables are glycogen No toxicity symptoms
among best formation reported
choices
Synthesized by GI
flora
Choline Important for Deficiency
Adult AI structural Muscle damage, liver
Men: 550 mg integrity of cell damage, and
Women: 425 mg membranes nonalcoholic fatty
Widespread: milk, Necessary for liver disease
liver, beef, acetylcholine (a Toxicity
beans, eggs, neurotransmitter) Extremely high intakes
peanuts, formation may cause fishy
cruciferous Plays a role in body odor, sweating,
vegetables modulating gene salivation,
(broccoli, expression, cell hypotension, and
brussels sprouts, membrane hepatoxicity
cauliflower) signaling, lipid
Processed foods transport and
with added metabolism, and
lecithin (an early brain
emulsifier): development
salad dressings,
gravies,
margarine
Vitamin C Synthesis of Deficiency
Adult RDA collagen, the Scurvy, characterized by
Men: 90 mg most abundant the following:
Women: 75 mg protein in fibrous Hemorrhaging that
• Citrus fruits and tissues, such as begins with pinpoint
juices, red and connective hemorrhages under
green peppers, tissue, cartilage, the skin and
broccoli, bone matrix, progresses to
cauliflower, tooth dentin, massive internal
brussels sprouts, skin, and tendon. bleeding
cantaloupe, Antioxidant that Muscle degeneration
kiwifruit, mustard protects vitamin Skin changes
greens, A, vitamin E, Delayed wound healing:
strawberries, PUFA, and iron reopening of old
tomatoes from destruction wounds
Promotes iron Softening of the bones
absorption → malformations,
Involved in the pain, easy fractures
metabolism of Soft, loose teeth
certain amino Anemia
acids Increased susceptibility
Thyroxin synthesis to infection
Immune system Hysteria and depression
functioning Toxicity
Diarrhea, mild GI upset
Thiamin
Thiamin (vitamin B1) is a coenzyme in the metabolism of carbohydrates and
branched-chain amino acids. In addition to its role in energy metabolism,
thiamin is important in nervous system functioning.
• In the United States and other developed countries, the use of
enriched breads and cereals has virtually eliminated the thiamin
deficiency disease known as beriberi.
• Today, thiamin deficiency is usually seen only in alcoholics with
limited food consumption.
• Chronic alcohol abuse impairs thiamin intake, absorption, and
metabolism. Edema occurs in wet beriberi, and muscle wasting is
prominent in dry beriberi. Cardiac and renal complications can be
fatal.
Riboflavin
Riboflavin (vitamin B2) is an integral component of the coenzymes flavin
adenine dinucleotide and flavin mononucleotide that function to release
energy from nutrients in all body cells.
• Flavin coenzymes are also involved in the formation of some
vitamins and their coenzymes and in the conversion of
homocysteine to methionine.
• Riboflavin is unique among water-soluble vitamins in that milk and
dairy products contribute the most riboflavin to the diet.
• Biochemical signs of an inadequate riboflavin status can appear
after only a few days of a poor intake.
• Seniors and teens are at greatest risk for riboflavin deficiency.
• Riboflavin deficiency interferes with iron handling and contributes
to anemia when iron intake is low.
• Certain diseases, such as cancer, heart disease, and diabetes,
precipitate or exacerbate riboflavin deficiency.
Homocysteine
an amino acid correlated with increased risk of heart disease.
Methionine
an essential amino acid.
Niacin
Niacin (vitamin B3) exists as nicotinic acid and nicotinamide. A unique
feature of niacin is that the body can make it from the amino acid
tryptophan. Because of this additional source of niacin, niacin requirements
are stated in niacin equivalents (NEs). Niacin is part of the coenzymes
nicotinamide adenine dinucleotide and nicotinamide adenine dinucleotide
phosphate (NADP), which are involved in energy transfer reactions in the
metabolism of glucose, fat, and alcohol in all body cells.
Niacin Equivalents (NEs)

the amount of niacin available to the body, including that made from tryptophan.
• Reduced NADP is used in the synthesis of fatty acids, cholesterol,

and steroid hormones.
Pellagra, the disorder caused by severe niacin deficiency, was common in
the southern United States before grain products were enriched with niacin
in the early 20th century.
• Today, pellagra is rare in the United States and usually is seen only
in alcoholics.
• Once widespread in areas that rely on corn as a staple, such as parts
of Africa and Asia, pellagra is now mostly seen only in populations
during food emergencies.
• Niacin deficiency may be treated with niacin, tryptophan, or both.
Because a deficiency of niacin rarely occurs alone, treatment is most
effective when other B-complex vitamins are also given, especially thiamin
and riboflavin. Large doses of niacin in the form of nicotinic acid (1000–
2000 mg/day) are used therapeutically to lower total LDL cholesterol, lower
triglycerides, and raise high-density lipoprotein cholesterol.
• Flushing is a common side effect caused by vasodilation.
• Large doses may cause liver damage and gout and should be used
only with a doctor’s supervision.
• The UL of 35 mg of NE does not apply for clinical applications
using niacin as a drug.
Vitamin B6
Vitamin B6 and pyridoxine are group names for six related compounds that
include pyridoxine, pyridoxal, and pyridoxamine. All forms can be
converted to the active form, pyridoxal phosphate, which is involved in
nearly 100 enzymatic reactions, mostly involving protein metabolism.
• Unlike other B vitamins, vitamin B6 is stored extensively in muscle
tissue.
• A combination of vitamin B6 and doxylamine succinate (an
antihistamine) in a delayed-release combination pill is associated
with a 70% reduction in nausea and vomiting in pregnancy (Niebyl,
2010).
• A randomized, placebo-controlled clinical trial showed that it is
safe (not a teratogen) and effective as an antiemetic for mild to
moderate nausea and vomiting during pregnancy
(Nuangchamnong & Niebyl, 2014).
Deficiencies of vitamin B6 are uncommon but are usually accompanied by
deficiencies of other B vitamins, such a folic acid and vitamin B12.
• People at risk of vitamin B6 deficiency include those with impaired
renal function, autoimmune diseases, and malabsorption disorders
such as celiac disease.
• Vitamin B6 deficiency also occurs in people with alcohol
dependency (because the metabolism of alcohol promotes the
destruction and excretion of vitamin B6) and those on certain drug
therapies such as isoniazid, the antituberculosis drug that acts as a
vitamin B6 antagonist.
No adverse effects have been reported with high intakes of vitamin B6 from
food.
• High intake of supplemental vitamin B6 (1–6 g oral/day for 12–40
months) can cause severe and progressive sensory neuropathy
characterized by ataxia (Kulkantrakorn, 2014).
• The severity of symptoms is dose dependent.
• Symptoms usually disappear if supplements are discontinued as
soon as symptoms appear (National Institutes of Health, Office of
Dietary Supplements, 2019b).
Folate
Folate is the generic term for this B vitamin that includes both synthetic
folic acid found in vitamin supplements and fortified foods and naturally
occurring folate in foods such as green leafy vegetables, legumes, seeds,
liver, and orange juice.
• Dietary folate equivalents, used in establishing folate requirement,
are based on the assumption that natural food folate is
approximately only half as available to the body as synthetic folic
acid.
• A large number of factors influence the bioavailability of natural
folates, and different plant and animal sources of folate may have
varied levels of bioavailability (Saini et al., 2016).
Much like the enterohepatic circulation of bile, folate is recycled through
the intestinal tract. A healthy GI tract is essential to maintain folate balance.
• When GI integrity is impaired, as in malabsorption syndromes,
failure to reabsorb folate quickly leads to folate deficiency.
• GI cells are particularly susceptible to folate deficiency because they
are rapidly dividing cells that depend on folate for new cell
synthesis. Without the formation of new cells, GI function declines
and widespread malabsorption of nutrients occurs.
Folate deficiency impairs DNA synthesis and cell division and results in
macrocytic anemia and other clinical symptoms.
• It is prevalent in all parts of the world. In developing countries,
folate deficiency commonly is caused by parasitic infections that
alter GI integrity.
• In the United States, alcoholics are at highest risk of folate
deficiency because of alcohol’s toxic effect on the GI tract.
• The groups at risk because of poor intake include seniors, fad
dieters, and people of low socioeconomic status.
• New tissue growth increases folate requirements, so infants,
adolescents, and pregnant women may have difficulty consuming
adequate amounts.
Studies show that an adequate intake of folate before conception and during
the first trimester of pregnancy reduces the risk of neural tube defects (e.g.,
spina bifida) in infants (Medical Research Council Vitamin Study Research
Group, 1991).
• This discovery prompted the U.S. Public Health Service to
recommend that all women of childbearing age who are capable of
becoming pregnant consume 400 mcg of synthetic folic acid from
fortified food and/or supplements in addition to folate from a varied
diet (U.S. Preventive Services Task Force, 2017).
• Folic acid fortification of enriched bread and grain products is
mandatory in the United States. These products have become an
important source of folic acid because grains are so widely
consumed in the United States.
The UL for folic acid is 1000 mg/day from fortified food or supplements,
exclusive of food folate.
• Large amounts of folic acid may mask vitamin B12 deficiency by
correcting the megaloblastic anemia. However, it does not correct
the neurologic abnormalities, which if left untreated, may be
irreversible.
Recall Marcus. He has a restricted diet and accepts only a‐

limited variety of foods, so he may be under- or
overconsuming certain nutrients. His parents give him a
multivitamin with minerals, plus additional supplements of
vitamin D, vitamin C, and calcium. What questions would
you ask about the supplements he is taking? Should
Marcus’s parents keep a food diary so that his total vitamin
intake from food and supplements can be estimated?
Vitamin B12
Vitamin B12 (cobalamin) has several interesting features.
• First, vitamin B12 has an interdependent relationship with folate:
Each vitamin must have the other to be activated.
• Because it activates folate, vitamin B12 is involved in DNA synthesis
and maturation of red blood cells.
• Like folate, vitamin B12 functions as a coenzyme in homocysteine
metabolism.
• Unlike folate, vitamin B12 has important roles in maintaining the
myelin sheath around nerves.
• For this reason, large doses of folic acid cannot halt the
progressive neurologic impairments that only vitamin B12 can
treat, although they can alleviate the anemia caused by vitamin
B12 deficiency.
• Nervous system damage may be irreversible without early
treatment with vitamin B12.
Vitamin B12 also holds the distinction of being the only water-soluble
vitamin that does not occur naturally in plants.
• Fermented soy products and algae may be enriched with vitamin
B12, but it is in an inactive, unavailable form.
• Some ready-to-eat cereals are fortified with vitamin B12.
• All animal foods contain vitamin B12.
Another unique feature of vitamin B12 is that it requires an intrinsic factor
(IF), a glycoprotein secreted in the stomach, to be absorbed from the
terminal ileum.
• But before it can bind to the IF, natural vitamin B12 must first be
separated from the small peptides to which it is bound in food
sources. Separation is accomplished by pepsin and gastric acid.
• Conversely, synthetic vitamin B12 found in enriched foods and
supplements does not require this separation step because it is in
free form.
Vitamin B12 deficiency symptoms may take 5–10 years or longer to develop
because the liver can store relatively large amounts of B12 and the body
recycles B12 by reabsorbing it. Vitamin B12 deficiency can be caused by the
following:
• Dietary deficiencies, especially in vegans who consume no animal
products.
• Although once thought to be rare, studies show relatively high
vitamin B12 deficiency prevalence among vegetarians (Pawlak et
al., 2014).
• Vegans who do not consume vitamin B12 supplements are
especially at high risk.
• A dietary deficiency is preventable with regular consumption of
oral supplements or vitamin B12–fortified foods.
• Pernicious anemia is an autoimmune gastritis in which destruction
of parietal cells leads to achlorhydria and failure to produce IF.
• Even when intake is adequate, vitamin B12 deficiency occurs from
severe vitamin B12 malabsorption.
• Conditions that impair the integrity of the stomach (e.g., total or
partial gastrectomy, gastric bypass or other bariatric surgery) or
bowel (e.g., ileal resection, inflammatory bowel disease) and
Supplementation via injections, nasal gels, and sprays are available.
Large oral doses have also been found to be an effective treatment
(Chan et al., 2016).
• These conditions can cause severe deficiency related to vitamin
B12 malabsorption
• Protein-bound vitamin B12 malabsorption is a milder form of
atrophic gastritis in which low gastric acid secretion impairs the
freeing of protein-bound vitamin B12 in foods.
• It is frequently attributed to aging and affects up to 20% of older
adults (Lewerin et al., 2008).
• It may also occur secondary to the use of medications that suppress
gastric acid secretion.
• This mild form of malabsorption can be treated with large
doses of oral supplements.
• As a preventive measure, the National Academy of Sciences Food
and Nutrition Board recommends that people older than age 50
years obtain most of their requirement from fortified foods or
supplements (Food and Nutrition Board, IOM, 1998).
Other B Vitamins
Pantothenic acid is part of coenzyme A (CoA), the coenzyme involved in
the formation of acetyl-CoA and in the tricarboxylic acid (TCA) cycle.
• Pantothenic acid participates in >100 different metabolic reactions.
• It is assumed that the average American diet provides adequate
amounts of pantothenic acid.
As a coenzyme, biotin is involved in the TCA cycle, gluconeogenesis, fatty
acid synthesis, and chemical reactions that add or remove carbon dioxide
from other compounds.
• Significant amounts of biotin are synthesized by GI flora, but it is
not known how much is available for absorption.
• It is assumed that the average American diet provides adequate
amounts of biotin.
Choline
Choline is an essential nutrient commonly categorized with the B vitamins.
• Choline is required for the structural integrity of cell membranes.
• Although essential to life, few data exist on the effects of inadequate
dietary intake in healthy people (Food and Nutrition Board, IOM,
1998).
• It is possible that the requirement for choline can be met by
endogenous synthesis at some stages of the life cycle.
Vitamin C
Vitamin C (ascorbic acid) may be the most famous vitamin. Its long history
dates back more than 250 years when it was determined that something in
citrus fruits prevents scurvy, a disease that killed as many as two thirds of
sailors on long journeys. Years later, British sailors acquired the nickname
“Limeys” because of Great Britain’s policy to prevent scurvy by providing
limes to all sailors. It wasn’t until 1932 that the anti-scurvy agent was
identified as vitamin C. Acute vitamin C deficiency leads to scurvy.
• Overt deficiency symptoms occur only if vitamin C intake is
approximately ≤10 mg/day for many weeks.
• Even though scurvy is deadly, it can be cured within a matter of
days with moderate doses of vitamin C.
• Severe vitamin C deficiency is rare in developed nations but can
occur in people who do not eat enough fruits and vegetables.
• It is estimated that 90% of vitamin C in the typical diet comes
from fruits and vegetables.
• The groups most at risk of vitamin C inadequacy include smokers
who need more vitamin C because smoking increases oxidative
stress and metabolic turnover of vitamin C (Food and Nutrition
Board, IOM, 2000).
• Smokers are advised to increase their intake by 35 mg/day.
• The other groups at risk of inadequate intake are people with severe
malabsorption and those with end-stage renal disease on chronic
hemodialysis.
There is no clear and convincing evidence that large doses of vitamin C

prevent colds in the general population; however, in five trials, vitamin C
decreased the risk of colds in people under physical stress (e.g., marathon
runners or soldiers in subarctic environments) by 50% (Hemilä & Chalker,
2013). Efficacy is difficult to measure because it may be influenced by how
much, how often, and how long supplements are used and by which
outcome it is measured, such as frequency of colds, length of cold, and
severity of symptoms.
VITAMINS IN HEALTH PROMOTION
A premise of the Dietary Guidelines for Americans, 2020–2025 is that

nutrient needs should be met primarily from nutrient-dense foods and
beverages, not from supplements (U.S. Department of Agriculture [USDA],
U.S. Department of Health and Human Services [USDHHS], 2020).
Vitamins are found in all MyPlate food groups; however, items within each
group vary in type and amount of vitamins they provide. For instance,
kiwifruit is high in vitamin C (83 mg/½ cup) whereas pears are not (3 mg/½
cup). Eating a variety of nutrient-dense items within each group helps
ensure nutritional adequacy.
What Studies Reveal

Table about Vitamin
6.4 Supplements and Chronic
Disease Prevention
Vitamins Chronic Disease What Research Reveals
Beta Age-related A landmark trial designed to test
carotene macular whether beta-carotene
degeneration supplements could decrease
cancer incidence in people at
high risk was prematurely halted
when results showed a surprising
increase in lung cancer incidence
and deaths in smokers and male
asbestos workers (Omenn et al.,
1996; The Alpha-Tocopherol,
Beta-Carotene Cancer Prevention
Study Group, 1994).
The U.S. Preventive Services Task
Force recommends against beta-
carotene supplements for the
prevention of cardiovascular
disease or cancer (Moyer, 2014).
Carotenes, Heart disease and The Age-Related Eye Disease Study
Vitamin cancer found that participants at high
E, risk of developing advanced
Vitamin C AMD reduced their risk of
developing advanced AMD by
25% by taking a daily
supplement containing beta
carotene, vitamin E, vitamin C,
and zinc for 5 years (Age-Related
Eye Disease Study Research
Group, 2001).
Vitamin D Autoimmune A large review of observation and
diseases such randomized controlled trials of
as multiple vitamin D was used to examine
sclerosis vitamin D and 137 outcomes,
(hypertension, including skeletal, cancer,
cardiovascular cardiovascular, autoimmune,
diseases,
metabolic
syndrome, infections, metabolic, and other
type 2 diseases (Theodoratou et al.,
diabetes, 2014).
several types • No highly convincing evidence
of cancer, was found of a clear role of
cognitive vitamin D with any outcome.
decline, • There was some evidence for
depression, some outcomes (e.g., decreased
and respiratory risk of colorectal cancer,
diseases) cardiovascular disease prevalence,
hypertension, high body mass
index, type 2 diabetes), but
researchers concluded more
evidence is needed.
• Probable associations were found
with a few selected outcomes,
such as birth weight, dental
cavities in children, and
parathyroid hormone
concentrations in people on
dialysis.
Likewise, a 5-year-old nationwide,
randomized, placebo-controlled
trial of vitamin D among healthy
American adults showed that
high-dose vitamin D did not
reduce the incidence of cancer or
major cardiovascular events
(Manson et al., 2019).
Vitamin E Cancer Most randomized trials find that
vitamin E is not beneficial with
regard to total or site-specific
cancers (Wang et al., 2014).
A study in the post-trial follow-up to
the Selenium and Vitamin E
Cancer Prevention Trial
(SELECT) found that vitamin E
supplementation significantly
increased the risk of prostate
cancer in healthy men (Klein et
al., 2011).
The U.S. Preventive Services Task
Force recommends against
vitamin E supplements for the
disease or cancer (Moyer, 2014).
Vitamin Cardiovascular Large clinical trials have failed to
B6, folic disease show that supplemental B
acid, and vitamins lower the risk of
B12 cardiovascular events, even
though they lower homocysteine
levels (National Institutes of
Health, Office of Dietary
Supplements, 2019b). To date,
there is little evidence to support
the use of B6 alone or in
combination with folic acid and
B12, to lower the risk or severity
of cardiovascular disease and
stroke.
Vitamin Cancer The few clinical trials completed to
B6 Cognitive decline date do not show that vitamin B6
supplementation helps prevent
cancer or lowers its mortality risk
(National Institutes of Health,
Office of Dietary Supplements,
2019b).
More evidence is needed to
determine if vitamin B6
supplementation helps prevent or
treat cognitive decline in senior
adults (National Institutes of
Health, Office of Dietary
Supplements, 2019b).
Folate Cancer Evidence suggests adequate dietary
Alzheimer’s folate may decrease the risk of
disease, some cancers but the effects of
dementia supplemental folic acid on cancer
are not clear (NIH, ODS, 2019c).
Most clinical trial research has not
shown that folic acid
supplementation affects cognitive
function or the development of
Alzheimer’s disease or dementia
(NIH, ODS, 2019c).
Choline Cardiovascular Some observational studies show a
disease, link between choline intake and
peripheral these disorders, and others do
artery disease, not. More research is needed
Alzheimer’s (NIH, ODS, 2019d).
disease,
nonalcoholic
fatty liver
disease
Vitamin C Cancer prevention Evidence from most randomized
Cardiovascular clinical trials suggests that
disease vitamin C supplementation, alone
or in combination with other
micronutrients, does not affect
cancer risk (NIH, ODS, 2019e).
Findings from most intervention
trials do not provide convincing
evidence that the supplements of
vitamin C decrease the risk of
cardiovascular disease or lower
its morbidity or mortality (NIH,
ODS, 2019e).
MVM Cardiovascular A systematic review and meta-
disease analysis of existing systematic
reviews and meta-analyses and
single randomized controlled
trials found no consistent benefit
between MVM use and the
disease, myocardial infarction,
stroke, or all-cause mortality
during the study period.
Researchers speculate that a
longer period of study may be
needed to observe lower risk
because chronic diseases develop
over a long period of time
(Jenkins et al., 2018).
Shortfall Vitamins
Based on data from National Health and Nutrition Examination Survey
2015 to 2016, the mean intake of vitamin A, vitamin D, vitamin E, vitamin
C, and choline among both men and women age 20 and older is less than
the Dietary References Intakes (USDA, ARS, 2018). Vitamin D is among
the dietary components of public health concern for the general population
because low intakes are associated with health concerns (USDA, USDHHS,
2020). Figure 6.2 illustrates mean intake of these shortfall vitamins
expressed as a percentage of DRIs for each vitamin. The majority of the
U.S. population has low intakes of key food groups or certain subgroups
that provide these specific vitamins.
Figure 6.2 ▲ Mean intake of shortfall vitamins as a percentage of the
Recommended Dietary Allowance in adult men and women. (Data from
the USDA, ARS. [2018]. Nutrient intakes from food and beverages: Mean
amounts consumed per individual, by gender and age, What We Eat in
America, NHANES 2015–2016. www.ars.usda.gov/nea/bhnrc/fsrg)
Folate is found in fruits, vegetables, and protein foods and is

beneficial to everyone, especially pregnant clients. Folic acid is found
in fortified grains.
• Vitamin A: orange fruits and vegetables, dark-green vegetables, and

fortified dairy products.
• Vitamin D: fortified dairy products and seafood.
• Vitamin E: oils, whole grains, and dark-green vegetables.
• Vitamin C: fruits and vegetables.
• Choline: dairy products, certain vegetables
Vitamin-Rich Eating Patterns

Healthy eating patterns recommended by leading health agencies encourage
plant-based diets that emphasize fruits, vegetables, beans, peas, lentils, nuts,
whole grains, seafood, and other lean proteins—all in nutrient-dense forms.
Even further, they promote limiting foods that are nutrient poor, such as
sugar-sweetened beverages and processed meats. Strategies that will help
Americans increase their intake of shortfall nutrients and improve intake
overall are as follows:
• Consume more vegetables from all subgroups, concentrating on
variety. Box 6.2 provides tips for boosting fruit and vegetable
intake.
• Consume more fruit.
• Consume more whole grains in place of refined grains. Whole
grains provide more vitamin E than refined grains as well as
phytonutrients and antioxidants.
• Consume more nonfat and low-fat dairy products, especially those
fortified with vitamins A and D.
• Include a greater variety of nutrient-dense items within the protein
foods group, such as more seafood (e.g., provides vitamin D) and
nuts and seeds (e.g., provide vitamin E).
• Replace solid fats with oils, which will improve vitamin E intake.
BOX Tips for Boosting Fruit and Vegetable

6.2 Intake
Vegetables and Fruits

• Intake recommendations among patterns intended for adults (1600–
3200 calories/day) range from 1½ to 2½ c of fruit per day and from 2
to 4 c of vegetables per day.
• Fill half the dinner plate with vegetables or vegetables and fruit.
• Buy a new fruit or vegetable when you go grocery shopping.
Vegetables
• Eat a variety of vegetables in different colors. Aim for at least one
green, one orange, one red, one citrus, and one legume serving every
day.
• Store vegetables correctly to preserve vitamin content. Keep most in
the refrigerator.
• Cook vegetables for as short a time as possible in as little water as
necessary. Microwaving is a better option than boiling.
• Keep fresh vegetables on the top shelf of the refrigerator in plain view.
• Start at least one meal each day with a fresh salad.
• Eat raw vegetables for snacks.
• Add vegetables to other foods, such as zucchini to spaghetti sauce,
grated carrots to meat loaf, and spinach to lasagna.
• Eat occasional meatless entrees such as pasta primavera, vegetable stir
fry, or black beans and rice.
• Order a vegetable when you eat out.
Fruit
• Leave a bowl of fruit on the center of your table.
• Snack on fruit. Add fruit to salads.
• Use fruit as a side dish.
• Eat fruit for dessert.
Consider Marcus. One of his food obsessions is a fortified‐

gluten-free cereal. It is fortified with 100% of the Daily
Value (DV) for many vitamins—but those DVs are based on
adult requirements, not recommendations for children.
Marcus eats a few servings of this cereal daily, so he is
getting much larger amounts of certain vitamins and
minerals than is required. If the percentage of the DV is not
valid due to his age, how can his vitamin intake from the
cereal be determined? Would you encourage Marcus’s
parents to find a nonfortified gluten-free cereal? Would you
recommend they discontinue his vitamin and mineral
supplements?
Phytonutrients: Technically Not Vitamins but

Health Enhancing
Phytonutrients, also known as phytochemicals, are literally plant (“phyto”
in Greek) chemicals. They are a broad, diverse, and bioactive class of
nonnutritive compounds that function like the immune system of plants to
protect them against viruses, bacteria, and fungi. In foods, Phytonutrients
impart color, taste, aroma, and other characteristics. When eaten in the
“package” of fruit, vegetables, whole grains, or nuts, these chemicals work
together with nutrients and fiber to promote health by acting as
antioxidants, detoxifying enzymes, stimulating the immune system,
regulating hormones, or inactivating bacteria and viruses. More than 25,000
phytochemicals have been identified; often, their actions in the body are
complementary and overlapping.
Phytonutrients
bioactive, nonnutrient plant compounds associated with a reduced risk of chronic diseases.
Phytonutrients are hypothesized to be a large part of the reason why

eating patterns high in plants, namely, fruits and vegetables; whole grains;
legumes; nuts; and tea are associated with lower risk of chronic disease,
such as heart disease, cancer, and diabetes. Box 6.3 lists examples for
phytonutrients and their connection to health.
Examples of Phytonutrients and Their

BOX
Connection to Health
6.3
Lycopene in tomatoes and tomato products may reduce the risk of
prostate cancer.
Lignans in flaxseed and whole grains may reduce the risk of certain kinds
of cancer.
Genistein in soybeans may decrease the risk of breast and uterine cancer.
Isothiocyanates in cruciferous vegetables (broccoli, cabbage, kale, etc.)
may induce detoxification of carcinogens.
Lutein in dark-green leafy vegetables may reduce the risk of age-related
eye diseases.
Resveratrol in red wine and red grape juice may lower the risk of heart
disease by improving blood flow to the heart and preventing blood
clots.
Catechins in green tea may help prevent DNA damage by neutralizing
free radicals.
• At this time, researchers simply do not know all the components in

plants, how they function, which ones are beneficial, which ones are
potentially harmful, and the ideal combination and concentration of
these chemicals to be able to create a pill to substitute for a varied
diet rich in plants.
• More than likely, it is the total package and balance of nutrients and
nonnutritive substances that make fruits and vegetables so healthy.
• Until science catches up to nature, the best advice is to eat a diet rich
in a variety of plants.
Vitamin Supplements
Multivitamin and mineral (MVM) supplements are the most commonly
used dietary supplements among American adults in the United States
(Marra & Bailey, 2018). Depending on the definition of MVM, an
estimated one third of American adults use MVM and among adults age 60
and older the percentage rises to 40 (Kantor et al., 2016). Supplement use is
associated with several sociodemographic variables (Kantor et al., 2016):
• Supplement use increases with age.
• Women are more likely than men to use supplements.
• Use is highest among non-Hispanic white adults.
• Supplement use is highest among the most highly educated.
• Supplement users most often report their health status as excellent.
• “Improve overall health,” “maintain health,” “supplement the diet,”
and “prevent health problems” are the most commonly cited
motivations for general supplement use (Baily et al., 2012).
Think of Marcus. As with healthy adults, studies of

children with autism taking supplements show that the
children most likely to take supplements were less likely to
need them. This may reflect heightened awareness of
nutrition by some families in regard to both food and
supplements. Is too much better than too little?
The shortfall nutrients identified above, namely vitamins A, C, D, E, and

choline, indicate that a high prevalence of inadequate intakes relative to the
DRIs exists across the population and that underconsumption has been
linked to adverse health outcomes (Marra& Bailey, 2018). Many Americans
do not eat the amount and types of foods necessary to meet recommended
nutrient intakes. MVM supplements can bridge the gap in meeting those
nutrient needs.
Although MVM can help Americans consume an adequate intake of
nutrients, they are not a guarantee of good health.
• Consuming nutrients in supplement form increases the risk of
exceeding the UL of some nutrients.
• Supplements have not been shown effective at reducing the risk of
chronic diseases in generally healthy people (Huang et al., 2007).
Table 6.4 summarizes studies that examined the role of vitamin
supplements in chronic disease.
The U.S. Preventative Services Task Force position on the use of
multivitamins is that current evidence is insufficient to assess the balance of
benefits and risks for the prevention of cardiovascular disease or cancer
(U.S. Preventive Services Task Force, 2014). Specially formulated
supplements containing carotenes, vitamin E, and vitamin C have been
found to reduce the risk of developing advanced age-related macular
degeneration (AMD) among people at high risk (see Table 6.4). In general,
groups that may benefit from a multivitamin supplement include the
following:
• Dieters who consume fewer than 1200 cal/day.
• Even with optimal food choices, it may not be possible to
consume adequate amounts of all nutrients on a low-calorie diet.
• Vegans, who eat no animal products, need supplemental vitamin B12
because it is found naturally only in animal products.
• Vegetarians may also need vitamin D if sunlight exposure is
inadequate because the only plant sources of vitamin D are some
fortified margarines, mushrooms exposed to UV light, and some
fortified cereals.
• People with poor appetite or illness or those who intentionally
eliminated one or more food groups from their diet on a regular
basis.
• Older adults. Risk factors in this population include limited food
budget, impaired chewing and swallowing, social isolation, physical
limitations that make shopping or cooking difficult, or a decreased
sense of taste leading to poor appetite.
• It is recommended that people 50 and over consume 2.4 mcg/day
of vitamin B12 through supplements or fortified food.
• Women of childbearing age who may become pregnant. The U.S.
Preventive Services Task Force recommends all women who are
capable of becoming pregnant take a daily supplement containing
400 to 800 mcg of folic acid for the prevention of neural tube
defects (U.S. Preventive Services Task Force, 2017).
• Alcohol-dependent people because alcohol alters vitamin intake,
absorption, metabolism, and excretion; the nutrients most
profoundly affected are thiamin, riboflavin, niacin, folic acid, and
pantothenic acid.
• People who are food insecure, meaning they may not always have
sufficient money or other resources for food for all household
members.
• People with chronic illness or chronic use of a medication that
impairs nutrient absorption or increases nutrient metabolism or
excretion.
Choosing a Supplement
Although there is little scientific evidence to suggest that vitamin
supplements can benefit the average person, there is also little evidence of
harm from low-dose multivitamin or MVM supplements.
• Vitamins work best together and in balanced proportions, so a
multivitamin that provides no more than 100% of the DV is usually
better than single-vitamin supplements that tend to provide doses
much greater than the RDA.
• Pills are not a substitute for healthy food: “supplement” means “add
to,” not “replace.”
• MVM supplements are limited in what they contain. They do not
provide all the health-enhancing compounds found in foods, such
as phytonutrients and fiber.
• The Food and Drug Administration (FDA) requires a standardized
“Supplement Facts” label on all supplements.
• Like the “Nutrition Facts” label, the supplement label is intended
to provide consumers with better information.
• According to the FDA, “high potency” may be used to describe
individual vitamins or minerals that are present at ≥100% of the
Reference Daily Intakes.
• When possible, people should choose an MVM appropriately
tailored to their age, sex, or condition, such as pregnancy. For
instance, MVM for older adults may provide more vitamin D and
vitamin B12 than MVM for younger adults.
How Do You Respond?
Is it better to take vitamin supplements with
meals or between meals? In general, it is better to
take supplements with meals because food enhances the
absorption of some vitamins.
What does “USP” on the vitamin label mean?
USP (U.S. Pharmacopeia) means the product passes tests
for disintegration, dissolution, strength, and purity. It does
not ensure that the supplement is safe or beneficial to
health.
Is price an indication of quality? Should I buy
the most expensive vitamins? No, cost is not an
indication of quality. Large retail chains are high-volume
customers and can demand their own top-quality, private
label supplements that are comparable to brand-name
varieties in content and quality. Content and freshness are
key considerations with vitamins.
REVIEW CASE STUDY
Michael is a 22-year-old college student who lives off campus. He has a

kitchen in his apartment, but he has neither time nor interest in making or
stocking his own food. All three of his daily meals come from fast-food
restaurants. A typical day’s intake is shown to the right.
• What vitamins is Michael probably lacking in his diet? What vitamins is

he probably getting enough of?
• Are there better choices he could make at fast-food restaurants that would
improve his vitamin intake?
• What suggestions would you make for keeping quick and easy food in his
apartment that would improve his vitamin intake without being too much
bother?
• Michael asks, “Can I just take a multivitamin so I don’t have to make
changes in my eating habits?” How would you respond?
Breakfast: Two egg and bacon sandwiches on English muffins, large

coffee with creamer and sugar.
Lunch: Two cheeseburgers with ketchup, large french fries, soft drink,
and cookies.
Dinner: A foot-long submarine with deli meats, cheese, mayonnaise,
lettuce, tomato, onion, and pickles; bag of potato chips; and soft
drink.
Snacks: Chocolate bar, chips and salsa, and popcorn.
STUDY QUESTIONS
1 When developing a teaching plan for a client who is on warfarin

(Coumadin), which of the following foods would the nurse suggest that
the client consume consistently because of their vitamin K content?
a. Vegetable oils, fruit, and seafood
b. Brussels sprouts, cauliflower, and spinach
c. Fortified cereals, whole grains, and nuts
d. Dried peas and beans, wheat germ, and seeds
2 A client asks if it is better to consume folic acid from fortified foods or
from a vitamin pill. What is the nurse’s best response?
a. “It is better to consume folic acid through fortified foods because it
will be better absorbed than through pill form.”
b. “It is better to consume folic acid through vitamin pills because it will
be better absorbed than through fortified foods.”
c. “Fortified foods and vitamin pills have the same form of folic acid, so
it does not matter which source you use because they are both well
absorbed.”
d. “It is best to consume naturally rich sources of folate because that form
is better absorbed than the folic acid in either fortified foods or vitamin
pills.”
3 Which population is at risk for combined deficiencies of thiamin,
riboflavin, and niacin?
a. Pregnant women
b. Vegetarians
c. Alcoholics
d. Athletes
4 Which vitamin is given in large doses to facilitate wound and bone
healing?
a. Vitamin A
b. Vitamin D
c. Vitamin C
d. Niacin
5 Which statement indicates that the client understands the instructions
given about using a vitamin supplement?
a. “USP on the label guarantees safety and effectiveness.”
b. “Natural vitamins are always better for you than synthetic vitamins.”
c. “Vitamins are best absorbed on an empty stomach.”
d. “Taking a multivitamin cannot fully make up for poor food choices.”
6 The client asks if taking supplements of beta carotene will help reduce
risk of cancer. What is the nurse’s best response?
a. “Supplements of beta carotene may help reduce the risk of heart
disease but not of cancer.”
b. “Supplements of beta carotene have not been shown to lower the risk
of cancer and may even promote cancer in certain people.”
c. “Although evidence is preliminary, taking beta-carotene supplements
is safe and may prove to be effective against cancer in the future.”
d. “Natural supplements of beta carotene are generally harmless;
synthetic supplements of beta carotene may increase cancer risk and
should be avoided.”
7 A client is diagnosed with pernicious anemia. What vitamin are they not
absorbing?
a. Folic acid
b. Vitamin B6
c. Vitamin B12
d. Niacin
8 A client with hyperlipidemia is prescribed niacin. The client asks if they
can simply include more niacin-rich foods in their diet in order to forgo
niacin in pill form. What is the nurse’s best response?
a. “The dose of niacin needed to treat hyperlipidemia is far more than can
be consumed through eating a niacin-rich diet.”
b. “You can’t get the therapeutic form of niacin through food.”
c. “Niacin from food is not as well absorbed as niacin from pills.”
d. “If you are able to consistently choose niacin-fortified foods in your
diet, then your doctor may allow you to forgo the pills and rely on
dietary sources of niacin.”
CHAPTER SUMMARY VITAMINS

Vitamins do not provide calories but are involved in the metabolism of
energy.
• Only small amounts are needed: microgram or milligram quantities.
• They are essential in the diet because they cannot be made by the body
or they are synthesized in inadequate amounts.
• Fortification and enrichment have virtually eliminated vitamin
deficiencies in healthy Americans.
• If a variety of nutritious foods are consumed, then vitamin intake will
likely be adequate for most people.
• Vitamins are organic compounds that are soluble in either water or fat.
Their solubility determines how they are absorbed, transported
through the blood, stored, and excreted.
Fat-Soluble Vitamins
Vitamins A, D, E, and K are the fat-soluble vitamins. They do not need
to be consumed daily because they are stored in the liver and adipose
tissue.
Vitamin A is preformed or from the precursor beta carotene, and
involved in vision, growth, development, and immune system
functioning. Preformed vitamin A is toxic in large amounts and can
cause birth defects during pregnancy.
Vitamin D naturally occurs in few foods. A major source is endogenous
synthesis from sunlight on the skin. Lack of adequate sunlight is the
biggest cause of deficiency. It maintains serum calcium and
phosphorus concentrations to maintain bone integrity. Excessive
intakes can cause hypercalcemia, hypercalciuria, and vascular and
soft-tissue calcification.
Vitamin E acts as an antioxidant to protect vitamin A and
polyunsaturated fats. Richest sources are vegetable oils, green leafy
vegetables, and fortified cereals. It is relatively nontoxic.
Vitamin K is a coenzyme for reactions involved in blood clotting and
bone metabolism. It is synthesized by intestinal microbiota. Dietary
sources include green leafy vegetables, other vegetables, and eggs.
Certain anticoagulants and antibiotics interfere with vitamin K
metabolism or synthesis.
Water-Soluble Vitamins
The B-complex vitamins and vitamin C are water-soluble. A daily intake
is necessary because they are generally not stored in the body. They are
considered nontoxic because they are excreted when consumed in excess.
Thiamin (B1), riboflavin (B2), and niacin (B3) share similar sources
(e.g., refined grains) and function as coenzymes in energy
metabolism. Americans consume more than required. People who
abuse alcohol are most at risk for deficiency.
Vitamin B6 is involved in amino acid and fatty acid metabolism and
helps produce several body compounds. It is stored extensively in
muscle tissue. Large doses over long periods of time cause
neurological symptoms.
Folate is the umbrella name for food form (folate) and synthetic form
(folic acid) that occurs in fortified foods and supplements. It acts as a
coenzyme in DNA synthesis. It helps prevent neural tube defects
when taken in adequate amounts before conception and through the
first trimester.
Vitamin B12 occurs only in animal products. It needs IF in the stomach
for absorption. The liver stores may last 5–10 years. Deficiency
symptoms include anemia and neurologic impairments that can be
permanent.
Other B vitamins, such as pantothenic acid and biotin, are widespread
in the diet and act as coenzymes in energy metabolism. It is assumed
that the average American diet provides adequate amounts of both.
Choline is often categorized with B vitamins. It is necessary for
structural integrity of cell membranes. The best sources are milk,
liver, and eggs. The emulsifier lecithin provides choline.
Vitamin C is important for collagen formation, wound healing, and
immune system functioning and acts as an antioxidant. Best sources
are citrus fruits and juices. Scurvy can occur after a month of poor
vitamin C intake and can be fatal but is quickly and easily cured with
supplements.
Vitamins in Health Promotion

Vitamin needs should be met primarily from food, not from supplements.
Shortfall nutrients and vitamin-rich eating patterns: Vitamins that
are under-consumed by American adults are vitamins A, D, E, C, and
choline.
• Key food groups that supply these vitamins—vegetables, fruits, whole
grains, and dairy—are under-consumed by the majority of Americans.
• To obtain adequate amounts of these shortfall vitamins, Americans are
urged to eat more fruit, preferably whole fruits; more vegetables in
greater variety; whole grains in place of refined grains; more seafood;
vitamin A- and D-fortified dairy products; and oils in place of solid
fats.
Phytonutrients. Phytonutrients are bioactive plant chemicals that
promote health by various methods, such as acting as antioxidants,
detoxifying enzymes, stimulating the immune system, and regulating
hormones.
• Not enough is known about phytonutrients to elevate them to the
status of essential nutrients.
• Different plants have different phytochemicals: Eating a variety of
plants provides a variety of phytochemicals.
Vitamin supplements: More than half of American adults take a
supplement. Usage increases among older people. Most people who
take them say they have excellent health but take supplements to
improve their health.
• MVM supplements can bridge the gap in meeting vitamin needs in
people who do not have a vitamin-rich eating pattern. They do not
provide all the healthful substances found in food.
• Vegans, older adults, people with certain chronic diseases, and people
dependent on alcohol are among the groups who may benefit from
MVM.
• Taking an MVM that provides no more than 100% of the DV is
usually better than taking individual nutrients.
• People should use supplements tailored to their sex, age, and condition
(e.g., pregnancy).
• More is not better. Studies using supplements to reduce the risk of
chronic disease generally have not shown benefits, with the exception
of reducing the risk of AMD in certain groups.
Figure sources: shutterstock.com/Happy Zoe, shutterstock.com/Gts, and
shutterstock.com/RudchenkoLiliia.

book at
Websites
Dietary Reference Intakes from the Institute of Medicine at www.nap.edu
National Institutes of Health Office of Dietary Supplements at ods.od.nih.gov
Produce for Better Health Foundation at www.fruitsandveggiesmorematters.org
U.S. Department of Agriculture Nutrient Data Laboratory at fnic.nal.usda.gov/food-
composition/usda-nutrient-data-laboratory
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Chapter Water and Minerals
7
Myra Johnson
Myra is a healthy, active 83-year-old woman who is
conscientious about healthy eating and exercise. She
read about the many health benefits from using aloe
to detox and decided to give them a try. Over a period
of diligent use, she developed diarrhea but passed it
off as part of the detox process. Her family took her
to the emergency department when she exhibited
what they thought were signs of a stroke: weakness,
exhaustion, and delirium. What may be causing her
symptoms?
Learning Objectives
1 Discuss a healthy person’s fluid requirement.

2 Give examples of mechanisms by which the body maintains mineral
homeostasis.
3 Identify sources of minerals.
4 Discuss functions of minerals.
5 Explain why Americans should eat less sodium.
6 Discuss the potential benefits from increasing calcium and potassium
intake.
7 Describe the Dietary Approaches to Stop Hypertension (DASH) diet.
Body fluids consist of water and chemicals. Among those chemicals are
inorganic elements that arise from the earth’s crust, known as minerals.
Although minerals account for only about 4% of the body’s total weight,
they are found in all body fluids and tissues. Some minerals are electrolytes
that dissociate (dissolve) into ions in water and are able to conduct
electricity. Although minerals—including electrolytes—are micronutrients,
they are vital for life and essential in the diet.
This chapter discusses water, electrolytes, major minerals, and trace
minerals. Minerals in health promotion are presented.
Inorganic
not containing carbon or concerning living things.
WATER
Water is fundamental to life. It is the single largest constituent of the human

body, averaging approximately 60% of the total body weight. It is the
medium in which all biochemical reactions take place. Although most
people can survive 6 weeks or longer without food, death occurs in a matter
of days without water.
Water occupies essentially every space within and between body cells
and is involved in virtually every body function. Water performs the
following functions:
• Provides shape and structure to cells: Approximately two thirds of
the body’s water is located within cells (intracellular fluid). Muscle
cells have a higher concentration of water (70% to 75%) than fat,
which is only about 25% water. Men generally have more muscle
mass than women and, therefore, have a higher percentage of body
water.
• Regulates body temperature: Because water absorbs heat slowly, the
large amount of water contained in the body helps to maintain body
temperature homeostasis despite fluctuations in environmental
temperatures. Evaporation of water (sweat) from the skin cools the
body.
• Aids in the digestion and absorption of nutrients: Approximately 7
to 9 L of water is secreted in the gastrointestinal (GI) tract daily to
aid in digestion and absorption. Except for the approximately
100 mL of water excreted through the feces, all of the water
contained in the GI secretions (saliva, gastric secretions, bile,
pancreatic secretions, and intestinal mucosal secretions) is
reabsorbed in the ileum and colon.
• Transports nutrients and oxygen to cells: By moistening the air sacs
in the lungs, water allows oxygen to dissolve and move into blood
for distribution throughout the body. Approximately 92% of blood
plasma is water.
• Serves as a solvent for vitamins, minerals, glucose, and amino
acids: The solvating property of water is vital for health and
survival.
• Participates in metabolic reactions: For instance, water is used in
the synthesis of hormones and enzymes.
• Eliminates waste products: Water helps to excrete body wastes
through urine, feces, and expirations.
• Is a major component of mucus and other lubricating fluids: Water
reduces friction in joints where bones, ligaments, and tendons come
in contact with each other, and it cushions contacts between internal
organs that slide over one another.
Water Balance
Water balance is the dynamic state between water output and water intake.
Under normal conditions, output and intake are approximately equal (Fig.
7.1).
Figure 7.1 ▲ Water balance approximations.
Water Output
On average, adults lose approximately 1750 to 3000 mL of water daily.
Extreme environmental temperatures (very hot or very cold), high altitude,
low humidity, and strenuous exercise increase insensible water losses from
respirations and the skin. Water evaporation from the skin is also increased
by prolonged exposure to heated or recirculated air, for example, during
long airplane flights. Sensible water losses from urine and feces make up
the remaining water loss. Because the body needs to excrete a minimum of
500 mL of urine daily to rid itself of metabolic wastes, the minimum daily
total fluid output is approximately 1500 mL. To maintain water balance,
intake should approximate output.
Insensible Water Loss

immeasurable losses.
Sensible Water Loss
measurable losses.
Water Intake
Liquids, solid foods, and metabolism are all sources of water. Water intake
averages about 2.5 L/day, of which approximately 80% is from fluids and
20% from solid food (Institute of Medicine [IOM], 2005). Except for oils,
almost all foods contain water, with fruits and vegetables providing the
most (Fig. 7.2). Depending on total calorie intake, the body produces
approximately 250 to 350 mL of metabolic water daily from the
catabolism of carbohydrates, protein, and fat.
Figure 7.2 ▲ Percentage of water content of various foods.
Metabolic Water
water produced as a by-product from the breakdown of carbohydrates, protein, and fat for energy.
Water Recommendations
Water is an essential nutrient because the body cannot produce as much
water as it needs. There is no Recommended Dietary Allowance (RDA) for
water because of insufficient evidence linking a specific amount of water
intake to health; actual requirements vary depending on diet, physical
activity, environmental temperatures, and humidity. The Adequate Intake
(AI) for total water, which includes drinking water, water in beverages, and
water in food, is based on the median total water intake from U.S. food
consumption survey data (IOM, 2005).
• For men age 19 and older, the AI is 3.7 L/day, which includes 3 L as
fluids.
• For women of the same age, the AI is 2.7 L, which includes
approximately 2.2 L from fluids.
• Similar to AIs set for other nutrients, daily intakes below the AI may
not be harmful to healthy people because normal hydration is
maintained over a wide range of intakes. Amounts higher than the
AI are recommended for rigorous activity in hot climates.
• Because the body cannot store water, it should be consumed
throughout the day.
For healthy people, the universal, age-old advice has been to drink at least
eight 8-oz glasses of water daily.
• Although that may be excellent advice, there is little scientific
evidence to support this recommendation (Valtin, 2002).
• For healthy people, hydration is unconsciously maintained with ad
lib access to water. In healthy adults, thirst is usually a reliable
indicator of water need, and fluid intake is assumed to be adequate
when the color of urine produced is pale yellow.
• In some conditions and for some segments of the population, the
sensation of thirst is blunted and may not be a reliable indicator of
need. For the senior adults and children, and during hot weather or
strenuous exercise, drinking fluids should not be delayed until the
sensation of thirst occurs because by then fluid loss is significant.
Estimating Fluid Requirements

Box 7.1 outlines several methods for estimating fluid requirements.
However, according to the Academy of Nutrition and Dietetics Evidence
Analysis Library, there is no evidence to validate any of these equations
despite their widespread use in clinical practice (Academy of Nutrition and
Dietetics, Evidence Analysis Library, 2007).
BOX Methods to Estimate Fluid Needs
7.1
Method
• Simple method based on kg of body weight 30 mL/kg body weight for
average adults
Example: A 70-kg person needs 2100 mL/day
(70 kg × 30 mL/kg = 2100 mL/day)
• Alternative method based on kilogram of body weight
• Provide 1500 mL for the first 20 kg of weight and 20 mL/kg for each remaining kilograms.
Example: A 70-kg person needs 2500 mL/day
1500 mL + (50 kg
remaining × 20 mL/kg) = 1500 mL + 1000 mL = 2500 mL
• RDA method
• 1 mL/cal consumed
Example: A person consuming 2000 cal/day needs
2000 mL/day.
(2000 cal/day × 1 mL/cal = 2000 mL/day)
• Fluid balance method
• Urine output/d + 500 mL
Excessive Fluid Intake

A chronic high intake of water has not been shown to cause adverse effects
in healthy people who consume a varied diet as long as intake approximates
output (IOM, 2005). An excessive water intake may cause hyponatremia,
but it is rare in healthy people who consume a typical diet. Athletes in
endurance events who drink too much water, fail to replace lost sodium, or
both are at risk of hyponatremia. See Table 7.1 for excess fluid related to
clinical conditions.
Table Causes, Signs and
Symptoms, and Treatment
7.1 of Fluid, Sodium,
and Potassium Imbalances
Inadequate Fluid Intake

An inadequate intake of water can lead to dehydration, characterized by
impaired mental function, impaired motor control, increased body
temperature during exercise, increased resting heart rate when standing or
lying down, and an increased risk of life-threatening heat stroke. A net
water loss of 1% to 2% of body weight causes thirst, fatigue, weakness,
vague discomfort, and loss of appetite. A loss of 7% to 10% leads to
dizziness, muscle spasticity, loss of balance, delirium, exhaustion, and
collapse. If left untreated, dehydration ends in death.
Clinical situations in which water losses are increased—and thus water
needs are elevated—include vomiting, diarrhea, fever, thermal injuries,
uncontrolled diabetes, hemorrhage, certain renal disorders, and the use of
drainage tubes (Table 7.1).
Recall Myra. She lost excessive amounts of fluid from

diarrhea and is diagnosed with dehydration. Why didn’t she
feel thirsty as she became dehydrated?
FLUID AND ELECTROLYTE

BALANCE
Fluids in each body compartment are regulated by membranes (e.g., cell

membranes and capillary membranes), the concentration of electrolytes,
and hydrostatic pressure. In all electrolyte solutions, the number of negative
and positive charges is equal. If an anion enters a cell, a cation must also
enter or another anion must leave in order to maintain electrical neutrality.
This balance of negative and positive ions occurs both within cells and
outside cells, although the amounts and proportions of ions differ in each
compartment.
Cations are positively charged ions such as sodium and potassium.
Anions, such as chloride, are negatively charged. These electrolytes help
regulate nerve and muscle function, acid–base balance, and water balance.
Electrolytes Attract Water
Sodium and chloride are found primarily in extracellular fluid and
potassium and phosphates are located mostly in the intracellular fluid. The
fluid levels within each compartment are maintained by the concentration
of electrolytes in each. If the concentration of electrolytes is high, fluid
moves into that compartment through the process of osmosis. Electrolytes
can actively move in and out of cells to adjust fluid levels because
electrolytes attract water.
Electrolyte Balance
Electrolyte concentrations in the body are held at a nearly constant level by
feedback mechanisms involving the kidneys. The kidneys maintain
electrolyte balance by filtering electrolytes and water from the blood and
excreting excesses into the urine. Electrolyte imbalances, and
accompanying fluid imbalance, occur when the body is unable to
compensate for deficits or excesses, such as in the case of dehydration or
over hydration; the use of certain medications; heart, kidney, or liver
disorders; or inappropriate IV or enteral feedings. Table 7.1 summarizes
imbalances of sodium and potassium.
UNDERSTANDING MINERALS
Unlike the macronutrients and vitamins, minerals are inorganic elements

from the earth, not organic substances from plants or animals. Minerals do
not undergo digestion nor are they broken down or rearranged during
metabolism. Although they combine with other elements to form salts (e.g.,
sodium chloride) or with organic compounds (e.g., iron in hemoglobin),
they always retain their chemical identities. Unlike vitamins, minerals are
not destroyed by light, air, heat, or acids during food preparation. Minerals
are lost only when they leach from foods soaked in water. When food is
completely burned, minerals are the ash that remains.
Mineral Classifications
The classification as major minerals or trace minerals (elements) is based
on the quantity in the body and amount needed, not by their importance.
Both groups are essential for life.
• Calcium, phosphorus, magnesium, sulfur, sodium, potassium, and
chloride are considered major minerals because they are present in
the body in amounts greater than 5 g (the equivalent of 1 tsp).
• Iron, iodine, zinc, selenium, copper, manganese, fluoride,
chromium, and molybdenum are classified as trace minerals, or
trace elements, because they are present in the body in amounts less
than 5 g.
• As many as 30 other potentially harmful minerals are present in the
body, including lead, gold, and mercury. Their presence appears to
be related to environmental contamination.
General Functions
Minerals function to provide structure to body tissues and to regulate body
processes such as fluid balance, acid–base balance, nerve cell transmission,
muscle contraction, and vitamin, enzyme, and hormonal activities (Table
7.2).
Table General
Functions of
7.2 Minerals
Functions Examples
Functions Examples
Provide structure Calcium, phosphorus, and magnesium provide
structure to bones and teeth.
Phosphorus, potassium, iron, and sulfur provide
structure to soft tissues.
Sulfur is a constituent of skin, hair, and nails.
Fluid balance Sodium, potassium, and chloride maintain fluid
balance.
Acid–base balance Sodium hydroxide and sodium bicarbonate are
part of the carbonic acid–bicarbonate system
that regulates blood pH.
Phosphorus is involved in buffer systems that
regulate kidney tubular fluids.
Nerve cell Sodium and potassium are involved in
transmission and transmission of nerve impulses.
muscle contraction Calcium stimulates muscle contractions.
Sodium, potassium, and magnesium stimulate
muscle relaxation.
Vitamin, enzyme, Cobalt is a component of vitamin B12.
and hormone Magnesium is a cofactor for hundreds of enzymes.
activity Iodine is essential for the production of thyroxine.
Chromium enhances the action of insulin.
Mineral Balance
The body has several mechanisms by which it maintains mineral balance,
depending on the mineral involved, such as the following:
• Releasing minerals from storage for redistribution: Calcium is
released from the bone to maintain serum levels when intake is
inadequate.
• GI absorption: For example, iron absorption increases when the
body is deficient.
• Urinary excretion: For instance, virtually all of the sodium
consumed in the diet is absorbed. The only way the body can rid
itself of excess sodium is to increase urinary sodium excretion. For
most people, the higher the intake of sodium, the greater is the
amount of sodium excreted in the urine.
Mineral Toxicities
Minerals that are easily excreted, such as sodium and potassium, do not
accumulate to toxic levels in the body under normal circumstances. Stored
minerals can produce toxicity symptoms when intake is excessive, but
excessive intake is not likely to occur from eating a balanced diet. Instead,
mineral toxicity is related to excessive use of mineral supplements,
environmental or industrial exposure, human errors in commercial food
processing, or alterations in metabolism. For instance, in 2008, the most
serious selenium toxicity outbreak that has ever occurred in the United
States was caused by an improperly manufactured dietary supplement that
contained 200 times the labeled concentration of selenium (Morris & Crane,
2013).
Mineral Interactions
Mineral balance is influenced by hundreds of interactions that occur among
minerals and between minerals and other dietary components or
medications. Mineral status must be viewed as a function of the total diet,
not just from the standpoint of the quantity consumed. Examples follow:
• Vitamin D and lactose promote calcium absorption.
• Vitamin C enhances the absorption of nonheme iron.
• High-dose iron supplements can impair zinc absorption.
• High-dose zinc supplements can inhibit copper absorption.
• Corticosteroids can deplete calcium.
• Thiazide diuretics, proton pump inhibitors, and some antibiotics can
deplete magnesium.
Sources of Minerals
Key minerals are found in all food groups; items within each group vary in
the amount and kind of minerals they provide (Table 7.3).
• Generally, unrefined or unprocessed foods have more minerals than
refined foods.
• Trace mineral content varies with the content of soil from which the
food originates.
• Within most food groups, processed foods are high in sodium and
chloride.
• Drinking water contains varying amounts of calcium, magnesium,
and other minerals; sodium is added to soften water. Fluoride may
be a natural or added component of drinking water.
Table Major Sourcesa of

Selected Minerals by
7.3 Food Groupb
Mineral Supplements
Mineral supplements, alone or combined with vitamins, contribute to
mineral intake.
• To the greatest extent possible, nutrient needs should be met through
food, not through supplements.
• The degree to which a supplement can improve nutrient adequacy
depends on the nutrients contained in the supplement. For instance,
multivitamin and mineral supplements often contain low amounts of
potassium, calcium, and magnesium (Marra & Bailey, 2018).
• The effectiveness of mineral supplements is affected by their form
and the amount of the elemental mineral in the mineral salt (Marra
& Bailey, 2018). For instance, calcium carbonate has the highest
concentration of calcium but needs an acidic medium for optimal
absorption and maximum absorption occur at doses ≤500 mg.
MAJOR ELECTROLYTES
Sodium, chloride, and potassium are major minerals that are also major
electrolytes in the body. Table 7.4 highlights recommended intakes, sources,
functions, deficiency symptoms, and toxicity symptoms of these minerals.
Additional features follow.
Table Summary of
Major
7.4 Electrolytes
Electrolyte and Deficiency/Toxicity

Sodium (Na) Fluid and electrolyte Deficiency
Adult AI: balance, acid– Rare, except with
19 y and older: 1.5 g base balance, chronic diarrhea or
UL: not determined maintains muscle vomiting and
CDRR: irritability, certain renal
14 y and older: regulates cell disorders; nausea,
Reduce intake if membrane dizziness, muscle
above 2300 permeability and cramps, and apathy
mg/day nerve impulse
• Processed foods; transmission Toxicity
Hypertension and
canned meat,
edema
vegetables, and
soups; convenience
foods; and
restaurant and fast
foods
Potassium (K) Major cation of Deficiency
Adult AI: intracellular fluid Muscular weakness,
Men 19 y and older: Maintains fluid paralysis, anorexia,
3400 mg balance, and confusion
Women 19 y and maintains acid– (occurs with
older: 2600 mg base balance, dehydration)
No UL transmits nerve Toxicity (from
No CDRR impulses, supplements/drugs)
• Baked potato catalyzes
metabolic Muscular weakness,
with skin,
reactions, aids in vomiting
canned tomato
products, carbohydrate
sweet metabolism and
potatoes, protein synthesis,
prunes, clams, controls skeletal
molasses, muscle
contractility
milk, yogurt,
tomato juice,
prune juice,
legumes,
bananas,
artichokes,
fish, avocados,
raisins,
spinach,
kiwifruit
Chloride (Cl) Fluid and electrolyte Deficiency
Adult AI: 19–50 y: balance, acid– Rare, may occur
2.3 g base balance, secondary to
50–70 y: 2.0 g component of chronic diarrhea or
>70 y: 1.8 g hydrochloric acid vomiting and
Adult UL: 3.6 g in stomach certain renal
1 tsp salt = 3600 disorders: muscle
mg Cl cramps, anorexia,
apathy
Same sources as
• sodium
Toxicity
Normally harmless;
can cause vomiting
Think of Myra. The speed with which her food moved

through the GI tract interfered with the absorption of fluid,
electrolytes, and nutrients. She was given IV replacement
fluid, an antidiarrheal medication, and oral fluids. What
should Myra understand about the need for “detox” and its
potential risks?
Sodium
By weight, salt (sodium chloride) is approximately 40% sodium; 1 tsp of
salt provides 2325 mg of sodium. Of the total average intake of sodium
among U.S. adults (Harnack et al., 2017).
• approximately 71% is sodium added to food outside the home, such
as from processing or at eating establishments. Box 7.2 gives
examples of sodium additives added to foods.
• only 14% is sodium that occurs naturally in foods such as milk,
meat, poultry, and vegetables.
• 5.6% is salt added to food during cooking.
• 5% is from salt added at the table.
• less than 0.5% comes from home tap water consumed as a beverage
and dietary supplements.
Almost 98% of all sodium consumed is absorbed; yet, humans are able to
maintain homeostasis over a wide range of intakes, largely through urinary
excretion.
• A salty meal causes a transitory increase in serum sodium, which
triggers thirst.
• Drinking fluids dilutes the sodium in the blood to normal
concentration, even though the volume of both sodium and fluid is
increased.
• The increased volume stimulates the kidneys to excrete more
sodium and fluid together to restore normal blood volume.
• Conversely, low blood volume or low extracellular sodium
stimulates the hormone aldosterone to increase sodium reabsorption
by the kidneys.
• In people who have minimal sweat losses, sodium intake and
sodium excretion are approximately equal.
The Dietary Reference Intake (DRI) recommendations for sodium were
recently revised since being established in 2005 (Food and Nutrition Board,
National Academies of Sciences, Engineering, and Medicine, 2019).
• The AI for sodium is 1500 mg for everyone aged 14 and older,
which is less than half of the average sodium intake (see following
section).
• The Dietary Guidelines recommend sodium intake to be less than
2300 mg/day for everyone aged 14 and older (U.S. Department of
Agriculture [USDA] & U.S. Department of Health and Human
Services [USDHHS], 2020). This is the same level of intake cited in
the new DRI category, Chronic Disease Risk Reduction (CDRR),
which was set based on evidence of the benefits of lowering sodium
intake on cardiovascular disease (CVD) risk, hypertension risk,
systolic blood pressure, and diastolic blood pressure (Food and
Nutrition Board, National Academies of Sciences, Engineering, and
Medicine, 2019).
Wide variations in sodium intake exist between cultures and between

individuals within a culture, based on the amount of processed foods
consumed. On average, Americans consume far more sodium than needed
or recommended.
• Average intakes of sodium for people ages 1 and older is 3393
mg/day, with a range of approximately 2000 to 5000 mg/day
(USDA & USDHHS, 2020).
• Top sources of sodium in the U.S. population ages 1 and older are
depicted in Figure 7.3.
BOX Examples of Sodium Additives

7.2
To enhance flavor
Sodium chloride
Monosodium glutamate
Soy sauce
Teriyaki sauce
To preserve freshness
Brine
Sodium sulfite (for dried fruits)
To prevent the growth of yeast and/or bacteria

Sodium benzoate
Sodium nitrate or sodium nitrite
Sodium lactate
Sodium diacetate
To prevent the growth of mold
Sodium propionate
As an antioxidant
Sodium erythorbate
As a sweetener
Sodium saccharin
As a binder/thickener
Sodium caprate
Sodium caseinate
As a leavening agent
Sodium bicarbonate (baking soda)
Baking powder
As a stabilizer
Sodium citrate
Disodium phosphate
Potassium
Like sodium, the DRIs for potassium were updated in 2019 (Food and
Nutrition Board, National Academies of Sciences, Engineering, and
Medicine, 2019). As with all AIs, they are estimates for an intake level in
apparently healthy people rather than an estimate of potassium requirement.
• Due to a lack of a specific indicator of potassium adequacy, the AIs
are based on the highest median potassium intake of adults with
normal blood pressure and no reported history of CVD across two
nationally representative surveys (Food and Nutrition Board,
National Academies of Sciences, Engineering, and Medicine, 2019).
• The newest AI reflects an overall decrease for people age 1 and
older.
• Despite moderately strong evidence that potassium supplements
lower blood pressure, especially in hypertensive adults, a CDRR,
which would have identified the intake level below which chronic
disease risk increases, was not established. This is because of
unexplained inconsistency in the evidence, a lack of intake–response
relationship, and limited evidence for relationships between
potassium intake and chronic disease endpoints.
• An Upper Limit has not been set because in healthy people high
intake increases urinary losses, not serum levels.
Chloride
Because almost all the chloride in the diet comes from salt (sodium
chloride), the AI for chloride is set at a level equivalent (on a molar basis)
to that of sodium. Unlike sodium, the DRIs for chloride have not changed
since they were established in 2005.
• The AI for adults ages 19 to 50 is 2.3 g/day, the equivalent to 1500
mg sodium.
• Sodium and chloride share dietary sources, conditions that cause
them to become depleted in the body, and signs and symptoms of
deficiency.
MAJOR MINERALS
The remaining major minerals are calcium, phosphorus, magnesium, and

sulfur. Table 7.5 highlights recommended intakes, sources, functions,
deficiency symptoms, and toxicity symptoms of these minerals. Additional
features follow.
Table Summary of
7.5 Major Minerals
Deficiency/Toxicity
Signs and
Mineral and Sources Functions Symptoms
Deficiency/Toxicity
Signs and
Calcium (Ca) Bone and teeth Deficiency
Adult RDA formation and Children: impaired
Men: maintenance, growth
19–70 y: 1000 mg blood clotting, Adults:
>70: 1200 mg nerve osteoporosis
Women: transmission, Toxicity
19–50 y: 1000 mg muscle Constipation,
51 and older: 1200 mg contraction and increased risk
Adult UL: relaxation, cell of renal stone
19–50 y: 2500 mg membrane formation,
>50 y: 2000 mg permeability, impaired
blood pressure absorption of
• Milk, yogurt, hard
natural cheese, iron and other
pasteurized minerals
processed
American cheese,
bok choy, broccoli,
Chinese/Napa
cabbage, collards,
kale, okra, turnip
greens, fortified
breakfast cereal,
fortified orange
juice, legumes,
fortified soy milk,
almonds
• Less well-absorbed
sources: spinach, beet
greens, Swiss chard
Deficiency/Toxicity
Signs and
Phosphorus (P) Bone and teeth Deficiency
Adult RDA formation and Unknown
Men and women: 700 mg maintenance, Toxicity
Adult UL: acid–base Low blood calcium
70 y: 4 g/day balance, energy
>70 y: 3 g/day metabolism,
cell membrane
• All animal
structure,
products (meat,
poultry, eggs, regulation of
hormone and
milk), ready-to-eat
cereal, dried peas coenzyme
activity
and beans; bran
and whole grains;
raisins, prunes,
dates
Deficiency/Toxicity
Signs and
Magnesium (Mg) Bone formation: Deficiency
Adult RDA cofactor for Weakness,
Men: >300 enzymes; confusion;
19–30 y: 400 mg involved in growth failure
>30 y: 420 mg muscle and in children
Women: nerve function, Severe deficiency:
19–30 y: 310 mg protein convulsions,
>30 y: 320 mg synthesis, blood hallucinations,
Adult UL: 350 mg/day glucose control, tetany
from supplements only blood pressure Toxicity
(does not include regulation, No toxicity
intake from food and RNA and DNA demonstrated
water) synthesis from food
Supplemental Mg
• Spinach, beet
greens, okra, Brazil can cause
diarrhea,
nuts, almonds,
cashews, bran nausea, and
cramping.
cereal, dried peas
Excessive Mg from
and beans, halibut,
magnesium in
tuna, chocolate,
Epsom salts
cocoa
causes diarrhea
Sulfur(S) Component of Deficiency
No recommended intake disulfide Unknown
or UL bridges in Toxicity
proteins; In animals,
• All protein foods (meat,
component of excessive
poultry, fish, eggs, milk,
biotin, thiamin, intake of sulfur-
dried peas and beans,
nuts) and insulin containing
amino acids
impairs growth.
Calcium
Calcium is the most plentiful mineral in the body, making up about half of
the body’s total mineral content.
• Almost all of the body’s calcium (99%) is found in bones and teeth,
where it combines with phosphorus, magnesium, and other minerals
to provide rigidity and structure.
• Bone tissue serves as a large, dynamic reservoir that releases
calcium to maintain constant concentrations of calcium in blood,
muscle, and intercellular fluids when dietary intake of calcium is
inadequate.
• Continuous remodeling of bone occurs naturally throughout life as
calcium is deposited and resorbed.
• The balance between bone formation and bone breakdown changes
with aging. From birth through adolescence, bone formation
exceeds bone breakdown. In young adults, the processes occur at
approximately the same rate. After the age of about 30, net bone
loss occurs in all people.
• A high calcium intake may help maximize bone density.
Calcium balance—or, more accurately, calcium balance in the blood—is
achieved through the action of vitamin D and hormones.
• When blood calcium levels fall, the parathyroid gland secretes
parathormone (PTH), which promotes calcium reabsorption in the
kidneys and stimulates the release of calcium from bones.
• Vitamin D has the same effects on the kidneys and bones and
additionally increases the absorption of calcium from the GI tract.
• Together, the actions of PTH and vitamin D restore low blood
calcium levels to normal, even though bone calcium content may
fall.
• A chronically low calcium intake compromises bone integrity
without affecting blood calcium levels. When blood calcium levels
are too high, the thyroid gland secretes calcitonin, which promotes
calcium deposition in the bone using excess calcium from the blood.
Phosphorus
After calcium, the most abundant mineral in the body is phosphorus.
Approximately 85% of the body’s phosphorus is combined with calcium in
bones and teeth. The rest is distributed in every body cell. As with calcium,
phosphorus metabolism is regulated by vitamin D and PTH. Normally,
about 40% to 60% of natural phosphorus from food sources is absorbed.
Animal proteins, dairy products, and legumes are rich natural sources of
phosphorus.
Phosphate food additives—which are used to extend shelf life, improve
taste, improve texture, or retain moisture—are present in many processed
foods.
• Phosphate additives are estimated to contribute approximately 10%
to 50% of phosphorus intakes in Western countries (Itkonen et al.,
2018). Their absorption rate is approximately 70% (Scanni et al.,
2014).
• Most Americans consume more phosphorus than recommended.
While some studies have found an association between high
phosphorus intakes and adverse effects on cardiovascular, kidney,
and bone health as well as increased risk of death (Chang et al.,
2014), others have found no link between high intakes and increased
disease risk (National Institutes of Health [NIH], Office of Dietary
Supplements [ODS], 2019a).
• Phosphate content is not listed on the “Nutrition Facts” label, so
consumers are not able to compare brands to find lower phosphate
choices.
Magnesium
Magnesium is the fourth most abundant mineral in the body; approximately
50% to 60% of the body’s magnesium content is deposited in bone with
calcium and phosphorus and most of the rest is stored in various soft tissues
and muscles. Less than 1% of total magnesium is in the blood, which is
tightly regulated and not indicative of total body magnesium. The kidneys
maintain magnesium balance by altering the amount excreted in the urine.
The National Health and Nutrition Examination Survey (NHANES)
data for 2015 to 2016 show the mean intake of magnesium for adults age 20
and older is less than the RDAs (USDA & Agricultural Research Service
[ARS], 2018). However, intake data do not include the magnesium content
of water, which is significant in water classified as “hard.” However, as
much as 80% to 90% of the magnesium in food is lost in processing (de
Baaij et al., 2015). For instance, an average slice of white (refined) bread
provides 7 mg of magnesium compared to 24 mg found in whole wheat
bread.
Symptomatic magnesium deficiency from a low intake in otherwise
healthy people is uncommon because the kidneys limit urinary excretion.
• Magnesium deficiency is more commonly the result of certain
disorders that increase urinary excretion of magnesium, such as type
2 diabetes, or impair its absorption, such as celiac disease and small
intestine bypass or resection.
• People who abuse alcohol are at risk of magnesium deficiency
secondary to poor intake, altered absorption, and/or excess urinary
excretion.
• Aging is associated with lower magnesium intake, decreased
absorption, and increased excretion.
• Certain medications, such as thiazide diuretics, proton pump
inhibitors, and some antibiotics, can lead to magnesium depletion
(de Baaij et al., 2015).
Recall Myra. Her fluid and electrolyte status was the

immediate priority. However, general malabsorption of
nutrients also occurred due to the diarrheal effect of the aloe.
What would you tell Myra about what she should eat and
how much fluid she should consume? What strategies may
help her drink enough fluid given that she doesn’t
experience thirst?
Sulfur
Sulfur does not function independently as a nutrient, but it is a component
of biotin, thiamin, and the amino acids methionine and cysteine.
• The proteins in skin, hair, and nails are made more rigid by the
presence of sulfur.
• Although food and various sources of drinking water provide
significant amounts of sulfur, the major source of inorganic sulfate
for humans is body protein turnover of the amino acids methionine
and cysteine.
• The need for sulfur is met when the intake of sulfur amino acids is
adequate. A sulfur deficiency is likely only when protein deficiency
is severe.
TRACE MINERALS
Although the presence of trace minerals in the body is small, their impact
on health is significant. Each trace mineral has its own range over which the
body can maintain homeostasis (Fig. 7.4). People who consume an adequate
diet derive no further benefit from supplementing their intake with minerals
and may induce a deficiency by upsetting the delicate balance that exists
between minerals. Even though too little of a trace mineral can be just as
deadly as too much, routine supplementation is not recommended. Factors
that complicate the study of trace minerals are as follows:
• The high variability of trace mineral content of foods. The mineral
content of the soil from which a food originates largely influences
trace mineral content. Other factors that influence a food’s trace
mineral content are the quality of the water supply and degree of
food processing. Because of these factors, the trace mineral content
listed in food composition databases may not represent the actual
amount in a given sample.
Food composition data are not available for all trace minerals. Food
• composition databases generally include data on the content of iron,
zinc, manganese, and selenium, but data on other trace minerals,
such as iodine, chromium, and molybdenum, are not readily
available.
• Bioavailability varies within the context of the total diet. Even when
trace element intake can be estimated, the amount available to the
body may be significantly less because the absorption and
metabolism of individual trace elements is strongly influenced by
mineral interactions and other dietary factors.
• Reliable and valid indicators of trace element status (e.g., measured
serum levels, results of balance studies, and enzyme activity
determinations) are not available for all trace minerals, so
assessment of trace element status is not always possible.
Figure 7.3 ▲ Top sources and average intakes of sodium: U.S.
population ages 1 and older. (Source: U.S. Department of Agriculture &
U.S. Department of Health and Human Services [2020]. Dietary guidelines
for Americans, 2020–2025. https://www.dietaryguidelines.gov; Data
Source: Analysis of What We Eat in America, NHANES, 2013–2016, ages
1 and older, 2 days, dietary intake data, weighted.)
Note. PBJ.
Table 7.6 highlights recommended intakes, sources, functions, deficiency

symptoms, and toxicity symptoms of trace minerals. Additional features
follow.
Table Summary of
7.6 Trace Minerals
Deficiency/Toxicity
Mineral and Signs and
Sources Functions Symptoms
Deficiency/Toxicity
Iron (Fe) Oxygen transport via Deficiency
Adult RDA hemoglobin and Impaired immune
Men: 8 mg myoglobin; function,
Women: constituent of decreased work
19–50 y: 18 mg enzyme systems capacity, apathy,
>50 y: 8 mg lethargy, fatigue,
Adult UL: 45 mg itchy skin, pale
nail beds and eye
• Beef liver,
red meats, membranes,
impaired wound
fish, poultry,
clams, tofu, healing,
intolerance to
oysters,
cold
lentils, dried
temperatures
peas and
Toxicity
beans,
fortified Increased risk of
infections,
cereals,
bread, dried apathy, fatigue,
lethargy, joint
fruit
disease, hair loss,
organ damage,
enlarged liver,
amenorrhea,
impotence
Accidental poisoning
in children
causes death
Deficiency/Toxicity
Zinc (Zn) Required for the Deficiency
Adult RDA catalytic activity of Growth retardation,
Men: 11 mg approximately 100 hair loss,
Women: 8 mg enzymes; involved diarrhea, delayed
Adult UL: 40 mg in immune function, sexual
protein synthesis, maturation and
Oysters, red
wound healing, impotence, eye
meat,
poultry, DNA synthesis, cell and skin lesions,
division, normal anorexia, delayed
dried peas
• and beans, growth and wound healing,
development, sense taste abnormality,
fortified
of taste and smell mental lethargy
breakfast
Toxicity
cereals,
Anemia, elevated
yogurt,
cashews, low-density
lipoprotein,
pecans, milk
lowered high-
density
lipoprotein,
diarrhea,
vomiting,
impaired calcium
absorption, fever,
renal failure,
muscle pain,
dizziness,
reproductive
failure
Deficiency/Toxicity
Iodine Component of thyroid Deficiency
Adult RDA hormones that Goiter, weight gain,
150 mcg regulate growth, lethargy
Adult UL: 1100 development, and During pregnancy
mcg metabolic rate may cause severe
and irreversible
• Iodized salt,
seafood, mental and
physical
bread, dairy
products retardation
(cretinism)
Toxicity
Enlarged thyroid
gland, decreased
thyroid activity
Selenium (Se) Component of >2 dozen Deficiency
Adult RDA selenoproteins that Enlarged heart, poor
Men and women: 55 are involved in heart function,
mcg reproduction, thyroid impaired thyroid
Adult UL: 400 hormone activity
mcg/day metabolism, DNA Toxicity
• Brazil nuts, synthesis, and are Rare; nausea,
antioxidants vomiting,
seafood,
organ and abdominal pain,
diarrhea, hair and
muscle
nail changes,
meats,
nerve damage,
poultry,
fatigue
cereals and
other grains,
dairy
products,
eggs
Deficiency/Toxicity
Copper (Cu) Cofactor of enzymes is Deficiency
Adult RDA involved in energy Rare; anemia, bone
900 mcg production, iron abnormalities
Adult UL: 10,000 metabolism, Toxicity
mcg neuropeptide Vomiting, diarrhea,
• Organ activation, liver damage
connective tissue
meats,
seafood, synthesis, and
neurotransmitter
nuts, seeds,
whole synthesis
grains,
cocoa
products,
drinking
water
Manganese (Mn) Cofactor of many Deficiency
Adult AI enzymes is involved Rare
Men: 2.3 mg in amino acid, Toxicity
Women: 1.8 mg cholesterol, glucose, Rare; nervous
Adult UL: 11 mg and carbohydrate system disorders
• Widely metabolism; bone
formation,
distributed
reproduction,
in foods; top
sources in immune functioning,
blood clotting
U.S. diets
are grain
products,
tea, and
vegetables
Deficiency/Toxicity
Fluoride (Fl) Formation and Deficiency
Adult AI maintenance of tooth Susceptibility to
Men: 4 mg enamel, promotes dental decay;
Women: 3 mg resistance to dental may increase risk
Adult UL: 10 mg decay, role in bone of osteoporosis
formation and
• Fluoridated
water, water that integrity Toxicity
Fluorosis (mottling
naturally contains
fluoride, tea, of teeth), nausea,
vomiting,
seafood
diarrhea, chest
pain, itching
Deficiency/Toxicity
Chromium (Cr) Enhances the action of Deficiency
Adult AI insulin; appears to be Rare; insulin
Men: involved in the resistance,
19–50 y: 35 mcg metabolism of impaired glucose
>50 y: 30 mcg carbohydrates, tolerance
Women: protein, and fat
19–50 y: 25 mcg Toxicity
>50 y: 20 mcg Dietary toxicity
Adult UL: unknown
Undetermined
• Widely
distributed
but most
foods
provide only
in 1–2
mcg/serving;
meat, whole
grains, some
fruits, and
vegetables
are good
sources
Molybdenum (Mo) Component of many Deficiency
Adult RDA enzymes; works with Unknown
45 mcg riboflavin to Toxicity
Adult UL: 2000 incorporate iron into Occupational
mcg hemoglobin exposure to
• Milk, molybdenum
dust causes gout-
legumes,
bread, grains like symptoms.
Iron
Approximately two thirds of the body’s 3 to 5 g of iron is contained in the
heme portion of hemoglobin. Iron is also found in transferrin, the transport
carrier of iron, and in enzyme systems that are active in energy metabolism.
Ferritin, the storage form of iron, is located in the liver, bone marrow, and
spleen.
Iron in foods exists in two forms: heme iron and nonheme iron.
• The majority of iron in the diet is nonheme iron. Plants and iron-
fortified foods contain only nonheme iron.
• Nonheme iron absorption is inhibited by phytates found in legumes
and grains and oxalates found in spinach and chard. Its absorption is
promoted by the presence of heme iron and vitamin C (e.g., orange
juice, tomatoes). However, within the context of a varied, mixed
eating pattern, nonheme iron enhancers and inhibitors have little
impact on most people’s iron status (NIH, ODS, 2019b).
• Heme iron is found in meats, seafood, and poultry. Heme iron has
higher bioavailability than nonheme iron and is less affected by
other dietary components.
Based on average absorption rates and to compensate for daily (and
monthly) iron losses, the RDA for iron is set at 8 mg for men and
postmenopausal women and 18 mg for premenopausal women.
• Most adult men and postmenopausal women consume adequate
amounts of iron.
• Iron requirements increase during growth and in response to heavy
or chronic blood loss.
• Because the typical American diet provides only 6 to 7 mg of iron
per 1000 cal, many menstruating women simply do not consume
enough calories to satisfy their iron requirements.
Iron deficiency is the most common cause of anemia and infants and young
children are at the highest risk (NIH, ODS, 2019b).
• Women of reproductive age and pregnant women are also at risk of
iron deficiency.
• Nonnutritional risk factors for iron deficiency, particularly among
older populations, include blood loss, malabsorption disorders,
kidney disease, and cancer.
Iron deficiency can lead to iron deficiency anemia, a microcytic,
hypochromic anemia, occurs when total iron stores become depleted.
Symptoms include extreme fatigue, weakness, pale skin, and dizziness or
lightheadedness. A complete blood count usually shows low hemoglobin
and hematocrit, low mean cellular volume, low ferritin, low serum iron,
high transferrin or total iron-binding capacity, and low iron saturation.
• Iron deficiency during pregnancy is associated with poor pregnancy
outcome, such as premature delivery, low birth weight, and
increased perinatal infant mortality and maternal death.
• In young children, iron deficiency increases the risk of
developmental delays and behavioral disturbances. Because very
little iron is excreted from the body, the potential for toxicity is
moderate to high when iron absorption is excessive.
• The most common cause of iron overload is hemochromatosis, one
of the most common genetic disorders in the United States.
• The absorption of excessive amounts of iron leads to iron
accumulation in body tissues, especially the liver, heart, brain,
joints, and pancreas. If left untreated, excess iron can cause heart
disease, liver cancer, cirrhosis, diabetes, and arthritis.
• Phlebotomies or chelation are used to reduce body iron. A low-
iron diet is not recommended as part of treatment, nor could it be
realistically achieved given the prevalence of iron enrichment and
iron fortification in the U.S. food supply.
• Excessive dietary iron intake poses very little risk in adults with
normal GI function because the body adjusts the rate of iron
absorption accordingly.
Zinc
The small amount of zinc contained in the body (about 2 g) is found in
almost all the cells and is especially concentrated in the eyes, bones,
muscles, and prostate gland. Zinc in tissues is not available to maintain
serum levels when intake is inadequate, so an adequate daily intake is
necessary.
There is no single laboratory test that adequately measures zinc status,
so zinc deficiency is not readily diagnosed.
• Risk factors for zinc deficiency include poor calorie intake,
alcoholism, sickle cell disease, and malabsorption syndromes such
as celiac disease, Crohn’s disease, and short bowel syndrome.
• Vegetarians are also at increased risk because zinc is only half as
well absorbed from plants as it is from animal sources.
Iodine
Iodine is found in the muscles, the thyroid gland, the skin, the skeleton,
endocrine tissues, and the bloodstream. It is an essential component of
thyroxine (T4) and triiodothyronine (T3), the thyroid hormones responsible
for regulating metabolic rate, body temperature, reproduction, growth, the
synthesis of blood cells, and nerve and muscle function. It may also play a
role in immune response (IOM, 2001).
Most foods are naturally low in iodine.
• The iodine content of vegetables and grains varies with the soil
content. Iodine-deficient soil around the Great Lakes was known as
a “goiter belt” region in the United States.
• Processed foods almost always contain salt that is not iodized (NIH,
ODS, 2019c).
• Milk is naturally low in iodine but has become an important source
of iodine partly because of the use of iodine feed supplements and
iodine-containing disinfectants used to sanitize udders, milking
machines, and milk tanks.
• Some breads provide iodine due to the use of iodate dough
conditioners.
• Seaweed (e.g., kelp, nori, and kombu) is one of the best food
sources of iodine but its content is highly variable.
• The United States has generally been considered iodine sufficient
since table salt began to be voluntarily iodized in 1924 (Perrine et
al., 2010).
• Iodine deficiency has multiple adverse effects on growth and
development (NIH, ODS, 2019c).
• Hypothyroidism occurs when iodine intake falls below 10 to 20
mcg/day. It may be accompanied by goiter, which is often the
earliest sign of iodine deficiency. The effect of goitrogens on iodine
balance is clinically insignificant except when iodine deficiency
exists.
• Iodine deficiency in pregnant women can cause major
neurodevelopmental deficits and growth retardation in the fetus, as
well as miscarriage and stillbirth. Cretinism, characterized by a lack
of physical and mental development, can be caused by severe iodine
deficiency in utero.
• Less severe iodine deficiency in infants and children can also cause
neurodevelopmental deficits.
• Adults with mild-to-moderate iodine deficiency may have goiter,
impaired mental function, and reduced work productivity secondary
to hypothyroidism (NIH, ODS, 2019c).
Goitrogens
thyroid antagonists found in cruciferous vegetables (e.g., cabbage, cauliflower, broccoli),
soybeans, and sweet potatoes.
Few foods naturally provide iodine. Nurses should be aware that
iodized salt has iodine added to it. The iodine is not naturally
occurring. Seafood has naturally occurring iodine due to the iodine
in sea water.
Selenium
Selenium is a component of a group of enzymes, called glutathione
peroxidases, that function as antioxidants to disarm free radicals produced
during normal oxygen metabolism.
• The selenium content in plant foods varies widely depending on
where they were grown.
• Most Americans consume more than the RDA for selenium
according to NHANES data (USDA & ARS, 2018).
• Selenium deficiency is very rare in the United States. It is most
likely to occur in people undergoing hemodialysis due to removal of
selenium from the blood and poor selenium intake. People with
human immunodeficiency virus may be at risk due to diarrhea and
malabsorption.
Copper
Copper is distributed in muscles, liver, brain, bones, kidneys, and blood.
Americans typically consume adequate amounts of copper.
• Excess zinc intake has the potential to induce copper deficiency by
impairing its absorption, but copper deficiency is rare.
• Supplements, not food, may cause copper toxicity, as do some rare
genetic disorders, such as Wilson disease.
Manganese
Mean manganese intake among American adults is well above the AI, and
dietary deficiencies have not been noted.
• Manganese toxicity is a well-known occupational hazard for miners
who inhale manganese dust over a prolonged period of time, leading
to central nervous system abnormalities with symptoms similar to
those of Parkinson disease.
• There is some evidence to suggest that high manganese intake from
drinking water, which may be more bioavailable than manganese
from food, also produces neuromotor deficits similar to Parkinson
disease.
Fluoride
Fluoride promotes the mineralization of developing tooth enamel prior to
tooth eruption and the remineralization of surface enamel in erupted teeth.
• It concentrates in plaque and saliva to inhibit the process by which
cariogenic bacteria metabolize carbohydrates to produce acids that
cause tooth decay.
• Fluoridation of municipal water is credited with a major decline in
the prevalence and severity of dental caries in the U.S. population
and is deemed one of the 10 great public health achievements of the
20th century (Centers for Disease Control and Prevention [CDC],
1999). Water fluoridation has been credited with reducing tooth
decay by 25% in children and adults (CDC, 2019a).
Cariogenic
cavity promoting.
• Numerous organizations endorse fluoridation of municipal water,

including the American Academy of Pediatrics, the American
Association of Public Health Dentistry, the American Dental
Association, and the U.S. Task Force on Community Preventive
Services.
• Young children are susceptible to mottled tooth enamel if they
ingest several times more fluoride than the recommended amount
during the time of tooth enamel formation. The swallowing of
fluoridated toothpaste is to blame.
Chromium
Although chromium is an essential trace mineral, its functions and
requirements are not well defined (NIH, ODS, 2019d).
• Chromium enhances the action of insulin; however, there is no clear
scientific evidence that supplements are effective in improving
glucose control in patients with existing type 2 diabetes (Costello et
al., 2016).
• Because existing databases lack information on chromium, few food
intake studies utilizing few laboratories are available to estimate
usual intake. However, it appears that average intake is adequate.
Molybdenum
Molybdenum is a cofactor for certain enzymes. Usual intake is well above
the RDA. Dietary deficiencies and toxicities are unknown.
Other Trace Elements

Limited human studies suggest arsenic, boron, nickel, silicon, and
vanadium may have a role in human health. However, there is insufficient
data to set RDAs or AIs for any of these trace minerals. Based on animal
studies, UL were set for boron, nickel, and vanadium.
WATER AND MINERALS IN HEALTH
PROMOTION
Health is “promoted” when water (beverage) choices are healthy and when
the intake of minerals is not excessive (e.g., sodium) or inadequate (e.g.,
calcium and potassium).
Choose Healthy Beverages

Beverages are often overlooked when people consider their food intake, but
they are an important part of eating patterns. Some beverages provide
nutrients such as protein, vitamins, minerals, and phytonutrients; others are
considered empty calories because they provide calories with few or no
nutrients.
• The primary beverages consumed should be calorie free, such as
water, or contribute beneficial nutrients, such as non fat and low-fat
milk and 100% juice.
• Coffee, tea, and flavored waters that are free of added sugar and
cream are also options. Healthy adults can consume up to 400
mg/day of caffeine without dangerous effects (USDA & USDHHS,
2020), which is approximately equivalent to four 8-oz cups of
coffee.
• If consumed at all, sugar-sweetened beverage intake should be
limited. Sugar-sweetened beverage intake has been linked to obesity
in adults and children (Luger et al., 2017) and increased risk of type
2 diabetes and atherosclerotic CVD (Arnett et al., 2019).
• Substituting artificially sweetened beverages may help adults who
habitually consume large amounts of sugar-sweetened beverages
transition to water easier (Arnett et al., 2019).
• If consumed at all, alcohol intake should be limited to a moderate
intake or less. Moderate is defined as up to one drink per day for
women and up to two drinks per day for men and only by adults of
legal drinking age.
Consider Myra. Which fluids should she be encouraged to

use to satisfy her fluid recommendation? Would more than 8
glasses of fluid a day be excessive?
Reduce Sodium Intake
Figure 7.4 ▲ Health effects seen over a range of trace mineral intakes.
BOX Tips for Lowering Sodium Intake

7.3
Know what labeling terms mean:
• Sodium-free has less than 5 mg sodium per serving.
• Very low sodium has less than 35 mg per serving.
• Low sodium has less than 140 mg per serving.
• Reduced or less sodium has at least 25% less sodium per serving than
the traditional food.
• Light in sodium has 50% less sodium than the traditional food.
• Salt-free has less than 5 mg of salt.
• Unsalted or no added salt means no salt was added during processing,
although the food itself may contain natural sodium.
Make better choices

• Avoid or limit convenience foods, such as boxed mixes, frozen
dinners, and canned foods.
• Eat home-cooked meals more often.
• Eat more fresh or frozen vegetables.
• Compare labels to choose brands or varieties with the lowest amount
of sodium.
• Replace processed meats with fresh meats
• Use cheese sparingly.
• Choose nut butters with no sodium added.
• Cook rice and pasta without salt.
• Use lower-salt condiments, such as vinegar or reduced sodium ketchup
or Worcestershire sauce.
• Substitute homemade vinegar and oil dressing for bottled varieties.
• If you use canned vegetables, drain away liquid and rinse thoroughly.
• Limit salty snacks.
• Instead of salt, season food with spices, herbs, lemon, vinegar, or salt-
free seasonings.
According to the Agency for Healthcare Research and Quality (2018), a
review of studies on the effects of decreasing sodium intake and increasing
potassium showed the following: (Agency for Healthcare Research and
Quality [AHRQ], 2018):
• Reducing sodium intake lowers blood pressure in normotensive
adults and more so in adults with hypertension.
• Higher sodium intake may be related to higher risk of developing
hypertension.
• Using potassium-containing salt substitutes to lower sodium intake
likely reduces blood pressure in adults.
• Sodium intake may be associated with all-cause mortality.
• Lowering sodium intake may lower the risk of combined CVD
morbidity and mortality.
Since its inception in 1980, every edition of the Dietary Guidelines for
Americans has urged Americans to lower their sodium intake to prevent and
treat hypertension, CVD, and stroke. Despite the long-standing advice to eat
less sodium, the average sodium intake (3393 mg/day) remains well above
recommended amounts (<2300 mg/day) (USDA & USDHHS, 2020).
Figure 7.3 shows the top sources of sodium among Americans ages 1 and
older. Tips for reducing sodium intake are shown in Box 7.3.
Shortfall Minerals
The Dietary Guidelines have identified potassium and calcium as shortfall
minerals that are considered public health concerns because low intakes are
associated with health issues (USDA & USDHHS, 2020). Low intakes of
vegetables, fruits, and dairy contribute to the underconsumption of these
two minerals. Menstruating and pregnant women may also not consume
enough iron. Figure 7.5 depicts the mean intake of these minerals as a
percent of the DRI for adults 20 and older. Health concerns related to low
intakes of potassium and calcium as well as suggestions for improving the
intake of each are presented in the following.
Figure 7.5 ▲ Mean intake of shortfall minerals as a percentage of the
dietary reference intakes in adult men and women aged 20 and older.
(Source: U.S. Department of Agriculture & Agricultural Research Service.
[2018]. Nutrition intakes from food: Mean amounts consumed per
individual, by gender and age. What We Eat in America, NHANES 2015–
2016.
https://www.ars.usda.gov/ARSUserFiles/80400530/pdf/1516/tables_1-
56_2015-2016.pdf)
Potassium
Lower intakes of potassium and higher intakes of sodium are associated
with higher blood pressure (Jackson et al., 2018).
• This finding supports the dietary advice to lower sodium intake and
increase potassium intake because hypertension is a key modifiable
risk factor for CVD.
• Increasing potassium intake also most likely lowers blood pressure
in adults with existing hypertension (AHRQ, 2018).
Potassium is widespread across food groups, but not all foods within a
group have high potassium levels. Variety helps ensure adequacy. High
potassium choices include the following:
• Fruits: prune juice, kiwifruit, dried fruit (e.g., dates, prunes, raisins),
banana, avocado, purple passion fruit
• Vegetables: baked potato with the skin, other types of cooked
potatoes, sweet potato baked in the skin, fresh spinach, beets,
artichoke, tomato paste and sauce, winter squash
• Grains: bran and certain bran cereals
• Dairy: milk (nonfat, low fat, whole, buttermilk), yogurt
• Protein foods: beans (e.g., baked, navy, pinto, refried), lentils,
salmon, pollock
Calcium
There are no short-term adverse effects of low calcium intake because
serum calcium levels are tightly regulated by vitamin D and parathyroid
hormone.
• Hypocalcemia occurs primarily from alterations in calcium
metabolism (e.g., parathyroid disorders, kidney disease) or the use
of certain medications.
• The long-term risk of low calcium intake is osteopenia, a condition
characterized by a significant decrease in bone mineral density. If
left untreated, osteopenia can progress to osteoporosis.
• Low calcium intake is associated with low bone mass, rapid bone
loss, and high fracture rates (NIH Osteoporosis and Related Bone
Diseases National Resource Center, 2018).
Milk is a nearly perfect source of calcium because it contains vitamin D and
lactose, which promote calcium absorption.
• People who are lactose intolerant can obtain calcium from lactose-
reduced milk, acidophilus milk, and lactose-free yogurt.
• Low-oxalate green vegetables, such as broccoli, bok choy, collard
greens, and kale, are good sources of calcium.
• Significant amounts of calcium can also be found in calcium-
fortified foods, such as fruit juices, tomato juice, and ready-to-eat
breakfast cereals.

The healthy eating patterns repeated throughout this book, such as the
Healthy U.S.-Style Eating Pattern, the Mediterranean diet, and the generic
“plant-based diet,” can be used to help ensure AIs of minerals, specifically
the shortfall minerals potassium and calcium. These patterns are also lower
in sodium. According to the Dietary Guidelines for Americans, another
eating pattern, the Dietary Approaches to Stop Hypertension (DASH) diet,
is healthy eating pattern that has many of the same characteristics as the
Healthy U.S.-Style Eating Pattern (USDA & USDHHS, 2020). The most
notable difference is that the DASH diet recommends ⅓ to ½ less oils.
• The DASH diet was designed to see if a healthy eating pattern, not
specifically individual nutrients, could lower high blood pressure
(Appel et al., 1997).
• The results clearly showed that, even without lowering sodium
intake, an eating pattern rich in fruit, vegetables, low-fat dairy
products, and whole grains; moderate in poultry, fish, and nuts; and
low in fat, red meat, and added sugar lowered blood pressure and
also low-density lipoprotein cholesterol (LDL-C). Adding a sodium
restriction improves its blood pressure–lowering effect.
• Its blood pressure–lowering effect likely comes from a combination
of factors, including its high content of potassium, calcium, and
magnesium.
• Table 7.7 features a 2000-cal DASH eating pattern
• Protein foods: chicken breast, salmon, canned clams, nuts and seeds
Table Daily and Weekly Eating

Plan for a 2000-Cal
7.7 Dietary Approaches to
Stop Hypertension Diet
Daily
Food Group and Serving Size Servings
Fruit, ½ c 4–5
Vegetables, 1 c leafy greens or ½ c other vegetables 4–5
cooked or raw
Grains, preferably whole grains, 1 ounce equivalents 6–8
Protein 6 oz or less
Dairy (nonfat or low fat), 1 cup 2–3
Oils 8–12 g
Sodium 2300 mg
Weekly
servings
Nuts (1/3 c), seeds (2 tbsp), legumes (½ c cooked) 4–5
Sweets ≤5
Source: National Institutes of Health National Heart, Lung, and Blood Institute. DASH Eating Plan.
https://www.nhlbi.nih.gov/health-topics/dash-eating-plan
How Do You Respond?

Do zinc lozenges cure the common cold? Meta-
analyses of randomized, double-blind, placebo-controlled
trials show that zinc lozenges may reduce the duration of
colds by approximately 33% (e.g., Hemila, 2017). More
research is needed to determine the optimal dosage,
formulation, and duration of treatment. However, the
safety of intranasal zinc has been questioned based on
numerous reports linking their use to a loss of the sense of
smell, which in some cases has been long-lasting or
permanent (NIH, ODS, 2019e).
Does chlorine in drinking water cause cancer?
Chlorine is added to drinking water as a disinfectant to
control microbial contaminants. It is allowed at levels up
to 4 ppm, a level at which no harmful health effects are
likely to occur. Concern arises from trihalomethanes
(THM), a group of organic chemicals that often occur in
drinking water from the reaction between naturally
occurring organic and inorganic matter and chlorine. The
Environmental Protection Agency (EPA) has established a
Maximum Contaminant Level (MCL) for total THMs in
public drinking water to ensure that any potential adverse
effects are outweighed by the benefit of reducing the risk
of acute GI diseases related to contamination. The MCL
for total THMs is 80 ppb. The small quantities of THMs
allowed in water are not enough to cause cancer risk
because they fall far below where risk is determined to
begin. The benefits of chlorine in preventing outbreaks of
cholera, hepatitis, and other diseases far outweigh the
negligible effects of THM.
What are chelated minerals? A chelated mineral is a
mineral that has been chemically combined with an amino
acid to protect it from other food components such as
oxalates and phytates that can bind to the mineral and
prevent it from being absorbed. There is no evidence to
support claims that chelated minerals are better than non-
chelated minerals.
REVIEW CASE STUDY
Bill is a 45-year-old bachelor who eats a grab-and-go breakfast, eats all of

his lunches out, and has takeout or “something easy” for dinner. Bill’s
doctor is concerned that his blood pressure is progressively rising with
every office visit and has advised him to “cut out the salt” to lower his
sodium intake. Bill rarely uses salt from a salt shaker and is unsure what
else he can do to lower his sodium intake. A typical day’s intake is shown
on the right:
• What foods did Bill eat yesterday that were high in sodium? What
foods were relatively low in sodium? What would be better choices
for him when eating out? How could he lower his sodium intake
while still relying on “something easy” when he prepares food at
home?
• Knowing that potassium may help blunt the effect of a high sodium
intake on blood pressure, what foods would you recommend he add
to his diet that would increase his potassium intake?
• In overweight people, weight loss helps lower high blood pressure.
Bill is “a little heavy.” What changes/substitutions would help him
lose weight?
Breakfast: Black coffee and two jelly doughnuts

Midmorning snack: Black coffee and cookies
Lunch: Two fast-food tacos with tortilla chips and salsa or a 6-in cold
cut submarine with potato chips, cola
Midafternoon snack: Candy bar
Dinner: If takeout, then Chinese food or pizza. If “something easy,” then
boxed macaroni and cheese with a couple of hot dogs, canned soup
with a cold cut sandwich, or frozen TV dinners.
Dessert: Instant pudding, ice cream, or candy bars
Evening snacks: Cereal and milk or potato chips and dip
STUDY QUESTIONS
1 A healthy, young adult client asks how much water he should drink daily.
Which of the following would be the nurse’s best response?
a. “The old adage is true: Drink eight 8-oz glasses of water daily.”
b. “Drink to satisfy thirst and you will consume adequate fluid.”
c. “You can’t overconsume water, so drink as much as you can spread out
over the course of the day.”
d. “It is actually not necessary to drink water at all. It is equally healthy
to meet your fluid requirement with sugar-free soft drinks.”
2 When developing a teaching plan for a client who is lactose intolerant,
which of the following foods would the nurse suggest as sources of
calcium the client could tolerate?
a. cheddar cheese, bok choy, broccoli
b. spinach, beet greens, nonfat milk
c. poultry, meat, eggs
d. whole grains, nuts, cocoa
3 The client asks what makes the DASH diet different from a Healthy U.S.-
Style Eating Pattern. What is the best response?
a. “They are basically the same except that the DASH diet is lower in
calories.”
b. “The DASH diet is low in dairy products and grains.”
c. “The DASH diet recommends significantly less oils.”
d. “The DASH diet is lower in protein foods.”
4 Which of the following recommendations would be most effective at
increasing potassium intake?
a. Choose enriched grains in place of whole grains.
b. Consume more fruits, vegetables, and dairy.
c. Eat more red meat in place of poultry.
d. Because there are few good dietary sources of potassium, it is best
obtained by taking potassium supplements.
5 A client asks why eating less sodium is important for healthy people.
Which of the following is the nurse’s best response?
a. “Low-sodium diets tend to be low in fat and therefore may reduce the
risk of heart disease.”
b. “Low-sodium diets are only effective at preventing high blood
pressure, not lowering existing high blood pressure, so the time to
implement a low-sodium diet is when you are healthy.”
c. “Lowering sodium intake lowers blood pressure in healthy people and
may also decrease the risk of atherosclerotic heart disease.”
d. “Low-sodium diets are inherently low in calories and help people lose
weight, which can help prevent a variety of chronic diseases.”
6 Which of the following foods provides iron in a form that would be
absorbed best?
a. red meat
b. iron-fortified cereal
c. legumes
d. enriched bread
7 A client says he never adds salt to any foods that his wife serves, so he
believes he is consuming a low-sodium diet. Which of the following is
the nurse’s best response?
a. “If you don’t add salt to any of your foods, you are probably eating a
low-sodium diet. Continue with that strategy.”
b. “Even though you aren’t adding salt to food at the table, your wife is
probably salting food as she cooks. She should stop doing that.”
c. “Lots of foods are naturally high in sodium, such as milk and meat; in
addition to not using a salt shaker, you must also limit foods that are
naturally high in sodium.”
d. “The major sources of sodium are processed and convenience foods.
Limiting their intake makes the biggest impact on overall sodium
intake.”
8 What should you tell the client about taking mineral supplements?
“Most Americans are deficient in minerals, so it is wise to take a
a.
multimineral supplement.”
b. “Like water-soluble vitamins, if you consume more minerals than your
body needs, you will excrete them in the urine, so do not worry about
taking in too much.”
c. “If you do not have a mineral deficiency, supplements are not
necessary and can lead to a potentially excessive intake that can cause
adverse health effects.”
d. “Mineral deficiencies do not exist in the United States, so you do not
need to waste your money on them.”
CHAPTER SUMMARY Water and

Minerals
Body fluids consist of water and chemicals, such as minerals. Because
water is involved in almost every body function, is not stored, and is
excreted daily, it is more vital to life than food.
Water
Under normal conditions, water intake equals water output to maintain
water balance.
• In most healthy people, thirst is a reliable indicator of need.
• activity, climate, and health affect the body’s need for water.
Fluid and Electrolyte Balance

Some minerals are electrolytes that dissociate (dissolve) into ions in
water and are able to conduct electricity. Membranes (e.g., cell
membranes, capillary membranes), the concentration of electrolytes, and
hydrostatic pressure work to regulate the fluids in each body
compartment.
Understanding Minerals
Minerals are found in all body fluids and tissues. Minerals are inorganic
elements from the earth’s crust.
• provide structure to body tissues and regulate body processes
• vary in how they are regulated by the body, such as by the rate of
absorption, urinary excretion, or storage
• can be toxic but generally only from excess supplemental intake or
environmental exposure.
• Minerals interact with one another and other dietary components
which alters bioavailability.
• are found in all food groups to varying degrees.
• should only be taken in supplemental form if needed.
Major Electrolytes
Sodium, potassium, and chloride are major minerals in addition to being
electrolytes.
• Sodium: Approximately 71% of sodium is added to food outside the
home. Americans eat too much sodium. Americans should limit
sodium intake if above 2300 mg to lower the risk of chronic disease.
• Potassium: Most Americans do not consume enough potassium.
Wholesome foods provide more potassium than processed foods.
Increasing potassium intake lowers blood pressure.
• Chloride: Almost all dietary chloride comes from salt (sodium
chloride).
Major Minerals
Major minerals are present in the body in amounts >5 g.
• Calcium: The most plentiful mineral in the body. Bone tissue serves
as a dynamic reservoir to release calcium as needed to maintain serum
levels. Dairy products provide a well-absorbed source of calcium.
• Phosphorus: The phosphorus content of foods goes up with
processing. Americans may be eating more than required.
• Magnesium: A cofactor for more than 300 enzymes in the body. Half
the body’s magnesium content is deposited in bone.
• Sulfur: Does not function independently as a nutrient but is a
component of some amino acids and vitamins. Sulfur intake is
adequate if protein intake is adequate.
Trace Minerals
A delicate balance exists between trace minerals: too much of one can
create a deficiency of another.
• Iron: Bioavailability varies with the type of iron consumed. Iron
deficiency is not uncommon
• Zinc: Because there is no single lab test that measures zinc status, zinc
deficiency is not readily diagnosed.
• Iodine: Most foods are low in iodine. Iodized salt enables Americans
to consume adequate iodine. Processed foods almost always contain
non-iodized salt.
• Selenium, Copper, Manganese, and Molybdenum: Americans
consume adequate amounts of these minerals. Dietary deficiencies are
rare.
• Fluoride: Fluoridated water has dramatically reduced the prevalence
and severity of cavities in the United States population. Bottled water
may not be fluoridated.
• Chromium: Enhances the action of insulin.
Water and Minerals in Health

Promotion
• Water, low-fat or non fat milk, and 100% juice should be the primary
beverages of choice. Artificially sweetened beverages may help people
transition from sugar-sweetened beverages to water.
• Americans are urged to eat less sodium to lower blood pressure and
possibly CVD morbidity and mortality. Eating fewer processed foods
lowers sodium intake.
• Potassium and calcium are shortfall nutrients of concern because not
eating enough of these minerals is associated with health problems.
Iron intake may be inadequate in young children, menstruating
women, and pregnant women.
• The DASH diet is an eating pattern rich in potassium, calcium, and
magnesium and limited in sodium. It has been shown to lower high
blood pressure and LDL-C. It is very similar to the Healthy U.S.-Style
Eating Pattern.
Figure sources: shutterstock.com/KieferPix, shutterstock.com/SNP_SS, shutterstock.com/Antonina
Vlasova

book at
Websites
Dietary supplement fact sheets from the National Institutes of Health, Office of Dietary Supplements
at https://ods.od.nih.gov/HealthInformation/healthprofessional.aspx
National Academy of Sciences, Institute of Medicine for Reference Dietary Intakes at www.nap.edu
National Dairy Council at www.nationaldairycouncil.org
Nutrient content of foods at the UDA’s Food Data central website at https://fdc.nal.usda.gov/
References
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chronic disease outcomes and risks. Evidence Summary. Comparative Effectiveness Review,
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Chapter Energy Balance
8
Kyla and Garrett Wilkinson

Kyla and Garrett are both 25 years old and have been
married 6 months. Since then, Kyla has gained 10 to
15 pounds and Garrett has gained 40 pounds, which
they attribute to eating dinner out three to four times a
week and getting takeout the other days of the week.
They are shocked at how quickly “things got out of
control” and want to adopt a healthier lifestyle before
embarking on parenthood.
Learning Objectives
1 Discuss the three factors that contribute to total calorie expenditure.

2 Calculate an individual’s basal metabolic rate.
3 Calculate a person’s total calorie requirement.
4 Determine an individual’s body mass index (BMI).
5 Evaluate weight status based on BMI.
6 Explain the value of measuring a person’s waist circumference.
7 Discuss strategies that promote portion control.
8 Give examples of healthier substitutes for calorically dense foods.
9 Calculate the calorie value of a food or eating pattern based on the
macronutrient composition.
10 Summarize key physical activity guidelines for adults.
The state of energy balance is determined by comparing the number of

calories consumed to the number of calories expended. Body weight
changes over time when the ratio of calorie intake to calorie output changes.
This chapter discusses states of energy balance, energy intake, energy
output, and how total calorie requirements are estimated. Methods of
evaluating body weight are presented. Energy in health promotion focuses
on consuming the appropriate number of calories, being physically active,
and reducing sitting time.
STATE OF ENERGY BALANCE
Energy balance occurs when the number of calories consumed is

approximately equal to the number of calories expended over time. Body
weight remains stable (Fig. 8.1).
• A positive energy balance occurs when calorie intake exceeds
calorie expenditure, whether the imbalance is caused by overeating,
low activity, or both (Fig. 8.2). Over time, the calories consumed in
excess of expenditure contribute to weight gain. Because a pound of
body fat is equivalent to 3500 calories, a surplus of 500 cal/day over
a 7-day period theoretically results in a 1-pound weight gain.
• Conversely, a negative calorie balance occurs when calorie
expenditure exceeds intake, whether the imbalance is from
decreasing calorie intake, increasing physical activity (PA), or
(preferably) both (Fig. 8.3).
Figure 8.1 ▲ A state of energy balance: Calorie intake is equal to
calorie expenditure.
Figure 8.2 ▲ A positive energy balance: Calorie intake is greater than
Figure 8.3 ▲ A negative energy balance: Calorie intake is less than
Energy Intake
The energy value of food is measured in kilocalories, which is commonly
shortened to calories. Nutrients that provide calories are carbohydrates,
protein, and fat (Fig. 8.4). Alcohol also provides calories. The total number
of calories in a food or eating pattern can be estimated by multiplying the
total grams of these nutrients by the appropriate calories per gram—namely,
4 cal/g for carbohydrates and protein, 9 cal/g for fat, and 7 cal/g for alcohol.
Box 8.1 features an example.
Calorie
unit by which energy is measured; the amount of heat needed to raise the temperature of 1 kg of
water by 1°C. Technically, calorie is actually kilocalorie or kcal.
Figure 8.4 ▲ Sources of calorie intake and calorie expenditure.
BOX Calculating the Calories in Food

8.1
A double fast-food burger provides 49 g carbohydrate, 67 g protein, and

75 g fat.
49 g CHO × 4 cal/g = 196 cal
67 g pro × 4 cal/g = 268 cal
75 g fat × 9 cal/g = 675 cal
Total calories = 1139 cal
Counting Calories
“Counting calories” can be practiced in a number of ways—manually,
online, or with a mobile phone app.
• It is a tedious and imprecise process dependent on knowing or
accurately measuring the amount of all foods consumed.
• Another drawback is that food composition databases used to assign
nutrient and calorie values to food represent average analysis of a
number of food samples, not the actual specific food consumed.
Estimating Calories
An imprecise but easy way to estimate calorie intake is to use a food group
approach, such as the Food Lists for Weight Management (American
Diabetes Association & Academy of Nutrition and Dietetics, 2019).
• Each food group is assigned average calorie content for a specified
serving size (Table 8.1).
• After counting servings consumed from each food group, the
approximate total calories can be calculated.
• Separate lists exist for combination foods such as casseroles,
sandwiches, and fast foods that do not fit into a single food group.
• Counting actual portion sizes (e.g., the amount eaten), not just
serving sizes (generally the amount recommended), is vital for
accuracy. For instance, 6 almonds are considered a serving, not ¼ c
that may be listed on the Nutrition Facts label.
The drawback of counting calories by any method is that appropriate

calories are only one aspect of a healthy eating pattern and nutritional
adequacy is not guaranteed. For instance, an individual can consume the
appropriate number of calories, but if the calories come from burgers and
fries rather than from fruit, vegetables, and whole grains, the eating pattern
is not healthy, even though it is calorie appropriate.
Table Calories by
8.1 Food Lists
Average
Representative Calories per
Food Group Serving Size Serving
Starch (breads, grains, cereals, 1 oz bread 80
starchy vegetables, dried
peas, and beans)
Fruits 1 small fresh fruit, 60
½ cup canned or
frozen fruit
Milk 1 cup
Fat-free, low-fat, 1% 100
Reduced fat, 2% 120
Whole 160
Non-starchy vegetables ½ cup cooked or 1 25
cup raw
Protein foods 1 oz
Plant-based protein Varies
Lean 45
Medium fat 75
High fat 100
Fat/oils 1 tsp butter or 45
margarine
Sweets, desserts Varies Varies
For example:
Number of Servings Calories per Calories
Consumed Serving Consumed per
Food Group
6 grains 80 480
4 fruit 60 240
5 vegetables 25 125
½ cup nonfat milk 80 200
6 oz medium-fat protein 75 450
3 tsp oils 45 135
Average
Representative Calories per
Food Group Serving Size Serving
Total calories per 1630
day
Recall Kyla and Garrett. A food record would help

identify the types, amounts, and pattern of food they eat so
that a strategy to improve intake can be formulated. What
other factors need to be assessed before recommending
changes to their intake?
Energy Expenditure
Calories are also the unit by which energy expended by the body is
measured. The body uses energy for involuntary activities and purposeful
PA. The thermic effect of food is another category of energy expenditure,
although in practice it is often disregarded. The total of these expenditures
represents an estimate of the number of calories a person expends in a day
(Fig. 8.4).
Basal Metabolism
Basal energy expenditure (BEE) or basal metabolic rate (BMR) is the
number of calories required to fuel the involuntary activities of the body at
rest after a 12-hour fast.
• Involuntary body activities include maintaining body temperature
and muscle tone, producing and releasing secretions, propelling the
gastrointestinal tract, inflating the lungs, and beating the heart.
• For most American adults, BEE accounts for 60% to 70% or more
of total calories expended. The less active a person is, the greater is
the proportion of calories used for BEE.
• The term BEE is often used interchangeably with resting metabolic
rate (RMR) or resting energy expenditure (REE), even though
they are slightly different measures.
• Online tools are available to calculate BEE (e.g.,
https://www.omnicalculator.com/health/BEE).
• BEE can also be manually calculated using any number of formulas,
such as the Mifflin-St Jeor equation (Box 8.2).
• A drawback of using predictive formulas based on weight is that
they do not account for other variables that affect BEE, such as body
composition (Table 8.2).
Basal Energy Expenditure (BEE) or Basal Metabolic Rate
(BMR)
the number of calories expended in a 24-hour period to fuel the involuntary activities of the body
at rest and after a 12-hour fast.
Resting Metabolic Rate (RMR) or Resting Energy

Expenditure (REE)
the number of calories expended in a 24-hour period to fuel the involuntary activities of the body
at rest. RMR does not adhere to the criterion of a 12-hour fast, so it is slightly higher than BEE
because it includes energy spent on digesting, absorbing, and metabolizing food.
Estimating Total Calorie Requirements:

BOX
Basal Energy Expenditure + Calories for
8.2 Physical Activity
1. Estimate BEE with the Mifflin-St Jeor formula (simplified equation)
Men: BEE = 10 × weight (kg) + 6.25 × height (cm) − 5 ×
age (years) + 5
Women: BEE = 10 × weight (kg) + 6.25 × height (cm) − 5 ×
age (years) − 161
2. Multiply BEE by the appropriate factor for usual intensity of
activity to determine total calories needed.
Sedentary (little or no exercise): BEE × 1.2
Lightly active (light exercise/sports 1–3 days/week): BEE ×
1.375
Moderately active (moderate exercise/sports 3–5
days/week): BEE × 1.55
Very active (hard exercise/sports 6–7 days/week): BEE ×
1.725
Extra active (very hard exercise/sports and physical job):
BEE × 1.9
Example: A 25-year-old sedentary woman is 5 ft 5 in. tall
(165 cm) and weighs 142 pounds (65 kg).
1. Use Mifflin-St Jeor formula for women to calculate BEE. Women:
BEE = 10 × weight (kg) + 6.25 × height (cm) − 5 × age (years) −
161
(10 × 65) + (6.25 × 165) − (5 × 25) − 161
650 + 1031 − 125 − 161
BEE = 1395 cal
2. Multiply by BEE activity factor to determine total calorie
requirements
Total calorie requirements for sedentary activity: BEE × 1.2
1395 × 1.2
Total calorie requirements = 1674 cal
Table Factors That Affect

Basal Energy
8.2 Expenditure
• The actual amount of energy expended on PA depends on the
intensity and duration of the activity and the weight of the person
performing the activity. The more intense and longer the activity, the
greater the number of calories burned.
• Heavier people who have more weight to move use more energy
than lighter people to perform the same activity.
• A rule-of-thumb method for estimating daily calories expended on
PA is to calculate the percentage increase above BEE on the basis of
estimated intensity of usual daily activities (Box 8.2).
• Wearable fitness tracking devices and smart watches can record
fitness-related metrics using algorithms and sensors, such as
temperature sensors and optical sensors. Trackers measure motion,
which is then converted into steps and activity; from there, calories
and sleep quality are estimated. Apps present the data after more
fine-tuning with algorithms. Due to differences in sensors and
algorithms, reported statistics vary among individual devices even
when the same data are used. Tracking devices provide an estimate,
not an actual reading.
Thermic Effect of Food

The thermic effect of food represents the calories spent on processing
food.
• In a normal mixed diet, the thermal effect of food is estimated to be
about 10% of the total calorie intake. For instance, people who
consume 1800 cal/day use about 180 calories to process their food.
• The actual number of calories spent varies with the composition of
food eaten, the frequency of eating, and the size of meals consumed.
• Although it represents an actual and legitimate use of calories, the
thermic effect of food in practice is often disregarded when calorie
requirements are estimated because it constitutes such a small
amount of energy and is imprecisely estimated.
Thermic Effect of Food

an estimation of the amount of energy required to digest, absorb, transport, metabolize, and store
nutrients.
ESTIMATING TOTAL CALORIE

REQUIREMENTS
Total calorie needs can be imprecisely estimated by using predictive

equations, of which more than 200 have been published. The following are
different approaches for estimating calorie needs; all yield estimates, not
precise measurements.
• Use BEE and activity factor to estimate total calories (Box 8.2).
• Use a simple formula based on kilogram of body weight. For
nonobese adults, a standard of 25 to 30 cal/kg is often used.
• Use a standard reference that lists estimated daily calorie needs
based on gender, age, and activity (Table 8.3).
Table Estimated Calorie Needs

8.3 per Day by Age, Sex, and
Physical Activity Level,
Ages 2 and Older
Think of Kyla and Garrett. They want to lose weight, and

they also want to eat healthy. Often, people forget about
health and just concentrate on calories and weight. Although
their estimated calories as sedentary 25-year-olds are 2000
calories for Kyla and 2400 calories for Garrett, they do not
want to count calories or measure serving sizes. What
strategies can they use to eat a healthy, calorie-appropriate
eating pattern that will promote weight loss without actually
counting calories?
EVALUATING WEIGHT STATUS
From a health perspective, healthy or desirable weight is that which is

statistically correlated to good health. But the relationship between body
weight and good health is more complicated than simply the number on the
scale. For instance, although increased body weight is a risk factor for type
2 diabetes, the actual risk is more accurately related to the quantity and
distribution of body fat (Després, 2012). However, methods to accurately
assess quantity of body fat and its distribution are not readily available or
cost effective (Hsu et al., 2015). Body mass index (BMI), waist
circumference, and waist-to-height ratio (WHR) may be used to identify
risk for obesity and obesity-related comorbidities.
Body Mass Index

Historically, a quick and easy method of calculating ideal body weight and
evaluating weight for height is the Hamwi method (Table 8.4). However,
since the early 1980s, weight status has been assessed by BMI.
Ideal Body Weight
the formula given here is a universally used standard in clinical practice to quickly estimate a
person’s reasonable weight based on height and sex, even though this and all other methods are
not absolute.
• BMI is calculated by dividing weight in kilograms by height in

meters squared (kg/m2).
• Nomograms and tables that plot height and weight to determine
BMI eliminate complicated mathematical calculations (Table 8.5).
• Established cutoffs identify overweight as a BMI ≥25 and obese as a
BMI ≥30, which are based on the rationale that adults with a BMI
≥25 have increased risks for both morbidity and mortality (National
Heart, Lung, and Blood Institute Obesity Task Force, 1998). Those
risks include coronary heart disease, hypertension,
hypercholesterolemia, type 2 diabetes, and other diseases.
Table Evaluating
8.4 Weight
Standard Calculation Interpretation

Percentage of “ideal” Hamwi method calculation • ≤69%
body weight as for ideal body weight severe
determined by the Women: Allow 100 pounds malnutrition
Hamwi method. for the first 5 ft of height;
add 5 pounds for each • 70%–79%
additional inch. moderate
malnutrition
Men: Allow 106 pounds for
the first 5 ft of height; • 80%–89%
add 6 pounds for each mild
additional inch. malnutrition
• 90%–110%
within
normal
range
• 110%–
119%
overweight
• ≥120%
obese
≥200%
morbidly
• obese
Body mass index For men and women: weight • ≤18.5, may
in kg ÷ height in meters ↑ health risk
squared
• 18.5–24.9,
healthy
weight
• 25–29.9,
overweight
• 30–34.9,
obesity
class 1
35–39.9,
obesity
• class 2
• ≥40, obesity
class 3
Table Body Mass

8.5 Index
Controversy Surrounding Body Mass Index
Despite its widespread use as a screening tool, BMI is not without
controversy.
• The BMI levels that define overweight and obesity are somewhat
arbitrary because the relationship between increasing weight and
risk of disease is continuous.
• BMI does not take sex into account, nor body composition; a lean
athlete may have well-developed muscle mass and little fat tissue,
yet if their BMI is high, they would fall under the designation of
overweight or obese. Conversely, a senior adult may have a normal
BMI and be deemed “healthy” despite a low percentage of muscle
mass masked by a high amount of body fat.
• BMI does not take body fat distribution into account.
• Health risks related to BMI occur at different cutoff points for
certain populations. For instance, the American Diabetes
Association recommends that testing for diabetes be considered for
all Asian and Asian American adults who have a BMI ≥23 (Hsu et
al., 2015).
Body Fat Distribution
As far back as the 1940s, researchers noted that central obesity fat
distribution, commonly referred to as an apple shape, posed greater health
risks than when fat was deposited peripherally, or a pear shape (Fig. 8.5).
Even after controlling for BMI, people who have a primarily upper-body fat
distribution are at increased risk of type 2 diabetes, cardiovascular disease,
cancer, and death (Sun et al., 2019; Zhang et al., 2008). Within the last few
decades, it has been shown that health risks, predominately hypertension,
cardiovascular disease, and type 2 diabetes, are more accurately determined
by assessing the relative distribution of excess fat rather than by total fat
amount (Després, 2012). Waist circumference and WHR are screening tools
for identifying central obesity.
Central Obesity
proportionally greater amount of fat in the upper body compared to the hips and lower
extremities.
Figure 8.5 ▲ Pear shape versus apple shape.
Waist Circumference
• The current waist circumference cutoff points in common use are
>40 in. for men and >35 in. for women (National Institutes of
Health, National Heart Lung and Blood Institute, 2000).
• The World Health Organization/International Diabetes Foundation
uses the cutoff points of >37 in. in men and >31.5 in. in women
(WHO, 2008).
• As with BMI, ethnic groups differ in regard to where risk begins in
relation to waist circumference. For instance, thresholds for central
obesity among people of South Asian, Japanese, and Chinese origin
are 35.5 in. for men and 31.5 in. for women (Purnell, 2018).
• These cutoff points are somewhat arbitrary because the relationship
between cardiovascular risk and waist circumference is continuous:
the greater the waist circumference, the greater the risks.
Waist-to-Height Ratio
• Waist-to-height ratio (WHR) may be a better screening tool than
both waist circumference and BMI for cardiometabolic risk factors
such as hypertension, diabetes, dyslipidemia, metabolic syndrome,
and cardiovascular disease (Ashwell et al., 2012).
• WHR is a simple, easy, and practical tool that can identify “early
health risk” (Ashwell & Gibson, 2014).
• WHR is calculated by dividing waist measurement by height
measurement. The suggested cutoff value of 0.5 translates to the
practical advice of “keep your waist to less than half your height,”
which the authors suggest can be cheaply and easily determined by a
single piece of string (Ashwell et al., 2012).
• This boundary value of 0.5 has been used around the world, and
findings in many populations support the premise that WHR is an
effective index to identify health risks. It also has a clearer
relationship with mortality than BMI (Ashwell & Gibson, 2016).
Recall Kyla and Garrett. Kyla is 5 ft 5 in. tall, currently

weighs 150 pounds, and has a waist size of 31 in. Garrett is
6 ft tall, currently weighs 210 pounds, and has a waist size of
36 in. Evaluate their BMI, waist circumference, and WHR.
ENERGY BALANCE IN HEALTH
PROMOTION
Guidelines put forth by public health agencies consistently urge Americans

to attain and maintain a healthy body weight. Factors involved in achieving
that goal are to consume the appropriate number of calories, be physically
active, and reduce sitting time.
Consume Appropriate Calories

An “appropriate” calorie level is one in which the individual is able to attain
and maintain a healthy weight. Table 8.3 can be used as a reference to
choose a reasonable calorie level based on age, sex, and activity; the
appropriateness of the calorie level is determined by monitoring body
weight over time.
• After the appropriate calorie level is determined, it can be translated
into daily servings per food group using a healthy eating pattern,
such as the Healthy U.S.-Style Eating Pattern, Healthy
Mediterranean-Style Eating Pattern, or Healthy Vegetarian Eating‐
Pattern, described in Chapter 2. Another option is the DASH diet
(Chapter 7).
• Choosing appropriate serving sizes is vital to ensuring the
appropriate calorie intake. Table 8.6 illustrates how portion sizes
have grown over the last 20 years. Even overconsumption of healthy
food can lead to a positive calorie balance and weight gain over
time.
• Changing the environment that promotes large portion sizes may
help people “right size” portions (Box 8.3).
BOX Strategies to Promote Portion Control

8.3
Focus on efforts to make food less accessible and less visible.
• Switch to smaller plates, bowls, and glasses.
• Buy smaller packages of food at the grocery store; forgo the jumbo
size.
• Buy prepackaged, portion-controlled items, such as 100 calorie packs.
• Store food out of sight.
• Order smaller portions at restaurants.
• Fill a doggie bag before beginning to eat.
Portion Distortion: A
Table Comparison between
8.6 Portion Sizes 20 Years
Ago and Today
Beyond Calories: Diet Quality

Although the appropriate calorie intake is important for weight, a healthy
eating pattern must also provide adequate amounts of all essential nutrients
while limiting foods or nutrients linked to an increased risk of chronic
disease.
• A simple strategy to achieve a balanced mix of foods is to use the
MyPlate depiction of filling ½ the plate with fruits and vegetables,
approximately ¼ with grains, and ¼ with protein with a choice of
dairy on the side.
• Growing evidence suggests that overall nutrient composition is
important in determining overeating and weight gain (Stinson et al.,
2018). Eating a relatively larger percentage of foods high in fat
(≥45% calories from fat) and high in simple sugars (≥30% of
calories) appears to promote overeating and weight gain.
• Higher intake of ultra-processed food has also been associated with
excess weight, and the association is more pronounced in women
(Juul et al., 2018).
• Foods that qualify as ultra-processed include “junk food” (sugar-
sweetened beverages, potato chips, candy), commercial baked
goods, commercial breads, canned soups, flavored yogurt, and
low-calorie frozen dinners.
• Although these foods may contribute essential nutrients, they tend
to be high in saturated fat, added sugar, and sodium and are
considered poor in nutrition quality.
• “Fat-free” or “sugar-free” versions of ultra-processed foods do
not make them “healthier,” nor do they necessarily lower their
calorie content.
• Conversely, substituting healthier alternatives for calorie-dense
foods within all food groups can help ensure nutrient needs are met
without exceeding calorie limits (Box 8.4).
• Plant-based diets may help reduce the risk of chronic diseases, such
as cardiovascular disease, certain types of cancer, and diabetes.
Healthier Alternatives
BOX
8.4
Here are some foods that contain extra calories from solid fats and/or
added sugars and some healthier alternatives. Choices on the right side
are more nutrient dense—lower in solid fats and added sugars. Try these
new ideas instead of your usual choices. This guide gives sample ideas; it
is not a complete list. Use the “Nutrition Facts” label to help identify
more alternatives.
More Calorically Dense Healthier Alternatives
Foods
Milk Group Plain fat-free yogurt with fresh fruit or

Sweetened fruit yogurt vanilla flavoring
Whole milk Low-fat or fat-free milk
Natural or processed Low-fat or reduced-fat cheese
cheese
Protein Foods Beef round steaks and roasts (eye of

Beef (corned beef, prime cuts round, top round), top sirloin, top
of beef, short ribs, 85% loin, 90% lean or higher ground beef
lean or lower ground
beef) Chicken breast without skin
Low-fat lunch meats (95%–97% fat
Chicken legs with skin free)
Lunch meats (such as Hot dogs (lower fat)
bologna) Canadian bacon or lean ham
Hot dogs (regular) Cooked or canned kidney or pinto beans
Bacon or sausage
Refried beans
More Calorically Dense Healthier Alternatives
Foods
Grain Group Reduced-fat granola
Granola Unsweetened cereals with cut-up fruit
Sweetened cereals Pasta with vegetables (primavera)
Pasta with cheese sauce Pasta with red sauce (marinara)
Pasta with white sauce Toast or bread (try whole-grain types)
(alfredo)
Croissants or pastries
Fruit Group Fresh apple or berries
Apple or berry pie Unsweetened applesauce
Sweetened applesauce Canned fruit packed in juice or “lite”
Canned fruit packed in syrup
syrup
Vegetable Group Oven-baked french fries
Deep-fried french fries Baked potato with salsa
Baked potato with cheese Steamed or roasted vegetables
sauce
Fried vegetables
Solid Fats Light or fat-free cream cheese
Cream cheese Plain low-fat or fat-free yogurt
Sour cream Light-spread margarines, diet margarine
Regular margarine or butter
Added Sugars Seltzer mixed with 100% fruit juice

Sugar-sweetened soft Unsweetened tea or water
drinks Unsweetened applesauce or berries as a
Sweetened tea or drinks topping
Syrup on pancakes or Fresh or dried fruit
french toast Experiment with reducing amount and
Candy, cookies, cake, or adding spices (cinnamon, nutmeg,
pastry etc.)
Sugar in recipes
Be Physically Active
Physical activity is one of the most important actions people of all ages can
do to improve their health, yet 80% of American adults are not meeting the
key guidelines for both aerobic and muscle-strengthening activity (Box 8.5)
(U.S. Department of Health and Human Services [USDHHS], 2018). An
estimated 10% of premature mortality is linked to lack of physical activity.
The chronic disease prevention and health promotion benefits of regular
physical activity are many (Box 8.6). Research shows the following
benefits of physical activity:
• Regular moderate to vigorous physical activity reduces the risk of
many adverse health outcomes.
• Some physical activity is better than none.
• For most health outcomes, additional benefits occur as the amount
of physical activity increases through higher intensity, greater
frequency, and/or longer duration. Tips for increasing activity
appear in Box 8.7.
• Substantial health benefits for adults occur with 150 to 300 minutes
a week of moderate-intensity physical activity, such as brisk
walking. Additional benefits occur with more physical activity.
• Both aerobic and muscle-strengthening physical activity is
beneficial.
• Health benefits occur for children and adolescents, young and
middle-aged adults, older adults, and those in every studied racial
and ethnic group.
• The health benefits of physical activity occur for people with
chronic conditions or disabilities.
• The benefits of physical activity generally outweigh the risk of
adverse outcomes or injury.
Although exercise should be spread across the week if possible,
muscle-strengthening activities for recently ill clients who need to
increase their physical activity to prevent further deterioration
should be undertaken at least twice a week.
Think of Kyla and Garrett. They admit that they get

hungry after doing cardio at the gym and may be sabotaging
themselves by eating too much afterward. What would you
suggest they consume after working out if they cannot wait
until the next meal to eat?
BOX Key Physical Activity Guidelines for Adults

8.5
Adults should move more and sit less throughout the day. Some physical
activity is better than none. Adults who sit less and do any amount of
moderate to vigorous physical activity gain some health benefits.
For substantial health benefits, adults should do at least 150 minutes
(2 hours and 30 minutes) to 300 minutes (5 hours) a week of moderate-
intensity aerobic physical activity or 75 minutes (1 hour and 15 minutes)
to 150 minutes (2 hours and 30 minutes) a week of vigorous-intensity
aerobic physical activity or an equivalent combination of moderate- and
vigorous-intensity aerobic activity. Preferably, aerobic activity should be
spread throughout the week.
Additional health benefits are gained by engaging in physical activity
beyond the equivalent of 300 minutes (5 hours) of moderate-intensity
physical activity a week.
Adults should also do muscle-strengthening activities of moderate or
greater intensity and those that involve all major muscle groups on 2 or
more days a week, as these activities provide additional health benefits.
Source: U.S. Department of Health and Human Services. (2018). Physical activity guidelines for
Americans. https://health.gov/paguidelines/default.aspx
BOX Health Benefits Associated with Regular

8.6 Physical Activity
Strong or moderate evidence shows that adults and older adults receive
the following health benefits from regular physical activity:
• lower risk of all-cause mortality
• lower risk of cardiovascular disease mortality
• lower risk of cardiovascular disease (including heart disease and
stroke)
• lower risk of hypertension
• lower risk of type 2 diabetes
• lower risk of adverse blood lipid profile
• lower risk of cancers of the bladder, breast, colon, endometrium,
esophagus, kidney, lung, and stomach
• improved cognition
• reduced risk of dementia (including Alzheimer’s disease)
• improved quality of life
• reduced anxiety
• reduced risk of depression
• improved sleep
• slowed or reduced weight gain
• weight loss, particularly when combined with reduced calorie intake
• prevention of weight regain following initial weight loss
• improved bone health
• improved physical function
• lower risk of falls (older adults)
• lower risk of fall-related injuries (older adults)
Americans. https://health.gov/paguidelines/default.aspx
BOX Tips for Increasing Physical Activity

8.7
• Find something enjoyable: The best chance of success comes from

choosing a physical activity that is enjoyable to the individual. The
best activity or exercise is one that is performed, not just contemplated.
• Use the buddy system: Committing to an exercise program or
increased physical activity with a friend makes the activity less of a
chore and helps to sustain motivation.
• Spread activity over the entire day if desired: This recommendation
is particularly important for people who “don’t have time to exercise.”
Many people find it easier to fit three 10-minute activity periods into a
busy lifestyle than to find 30 uninterrupted minutes to dedicate to
activity.
• Start slowly and gradually increase activity: For people who have
been inactive, it is prudent to start with only a few minutes of daily
activity, such as walking, and gradually increase the frequency,
duration, and then intensity. People with existing health problems such
as diabetes, heart disease, and hypertension should consult a physician
before beginning a program, as should all men older than 40 years and
all women older than 50 years.
• Move more: Just moving more can make a cumulative difference in
activity. Take the stairs instead of the elevator, park at the far end of
the parking lot, mow the lawn with a push mower, do gardening,
yardwork, walk around while talking on the phone, walk instead of
driving short distances, play golf without a golf cart or caddy, or
fidget.
• Track it: Just as people tend to underestimate the amount of food they
eat, people usually overestimate the amount of physical activity they
perform. Monitoring physical activity provides objective data for
evaluating progress.
Reduce Sitting Time

A relatively new area of research is the health effects of sedentary behavior.
Although the 2018 Advisory Committee found a strong relationship
between sedentary behavior time and the risk of all-cause mortality and
cardiovascular disease mortality in adults, evidence has been insufficient to
recommend a specific sedentary time target for adults or youth. This is
because the risk from sedentary behavior is dependent upon the amount of
moderate to vigorous physical activity performed.
Figure 8.6 illustrates the relationship between sedentary behavior,
moderate to vigorous physical activity, and the risk of all-cause mortality.
Figure 8.6 ▲ Relationship among moderate to vigorous physical
activity, sitting time, and risk of all-cause mortality in adults. (Source:
U.S. Department of Health and Human Services Physical Activity
Guidelines for Americans from Ekelund, U., Steene-Johannessen, J., &
Brown, W. J. [2016, September]. Does physical activity attenuate or even
eliminate, the detrimental association of sitting time with mortality? A
harmonized metaanalysis of data from more than 1 million men and
women. Lancet, 388[10051], 1302–1310. https://doi.org/10.1016/S0140-
6736(16)30370-1)
• The risk of all-cause mortality improves from red (highest risk) →

orange → yellow → green (lowest risk).
• The all-cause mortality risk is greater with the highest daily sitting
time (red, upper left corner) but begins to improve (becomes orange)
with only small amounts of moderate to vigorous physical activity.
This suggests that sedentary adults can reduce their risk of all-cause
mortality by replacing some sitting time with even light physical
activity.
• At the greatest volume of moderate to vigorous physical activity, the
risk is low even for people who sit the most (green, upper right
corner).
• Even adults who sit the least (orange, lower left corner) are at
increased risk if they do not perform any moderate to vigorous
activity.
• Because Americans do not meet physical activity guidelines and
have high levels of sitting time, most Americans would benefit from
moving more and sitting less.
Consider Kyla and Garrett. In addition to the cardio

exercise they are already doing, what other PA
recommendations may be helpful? They have sedentary
jobs. What suggestions would you make to help them
become more active during the work day?
How Do You Respond?

Is eating breakfast helpful for losing weight?
Although often extolled as “the most important meal of
the day,” there is increasing evidence that eating breakfast
does not improve weight loss (St-Onge et al., 2017). In
fact, recommending breakfast to adults to promote weight
loss may have the opposite effect due to an increase in
total daily calorie intake (Sievert et al., 2019). Although
eating breakfast may not promote weight loss in adults, it
should still be encouraged as part of an overall healthy
lifestyle.
Is intermittent fasting a good way to lose
weight? Intermittent fasting has been labeled “the next
big weight loss fad” (Collier, 2013). Intermittent fasting is
a broad term that includes many variations of taking a
break from eating, such as fasting for up to 24 hours once
or twice a week with ad lib food for the remaining days;
eating only for 8 hours and then fasting for the other 16
hours of the day; and alternate-day fasting. There is
evidence that both alternate-day fasting and periodic
fasting may be effective for weight loss, although there
are no data to indicate whether the weight loss can be
sustained over the long term (St-Onge et al., 2017). A
review of animal studies and recent clinical trials also
suggests that intermittent fasting may have beneficial
effects on cardiovascular biomarkers and may decrease
inflammation and oxidative stress (Stockman et al.,
2018). Intermittent fasting appears to be a viable weight
loss method, though a continuous calorie-restricted diet
may be as effective (Stockman et al., 2018). Further long-
term human studies are needed using a consistent
definition of intermittent fasting.
REVIEW CASE STUDY

Tonya is 5 ft 3 in. tall, weighs 151 pounds, and is 38 years old. Her waist
circumference is 37 in. As a receptionist for a law firm and mother of two
socially active children, her life is busy but sedentary. She simply does not
have the time or energy to stay with an exercise program after working all
day and caring for her children. She would like to lose about 20 pounds but
knows “dieting” doesn’t work for her—all the diets she has tried in the past
have left her hungry and feeling deprived. Losing weight has taken on
greater importance since her doctor told her that both her blood pressure
and glucose level are at “borderline” high levels.
• What is her BMI? Assess her weight based on BMI.

• Estimate her total calorie requirements using the Mifflin-St Jeor method
of calculating BEE and adding calories for a sedentary lifestyle. How
does it compare to the level of calories recommended in Table 8.3 for a
woman of her age and sedentary lifestyle?
• Which calorie level do you think is most accurate? Why?
• How many calories would she need to eat to lose 1 pound of weight per
week if her activity level stays the same? Two pounds per week? Is a 2-
pound weight loss per week a reasonable goal?
• To help her avoid feeling hungry while eating fewer calories, what foods
would you recommend she consume more of? She knows she should
drink fewer soft drinks. What advice would you give her to help her do
that?
STUDY QUESTIONS
1 For most Americans, the largest percentage of their total calories

expended daily is from
a. Physical activity.
b. thermal effect of food.
c. basal energy expenditure.
d. sitting.
2 A nurse knows that their instructions about portion control have been
effective when the client verbalizes that they will
a. prepare a doggie bag after they feel they are full enough while eating
out.
b. use a smaller dinner plate.
c. be careful not to overfill their cereal bowl when they serve themselves
from the large, family-sized box.
d. remind themselves not to overeat.
3 A client asks how they can speed up their metabolism. Which of the
following is the best response?
a. “You can’t. Metabolic rate is genetically determined.”
b. “Ask your doctor to check your thyroid hormone levels. Taking
thyroid hormone will stimulate metabolism.”
c. “Include strength training in your exercise program because adding
muscle tissue will increase metabolic rate.”
d. “Eat fewer calories because that will stimulate metabolic rate.”
4 How much weight will a person lose in a week if they eat 500 fewer
cal/day than they need and increase their exercise expenditure by 500
cal/day?
a. 1 pound per week.
b. 2 pounds per week.
c. 3 pounds per week.
d. There isn’t enough information provided to estimate weekly weight
loss.
5 Using a simple formula based on calories per kilogram of body weight,
how many calories per day would a healthy-weight adult who weighs 70
kg need?
a. 2350 to 2800 calories
b. 2100 to 2350 calories
c. 1750 to 2100 calories
d. 1400 to 1750 calories
6 Waist circumference is an indicator of
a. percentage of body fat.
b. central obesity.
c. the ratio of body fat to muscle mass.
d. BMI.
7 Which of the following substitutions results in a less calorically dense
choice?
a. Canadian bacon in place of bacon
b. refried beans instead of cooked or canned pinto beans
c. natural cheese instead of low-fat cheese
d. baked potato with cheese sauce instead of baked potato with salsa
8 A BMI of 26 is classified as
a. normal
b. overweight
c. class 1 obesity
d. class 2 obesity
CHAPTER SUMMARY ENERGY

BALANCE
Calories are derived from the metabolism of carbohydrates, protein, fat,
and alcohol. Calories are expended to fuel basal metabolic functions,
physical activity, and digesting, absorbing, and metabolizing food.
State of Energy Balance

The relationship between calorie intake and calorie expenditure
determines energy balance.
• A neutral balance occurs when calorie intake and expenditure are
approximately equal. Body weight stays stable.
• A positive balance occurs when calorie intake exceeds expenditure.
Over time, body weight increases.
• A negative balance occurs when calorie intake is less than
expenditure. Over time, weight loss occurs.
Estimating Total Calorie

Requirements
Ways to estimate total calorie requirement include
• using a predictive equation based on gender, height, weight, age, and
activity level, such as the Mifflin-St Jeor formula,
• using a standard of 25 to 30 cal/kg for healthy adults,
• referring to a list of estimated calorie needs based on age, gender, and
activity level.
Evaluating Weight Status

Methods to evaluate body weight include the following:
• BMI, which uses height and weight, does not distinguish between
genders, nor does it compensate for body composition (e.g., muscle
mass) or body weight distribution.
• Waist circumference assesses fat distribution to identify central
obesity, which increases the risk of cardiovascular disease, type 2
diabetes, and all-cause mortality.
• WHR divides waist circumference by height. Results >0.5 indicate
central obesity risk. Simple advice is to “keep your waist to less than
half your height.”
Energy Balance in Health

Promotion
Health is promoted when individuals consume the appropriate number of
calories, are physically active, and limit sitting time.
Consume an appropriate number of calories.
• After the appropriate number of calories has been determined by any
of the previously discussed methods, a heatlhy eating pattern can be
used to determine the number of servings per food group
recommended to meet nutrient needs without exceeding calorie limits.
• Some foods, such as foods high in added fat, high in added sugar, and
ultra-processed foods, may promote weight gain more than wholesome
foods that characterize a healthy plant-based eating pattern.
• Portion control is inherent in achieving the appropriate number of
calories.
• Making food less visible and accessible may help control overeating.
Be physically active.
• Any exercise is better than none.
• Generally, the more activity the better.
• Moderate to vigorous activity should occur on most days of the week.
• Health benefits from physical activity are physical, emotional, and
even cognitive.
• Strength training twice a week is recommended.
Sit less.
• There is a strong relationship between sedentary behavior time and the
risk of all-cause mortality and cardiovascular disease mortality in
adults.
• The risk from sedentary behavior is dependent upon the amount of
moderate to vigorous physical activity performed.
• The all-cause mortality risk is greatest with the highest daily sitting
time in combination with the least moderate-to-vigorous physical
activity.
Sedentary adults can reduce their risk of all-cause mortality by
• replacing some sitting time with even light physical activity.
Figure sources: shutterstock.com/Jose Luis Stephens and shutterstock.com/txking

book at
Websites
American College of Sports Medicine at www.acsm.org
Calculate your own calories at https://www.mayoclinic.org/healthy-lifestyle/weight-loss/in-
depth/calorie-calculator/itt-20402304
National Institute of Diabetes and Digestive and Kidney Diseases, Weight-Control Information
Network at https://www.niddk.nih.gov/health-information/health-communication-
programs/win/Pages/community-groups-organizations.aspx
Physical Activity Guidelines for Americans at https://health.gov/paguidelines/default.aspx
President’s Council on Physical Fitness and Sports at www.fitness.gov
References
American Diabetes Association & Academy of Nutrition and Dietetics. (2019). Choose your foods:
Food lists for weight management. American Diabetes Association.
Ashwell, M., & Gibson, S. (2014). A proposal for a primary screening tool: “Keep your waist
circumference to less than half your height.” BMC Medicine, 12(207).
https://doi.org/10.1186/s12916-014-0207-1
Ashwell, M., & Gibson, S. (2016). Waist-to-height ratio as an indicator of “early health risk”:
Simpler and more predictive than using a “matrix” based on BMI and waist circumference. BMJ
Open, 6, e010159. https://doi.org/10.1136/bmjopen-2015-010159
Ashwell, M., Gunn, P., & Gibson, S. (2012). Waist-to-height ratio is a better screening tool than waist
circumference and BMI for adult cardiometabolic risk factors: Systematic review and meta-
analysis. Obesity Reviews, 13(3), 275–286. https://doi.org/10.1111/j.1467-789X.2011.00952.x
Collier, R. (2013). Intermittent fasting: The science of going without. Canadian Medical Association
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Després, J. (2012). Body fat distribution and risk of cardiovascular disease: An update. Circulation,
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Hsu, W., Araneta, M., Kanaya, A., Chiang, J., & Fujimoto, W. (2015). BMI cut points to identify at-
risk Asian Americans for type 2 diabetes screening. Diabetes Care, 38(1), 150–158.
https://doi.org/10.2337/dc14-2391
Juul, F., Martinez-Steele, E., Parekh, N., Monteiro, C. A., & Chang, V. W. (2018). Ultra-processed
food consumption and excess weight among US adults. British Journal of Nutrition, 120(1), 90–
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National Heart, Lung, and Blood Institute Obesity Task Force. (1998). Clinical guidelines on the
identification, evaluation, and treatment of overweight and obesity in adults—The evidence
report. Obesity Research, 6(Suppl. 2), 51S–209S.
National Institutes of Health, National Heart Lung and Blood Institute. (2000). The practical guide
identification, evaluation, and treatment of overweight and obesity in adults. NIH Publication
Number 00-4084. https://www.nhlbi.nih.gov/files/docs/guidelines/prctgd_c.pdf#page=19
Purnell, J. (2018). Definitions, classification, and epidemiology of obesity. [Updated April 12, 2018].
In K. R. Feingold, B. Anawalt, A. Boyce, et al. (Eds.), Endotext [Internet]. MDText.com, Inc.;
2000-. https://www.ncbi.nlm.nih.gov/books/NBK279167/
Sievert, K., Hussain, S. M., Page, M. J., Wang, Y., Hughes, H. J., Malek, M., & Cicuttini, F. M.
(2019). Effect of breakfast on weight and energy intake: Systematic review and meta-analysis of
randomised controlled trials. British Medical Journal, 364, 142. https://doi.org/10.1136/bmj.l42
Stinson, E. J., Piaggi, P., Ibrahim, M., Venti, C., Krakoff, J., & Votruba, S. B. (2018). High fat and
sugar consumption during ad libitum intake predicts weight gain. Obesity, 26(4), 689–695.
https://doi.org/10.1002/oby.22124
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worth the weight? Current Obesity Reports, 7, 172–185. https://doi.org/10.1007/s13679-018-
0308-9
St-Onge, M.-P., Ard, J., Baskin, M., Chiuve, S., Johnson, H., Kris-Etherton, P., & Varady, K., & on
behalf of the American Heart Association Obesity Committee of the Council on Lifestyle and
Cardiometabolic Health; Council on Cardiovascular Disease in the Young; Council on Clinical
Cardiology; and Stroke Council. (2017). Meal timing and frequency: Implications for
cardiovascular disease prevention—A scientific statement from the American Heart Association.
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Shadyab, A. H., Chlebowski, R. T., Manson, J. E., & Bao, W. (2019). Association of normal-
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https://doi.org/10.1001/jamanetworkopen.2019.7337
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Zhang, C., Rxrode, K. M., van Dam, R. M., Li, T. Y., & Hu, F. B. (2008). Abdominal obesity and the
risk of all-cause cardiovascular, and cancer mortality. Sixteen years of follow-up in US Women.
Circulation, 117(13), 1658–1667. https://doi.org/10.1161/CIRCULATIONAHA.107.739714
UNIT TWO
Nutrition in Health Promotion

Chapter Food and Supplement
9 Labeling
Rebecca McNally
Rebecca McNally is recently graduated from college.
As an undergraduate, she gained 25 pounds, which
she attributes to fast food, irregular eating patterns,
convenience foods, snacking, and alcohol. Now that
she is living in her own apartment, Rebecca wants to
get her weight under control and eat healthier so she
has more energy.
Learning Objectives
1 Describe requirements for listing ingredients on the label.

2 Explain how the Nutrition Facts label can help consumers make better
food choices.
3 Give examples of an unqualified health claim and a qualified health
claim.
4 Describe how the regulation and marketing of dietary supplements differ
from regulation and marketing of drugs.
Suggest precautions supplement users should take to limit the potential
5 for adverse effects.
6 Discuss the use of cannabidiol.
Interest in food labeling began in the 1960s, when consumers became

concerned about what was in the processed foods they were eating (Brown,
2019). The government responded with new labeling regulations, which
have evolved over time to the labels we have today. Nutrition labeling is a
tool consumers can use to choose a healthy diet. This chapter presents food
labeling regulations, dietary supplement regulations, and the growing
popularity of cannabidiol (CBD).
FOOD LABELING
Food labeling laws date back to 1967, when the Fair Packaging and
Labeling Act directed the Federal Trade Commission (FTC) and the U.S.
Food and Drug Administration (FDA) to issue regulations mandating that
specific information be included on the food label: the name and form (e.g.,
sliced or chopped) of the product; the net amount of the food or beverage
by weight, measure, or count; and the name and address of the
manufacturer, packer, or distributor. The purpose of the Fair Packaging and
Labelling Act was to enable value comparisons and to prevent unfair or
deceptive packaging and labeling. Current labeling regulations covered in
the next section include ingredient lists, Nutrition Facts, additional labeling
regulations and allowed claims, and industry-originated labeling.
Ingredient List
The ingredients of packaged (canned, bottled, boxed, and wrapped) foods
must be listed in descending order by weight. The further down the list an
item appears, the less of that ingredient is in the product. This information
gives the consumer a relative idea of how much of each ingredient is in a
product but not the proportion. Ingredients present in amounts of ≤2% by
weight can be listed after a quantifying statement such as “contains 2% or
less of …”; however, this 2% rule does not remove the requirement that
ingredients be declared regardless of their level.
Nutrition Facts
In the spring of 2016, the FDA published final rules on an updated
Nutrition Facts panel that reflects new scientific information, including the
link between diet and chronic disease such as obesity and heart disease
(U.S. Food and Drug Administration [FDA], 2020a). Most foods were
required to bear the new label by January 1, 2020. Smaller food
manufacturers have until January 1, 2021, to comply. Manufacturers of
single ingredient sugars (e.g., honey, maple syrup) have until July 1, 2021,
to make the changes. Figure 9.1 features the updated Nutrition Facts label.
Changes are summarized in the following section.
Figure 9.1 ▲ The new nutrition facts label and key changes to nutrition
facts. (Source: U.S. Food and Drug Administration. [2020a, July 10].
Changes to the nutrition facts label. https://www.fda.gov/food/food-
labeling-nutrition/changes-nutrition-facts-label)
Greater Understanding of Nutrition Science

The Nutrition Facts label reflects what is currently known about nutrition
and health. Added sugars are included in both grams and as the Percent
Daily Value (%DV), based on the guideline that the daily intake of calories
from added sugars not exceed 10% of total calories consumed. Added
sugars were previously not included.
• The Daily Values (DVs) for sodium, dietary fiber, and vitamin D
are based on newer scientific evidence.
• The micronutrients required in both gram amount and %DV are
vitamin D, calcium, iron, and potassium. Potassium and vitamin D
are new to the label because they are nutrients of public health
significance. Vitamin A and C content are no longer required
because deficiencies of these nutrients in the general population are
not common.
• “Calories from fat” is eliminated based on evidence that the type of
fat consumed is more important than total fat intake.
Percent Daily Value (%DV)

amount of nutrients to consume, or not exceed, which is used on both food and dietary
supplement labels. The %DV refers to the percentage of the nutrient in one serving of food based
on the daily goal in a 2000-calorie diet.
Daily Values (DVs)

reference values established by the FDA for use on food labels. For some nutrients (e.g., sodium),
they are amounts that should not be exceeded; for others (e.g., fiber), they are amounts to strive
toward. For nutrient intakes that are based on the percentage of calories consumed, 2000 calories
is the standard used.
Updated Serving Sizes

Changes to the label reflect how people currently eat and drink.
• Serving sizes must be based on amounts of foods and beverages that
people are actually eating, not what they should be eating or the
previous serving size requirements published in 1993. For instance,
the reference amount for a serving of soda is now 12 oz, not 8 oz,
and the reference amount for a serving of ice cream has increased to
2/3 cup from ½ cup.
• Packaged foods and beverages that are typically consumed in one
sitting are labeled as a single serving; therefore, calories and nutrient
information listed are for the entire package. For instance, a 20-oz
soft drink, typically consumed in one sitting, is labeled as one
serving, not 2½ servings.
• A dual-column label is required on certain larger packages that
could be consumed in either one or multiple sittings, such as a 24-oz
bottle of soft drink or a pint of ice cream. One column is per serving
and one per package.
Refreshed Design
The iconic look of the label was slightly changed to ensure consumers have
access to information they need to make informed decisions. The font size
is larger for calories, servings per container, and serving size.
• The number of calories and the serving size declaration are in bold
type to emphasize their importance in public health concerns such as
obesity, diabetes, and cardiovascular disease.
• The footnote more clearly explains the meaning of the %DV. It
reads, “The % Daily Value tells you how much a nutrient in a
serving of food contributes to a daily diet. Two thousand calories a
day is used for general advice.”
Recall Rebecca. She has begun to read labels now that she
is doing her own grocery shopping and meal prep. What are
the most important Nutrition Facts for her to focus on to
make healthy choices?
Food Labeling Exemptions

Almost 90% of all packaged foods provide nutrition information. Some
foods are exempt from labeling.
• raw foods: fresh fruits, vegetables, and fish
• foods containing insignificant amounts of nutrients, such as coffee,
tea, and spices
• bulk food
• foods in packages with a surface area for labeling of <12 square
inches, such as breath mints
Additional Label Declarations

Regulations regarding allergens, gluten-free products, and the country of
origin have been enacted through various other labeling acts.
Allergens
Manufacturers are required to clearly state if a food product contains any
ingredients that contain protein from the eight major food allergens listed in
Box 9.1. These eight allergens are responsible for 90% of all food allergies.
BOX Major Allergens That Must Be Declared on

9.1 the Food Label
Milk
Eggs
Fish
Crustacean shellfish
Tree nuts
Peanuts
Wheat
Soybeans
Gluten-Free
Regulations require that a product must contain <20 ppm of gluten to be
labeled as gluten-free. Products that are naturally gluten-free, such as
tomatoes, may be labeled gluten-free. Although some consumers think the
20 ppm threshold is too high, the Celiac Disease Foundation supports 20
ppm as a suitable safety threshold (Celiac Disease Foundation, 2014).
Country of Origin
The USDA requires Country of Origin labeling on beef, lamb, pork,
chicken, fish, shellfish, peanuts, fresh and frozen fruits and vegetables,
pecans, macadamia nuts, and ginseng. Certain exemptions apply. Although
Country of Origin does not provide information regarding food safety, it
does enable consumers to make informed decisions about purchasing items
from countries that may not regulate pesticides or antibiotic use as closely
as the United States. Three categories are defined:
• U.S.-only origin
• foreign-only origin
• mixed origin (This category must be labeled with the country of
birth, raising, and slaughter.)
FDA-Allowed Claims
The FDA allows three types of claims on food and dietary supplement
labels: nutrient content claims, health claims, and structure/function
claims.
Nutrient Content Claims

label descriptions of the amount of a nutrient or substance provided in a food or beverage.
Health Claim
a statement that describes a relationship between a food, food substance, or dietary supplement
ingredient and a reduced risk of disease or a disease-related condition.
Structure/Function Claims
statements identifying relationships between nutrients or dietary ingredients and a body function.
Nutrient Content Claims

Terms such as low, free, and high describe the level of a nutrient or
substance in a food. The terms are legally defined, so they are reliable and
valid. Nutrient claims may also compare the level of a nutrient to that of
comparable food with terms such as more, reduced, or light. Box 9.2
defines the terms used in nutrient claims.
BOX Definitions of Terms Used in Nutrient
9.2 Claims
Free: the product contains virtually none of that nutrient. Free can refer
to calories, sugar, sodium, salt, fat, saturated fat, and cholesterol.
Low: there is a small enough amount of a nutrient that the product can be
used frequently without concern about exceeding dietary
recommendations. Low sodium, low calorie, low fat, low saturated
fat, and low cholesterol are all defined as to the amount allowed per
serving. For instance, to be labeled low cholesterol, a product must
have no more than 20 mg cholesterol per serving.
Very low: refers to sodium only. The product cannot have >35 mg
sodium per serving.
Reduced or less: the product has at least a 25% reduction in a nutrient
compared to the regular product.
Light or lite: the product has fewer calories than a comparable product
or 50% of the fat found in a comparable product.
Good source: the product provides 10% to 19% of the DV for a nutrient.
High, rich in, or excellent source: the product has at least 20% of the
DV for a nutrient.
More: the product has at least 10% more of a desirable nutrient than does
a comparable product.
Lean: meat or poultry products with <10 g fat, <4 g saturated fat, and
<95 mg cholesterol per standardized serving and per 100 g.
Extra lean: meat or poultry products with <5 g fat, <2 g saturated fat,
and <95 mg cholesterol per standardized serving and per 100 g.
Health Claims
A health claim proposes a relationship between a food or substance in a
food and a disease or health-related condition. There are two types of health
claims, and they differ in the degree of scientific evidence that supports the
claim.
Unqualified Health Claims
Unqualified health claims, also known as authorized health claims, are
supported by significant scientific agreement (SSA) among experts who
have examined the evidence (Box 9.3).
• These claims are referred to as unqualified health claims because
they do not require a disclaimer about the strength of evidence
supporting the claim.
• Foods must contain enough of the nutrient to contribute at least 10%
of the DV and must not contain any nutrient of substance that
increases the risk of a disease or health condition (Brown, 2019).
For instance, whole milk cannot make the claim regarding calcium
and osteoporosis because its saturated fat content is high.
Examples of Approved Unqualified Health

BOX
Claims That Are Supported by Significant
9.3 Scientific Agreement
Cancer Risk
• Dietary fat
• Fruits and vegetables
• Fiber-containing grain products
Coronary Heart Disease Risk

• Saturated fat and cholesterol
• Fruits, vegetables, and grain products that contain fiber, particularly
soluble fiber
• Plant sterol/stanol esters
• Soluble fiber, such as that found in whole oats and psyllium seed husk
• Soy protein
Useful in Not Promoting Dental Caries

• Dietary noncariogenic carbohydrate sweeteners (e.g., sugar alcohols
such as xylitol and sorbitol and the nonnutritive sweetener sucralose)
Hypertension Risk
• Sodium
Neural Tube Defect Risk

• Folate
Osteoporosis Risk
• Calcium
• Calcium and vitamin D
Unqualified Health Claim

a type of health claim supported by significant scientific agreement.
Qualified Health Claims

The FDA allows certain qualified health claims when the relationship
between food, a food component, or a supplement is not strong enough to
meet SSA or published authoritative standards.
Qualified Health Claim
a type of health claim that must be qualified by a statement that specifies the degree of scientific
evidence that supports it. These claims are based on the weight of evidence but are not considered
to be backed by significant scientific agreement.
• The term qualified as it relates to health claims means that the claim
is limited in some way.
• FDA-approved language allowed for these claims is very specific,
and companies must petition the FDA for prior written permission
to make a qualified health claim.
• The weakest claim is as follows: “Very limited and preliminary
scientific research suggests [health claim]. The FDA concludes that
there is little scientific evidence supporting this claim.”
• Examples of qualified health claims are listed in Box 9.4.
BOX Examples of Qualified Health Claims

9.4
Cancer Risk
• Green tea
• Selenium
• Antioxidant vitamins
• Tomatoes and/or tomato sauce (prostate, ovarian, gastric, and
pancreatic cancers)
Cardiovascular Disease Risk

• Nuts
• Walnuts
• Monounsaturated fatty acids from olive oil
• Omega-3 fatty acids
• B vitamins
• Unsaturated fatty acids from canola oil
• Corn oil
Hypertension Risk and Pregnancy-Induced Hypertension

and Preeclampsia
• Calcium
Remember Rebecca. She is unsure of the value of health

claims she has seen on nuts. She’s been avoiding them
because they are high in calories, but Rebecca heard the
claim that they may reduce the risk of heart disease. She’s
wondering if she should add them to her diet. What would
you tell Rebecca?
Structure/Function Claims
Structure/function claims suggest the possibility that a food may improve or
support body function, which is a fine distinction from the approved health
claims that relate a food or nutrient to a disease.
• An example of a disease claim needing approval is “suppresses
appetite to treat obesity,” whereas a function claim that does not
need approval is “suppresses appetite to aid weight loss.”
• These structure claims had previously been used primarily by
supplement manufacturers with the following disclaimer: “These
statements have not been evaluated by the FDA. This product is not
intended to diagnose, treat, cure, or prevent any disease.”
• Structure/function claims are now appearing on food labels and do
not require a disclaimer.
• Unlike health claims that can appear only on foods that meet other
nutritional criteria (e.g., they cannot be high in fat, cholesterol,
sodium), structure/function claims can appear on junk foods.
• Structure/function claims do not require FDA approval, so there
may be no evidence to support the claim.
• See Box 9.5 for structure/function claims that do not need prior
approval.
BOX Structure/Function Claims That Do Not

9.5 Need Approval
Improves memory
Improves strength
Improves digestion
Boosts stamina
For common symptoms of premenstrual syndrome
For hot flashes
Helps you relax
Helps enhance muscle tone or size
Relieves stress
Helps promote urinary tract health
Maintains intestinal flora
For hair loss associated with aging
Prevents wrinkles
For relief of muscle pain after exercise
To treat or prevent nocturnal leg muscle cramps
Helps maintain normal cholesterol levels
Provides relief of occasional constipation
Supports the immune system
Industry-Originated Labeling
Over the last decade, many food manufacturers and some health
organizations have added a variety of nutrition symbols and rating systems
to the front of food packages to show how nutritious they are. For instance,
to guide consumers toward heart healthy choices, the American Heart
Association Heart-Check utilizes a single symbol that features a red heart
with a check mark in it and accompanied by the words American Heart
Association Certified. The Whole Grain Council’s Whole Grain Stamp is a
front-of-package symbol used to indicate the presence of a food group or
ingredient. Although intended to simplify choices for consumers, having
too many types of front-of-package labels may actually increase confusion.
Facts Up Front
The Grocery Manufacturers Association and Food Marketing Institute
created a voluntary front-of-package labeling initiative known as Facts Up
Front.
• In a standardized format, four basic icons provide information from
the Nutrition Facts panel on calories, saturated fat, sodium, and
sugar. All four basic icons must appear.
• Up to two additional nutrients that have positive health benefits—
namely, potassium, fiber, protein, vitamin A, vitamin C, vitamin D,
calcium, and iron—may be added (Fig. 9.2). These additional
nutrients can be placed on a package only when one serving
provides 10% or more of the DV.
• Smaller packages may limit the icon to just calories.
Figure 9.2 ▲ Facts Up Front.
DIETARY SUPPLEMENTS
As defined by law, a dietary supplement is a product other than tobacco that

• is intended to supplement the diet,
• contains one or more dietary ingredients, including vitamins,
minerals, herbs or other botanicals, amino acids, and other
substances or their constituents,
• is taken by mouth as a pill, capsule, tablet, or liquid, and
• must be labeled as a dietary supplement on the front panel (Fig. 9.3).
Figure 9.3 ▲ Supplement label. (Source: Council for Responsible
Nutrition. [2017]. Dietary supplement labeling.
https://www.crnusa.org/sites/default/files/pdfs/DS-RegsLabel-2017.pdf)
Think of Rebecca. She bought melatonin supplements
because she read online that melatonin promotes sleep. What
would you tell Rebecca about supplements in general?
Supplement Popularity
In 2018, Americans spent $42.6 billion on dietary supplements (Reports
and Data, 2019). Potential health benefits (Box 9.6), an aging population,
increasing healthcare costs, and medical discoveries are among the factors
fueling consumer interest in dietary supplements. Supplement use is
widespread because they are readily accessible, are low in cost, appeal to
people as natural cures, are presumed to be safe and effective, and allow
consumers to take charge of their own health (Starr, 2015).
BOX Top Reasonsa Adults Cite for Taking

9.6 Supplements
For overall health/wellness benefits: 30%

For energy: 24%
For immune health: 20%
To fill nutrient gaps: 19%
For heart health: 18%
For healthy aging: 18%
Reasons are not limited to one response per survey participant.
a
Source: Council for Responsible Nutrition (CRN). (2019). Who takes dietary supplements? And
why? 2019 CRN Consumer Survey on Dietary Supplements.
https://www.crnusa.org/2019survey
While vitamins account for the largest share of the supplement market,
sales of herbs and botanicals continue to grow at the fastest pace among
supplement categories and represent the second largest category of
supplement sales (Nutrition Business Journal, 2019). The top 10 selling
herbal dietary supplements in U.S. Natural Channels (e.g., natural and
health food specialty retail outlets) are listed in Box 9.7.
BOX The Top 10 Selling Herbal Dietary
Supplements in U.S. Natural Channels
9.7
1. CBD
2. Turmeric
3. Elderberry
4. Wheatgrass/barley grass
5. Flax seed/flax oil
6. Aloe vera
7. Ashwagandha
8. Milk thistle
9. Echinacea
10 Oregano
Source: Smith, T., Gillespie, M., Eckl, V., & Reynolds, C. M. (2019). Herbal supplement sales in
U.S. increase by 9.4% in 2018. HerbalGram, Fall 2019(123), 62–73.
http://cms.herbalgram.org/herbalgram/issue.html?Issue=123
Good Manufacturing Practices

The FDA requires dietary supplements to be produced using current good
manufacturing practices. Identity, purity, strength, and composition are
required to be accurately reflected on the label. This is intended to protect
consumers by requiring supplements to
• meet quality standards for manufacturing processes,
• be free of contaminants or impurities such as natural toxins,
bacteria, pesticides, glass, lead, or other substances,
• be manufactured to ensure identity, purity, and composition, and
• have an accurate listing of ingredients.
Supplement Regulations: Similarities with Food

Labeling
By law, supplement labels share certain characteristics with food labels.
• The Supplement Facts panel is similar to the Nutrition Facts panel
(Fig. 9.1).
• Nondietary ingredients such as fillers, artificial colors, sweeteners,
flavors, or binders must be listed in descending order by weight.
• Health claims, nutrient content claims, or structure/function claims
(as discussed under the FDA-allowed claims for food labeling in the
previous section) are allowed.
• Supplements that make a structure/function claim must also include
the disclaimer that reads, This statement has not been evaluated by
the FDA. This product is not intended to diagnose, treat, cure, or
prevent any disease.
Herbal Supplements
supplements from plants or parts of plants used to alleviate health problems or promote wellness.
Some herbal supplements (such as cranberry) have few or no drug–

supplement interactions whereas others, such as ginseng, St. John’s
work, and ginkgo biloba, have significant interaction potential.
Because herbal supplements may have significant interactions with
each other or with prescribed medications, users should consult their
healthcare provider before using.
User Beware: Herbs Are Like Unapproved Drugs

In their medicinal sense, herbs are technically unapproved drugs.
Approximately 30% of drugs used today originated from plants (e.g.,
paclitaxel, aspirin, digoxin). In the United States, dietary supplements do
not have to meet the same standards as drugs and over-the-counter
medications. However, dietary supplements cannot claim to be used for the
diagnosis, treatment, cure, or prevention of disease. Supplements differ
greatly from conventional drugs in how they are marketed and regulated.
Safety and Effectiveness Are Not Proven

Although the functions and requirements of vitamins and minerals are fairly
well understood, scientific research is lacking for many herbal products.
Many people mistakenly believe natural is synonymous with safe. They
assume that herbs must be harmless because they come from flowers,
leaves, and seeds. In truth, herbs are not guaranteed to be safe or effective.
• Before a drug can be marketed, the FDA must authorize its use
based on the results of clinical studies performed to determine
safety, effectiveness, possible interactions with other substances, and
appropriate doses.
• In contrast, the regulations regarding dietary supplements are lax.
• Ingredients sold in the United States before October 15, 1994, are
assumed to be safe and so do not require FDA review for safety
before they are marketed. The FDA is limited in regulating these
supplements.
• Dietary supplement manufacturers that want to market a new
dietary ingredient must submit information to the FDA that
supports their conclusion that reasonable evidence exists that the
product is safe for human consumption.
• Manufacturers do not have to prove to the FDA that dietary
supplements are safe or effective; however, they are not supposed
to market unsafe or ineffective products and are required to report
all serious dietary supplement adverse events to the FDA.
• Once a product is marketed, the responsibility lies with the FDA
to take action against supplement manufacturers if one of their
products is a significant or unreasonable risk of illness or injury
when used as recommended; poses an imminent hazard to public
health or safety; is a new ingredient for which there is inadequate
safety information; or has been adulterated (Resnik, 2017). The
burden of proof falls on the FDA to demonstrate that a product
meets one of these conditions before taking action against a
manufacturer.
• When the FDA determines that a supplement is unsafe, it issues a
consumer advisory discouraging its use.
• One study estimated that at least 1 in 12 American adults take an
herbal supplement known to cause kidney damage. Other
supplements are known carcinogens, hepatotoxins, and hormone
modulators (Starr, 2015).
New Dietary Ingredient
supplement ingredient not marketed in the United States before October 15, 1994.
Strength and Dosages Are Not Standardized

Dietary supplements are not required to be standardized in the United
States. This means there is no safeguard to ensure batch-to-batch
consistency in products.
• The concentration of active compounds in different batches of
supposedly identical plant material can vary greatly.
• Factors that influence concentration include the variety of plant
used, the part of the plant used (e.g., the stems or leaves), and the
maturity of the plant at harvest.
• Supplements may theoretically be marketed in any concentration as
long as the daily recommended value, if applicable, is specified on
the label.
• Recommended dosages vary among manufacturers because there is
no premarket testing to determine optimum dosage or maximum
safe dosage.
• Other than manufacturer responsibility to ensure safety, there are no
regulations that limit a serving size of any supplement.
• Many people believe that if a little is good, then more is better. They
proceed to megadoses, which raises additional safety concerns
(Starr, 2015).
Standardized
a manufacturing process that ensures product consistency from batch to batch.
Warnings Are Not Required

Unlike drugs, supplements are not required to carry warning labels about
potential side effects, adverse effects, or supplement–drug interactions. Due
to lack of extensive research, problems with supplements are not even
known. There are also no advisories about who should not use the product.
Supplements Are Self-Prescribed

A major concern with self-medication is that consumers may misdiagnose
their condition or forsake effective conventional medical care to treat
themselves in a way that they regard as natural.
• Patients may not inform their physicians about their use of herbs, so
side effects and herb–drug interactions go undiagnosed and
unreported.
• The responsibility for determining whether a product has been
recalled by the FDA rests with the user.
• Suggested precautions for supplement users are summarized in Box
9.8.
BOX Suggested Precautions for Supplement

9.8 Users
Clients who choose to use supplements should

• evaluate the potential benefits compared to the potential risks using
scientific evidence,
• recognize that natural does not necessarily mean safe and the terms
standardized, verified, and certified do not guarantee quality or
consistency,
• understand that if it sounds too good to be true, then it probably is,
• check with the FDA website for consumer advisories on supplements
to avoid,
• discuss supplement use with the physician,
• be aware that some supplements have been found to be contaminated
with prescription drugs or other compounds, especially supplements
marketed for weight loss, sexual health, and athletic performance,
• take only single supplement products and keep the dose small to
prevent and manage adverse side effects and supplement–drug
interactions,
• take supplements at different times from prescribed medications to
help reduce the potential for supplement–drug interactions,
• discontinue supplements immediately if adverse side effects or
supplement–drug interactions occur, and
• avoid herbs and other botanical supplements if they are pregnant or
lactating women or children under the age of 6 years.
Cannabidiol
One relatively new product to the marketplace is CBD. Beginning in 2018,
sales of CBD skyrocketed, making it the top selling product in the natural
channel as well as the fastest growing ingredient (Smith et al., 2019).
Currently, CBD may be found in hundreds of supplements, foods, and other
products such as drinks, pet products, lotions, and chewable gummies. The
marketplace for CBD products is growing faster than the science behind it
and federal laws to regulate it (MacCleery, 2019).
CBD is the second most prevalent active ingredient in cannabis
(marijuana), second only to tetrahydrocannabinol or THC. Although CBD
is a component of medical marijuana, it is derived from the hemp plant.
According to the World Health Organization, “In humans, CBD exhibits no
effects indicative of any abuse or dependence potential. … There is no
evidence of public health related problems associated with the use of pure
CBD” (World Health Organization [WHO], 2017; p.5). Unlike THC, CBD
does not cause euphoria—or a high. However, it does change
consciousness, promoting a mellow feeling, diminishing the sensation of
pain, and increasing comfort (Harvard Health Publishing, 2019).
The strongest evidence for using CBD is its effectiveness in treating
certain epilepsy syndromes that usually do not respond to antiseizure
medications. The FDA has approved only one CBD product, the
prescription drug Epidiolex, for treatment of two severe seizure disorders in
children. There is moderate evidence that CBD can improve sleep
disorders, fibromyalgia pain, muscle spasticity related to multiple sclerosis,
and anxiety (Harvard Health Publishing, 2019).
The legal status of CBD is murky. The FDA has concluded that THC
and CBD products do not meet the definition of dietary supplement because
CBD is an active ingredient in an approved drug (Epidiolex). The FDA
further states that it is “illegal to market CBD by adding it to a food or
labeling it as a dietary supplement” (FDA, 2020b).
In the meantime, the FDA claims it is cracking down on companies that
are using “egregious and unfounded claims” to market their products to
“vulnerable populations” (Harvard Health Publishing, 2019). Because it is
illegal to advertise that CBD-infused products can prevent, treat, or cure
human disease without competent and reliable scientific evidence to support
such claims, the FTC has issued warning letters to companies that have
advertised their CBD-infused products can treat or cure a variety of serious
diseases and health conditions, including cancer, Alzheimer’s disease,
multiple sclerosis, fibromyalgia, colitis, autism, bipolar disorder, and
traumatic brain injuries (Federal Trade Commission [FTC], 2019).
Think of Rebecca. She is not satisfied with the results of

using melatonin. She is curious about whether CBD can
improve her sleep issues. What would you tell her about
using CBD?
The consumer watchdog organization Center for Science in the Public

Interest (CSPI) has filed comments with the FDA asking the agency to play
a more active role in ensuring these products are safe, accurately labeled,
free of adulterants and contaminants, and that consumers are aware of
relevant risks (MacCleery, 2019). CSPI urges the FDA to especially take
action on products that pose the greatest public health risks such as products
that appeal to children and youth and products found to be mislabeled or
contaminated.
Caution is advised (Harvard Health Publishing, 2019):
• Buy only from a dispensary (if marijuana is legal in your state)
because the amount of CBD in the product must be labeled as well
as whether it contains any THC.
• Like other supplements, CBD products are not standardized, so the
dosing may vary.
• The safest way to take CBD is orally via a tablet, chewable, or
tincture.
• Although CBD appears to be safe, it can produce nausea, fatigue,
and irritability and may interact with certain medications.
• Regular use is not appropriate for anyone under the age of 21.
How Do You Respond?

I need only 1600 calories a day. How can I make
the Nutrition Facts label work for me when it is
based on a 2000-calorie diet? Recognize that the
%DV listed for total fat, saturated fat, total carbohydrate,
dietary fiber, and added sugars—nutrients whose DV is
based on calories—will underreport the percent
contribution when daily intake is <2000 calories. For
instance, Americans are urged to limit their intake of
added sugars to 10% of total calories, which is 50 g/day
in a 2000-calorie eating pattern, but only 40 g in a 1600-
calorie pattern (1600 × 10% = 160 cal ÷ 4 cal/g = 40 g). A
serving of fruited yogurt lists added sugars at 9 g with a
DV of 18% (because labels are based on a 2000-calorie
eating pattern) but in a 1600-calorie eating pattern, 9 g
translates to 22.5% DV of added sugar (9 g ÷ 40 g × 100
= 22.5%). Use calorie-based %DV to get a relative idea of
what a serving will contribute to your intake and compare
%DV among brands if possible. Nutrients with a DV that
are not based on calorie intake, such as cholesterol and
sodium, will accurately reflect their percent contribution
to all eating patterns regardless of the total calorie
content.
Can a dietary supplement help me lose weight?
The FDA does not regulate supplements for weight loss
with the same standards applied do prescription or over-
the-counter medications for weight loss. Manufacturers
are responsible for ensuring their supplements are safe
and that the labels are not misleading but supplements do
not need to prove efficacy. Even if there was evidence of
efficacy, if the composition and quality of ingredients
cannot be reliably ensured, effectiveness may be altered
(Starr, 2015). The FDA faces multiple challenges in
enforcing existing regulations, so consumers are not well
protected against supplements that are ineffective or
potentially harmful.
REVIEW CASE STUDY
Maria is 52 years old, has a healthy body mass index, and does not have any
health problems. She prides herself on her knowledge of holistic treatments
and goes to the doctor only when her attempts to treat herself fail. She
occasionally takes one aspirin a day because she has heard that it can
prevent heart attacks. She tries to eat a healthy diet and uses supplements to
give her added protection against chronic diseases, especially heart disease,
which runs in her family. Currently, she takes turmeric, garlic, and fish oil
supplements to keep her blood thin. She routinely drinks omega-3–fortified
orange juice. She attributes the bruises on her legs to being clumsy. She is
thinking about adding vitamin E to her regimen because she heard it may
also lower the risk of heart disease by thinning the blood. She is thinking
about discontinuing her use of garlic pills and fish oil supplements and
eating more garlic and fish in her diet instead.
• What are the dangers of her present regimen? What may be responsible
for the bruising she is experiencing?
• What would you tell Maria about the use of supplements in general?
About the types and combination of supplements she is currently using?
What specific changes would you suggest she make?
• What would you tell her about using juice fortified with omega-3?
• Is it safer for her to eat more garlic and fish instead of taking them as
supplements? Is it as effective as taking them as supplements? Could she
overdose on garlic and fish oil from food?
• What questions would you ask about her diet to see if there are any
improvements in her eating habits she could make to reduce the risk of
heart disease?
STUDY QUESTIONS
1 Which statement indicates that the client needs further instruction about
reading nutrition labels?
a. “The %DV is based on a 2000-calorie eating pattern.”
b. “The %DV represents the percentage of calories from carbohydrate,
protein, and fat in that food.”
c. “The dual-column labels show information per serving and per
package.”
d. “The serving size listed on the label is based on how much people
actually consume, not on what they should be eating.”
2 The nurse knows her instructions about label reading have been effective
when the client verbalizes that fat-free on the label means
a. the product is free of any ingredients that contain any fat.
b. the product does not contain any fat or saturated fat.
c. there is <0.5 g of fat in a serving.
d. there is <1 g of fat in a serving.
3 The nurse knows her instructions about nutrient claims on the label have
been effective when the client says,
a. “‘Excellent source’ is not defined, so it cannot be trusted.”
b. “‘Excellent source’ means a serving of the food must provide at least
20% of the DV for that nutrient.”
c. “‘Excellent source’ means a serving of the food must provide a day–s
worth of that nutrient.”
d. “‘Excellent source’ means a serving of the food provides 10% more of
a desirable nutrient than does a comparable product.”
4 What is the component in allergens that is responsible for triggering an
allergic attack in susceptible people?
a. sugar
b. starch
c. protein
d. fat
5 The nurse knows her instructions about gluten-free labeling are
understood when the client verbalizes one of the following statements:
a. “Only foods that have been specially made gluten-free, not foods that
are naturally gluten-free, can be labeled gluten-free.”
b. “Gluten-free means there are no detectable amounts of gluten in the
product.”
c. “Products labeled gluten-free are limited to foods that are naturally
gluten-free.”
d. “Gluten-free products provide <20 ppm of gluten per serving.”
6 The client asks if a tea that claims to improve memory really works.
a. “If the tea claims to improve memory, then it has been tested and
proven effective at improving memory.”
b. “The tea probably works but you need to try it to know.”
c. “Function claims like ‘improve memory’ can be used on labels without
supporting proof that they are accurate.”
d. “That type of claim is illegal and should not appear on any food label.”
7 Which statement about supplements is accurate?
a. All supplements must be tested for safety and effectiveness before they
can be marketed.
b. Supplement dosages are standardized.
c. Proper handling of supplement ingredients is required by law.
d. Warnings about potential side effects or interactions must be stated on
the packaging.
8 Which of the following statements about CBD is accurate?
a. The FDA defines CBD as a dietary supplement.
b. CBD is the most active ingredient in marijuana.
c. CBD may be addictive over time.
d. CBD is the active ingredient in a drug approved by the FDA.
CHAPTER SUMMARY FOOD AND SUPPLEMENT

LABELING
Food Labeling
Food labels are a learning tool to help consumers make healthier food
choices.
• Ingredient list: all ingredients are listed in descending order by

weight. Relative amounts are identified but not the proportion of
ingredients.
• Nutrition Facts label: intended to provide consumers with reliable
and useful information to help avoid nutritional excesses.
• Serving sizes: updated to reflect the amounts people typically eat,
not what they “should” eat.
• A dual column of Nutrition Facts appears on some packages that
may be consumed in one or more sittings.
• Vitamin D and potassium are now required to be listed in gram and
%DV quantities because these are nutrients of public health
concern.
• Vitamins A and C content is no longer required because deficiencies
of these vitamins are uncommon.
• Added sugars are a newly added feature.
• Additional labeling regulations are to inform consumers about what
they are eating.
• Foods containing any of the eight major allergens that are
responsible for 90% of all allergies must declare them on the label.
• Gluten-free labeling is allowed for products that provide <20 ppm
of gluten.
• Country of Origin applies to certain foods defined by three
categories.
• FDA-allowed claims
• Nutrition content claims defines the level of a nutrient or substance
in a food, such as free, good source, or lean.
• Health claims describe a relationship between a food or substance in
a food and a disease or health-related condition.
• Unqualified health claims do not require a disclaimer because they
are backed by SSA.
• Qualified health claims are supported by weaker evidence and must
be accompanied by a disclaimer.
• Structure/function claims: offer possibility that a food may improve
or support body function. They must be accompanied by the
disclaimer, these statements have not been evaluated by the FDA.
• Facts Up Front is an industry-driven labeling system that gives basic
Nutrition Facts information for calories, saturated fat, sodium, and
sugar. Up to two more specified optional nutrients may be added.
Dietary Supplements
Dietary supplements are intended to add to (not replace) a healthy eating
pattern, if necessary.
• Supplements are widely used. Consumers often confuse natural with
safe or effective.
• Supplements must be labeled as supplements, include a Supplement
Facts panel, and list ingredients, if applicable.
• Supplement regulation differs greatly from how drugs are regulated.
• Safety and efficacy are not proven.
• Strength and dosing are not standardized.
• Warnings about side effects or supplement–drug interactions are not
required.
• Supplements are self-prescribed and megadosing may be a problem.
• The burden of proof to remove a product from the market rests with
the FDA, not with the manufacturer.
• The statement buyer beware is good advice for people thinking of
using a supplement.
• CBD is a relatively new product that is being marketed as a
supplement, although the FDA has ruled that it is not a supplement.
Science and regulations have not kept pace with its fast growing
popularity.
Figure sources: shutterstock.com/tmcphotos and shutterstock.com/Infinity Time

book at
Websites
Nutrition Facts Information
Changes to the Nutrition Facts Label at https://www.fda.gov/food/food-labeling-nutrition/changes-
nutrition-facts-label
Supplement Information
National Center for Complementary and Alternative Medicine Clearinghouse provides information
on complementary and alternative medication at www.nccam.nih.gov
Office of Dietary Supplements (ODS) of the National Institutes of Health at http://ods.od.nih.gov/
Tips for dietary supplement users at https://www.fda.gov/food/information-consumers-using-dietary-
supplements/tips-dietary-supplement-users
References
Brown, A. C. (2019). Understanding food principles and preparation (6th ed.). Cengage Learning.
Celiac Disease Foundation. (2014, August 5). 10 fast facts about the FDA gluten-free labeling rule.
https://celiac.org/about-the-foundation/featured-news/2014/08/fda-gluten-free-food-labeling-
information-page
Federal Trade Commission. (2019, September 10). FTC sends warning letters to companies
advertising their CBD-infused products as treatments for serious diseases, including cancer,
Alzheimer’s, and multiple sclerosis. https://www.ftc.gov/news-events/press-releases/2019/09/ftc-
sends-warning-letters-companies-advertising-their-cbd-infused
Harvard Health Publishing. (2019, August). CBD products are everywhere. But do they work?
https://www.health.harvard.edu/staying-healthy/cbd-products-are-everywhere-but-do-they-work
MacCleery, L. (2019, July 19). CSPI urges FDA to take steps to reduce risks of cannabis use. Center
for Science in the Public Interest. https://cspinet.org/news/cspi-urges-fda-take-steps-reduce-risks-
cannabis-use-20190716
Nutrition Business Journal. (2019). 2018 NBJ supplement business report.
https://www.nutritionbusinessjournal.com/reports/2018-nbj-supplement-business-report
Reports and Data. (2019, March 25). Dietary supplements market to reach USD 210.3 billion by
2026. http://www.globenewswire.com/news-release/2019/03/25/1760423/0/en/Dietary-
Supplements-Market-To-Reach-USD-210-3-Billion-By-2026-Reports-And-Data.html
Resnik, D. B. (2017). Proportionality in public health regulation: The case of dietary supplements.
Food Ethics, 2, 1–6. https://doi.org/10.1007/s41055-017-0023-3
Smith, T., Gillespie, M., Eckl, V., Knepper, J., & Reynolds, C. M. (2019). Herbal supplement sales in
U.S. increase by 9.4% in 2018. http://cms.herbalgram.org/herbalgram/issue123/files/HG123-
HMR.pdf
Starr, R. R. (2015). Too little, too late: Ineffective regulation of dietary supplements in the United
States. American Journal of Public Health, 105(3), 478–485.
https://doi.org/10.2105/AJPH.2014.302348
U.S. Food and Drug Administration. (2020a, July 10). Changes to the nutrition facts label.
https://www.fda.gov/food/food-labeling-nutrition/changes-nutrition-facts-label
U.S. Food and Drug Administration. (2020b, March 5). What you need to know (and what we’re
working to find out) about products containing cannabis or cannabis-derived compounds,
including CBD. https://www.fda.gov/consumers/consumer-updates/what-you-need-know-and-
what-were-working-find-out-about-products-containing-cannabis-or-cannabis
World Health Organization. (2017). Cannabidiol (CBD).
https://www.who.int/medicines/access/controlled-substances/5.2_CBD.pdf
Chapter Consumer Interests and
10 Concerns
Paul Youngblood
Paul is a 63-year-old single man with mild
developmental and cognitive impairments who has
lived with his mother for his entire life. He has held
the same part-time entry-level position at a local
hardware store for 40 years. His mother’s recent death
means he will be living independently for the first
time in his life. He has no life skills pertaining to
shopping or cooking because his mother always took
care of that.
Learning Objectives
1 Discuss points to consider when evaluating the credibility of nutrition

information.
2 Give examples of conventional and modified functional foods.
3 Interpret labeling on organic products.
4 Discuss the benefits and disadvantages of consuming organic foods.
5 Teach clients about the four simple steps to keep food safe.
6 Debate the safety of genetically modified food.
7 Explain the reason why some foods are irradiated.
8 Define issues of food access: food insecurity and food deserts.
The proliferation of cyberspace information—and misinformation—gives

millions of Americans ready access to nutritional concepts. Advances in
food technology have brought us functional foods, bioengineering, and
food irradiation as well as new questions about food safety and optimal
nutrition. The ever-evolving science of nutrition has progressed from three
square meals a day and a well-rounded diet to MyPlate. This is an era that
presents old and new challenges for health professionals.
Functional Foods
commonly (not legally) defined as foods that provide health benefits beyond basic nutrition.
Food Irradiation
treatment of food with approved levels of ionizing radiation for a prescribed period of time and a
controlled dose to destroy bacteria and parasites that would otherwise cause foodborne illness.
This chapter begins with consumer information and misinformation.

Consumer interests discussed include functional food, organic foods,
foodborne illnesses, biotechnology, antibiotics in the food supply, and
irradiation. Issues of food access, namely, food insecurity and food deserts,
are presented.
CONSUMER INFORMATION AND

MISINFORMATION
The role of food has shifted from simply a means to prevent deficiency
diseases to a tool for optimizing health, preventing chronic disease, and
delaying aging. Several factors are driving this “food as medicine”
paradigm, including
• consumer interest in managing their own health,
• increasing age of the population,
• escalating health care costs,
• technologic advances, such as biotechnology,
• the obesity epidemic, and
• evidence-based science that links healthy eating patterns to a
reduced risk of chronic disease.
Combating Misinformation
Nutrition misinformation abounds. Breaking news stories may be little
more than spin (a favorable slant in news articles) or incomplete coverage
of preliminary results from scientific studies, which are often discounted
later as more research is completed. Although information available on the
Internet is vast, there are no regulatory safeguards in place to ensure the
information is accurate. Junk science coexists with legitimate data. It is the
responsibility of each individual consumer to evaluate the reliability of
information (Box 10.1).
Many people treat nutrition as a belief system rather than as a science
and formulate opinions in response to emotional appeals rather than
scientific evidence. Others assume that anything that appears in print form
(e.g., in a book, magazine, or newspaper) is accurate and not everyone
recognizes the shortcomings of the Internet. If client beliefs are unsupported
but harmless, then you may risk alienating them for no reason by trying to
convince them that they’re misinformed. Determine how much of an
emotional investment the client has in believing harmless misinformation.
Be aware that casual or judgmental dismissal of misinformation can cause
clients to become defensive and distrustful; clients may conclude that you
are not as up to date as they are about nutrition, and they may reject you as
a credible reference.
BOX Points to Consider When Evaluating the

10.1 Credibility of Information
• Was the research conducted at a reputable institution or an impressive-
sounding but unknown facility?
• The distinction between correlation and causation may be blurred, and
inappropriate conclusions may be made from study results.
• Generally, if it sounds too good to be true, it usually is.
• Features or articles that fail to identify how much or little of a food
should be eaten, how often it should be eaten, or to whom the advice
applies do not give consumers enough information to appropriately
judge what the study means to them personally.
• Other types of media inaccuracy include generalizing a study to a
broader population than was actually studied and overstating the size
of the effect.
• URLs ending in .edu (educational institutions), .org (organizations), or
.gov (government agencies) are more credible than those ending in
.com (commercial). A commercial website’s main objective may be to
sell a product.
• Anyone who stands to benefit economically by promoting a food,
supplement, or diet is not likely to be an objective resource.
Recall Paul. He is used to treating himself to fast-food

meals and eating the food that mom buys—without thought
about nutrition and health. He is not capable of applying
critical thinking to news about nutrition, and he is easily
directed by his eagerness to please. What points should a
learning plan include that enable Paul to purchase and
prepare food for himself?
CONSUMER-RELATED INTERESTS
As knowledge of nutrition in health and disease continues to grow,
consumers interested in self-directed care look to food- and nutrition-related
strategies to ensure health and wellness. Some of those strategies are
discussed in the following sections.
Functional Foods
Functional foods are one of the fastest growing segments of the food
industry. The term has no legal meaning in the United States; it is currently
a marketing, not a regulatory, term. In reality, all food is in essence
“functional” in that it provides calories and nutrients necessary to sustain
life; however, functional food is generally considered a food or food
component that provides health benefits beyond basic nutrition.
The Academy of Nutrition and Dietetics defines functional foods as
“whole foods along with fortified, enriched, or enhanced foods that have a
potentially beneficial effect on health when consumed as part of a varied
diet on a regular basis at effective levels” (Crowe & Francis, 2013; p.
1097). Whole or natural functional foods are foods that are not modified in
any way. Examples include whole fruits, vegetables, whole grains, nuts,
legumes, and fish. Table 10.1 gives examples of natural functional foods
and their potential health benefits. Modified functional foods have one or
more functional ingredients added, which can occur through enrichment,
fortification, or other means (e.g., enzymatic, chemical, technological).
Examples include calcium-fortified orange juice, fermented dairy products,
and omega-3 fatty acid–enriched eggs.
Functional food definitions may also include nutraceuticals, dietary
supplements, and medical foods (Litwin et al., 2018).
Table Natural Functional

10.1 Foods
Potential Health
Food Active Ingredient Benefits
Berries: Anthocyanins May reduce the risk of
strawberries, Alzheimer’s
cranberries, disease through
blueberries, anti-inflammatory
raspberries, and antioxidant
black berries properties
Soy foods Soy protein Lower total and low-
density lipoprotein
(LDL) cholesterol;
may inhibit tumor
growth
Oats, oatmeal, Soluble fiber (beta- Lower total and LDL
barley, rye glucan) cholesterol
Fatty fish Omega-3 fatty acids Lower triglycerides,
lower heart
disease, lower
cardiac deaths, and
lower fatal and
nonfatal heart
attacks
Purple grape juice or Resveratrol Decrease platelet
red wine aggregation
Cranberry juice, Proanthocyanidins Reduces bacteriuria
strawberries, and procyanidins
cinnamon
Green tea Catechins Reduces the risk of
certain cancers,
such as breast and
prostate cancer
Potential Health
Tomatoes and Lycopene Reduce the risk of
tomato products prostate, ovarian,
gastric, and
pancreatic cancer
Yogurt and Probiotics Promote
fermented dairy gastrointestinal,
products immune,
cardiovascular, and
metabolic health
Nuts, olive oil Monounsaturated Reduce the risk of
fatty acids and cardiovascular
vitamin E disease
Citrus fruits Flavanones Neutralize free
radicals; promote
cellular antioxidant
defenses
Cruciferous Sulforaphane Reduce the risk of
vegetables (e.g., certain types of
broccoli, cancer
cauliflower,
cabbage)
Garlic, onions, leeks, Sulfur compounds Lower total and LDL
scallions cholesterol; may
promote healthy
immune function
Orange, red, and Beta carotene Neutralize free
dark green fruits radicals, which
and vegetables may damage cells;
may inhibit cancer
growth; may
improve immune
response
Potential Health
Spinach, kale, Lutein, zeaxanthin Lower risk of age-
collard greens, related macular
corn degeneration
Source: Litwin, N., Clifford, J., & Johnson, S. (2018). Functional foods for health.
https://extension.colostate.edu/topic-areas/nutrition-food-safety-health/functional-foods-for-health-
9-391; American Institute for Cancer Research. Phytochemicals: The cancer fighters in your foods.
https://www.aicr.org/reduce-your-cancer-risk/diet/elements_phytochemicals.html
Nutraceuticals
isolated, modified, and/or synthetic bioactive components that are typically given as a dietary
supplement.
Medical Foods
foods formulated to meet nutrient needs of a patient, such as an enteral tube feeding formula; used
in the dietary management of a disease and/or medical condition under the supervision of the
physician.
It is likely that more foods will be considered functional and the supply
of manufactured functional foods will expand exponentially as scientific
evidence mounts in the role of specific nutrients or food substances in
preventing chronic diseases such as heart disease, cancer, diabetes,
hypertension, and osteoporosis. Natural functional foods—namely, fruits,
vegetables, nuts, whole grains, and fatty fish—are the foundation of a
healthy eating pattern. Modified functional foods should be viewed as an
option to optimize a healthy eating plan but not as a miracle food to
compensate for poor food choices.
Recall Paul. He heard about functional foods but has been

unable to find them on food labels in the grocery store. What
would you tell Paul about natural and modified functional
foods?
Organically Grown Foods

Sale of organic food in the United States has grown from $1 billion in 1990
to over $47.9 billion in 2018 and represents approximately 5.7% of total
food sales (Organic Trade Association, 2019). Fresh fruits and vegetables
have been the top-selling category of organically grown food since retail
sale of organic food began more than 30 years ago. Consumers have the
impression that organic vegetables and fruits are safer, more nutritious, and
healthier, but findings are complicated and dependent upon how those
terms are defined.
Safety
Although consumers often have the perception that organic foods are safer
than conventionally produced foods, organic standards do not specifically
address safety issues such as microbial or chemical hazards (Harvey et al.,
2016).
• Foodborne illness outbreaks reported from organic food have
increased in recent years. This parallels the increase in organic food
intake.
• Unfortunately, the risk of outbreaks due to organic foods compared
to that of conventional foods cannot be assessed because foodborne
outbreak surveillance does not systematically collect information
about food production methods.
• Reviews that assessed whether organic produce is more or less
susceptible to microbial contamination compared to conventional
produce did not find any significant difference (Gomiero, 2018).
• Food safety precautions are necessary with all food—organic and
conventional foods.
• Raw milk and fresh produce, whether conventionally or organically
produced, are common vehicles for pathogens.
Organic: In a chemical sense, organic means containing carbon. Generally,
organic refers to living organisms; as such, all plants and animals are
technically organic. Organic foods are grown and processed according to
federal guidelines that cover soil quality, animalraising practices, pest and
weed control, and the use of additives. Organic produce is grown on soil
that had no prohibited synthetic fertilizers and pesticides. Organic meat
requires that animals have the ability to graze on pasture, are fed 100%
organic feed, and do not receive antibiotics or hormones. Organic processed
foods must be free of artificial preservatives, colors, and flavors and be
made from organic ingredients, with few exceptions.
Nutritional Value
Evidence that organic food is more nutritious than conventional food is
relatively scarce. It is difficult to reliably measure nutritional differences
due to many variables, including an exact definition of conventional, the
maturity of the samples used, the varieties of individual plants chosen, the
study designs (e.g., farm surveys, retail surveys), and the question whether
produce has been grown in the same region and climatic conditions
(Gomiero, 2018). A review by Hurtado-Barroso et al. (2019) cites
numerous studies, which show the following:
• Organic produce provides higher levels of phytonutrients (e.g.,
polyphenols, anthocyanin, flavonoids, quercetin), vitamin C, and
carotenoids than conventional produce. The clinical significance is
unknown.
• Organic animal products, such as meat and milk, have higher levels
of omega-3 fatty acid than conventionally grown animals, but the
differences and amounts are too low to have any effect on human
health (Hurtado-Barroso et al., 2019).
Impact on Health
The impact of organic foods on health is potentially multifaceted.
• Even though antioxidant levels are higher in organic produce than
conventional produce, nutrition intervention studies performed so
far have not shown a clear association between antioxidant levels in
people and whether they consume organic or conventionally grown
foods (Hurtado-Barroso et al., 2019).
• Organic diets unequivocally expose consumers to fewer pesticides
and with residues of much lower toxicity compared to conventional
foods (Gomiero, 2018). Large prospective cohort studies are needed
to assess the relationship between pesticide exposure in
conventional foods and human disease.
• Organic animals have the potential to reduce antibiotic-resistant
infections in humans.
• All milk contains growth hormone. Whether present naturally or
given to increase milk production, growth hormone is a peptide
hormone that is digested in the human gastrointestinal (GI) tract.
Organic Labeling
The U.S. Department of Agriculture (USDA) ensures that the production,
processing, and certification of organically grown foods adhere to strict
national standards and that organic labeling meets criteria that define the
four official organic categories (Table 10.2).
Table U.S. Department of Agriculture

Criteria for Labeling Organic
10.2 Products
Labeling
Organic Term and Definition Allowed
Labeling
May include
• 100% Organic: all of the ingredients must be USDA organic
certified organic (except salt and water). Crops seal and/or
must be grown without synthetic fertilizers and “100% organic”
pesticides. Natural products like manure, claim.
compost, and naturally occurring chemicals in
the environment (e.g., nicotine, sulfur) may be
used when growing the food.
• Food irradiation, sewage sludge, and GMOs are
not allowed.
• Organic livestock must be raised on 100%
organic feed, allowed to graze at pasture at least
4 months of the year, and obtain 30% of their
feed through grazing.
• Hormones and antibiotics are prohibited.
• Organic milk must come from cows not treated
with antibiotics or hormones.
Organic: at least 95% of ingredients must be May include
certified organic. USDA organic
seal and/or
“organic” claim.
Labeling
Made with organic ingredients: at least 70% of May state “made
the ingredients must be certified organic. with organic
…” (insert up
to 3
ingredients or
ingredient
categories)
Cannot use
organic seal,
represent
finished
product as
organic, or
state “made
with organic
ingredients.”
Contains organic: less than 70% of ingredients are May only list
certified organic. organic
ingredients on
the ingredient
list—for
example,
“Ingredients:
water, barley,
organic beans
…”
Cannot use
organic seal
or the word
organic on
the display
panel
Source: U.S. Department of Agriculture. (n.d.). Organic labeling standards.
https://www.ams.usda.gov/grades-standards/organic-labeling-standards
Final Considerations
Organic food is usually more expensive because of higher production costs,
greater losses, and smaller yields. For instance, a gallon of organic milk
typically costs twice as much as a gallon of store-brand or name-brand
milk. However, not all organic foods are appreciably more expensive than
their conventional counterparts, such as oranges, grapes, and bread.
Despite the controversy regarding the risks of pesticide residues in food,
both sides agree that the benefits of eating a diet rich in plants outweigh any
potential risks of pesticide exposure. Each year, the Environmental Working
Group (EWG) compiles a list of the Dirty Dozen™ and the Clean 15™,
which identify fruits and vegetables with the most and least levels of
pesticides, respectively (EWG, 2019) (Table 10.3). This list may help
consumers save money while lowering pesticide exposure by helping them
choose conventionally grown “clean” items and selecting organic versions
of the “dirtiest” produce.
Table The Dirty Dozen™ and the

10.3 Clean 15™
The Environmental Working Group’s Shopper’s Guide 2020 ranks

pesticide contamination through analysis of more than 43,700 samples
taken by the USDA and FDA. Each year, only a subset of fruits and
vegetables are tested, not each crop. Ranking is based on six measures of
pesticide contamination:
• Percentage of samples with detectable pesticides

• Percentage of samples with two or more detectable pesticides
• Average number of pesticides found on a single sample
• Average amount of pesticides found; measured in parts per million
• Maximum number of pesticides found on a single sample
• Total number of pesticides found on the crop
The Dirty Dozen™ (with 1 being The Clean 15™ (with 1 being
“dirtiest”) “cleanest”)
1. Strawberries 1. Avocados
2. Spinach 2. Sweet corn
3. Kale 3. Pineapples
4. Nectarines 4. Onions
5. Apples 5. Papayas
6. Grapes 6. Sweet peas (frozen)
7. Peaches 7. Eggplant
8. Cherries 8. Asparagus
9. Pears 9. Cauliflower
10. Tomatoes 10. Cantaloupe
11. Celery 11. Broccoli
12. Potatoes 12. Mushrooms
13. Cabbage
14. Honeydew melon
15. Kiwi
Source: Environmental Working Group Science Team. (2020). EWG’s 2020 shopper’s guide to
pesticides in produce. https://www.ewg.org/foodnews/summary.php. Copyright © Environmental
Working Group, www.ewg.org. Reproduced with permission.
Think of Paul. He watched a documentary on pesticides in

the food supply and is convinced he will get cancer if he eats
conventionally grown produce. However, he can’t afford
organic fruits and vegetables, so he has decided he is better
off not eating any fruits and vegetables rather than eating
conventional ones. What would you say to Paul?
Foodborne Illness
In a 2019 survey, foodborne illness from bacteria was selected as the top
food safety concern among polled Americans (International Food
Information Council Foundation, 2019). The Centers for Disease Control
and Prevention (CDC) estimates that every year, approximately 48 million
Americans experience a foodborne illness, resulting in 128,000
hospitalizations and 3000 deaths (Centers for Disease Control and
Prevention [CDC], 2018). Relatively few of these illnesses occur in a
recognized outbreak, yet outbreaks provide insight into the pathogens and
foods that cause illness (CDC, 2019). In 2017, 841 foodborne disease
outbreaks were reported, resulting in 14,481 illnesses, 827 hospitalizations,
20 deaths, and 14 food product recalls. More than 90% of confirmed,
single-etiology outbreak illnesses were caused by only four pathogens
(Fig. 10.1). Table 10.4 summarizes details of these four pathogens. It also
includes Listeria because it is one of the leading causes of death from
foodborne illness.
Figure 10.1 ▲ Pathogens identified as the cause of illness in confirmed,
single-etiology foodborne illness outbreaks, 2017. (Source: Centers for
Disease Control and Prevention [CDC]. [2019]. Surveillance for foodborne
disease outbreaks, United States, 2017, annual report.
https://www.cdc.gov/fdoss/pdf/2017_FoodBorneOutbreaks_508.pdf?
deliveryName=DM9453)
Table The Four Pathogens Linked to

Nearly 90% of Foodborne Illness
10.4 in U.S. Outbreaks, 2017
Foodborne Illness
an illness transmitted to humans via food.
Outbreak
the occurrence of two or more cases of a similar illness resulting from ingestion of a common
food.
Food Vehicles of Transmission

The microorganisms that cause foodborne illness are found widely in nature
and are transmitted to people from within food (e.g., meat, fish), from on
food (e.g., eggshell, vegetables), from unsafe water, or from human or
animal feces. Any uncooked food that is handled by someone who is ill
poses a risk. All food categories were involved in outbreaks, but the
frequency varies for each category. Foods causing the most outbreak-
associated illnesses in 2017 are listed in Box 10.2.
BOX Foods Causing the Highest Percentage of

10.2 Illnesses Based on 2017 Outbreaks
Food Implicated Percentage of Total Illnesses

Turkey 16
Chicken 13
Fruits 13
Pork 10
Leafy vegetables 9
Beef 9
Mollusks 7
Fish 4
Food Implicated Percentage of Total Illnesses
Dairy 2
Eggs 2
Sprouts 2
Source: Centers for Disease Control and Prevention (CDC). (2019). Surveillance for foodborne
disease outbreaks, United States, 2017, annual report.
https://www.cdc.gov/fdoss/pdf/2017_FoodBorneOutbreaks_508.pdf?deliveryName=DM9453
Symptoms
The most common symptoms of foodborne illness may be mistaken for the
“stomach flu:” diarrhea, nausea, vomiting, fever, abdominal pain, and
headaches.
• Most cases are self-limiting and run their course within a few days.
• Symptoms that warrant medical attention include bloody diarrhea
(possible Escherichia coli 0157:H7 infection), a stiff neck with
severe headache and fever (possible meningitis related to Listeria),
excessive diarrhea or vomiting (possible life-threatening
dehydration), and any symptoms that persist for more than 3 days.
• Infants, pregnant women, senior adults, and people with
compromised immune systems (e.g., people with AIDS, cancer,
organ transplant recipients, people taking corticosteroids) are
particularly vulnerable to the effects of foodborne illness.
Prevention
The major cause of foodborne illnesses is unsanitary food handling. Box
10.3 features actions to reduce the risk of contamination.
BOX Actions to Reduce the Risk of Foodborne

10.3 Illness
• Wash hands thoroughly with soap and water for at least 20 seconds
after using the restroom, before cooking, and after each touch of raw
meat, poultry, seafood, or eggs.
• Avoid cross contamination. Wash cutting boards, counter, utensils,
serving platters, etc. after they have been in contact with raw meats,
poultry, seafood, or eggs. Do not reuse marinades that have been in
contact with raw meats. Do not rinse raw poultry or meat.
• Cook food thoroughly. Check internal temperature with a thermometer.
• Chill leftovers and takeout foods within 2 hours.
• Refrigerate cold foods at 40° or less.
• Clean produce, except for prewashed greens. Gently rub under cold
running water. Scrub firm produce with a clean vegetable brush, even
when the rind will be cut away. Remove outer leaves, if appropriate.
Consider Paul. He is very proud of his cooking

accomplishment—a big pot of homemade chili. You learn
that he keeps it on the stove all the time and heats it up when
it is time for lunch and dinner so he doesn’t have to wash the
pan. What points would you include in teaching Paul about
food safety?
Food Biotechnology
Food biotechnology combines biotechnology and genetic engineering to
improve food. Food biotechnology is usually described as genetically
engineered (GE) or genetically modified organisms (GMO). In food
biotechnology, recombinant deoxyribonucleic acid in genes associated with
desirable characteristics are transferred from one plant to another. This is a
quicker, more controlled, and more predicable version of old-fashioned
crossbreeding.
Food Biotechnology
a process that involves taking a gene with a desirable trait from one plant and inserting it into
another with the goal of changing one or more of its characteristics; also called genetically
engineered food.
In 1994, the Flavr Savr tomato became the first GE plant approved by
the U.S. Food and Drug Administration (FDA) for human consumption in
the United States. It was modified to delay ripening and improve resistance
to rot. Today, 26 countries grow biotech crops on 191.7 million hectares
(International Service for the Acquisition of Agri-Biotech Applications
[ISAAA], 2018). The United States is the leading producer of biotech crops
with more than 74 million hectares, according to the ISAAA (2018).
• The primary crops grown in the United States are corn, cotton,
soybeans, alfalfa, sugar beets, canola, squash, papaya, potatoes, and
apples.
• Ninety-three percent of all the corn, soybeans, and cotton in the
United States are grown using biotechnology.
• Ingredients made from these top crops, such as soybean oil, corn oil,
and corn syrup, are pervasive in processed foods available in U.S.
grocery stores, such as cereals, frozen pizza, hot dogs, and soft
drinks.
• In addition to permeating the food supply, biotechnology has
provided breakthrough health care products and technologies,
beginning with FDA approval of recombinant human insulin in
1982.
• Currently, there are more than 250 biotechnology health care
products and vaccines available, many for previously untreatable
diseases (Biotechnology Innovation Organization, 2016).
Benefits of Biotechnology
Perhaps the greatest potential benefit of GE foods is in increasing global
crop yields to meet the world’s increasing demand for food. The Food and
Agricultural Organization projects the global population to expand to
approximately 9.7 billion by 2050, an almost 50% increase from 2013
(Raman, 2018). Current agricultural practices alone cannot sustain the
world’s population and eradicate malnutrition and hunger on a global scale
in the future (Raman, 2018). Producing more food on less acreage has the
potential to better meet the world’s need for food. Other potential benefits
are listed in Box 10.4.
BOX Potential Benefits of Biotechnology

10.4
• Healthier crops: Some plants are genetically modified to increase

their resistance to plant viruses and other diseases. This means they
can be raised using fewer pesticides to help reduce production costs
and environmental residues.
• Greater resistance to severe weather: Crop loss will be reduced and
year-round availability of fresh crops increases. One example is a
biotech drought-tolerant corn.
• Longer shelf life and increased freshness: Plants can be made to
ripen more slowly, staying fresher longer—a big plus for
transportation.
• Higher nutritional value: Plants can be genetically modified to
contain more micronutrients or protein, or less fat. For instance,
Golden Rice has been GE as a humanitarian project to provide beta
carotene, the precursor of vitamin A. In developing countries where
rice is the staple crop and where vitamin A deficiency is endemic,
Golden Rice has the potential to prevent the 4500 daily child deaths
caused by vitamin A deficiency (Dubock, 2017). Vitamin A deficiency
mostly affects children under the age of 5; it is known as the major
cause of childhood blindness globally and causes death related to
impaired immune system functioning.
• Healthier composition: For instance, Innate potato has been approved
for use in the United States. It has lower levels of acrylamide, a
potential carcinogen in humans produced when potatoes are cooked at
high temperatures.
• Better flavor: Genetic modification has produced sweeter melons and
sweeter strawberries.
• Improved characteristics: An example is celery without strings.
• New food varieties through crossbreeding: Broccoflowers (a blend
of broccoli and cauliflower) and tangelos (a tangerine–grapefruit
hybrid) are examples.
• Products such as consistent, reliable, and highly purified enzymes used
in cheese production can replace the more expensive and variable
enzyme rennin that is obtained from calf’s stomach.
How the U.S. Food and Drug Administration Regulates

Genetically Engineered Foods
Foods from GE plants must meet the same requirements, including safety
requirements, as foods from traditionally bred plants (U.S. Food and Drug
Administration [FDA], 2020).
• A voluntary consultation process with developers of GE plants
culminates in the GE plant developer completing a safety
assessment and submitting the summary to the FDA.
• Any safety and other regulatory concerns expressed by the FDA
must be resolved before the food product can be brought to market.
• As of 2018, more than 150 GE plant varieties have been evaluated.
Acceptance
Major health organizations that endorse the responsible use of genetic
engineering as a safe and effective means to improve food security and
reduce negative effects of agriculture include the American Medical
Association, the National Academy of Sciences, the American Association
for the Advancement of Science (AAAS), the American Council on Science
and Health, and the World Health Organization (American Council on
Science and Health [ACSH], 2016).
• These endorsements are based on the research of independent
groups worldwide that concludes that GE foods are safe for
consumers.
• According to a Pew Research Center survey, 88% of scientists in the
AAAS think that GE foods are safe to eat, yet only 37% of the
general public shares this thought (Pew Research Center, 2015).
Public Concerns Regarding Health

Commonly expressed concerns are how GMOs may affect consumer health,
such as unwanted changes in nutritional content, the creation of allergens,
and toxic effects on bodily organs.
• GMO fears are still theoretical, like the possibility that an inserted
gene could have a negative impact on other desirable genes
naturally present in the crop.
• According to Edward Parson, a codirector of the Emmett Institute
on Climate Change and the Environment at University of California,
Los Angeles, after more than a quarter century of growing GMO
crops in North America, no detrimental impacts have been detected
in North America compared to Europe, where people have little
exposure to GMOs (Brown, 2016).
• Parson also adds that it is not possible to prove a food is safe. It is
only possible to say that no hazard has been shown to exist (Brown,
2016).
Research on Safety
GMOs appear as a class to be no more likely to cause harm than
traditionally bred and grown food sources, though each new product will
require careful analysis and safety assessment (Norris, 2015). Findings from
worldwide independent researchers on various aspects of GMO safety,
especially as it pertains to consumer health and toxicity, are as follows
(Norris, 2015):
• No relationship between GMOs and mutations exists.
• Fertility, pregnancy, and offspring are unaffected by GMOs.
• Organ health and function are unaffected by GMOs.
• There is no evidence for gene transfer between GMOs and
consumers.
Environmental Concern
Glyphosate (also known by its brand name Roundup) is a broad-spectrum
herbicide that kills weeds by preventing them from making an essential
protein. The problem is that it works on crops as well as weeds, which led
researchers to develop GE “Roundup Ready crops” (soybeans, cotton, corn)
that contain a gene from bacteria that makes them immune to the herbicide.
• The widespread use of Roundup eventually led to the development
of glyphosate-resistant weeds, causing farmers to resort to spraying
herbicides that were much more toxic than Roundup in an attempt to
keep superweeds from spreading.
• Greater use of herbicides increases the likelihood of higher
concentrations of chemicals running off into nearby ecosystems and
damaging the environment.
• In order for GMOs to live up to their potential, conscientious
research on negative environmental risks must occur.
• The goal should be to support only safe products that represent an
improvement over the original product and focus opposition to
products that carry risks (Brody, 2018).
Labeling Regulations
In July 2016, Congress passed a law directing the USDA to establish a
national mandatory standard for disclosing foods that are or may be
bioengineered (U.S. Department of Agriculture [USDA], 2019).
• Bioengineered foods are defined as foods that contain detectable
genetic material that has been modified through certain lab
techniques and cannot be created through conventional breeding or
found in nature. They may be identified by a symbol, words,
scannable links, or by other means.
• The mandatory compliance date is January 1, 2022, on all food
products that require disclosure.
• In the meantime, many national food manufacturers are voluntarily
disclosing on the label that their products contain GE ingredients.
• Foods that carry a symbol that states derived from bioengineering or
that disclose the product contains ingredients derived from
bioengineering are not bioengineered foods because these foods do
not contain detectable modified genetic material. Specific voluntary
disclosures for these type of products apply.
Antibiotics in the Food Supply

Antibiotics are valuable for treating infections in both humans and animals.
Antibiotics are approved for use in food animals under specific situations:
to treat disease in animals that are sick, to control disease in a group of
animals when some of the animals are sick, and to prevent disease in
animals that are at risk for becoming sick (CDC, 2018). Previously,
antibiotics were often routinely given in low doses to healthy animals for
the purpose of promoting growth, increasing feed efficiency, or preventing
disease in crowded, unhygienic living conditions. This ultimately
contributed to the emergence of antibiotic-resistant bacteria.
Antibiotic-resistant bacteria can be transmitted to humans through the
food supply and can cause antibiotic-resistant infections (Fig. 10.2).
• When food animals are slaughtered, antibiotic-resistant bacteria
from the gut can contaminate meat and other animal products.
• Antibiotic-resistant bacteria in manure can contaminate irrigation
water, which in turn can contaminate fruits and vegetables.
Since January 2017, federal regulations have prohibited the use of
antibiotics in healthy animals for the purpose of promoting weight gain and
require a veterinarian’s approval before using antibiotics that are important
for human health.
Figure 10.2 ▲ Antibiotic resistance from the farm to the table. (Source:
Centers for Disease Control and Prevention. [2019, December 11].
Antibiotic resistance and food safety.
http://www.cdc.gov/foodsafety/challenges/from-farm-to-table.html)
Antibiotic-Free Labeling
All animal farming must adhere to strict rules to ensure there are no
antibiotic residues in the animal prior to slaughter. Antibiotic-free on food
labels is not officially defined.
• Antibiotic-free does not guarantee the animal does not carry
antibiotic-resistant bacteria. All animals have bacteria in their gut,
some of which may be resistant.
• The Organic label on a meat, poultry, dairy, or egg means no
antibiotics were given to the animal. The exception is that chickens
and turkeys can be given antibiotics in the hatchery while the chick
is still in the egg and on its first day of life. The Organic label
combined with the raised without antibiotics label means that the
chicken or turkey were not given antibiotics at any time.
• The labels for raised without antibiotics, no antibiotics ever, and
never given antibiotics mean that no antibiotics of any kind were
used in raising the animal. Although documentation is sent to the
USDA to support the claim, inspections are not conducted.
Food Irradiation
To many consumers, the term irradiated food conjures up visions of
radioactive fallout. In truth, irradiation is a safe and effective technology
that can prevent many foodborne illnesses by reducing or eliminating
pathogens, controlling insects, or killing parasites. Irradiation also reduces
food losses from infestation, contamination, and spoilage.
• Irradiation is sometimes referred to as electronic pasteurization, but
it does not use heat. Bacteria, mold, fungi, and insects are destroyed
as radiant energy, such as gamma rays, electron beams, and X-rays,
passes through the food.
• Irradiation does not change the taste, texture, or appearance of food.
• A small amount of new compounds are formed that are similar to
the changes seen in food as it is cooked, pasteurized, frozen, or
otherwise prepared.
• Except for a slight decrease in thiamin, the nutrient losses are less
than or about the same as losses caused by cooking and freezing.
• Shelf life may be prolonged because irradiation kills any living cells
that may be contained in the food, such as in seeds or potatoes. For
instance, irradiated potatoes do not sprout during storage.
• Irradiation does not hide spoilage or eliminate the need for safe food
handling; irradiated food can still become contaminated through
cross contamination.
Irradiation is endorsed by the World Health Organization, the CDC, and the
USDA. More than 40 countries have approved applications to irradiate over
40 different foods (McHugh, 2019). Research on irradiation as a part of an
overall system of ensuring food safety is ongoing.
• The FDA first approved the use of radiation in 1963 and is
responsible for establishing the maximum radiation dose allowed on
foods.
• Approximately one third of the spices and seasonings used in the
United States are irradiated. Other foods approved for irradiation are
listed in Box 10.5.
• Federal law requires irradiated food to be labeled with the
international symbol of the Radura (Fig. 10.3) and state “treated
with irradiation” or “treated by irradiation.”
Figure 10.3 ▲ Radura: the international symbol for irradiation.
BOX Foods Approved for Irradiation in the

10.5 United States
• Wheat flour
• Beef and pork
• Crustaceans
• Fresh fruits and vegetables
• Poultry
• Seeds for sprouting
• Shell eggs
• Shellfish
• Spices and seasonings
• Source: McHugh, T. (2019). Realizing the benefits of food irradiation. https://www.ift.org/news-
and-publications/food-technology-magazine/issues/2019/september/columns/processing-food-
irradiation
FOOD ACCESS
Food access is influenced by the affordability and proximity of food

retailers—concepts that are relative to a consumer’s socioeconomic status
and access to transportation. The ability to choose a healthy diet is impaired
when there is limited access to a variety of culturally appropriate, healthy,
affordable foods. Food insecurity and food deserts describe problems of
food access.
Food Insecurity
Household food insecurity describes households whose access to adequate
food is limited by a lack of money and other resources (Coleman-Jensen et
al., 2019). The extent and severity of food insecurity are monitored by the
USDA via a nationally representative annual survey. Referring to the year
2018, Coleman-Jensen et al. have reported the following findings:
• An estimated 11.1% of U.S. households were food insecure at least
some time during 2018. This figure represents a decline in food
insecurity from 11.8% in the previous year.
• In households with very low food security among children, children
were hungry, skipped a meal, or did not eat for a whole day because
there was not enough money for food.
• Rates of food insecurity were higher than the national average for
certain groups: households with incomes near or below the federal
poverty line, households with children and particularly households
with children headed by single women or men, women and men
living alone, Black- and Hispanic-headed households, and
households in principal cities.
• About 56% of food-insecure households in the survey reported that
within the previous month they had participated in one or more of
the three largest federal nutrition assistance programs, including
Supplemental Nutrition Assistance Program (SNAP, formerly the
Food Stamp Program); Special Supplemental Nutrition Program for
Women, Infants, and Children (WIC); and National School Lunch
Program.
Food Deserts
Food deserts occur predominately in low-income areas, where a substantial
proportion of the residents experience a lack of access to a supermarket. A
food desert is defined as living at least half a mile from the nearest
supermarket, supercenter, or large grocery store in an urban area or more
than 10 miles from a supermarket in a rural area (USDA, ERS, 2019).
Without ready access to supermarkets, access to fresh fruits, vegetables,
whole grains, low-fat milk, and other healthy whole foods is low. Poor
access to healthy foods could lead to poor diet quality and increased risk of
chronic diseases such as obesity or diabetes.
Data from USDA’s National Household Food Acquisition and Purchase
Survey revealed that both low-income and higher-income households
consider store characteristics other than proximity when deciding where to
shop (Ver Ploeg & Rahkovsky, 2016). Households often do not shop at the
nearest supermarket to obtain groceries regardless of whether the mode of
transportation is driving, walking, biking, or public transit (Ver Ploeg &
Rahkovsky, 2016).
SNAP households are more sensitive to price than proximity, which
may explain why households bypass the closest store for stores farther away
that offer lower prices (Ver Ploeg & Rahkovsky, 2016).
• The prices of different food groups have a larger effect on what is
purchased than does access. In fact, the effects of food access were
negligible when price and demographic factors were accounted for.
• Low income is more strongly associated with buying unhealthy food
than living in an area with limited access to supermarkets
(Rahkovsky & Snyder, 2015).
• Results suggest that improving access to healthy foods itself will not
likely have a major impact on diet quality (Ver Ploeg & Rahkovsky,
2016).
• The cost of food, income available to spend on food, consumer
knowledge about nutrition, and food preferences may be more
important factors in food purchase decisions than access.
Remember Paul. He drives to a big-box store to buy

groceries in order to make his food dollars stretch. He is a
novice cook at best, so he relies on sandwiches made from
deli meats, boxed macaroni and cheese, and frozen dinners,
which he knows are expensive. What advice would you give
Paul about food purchasing? What federal nutrition
assistance programs may he be eligible for?
How Do You Respond?

Is chicken labeled hormone-free safer and more
healthy than chicken without that label? All
animals naturally produce hormones, so there is no such
thing as hormone-free chicken or any other animals.
However, the USDA prohibits the use of hormones in
raising chicken, so no chickens are given hormones—
whether or not that is stated on the label. To increase
transparency, any chicken label that states no hormones
added must also include the phrase federal regulations
prohibit the use of hormones.
Can you prevent foodborne illness by washing
produce? Although washing produce—even varieties
that you peel—is recommended, it cannot guarantee food
safety. For instance, it is difficult to remove sticky
bacteria from leafy greens like spinach. Even triple-
washed or thoroughly washed ready-to-eat bags of
spinach, lettuce, and mixed greens may be contaminated
with bacteria because cleaning processes that use
chlorinated water kill only 90% to 95% of microbes when
performed correctly. And with other produce, such as
melon, mango, or apple, bacteria might have migrated to
the inside of the fruit, such as traveling through the apple
core to the interior, so washing will not remove it. Safe
food handling at home is important but cannot guarantee
safety.
REVIEW CASE STUDY
You have been asked to present a class on consumer-related interests

regarding food for young mothers. They want to hear about organic foods,
GMOs, antibiotics, and foodborne illness.
• List the major points you would cover for each topic.
• What points would you emphasize?
• Do you have a bias on any of these topics?
• How do you deal with personal bias when imparting information?
• What additional information do you think you need to make a complete
and balanced presentation on the topics?
• Are there any additional topics of interest you think should be included?
Why?
STUDY QUESTIONS
1 What percentage of ingredients must be organic for a product to bear the

USDA organic seal and state that it is organic?
a. 70%
b. 80%
c. 95%
d. 100%
2 A client wants to eat more conventional functional foods. Which of the
following would the nurse recommend?
a. omega-3 fatty acid–enriched milk and orange juice
b. yogurt and cheese
c. rice and enriched pasta
d. berries and green leafy vegetables
3 The client asks the nurse whether GMOs are safe. Which of the following
is the nurse’s best response?
a. “Not enough is known about GMOs to know if they have a negative
impact on health.”
b. “GMOs probably cause reproductive health issues and may cause gene
mutations. It is best to avoid them.”
c. “As a group, GMOs do not pose health risks.”
d. “It is best to try to avoid them if you can.”
4 Which pathogen is not killed by hand sanitizers?
a. norovirus
b. Salmonella
c. E. coli
d. Listeria
5 A client asks how they can minimize their risk of foodborne illness.
Which of the following should the nurse include in their response as the
best way to reduce the risk? Select all that apply.
a. “Wash your hands before and after handling food.”
b. “Rely on organically grown foods as much as possible.”
c. “Cook foods thoroughly.”
d. “Avoid cross contamination by using separate surfaces for meats and
foods that will be eaten raw.”
6 What is the best response to a client’s question about if organic food is
worth the extra cost?
a. “Is there anything more important to spend money on than your
health?”
b. “There is no difference in pesticide levels and nutritional value of
organically grown foods compared to conventional foods.”
c. “Buying organic foods is an individual decision; some may have more
nutritional value than their conventional counterparts, and they do
have lower pesticide levels.”
d. “It is worth it to buy organic produce but not organic meats.”
7 A client asks how they can avoid meat and poultry that are given
antibiotics. What is the nurse’s best response?
a. “Meat and poultry labeled as organic cannot be given antibiotics.”
b. “There is no way to avoid meat and poultry that have been given
antibiotics.”
c. “Buy meat and poultry labeled as natural or all natural.”
d. “Buy meat and poultry labeled as American Humane Association.”
8 A client asks how they can avoid buying foods that are GE. What is the
nurse’s best response?
a. “Foods labeled as organic cannot be genetically engineered.”
b. “There is no way to avoid genetically engineered foods.”
c. “Buy foods that have the Radura symbol on them. This symbol means
they cannot be genetically engineered.”
d. “Buy foods labeled as natural because they cannot be genetically
engineered.”
CHAPTER SUMMARY CONSUMER

INTERESTS AND CONCERNS
Consumer Information and

Misinformation
The field of nutrition is rapidly changing and growing. Nutrition
misinformation is everywhere and can be difficult to refute in a client
who is convinced that what they know is accurate.
Consumer-Related Interests
• Functional foods contain substances that appear to enhance health
beyond their basic nutritional value. Plants that are rich in
phytochemicals are natural functional foods.
• Organically grown foods are regulated by USDA standards.
• They are not bacteriologically safer than their conventional
counterparts.
• They have more phytochemicals and maybe other nutrients, but it is
difficult to measure and the clinical significance is unknown.
• They have lower levels of pesticides than conventionally grown
foods and cannot be GMOs.
• Organic animals cannot be given antibiotics or hormones and must
be raised on 100% organic feed.
• Foodborne illnesses sicken thousands of Americans annually.
• Norovirus is often the most implicated pathogen in foodborne
illness outbreaks.
• Common food vehicles for foodborne illnesses are turkey, chicken,
fruits, and green leafy vegetables.
• Handwashing, temperature control, and avoiding cross
contamination help prevent foodborne illness.
• Food biotechnology combines technology with genetic engineering to
transfer genes for modern-day crossbreeding.
• GE can produce more nutritious plants that are better at resisting
disease, drought, and salty conditions.
• The FDA controls GMO foods through a voluntary process of
approval.
• Numerous scientific organizations endorse GE; consumers are much
less accepting.
• Studies do not show that there are adverse health effects from
GMOs.
• Superweeds have developed from the overuse of pesticides
delivered on GMO crops that have been made resistant to it.
Antibiotics. Routine use of antibiotics in healthy animals to promote
growth or prevent infection has been linked to antibiotic resistance that
can be passed to humans through the food supply. Antibiotic use in
healthy animals for the purpose of promoting weight gain is now
prohibited by federal law.
Irradiation is used to reduce or eliminate pathogens that can cause
foodborne illness. The food remains uncooked and completely free of
any radiation residues.
Food Access
Food access refers to the affordability and access to healthy food.
• Food-insecure households have limited access to food due to lack of

money or other resources.
• Food deserts occur in low-income areas with limited access to
supermarkets.
• Increasing access to healthy food itself is not likely to improve diet
quality.
• The price of food, available income, nutrition knowledge, and food
preferences may have a greater effect on food choices than access.
Figure sources: shutterstock.com/wavebreakmedia and shutterstock.com/Erin Deleon

book at
Websites
Reliable Nutrition Information
Academy of Nutrition and Dietetics at www.eatright.org
American Cancer Society at www.cancer.org
American Council on Science and Health at www.acsh.org
American Diabetes Association at www.diabetes.org
Center for Science in the Public Interest at www.cspinet.org
Health on the Net Foundation at www.hon.ch
International Food Information Council at www.foodinsight.org
National Cancer Institute, National Institutes of Health at www.nci.nih.gov
National Heart, Lung, and Blood Institute, National Institutes of Health at www.nhlbi.nih.gov
New Wellness Consumer Health Information at www.netwellness.org
Nutrition.gov at www.nutrition.gov
U.S. Department of Agriculture Food and Nutrition Information Center at fnic.nal.usda.gov
U.S. Department of Health and Human Services Healthfinder at www.healthfinder.gov
U.S. Food and Drug Administration Center for Food Safety and Applied Nutrition at
https://www.fda.gov/about-fda/office-foods-and-veterinary-medicine/center-food-safety-and-
applied-nutrition-cfsan
Food Safety
Partnership for Food Safety Education at www.fightbac.org
U.S. Food and Drug Administration at www.fda.gov
References
American Council on Science and Health. (2016). Why ACSH supports GMOs and biotechnology.
https://www.acsh.org/news/2016/11/18/why-acsh-supports-gmos-and-biotechnology-10459
Biotechnology Innovation Organization. (2016). Biotechnology Industry Organization changes name
to Biotechnology Innovation Organization.
https://www.businesswire.com/news/home/20160104006245/en/Biotechnology-Industry-
Organization-Biotechnology-Innovation-Organization
Brody, J. (2018). Are GMOS foods safe? New York Times.
https://www.nytimes.com/2018/04/23/well/eat/are-gmo-foods-safe.html
Brown, E. (2016). Go ahead: Eat your genetically modified vegetables. Zocalo Public Square.
https://www.zocalopublicsquare.org/2016/12/15/go-ahead-eat-genetically-modified-
vegetables/events/the-takeaway/
Centers for Disease Control and Prevention (CDC). (2018). Food and food animals.
https://www.cdc.gov/drugresistance/food.html
Centers for Disease Control and Prevention (CDC). (2019). Surveillance for foodborne disease
outbreaks, United States, 2017, Annual report.
https://www.cdc.gov/fdoss/pdf/2017_FoodBorneOutbreaks_508.pdf
Coleman-Jensen, A., Rabbit, M., Gregory, C., & Singh, A. (2019). Household food security in the
United States in 2015 (ERR-275). U.S. Department of Agriculture, Economic Research Service.
https://www.ers.usda.gov/webdocs/publications/94849/err-270.pdf?v=963.1
Crowe, K., & Francis, C. (2013). Position of the academy of nutrition and dietetics: Functional foods.
Dubock, A. (2017). An overview of agriculture, nutrition and fortification, supplementation and
biofortification: Golden Rice as an example for enhancing micronutrient intake. Agriculture &
Food Security, 6(59). https://doi.org/10.1186/s40066-017-0135-3
Gomiero, T. (2018). Food quality assessment in organic vs. conventional agricultural produce:
Findings and issues. Applied Soil Ecology, 123, 714–728.
https://doi.org/10.1016/j.apsoil.2017.10.014
Harvey, R., Zakjour, C., & Gould, L. (2016). Foodborne disease outbreaks associated with organic
foods in the United States. Journal of Food Protection, 79(11), 1953–1958.
https://doi.org/10.4315/0362-028X.JFP-16-204
Hurtado-Barroso, S., Tresserra-Rimbau, A., Vallverdú-Queralt, A., & Lamuela-Raventós, R. M.
(2019). Organic food and the impact on human health. Critical Reviews in Food Science and
Nutrition, 59(4), 704–714. https://doi.org/10.1080/10408398.2017.1394815
International Food Information Council Foundation. (2019). 2019 food & health survey.
https://foodinsight.org/wp-content/uploads/2019/05/IFIC-Foundation-2019-Food-and-Health-
Report-FINAL.pdf
International Service for the Acquisition of Agri-Biotech Applications. (2018). ISAAA Brief54-
2018: Executive summary.
http://www.isaaa.org/resources/publications/briefs/54/executivesummary/default.asp
Litwin, N., Clifford, J., & Johnson, S. (2018). Functional foods for health.
https://extension.colostate.edu/topic-areas/nutrition-food-safety-health/functional-foods-for-
health-9-391/
McHugh, T. (2019). Realizing the benefits of food irradiation. https://www.ift.org/news-and-
publications/food-technology-magazine/issues/2019/september/columns/processing-food-
irradiation
Norris, M. (2015). Will GMOs hurt my body? The public’s concerns and how scientists have
addressed them. http://sitn.hms.harvard.edu/flash/2015/will-gmos-hurt-my-body/
Organic Trade Association. (2019). US organic sales break through $50 billion mark in 2018.
https://ota.com/news/press-releases/20699
Pew Research Center. (2015). Public and scientists’ view on science and society.
https://www.pewresearch.org/science/2015/01/29/public-and-scientists-views-on-science-and-
society/
Rahkovsky, I., & Snyder, S. (2015). Food choices and store proximity (EER-195).
http://www.ers.usda.gov/media/1909239/err195.pdf
Raman, R. (2018). The impact of Genetically Modified (GM) crops in modern agriculture: A review.
GM Crops & Food, 8(4), 195–208. https://doi.org/10.1080/21645698.2017.1413522
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regulations/be
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Ver Ploeg, M., & Rahkovsky, I. (2016). Recent evidence on the effects of food store access on food
choice and diet quality. https://www.ers.usda.gov/amber-waves/2016/may/recent-evidence-on-
the-effects-of-food-store-access-on-food-choice-and-diet-quality/
Cultural and Religious
Chapter Influences on Food and
11 Nutrition
Phouvong Chanthavong
Phouvong is a 61-year-old man who immigrated with
his wife and two daughters to the United States from
Laos at the age of 35. He does not speak English, but
his daughters are bilingual. He has just been admitted
to the hospital for pneumonia, where it was
discovered he also has type 2 diabetes.
Learning Objectives
1 Suggest ways to eat healthy while eating out.

2 Describe the characteristics of traditional food practices for different
cultural groups in the United States.
3 Discuss the nutrition-related health concerns of different cultural groups
in the United States.
4 Explain the general ways in which people’s food choices change as they
become acculturated to a new area.
5 Summarize dietary laws followed by major world religions.
Food and nutrition rank on the same level as air as basic necessities of life
in Maslow’s hierarchy of needs. Obviously, death eventually occurs without
food. But unlike air, food does so much more than simply sustain life. Food
is loaded with personal, social, and cultural meanings that define our food
values, beliefs, and customs. The concept that food nourishes the mind as
well as the body broadens nutrition to an art as well as a science. Nutrition
is not simply a matter of food or no food but rather a question of what kind,
how much, how often, and why. It is important to balance wants with needs
and pleasure with health in order to nourish the body, mind, and soul.
This chapter discusses what America eats and the impact of culture on
food choices. Traditional food practices, changes in food practices related to
acculturation, and nutrition-related health problems of major cultural
subgroups in the United States are presented. Religious food practices are
outlined.
Culture
encompasses the total way of life of a particular population or community at a given time.
AMERICAN CUISINE
American cuisine is a rich and complex melting pot of foods and cooking
methods. They have been adapted and adopted from cuisines brought to the
United States by immigrants beginning with early settlers from northern
and southern Europe. Cuisines from around the globe melded as the influx
of immigrants continued. Today, it is difficult to determine which foods are
truly American and which are an adaptation from other cultures. Swiss
steak, Russian dressing, and chili con carne are American inventions.
Cross-cultural food creations, such as Tex-Mex wontons and tofu lasagna,
reaffirm the ongoing melting-pot nature of American cuisine. American
cuisine is also shaped by advances in technology, societal changes in
lifestyle, and product innovation (Table 11.1).
Table American Cuisine as Influenced
by Advances in Technology, ‐
11.1 Societal Changes in Lifestyle, and
Product Innovation
Food Away from Home

Convenience foods and meals from restaurants (either dine-in or takeout)
are a driving force in current food trends. Food away from home (FAFH)
accounts for more than 40% of food spending (Binkley & Liu, 2019). The
National Health and Nutrition Examination Survey data show that among
men and women age 20 and older, 33% of total calorie intake comes from
food and beverages consumed away from home (U.S. Department of
Agriculture, Agricultural Research Service, 2018).
Convenience Food
broadly defined as any product that saves time in food preparation, ranging from bagged fresh
salad mixes to frozen packaged complete meals.
Numerous studies have found that the nutritional quality of FAFH is

lower than that of food consumed at home. For instance, Nguyen and Powel
(2014) found that both fast-food and full-service restaurant food intake
among adults is associated with significant increases in the intake of
calories, sugar, saturated fat, and sodium. Conversely, eating home-cooked
meals more than five times per week is associated not only with better diet
quality but also with a greater likelihood of having normal-range body mass
index (BMI) and percentage of body fat (Mills et al., 2017). Box 11.1
features findings on FAFH.
BOX Food at Home and Food Away from

11.1 Home: Nutrition Differences
• FAFH tends to consist of less healthy foods and more calorically dense
types of food within all food groups, such as white potatoes instead of
sweet potatoes and high-fat burgers instead of low-fat burgers.
• The higher caloric density of FAFH is partly due to higher-fat cooking
methods such as frying instead of baking.
• Meat and soft drinks are more important in FAFH meals.
• Fruit and milk are seldom consumed as part of FAFH.
• FAFH is estimated to be responsible for the increasing consumption of
potatoes, chicken, beef, lettuce, and cheese.
• Evidence shows that more frequent consumers of FAFH tend to have
less healthy home diets than non-FAFH consumers, suggesting that
FAFH diners select less healthy foods regardless of the source.
Source: Binkley, J., & Liu, Y. (2019). Food at home and away from home: Commodity
composition, nutrition differences, and differences in consumers. Agricultural and Resource
Economics Review, 48(2), 221–252. https://www.cambridge.org/core/services/aop-cambridge-
core/content/view/FD229E025ACD524B31C6D1DA48AFD2DF/S1068280519000017a.pdf/di
v-class-title-food-at-home-and-away-from-home-commodity-composition-nutrition-
differences-and-differences-in-consumers-div.pdf
Eating out has evolved from a special treat to a regular event, so

planning and menu savvy are needed to ensure that eating out is consistent
with eating healthy and not contrary to it. Tips for eating healthy while
eating out appear in Box 11.2. Best bet choices from various ethnic‐
restaurants are listed in Box 11.3.
BOX Tips for Eating Healthy While Eating

11.2 Out
Plan Ahead
• Choose the restaurant carefully so you know there are reasonable

choices available.
• Check online or call ahead to inquire about menu selections. This is an
especially important strategy when the ___location is not a matter of
choice but, rather, a requirement such as for business luncheons or
conferences. It may be possible to make a special request ahead of
time.
Don’t Arrive Starving
• People become much less discriminating in their food choices when

they are hungry.
• Eating a small, high-fiber snack an hour or so before going out to
dinner, such as whole wheat crackers with peanut butter or a piece of
fresh fruit with milk, can take the edge off hunger without bankrupting
healthy eating.
Balance the Rest of the Day

When eating out is an occasion, such as for a birthday or anniversary
• celebration, make healthier choices the rest of the day to compensate
for a planned indulgence.
Practice Portion Control
• Order the smallest size meat available.

• Create a doggie bag before eating; if you wait until the end of the
meal, there may not be any left.
• Order regular size, not biggie size or supersize.
• Order a la carte. Is a value meal a “better value” if it undermines your
attempt to eat healthily?
• Order a half portion when available.
• Order two (carefully chosen) appetizers in place of an entrée, or order
an appetizer and split an entrée with a companion.
Know the Terminology

Calorie-laden words to watch out for include the following:
• Buttered
• Battered
• Breaded
• Deep fried
• Au gratin
• Creamy
• Crispy
• Alfredo
• Bisque
• Hollandaise
• Parmigiana
• Béarnaise
• En croute
• Escalloped
• French fried
• Pan fried
• Rich
• Sautéed
• With gravy, with mayonnaise, with cheese
Less fatty terms are baked, braised, broiled, cooked in its own juice,
grilled, lightly sautéed, poached, roasted, and steamed.
Beware of Hidden Fats, Such as

• High-fat meats
• Nuts
• Cream and full-fat milk
• Full-fat salad dressings and mayonnaise
• Sauces and gravies
Make Special Requests
• Order sauces and gravies “on the side.”

• Ask that lower-fat items be substituted for high-fat items (e.g., a baked
potato instead of french fries).
• Substitute brown rice for white rice.
• Request an alternate cooking method (e.g., broiled instead of fried).
BOX Best Bet Choices from Fast-Food and

11.3 Ethnic Restaurants
Fast Foods
English muffins or bagels with spreads on the side
Oatmeal
Butter, margarine, or syrups on the side—not added to food
Baked potato—plain or with reduced-fat or fat-free dressings or salsa
Pretzels or baked chips
Regular, small, or junior sizes
Ketchup, mustard, relish, BBQ sauce, and fresh vegetables as toppings
Grilled chicken sandwiches without “special sauce”
Veggie burger
Small roast beef on roll
Corn tortilla burritos with chicken, beans, veggies, and guacamole
Grilled chicken nuggets
Fruit ’n yogurt parfait
Lean, 6-in. subs on whole-grain rolls with extra vegetables
Side salads with reduced-fat or fat-free dressings
Salads with grilled chicken
Low-fat or nonfat milk
Fresh fruit
Specialty coffees with skim milk
Pizza
Thin crust
Vegetables: onions, spinach, tomatoes, broccoli, mushrooms, peppers
Lean meats: Canadian bacon, ham, grilled chicken, shrimp, crab meat
Half-cheese pizza
Salad as a side dish
Mexican
Sauces: salsa, mole, picante, enchilada, pico de gallo
Guacamole in place of cheese and sour cream
Black bean soup, gazpacho
Soft, nonfried corn tortillas, as in bean burritos or enchiladas
Refried beans (without lard)
Arroz con pollo (chicken with rice)
Grilled meat, fish, or chicken
Steamed vegetables
Soft-shell chicken, shrimp, or veggie tacos
A la carte or half entrée
Fajitas: chicken, seafood, vegetable, beef
Flan (usually a small portion)
Chinese
Hot-and-sour soup, wonton soup
Chicken chow mein
Chicken or beef chop suey
Moo Shu vegetables
Moo Goo Gai Pan
Buddha’s Delight
Chicken lettuce wraps
Shrimp with garlic sauce or black bean sauce
Stir-fried and teriyaki dishes
Steamed rice instead of fried
Steamed spring rolls
Tofu
Steamed dumplings and other dim sum instead of egg rolls
Sauce on the side
Italian
Minestrone
Garden salad; vinegar and oil dressing
Cioppino (seafood stew)
Breadsticks, bruschetta, Italian bread
Sauces: red clam, marinara, wine, cacciatore, fra diavolo, marsala
Fresh fish, shrimp, veal, chicken without breading
Pasta primavera
Choose vegetables for a side dish instead of pasta or potatoes
Limit “unlimited” bread or breadsticks
Italian ice, sorbet, or fruit
Indian
Raw vegetable salads, Mulligatawny soup (lentil soup)
Tandoori meats
Condiments: fruits and vegetable chutneys, raita (cucumber and yogurt
sauce)
Lentil and chickpea curries
Kebobs (with brown rice instead of pilaf)
Aloo Gobi
Chana Masala
Naan (bread baked in tandoori oven)
Dal
Japanese
Edamame
Miso soup (high in sodium)
Sashimi, sushi, norimaki, temaki
Sushi—cooked varieties include imitation crab, cooked shrimp,
scrambled egg
Most combinations of grilled meats or seafood
Teriyaki chicken, tofu, or seafood
Soba noodles
Green tea
Greek
Gigantes Plaki (large white beans baked in tomato sauce)
Avgolemono (Greek chicken noodle soup)
Lentil soup
Greek salad, tabouli
Souvlaki salad or sandwich made with pork, chicken, lamb, or beef
Shish kebabs
Pita bread
Make a meal of appetizers: baba ghanoush (smoked eggplant), hummus
(mashed chickpeas), dolma (stuffed grape leaves), and tabbouleh
(cracked wheat salad). Olive oil is often poured on the baba
ghanoush, hummus, and other foods, so ask for it on the side.
THE EFFECT OF CULTURE
Culture has a profound and unconscious effect on food choices. Yet, within,
among, and across cultural groups, individuals or subgroups may behave
differently from the socially standardized foodway because of age, sex,
state of health, household structure, or socioeconomic status. Race,
ethnicity, and geographic region are often inaccurately assumed to be
synonymous with culture. This misconception leads to stereotypic
grouping, such as assuming that all Jewish people adhere to orthodox food
laws or that all Americans from the South eat sausage, biscuits, and gravy.
Subgroups within a culture display a unique range of cultural
characteristics that affect food intake and nutritional status. What is edible,
the role of food, how food is prepared and seasoned, the symbolic use of
food, and when and how food is eaten are among the many characteristics
defined by culture.
Foodway
an all-encompassing term that refers to all aspects of food, including what is edible, the role of
certain foods in the diet, how food is prepared, the use of foods, the number and timing of daily
meals, how food is eaten, and health beliefs related to food.
Subgroups
unique cultural groups that exist within a dominant culture.
The characteristics of culture are that it

• has an inherent value system that defines what is considered
“normal,”
• is learned, not instinctive,
• is passed from generation to generation,
• has an unconscious influence on its members, and
• resists change but is not static.
Culture Defines What Is Edible

Culture determines what is edible and what is inedible. To be labeled a
food, an item must be readily available, safe, and nutritious enough to
support reproduction. However, cultures do not define as edible all sources
of nutrients that meet those criteria. For instance, in the United States, horse
meat, insects, and dog meat are not considered food, even though they meet
the food criteria. Culture overrides flavor in determining what is offensive
or unacceptable. For example, you may like a food (e.g., rattlesnake) until
you know what it is; this reflects disliking the idea of the food rather than
the actual food itself. An unconscious food selection decision process
appears in Figure 11.1.
Figure 11.1 ▲ Food selection and decision-making.
Edible
foods that are part of an individual’s diet.
Inedible
foods that are usually poisonous or taboo.
The Role of Certain Foods in the Diet
Every culture ranks food based on cost and availability.
• Core or staple foods serve as the foundation of the diet. They are
usually bland, inexpensive, easy to prepare, and provide a
significant source of calories.
• Core foods are typically complex carbohydrates, such as cereal
grains (rice, wheat, millet, corn), starchy tubers (potatoes, yams,
taro, cassava), and starchy vegetables (plantain or green bananas).
Core Foods
the important and consistently eaten foods that form the foundation of the diet. They are the
dietary staples.
Consider Phouvong. A core food in his eating pattern is

sticky rice, a type of rice referred to as glutinous because it
holds together when picked up, not because it contains
gluten. Through an interpreter, the nurse learns that
Phouvong eats a traditional Laotian eating pattern and will
not eat American food. The only food he eats that is not
prepared by his wife is prepared by other Laotians in his
tightly knit community. What information would be
important to obtain in order to meet his nutritional needs in a
culturally appropriate manner?
Secondary foods are foods that are widely consumed but not on a daily
basis. Examples of secondary foods are vegetables, legumes, nuts, fish,
eggs, and meats.
Secondary Foods
foods that are widespread in the diet but not eaten consistently.
Peripheral, or occasional, foods are eaten sporadically and are

typically based on an individual’s preference, not on cultural norms. They
may be foods that are reserved for special occasions, not readily available,
or not generally well tolerated (as is the case with milk among Asian
Americans).
Peripheral, or Occasional, Foods
foods that are infrequently consumed.
How Food Is Prepared and Seasoned

Traditional methods of preparation vary between and within cultural
groups. For instance, vegetables often are stir-fried in Asian cultures but
boiled in Hispanic or Latinx cultures. What is deemed a healthy cooking
method in the United States, such as baking and grilling, may be seen by
other groups as causing an undesirable change in the nature of the food
(Carr, 2012). Traditional seasonings may be the distinguishing feature
between one culture’s food and another’s, such as garam masala in Indian
cooking and lemon grass in Thai cuisine. The choice of seasonings is based
on availability and varies among geographic regions and seasons.
Recall Phouvong. A Laotian comfort food is pho, a beef

broth–based soup that is made by boiling the broth and then
adding sliced raw beef with the idea that the broth cooks the
meat. His wife is smuggling pho, sticky rice, and a variety of
other foods into the hospital because he will not eat
American food. His wife has been hiding the food in his
bedside table to avoid getting in trouble. What should the
nurse do?
Symbolic Use of Foods

Each culture has food customs and bestows symbolism. Culture defines that
foods
• are served as meals versus snacks,
• are used in celebration,
• provide comfort,
• are gendered as feminine (e.g., salad) or masculine (e.g., steak),
• express love, are used to reward or punish, display piety, or express
moral sentiments, and
• demonstrate belongingness to a group or proclaim the separateness
of a group.
When and How Food Is Eaten

All cultures eat at least once a day. Some may eat five or more meals each
day. Food may be eaten with chopsticks, a knife and fork, or fingers. In the
United States, eating with bad manners may be associated with animal
behavior, as in eating like a pig, chewing like a cow, or wolfing down food.
Think of Phouvong. He eats sticky rice with his hands and

sometimes dips it in fish paste or pho. Are you able to
remain nonjudgmental in your reaction? What measures can
you take to help minimize Phouvong’s risk of foodborne
illness?
Cultural Values
Cultural values define desirable and undesirable personal and public
behavior and social interactions. Understanding the client’s cultural values
and their impact on health and food choices facilitates cross-cultural
nutrition care. Table 11.2 highlights the contrast between selected American
cultural values and values of more traditional cultures.
Table A Contrast of Cultural

Values
11.2
Potential
Considerations of
American Values Traditional Values Traditional Values
Personal control Fate Patients may not
Individuals believe Individuals may have consider
they have an external locus of themselves active
personal control control, believing participants in their
over their that what happens own healing but
future. to them is out of rather recipients.
their control and
that their personal
habits have little or
no effect.
Individualism Group welfare Establish close rapport
Interests and needs The needs of the group with the patient by
of the (family) are valued asking about the
individual have over the needs of family; make
preference over the individual; family feel
those of the decisions may be welcome.
group. left up to the head Involve family in
of the family. planning.
Emphasize the
good of the entire
family rather than
individual benefits.
Time dominates Human interaction Expediency and
Being on time and dominates efficiency may be
not wasting Personal interaction is counterproductive.
time are virtues. more important Pause while talking.
than time Avoid interruptions.
management.
Potential
Considerations of
American Values Traditional Values Traditional Values
Informality Formality Use a formal tone,
Informality is Informality may be especially with
viewed as a equated with older people.
sign of disrespect.
friendliness.
Directness Indirectness It may be appropriate
Honest, open Straightforwardness to avoid eye
communication may be rude or too contact.
is considered personal. Talking in the third
effective person; for
communication. example,
“someone who
wants to eat less
sodium may
choose fresh
vegetables over
canned” is valued
over “you should
… .”
Asking questions may
be considered
disrespectful; ask
questions
judiciously.
Role of Food in Health or Disease

Almost all cultures define certain foods that promote wellness, cure disease,
or impart medicinal properties. For instance, many people who are Chinese
believe that health is a balance between yin and yang forces in the body.
Diseases caused by yin forces are treated with yang-force foods and vice
versa. Obtaining candid information about health beliefs requires health
professionals to be culturally knowledgeable and sensitive and to ask
questions that are open ended and nonjudgmental (Hagan et al., 2017) (Box
11.4).
BOX Questions That May Aid in

11.4 Understanding Health Beliefs
• What does it mean to be healthy?

• What do you do to keep healthy?
• What do you teach your children about health?
• What health practices do you engage in that differ from what your
ancestors did?
• What do you think makes a person sick?
• When a person is sick, do you think they are in control of making
themselves better?
• What do you do when you are sick?
• Who helps you when you are sick?
• Have you been to a folk healer or used folk medicine when you are
sick?
• Where do you get health information?
Source: Eggenberger, S., Grassley, J., & Restrepo, E. (2006). Culturally competent nursing care
for families: Listening to the voices of Mexican-American women. OJIN: The Online Journal
of Issues in Nursing, 11(3). https://doi.org/10.3912/OJIN.Vol11No03PPT01
Body Image
Culture also shapes body image. In the United States, you can never be too
thin, and thinness, particularly in women, is insert often equated with
beauty and status. Obesity and being overweight may be viewed as a
character flaw. Conversely, thinness has historically been a risk factor for
poor health or associated with poverty or insufficient food supplies. In
many cultures today, including those of some African, Mexican, Native
American, and Caribbean Islander cultures, being overweight is a sign of
health, beauty, and prosperity (Kittler et al., 2012). To some people, healthy
eating is synonymous with eating large quantities of food rather than
making more nutritious food choices.
Dietary Acculturation
Dietary acculturation occurs when eating patterns of immigrants change
to resemble those of the dominant or mainstream culture. In the United
States, acculturation is linked to an increased risk of chronic disease and
obesity; however, its effect on diet quality is not always consistent. For
instance, acculturation of immigrants who are from South Asia in Canada
led to both positive changes (a greater intake of fruit and vegetables and a
decrease in deep fat frying) and negative changes (an increased intake of
convenience foods, sugar-sweetened beverages, red meat, and increased
frequency of eating out) (Lesser et al., 2014). Clearly, acculturation is a
highly complex, dynamic, multidimensional process that is impacted by a
variety of personal, cultural, and environmental factors (Satia, 2009).
Associations of acculturation with diet are often inconsistent and do not fit
an expected pattern (Satia, 2009).
Dietary Acculturation
the process that occurs as members of a minority group adopt the eating patterns and food choices
of the host country.
Acculturation
the process that occurs as people who move to a different cultural area adopt the beliefs, values,
attitudes, and behaviors of the dominant culture; not limited to immigrants but affects anyone (to
varying degrees) who moves from one community to another.
Generally, food habits are one of the last behaviors people change
through acculturation. This is possibly because eating is done in the privacy
of the home and not in full view of the majority culture.
• Usually, first-generation Americans adhere more closely to cultural
food patterns and may cling to traditional foods to affirm their
cultural identity. First-generation citizens usually need help
choosing American replacements for their native foods.
• Second-generation Americans do not have the direct native
connection and may follow cultural patterns only on holidays and at
family gatherings, or they may give up ethnic foods but retain
traditional methods of preparation. Second-generation citizens may
need help selecting healthy American foods.
• Children tend to adopt new ways quickly as they learn from other
children at school.
BOX Points to Consider Regarding Dietary

11.5 Acculturation
• Generally with acculturation, the intake of sweets and fats increases,

neither of which has a positive effect on health.
• Dietary acculturation is most likely to change food choices for
breakfast and lunch rather than dinner, so focus on promoting healthy
food choices available in America for those meals.
• Portion control is a better option than advising someone to eliminate
an important native food from their diet. Lower-fat or lower-sodium
options, when available, may also be an acceptable option for the
client. Although giving up soy sauce may not be an option for an
American of Chinese origin, using a reduced-sodium version may be
doable.
• It is essential to determine how often a food is consumed in order to
determine the potential impact of that food. For instance, lard is
unimportant in the context of the total diet if it is used in cooking only
on special occasions.
• Don’t assume the client knows which American foods are considered
healthy.
• Suggest fruits and vegetables that are similar in texture to those that
are familiar but unavailable to the client.
Process of Acculturation
Ideally, people who acculturate will retain healthy traditional food practices,
adopt healthy new food behaviors, and avoid less healthy American food
habits. Actual food choices are influenced by income, education,
urbanization, geographic region, and family customs. Points to keep in
mind regarding dietary acculturation appear in Box 11.5.
• New foods are added to the diet.
• Status, economics, information, taste, and exposure are some of
the reasons why new foods are added to the diet.
• Eating American food may symbolize status and make people feel
more connected to their new culture.
• Frequently, new foods are added because they are relatively
inexpensive and widely available.
• Some traditional foods are replaced by new foods.
• Traditional foods may be difficult to find, be too expensive, or
have lengthy preparation times.
• Breakfast and lunch are most likely to be composed of convenient
American foods, whereas traditional foods are retained for the
major dinner meal, which has greater emotional significance.
• Some traditional foods are rejected.
• Children and adolescents are more likely than older adults to
reject traditional foods to become more like their peers.
• Traditional foods may be rejected because of an increased
awareness of the role of nutrition in the development of chronic
diseases. For instance, one reason why Indian immigrants who
have resided in the United States for a relatively long period tend
to eat significantly less ghee (clarified butter served with rice or
spread on Indian breads) may be that they are trying to decrease
their intake of saturated fat.
CULTURAL SUBGROUPS IN THE
UNITED STATES
It is projected that by the year 2044, more than half of all Americans will
belong to a cultural group (Colby & Ortman, 2015). The nutritional
implication of this shift in cultural predominance is that cultural
competence will become increasingly important to nursing care. Nutrition
information that is technically correct but culturally inappropriate does not
produce behavior change. Cultural competence facilitates nutrition care that
is consistent with the individual’s attitudes, beliefs, and values. Suggestions
for conducting effective cross-cultural nutrition counseling are listed in Box
11.6.
BOX Suggestions for Conducting Effective

11.6 Cross-Cultural Nutrition Counseling
• Establish rapport and respect cultural differences.

• Be knowledgeable about cultural food habits and health beliefs.
• Relevant guidance must include advice on traditional foods and
preparation methods to retain or reduce.
• Use culturally appropriate verbal and nonverbal communication.
• Determine the primary written and spoken language used in the
client’s home.
• Use trained interpreters when necessary.
• Determine whether the client prefers direct or indirect communication.
• Pare down information to only what the client needs to know.
• Emphasize the positive food practices of traditional health beliefs and
food customs.
• Explain medical reasons for recommended changes.
• Provide written material only after determining reading ability.
• Communicate consistent messages.
The minimum categories of race and ethnicity were established by the

U.S. Office of Management and Budget in 1997 and are still used today by
the U.S. Census Bureau (2020).
• Native North American or Alaska Native: people having origins
in any of the original peoples of North and South America,
including Central America, who maintain tribal affiliation or
community attachment.
• Asian: people having origins in any of the original peoples of the
Far East, Southeast Asia, or the Indian subcontinent. Cambodia,
China, India, Japan, Korea, Malaysia, Pakistan, the Philippine
Islands, Thailand, and Vietnam are examples.
• Black or African American: people having origins in any of the
Black racial groups of Africa.
• Native Hawaiian or Other Pacific Islander: people having origins
in any of the original peoples of Hawaii, Guam, Samoa, or other
Pacific islands.
• White: people having origins in any of the original peoples of
Europe, the Middle East, or North Africa.
• Hispanic, Latino, or Spanish: people of Cuban, Mexican, Puerto
Rican, South or Central American, or other Spanish culture or
origin. The term Spanish origin can be used in addition to Hispanic
or Latino regardless of race.
Each of these categories has multiple diverse subgroups. For instance,

the category of Native Americans comprises more than 573 tribes legally
recognized by the Bureau of Indian Affairs (Federal Register, 2019). In
addition, multiracial individuals represent a growing population.
TRADITIONAL DIETS
Traditional diets are generally considered healthy because they contain
large amounts of plant-based foods such as grains, vegetables, legumes,
tubers, and fruit and low amounts of foods from animals, such as red meat
(Valerino-Perea et al., 2019). However, it is difficult to define traditional
diets because actual food choices vary greatly within subgroups on the basis
of national, regional, and ethnic differences. For instance, foods eaten most
often in traditional Mexican diet differ by geographical regions such as
northern, central, and southern Mexico. Likewise, traditional diets change
over time. While insects are no longer part of the traditional Mexican diet,
eggs and milk appear to be recent additions (Valerino-Perea et al., 2019).
Generalizations about traditional eating practices and dietary changes
related to acculturation for three major cultural subgroups in the United
States are highlighted in the following sections. A summary of health
statistics by cultural group appears in Table 11.3.
Table Summary of Health Statistics

11.3 by Cultural Group
Black or African Americans
According to 2019 estimates, 13.4% of the population in 2018 was Black or
African American alone (U.S. Census Bureau, 2019). The majority of
people who are Black or African American can trace their ancestors to West
Africa, although some have immigrated from the Caribbean, Central
America, and East African countries. Since most are many generations
away from their original homeland, much of their native heritage has been
assimilated, lost, or modified. Box 11.7 highlights traditional food practices,
changes in intake related to acculturation, and traditional health beliefs.
Additional salient points are summarized in the following sections.
BOX Food and Culture of People Who Are

11.7 African American
Traditional Food and Eating Patterns
• The style of cooking that developed during the American slavery time
period when slaves were given the leftover or less desirable cuts of
meat. Farming, hunting, and fishing provided fish, wild game, and
vegetables.
• Traditional soul foods tend to be high in fat, cholesterol, and sodium
and low in protective nutrients, such as potassium (fruits and
vegetables), fiber (whole grains and vegetables), and calcium (milk,
cheese, and yogurt).
• Staples include corn and corn products (grits, cornmeal), rice, biscuits,
black-eyed peas, butter beans, lima beans, catfish, chitterlings (cleaned
and cooked intestines of hogs), breaded and fried beef, pork, poultry,
variety meats (oxtail, pig’s feet), pork rinds, greens (a variety of leafy
vegetables), melons, peaches, pecans, sweet and white potatoes, butter,
lard, bacon, fatback, fruit drinks, molasses, and sorghum.
Changes in Intake from Acculturation

• Greater intake of milk, at least among people who are Black
Americans living in urban areas.
• Fruit intake remains low and is based on availability.
• Vegetable intake remains low but greens remain popular.
• Commercially made bread is substituted for homemade biscuits.
• Packaged and luncheon meats are popular, but intake of fatty meats,
such as sausage and bacon, is high.
Traditional Health Beliefs
• Health beliefs of some are a blend of traditional African concepts and

those encountered through early contact with Native North Americans
and White Americans.
• Illnesses are classified as natural (stemming from the effects of cold,
dirt, and improper diet or divine punishment) or unnatural (the result
of witchcraft and conflict in the social network).
• Home remedies, natural therapies, and traditional healers may be used.
• Feelings of powerlessness may be evident among Black Americans
living in poverty.
Source: African American Registry. (n.d.). “Soul Food” in America: A brief history.
https://aaregistry.org/story/soul-food-a-brief-history; Snow, L. F. (1983). Traditional health
beliefs and practices among lower class black Americans. The Western Journal of Medicine,
139(6), 820–828.
Soul Food
Soul food describes traditional Southern African American food eaten by
people who are African American and cooking techniques that evolved
from West African, slave, and post-abolition cuisine. The term soul food
was first used in 1964 during the rise of the civil rights movement.
• Many soul food customs and practices are shared by in the Southern
United States, particularly those of lower socioeconomic status or
living in rural areas (Kulkarni, 2004).
• Soul food has become a symbol of identity for people who are
African American identity and from African heritage; however,
today, African American food habits usually reflect their current
socioeconomic status, geographic ___location, and work schedule more
than their African or Southern heritage (Kittler et al., 2012).
• Soul food may be reserved for special occasions and holidays.
Diet Quality
• In a study that examined dietary quality by race and ethnicity, the
intake of total vegetables, whole grains, milk, fiber, potassium, and
calcium is lower among people who are Black than people who are
White and intakes of sugar-sweetened beverages and added sugars
are higher (Hiza et al., 2013).
• Foreign-born people who are Black Americans are reported to have
a higher Healthy Eating Index score and Dietary Approaches to Stop
Hypertension diet scores compared with people who are Black
Americans born in the United States. They were more likely to be in
the top third for intake of vegetables, fruit, whole grains, and
omega-3 fatty acids (Brown et al., 2018).
Nutrition-Related Health Issues

• People who are Black Americans have among the highest rates of
morbidity and mortality from diet-related diseases (such as
hypertension, heart disease, and stroke) compared to other
racial/ethnic groups in the United States (Brown et al., 2018).
• Women who are Black Americans are Black are less likely to
perceive themselves as overweight than women who are women
who are White Americans of the same BMI (Langellier et al.,
2015a).
• Adults who are Black Americans have a significantly higher
likelihood of developing diabetes than adults who are of White
Americans—about 66 more cases of diabetes per 1000 people, with
the greatest difference being between women who are Black
Americans and White Americans (National Institutes of Health,
2018). Biological risk factors, including weight and fat around the
abdomen, are primarily responsible for the higher rates.
• The percentage of people who are Black Americans whose health is
fair or poor is greater than in any other ethnic group. This is also
true for infant mortality.
• The death rate for people who are Black Americans is generally
higher than that for people who are of White Americans for heart
diseases, stroke, cancer, asthma, influenza and pneumonia, diabetes,
HIV/AIDS, and homicide (Office of Minority Health, 2019a).
Hispanic or Latino Americans

People who are Hispanic or Latino Americans are a diverse group differing
in native language, customs, history, and foodways. According to 2019
estimates, approximately 18.5% of the U.S. population are poeple of
Hispanic or Latino descent (U.S. Census Bureau, 2019). People of Mexican
descent are the largest subgroup, at 63% of the American population of
people who are of Hispanic or Latino descent. Box 11.8 highlights
traditional food practices, changes in intake related to acculturation, and
traditional health beliefs. Additional salient points are summarized in the
following sections.
Diet Quality
• People of Hispanic origin who speak Spanish are more likely to
report consuming foods in the Healthy Eating Index as compared to
Hispanic people who are bilingual or prefer to speak English
(Reininger et al., 2017).
• Acculturation is associated with lower diet quality scores from
undesirable changes in the intake of vegetables, fruits, sodium, and
empty calories (Yoshida et al., 2017).
• Mexican Americans who speak English (sign of greater
acculturation) report eating more fast foods, pizza, non-homemade
meals, and more meals at sit-down restaurants than other Mexican
Americans who speak Spanish (Langellier et al., 2015b).
BOX Mexican American Food and Culture

11.8
• The traditional Mexican diet is influenced by Spanish and Native

North American cultures. It is generally a low-fat and high-fiber diet
rich in complex carbohydrates and vegetable proteins. There is an
emphasis on corn (maize), corn products, beans, chili, and squash.
Animal foods are limited.
• Individual foods cited most often include corn and corn products,
amaranth, rice, potato, sweet potato, beans, tomatoes, squash, citrus
fruits, guava, jicama, plums, prickly pear, turkey, chicken, duck,
venison, rabbit, beef, chili, salt, and onion.
• Items less frequently mentioned are as follows: avocado, pumpkin and
chia seeds, chocolate drinks, honey, sugar, and sugarcane.
• Tortillas are a staple and may be consumed at every meal.
• Chilies are a common main ingredient in meals.
• Rice is usually served first before the main meal.
• Four or five meals per day are consumed.
• Families gather at meals to build a sense of togetherness.
• Women prepare the food.
• Intake of fruits, vegetables, rice and beans, and fiber decreases.

• Use of lard and heavy cream decreases.
• Intake of traditional meat and vegetable preparations declines
drastically.
Flour tortillas replace corn. Sugar-sweetened beverages replace
•
traditional fruit-based beverages.
• Intake of white bread, sweetened cereals, red meat, cheese, and
saturated fat increases.
• Increase in FAFH.
• Intake of processed foods, refined carbohydrate, and added sugars
increases.
• The majority of people who are Mexican are Roman Catholic.

Religious and spiritual beliefs greatly influence health and illness
practices, which result from a blend of European folk medicine
introduced from rituals from Spain and Native North Americans.
• Illness is the result of punishment, worry, stress, fear, fatalism or luck,
and/or the supernatural/evil eye.
• Herbal and folk remedies are often used for self-treatment. Drinks, tea,
and ointments are common home remedies.
• Being overweight may be seem as a sign of wealth.
• The mother decides when an illness is beyond her ability to treat.
• Extended and nuclear families are highly valued and relied on for
intergenerational help.
• Respect is based on status and hierarchy in the community.
Source: United Nations Educational, Scientific, and Cultural Organization. Intangible cultural
heritage. (2010). Traditional Mexican cuisine—ancestral, ongoing community culture, the
Michoacan paradigm. https://ich.unesco.org/en/RL/traditional-mexican-cuisine-ancestral-
ongoing-community-culture-the-michoacan-paradigm-00400; Ohio State University Extension.
(n.d.). Mexican food and culture fact sheet. https://dune.une.edu/cgi/viewcontent.cgi?
article=1010&context=an_studedres; Sofianou, A., Fung, T., & Tucker, K. (2011). Differences
in diet pattern adherence by nativity and duration of U.S. residence in the Mexican-American
Population. Journal of the American Dietetic Association, 111(10), 1563–1569.
https://doi.org/10.1016/j.jada.2011.07.005; Valerino-Peres, S., Lara-Castor, L., Armstrong, M.
E. G., & Papadaki, A. (2019). Definition of the traditional Mexican diet and its role in health: A
systematic review. Nutrients, 11(11), 2803. https://doi.org/10.3390/nu11112803

• People who are Hispanic or Latino Americans have a high
prevalence of obesity and tend to be less physically active than
people who are non-Hispanic White Americans (Centers for Disease
Control and Prevention [CDC], 2019).
• People who are Hispanic or Latino Americans have a longer life
expectancy than people who are White Americans, at 84.1 years for
women and 79.6 years for men (Office of Minority Health, 2019b).
• People who are Hispanic or Latino Americans are more than twice
as likely to develop type 2 diabetes as people who are non-Hispanic
White Americans (CDC, 2019).
• Other health conditions that significantly affect people who are
Hispanic or Latino Americans are asthma, chronic obstructive
pulmonary disease, HIV/AIDS, suicide, and liver disease (Office of
Minority Health, 2019b).
Asian Americans
Approximately 5.9% of the U.S. population are of people of Asian origin
alone, according to 2019 census estimates (U.S. Census Bureau, 2019).
People who are Chinese comprise the largest subgroup of people who are
Asian American in the United States (Pew Research Center, 2019). The
term Asian Americans encompasses a diverse population originating from at
least 37 different ethnic groups; Pacific Islander includes about 25
nationalities (Kagawa-Singer et al., 2010). Two dietary commonalities exist
between these diverse cultures: emphasis on rice and vegetables with
relatively little meat and cooking techniques that include meticulous
attention to preparing ingredients before cooking. Box 11.9 highlights
traditional Chinese food practices, changes in intake related to
acculturation, and traditional health beliefs. Additional salient points are
summarized in the following sections.
BOX Chinese American Food and Culture

11.9
• The traditional Chinese diet is low in fat and dairy products and high
in complex carbohydrates and sodium.
• Rice is the staple for people living in the south of China. Products
made of wheat flour (noodles, dumplings, pancakes, steamed bread)
are staples in northern China.
• Vegetables are used extensively. Other foods commonly consumed
include sea vegetables, nuts, seeds, beans, soy foods, vegetable and nut
oils, herbs and spices, tea, wine, and beer.
• A variety of animal proteins are consumed. The use of fish and
seafood depends on availability.
• Most Chinese food is cooked. The exception is fresh fruit, which is
eaten infrequently.
• Few dairy products are consumed because lactose intolerance is
common.
• Sodium intake is generally assumed to be high because of traditional
food preservation methods (salting and drying) and condiments (e.g.,
soy sauce).
• Compared to other countries, people who are Chinese spend much
more time on cooking. It generally takes 1 to 2 hours to make a dinner.
• Usually elders and the young are served first, followed by men,
children, and women.
• Dinner is usually abundant and has 2 to 4 dishes and one soup.
• Rice remains a staple. Wheat bread and cereal intake increases.

• Intake of raw vegetables, salad, fruit, dairy, meat, sugar, and ethnic
food increases
• Fat intake increases as fast-food intake increases.
• Traditional vegetables are replaced by more commonly available ones.
• Illness and death may be viewed as a natural part of life.

• Health is maintained by balancing complementary energies such as
cold and hot, dark and light. These forces are called yin and yang.
• Foods are thought to have medicinal purposes, and body parts may be
healed by eating corresponding food parts, such as eating fish eyes to
improve vision.
• Foods and herbs may be used to restore the yin–yang balance, as may
other traditional remedies such as massage and acupuncture.
• Traditional approaches may be used before seeking Western medical
care.
• There is less emphasis on individual feelings and more on loyalty to
family and devotion to tradition. Decision-making may involve the
whole family.
Source: Ma, G. (2015). Food, eating behavior, and culture in Chinese society. Journal of Ethnic
Foods, 2(4), 195–199. https://doi.org/10.1016/j.jef.2015.11.004; University of Washington
Medical Center. (2007, April). Communicating with your Chinese patient.
https://depts.washington.edu/pfes/PDFs/ChineseCultureClue.pdf
Diet Quality
The traditional diet of people who are Chinese is low in fat and dairy
products and high in complex carbohydrates and sodium (Kittler et al.,
2012). With acculturation, the diet becomes higher in fat, protein, sugar, and
cholesterol.

• The cultural group of people who are Asian American has the
lowest percentage of people in fair or poor health.
• Life expectancy among women who are of Asian origin is 82.0
years, and it is 77.5 years (Office of Minority Health, 2019c). This is
longer than the average life expectancy of 81.1 years for women and
76.2 years for men among the total U.S. population (Murphy et al.,
2018).
• People who are Asian Americans have the lowest prevalence of
obesity among cultural groups in the United States.
• Epidemiologic studies show that diabetes risk in people who are of
Asian Americans occurs at lower BMI values than in White
Americans, partly because of the propensity for people of Asian
origin to develop visceral, not peripheral, adiposity (King et al.,
2012).
• At any given BMI level, men and women who are Asian Americans
have a greater percentage of body fat than men and women who are
White Americans.
• People who are Asian Americans have a high prevalence of chronic
obstructive pulmonary disease, hepatitis B, HIV/AIDS, smoking,
tuberculosis, and liver disease (Office of Minority Health, 2019c).
• Negative factors that may impact their health include infrequent
medical visits for fear of deportation, language/cultural barriers, and
lack of health insurance.
Recall Phouvong. His BMI is 24.5. Although that is

considered healthy, risk of type 2 diabetes starts at a lower
BMI in people of Asian descent than among other cultural
groups. Attaining a BMI less than 23 will help control
Phouvong’s type 2 diabetes. Options to promote weight loss
are to change the foods consumed, change the amounts,
and/or increase activity. Which option (or options) would
you recommend for Phouvong? How will you convey the
information given the language barrier?
FOOD AND RELIGION
Religion tends to have a greater impact on food habits than nationality or

culture. For example, Orthodox Jewish people follow kosher dietary laws
regardless of their national origin. Religious food practices vary
significantly even among denominations of the same faith. National
variations also exist. A person’s degree of orthodoxy affects how closely an
individual follows dietary laws. An overview of religious food practices
follows. Table 11.4 outlines major features of various religious dietary laws.
Table Summary of Dietary Laws of

11.4 Selected Religions
Kosher
a word commonly used to identify Jewish dietary laws that define clean and unclean foods, how
food animals must be slaughtered, how foods must be prepared, and when foods may be
consumed (e.g., the timing between eating milk products and meat products).
Christianity
The three primary branches of Christianity are Roman Catholicism, Eastern
Orthodox Christianity, and Protestantism. Dietary practices vary from none
to explicit.
• Roman Catholics do not eat meat on Ash Wednesday or on Fridays
of Lent. Food and beverages are avoided for 1 hour before
communion is taken. Devout Catholics observe several fast days
during the year.
• Eastern Orthodox Christians observe numerous feast and fast days
throughout the year.
• The only denominations in the Protestant faith with dietary laws are
The Church of Jesus Christ of Latter-day Saints and Seventh-Day
Adventists.
• Members of the Church of Jesus Christ of Latter-day Saints do not
use coffee, tea, alcohol, or tobacco. Followers are encouraged to
limit meats and consume mostly grains. Some Latter-day Saints fast
1 day a month.
• Most Seventh-Day Adventists are lacto-ovo vegetarians; those who
do eat meat avoid pork. Overeating is avoided, and coffee, tea, and
alcohol are prohibited. An interval of 5 to 6 hours between meals is
recommended, with no snacking between meals. Water is consumed
before and after meals. Strong seasonings, such as pepper and
mustard, are avoided.
Judaism
Orthodox, Conservative, and Reform are the three main denominations of
the Jewish faith in the United States. Hasidic Judaism is a sect within the
Orthodox. These groups differ in their interpretation of the precepts of
Judaism.
• Orthodox Jewish people believe that the laws are the direct
commandments of God, so they adhere strictly to dietary laws called
the kashrut (or kashruth) (Box 11.10). The laws are rigid, so
Orthodox Jewish people rarely eat outside the home except at homes
or restaurants with kosher kitchens.
• The laws focus on three major issues:
• Kosher animals are allowed.
• Blood is not allowed.
• Milk and meat are never combined.
• Reform Jewish people follow the moral law, but they may
selectively follow other laws; for instance, they may not follow any
religious dietary laws.
• Conservative Jewish people fall between the other two groups in
their beliefs and adherence to the laws. They may follow the Jewish
dietary laws at home but take a more liberal attitude on social
occasions.
BOX Kosher Dietary Laws

11.10
Kosher describes foods that are fit for consumption by Jewish people.
Certain species of animals (and their eggs and milk) are allowed while
others are forbidden.
• A mammal is kosher if it has split hooves and chews its cud: cows,
sheep, goats, and deer.
• Kosher birds are domestic varieties of chicken, turkey, goose, pigeons,
and ducks.
• Only fish and seafood that have fins and scales are kosher, such as
salmon, tuna, and herring.
• Fruits, vegetables, and grains are kosher but must be insect free.
• Milk and eggs (without blood spots) are kosher only if they come from
kosher animals.
• Wine and grape juice must be certified kosher.
• Kosher foods are labeled with a logo of the kosher-certifying agency,
of which there are well over 100 in the United States alone. Other
people who often purchase kosher foods include Muslims, Seventh-
Day Adventists, vegetarians, and people with allergies (e.g., shellfish)
or intolerances (e.g., milk).
Kosher foods are categorized as meat, dairy, or pareve (contains neither

meat nor dairy ingredients).
• Meat cannot be consumed at the same meal as dairy.
• Dairy products are not allowed within 1 to 6 hours after eating meat,
depending on the individual’s ethnic tradition.
• Meat cannot be eaten for 30 minutes after dairy products have been
consumed.
• Pareve foods can be mixed and eaten with either meat or dairy: kosher
eggs, fruits, vegetables, grains, margarine-labeled pareve, nondairy
creamers, and oils.
Certain foods and practices, such as the following, are forbidden:
• Non-kosher animals: carnivorous animals (e.g., lions), birds of prey,

pork, fish without scales or fins (e.g., shrimp, lobster, swordfish,
catfish, water mammals), reptiles, amphibians, worms, insects, rabbits,
squirrels, bears, dogs, cats, camels, and horses.
• Blood. Meat from allowed animals must be slaughtered under the
supervision of a rabbi or another authorized person to ensure blood is
properly removed. The animal’s throat is quickly, precisely, and
painlessly cut with a sharp knife.
• Food preparation on the Sabbath. Religious holidays are celebrated
with certain foods. For example, only unleavened bread is eaten during
Passover, and a 24-hour fast is observed on Yom Kippur.
Source: Chabad.org. What is kosher?
https://www.chabad.org/library/article_cdo/aid/113424/jewish/Kosher.htm
Islam
Muslim people eat as a matter of faith and for good health. Basic guidance
concerning food laws is revealed in the Quran (the divine book) from Allah
(the Creator) to Muhammad (the Prophet). For Muslim people, health and
food are considered acts of worship for which Allah must be thanked
(Minority Nurse, 2013a). Many halal laws are similar to the food laws of
Judaism. Halal foods are also identified with symbols. Islam also stresses
certain hygienic practices, such as washing hands before and after eating
and frequent teeth cleaning.
There are 11 generally accepted rules pertaining to halal (permitted)
and haram (prohibited) foods. The five major areas addressed by the halal
are as follows:
Halal
refers to Islamic dietary standards of lawful or permitted when used to describe food.
Haram
refers to Islamic dietary standards of prohibited or unlawful when used to describe food.
• Kosher and halal animals are allowed. Pork, carnivorous animals

with fangs (lions, wolves, dogs, etc.), birds with sharp claws
(falcons, eagles, owls, etc.), land animals without ears (frog, snakes,
etc.), shark, and products containing gelatin made from the horns or
hooves of cattle are not allowed.
• Blood is not allowed.
• Proper methods must be used for slaughtering.
• Carrion (decaying carcass) is not allowed.
• Intoxicants are forbidden, including pure vanilla containing alcohol
and wine vinegar.
Hinduism
A love of nature and desire to live a simple natural life are ideas that form
the basis of Hinduism (Minority Nurse, 2013b). A number of health beliefs
and dietary practices stem from the idea of living in harmony with nature
and having mercy and respect for all of God’s creations.
• Generally, Hindu people avoid all foods that are believed to inhibit
physical and spiritual development.
• Eating meat is not explicitly prohibited, but many Hindu people are
vegetarian because they adhere to the concept of ahimsa.
• Some foods, such as dairy products (e.g., milk, yogurt, ghee), are
considered to enhance spiritual purity. Pure foods can improve the
purity of impure foods when prepared together.
• Some foods, such as beef or alcohol, are innately polluted and can
never be made pure.
• Jainism, a branch of Hinduism, also promotes the nonviolent
doctrine of ahimsa. People who are devout Jains are complete
vegetarians and may avoid blood-colored foods like tomatoes and
root vegetables because harvesting them may cause the death of
insects.
Ahimsa
nonviolence as applicable to foods.
Buddhism
The Buddhist code of morality is set forth in the Five Moral Precepts:
• Do not kill or harm living things.
• Do not steal.
• Do not engage in sexual misconduct.
• Do not lie.
• Do not consume intoxicants (such as alcohol, tobacco, or mind-
altering drugs).
Believing that thoughtful food decisions can contribute to spiritual
enlightenment, a Buddhist asks themselves these questions (ElGindy,
2013):
• What food is this? This question evaluates the origin of the food and
how it reached the individual.
• Where does it come from? This question considers the amount of
work necessary to grow the food, prepare it, cook it, and bring it to
the table.
• Why am I eating it? This question reflects on whether the individual
deserves or is worthy of the food.
• When should I eat and benefit from this food? This question is
based on the idea that food is a necessity and a healing agent and
people are subjected to illness without food.
• How should I eat it? This question considers the premise that food is
received and eaten only for the purpose of realizing the proper way
to reach enlightenment.
In Buddhism, life revolves around nature with its two opposing energy
systems of yin and yang (ElGindy, 2013). Examples of these opposing
energy systems are heat/cold, light/darkness, good/evil, and sickness/health.
Illnesses may result from an imbalance of yin and yang. Most Buddhist
people subscribe to the concept of ahimsa (not killing or harming), so many
are vegetarians. Buddhist dietary practices vary widely depending on the
sect and country.
How Do You Respond?

Are meal kit delivery services as good as
traditionally prepared home-cooked meals? Meal
kits tend to get favorable reviews for taste, variety,
freshness, and convenience and eliminate waste from
leftovers. They are an attractive alternative to traditionally
prepared meals for people who do not have the time for,
or interest in, meal planning and food shopping, and they
enable people to try new cuisines without investing in
exotic ingredients, such as a bottle of a spice when only a
fraction of a teaspoon is needed. The downside is that
they are more expensive than traditionally prepared
meals, and the sodium content tends to be high. The
amount of food sent is for a specified number of people,
so there are usually no leftovers. This can be a positive or
a negative.
Is prepared food from grocery stores healthier
than other food outlets? The trend in buying
prepared foods from the grocery store began with the
desire for convenience. Its growth is fueled by consumer
perception that prepared food is fresher and healthier than
takeout dinners or convenience foods from the frozen
food aisle. However, the fresh food may not actually be
made on premises, sodium content is often high, serving
sizes are not suggested (so it is easy to overbuy and
overeat), and items are generally much more expensive
than making them at home. Whether or not grocery-store-
prepared foods are healthier than food from other outlets
depends on the items chosen, the amounts consumed, and
the methods of preparation.
REVIEW CASE STUDY
Elizabeth moved to the Midwest at the age of 26 from her native country,
Iceland, where she ate seafood almost every evening for dinner. She ate
fruit and vegetables daily, but the variety was limited. In her new home, she
complains that good seafood is hard to find—that it is not as fresh as it is at
home, it tastes different, and it is more expensive. She also misses the dark
brown and black breads she is accustomed to; she is willing to try American
breads but is unsure what variety is good. American fast food is well known
to her, but she does not want to rely on that to satisfy her need for familiar
foods. She wants to eat foods that are healthy, tasty, and affordable.
• What questions would you ask Elizabeth before coming up with

suggestions about foods she could try?
• What would you say to her about her frustration with the seafood
available locally? What suggestions would you make to her?
• What would you tell her about healthy breads? What fruits would you
recommend as healthy, tasty, and affordable? What vegetables?
STUDY QUESTIONS
1 Which of the following religions does not encourage a vegetarian diet?

a. Buddhism
b. Judaism
c. Seventh-Day Adventist
d. Hinduism
2 What is a descriptive word that indicates a low-fat cooking technique?
a. au gratin
b. breaded
c. roasted
d. battered
3 What are the characteristics of a traditional Chinese diet? Select all that
apply.
a. rich in dairy products
b. low in fat
c. high in sodium
d. vegetables used extensively
4 What are the characteristics of a traditional Mexican diet? Select all that
apply.
a. low in fat
b. high in fiber
c. rich in complex carbohydrates
d. rich in vegetable protein
5 What are the nutritional characteristics of a traditional soul food diet?
Select all that apply.
a. high in fat
b. high in sodium
c. high in potassium
d. high in cholesterol
6 Which of the following foods is not pareve?
a. fruit
b. vegetables
c. kosher eggs
d. milk
7 Which approach would be best when developing a teaching plan for an
overweight woman from Mexico?
a. Tell the client she will look better if she loses some of the extra weight
she is carrying around.
b. Encourage more nutritious food choices.
c. Advise the client that healthy eating will help her shed inches.
d. Provide a low-calorie diet and encourage her to eat low-calorie
American foods, such as artificially sweetened soda and low-fat ice
cream.
8 Muslims are prohibited from consuming
a. alcohol.
b. eggs.
c. beef.
d. shellfish.
CHAPTER SUMMARY CULTURAL
AND RELIGIOUS INFLUENCES
ON FOOD AND NUTRITION
American Cuisine
American cuisine has evolved from a melting pot of food, flavors, and
cooking techniques contributed by immigrants over the course of U.S.
history. Today, FAFH provides approximately one third of total calorie
intake.
The Effect of Culture

Culture defines what is edible: how food is handled, prepared, and
consumed; what foods are appropriate for particular groups within the
culture; the meaning of food and eating; attitudes toward body size; and
the relationship between food and health.
Acculturation
• Generally, first-generation Americans adhere more closely to cultural
food patterns; second-generation Americans may eat traditional food
only on special occasions.
• Acculturation is linked to an increased risk of chronic disease and
obesity, although not all dietary changes are negative. Dietary
counseling should encourage retention of healthy food practices,
adoption of healthy new food behaviors, and avoidance of less healthy
American food patterns.
Cultural Subgroups in the U.S.

Although generalizations can be made about traditional eating practices
and changes related to acculturation, actual food choices vary with
nationality, geographic ___location, socioeconomic status, and individual
preferences.
African American Diet.

Soul food describes traditional Southern African American foods and
cooking techniques that evolved from West African, slave, and post-
abolition cuisine.
• Traditional soul foods tend to be high in fat, cholesterol, and sodium

and low in protective nutrients, such as potassium, fiber, and calcium.
• Staples: corn and corn products (grits, cornmeal), rice, biscuits,
legumes, catfish, breaded and fried beef, pork, poultry, variety meats
(oxtail, pig’s feet), pork rinds, “greens.”
• Intakes of total vegetables, whole grains, milk, fiber, potassium, and
calcium are lower among Black Americans than White Americans,
and intakes of sugarsweetened beverages and added sugars are higher.
• Nutrition-related health concerns among Black Americans are obesity
and high rates of morbidity and mortality from hypertension, heart
disease, and stroke
Mexican American Diet.
The traditional diet is generally a low-fat, high-fiber diet rich in complex
carbohydrates and vegetable proteins, with an emphasis on corn, corn
products, beans, and rice.
• Staples: tomatoes, squash, avocado, cocoa, vanilla, grains (bread, rice,
tacos, tortillas), beans, rice, sweet potato, poultry fish, chorizo, and
cheeses.
• Acculturation is associated with undesirable changes in the intake of
vegetables, fruits, sodium, and empty calories. The intake of fast
foods, pizza, non-homemade meals, and meals at sit-down restaurants
increases.
• Nutrition-related health concerns are obesity and type 2 diabetes.
Inactivity is high; life expectancy is longer for Hispanics than White
Americans.
Chinese American Diet.

The traditional diet of Chinese people is low in fat and dairy products
and high in complex carbohydrates and sodium.
• Staples: rice (southern China), wheat products (northern China),
vegetables, sea vegetables, nuts, seeds, beans, soy foods, a variety of
meats, and tea.
• With acculturation, the diet becomes higher in fat, protein, sugar, and
cholesterol. The intake of raw vegetables, meat, ethnic foods, and fast
food increases.
• Nutrition-related health concerns are the risk of type 2 diabetes at a
lower BMI for Chinese Americans than for other groups; at any BMI
level, men and women who are Chinese Americans have a higher
percentage of body fat than White Americans. Chinese Americans
have the lowest percentage of people in fair or poor health and the
lowest prevalence of obesity.
Food and Religion

Religion tends to have a greater impact on food choices than nationality
or culture.
Christianity
• Dietary practices vary from none to explicit.
• Roman Catholics: This group does not eat meat on Ash Wednesday or
on Fridays of Lent and food; beverages are avoided for 1 hour before
communion is taken. Devout Catholics observe several fast days
during the year.
• Eastern Orthodox Christians observe numerous feast and fast days
throughout the year.
• Members of the Church of Jesus Christ of Latter-day Saints do not use
coffee, tea, or alcohol; limiting meat intake is encouraged.
• Seventh-Day Adventists: Lacto-ovo vegetarianism is common.
Overeating is avoided.
Judaism
• • Dietary restrictions vary among denominations.
• Kashrut is a list of dietary laws. The main principles are that animals
must be kosher, blood is not allowed, and milk and meat must not mix.
Islam
• Health and food are considered acts of worship.
• Halal foods are permitted; haram foods are prohibited.
• Kosher and halal animals are allowed, blood is not allowed, slaughter
must use proper methods, decaying carcasses are not allowed, and
intoxicants are forbidden.
Hinduism
• Dietary practices stem from the idea of living in harmony with nature
and having mercy for all of God’s creations.
• Many Hindu people are vegetarian, even though meat is not explicitly
forbidden.
• Foods considered pure foods enhance spiritual purity.
Buddhism
• The five moral precepts are to not kill or harm living things, steal,
engage in sexual misconduct, lie, and consume intoxicants.
• Food decisions should contribute to spiritual enlightenment.
Figure sources: shutterstock.com/Antwon McMullen, shutterstock.com/kazoka, and
shutterstock.com/Protasov AN

book at
Websites
• Cultural/Ethnic Food Guide Pyramids, USDA National Agricultural
Library at http://fnic.nal.usda.gov/dietary-guidance/myplatefood-
pyramid-resources/ethniccultural-food-pyramids
• Ethnic medicine information including nutrition information:
Harborview Medical Center, University of Washington at
www.ethnomed.org
• Office of Minority Health at http://minorityhealth.hhs.gov/
• Traditional diets at Oldways Preservation & Exchange Trust at
www.oldwayspt.org
• Website for information on fast food and eating out: Center for
Science in the Public Interest at www.cspinet.org
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Chapter Healthy Eating for
12 Healthy Babies
Rachel Stevens
Rachel is 27 years old and was diagnosed with
polycystic ovary syndrome (PCOS) at age 18 years.
She and her husband want to start a family, but she
has irregular periods and fears she will have a hard
time getting pregnant. She is 5 ft 5 in. and weighs 183
pounds, which gives her a body mass index (BMI) of
30.5. She has noticed that her PCOS symptoms get
worse the more weight she gains. She would also like
to lose some weight and “get healthy” before getting
pregnant.
Learning Objectives
1 Discuss prepregnancy nutrition considerations.

2 Evaluate a woman’s pattern and amount of weight gain during pregnancy
based on her prepregnancy body mass index.
3 Assess whether a woman may benefit from a multivitamin and mineral
supplement during pregnancy.
4 Describe characteristics of a healthy eating pattern during pregnancy.
5 Discuss the following lifestyle and dietary concerns during pregnancy:
alcohol, caffeine, nonnutritive sweeteners, fish, and foodborne illness.
6 Give examples of nutrition interventions used for nausea, constipation,
and heartburn during pregnancy.
7 List common risk factors for diabetes and hypertension during
pregnancy.
8 Discuss how lactation affects calorie and nutrient needs.
9 List benefits of breastfeeding for mother and infant.
Nutrition plays a vital role before, during, and after pregnancy and lactation
for both mother and child. Women who are healthy at the time of
conception are more likely to have a successful pregnancy and a healthy
infant. Being well nourished and within a healthy weight range prior to
conception provides an environment conducive to normal fetal growth and
development during the critical first trimester of pregnancy. During
pregnancy, the fetus cannot meet its genetic potential for development if the
supply of energy and nutrients is inadequate. Conversely, excessive weight
gain during pregnancy is strongly associated with maternal and fetal
complications, including obesity for both later in life. A healthy eating
pattern provides enough but not excessive amounts of calories and nutrients
to optimize maternal and fetal health.
This chapter discusses nutrition guidance for women before, during, and
after pregnancy, including weight gain recommendations, common
problems of pregnancy, and nutrition interventions for maternal health
conditions. Nutrition for lactation is discussed.
PREPREGNANCY NUTRITION
Studies show a strong link between prepregnancy health and nutritional
status and maternal and child health outcomes, with consequences that span
generations (Stephenson et al., 2018). For instance:
• Overweight and obese women need a longer time to conceive and
are at higher risk of infertility (Silvestris et al., 2018).
• A low folate status prior to conception increases the risk of neural
tube defects (U.S. Preventive Services Task Force, 2017).
• High body mass index (BMI) increases the risk for maternal
complications such as gestational hypertension, preeclampsia,
gestational diabetes, and cesarean section delivery (Stang &
Huffman, 2016).
• High BMI also increases the risk of poor fetal outcomes, including
preterm birth, macrosomia, shoulder dystocia, select birth defects,
and stillbirth (Stang et al., 2016).
• Prepregnancy overweight and obesity increase the risk childhood
obesity in the infant (Liu et al., 2016).
• Prepregnancy underweight increases the risk for small-for-
gestational-age births (Liu et al., 2016).
The preconception period may be a critical time to promote a healthy

lifestyle to reduce the risk of undesirable birth outcomes. Stephenson et al.
(2018) have shown that when initiated during pregnancy:
• Dietary interventions can reduce weight gain and adiposity in obese
women but have little impact on pregnancy outcomes.
• Multiple micronutrient supplementation appears to be “too little, too
late” to fundamentally improve child health outcomes.
Fortunately, a change in preconception eating patterns can improve

prepregnancy BMI (Mohammadi et al., 2018). Likewise, adequate nutrient
intakes prior to pregnancy helps ensure adequate micronutrient stores help
meet the needs of a growing embryo (Dahly et al., 2018). Improvements in
lifestyle should occur before conception to improve maternal and child
health (Stephenson et al., 2018).
Attain and Maintain Healthy Weight
Current estimates indicate that approximately half of women of
childbearing age are classified as overweight (BMI 25–29.9) or obese (BMI
≥ 30) (U.S. Department of Agriculture [USDA] & U.S. Department of
Health and Human Services [USDHHS], 2020). Some of the risks to mother
and infant related to entering pregnancy with a high BMI are stated earlier.
Another risk is that women who are overweight or obese frequently exceed
gestational weight gain (GWG) recommendations during pregnancy, which
increases the risk of postpartum weight retention (USDA & USDHHS,
2020).
• Because achieving healthy weight can take months to years to
accomplish, the ideal time to attain healthy weight may be during
adolescence when most women are not planning pregnancy
(Stephenson et al., 2018).
• All women who are contemplating pregnancy should be screened
during the preconception period to determine their weight status.
• All women with a BMI of 25 or higher should be counseled about
the risks of unhealthy weight to maternal health and future
pregnancies and given guidance to help them attain and maintain
healthy body weight.
Healthy Weight
BMI of 18.5 to 24.9.

The basic principles of healthy eating for the general U.S. population are
also appropriate during pregnancy and lactation:
• Consume a calorie-appropriate, nutrient-dense eating pattern that
includes plenty of fruits and vegetables of various kinds and colors,
whole grains in place of refined grains, a variety of lean protein
foods, low-fat or fat-free dairy products, and healthy oils in
moderation.
• Limit solid fats, added sugars, sodium, and refined grains.
• Meet nutrient needs primarily through food and beverages, not
supplements.
• Healthy eating patterns include the Healthy U.S.-style eating pattern
(similar to the Dietary Approaches to Stop Hypertension [DASH]
diet) and Mediterranean-style eating pattern. The Healthy
Vegetarian Eating Pattern can also be used during pregnancy with
careful attention to certain nutrients.
Recall Rachel. Weight loss and exercise can improve her

PCOS symptoms, improve her chance of becoming
pregnant, and lower her risk of adverse pregnancy outcomes.
How is Rachel’s BMI classified? What would be appropriate
calorie and weight goals for Rachel? What type of healthy
eating pattern would you recommend? What tools would
you recommend she use to help her eat healthy while
working toward a healthier weight?
Folic Acid
The U.S. Preventive Services Task Force, along with many other health-
related organizations, recommends that all women who are planning
pregnancy or capable of becoming pregnant take a daily multivitamin
supplement containing 400 to 800 mcg of folic acid based on high certainty
that the net benefit in preventing neural tube defects in the developing fetus
is substantial (U.S. Preventive Services Task Force, 2017). Most women do
not obtain the recommended daily intake of folate from food alone.
• The critical period for supplementation begins at least 1 month
before conception and continues through the first 2 to 3 months of
pregnancy (U.S. Preventive Services Task Force, 2017). Because
half of all pregnancies are unplanned, all women who are capable of
becoming pregnant should be advised to take folic acid
supplements.
Synthetic folic acid in supplements and fortified food is better
• absorbed and has greater availability than natural folate in food.
• Folic acid–fortified foods and food sources of natural folate are
encouraged in addition to using either a multivitamin or an
individual folic acid supplement (Box 12.1).
• Obese women, who are at increased risk of neural tube defects, may
benefit from a supplement containing 800 mcg of folic acid. Other
risk factors for neural tube defects include maternal diabetes and
mutations in folate-related enzymes.
• Obese and overweight women with a history of birth defects may
benefit from consuming up to 4 mg of folic acid supplements before
and between pregnancies (Stang et al., 2016).
Folate
natural form of the B vitamin involved in the synthesis of DNA; only one-half is available to the
body as synthetic folic acid.
Neural Tube Defects

major central nervous system birth defects, such as anencephaly (underdeveloped brain and an
incomplete skull) and spina bifida (incomplete closure of the spinal cord) that occur early in
pregnancy due to improper closure of the embryonic neural tube.
Folic Acid
synthetic form of folate found in multivitamins, fortified breakfast cereals, and enriched grain
products.
BOX Food Sources of Important Nutrients

12.1 before and during Pregnancy
Folate
Folic acid (fortified foods and supplements) is better absorbed than
natural folate in foods
• Natural sources: leafy green vegetables (e.g., spinach), asparagus,
and avocado; dried peas and beans, such as lentils, soybeans, and pinto
beans; and organ meats
• Fortified foods: 100% fortified ready-to-eat breakfast cereals;
enriched bread, rolls, pasta, and cereal
Iron
Heme iron is better absorbed than nonheme iron.
• Heme sources: beef liver, clams, mussels, oysters, red meats, fish,
and poultry
• Nonheme sources: beans, peas, lentils, dark green vegetables, and
iron-enriched or fortified foods, such as many whole wheat breads,
fortified breakfast cereals, and products made with enriched flour (e.g.,
white bread, pasta, rolls)
Iodine
• Natural sources: eggs, seafood, seaweed (e.g., kelp, nori, and

kombu)
• Fortified source: iodized salt. Milk and dairy products are
incidentally fortified with iodine via the use of iodine feed
supplements and iodine-containing disinfectants used to sanitize
udders, milking machines, and milk tanks
Calcium
• Natural sources: milk, yogurt, hard natural cheese, pasteurized

processed American cheese, bok choy, broccoli, Chinese/Napa
cabbage, collards, kale, okra, turnip greens, legumes, and almonds
• Fortified foods: fortified breakfast cereals, fortified orange juice,
fortified brands of nondairy milks (almond, soy, rice, coconut)
Vitamin D
• Natural sources: fatty fish (salmon, tuna, sardines, swordfish), beef
liver, cod liver oil, and egg yolks
• Fortified foods: milk (dairy and nondairy), breakfast cereals, and
orange juice
Other Healthy Lifestyle Practices

Lifestyle factors are among the several factors that influence whether a
pregnancy is considered high risk (Box 12.2). Healthy lifestyle practices are
recommended in the preconception period to prepare women for pregnancy.
• Do not smoke, drink alcohol, or use drugs.
• Avoid herbal supplements unless approved by a physician.
• Manage existing medical conditions such as diabetes and
hypertension.
BOX Factors That May Contribute to a High-

12.2 Risk Pregnancy
Maternal Age of <17 or >35

Preexisting Maternal Health Conditions
• Obesity, overweight, underweight

• Hypertension
• Diabetes
• PCOS
• Kidney disease
• Respiratory disease
• Autoimmune disease
Lifestyle Risks
• Alcohol use
• Tobacco use
• Drug use
Conditions of Pregnancy
• Multiple gestation
• Gestational diabetes
• Preeclampsia and eclampsia
• Previous preterm birth or stillbirth
• History of giving birth to an infant with birth defects
NUTRITION AND LIFESTYLE

DURING PREGNANCY
Many women are motivated during pregnancy to adopt healthy lifestyle

changes, which have the potential to make a long-lasting impact on the
health of mother and infant. The following sections cover nutrition-related
considerations during pregnancy.
Recommended Amount of Weight Gain

The weight of the infant, products of conception, and increases in maternal
organs, tissues, and fluids contribute to weight gain during pregnancy (Box
12.3). Current recommendations by the Institute of Medicine (2009) for
weight gain during pregnancy are based on prepregnancy BMI (see Table
12.1). These weight gain recommendations were based on observational
data, so they should be viewed as a guide, not an absolute requirement.
• Underweight: 28 to 40 pounds
• Normal/healthy BMI: 25 to 35 pounds
• Overweight BMI: 15 to 25 pounds
• Obese: 11 to 20 pounds
BOX Weight Gain Distribution in Normal

12.3 Pregnancy (Pounds)
Birth weight of baby 7.5

Placenta 1.5
Increase in maternal blood volume 4

Increase in maternal fluid volume 4
Increase in uterus 2
Increase in breast tissue 2
Amniotic fluid 2
Maternal fat tissue 7
Total 30
Table Recommended Weight Gain

Ranges Based on Maternal
12.1 Prepregnancy Body Mass Index
Weight Gain in Obese Women
Due to limited data, the weight gain guidelines do not recommend different
weight gain targets based on the severity of obesity, which are Class 1 (BMI
of 30–34.9), Class 2 (BMI of 35–39.9), and Class 3 (BMI of ≥40). The
optimal amount of weight severely obese women should gain during
pregnancy is a subject of debate (Hutcheon et al., 2015).
• No evidence exists that encouraging increased weight gain to
conform to the IOM guidelines will improve maternal or fetal
outcomes for obese pregnant women who are gaining less weight
than recommended but have a fetus that is growing appropriately
(American College of Obstetricians and Gynecologists Committee
on Obstetrics, 2013, reaffirmed 2016).
• Individualized care and clinical judgment are necessary to balance
the risks of a large for gestational age (LGA) fetus and small for
gestational age fetus, obstetric complications, and maternal weight
retention after pregnancy (American College of Obstetricians and‐
Gynecologists Committee on Obstetric Practice, 2013, reaffirmed
2016).
Recommended Pattern of Weight Gain

The Institute of Medicine (2009) recommends all women gain 1 to 4
pounds in the first trimester. Thereafter, recommended weekly weight gain
is based on prepregnancy BMI (see Table 12.1).
• Normal-weight women are urged to gain approximately 1
pound/week during the second and third trimesters; recommended
amounts of weekly gain for underweight, overweight, and obese
women are slightly different.
• To monitor the amount and pattern of weight gain throughout
pregnancy, weight gain is plotted on the appropriate grid based on
maternal prepregnancy weight status (Figs. 12.1–12.4).
• Although slightly higher or lower rates of weight gain can be
considered normal, obvious or persistent deviations warrant further
investigation.
Figure 12.1 ▲ Weight gain chart for women who begin pregnancy at a
normal weight: If your weight gain is within the shaded area, you’re on
track! (Source: Centers for Disease Control and Prevention. [2019, January
17]. Tracking your weight for women who begin pregnancy at a normal
weight. https://www.cdc.gov/reproductivehealth/pdfs/maternal-infant-
health/pregnancy-weight-
gain/tracker/single/Normal_Weight_Tracker_508Tagged.pdf)
Figure 12.2 ▲ Weight gain chart for women who begin pregnancy
overweight: If your weight gain is within the shaded area, you’re on
17]. Tracking your weight for women who begin pregnancy overweight.
https://www.cdc.gov/reproductivehealth/pdfs/maternal-infant-
gain/tracker/single/Overweight_Tracker_508Tagged.pdf)
Figure 12.3 ▲ Weight gain chart for women who begin pregnancy with
obesity: If your weight gain is within the shaded area, you’re on track!
(Source: Centers for Disease Control and Prevention. [2019, January 17].
Tracking your weight for women who begin pregnancy with obesity.
gain/tracker/single/Obese_Weight_Tracker_508Tagged.pdf)
Figure 12.4 ▲ Weight gain chart for women who begin pregnancy
underweight: If your weight gain is within the shaded area, you’re on
17]. Tracking your weight for women who begin pregnancy underweight.
gain/tracker/single/Underweight_Tracker_508Tagged.pdf)
Consider Rachel. She was able to lose 10 pounds with

exercise and healthy eating. After months of trying to
conceive, her physician prescribed clomiphene (Clomid) to
stimulate ovulation and she is now 4 weeks pregnant. How
should she modify her eating pattern? What would you tell
her about weight gain in the first trimester?
Increased Calorie Needs
Additional calories are needed to support growth of the fetus and maternal
tissues, but the increase is relatively small. Regardless of maternal weight
status, the Institute of Medicine (2009) recommends the following:
• 1st trimester: no extra calories
• 2nd trimester: +340 cal/day
• 3rd trimester: +452 cal/day
Controversy exists over the appropriate amount of calories for pregnant
women who are obese.
• Recently, and for the first time ever, researchers have provided
evidence-based recommendations for calorie intake in pregnant
women with obesity (U.S. Department of Health and Human
Services, 2019).
• Study findings suggest that pregnant women with obesity should not
consume extra calories during the first, second, and third trimesters
because increased need for calories can be met by mobilizing
maternal fat stores (Most et al., 2019).
Calories and Eating Patterns

The calorie levels of healthy eating patterns that are most relevant to
women who are pregnant or lactating are 1800, 2000, 2200, 2400, 2600,
and 2800 (USDA & USDHHS, 2020).
• In practice, women are not encouraged to actually “count” calories
but to use an eating pattern approach that specifies amounts of food
from each food group to approximate total calories.
• As an example, Figure 12.5 illustrates 3 calorie levels using a 5'6"-
tall, 130-pound, 25-year-old female who is sedentary.
• Calories range from 2000 to 2400 from before pregnancy through
the 3rd trimester.
• Notice how small the increase in food intake is from 2000 to 2400
calories: ½ c vegetables, 2 oz grains, and 1 oz protein foods.
• The difference in incremental increases are not exactly 340
calories as recommended for the second trimester or 452 calories
as recommended for the third trimester but are approximations.
• All eating patterns rely on averages and approximations because
actual calorie intake varies with individual foods chosen and the
amount consumed.
Figure 12.5 ▲ Examples of calorie levels that may be appropriate
before and during pregnancy. (Source: Adapted from U.S. Department of
Agriculture. [n.d.]. MyPlate. https://www.myplate.gov)
Current Intake of Pregnant and Lactating Women

On average, women who are pregnant or lactating have a higher-quality diet
(as measured by the Healthy Eating Index-2015 score) than adult women in
general (USDA & USDHHS, 2020). However, intakes are still not optimal.
On average,
• intake of total vegetables, fruits, dairy, and whole grains is below
recommended amounts;
• total protein foods intake is adequate but seafood intake is low; and
• limits for added sugars, saturated fat, and sodium are exceeded.
Vitamin and Mineral Requirements

The Dietary Reference Intakes (DRIs) for most nutrients increase during
pregnancy. Figure 12.6 illustrates the percent change during pregnancy of
selected nutrients compared to the DRIs for nonpregnant women aged 19 to
30 years. Vitamin D, vitamin K, and calcium do not appear in the figure
because their requirements do not change during pregnancy.
• Nutrient needs are not actually constant throughout the course of
pregnancy. Nutrient needs generally change little during the first
trimester (folic acid is an exception) and are at their highest during
the last trimester.
• Nutrient needs do not increase proportionately. For instance, the
need for iron increases by 50% during pregnancy, yet the
requirement for vitamin B12 increases by only about 10%. Actual
requirements during pregnancy vary among individuals and are
influenced by previous nutritional status and health history
including chronic illnesses, multiple pregnancies, and closely spaced
pregnancies.
• The requirement for one nutrient may be altered by the intake of
another. For instance, women who do not meet their calorie
requirements need higher amounts of protein.
• The intake of more food to meet increased calorie requirements and
the increase in absorption and efficiency of nutrient use that occurs
in pregnancy are generally enough to meet nutrient needs when
nutrient-dense food choices are made. Exceptions are discussed in
the following section.
Figure 12.6 ▲ Percent change in selected nutrient recommendations
during pregnancy and lactation compared to the DRIs for nonpregnant
women ages 19–30 years. The recommendations for nonpregnant
women are represented as 100%. (Source: Data from Institute of
Medicine of the National Academies. [2006]. Dietary reference intakes:
The essential guide to nutrient requirements. The National Academies
Press.)
Folic Acid
Folic acid has a vital role in DNA synthesis and thus is essential for the
synthesis of new cells and transmission of inherited characteristics.
It is recommended that during pregnancy, women consume a total of
600 mcg of folic acid daily from all sources, such as 400 mcg from prenatal
vitamins and the remainder from folic acid–fortified food and foods
containing natural folate (Box 12.1).
Iron
The Recommended Dietary Allowance (RDA) for iron increases from 18 to
27 mg/day during pregnancy to support the increase in maternal blood
volume and to provide iron for fetal liver storage, which sustains the infant
for the first 4 to 6 months of life. Even with careful selections, women are
not likely to consume adequate amounts of iron during pregnancy from
food alone (Box 12.1). However, both dietary iron absorption and the
mobilization of iron from maternal stores increase during pregnancy (Fisher
& Nemeth, 2017).
• Iron deficiency affects about 1 in 10 women who are pregnant and 1
in 4 women during their third trimester (USDA & USDHHS, 2020).
• Iron supplementation is commonly recommended during pregnancy
because iron deficiency and iron deficiency anemia during
pregnancy have been associated with adverse maternal and child
outcomes (Fisher & Nemeth, 2017).
Iodine
Iodine requirement increases substantially during pregnancy to support fetal
neurocognitive development. Although iodine intake is generally adequate
in women of childbearing age, those who do not use iodized salt or
consume other sources of iodine may not consume enough iodine during
pregnancy (Box 12.1) (USDA & USDHHS, 2020).
• Women should not be encouraged to increase their salt intake but
instead should ensure the salt they use in cooking and at the table is
iodized.
• Not all prenatal supplements contain iodine, so women who need a
supplement should be sure to read the label.
Calcium and Vitamin D
Calcium and vitamin D are among the nutrients of public health concern for
the general U.S. population, including women who are pregnant (USDA &
USDHHS, 2020). These nutrients may need to be supplemented during
pregnancy not because they cannot be consumed in adequate amounts but
because they may not be depending on actual food choices (Box 12.1).
• The RDA for calcium does not increase during pregnancy because
the rate of absorption and retention increases dramatically.
• Three cups of milk or the equivalent provides approximately 900
mg of calcium, close to the RDA of 1000 mg.
• Most multivitamins and prenatal vitamins have only 200 to 300
mg calcium, so an additional supplement may be needed if dietary
intake is inadequate.
• The RDA for vitamin D does not increase during pregnancy.
• Women who consume adequate amounts of vitamin D–fortified
milk and have regular exposure to sunlight will probably not need
supplemental vitamin D.
• Supplements are recommended for women who consume <600
IU.
Prenatal Supplements
Aside from iron and folic acid, women who consume a varied, nutrient-
dense eating pattern will probably meet vitamin and mineral needs during
pregnancy.
• One exception is that pregnant women who consume little or no
animal products should take a supplement of vitamin B12 if a reliable
dietary source (vitamin B12–fortified foods) is not consumed.
• Despite the likely nutrient adequacy of a varied, calorie-appropriate
eating pattern, prenatal vitamin and mineral supplements are
routinely recommended by physicians as insurance against less than
optimal food choices.
• Prenatal vitamins have higher amounts of iron, folic acid, and
calcium than regular multivitamin and mineral supplements.
• Although prenatal vitamins may not be needed, they are not likely to
be harmful.
Lifestyle and Dietary Concerns

Alcohol
Alcohol use during pregnancy can cause physical and neurodevelopmental
problems, such as mental retardation, learning disabilities, and fetal alcohol
syndrome.
• However, current data suggest small amounts of alcohol during
pregnancy may not be harmful to the fetus (Fox, 2018).
• Yet because alcohol is a potent teratogen and a “safe” level of
consumption is not known, women are advised to completely avoid
alcohol before and during pregnancy.
Fetal Alcohol Syndrome
a condition characterized by varying degrees of physical and mental growth failure and birth
defects caused by maternal intake of alcohol.
Teratogen
anything that causes abnormal fetal development and birth defects.
Caffeine
Data do not suggest an increased risk of adverse effects on pregnancy,
fertility, or fetal neurodevelopment with caffeine intake of 300 mg/day or
less (Morgan et al., 2013).
• It is not known if higher caffeine intake is correlated to miscarriage
(American College of Obstetricians and Gynecologists Committee
on Obstetric Practice, 2010, reaffirmed 2016).
• Pregnant women should limit caffeine intake to less than 300
mg/day, the approximate amount in two to three 8-oz cups of coffee
(Fox, 2018).
• Table 12.2 lists the amount of caffeine in various beverages and
foods.
Table Caffeine Content of Selected

12.2 Beverages and Foods
Serving Average Caffeine

Item Size (oz) Content (mg)
Coffee
Brewed 8 135
Instant 8 76–106
Decaffeinated instant 8 5
Starbucks coffee, blonde roast 16 360
Tea
Brewed, average blend 8 43
Brewed, green 8 30
Instant 8 15
Brewed, herbal 8 0
Snapple Lemon Tea 16 37
Soft drinks
Pepsi Zero Sugar 20 115
Mountain Dew, diet or regular 20 91
Dr. Pepper, diet or regular 12 41
Pepsi 12 38
Coca-Cola, Coke Zero, or diet 16 45
Pepsi
Ginger ale, 7UP, Squirt, tonic 12 0
water, Sprite
Energy drinks
Serving Average Caffeine
Item Size (oz) Content (mg)
Bang Energy 16 300
5-hour Energy 2 200
Red Bull 8.4 80
Full Throttle 8 80
Other beverages
Chocolate milk 8 8
Hot cocoa mix 9 5
Candy
Dark chocolate, semisweet 1 18
Hershey’s Milk Chocolate Bar 1.5 9
Source: Adapted from Government of Canada. (2012, April 13). Caffeine in foods.
https://www.canada.ca/en/health-canada/services/food-nutrition/food-safety/food-
additives/caffeine-foods.html; Center for Science and the Public Interest. (n.d.). Caffeine chart.
https://cspinet.org/eating-healthy/ingredients-of-concern/caffeine-chart
The use of nonnutritive sweeteners during pregnancy has been studied
extensively and still generates controversy.
• The U.S. Food and Drug Administration (FDA) has approved six
nonnutritive sweeteners as food additives and two as Generally
Recognized As Safe. They are deemed safe for consumption,
including during pregnancy, within defined levels of intake (U.S.
Food and Drug Administration, 2018).
• The American College of Obstetricians and Gynecologists states
that artificial sweeteners can be used in pregnancy but that data
regarding the use of saccharin are conflicting (Fox, 2018). However,
intake of that sweetener is typically low and likely safe.
• Even though their safety is established, cautious use is prudent.
Seafood
The intake of omega-3 fatty acids from at least 8 oz of fish/week during
pregnancy, especially docosahexaenoic acid (DHA), is associated with
improved infant visual and cognitive development (Mulder et al., 2014).
Nearly all fish contain trace amounts of mercury because it occurs naturally
in the environment, including waterways. Mercury can cause fetal
neurologic damage; however, the possible risk from mercury in fish is
offset by the neurobehavioral benefits of adequate DHA intake (Hagan et
al., 2017). Advice about eating fish from the FDA and EPA is as follows
(FDA, 2019):
• Women who are pregnant or breastfeeding are urged to consume 8
to 12 oz of a variety of seafood/week, from choices that are lower in
mercury. Two to 3 servings/week are recommended from among the
best choices: anchovy, Atlantic herring, Atlantic mackerel, mussels,
oysters, farmed and wild salmon, sardines, canned light tuna,
snapper, and trout. See Figure 4.3 in Chapter 4 for the complete list.
• Good choices are recommended once a week and include bluefish,
Chilean sea bass, grouper, halibut, mahi mahi, monkfish, snapper,
and albacore/white tuna (canned, fresh, or frozen).
• The following fish have the highest mercury levels and should be
avoided by pregnant women: king mackerel, marlin, orange roughy,
shark, swordfish, tilefish (from the Gulf of Mexico), and bigeye
tuna.
• For women who do not consume 2 to 3 servings of fish/week, there
is no clear evidence that omega-3 supplements improve outcomes in
children (Fox, 2018).
Foodborne Illness
Due to hormonal changes that decrease cell-mediated immune function,
pregnant women and their fetuses are at increased risk of developing
foodborne illness. Table 12.3 outlines foods to avoid and their alternatives.
Two pathogens that are of particular importance during pregnancy are
Listeria and Toxoplasma gondii because they can infect the fetus without
causing maternal illness.
Listeria
Listeria monocytogenes is an unusual bacterium because it can grow in
refrigerated temperatures, unlike most other foodborne pathogens.
• Many animals carry this bacterium without outward symptoms.
• Listeriosis is rare except in pregnant women, newborns, older
adults, and people with weakened immune systems.
• Listeriosis is usually a mild illness for pregnant women but causes
severe disease in the fetus or newborn and may result in
miscarriage, stillbirth, preterm labor, or newborn death (Centers for
Disease Control and Prevention [CDC], 2016).
• Pregnant women are 10 times more likely to get listeriosis than
other healthy adults (FoodSafety.gov, 2019).
Table Potential Food Safety Risks

12.3 during Pregnancy
Recommended
Foods to Avoid Potential Risks Alternatives
Raw seafood Parasites or Cook first to
Avoid: sushi, sashimi, raw bacteria 145° F
oysters, raw clams, raw Canned
scallops, ceviche, smoked
refrigerated smoked seafood
seafood
Recommended
Unpasteurized juice, cider, Escherichia coli or Pasteurized
and milk Listeria versions of
these
beverages or
boil
unpasteurized
versions for
at least 1
minute
Soft cheese made from E. coli or Listeria Hard cheese and
unpasteurized milk such cheese made
as Brie, feta, Camembert, from
Roquefort, queso blanco, pasteurized
queso fresco milk
Any other cheese made from
unpasteurized milk
Undercooked eggs such as in Salmonella Eggs with firm
homemade eggnog, raw yolks
batter, homemade Caesar Cook casseroles
salad dressing, tiramisu, or other
eggs benedict, dishes
homemade ice cream, containing
homemade hollandaise eggs to a
sauce temperature
of 160° F.
Use pasteurized
eggs to make
foods that
contain raw
or
undercooked
eggs.
Recommended
Premade deli salads (egg, Listeria Make these foods
pasta, chicken, etc.) at home.
Raw sprouts such as alfalfa, E. coli or Cook thoroughly.
clover, mung bean, and Salmonella
radish
Cold hot dogs and luncheon Listeria Reheat to
meats steaming hot
or 165° F
even if the
label says
“precooked.”
Undercooked meat and E. coli, Cook meat and
poultry including Salmonella, poultry above
refrigerated pâtés or meat Campylobacter, the USDA-
spreads from a deli or Toxoplasma recommended
meat counter gondii internal
temperature.
Use meat spreads
or pâté that
do not need
refrigeration
(e.g., canned,
jarred, sealed
pouches).
Raw dough or batter E. coli or Thoroughly cook.
Salmonella
Source: Foodsafety.gov. (2019, April 1). People at risk: Pregnant women.
https://www.foodsafety.gov/people-at-risk/pregnant-women
Toxoplasma gondii
Healthy people infected by the parasite Toxoplasma gondii may be
asymptomatic or may have flu-like symptoms. During pregnancy, the
consequences are more serious.
• Toxoplasmosis passed to the fetus can cause mental disability or
blindness, and hearing loss, which may not develop until later in
life.
• Occasionally infected newborns have serious eye or brain damage at
birth.
• In addition to the precautions outlined in Table 12.3, pregnant
women should also avoid changing cat litter (cats pass an
environmentally resistant form of the organism in their feces). If no
one else can change the litter, women should be advised to wear
disposable gloves and to thoroughly wash their hands in warm
soapy water afterward. Litter should be changed daily because the
parasite does not become infectious until 1 to 5 days after it is shed
in the feces (CDC, 2019a).
Physical Activity
Physical activity throughout all stages of life promotes health and reduces
the risk of chronic disease, such as cardiovascular disease, diabetes, and
obesity.
• Because of the benefits of exercise and the data supporting its safety
during pregnancy, women with uncomplicated pregnancies are
urged to engage in aerobic and strength-training exercises before,
during, and after pregnancy (American College of Obstetrics and
Gynecologists Committee on Obstetric Practice, 2020).
• Exercise recommendations for pregnant women do not differ from
those for the general public (American College of Obstetrics and
Gynecologists Committee on Obstetric Practice, 2020).
• A goal of 150 minutes/week of moderate exercise is recommended
(Box 12.4) (U.S. Department of Health and Human Services, 2018).
• Safe exercise should be encouraged, with attention paid to fall risk
and avoiding supine positions during the second and third
trimesters.
Key Physical Activity Guidelines for
BOX
Women during Pregnancy and the
12.4 Postpartum Period
• Women should do at least 150 minutes (2 hours and 30 minutes) of

moderate-intensity aerobic activity a week during pregnancy and the
postpartum period. Preferably, aerobic activity should be spread
throughout the week.
• Women who habitually engaged in vigorous-intensity aerobic activity
or who were physically active before pregnancy can continue these
activities during pregnancy and the postpartum period.
• Women who are pregnant should be under the care of a healthcare
provider who can monitor the progress of the pregnancy. Women who
are pregnant can consult their healthcare provider about whether or
how to adjust their physical activity during pregnancy and after the
baby is born.
Americans. U.S. Department of Health and Human Services.
Maternal Health
Common complaints associated with pregnancy, such as nausea, heartburn,
and constipation, may be prevented or alleviated by nutrition interventions
(Table 12.4). Excessive weight gain, pica, diabetes mellitus, hypertension
and preeclampsia, and maternal phenylketonuria (PKU) are discussed in the
following sections.
Table Common Complaints

12.4 Associated with Pregnancy
Complaint Possible Causes Nutrition Interventions
Nausea and Hypoglycemia, Eat easily digested carbohydrate
vomiting decreased foods (e.g., dry crackers,
(common gastric motility, melba toast, dry cereal, hard
during relaxation of candy) before getting out of
the first the cardiac bed in the morning.
trimester) sphincter, Eat frequent, small snacks of dry
anxiety carbohydrates (e.g., crackers,
hard candy) to prevent drop in
glucose.
Eat small frequent meals.
Avoid liquids with meals.
Limit high-fat foods because they
delay gastric emptying.
Eliminate individual intolerances
and foods with a strong odor.
Constipation Relaxation of Increase fiber intake, especially
gastrointestinal intake of whole-grain breads
(GI) muscle and cereals. Look for breads
tone and that provide at least 2 g
motility related fiber/slice and cereals with at
to increased least 5 g fiber/serving.
progesterone Drink at least eight 8-oz glasses
levels of liquid daily.
Increasing pressure Try hot water with lemon or
on the GI tract prune juice upon waking to
by the fetus help stimulate peristalsis.
Decrease in Participate in regular exercise.
physical
activity
Inadequate fiber
and fluid intake
Use of iron
supplements
Complaint Possible Causes Nutrition Interventions
Heartburn Decrease in GI Eat small, frequent meals and
motility eliminate liquids immediately
Relaxation of the before and after meals to
cardiac avoid gastric distention.
sphincter Avoid coffee, high-fat foods, and
Pressure of the spices.
uterus on the Eliminate individual intolerances.
stomach Avoid lying down or bending
over after eating.
Excessive Gestational Weight Gain

Excessive GWG, which increases the incidence of maternal and neonatal
complications, is a major public health concern (Gilmore et al., 2015).
• Maternal risks of excessive GWG include increased risk of cesarean
section, delivering an LGA neonate, and postpartum weight
retention (Johnson et al., 2015); type 2 diabetes, cardiovascular
disease, and metabolic syndrome are proposed long-term
complications (Gilmore et al., 2015). Figure 12.7 illustrates long-
and short-term metabolic consequences of excess GWG and
postpartum weight retention.
• Risks to the infant include macrosomia and increased risk of
childhood overweight or obesity (Kominiarek & Peaceman, 2017).
• In 2015, more than 48% of women who had a full-term, singleton
delivery gained more weight than the recommended amount of
weight (QuickStats, 2016).
Figure 12.7 ▲ Potential complications of excessive gestational weight
gain and postpartum weight retention. (Source: Gilmore, L. A., Klempel-
Donchenko, M., & Redman, L. M. [2015]. Pregnancy as a window to future
health: Excessive gestational weight gain and obesity. Seminars in
Perinatology, 39[4], 296–303.
https://doi.org/10.1053/j.semperi.2015.05.009)
Because excessive GWG early in pregnancy strongly predicts total

excessive GWG, weight monitoring should begin at the onset of pregnancy.
The American College of Obstetricians and Gynecologists recommends
BMI be calculated at the first prenatal visit and that appropriate weight
gain, eating pattern, and exercise be discussed at the first visit and
periodically throughout pregnancy (American College of Obstetricians and
Gynecologists, Committee on Obstetrics, 2013, reaffirmed 2016). A
combination of strategies may promote appropriate GWG.
• Women need to understand that calorie needs actually increase only
during the second and third trimesters and that the amount of
additional food needed is relatively small.
• Women who are obese may not need to increase calories at any time
during pregnancy (Most et al., 2019).
• Diet, exercise, and diet plus exercise interventions show a modest,
but significant, effect on preventing excessive GWG (Muktabhant et
al., 2015).
• Regular self-monitoring of weight gain, such as plotting weight gain
on the appropriate grid, should begin in early pregnancy and
continue between prenatal visits throughout pregnancy so corrective
action can be taken if necessary (Deputy et al., 2015).
• Other tools that may help women monitor behaviors include
pedometers and smart phone apps to monitor intake and activity.
• Frequent provider contact beyond routine prenatal care, such as with
a nurse or dietitian, may also help achieve appropriate GWG.
Remember Rachel. To help her avoid excessive weight

gain, her weight is plotted against her target range at every
prenatal visit. At her fourth month of pregnancy
appointment, she showed a 1-month weight gain of almost
double the recommended amount. What questions would
you ask Rachel? What would you advise her to do?
Pica
Pica was first described by Hippocrates in 400 BCE (Miao et al., 2015).
People who engage in pica may eat clay or dirt (geophagy); raw starch
(amylophagy); ice and freezer frost (pagophagy); or other items, including
laundry starch, soap, ashes, chalk, paint, and burnt matches (Lessen &
Kavanagh, 2015). Geophagy occurs most often.
Pica
purposeful ingestion of nonfood substances such as dirt, clay, starch, and ice.
Pica has long been associated with micronutrient deficiencies, but the
strength of this relationship is inconsistent (Miao et al., 2015).
• Pica may cause deficiencies by preventing the absorption of
micronutrients.
• It is also possible that micronutrient deficiencies cause humans to
crave and eat minerals from nonfood substances.
• Pica has been linked to a 2.4 times higher risk of anemia, a lower
hemoglobin concentration, lower hematocrit, and lower plasma zinc
regardless of whether the women practiced geophagy, pagophagy, or
amylophagy (Miao et al., 2015).
• Screening pregnant women for pica could be a proxy for identifying
risk of anemia or zinc deficiency. However, women may be
reluctant to report the intake of nonfood substances.
• Counseling should focus on the potential adverse effects of pica
(e.g., the effects of maternal anemia on the fetus).
Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) is defined as glucose intolerance
diagnosed during the second or third trimester of pregnancy. GDM is
associated with the following:
• Increased risk of delivering an LGA infant, which in turn increases
the risk of cesarean delivery, shoulder dystocia, macrosomia, birth
trauma, neonatal hypoglycemia, and neonatal hyperbilirubinemia
(Kampmann et al., 2015).
• Increased risk of obesity and type 2 diabetes for the offspring during
childhood or adolescence.
• Increased risk of type 2 diabetes for the mother. Approximately 50%
of women with GDM develop type 2 diabetes (CDC, 2019b).
More frequent prenatal medical appointments and at-home blood
glucose monitoring are needed to manage gestational diabetes. A nutritional
plan is based on the woman’s blood glucose records, physical activity,
weight gain records, and the use of medication, if any. For many women, a
healthy eating pattern and regular exercise will control blood glucose levels.
Nutritional considerations are as follows:
• Excessive GWG should be avoided.
• Research does not suggest there is an optimal calorie intake for
women with GDM or if their calorie needs differ from other
pregnant women (Duarte-Gardea et al., 2018).
• Pregnant women with GDM have the same nutrient needs as other
pregnant women.
• Evidence is lacking to determine an ideal amount (in grams or as a
percentage of total calories) of carbohydrate for all women with
GDM (Duarte-Gardea et al., 2018).
• For breakfast, lowering the amount of carbohydrates and
emphasizing carbohydrates with low glycemic index may help
achieve blood glucose targets. Individualization is based on the
woman’s blood glucose records.
• Smaller meals and multiple snacks may improve glucose control.
Three meals with two or more snacks help reduce postprandial rises
in blood glucose levels.
Preexisting Diabetes
Pregnant women with preexisting diabetes are at increased risk for a variety
of adverse outcomes to herself and the infant.
• Increased risk of premature birth or stillbirth
• Birth defects, hypoglycemia, and jaundice in the newborn
• Hydraminos, which can lead to preterm delivery
• Macrosomia with increased risk of cesarean birth
• Diabetes complications may develop in the mother, such as retinal
and kidney disease
• Mother may also develop hypertension or preeclampsia
Hydraminos
an increased amount of amniotic fluid in the amniotic sac.
Women with preexisting diabetes should achieve glycemic control

before conception and maintain control throughout pregnancy.
• The nutritional considerations for gestational diabetes mentioned
earlier apply to women with preexisting diabetes.
• Frequent modifications in the type and amount of antidiabetic
medication and the nutritional care plan are needed as the pregnancy
progresses.
Hypertensive Disorders of Pregnancy

Chronic hypertension, gestational hypertension, and preeclampsia fall under
the umbrella of hypertensive disorders during pregnancy (American
College of Obstetricians and Gynecologist, 2019).
• Chronic hypertension refers to elevated blood pressure that existed
before pregnancy or that develops in the first 20 weeks of gestation.
• It occurs in approximately 3% to 5% of pregnancies and is
increasingly more prevalent due to increases in obesity and
delaying childbirth until older age (Seely & Ecker, 2014).
• Potential complications include preeclampsia, fetal growth
restriction, placental abruption, preterm birth, and increased
likelihood of cesarean delivery (Seely & Ecker, 2014).
• Gestational hypertension is defined as a systolic blood pressure of
≥140 mm Hg or a diastolic reading of ≥90 mm Hg with onset after
20 weeks of gestation and without proteinuria.
• Often, gestational hypertension does not occur until 30 weeks or
later.
• Studies suggest that the chance of developing gestational
hypertension is more than 6 times higher among women who
begin pregnancy obese compared to women who are at normal or
healthy BMI at conception (Stang & Huffman, 2016).
• Preeclampsia is hypertension plus proteinuria, although it can occur
in the absence of proteinuria but with certain other symptoms.
• The incidence of preeclampsia has steadily increased in the
United States over the last three decades, in part because of trends
to delay pregnancy to a later age and the increased rate of obesity
(Stevens et al., 2017).
• Once preeclampsia is diagnosed, evidence-based interventions,
namely, treatment of high blood pressure, administration of
magnesium sulfate to prevent eclampsia, and inducing delivery,
may reduce the risk or severity of maternal and infant health
outcomes (Henderson et al., 2017).
Gestational Hypertension
systolic blood pressure of 140 mm Hg or greater or diastolic blood pressure of 90 mm Hg or
greater that develops in the second half of pregnancy and ends with childbirth.
Preeclampsia
a toxemia of pregnancy characterized by hypertension accompanied by proteinuria or edema, or
both.
Treating Hypertension
Early detection, classification, and treatment of hypertension with safe and
effective pharmacologic therapies are critical for improving maternal and
fetal outcomes (Leavitt et al., 2019). It is not known if lifestyle modification
improves blood pressure control during pregnancy (Seely & Ecker, 2014)
• It is not known if initiating or continuing a DASH diet improves
outcomes.
• There are no data to support limiting sodium intake to lower the risk
of preeclampsia.
• Losing weight if overweight and controlling preexisting diabetes or
hypertension before becoming pregnant may lower risks (American
College of Obstetricians and Gynecologists, 2019).
Maternal Phenylketonuria
Phenylalanine hydroxylase deficiency, traditionally known as
phenylketonuria (PKU), is an inborn error of phenylalanine (an essential
amino acid) metabolism, which causes severe neurologic damage when left
untreated.
Phenylketonuria (PKU)
an inborn error of phenylalanine (an essential amino acid) metabolism that results in retardation
and physical handicaps in newborns if they are not treated with a low-phenylalanine diet
beginning shortly after birth.
• Screening that detects PKU in the newborn leads to treatment that

can prevent the dramatic consequences such as developmental
disabilities (Vockley et al., 2014).
• As an essential amino acid, some phenylalanine is required but just
enough to support growth and development. A very low-protein diet
and supplements with low-phenylalanine or phenylalanine-free
medical foods (formulas) are used to meet protein and calorie needs
(Vockley et al., 2014).
• Later in childhood or adulthood when strict adherence to the diet
may wane, reversible and irreversible neuropsychiatric
consequences may develop. Because of that, lifelong dietary
restriction and therapy are recommended to improve quality of life
(American College of Obstetricians and Gynecologists, 2020).
• Frequent monitoring and dietary changes are necessary throughout
life stages and health challenges.
Medical Foods
a food formulated to be consumed orally or administered enterally under the supervision of a
physician for the specific dietary management of a disease or condition.
Mothers who have PKU need to adequately control of phenylalanine

levels before and throughout pregnancy to prevent fetal brain damage.
• It is recommended that low phenylalanine levels be achieved for at
least 3 months prior to conception.
• Strict adherence to the diet is vital (Box 12.5).
• Pregnant women with PKU should be monitored in consultation
with physicians familiar with PKU, with close follow-up with a
metabolic geneticist and healthcare providers who are experienced
in managing high-risk pregnancy (American College of
Obstetricians and Gynecologists, 2020).
• Most infants born to mothers with PKU do not inherit PKU and
cannot benefit from a low-phenylalanine diet after birth.
BOX Diet Guidelines for Pregnant Women

12.5 with Phenylketonuria
• Strict control of maternal blood phenylalanine levels is necessary to

eliminate risks to the developing fetus.
• Because phenylalanine is an essential amino acid, it must be provided
in the diet in limited amounts to support growth and protein synthesis.
• Low-phenylalanine diets are very low in total protein, so low-
phenylalanine or phenylalanine-free medical food beverages must be
consumed as a source of protein. They must be consumed in
prescribed amounts to support fetal growth and prevent maternal tissue
breakdown that would have the results similar to those caused by
eating too much protein.
• These products have long been the mainstay of diet therapy for PKU
and are designed to meet established dietary requirements. However,
they may not always contain adequate amounts of essential fatty acids,
vitamins, and minerals depending on individual circumstances
(Vockley et al., 2014).
• Other modified low-protein foods are available to increase diet variety
and provide an important source of calories. They are costly and the
cost may not always be covered by third-party payers (Vockley et al.,
2014).
• Diet beverages and foods sweetened with aspartame (NutraSweet) are
strictly forbidden.
Adolescent Pregnancy
Adolescent pregnancy increases health risks to both infant and mother.
Infants born to adolescent mothers are at higher risk of low birth weight
(LBW) and preterm delivery, especially in mothers younger than 15 years
old (Althabe et al., 2015). Infants born to adolescent mothers are more
likely to become teen mothers; adolescent pregnancy typically limits the
mother’s education and subsequent occupational opportunities. Compared
with adult women, pregnant adolescents
Low Birth Weight (LBW)
a baby weighing <2500 g or 5.5 pounds.
• are more likely to be physically, emotionally, financially, and

socially immature. Low socioeconomic status may be a major
reason for the high incidence of LBW infants and other
complications of adolescent pregnancy.
• may not have adequate nutrient stores because they need large
amounts of nutrients for their own growth and development.
Although adolescent growth for girls is usually complete by the age
of 15 years, physical maturity is not reached until 4 years after
menarche, which usually occurs by age 17 years.
• may still be growing so mother and fetus compete for nutrients.
• may give low priority to healthy eating. Dieting, erratic eating
patterns, reliance on fast foods, and meal skipping are common
adolescent practices.
• may have poor intake and status of certain micronutrients, such as
folate, iron, and vitamin D, which increases the risk of small-for-
gestational-age births in pregnant adolescents.
• may be more concerned with body image and confused about
weight gain recommendations; many do not understand why they
should gain more than 7 pounds, the weight of the average baby at
birth.
• are more likely to smoke during pregnancy. Smoking increases the
risk of premature birth.
• seek prenatal care later and have fewer total visits during pregnancy.
Nutrition Considerations
Appropriate weight gain and adequate nutrition are among the most
important modifiable factors that can be used to improve birth outcomes.
Optimal nutrition has the potential to decrease the incidence of LBW
infants and to improve the health of infants born to adolescents.
• Adolescents within the healthy BMI range are advised to gain
approximately 35 pounds to reduce the risk of delivering an LBW
infant.
• MyPlate is useful both in assessing dietary strengths and weaknesses
and in providing a framework for implementing dietary changes in a
way the adolescent can understand.
• Adolescents living with one or more adults may have little control
over what food is available to them; parents and significant others
should be encouraged to attend counseling sessions.
• Women, Infants, and Children (WIC) helps pregnant women obtain
adequate and nutritious food for themselves and their infants.
NUTRITION FOR LACTATION
With rare exceptions, breastfeeding is the optimal method of feeding and

nurturing infants. Both the American Academy of Pediatrics (AAP) and the
Academy of Nutrition and Dietetics recommend that infants be exclusively
breastfed for the first 6 months of life and that breastfeeding continue with
complementary foods until 1 year of age or longer (AAP, 2012; Lessen &‐
Kavanagh, 2015). Breastfeeding is an important public health strategy for
improving infant and child morbidity and mortality and improving maternal
morbidity (Lessen & Kavanagh, 2015). The benefits of breastfeeding for
both mother and infant are well recognized (Box 12.6).
BOX Benefits of Breastfeeding
12.6
For the Mother

There is strong evidence that breastfeeding
• reduces the risk of postpartum hemorrhage,

• delays ovulation, and
• reduces the risk of postpartum depression.
Other potential benefits that need additional study are as follows:
• Reduced risk of hypertension, postmenopausal breast and ovarian

cancer, premenopausal breast cancer, and comorbidities of excess
weight (e.g., type 2 diabetes)
• Postpartum weight loss
• Improved infant bonding
For the Infant

There is strong evidence that breastfeeding reduces risks of the
following:
• Nonspecific gastrointestinal infections

• Upper and lower respiratory tract infections
• Otitis media
• Sudden infant death syndrome
• Necrotizing enterocolitis among premature and low-birth-weight
infants
Other potential benefits that need additional study are as follows:
• Decreased risks of atopic dermatitis, autoimmune disorders, asthma,

later overweight or obesity, comorbidities related to excess weight
(e.g., type 2 diabetes, heart disease)
• Promotion of cognitive development
Source: Lessen, R., & Kavanagh, K. (2015). Position of the Academy of Nutrition and Dietetics: ‐
Promoting and supporting breastfeeding. Journal of the Academy of Nutrition and Dietetics,
115(3), 444–449. https://doi.org/10.1016/j.jand.2014.12.014
Promoting Breastfeeding
Social support and support from healthcare professionals influence success
with breastfeeding. As a learned behavior, not a physiologic response, the
ability to successfully breastfeed and the duration of lactation can be
positively affected by counseling.
• Preparation for breastfeeding should begin prenatally with
counseling, guidance, and support for both the woman and her
partner and continue throughout the gestational period. Certified
lactation consultants can help new mothers establish successful
breastfeeding.
• Despite the benefits of breastfeeding, many women choose not to
initiate breastfeeding, only partially breastfeed, or breastfeed for
only a short duration. A variety of factors may negatively affect the
duration of exclusive breastfeeding (Box 12.7).
• Even a short period of breastfeeding is better than not breastfeeding
at all. Women should be encouraged to breastfeed for as long as they
are able and not be made to feel guilty if they fall short of the
recommendations.
• Contraindications to breastfeeding are listed in Box 12.8.
BOX Factors That Negatively Affect the

12.7 Duration of Exclusive Breastfeeding
• Delayed initiation of breastfeeding

• Maternal postpartum infection
• Cesarean delivery
• Twin pregnancy
• Infant irritability
• Maternal employment
• Short duration of maternity leave
• Perceived breast milk insufficiency
• Giving water
• Use of a pacifier
• History of smoking during pregnancy
• Preexisting health problems
• Higher maternal age
• Intimate partner violence or lack of partner support
Source: Maharlouei, N., Pourhaghighi, A., Raeisi Shahraki, H., Zohoori, D., & Lankarani, K. B.
(2018). Factors affecting exclusive breastfeeding, using adaptive LASSO Regression.
International Journal of Community Based Nursing and Midwifery, 6(3), 260–271.
BOX Contraindications to Breastfeeding

12.8
Mothers should not breastfeed or feed expressed breast milk if
• an infant is diagnosed with galactosemia, a rare genetic metabolic

disorder
• the mother uses illegal drugs, such as PCP or cocaine
• the mother is infected with HIV
• the mother is infected with human T-cell lymphotropic virus type 1 or
type 2
• the mother has suspected or confirmed Ebola virus disease
Mothers should temporarily not breastfeed and should not feed
expressed milk if
• the mother is infected with untreated brucellosis (an infectious disease

caused by bacteria)
• the mother takes certain medications
the mother is undergoing diagnostic imaging with
•
radiopharmaceuticals
• the mother has active herpes simplex virus infection with lesions on
the breast
Mothers should temporarily not breastfeed but can feed expressed
milk if
• the mother has untreated, active tuberculosis

• the mother has active varicella (chicken pox) infection that developed
within 5 days prior to delivery to the 2 days after delivery
Source: Centers for Disease Control and Prevention. (2019, December 14). Contraindications to
breastfeeding or feeding expressed breast milk to infants.
https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/Contraindications-to-
breastfeeding.html
Nutrient Needs
Nutrient needs during lactation are based on the nutritional content of breast
milk and the “cost” of producing milk. The healthy eating pattern consumed
during pregnancy should continue during lactation. The higher calorie
intake from nutrient-dense foods can generally meet increased nutrient
needs. As illustrated in Figure 12.6, the requirements for many vitamins and
minerals are higher during lactation than during pregnancy.
• The content of macronutrients and most minerals in breast milk is
maintained at the expense of maternal stores if maternal intake is
inadequate. For instance, if calcium intake is inadequate, the
calcium content of breast milk is maintained at the expense of
maternal bone density.
• Maternal intake has been reported to influence the concentrations of
fatty acids and fat-soluble vitamins, namely, vitamins A, D, B6, and
B12 (Innis, 2014). However, most of the evidence on the relationship
between maternal intake and breast milk composition is limited and
weak (Bravi et al., 2016).
Calories
Well-nourished women who exclusively breastfeed need approximately 500
cal/day above their nonpregnant calorie needs to produce an adequate
supply of breast milk. However, recommended daily increases in calories
are less than 500 calories based on the idea that eating less than the total
will mobilize calories stored as fat during pregnancy, thereby helping
women regain their prepregnancy weight. Recommendations vary with the
length of breastfeeding:
• An extra 330 cal/day for the first 6 months.
• An extra 400 cal/day for the second 6 months.
• Breastfeeding supplemented with formula requires a smaller
increase in calorie intake.
For the sample woman used in Figure 12.5, the eating pattern
recommended while she exclusively breastfeeds for the first 6 months is
2400 calories, the same number of calories recommended during the third
trimester of pregnancy. This calorie level would allow her to mobilize fat
accumulated during pregnancy to provide the additional calories needed to
produce enough breast milk.
Adequacy of calorie intake is evaluated by changes in a woman’s
weight.
• Women who failed to gain enough weight during pregnancy, who
have inadequate fat reserves, or who lose too much weight while
breastfeeding may need to increase their calorie intake.
• Women who are not losing weight while lactating can reduce their
calorie intake after lactation is established.
• Generally, intake should not fall below 1500 to 1800 cal/day
because milk production may be decreased.
Fluid
A rule-of-thumb suggestion is that breastfeeding mothers drink a glass of
fluid every time the baby nurses and with all meals or approximately twelve
8-oz glasses of caffeine-free fluids/day.
• Thirst is a good indicator of need except among women who live in
a dry climate or who exercise in hot weather.
• Fluids consumed in excess of thirst quenching do not increase milk
volume.
Vitamins and Minerals Supplements

Generally, a woman eating a varied and balanced eating pattern of the
appropriate amount of calories should not need a vitamin or mineral
supplement.
• One exception is iron. Iron supplements may be needed to replace
depleted iron stores, not to increase the iron content of breast milk.
• Vegans who do not eat any animal products need a reliable source of
vitamin B12.
• Daily or intermittent high-dose vitamin D supplements enrich breast
milk and can be an alternative to giving vitamin D supplements to
infants (Umaretiya et al., 2017). Many mothers prefer taking
supplements themselves rather than giving them to the infant.
• Vitamin and mineral supplements are usually not necessary if a
balanced, varied eating pattern is consumed. However, many
healthcare professionals recommend women continue to take
prenatal vitamins during lactation.
Other Considerations
Other considerations concerning maternal intake and breast milk are as
follows:
• Highly flavored or spicy foods may have an impact on the flavor of
breast milk but need only be avoided if infant feeding is affected.
Infants rarely react to a food that mothers eat and the few foods that
have been observed to cause reactions differ among infants (Jeong et
al., 2017).
• Avoiding alcohol is the safest level of intake while breastfeeding.
However, moderate intake (up to 1 drink/day) has not shown to be
harmful. Because alcohol can be detected for about 2 to 3
hours/drink after consumption, mothers should wait at least 2 hours
after a single drink before nursing (CDC, 2018).
• Caffeine quickly enters breast milk after maternal consumption.
Insufficient high-quality data are available to make good evidence-
based recommendations on safe maternal intake (Drugs and
Lactation Database [LactMed], updated 2019). A daily limit of 300
mg might be a safe intake for most mothers (Table 12.2). Newborns
and preterm infants are especially sensitive to caffeine.
• Lactating women are urged to follow the same guidelines for
seafood consumption as pregnant women to ensure an adequate
concentration of DHA in breast milk. Eight to 12 oz/week of a
variety of seafood that is low in mercury is recommended because
its omega-3 fatty acid content is important for neurologic
development. Fish that have the highest mercury level should be
avoided.
It is not necessary for a mother to avoid highly flavored or spicy

foods while breastfeeding unless the infant is affected.
Postpartum Weight Retention

Excessive GWG increases the risk of postpartum weight retention and
obesity in mothers (see Fig. 12.7) and children (Deputy et al., 2015).
• Approximately half of women retain ≥10 pounds and nearly 1 in 4
women retain 20 pounds or more at 12 months postpartum (USDA
& USDHHS, 2020).
• Postpartum weight retention results in approximately 1 in 7 women
moving from a healthy weight classification before pregnancy to an
overweight classification postpartum (USDA & USDHHS, 2020).
• A combination of diet, regular physical activity, routine self-
monitoring of weight, and frequent provider contact may be most
effective at promoting postpartum weight loss (Deputy et al., 2015).
Think of Rachel. She gained 28 pounds during pregnancy

— more than the 11 to 20 pounds her doctor recommended.
She understands the importance of managing her weight for
her own health and for future pregnancies. She has been
successfully breastfeeding for 2½ months yet has not lost
any weight, so she will lower her calorie intake to help
promote weight loss. What would you recommend as an
appropriate calorie level and goal weight? What kind of
eating pattern may be healthiest for her given high risk for
type 2 diabetes and hypertension?
NURSING
PROCESS NORMAL
PREGNANCY
Jana is a 33-year-old moderately active professional who is entering the second trimester of
pregnancy with her first baby. Her prepregnancy BMI was 19.2. She has gained 4 pounds. She
plans on returning to work 8 weeks after delivery and wants to limit her weight gain to 10
pounds so that she can fit into her clothes by the time she returns to work. She has asked you
what she should eat that will be good for the baby but not cause her to get fat.
Assessment
Assessment
Medical– Medical history that may have nutritional

Psychosocial implications, such as diabetes, hypertension,
History lactose intolerance, PKU, or other chronic
disease
• Use of medications and over-the-counter drugs

• Adequacy of sunlight exposure
• Symptoms of constipation, including
frequency, interventions attempted, and results
• Any complaints related to pregnancy, such as
heartburn
• Usual frequency and intensity of physical
activity
• Attitude about pregnancy; knowledge about
normal amount and pattern of weight gain
during pregnancy
• Attitude/plan regarding breastfeeding
• Level of family/social support
Anthropometric Height, prepregnancy weight, pattern of 4-pound

Assessment weight gain during pregnancy
Biochemical and • Check hemoglobin to screen for iron deficiency

Physical anemia. (Many laboratory values change
Assessment during pregnancy related to normal changes in
maternal physiology and so cannot be validly
compared with nonpregnancy standards.)
• Check glucose, other laboratory values as
available.
• Assess blood pressure.
Assessment
Dietary • How is your appetite?

Assessment Do you follow a balanced and varied eating
pattern that includes all food groups from
• MyPlate in reasonable amounts?
• Do you eat at regular intervals?
• How have you modified your intake since
becoming pregnant?
• Do you eat nonfoods or have nonfood
cravings?
• Do you take a vitamin and/or mineral
supplement?
• Do you use alcohol, tobacco, caffeine, or herbal
supplements?
• What are your concerns about nutrient needs
during pregnancy?
• Do you have cultural, religious, or ethnic
factors that influence your food choices?
Analysis
Possible Nursing • Insufficient understanding of the importance of

Analysis adequate weight gain during pregnancy as
evidenced by a desire to limit total weight gain
to 10 pounds
Planning
Assessment
Client Outcomes The client will do the following:
• Consume an adequate, varied, and balanced

eating pattern based on MyPlate.
Explain the amount and pattern of
recommended weight gain during pregnancy.
• Gain approximately 1 pound of weight/week
during the remainder of pregnancy.
Nursing Interventions
Nutrition Therapy • Provide a 2400-calorie eating plan that includes

all food groups and emphasizes ample fruits
and vegetables, whole grains, lean protein, fat-
free dairy, and healthy fats.
Assessment
Client Teaching Instruct the client on the following:

• The role of nutrition and weight gain in the
outcome of pregnancy
• Choosing nutrient-dense foods over calorie-
dense items
• Choosing a variety of foods within each major
food group
• Selecting the appropriate number of servings
from each major food group
• Items to avoid during pregnancy: alcohol,
herbal supplements, unpasteurized juice, milk,
and cheese; raw seafood, undercooked eggs
and meats, premade deli salads, raw sprouts,
cold hot dogs, and luncheon meats
Behavioral matters including the following:
Abandoning the idea of limiting weight gain to
fit into clothes after pregnancy
• The importance of maintaining physical
activity
Where to find more information (see “Websites”
at the end of this chapter)
Evaluation
Evaluate and • Monitor amount and pattern of weight gain.

Monitor • Monitor quality and adequacy of intake based
on meal plan provided.
• Suggest changes in the food plan as needed.
• Provide periodic feedback and support.
How Do You Respond?
To limit calories and weight gain, can I just take
calcium supplements instead of drinking 3 cups
of milk day? Milk is a rich source of calcium but it
provides many other essential nutrients, such as protein,‐
vitamin D, riboflavin, potassium, and magnesium.
Calcium supplements cannot substitute for these
nutrients. Also, the absorption of calcium from milk is
promoted by the lactose and vitamin D content of milk
whereas the absorption of calcium from supplements
varies depending on the form of calcium, how well the
supplement dissolves, and the dose. A better option for
controlling calories is to choose nonfat milk or yogurt and
choose nutrient-dense foods from all food groups.
Should pregnant women avoid eating peanuts
during pregnancy to reduce the risk of peanut
allergy in their children? The advice to avoid
peanuts and other allergens during pregnancy has been
overturned. According to the AAP, there is a lack of
evidence to support maternal dietary restrictions either
during pregnancy or during lactation to prevent atopic
disease, such as atopic dermatitis, asthma, allergic
rhinitis, and food allergy (Greer et al., 2019).
REVIEW CASE STUDY
Sarah is 28 years old and 7 months pregnant with her third child. Her other
children are aged 2½ years and 1½ years. She had uncomplicated
pregnancies and deliveries. Sarah is 5 ft 6 in. tall; she weighed 142 pounds
at the beginning of this pregnancy, which made her prepregnancy BMI 23.
She has gained 24 pounds so far. Prior to her first pregnancy, her BMI was
20 (124 pounds). She is unhappy about her weight gain, but the stress of
having two young children and being a stay-at-home mom made losing
weight impossible.
She went online for her MyPlate plan, which recommends she consume
2400 cal/day. She doesn’t think she eats that much because she seems to
have constant heartburn. She takes a prenatal supplement, so she feels
pretty confident that even if her intake is not perfect, she is getting all the
nutrients she needs through her supplement. A typical day’s intake for her is
shown on the right:
• Evaluate her prepregnancy weight and weight gain thus far. How much
total weight should she gain?
• Based on the 2400-calorie meal pattern in Figure 12.5, what does Sarah
need to eat more of? What is she eating in more than the recommended
amounts? How would you suggest she modify her intake to minimize
heartburn?
• What would you tell her about weight gain during pregnancy? What
strategies would you suggest her after her baby is born that would help
her achieve her healthy weight?
• Is her conclusion about the adequacy of supplements appropriate? What
would you tell her about supplements?
Devise a 1-day menu for her that would provide all the food she needs in
the recommended amounts and alleviate her heartburn.
Breakfast: Cornflakes with whole milk (because the children drink

whole milk), orange juice
Snack: Bran muffin and whole milk
Lunch: Either a peanut butter and jelly sandwich or tuna fish sandwich
with mayonnaise, snack crackers, whole milk, and pudding or
cookies
Snack: Ice cream
Dinner: Macaroni and cheese, green beans, roll and butter, whole milk,
and cake or ice cream for dessert
Evening: Chips and salsa
STUDY QUESTIONS
1 A woman trying to become pregnant was told by her physician to take a

daily supplement containing 400 mg of folic acid. She asks why a
supplement is better than eating natural sources of folate through food.
Which statement is the nurse’s best response?
a. “There are few natural sources of folate in food.”
b. “Synthetic folic acid in supplements and fortified foods is better
absorbed, more available, and a more reliable source than the folate
found naturally in food.”
c. “Folate in food is equally as good as folic acid in supplements. It is
just easier to take it in pill form and then you don’t have to worry
about how much you’re getting in food.”
d. “If you are sure that you eat at least five servings of fruits and
vegetables every day, you don’t really need to take a supplement of
folic acid.”
2 A woman who was at her healthy weight when she got pregnant is
distraught by her 4-pound weight gain between 20 and 24 weeks of
gestation. Her weight gain up to 20 weeks was on target. What is the
a. “A 4-pound-per-month weight gain at this point in your pregnancy is
normal.”
b. “Although it is considerably less than the recommended amount, it is
not a cause for concern. Just be sure to follow your meal plan next
month so you get enough calories and nutrients.”
c. “I recommend you write down everything you eat for a few days so we
can identify where the problem lies.”
d. “A 4-pound weight gain in 1 month at this point in your pregnancy
may be a sign that you are at risk of preeclampsia. You should cut back
on the ‘extras’ in your eating pattern to limit your weight gain for next
month.”
3 The nurse knows her instructions on healthy eating during pregnancy
have been effective when the woman verbalizes she should
a. avoid seafood because of its mercury content.
b. limit alcohol to 2 drinks/day.
c. increase her intake of milk to 4 cups/day.
d. eliminate hot dogs and deli meats unless heated to steaming hot
immediately before eating.
4 At her first prenatal visit, an overweight woman asks how much weight
she should gain during the course of her pregnancy. What is the nurse’s
best response?
a. “You should not gain any weight during your pregnancy. You have
adequate calorie reserves to meet all the energy demands of pregnancy
without gaining additional weight.”
b. “You should try to gain less than 15 pounds.”
c. “Aim for a 15- to 25-pound weight gain.”
d. “The recommended weight gain for your weight is 25 to 35 pounds.”
5 Which of the following statements indicates that the pregnant woman
understands the recommendations about caffeine intake during
pregnancy?
a. “I have to give up drinking coffee and cola.”
b. “I will limit my intake of coffee to about 2–3 cups a day and avoid
other sources of caffeine.”
c. “As long as I don’t drink coffee, I can eat other sources of caffeine
because they don’t contain enough to cause any problems.”
d. “Caffeine is harmless during pregnancy, so I am allowed to consume
as much as I want.”
6 What nutrient is not likely to be consumed in adequate amounts during
pregnancy so a supplement may be needed?
a. Iron
b. Vitamin A
c. Vitamin B12
d. Vitamin C
7 A woman at 5 weeks of gestation is complaining of nausea throughout
the day. What should the nurse recommend?
a. Small, frequent meals of easily digested carbohydrates
b. Small, frequent meals that are high in protein
c. A liquid diet until the nausea subsides
d. Increasing fluids with all meals and snacks
8 Which of the following statements is true?
a. “Women who breastfeed almost always achieve their prepregnancy
weight at 6 weeks postpartum.”
b. “Weight loss during lactation is not recommended because it lowers
the quantity and quality of breast milk produced.”
c. “Most breastfeeding women do not have to increase their intake by the
full amount of calories it ‘costs’ to produce milk because they can
mobilize fat stored during pregnancy for some of the extra energy
required.”
d. “Women do not need to increase their calorie intake at all for the first 6
months of breastfeeding because they can use calories stored in fat to
produce milk.”
CHAPTER SUMMARY Healthy Eating
for Healthy Babies
Women who are healthy at the time of conception are more likely to have
a successful pregnancy and a healthy infant.
Preconception Nutrition
The preconception period may be a critical time to promote a healthy
lifestyle to reduce the risk of undesirable maternal and child health
outcomes. Before conception, women should:
• Attain and maintain a healthy BMI of 25 or less
• Consume an appropriate amount of calories with an emphasis on

fruits, vegetables, whole grains, lean proteins, and low-fat or fat-free
dairy; they should also consume healthy fats and limit added sugars,
solid fats, and sodium
• Take 400 to 800 mcg of folic acid to reduce the risk of neural tube
defects
• Be physically active
• Not smoke, drink alcohol, or use drugs
• Avoid herbal supplements unless approved by a physician
• Manage existing medical conditions such as diabetes and hypertension
Nutrition and Lifestyle during

Pregnancy
The same healthy nutrition and lifestyle recommendations for the
prepregnancy period continue throughout pregnancy. Additional
considerations are as follows:
• Keep the pattern and amount of weight gain within recommended
levels. Women with a normal BMI should gain a total 25 to 35 pounds
with 1 to 4 pounds gained in the first trimester and slightly less than 1
pound/week thereafter.
• Increase calories modestly. No increase is necessary in the first
trimester. Approximately 340 and 420 extra calories/day, respectively,
are needed during the second and third trimesters.
• The increased need for folic acid continues. Iron supplements are
routinely recommended. If food choices are less than optimal,
supplemental iodine, vitamin D, and calcium may be appropriate.
Prenatal vitamins and minerals are routinely recommended as a
safeguard.
Numerous environmental concerns need attention during pregnancy.
• Alcohol: There is not an established safe level of intake, although
occasional limited use may not be harmful.
• Caffeine: Amounts up to 300 mg/day, or approximately 2 to 3 cups of
brewed coffee, are assumed to be safe.
• Nonnutritive sweeteners: Approved sweeteners are safe during
pregnancy but cautious use is prudent.
• Seafood: 8 to 12 oz/week of fish with low mercury content is advised
to promote normal fetal growth and development while limiting
mercury exposure.
• Foodborne illness: Pregnant women are more susceptible to
foodborne illness due to hormonal changes. In addition to normal food
safety precautions, foods to avoid include unpasteurized milk and
juices, raw or undercooked meat, poultry, seafood, and eggs;
refrigerated smoked seafood, pâtés, and meat spreads; and
unpasteurized soft cheese, hot dogs, and deli meats unless heated to
steaming hot.
• Physical activity: Women should do at least 150 minutes (2 hours and
30 minutes) of moderate-intensity aerobic activity a week during
pregnancy and the postpartum period
Maternal Health
• Common complaints of pregnancy: Nausea, vomiting, constipation,
and heartburn may be alleviated by nutrition interventions.
• Excessive weight gain: Women should learn their BMI and weight
gain goals at the first prenatal visit. At prenatal appointments
throughout pregnancy, weight, diet, and exercise should be discussed.
Women should self-monitor weight gain, intake, and activity.
• Pica: The ingestion of nonfood stuffs is linked to micronutrient
deficiencies and anemia. Counseling should address the potential
risks.
• Gestational diabetes: Excessive weight gain should be avoided. Diet
and exercise may control blood glucose levels for many. Blood
glucose monitoring provides data to adjust the meal plan as necessary.
Small frequent meals and snacks and breakfasts that provide less
carbohydrate of low glycemic index foods may aid blood glucose
control.
• Preexisting diabetes: Frequent blood glucose monitoring and
adjustments in diet and exercise are needed to promote glycemic
control.
• Hypertensive disorders of pregnancy: Chronic hypertension,
gestational hypertension, and preeclampsia fall under this umbrella
term. Medications are used to control blood pressure. It is not known
if lifestyle modification improves blood pressure control during
pregnancy
• Maternal PKU: Women should achieve low phenylalanine levels
before conception to reduce the risk of fetal mental impairments. A
strict low-protein diet with low-phenylalanine medical formulas is
necessary to control phenylalanine intake while achieving adequate
calorie intake. Close monitoring is needed.
Adolescent Pregnancy
• Adolescent pregnancy increases health risks to both infant and mother.
• Adolescents within the healthy BMI range should gain approximately
35 pounds to reduce the risk of delivering an LBW infant.
Nutrition for Lactation

Breastfeeding is an important public health strategy for improving infant
and child morbidity and mortality and improving maternal morbidity.
Many nutrients are needed in higher amounts during lactation than
during pregnancy.
• Calories: Exclusive breastfeeding requires approximately 500 calories
extra/day, approximately 300 to 400 calories from food and the rest
from mobilized fat stores to help women return to prepregnancy
weight.
• Fluid: Women are encouraged to drink 8 oz of fluid with meals and
each time they breastfeed.
• Vitamin and mineral supplements: Are usually not necessary if a
balanced, varied eating pattern is consumed. However, many
healthcare professionals recommend women continue to take prenatal
vitamins during lactation.
• Alcohol: Women should not drink within 2 hours before nursing to
minimize concentration in breast milk.
• Caffeine: A daily limit of 300 mg might be a safe intake for most
mothers
• Fish consumption: Lactating women should follow the same
guidelines as during pregnancy are recommended, which is 8 to
12oz/week of lower mercury fish.
Postpartum weight retention: Is common and a risk factor for
•
obesity. Diet and exercise combined with self-monitoring are
recommended.
Figure sources: shutterstock.com/Kzenon, shutterstock.com/Prostock-studio, shutterstock.com/Iryna
Inshyna

book at
Websites
Academy of Nutrition and Dietetics at www.eatright.org
American Academy of Pediatrics at www.aap.org
American College of Obstetricians and Gynecologists at www.acog.org
La Lèche League International at www.lalecheleague.org
March of Dimes at www.marchofdimes.org
MyPlate for Pregnancy and Breastfeeding at www.choosemyplate.gov
Nutrition.gov at www.nutrition.gov
Supplemental Nutrition Program for Women, Infants, and Children (WIC) at
http://www.fns.usda.gov/wic/women-infants-and-children-wic
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Vockley, J., Andersson, H., Antshel, K., Braverman, N. D., Burton, B. K., Frazier, D. M., Mitchell, J.,
Smith, W. E., Thompson, B. H., & Berry, S. A., for the American College of Medical Genetics
and Genomics Therapeutics Committee. (2014). Phenylalanine hydroxylase deficiency:
Diagnosis and management guideline. Genetics in Medicine, 16(2), 188–200.
https://doi.org/10.1038/gim.2013.157
Nutrition for Infants,
Chapter Children, and
13 Adolescents
Luis Guzman
Luis is a 7-year-old boy who is 48 in. tall and weighs
90 pounds. He is the only child of a single mother
who worries that his weight is out of control. She
admits she lets him eat whatever he wants, even
though she knows he is eating inappropriately. His
grandmother is his primary caregiver before school
starts, and when school is not in session, and she also
gives him whatever he wants, including fast food
twice a week.
Learning Objectives
1 Discuss breastfeeding teaching points.

2 Describe key points about introducing solid foods into the diet.
3 Explain fluid and food recommendations for feeding infants.
4 Summarize eating characteristics and recommendations during early
childhood.
5 Discuss calorie needs during middle childhood and adolescence.
6 Identify food groups most likely to be underconsumed by youth ages 5 to
18.
7 Name nutrients most likely to be underconsumed by adolescents.
8 Define overweight and obesity in youth.
9 Describe the stages of obesity treatment in youth.
10Give examples of obesity prevention strategies from pregnancy through
adolescence.
The goals of nutrition and physical activity for children are to promote
optimal physical and cognitive development, a healthy weight, an
enjoyment of food, and a decreased risk of chronic disease (Ogata & Hayes,
2014). Actual nutrient requirements vary according to health status, activity
pattern, and growth rate. The greater the rate of growth, the more intense
the nutritional needs.
The health trends of American children are mixed. Although deficiency
diseases are rare and infant mortality has declined over recent decades, the
prevalence of overweight and obesity is a public health concern. Today,
nearly 1 out of 5 American children are obese, placing them at risk for
chronic diseases that were once only diagnosed in adults, such as coronary
artery disease, type 2 diabetes, hypertension, metabolic syndrome, and sleep
apnea. Today’s children may experience shorter life expectancies related to
young-onset obesity.
This chapter presents nutrition from birth through adolescence,
including calorie and nutrient needs and eating practices. Nutrition concerns
during childhood and adolescence—namely, poor diet quality and
overweight and obesity—are discussed.
INFANCY (BIRTH TO 1 YEAR)
Excluding fetal growth, growth in the first year of life is more rapid than at
any other time in the life cycle. Birth weight doubles in the first 6 months
(Box 13.1). From 6 to 12 months, rapid growth continues but at a slower
pace. The Centers for Disease Control and Prevention (CDC) (2010)
recommends that growth be monitored from birth to 2 years of age by using
the World Health Organization (WHO) growth charts. WHO growth charts
are based on growth of a population of healthy breastfed infants, whereas
the CDC growth charts from birth to 2 years are based on observational data
from overweight populations and include a large number of formula-fed
infants (Hagan et al., 2017). The WHO growth charts can be accessed at
www.cdc.gov/growthcharts/who_charts.htm#. Infants who are growing
appropriately are consuming adequate nutrition.
Over the course of the first year of life, significant change occurs in the
infant’s size, development, nutrient needs, and feeding patterns. As the
infant becomes more skillful in signaling hunger and satiety, the ability to
self-feed, and language, parents learn how to identify and assess infant cues
and gain a sense of confidence (Hagan et al., 2017).
Nutrient Needs
Adequate calories and nutrients are needed to support the unprecedented
rate of growth that occurs during the first year of life. Recommendations for
the amount of calories and nutrients infants should consume are
approximations based on estimated average intakes of healthy full-term
newborns that are exclusively breastfed by well-nourished mothers—even
though the content of breast milk varies and it is impossible to measure how
much an infant consumes.
Although the total amount of calories and nutrients is generally far less
than what adults need, proportionately infants require more calories and
nutrients than adults. Fat provides 40% to 50% of calories in breast milk
and infant formulas. This is a contrast to the recommendation that adults
consume 20% to 35% of their total calories from fat. Infants need
calorically dense fat to meet the demands of growth within the constraints
of small stomach capacity.
Because infants are born with low amounts of vitamin K stored in the
body and a decreased ability to utilize vitamin K, infants are given a single
intramuscular dose of vitamin K at birth to protect them from hemorrhagic
disease of the newborn. With few exceptions noted in the following section,
all other vitamin and mineral needs are met with breast milk or properly
prepared formula.
BOX Average Growth in the First Year of Life

13.1
First week of life
• May lose up to 10% of birth weight

By 14 days of age
• Birth weight regained

Between 4 and 6 months of age
• Birth weight doubles

• Usual weekly gain is 4 to 7 oz
From 6 months to 1 year
• Usual weekly gain of 2 to 3 oz in breastfed infants, 3 to 5 oz in

formula-fed infants
At 1 year
• Birth weight triples

• Length increases by 50%
Source: Hagan, J. F., Shaw, J. S., & Duncan, P. M. (Eds.). (2017). Bright futures: Guidelines for
health supervision of infants, children, and adolescents. American Academy of Pediatrics.
BOX
Composition of Breast Milk
13.2
Protein
• Amount is adequate to support growth without contributing to an
excessive renal solute load.
• Most of the protein is easy to digest whey.
• The concentration of potentially harmful amino acids (e.g.,
phenylalanine) is low and there are high levels of amino acids that
infants cannot synthesize (e.g., taurine).
Fat
• High content of linoleic acid (an essential fatty acid).

• High cholesterol content may help infants develop enzyme systems
capable of handling cholesterol later in life.
Minerals
The minerals are mostly protein bound and balanced to enhance
bioavailability. For instance, the rate of iron absorption from breast milk
is approximately 50% compared with about 4% for iron-fortified
formulas. Zinc absorption is better from breast milk than from either
cow’s milk or formula.
Enzymes
• Contains amylase to promote carbohydrate digestion when pancreatic
amylase levels are low.
• Contains lipases to promote fat digestion.
Renal Solute Load

• Minerals and protein in adequate, but not excessive, amounts keep
renal solute load suited to the immature kidneys’ inability to
concentrate urine.
• Contains antibodies and anti-infective factors. Although higher in
colostrum, breast milk contains antibodies.
• Bifidus factor promotes the growth of normal GI flora (e.g.,
Lactobacillus bifidus) that protect the infant against harmful GI
bacteria.
Breast Milk
Breast milk is specifically designed to support optimal growth and
development in the newborn, and its composition makes it uniquely
superior for infant feeding (Box 13.2). Breastfeeding is recommended for at
least the first year of life with exclusive breastfeeding for the first 6 months
of life (U.S. Department of Agriculture [USDA] & U.S. Department of
Health and Human Services [USDHHS], 2020).
• Some of the potential health benefits for the infant include reduced
risk of diarrhea and respiratory tract infection; possible protective
effect against inflammatory bowel disease, leukemias, and certain
types of type 1 diabetes; lowered risk of obesity in some
populations; lower risk of atopic illness; and close mother–infant
bonding (Hagan et al., 2017).
• All infants who are exclusively breastfed or who receive breast milk
and formula need a vitamin D supplement of 400 IU/day beginning
soon after birth (USDA & USDHHS, 2020).
Infant Formula
Infant formulas may be used in place of breastfeeding, as an occasional
supplement to breastfeeding, or when exclusively breastfed infants are
weaned before 12 months of age.
• The Infant Formula Act regulates the levels of nutrients in formulas,
specifying both minimum and maximum amounts of each essential
nutrient.
• Almost all formula used in the United States is iron fortified, a
practice that has greatly reduced the risk of iron deficiency in older
infants.
• Because the minimum recommended amount of each nutrient is
more than the amount provided in breast milk, nutrient supplements
are unnecessary for the first 6 months of life.
• Infant formula companies in the United States market directly to
consumers and release new formulas with or without slightly
different compositions on a regular basis, such as formulas with
added DHA or lutein to “support eye health.”
• There is debate over the associations between some formula
ingredients and health outcomes, such as the unknown effects of
adding prebiotics and probiotics to infant formulas (Rossen et al.,
2016). The U.S. Food and Drug Administration (FDA) does not
“approve” new formulas but rather reviews the proposed formula
composition and background information provided by the formula
manufacturer. The FDA is more empowered to evaluate safety than
efficacy of infant formulas (Abrams, 2015).
• Categories of infant formulas for full-term and preterm infants
include the following (American Academy of Pediatrics, 2020;
Rossen et al., 2016):
• Cow’s milk–based formulas account for 69% of formulas used;
most are iron fortified.
• Soy formulas. According to AAP, there are few circumstances for
choosing soy formula over cow’s milk–based formula.
• Hydrolyzed formulas are intended for infants with cow’s milk and
soy protein allergies.
• Specialized formulas are specifically altered to be lacking or
deficient in one or more nutrients (e.g., phenylalanine) so are not
suitable for healthy infants.
• Preterm formulas are designed to promote “catch-up growth.”
They are higher than routine formulas in calories, protein, and
certain minerals.
• Premature infant discharge formulas are less calorically dense
than preterm formulas but higher in calories than term formulas.
They are used to supplement breastfed preterm infants
Infant Feedings
Successful infant feeding requires parents to recognize verbal and
nonverbal feeding cues (Hagan et al., 2017).
• Newborns signal hunger by rooting, sucking, and hand movements.
Hunger cues in an older infant may include hand-to-mouth
movements, lip smacking, crying, excited arm and leg movements,
opening the mouth, and moving toward a spoon as it comes near.
• Depending on the infant’s age, satiety cues include fussiness during
feedings, slowing the pace of eating, turning away from the nipple,
stopping sucking, spitting out/refusing the nipple, falling asleep, or
spitting up milk.
Frequency of Breastfeeding
• In the first months of life, breastfed infants are fed a minimum of 8
to 12 times/24 hours, or approximately every 2 to 3 hours.
• Feedings become less frequent as the infant grows.
• Teaching points for breastfeeding are listed in Box 13.3.
BOX Teaching Points for Breastfeeding

13.3
• The infant should be allowed to nurse for 5 minutes on each breast on

the first day to achieve letdown and milk ejection. By the end of the
first week, the infant should be nursing up to 15 minutes/breast.
• Mothers should offer the breast whenever the infant shows early signs
of hunger. The first breast offered should be alternated with every
feeding so both breasts receive equal stimulation and draining.
• Even though the infant will be able to virtually empty the breast within
5 to 10 minutes once the milk supply is established, the infant needs to
nurse beyond that point to satisfy the need to suck and to receive
emotional and physical comfort.
• The supply of milk is equal to the demand—the more the infant sucks
or the more frequently milk is manually expressed, the more milk is
produced. Infants age 6 weeks or 12 weeks who suck more are
probably experiencing a growth spurt and so need more milk.
• Early substitution of formula or introduction of solid foods may
decrease the chance of maintaining lactation.
• Breast milk can be pumped, placed in a sanitary bottle, and
immediately refrigerated or frozen for later use. Milk should be used
within 24 hours if refrigerated or within 3 months if stored in the
freezer compartment of the refrigerator.
BOX Teaching Points for Formula Feeding

13.4
• Never force the infant to finish a bottle or to take more than they want.
• Discourage the misconception that “a fat baby = a healthy baby = good
parents.”
• Each feeding should last 20 to 30 minutes.
• Formula may be given at room temperature, slightly warmed, or
directly from the refrigerator; however, always give formula at
approximately the same temperature.
• Spitting up of a small amount of formula during or after a feeding is
normal. Feed the infant more slowly and burp more frequently to help
alleviate spitting up.
• Hold the infant closely and securely. Position the infant so that the
head is higher than the rest of the body.
• Avoid jiggling the bottle and making extra movements that could
distract the infant from feeding.
• Bottles should never be propped for independent feeding.
• Check the flow of formula by holding the bottle upside down. A steady
drip from the nipple should be observed. If the flow is too rapid
because of a too large nipple opening, the infant may overfeed and
develop indigestion. If the flow rate is too slow because of a too small
nipple opening, the infant may tire and fall asleep without taking
enough formula. Discard any nipples with holes that are too large, and
enlarge holes that are too small with a sterilized needle.
• Reassure caregivers that there is no danger of “spoiling” an infant by
feeding them when they cry for a feeding.
• Burp the infant halfway through the feeding, at the end of the feeding,
and more often if necessary to help get rid of air swallowed during
feeding. Burping can be accomplished gently rubbing or patting the
infant’s back as they are held on the shoulder, lie on their stomach over
the caregiver’s lap, or sit in an upright position.
• After the teeth erupt, the baby should be given only plain water for a
bedtime bottle-feeding.
Formula Feeding
The recommendations for formula feeding listed in the following are based
on meeting the infant’s total calorie and fluid needs, not for the maximum
volumes per feeding (Hagan et al., 2017). During growth spurts, infants
temporarily increase the volume of formula consumed. Teaching points for
formula feeding are listed in Box 13.4.
• In the first weeks of life,
• offer 2 oz every 2 to 3 hours; a newborn in the 50th percentile for
weight consumes an average of 20 oz formula/day with a range of
16 to 24 oz/day;
• more formula should be offered if the infant still appears hungry.
• Infants around the age of 2 months need 6 to 8 feedings/24 hours.
• A 4-month-old consumes an average of 31 oz/day (range of 26–36
oz/day) without complementary foods.
• At 6 months and older, formula intake is 24 to 32 oz/day in addition
to complementary foods. As solid food intake increases, the volume
of formula consumed decreases.
To avoid nursing bottle caries, infants should not be put to bed with
• a bottle of formula or other liquids that contain sugar (Fig. 13.1).
Figure 13.1 ▲ Nursing bottle caries. Notice the extensive decay in the
upper teeth. (Source: shutterstock.com/phungatanee)
Complementary Foods
Complementary foods, also known as solids, are added to the infant’s diet at
about 6 months of age and when the infant is developmentally ready
Nutrient Needs
Around 6 months of age, breast milk or formulas are not adequate as the
sole source of nutrition and nutrient-dense, developmentally appropriate
complementary foods become necessary.
• Infant iron stores are usually adequate for about the first 6 months of
life so the first solids offered should be iron-rich foods, such as
meats, seafood, and iron-fortified infant cereals.
• Iron-rich foods should continue through 11 months to maintain
adequate stores (USDA & USDHHS, 2020). Formula-fed infants
should continue to use iron-fortified formula.
• To support adequate zinc status, zinc-rich complementary foods,
such as meats, beans, and zinc-fortified cereals, are important from
age 6 months onward (USDA & USDHHS, 2020).
• At 6 months of age, exclusively breastfed infants and infants who
receive ready-to-use infant formula need supplemental fluoride.
• Infants who consume formula that is prepared with local water need
supplemental fluoride only if the water contains less than 0.3 ppm of
fluoride.
Introducing Solids
Initially, small amounts of pureed foods are offered. As the infant’s mouth
patterns, hand and body skills, and feeding skills develop, the amount and
texture of food offered progresses (Table 13.1).
• Iron-fortified cereal or pureed foods are usually recommended as
first foods; there is no evidence to support any particular order or
rate for introducing other solids.
• Generally, single-ingredient foods are introduced one at a time so
that allergic reactions, such as rashes, vomiting, or diarrhea, can be
identified.
• The amount of solid food taken at a feeding may vary from 1 to 2
tsp initially to ¼ to ½ cup as the infant gets older. To increase the
likelihood of acceptance, it may be beneficial to give a small
amount of formula or breast milk to take the edge off hunger before
introducing the first solid.
• After 3 days of apparent tolerance, another new food is introduced.
• Solids may be given 2 to 3 times/day with the infant deciding how
much to eat.
• Within a few months, the infant is eating texture-appropriate meats,
cereal, fruits, and vegetables in addition to breast milk and/or
formula.
• To limit the likelihood that infants will become picky eaters, a
variety of colors, flavors, and textures should be offered.
• It may take as many as 8 to 10 exposures over several months before
an infant “likes” a particular food.
• Establishing regular meal times and snack times instead of
continuous grazing will help prevent overweight and obesity (Hagan
et al., 2017).
Table For Child Care Providers:

Feeding Babies in Their First
13.1 Year
Baby’s When Baby Serve These Foods in the Child and

Age Can: Adult Care Food Program (CACFP):
Birth • Only suck Liquids only
through and swallow • Breast milk
5 • Iron-fortified infant formula
months
Around • Draw in Serve liquids mentioned earlier and add
6–8 upper or solid foods when babies are
months lower lip as developmentally ready, including the
spoon is following:
removed • Cooked, plain pureed/mashed
from mouth vegetables
• Move tongue • Plain pureed/mashed fruit
up and down • Plain pureed/mashed meat and meat
• Sit up with alternates (dairy and protein foods):
support meat, poultry, fish, whole eggs, cheese,
• Swallow soft yogurt, and cooked dry beans and peas
solid foods Iron-fortified infant cereals, bread,
without small pieces of crackers
choking
• Open the •
mouth when
they see food
• Drink from a
cup with
help, with
spilling
Around • Move tongue Serve liquids and foods mentioned
8–12 from side to earlier, and add a variety of new
months side solid foods and textures such as the
• Begin spoon- following:
feeding • Fortified ready-to-eat cereal, teething
themselves biscuits, crackers, and toasts
with help • Finely chopped vegetables
• Begin to • Finely chopped fruit
chew and • Finely chopped meat and meat
have some alternates (dairy and protein foods):
teeth meat, poultry, fish, whole eggs, cheese,
• Begin to hold yogurt, and cooked dry beans and peas
food and use
their fingers
to feed
themselves
• Drink from a
cup with
help, with
less spilling
Source: U.S. Department of Agriculture Food and Nutrition Service. (2019). Feeding infants in the
child and adult care food program. FNS 786. https://fns-
prod.azureedge.net/sites/default/files/resource-files/FI_FullGuide-a.pdf
Feeding Guidelines
Parents decide what infants (and children) are offered, whereas infants (and
children) always decide whether to eat and how much to eat (Satter, 2016).
Parents need to trust their child’s natural ability to eat the amount of food
they need. By 12 months of age, infants should be eating a variety of table
foods and various textures.
Fluids
• Breast milk and/or iron-fortified formula are consumed until the
infant reaches the age of 12 months. Breastfeeding may continue
longer, if desired.
• Plain cow milk is avoided until 12 months of age because it lacks
adequate iron and has excessive amounts of sodium, potassium, and
protein compared to formula or breast milk (Rossen et al., 2016).
Food
• Three to 5 solid feedings/day are appropriate. Infants should be
included in family meals whenever possible even if eating times do
not align (Provincial Health Services Authority, 2016).
• Fat intake should not be restricted because infants and young
children need proportionately more fat than older children and
adults.
• Foods and beverages that should not be given are those that
• are higher sodium, such as some salty snacks, commercial toddler
foods, and processed meats. Preference for salty foods may be
established early in life (USDA & USDHHS, 2020).
• have added sugars. The high nutritional requirements for healthy
growth and development leave virtually no room for foods with
low nutritional value.
• contain low- and no-calorie sweeteners so as to not promote a
taste preference for overly sweet foods (USDA & USDHHS,
2020).
• contain honey in any form, including cooked or pasteurized,
because it may contain botulism spores.
• are unpasteurized, such as unpasteurized juices, milk, yogurt, or
cheeses because they may contain harmful bacteria (USDA &
USDHHS, 2020).
• may cause choking (Box 13.5).
Foods That May Cause Choking in Small

BOX Children
13.5
Round slices of hot dogs and sausages
Hard candy
Cough drops
Peanuts and other whole nuts
Whole grapes and cherries
Raw carrot sticks
Whole cherry or grape tomatoes
Large pieces of raw vegetables or fruit
Olives with pits
Tough meat
Celery
Popcorn
Dried fruit
Marshmallows
Potato and corn chips and similar snack foods
Chewing gum
Food Allergies
According to the American Academy of Pediatrics (Greer et al., 2019)
• there is no evidence that delaying the introduction of allergenic
foods, including peanuts, eggs, and fish, beyond 4 to 6 months of
age prevents atopic disease
• evidence now shows that early introduction of infant-safe forms of
peanuts (e.g., small amounts of thinned peanut butter mixed in
infant cereal or yogurt) reduces the risk for peanut allergies.
• High-risk infants should be introduced to peanuts as early as 4 to
6 months of age.
• Infants with mild-to-moderate risk (e.g., mild-to-moderate eczema)
should be introduced to peanuts around 6 months of age.
• Low-risk infants (no eczema or any food allergy) should be given
peanut-containing food when age appropriate (e.g., after 6 months
of age if exclusively breastfed).
NUTRITION DURING EARLY
CHILDHOOD (1–5 YEARS)
Adequate nutrition during early childhood focuses on promoting normal

growth through the appropriate amount and types of foods within an
environment that allows the child to self-regulate (Hagan et al., 2017).
Beginning at age 2 years, CDC growth charts are used to monitor size and
growth patterns by plotting body mass index (BMI) for age (Figs. 13.2 and
13.3). Weight status outside the definition of normal or healthy (Table 13.2)
and deviations in a child’s percentile channel warrant further attention.
Physical activity is intertwined with nutrition in promoting growth and
development and overall health. Key physical activity guidelines for
preschool-aged children state that children ages 3 to 5 should be physically
active throughout the day and that adult caregivers should encourage active
play that includes a variety of activity types (USDHHS, 2018).
Parental Influences on Eating Habits

Early parental influence is associated with the development of a child’s
relationship with food later in life (Ogata & Hayes, 2014). Young children
are especially dependent on parents and caregivers as to which foods are
available, the portion sizes offered, how often eating occurs, and the social
context of eating. For instance, eating all food on the plate, dessert used as a
reward, and eating regularly scheduled meals are behaviors that may be
instilled in children by their parents. Parents who offer large food portions
(especially of calorie-dense, sweet, or salty foods), pressure their child to
eat or restrict the child’s eating, and model excessive eating undermine the
child’s ability to self-regulate food intake (Ogata & Hayes, 2014).
Figure 13.2 ▲ Body mass index-for-age percentiles for boys. (Source:
Adapted from the CDC. [2010]. Growth charts. National Center for Health
Statistics. https://www.cdc.gov/growthcharts/)
As the infant becomes a toddler, parents determine what food is served,

when food is served, and where it is served. Dividing feeding
responsibilities into parental tasks and child tasks helps children become
competent eaters who are able to self-regulate intake, thereby decreasing
the risk of overweight/obesity and disordered eating (Box 13.6) (Satter,
2016).
Developmental Milestones Related to Eating

The dramatic decrease in growth rate that occurs after the first year of life is
reflected in a decrease in appetite and unpredictable food intake as calorie
needs per kilogram of body weight decrease. At age 1 year, the child should
be drinking from a cup. By the age of 2, the toddler should eat most of the
same foods as the rest of the family with precautions taken to avoid
choking. The typical daily pattern is 3 meals and 2 to 3 snacks. By 24
months of age, toddlers should be able to use utensils and spill little of their
food.
Figure 13.3 ▲ Body mass index-for-age percentiles for girls. (Source:
Adapted from the CDC. [2010]. Growth charts. National Center for Health
Statistics. https://www.cdc.gov/growthcharts/)
Eating characteristics from age 2 to 5 or 6 are as follows (Provincial

Health Services Authority, 2016):
• Young children continue to be at risk of choking until around the
age of 4 years.
• Beginning around 15 months of age, a child may develop food jags
as a normal expression of autonomy as the child develops a sense of
independence.
• By the end of the second year, children can completely self-feed and
can seek food independently.
• Picky eating is a normal behavior.
• Adult role modeling is important.
Table Childhood and Adolescent

Weight Status Based on Body
13.2 Mass Index Percentile Categories
Weight Status
BMI Percentile Range a
Category
<5th Underweight
≥5th–84th Normal or healthy
weight
≥85th–94th Overweight
≥95th Obese
Classification of Severe Obesityb
≥95th percentile Class 1 Obesity
≥120% of the 95th percentile or a BMI ≥ 35 Class 2 Obesity
(whichever is lower)
Weight Status
BMI Percentile Range a
Category
≥140% of the 95th percentile or a BMI ≥ 4 0 Class 3 Obesity
(whichever is lower)
a
Centers for Disease Control and Prevention. (2018, July 3). Defining childhood obesity. Overweight
& Obesity. https://www.cdc.gov/obesity/childhood/defining.html
b
Skinner, A. C., Ravanbakht, S. N., Skelton, J. A., Perrin, E. M., & Armstrong, S. C. (2018).
Prevalence of obesity and severe obesity in U.S. children, 1999–2016. Pediatrics, 141(3),
BOX Parents’ and Children’s Responsibilities

13.6 in Feeding
Parents’ feeding jobs:
• Choose and prepare the food.

• Provide regular meals and snacks.
• Make eating times pleasant.
• Step-by-step, show children by example how to behave at family
mealtime.
• Be considerate of children’s lack of food experience without catering
to likes and dislikes.
• Do not let children have food or beverages (except for water) between
meal and snack times.
• Let children grow up to get bodies that are right for them.
Children’s eating jobs:
• Children will eat.

• They will eat the amount they need.
• They will learn to eat the food their parents eat.
• They will grow predictably.
• They will learn to behave well at mealtime.
Source: Satter, S. (2016). Ellyn Satter’s division of responsibility in feeding.
https://www.ellynsatterinstitute.org/wp-content/uploads/2016/11/handout-dor-tasks-cap-
2016.pdf
Calories and Nutrient Needs

Daily calorie needs for ages 12 to 23 months range from 800 to 1000 for
both girls and boys (USDA & USDHHS, 2020). Two- to 5-year-old
children need 1000 to 1600 cal/day depending on activity (Table 13.3).
• Estimated calorie needs were based on reference median length or
height and reference weight (healthy) (USDA & USDHHS, 2020).
Actual needs may vary.
• All foods within the eating patterns are to be in nutrient-dense forms
and made with minimal added sugars, refined starch, or sodium. The
exception is that whole milk, reduced-fat plain yogurt, and reduced-
fat cheese are recommended until the age of 2.
• Under the age of 2, there is no room for calories for other uses (e.g.,
added sugars, saturated fat, or more than recommended amounts of
any food group).
• If consuming up to 2 oz of seafood/week, children should only be
fed cooked varieties of seafood that have low amounts of mercury,
such as catfish, cod, flounder, salmon, and haddock. See Chapter 4
for more on seafood.
Table Estimated Calorie Needs per

Day by Age, Sex, and Physical
13.3 Activity Level, Ages 2 to 18
Feeding Guidelines
The Dietary Guidelines for Americans recommends a healthy eating pattern
be followed from 12 months of age through adulthood (USDA &
USDHHS, 2020). Healthy eating patterns are adequate to meet nutrient
needs, help achieve a healthy body weight, and reduce the risk of chronic
disease.
Table 13.4 outlines the Healthy U.S.-Style eating pattern for ages 12 to
23 months; Table 13.5 outlines eating patterns appropriate from the age 2 to
18. General considerations regarding fluid and food intake are summarized
in the following sections.

for Toddlers Ages 12 to 23
Table Months Who Are No Longer
Receiving Human Milk or Infant
13.4 Formula, with Daily or Weekly
Amounts from Food Groups and
Components
Table Healthy U.S.-Style Eating

Pattern: Recommended
13.5 Amounts of Food from Each
Food Group from 1400 Calories
to 3200 Calories Levels
Source: U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2020,
Fluid
From 12 to 23 months
• Whole milk becomes a major source of nutrients, including fat;
children between the ages of 1 and 2 years have a relatively higher
need for fat to support growth and development. Milk intake should
not exceed 2 to 3 cups/day (Muth, 2019) because, in greater
amounts, it may displace the intake of iron-rich foods from the diet
and promote milk anemia.
• The child may consume 1 to 4 cups of water/day. Only water should
be allowed between meals and snacks and water should be offered
when the child is thirsty.
• Children should not be given sugar-sweetened beverages, such as
regular soda, sports, drinks, and flavored water, as well as
caffeinated beverages.
Milk Anemia
an iron deficiency anemia related to excessive milk intake, which displaces the intake of iron-rich
foods from the diet.
From ages 2 to 5
• Children should drink 2 to 2½ cups/day of low-fat or nonfat milk
and 1 to 5 cups of water daily (Muth, 2019).
• Because young children introduced to sweet drinks at a young age
develop a strong preference for them, 100% fruit juice should be
offered only when whole fruit is not available (Muth, 2019).
Recommended daily limits for 100% fruit juice are no more than 4
oz for children aged 2 to 3 and 4 to 6 oz for 4- to 5-year-olds.
Food
• A variety of nutrient-dense foods from all food groups should be
offered.
• The MyPlate graphic illustrates the concept of balance (Fig. 13.4)
• A regular schedule of 3 meals and 2 to 3 nutrient-dense snacks
should be established.
• Although the food children need is the same as adults, the portion
sizes are not. A rule-of-thumb guideline to determine age-
appropriate serving sizes is to provide 1 tbsp of food/year of age
(e.g., the serving size for a 3-year-old is 3 tbsp). By age 4 to 6,
serving size may be close to adult size.
• To decrease the risk of choking, foods that are difficult to chew and
swallow should be avoided until around the age of 4 (see Box 13.5).
• Meals and snacks should be supervised.
• Foods should be prepared in forms that are easy to chew and
swallow (e.g., cut grapes into smaller pieces and spread peanut
butter thinly).
• Infants should not be allowed to eat or drink from a cup while
lying down, playing, or strapped in a car seat.
Figure 13.4 ▲ MyPlate graphic. (Source: U.S. Department of
Agriculture. [n.d.]. MyPlate graphics. https://www.myplate.gov)
Promoting Healthy Habits

Healthy child-feeding practices are critical for helping children develop
healthy eating habits later in life (Provincial Health Services Authority,
2016).
• Toys, books, and/or screens should not be used during mealtime to
avoid distracted eating.
• Children should not be pressured or cajoled into eating more.
• Avoid empty calorie foods. Hot dogs, burgers, pizza, cookies, cakes,
and candy are only occasional treats.
• Sweet drinks, such as flavored milk, plant-based milks (except for
soymilk), artificially sweetened drinks, sugar-sweetened beverages,
and caffeinated drinks, should be avoided.
• Portions offered should be small. Allow the child to ask for more.
• Give children the opportunity to improve self-feeding skills, even
though it may be messy.
• Toddlers and preschoolers are often ready to leave the table after 15
to 20 minutes. Food should be removed from the table at that time.
• Eating with the family is associated with better diet quality and
lower rates of overweight/obesity and less disordered eating
(Provincial Health Services Authority, 2016).
• Behaviors in young children that may indicate nutrition risk include
the following:
• Poor appetite
• Inadequate intake from any food group
• Frequent intake of fast food
• Consumption of sugar-sweetened or artificially sweetened
beverages
• Persistent bottle feeding
• Child does not eat with the family
• Growth or weight concerns
NUTRITION FOR CHILDREN (6–10

YEARS) AND ADOLESCENTS (11–18
YEARS)
Physical growth rate during childhood is slow and steady. Annually,
children gain an average of 7 pounds and 2.5 in in height. Body fat
increases in preparation for the adolescent growth spurt.
The slow growth of childhood abruptly and dramatically increases with
pubescence until the rate is nearly as rapid as that of early infancy. On
average, the growth spurt and puberty begin at ages 9 to 11 for girls and 10
to 12 for boys (Hagan et al., 2017). Because peak weight occurs before
peak height, many girls and parents become concerned about what appears
to be excess weight.
Adolescence is a period of physical, emotional, social, and sexual
maturation. Approximately 15% to 20% of adult height and 50% of adult
weight are gained during adolescence. Fat distribution shifts and sexual
maturation occurs. Sex differences are obvious. For instance, girls generally
experience peak growth at 12 years and boys usually peak at 14 years.
Stature growth ceases at a median age of approximately 21 years.
Nutritional needs increase later for boys than for girls.
Physical activity encompassing a variety of age-appropriate, enjoyable
activities should be a regular part of daily living for all healthy Americans.
Health benefits attributed to physical activity in middle childhood and
adolescence include improved bone health, weight status, cardiorespiratory
and muscular fitness, cardiometabolic health, and cognition, as well as
lower risk of depression (USDHHS, 2018). Key physical activity guidelines
for children and adolescents are listed in Box 13.7.
Calorie Needs
Estimated daily calorie requirements for children and adolescents are
included in Table 13.3. Table 13.5 lists Healthy U.S.-Style Eating Pattern
recommendations for the range of calorie levels that are appropriate from
childhood through adolescence. Generalizations are summarized in the
following section.
BOX Key Physical Activity Guidelines for

13.7 Children and Adolescents
It is important to provide young people opportunities and

encouragement to participate in physical activities that are appropriate for
their age, are enjoyable, and offer variety.
Children and adolescents ages 6 to 17 years should do at least 60
minutes (1 hour) of moderate-to-vigorous physical activity daily:
Aerobic: Most of the 60 minutes or more/day should be either moderate-

or vigorous-intensity aerobic physical activity and should include
vigorous-intensity physical activity on at least 3 days a week.
Muscle strengthening: As part of their 60 minutes or more of daily
physical activity, children and adolescents should include muscle-
strengthening physical activity on at least 3 days a week.
Bone strengthening: As part of their 60 minutes or more of daily
physical activity, children and adolescents should include bone-
strengthening physical activity on at least 3 days a week.
Americans (2nd ed.). https://health.gov/sites/default/files/2019-
09/Physical_Activity_Guidelines_2nd_edition.pdf
During Middle Childhood (6–10 Years of Age)

• Total calorie needs steadily increase, although calories per kilogram
of body weight progressively fall.
• Sedentary boys need an average intake of 1400 to 1600 cal/day and
sedentary girls need 1200 to 1400 cal/day.
• An additional 200 cal/day are recommended for children who are
moderately active, and another increase of 200 cal/day may be
needed for those who are active.
• These are calorie estimates, not prescriptions, and counting calories
is not appropriate.
• The challenge in childhood is to meet nutrient requirements without
exceeding calorie needs.
During Adolescence
• Calorie needs and appetite increase to support the rapid rate of
growth, but exactly when those increases occur depends on the
timing and duration of the growth spurt.
• Due to wide variations in the timing of the growth spurt among
individuals, chronological age is a poor indicator of physiologic
maturity and nutritional needs.
• Girls require fewer calories than boys because they have
proportionally more fat tissue and less muscle mass from the effects
of estrogen. Girls also experience less bone growth than boys.
Nutrient Needs
The Dietary Reference Intakes category of children is divided into two age
groups: 1- to 3-year-olds and 4- to 8-year-olds. Thereafter, age groups are
further divided by sex: For both girls and boys, the age groups through
adolescence are 9- to 13-year-olds and 14- to 18-year-olds. Generally,
nutrient needs increase with each age grouping and reach adult levels at the
14- to 18-year-old age group.
Promoting Healthy Habits

During childhood, parents continue to have the greatest influence on
children’s behaviors and attitudes regarding food, although outside
influences such as friends and media become increasingly significant.
School, friend houses, childcare centers, and social events present
opportunities for children to make their own choices beyond parental
supervision.
BOX Healthy Snacks

13.8
Unsweetened whole-grain cereal with or without milk
Lean meat or cheese on whole-grain bread or crackers
Graham crackers and fig bars
Whole-grain cookies or muffins made with oatmeal, dried fruit, or iron-fortified cereal
Raw vegetables and vegetable juices
Fresh fruit or canned fruit without sugar
Low-fat yogurt with or without fresh fruit added
Nuts (when age appropriate)
Air-popped popcorn (not before age 4 years)
Peanut butter on bread, whole grain crackers, celery, and apple slices
Nonfat or 1% milk (after age 2 years)
Low-fat cheese and low-fat cottage cheese
Popcorn cakes
As adolescents become increasingly independent, more self-selected

meals and snacks are purchased and eaten outside the home. The influence
of peer pressure on food choices increases. A natural increase in appetite
and a decrease in physical activity increase the risk of overeating.
• Parents should decide what nutritious food is served and when;
children should decide how much to eat.
• Have family meals as frequently as possible. Children and
adolescents who have a high frequency of eating family meals tend
to have better quality eating patterns as evidenced by higher intakes
of fruits, vegetables, grains, and calcium-rich foods and lower
intakes of carbonated beverages (Golden et al., 2016). A higher-
quality eating pattern also leads to a more appropriate intake of
calories, protein, iron, folate, fiber, and vitamins A, C, D, and B6.
• Family meals should be a pleasant social interaction experience
without the distraction of electronic devices.
• Parents should continue to model healthy eating behaviors by
providing and consuming nutrient-dense meals and snacks (Box
13.8).
• Encourage adolescents to make healthy food choices when eating
away from home.
• Avoid or limit calorie-dense foods, such as fried foods, sugar-
sweetened beverages, most fast foods, chips, and fatty meats.
• The MyPlate graphic (see Fig. 13.4) illustrates the concept of
balance and proportion that is appropriate for all people over the age
of 2 years.
Diet Quality during Middle Childhood and

Adolescence
Analysis shows that from an early age, eating patterns are not aligned with
the Dietary Guidelines (USDA & USDHHS, 2020). During 2015 to 2016,
the Healthy Eating Index-2015 score for children ages 2 to 4 was 61 out of
100, indicating poor quality. Scores deteriorated throughout the childhood
age groupings to a score of 51 among ages 14 to 18.
• Across the 5- to 8-year-old, 9- to 13-year-old, and 14- to 8-year-old
age groupings (USDA & USDHHS, 2020)
• consumption of total vegetables, all vegetable subgroups, fruit,
dairy, whole grains, and seafood was below recommended levels
of intake.
• consumption of refined grains, added sugar, saturated fat, and
sodium was above recommended levels of intake.
• For both girls and boys, average intake is inadequate in fiber,
choline, vitamin C, vitamin D, vitamin E, potassium, and
magnesium (U.S. Department of Agriculture [USDA] &
Agricultural Research Service [ARS], 2018).
• Additionally, girls have inadequate intakes of vitamin A, calcium,
and iron (USDA & ARS, 2018). Nutrients of particular concern for
adolescents are highlighted in Box 13.9.
BOX Nutrients of Particular Concern during

13.9 Adolescence
Calcium
• Approximately half of adult bone mass is accrued during adolescence;
optimizing calcium intake during adolescence increases bone
mineralization and may decrease the risk of fracture and osteoporosis
later in life.
• For boys and girls from age 9 to 18 years, the Recommended Dietary
Allowance (RDA) for calcium is 1300 mg—higher than at any other
time in the life cycle. The RDA drops to 1000 mg/day for young adults
aged 19 to 21.
• Low intakes of calcium are related to underconsumption of dairy.
• Nondairy sources of calcium include the following:
• Calcium-fortified orange juice, soy milk, and breakfast cereals
• Certain greens such as bok choy, collard greens, kale, and turnip
greens
Iron
• Adolescents have increased needs for iron related to an expanding

blood volume, the rise in hemoglobin concentration, and the growth of
muscle mass.
• In boys, peak iron requirement occurs between 14 and 18 years of age
as muscle mass expands. Their RDA is 11 mg iron/day.
• The requirement for iron in adolescent girls increases to 15 mg/day at
14 to 18 years of age to account for menstrual losses.
• Girls tend to develop an iron deficiency slowly after puberty,
particularly if menstrual losses are compounded by poor eating habits
or chronic fad dieting.
• Heme iron, found in meats, is better absorbed than nonheme iron,
which is found in plants, such as iron-fortified cereals and enriched
bread.
• Nonheme iron absorption increases when a source of vitamin C, such
as orange juice or tomatoes, is consumed at the same time.
Folic Acid (in young women)

All young women capable of becoming pregnant are advised to
•
consume 400 mcg of synthetic folic acid daily, from either
supplements or fortified foods, in addition to folate naturally present in
food, to reduce the risk of neural tube defects.
• Natural folate is found in certain foods, such as legumes, organ meats,
and dark green leafy vegetables. It is not as well absorbed as synthetic
folic acid.
NURSING
PROCESS Well Child
Amanda is a 24-month-old girl who is seen regularly in the well-baby

clinic for her checkups and immunizations. At this visit, you discover
that her height and weight are in the 25th percentile for her age. Records
indicate that previously, she had consistently ranked in the 75th
percentile for weight and 50th percentile for height. The change has
occurred over the last 6 months. Her mother complains that Amanda is
“fussy” and has lost interest in eating.
Assessment
Assessment
Medical– • Medical history including prenatal, perinatal,

psychosocial and birth history; specifically assess for
history gastrointestinal (GI) problems such as slow
gastric emptying, constipation, diarrhea, and
allergies.
• Use of medications that can cause side effects
such as delayed gastric emptying, diarrhea,
constipation, or decreased appetite
• Level of development for age
• Elimination and reflux patterns, if applicable
Caregiver’s ability to understand; attitude
toward health and nutrition and readiness to
• learn
• Psychosocial and economic issues such as the
living situation, who does the shopping and
cooking, adequacy of food budget, need for
food assistance, and level of family and social
support
• Use of vitamins, minerals, and nutritional
supplements: what, how much, and why they
are given
Anthropometric • Obtain height and weight to calculate BMI;

assessment determine BMI-for-age percentile.
• Head circumference for age
• Pattern of weight gain and growth
Biochemical and • Laboratory values, including hemoglobin and

physical hematocrit, and the significance of any other
assessment values that are abnormal
Assessment
Dietary • Food records, if available

Assessment Interview the primary caregiver to assess the
following:
• • What does Amanda usually eat in a 24-hour
period, including types and amounts of food,
frequency and pattern of eating, and texture
of foods eaten?
• How does her intake compare to a 1000-
calorie (the calorie level appropriate for 2-
year-olds) MyPlate intake pattern?
• What food groups is she consuming less than
recommended amounts of?
• Are self-feeding skills appropriate for
Amanda’s age?
• Is the mealtime environment positive?
• What is the caregiver’s attitude about
Amanda’s current weight, recent weight loss,
and eating behaviors?
• Are the caregiver’s expectations about how
much Amanda should eat reasonable and
appropriate? What is the problem according
to the caregiver?
• Are there cultural, religious, and ethnic
influences on the family’s eating habits?
Analysis
Possible Nursing Malnutrition risk related to loss of interest in

Analysis eating as evidenced by a decrease of two
percentile channels in growth charts.
Assessment
Planning

• Experience appropriate growth in height and
weight.
• Consume, on average, an intake consistent with
MyPlate recommendations for a 1000-calorie
eating pattern by eating a variety of foods
within each food group.
• Achieve or progress toward age-appropriate
feeding skills.
Nutrition Therapy Promote MyPlate food plan of 1000 calories,

which is appropriate for her age.
Client Teaching Instruct the caregiver on the following:

• The role of nutrition in maintaining health and
promoting adequate growth and development,
including the importance of adequate calories
and protein
• Eating plan essentials, including the
importance of the following:
• Choosing a varied diet to help ensure an
adequate intake
• Providing foods of appropriate texture for
age
• Providing three meals plus three or more
planned snacks to maximize intake
Assessment
• Providing liquids after meals, instead of with
meals, to avoid displacing food intake
• Avoiding low-nutrient-dense foods (e.g.,
fruit drinks, carbonated beverages,
sweetened cereals) because they displace the
intake of more nutritious foods
• The need to modify the diet, as appropriate,
to improve elimination patterns
Address behavioral matters, such as the

following:
• Providing a positive mealtime environment
(e.g., limiting distractions, having the child
well rested before mealtime)
• Not using food to punish, reward, or bribe the
child
• Promoting eating behaviors and skills
appropriate for the age
• Keeping accurate food records
• Modifying foods to increase their nutrient
density, such as by fortifying milk with skim
milk powder; using milk in place of water in
recipes; melting cheese on potatoes, rice, or
noodles
Evaluation
Assessment
Evaluate and • Monitor growth in height and weight.

Monitor • Evaluate food records to assess adequacy of
intake according to a 1000-calorie MyPlate
plan.
• Progress toward age-appropriate feeding skills.
Think of Luis. His calorie intake is excessive as evidenced

by his weight, and his essentially self-selected diet is of poor
quality. Luis’s doctor has warned his mother that his
diastolic blood pressure is high and that he is overweight.
His mother evades answering questions about Luis’s typical
eating pattern. How do you proceed with helping them
achieve a healthier intake without knowing what his usual
intake is?
OVERWEIGHT AND OBESITY
Maintaining healthy weight during childhood and adolescence is crucial for

overall health and well-being during these periods and into adulthood.
Although a variety of factors affect body weight (e.g., heredity, metabolism,
health), nutrition and physical activity are the two most important
behavioral determinants (Hagan et al., 2017). A healthy, nutrient-dense
eating pattern and regular physical activity are vital to preventing
overweight and obesity.
Weight status in children and adolescents is defined by BMI percentiles
specific for age and sex (Table 13.2). Standards for defining severe obesity
are included in that table. During late adolescence, adult cutoffs for
overweight (BMI ≥ 25) and obesity (BMI ≥ 30) can be used when doing so
would define overweight and obesity at weights lower than the 84th and
95th percentile channels, respectively. For instance, a 17-year-old girl with
a BMI of 25.2 is slightly below the 85th percentile (healthy weight), yet by
adult standards she is overweight (Hagan et al., 2017).
Overweight and Obesity Prevalence

The prevalence of overweight and obesity has been increasing in the United
States for 4 decades (Skinner et al., 2018). Currently, 41% of children and
adolescents are overweight or obese, and the prevalence is higher among
Hispanic and non-Hispanic Black children and adolescents than non-
Hispanic Asians and Whites (USDA & USDHHS, 2020).
Risks Associated with Obesity in Youth

Youth who are obese are at risk of becoming obese adults; the higher the
degree of excess weight, the more likely obesity will persist into adulthood
(Singh et al., 2008). Chronic conditions related to obesity previously seen
only in adults, such as type 2 diabetes, hypertension, dyslipidemia,
nonalcoholic fatty liver disease, obstructive sleep apnea, and cardiovascular
disease, are now affecting an increasing number of adolescents and even
children (Hagan et al., 2017). Children and adolescents with obesity are
also more likely to experience psychological concerns (e.g., anxiety,
depression) and social concerns (bullying, stigmatization) (USDA &
USDHHS, 2020).
Recall Luis. At 48 in. tall and 90 pounds, his BMI is

approximately 27.5. His mother is obese and claims she
gained 40 pounds during pregnancy, which is excessive.
Although his mom says they rarely eat red meat or fried
food, she admits he eats at will, often asking for sugar-
sweetened and low-fiber cereal within 15 minutes of eating
dinner. His favorite dinner is breaded chicken fingers, baked
french fries, and a sweetened beverage. What
recommendations would you make for improving the quality
of his favorite dinner? How would you advise Luis’s mother
to respond to his request for more food so soon after eating
dinner?
Obesity Screening
The United States Preventive Services Task Force recommends that
clinicians screen for obesity in children and adolescents aged 6 and older
and offer or refer them to comprehensive, intensive behavioral interventions
to promote improvements in weight status (U.S. Preventive Services Task
Force, 2017).
• Among young children, maternal diabetes, maternal smoking, high
gestational weight gain, rapid infant growth, and short sleep
duration are risk factors for obesity (O’Connor et al., 2016).
• Although all children and adolescents are at risk for obesity, certain
specific risk factors have been identified, namely (O’Connor et al.,
2016)
• parental obesity
• poor diet (e.g., consumption of sugar-sweetened beverages and
calorie-dense foods)
• low levels of physical activity
• inadequate sleep
• sedentary behaviors, such as high amounts of screen time
• low family income
• The racial/ethnic differences in obesity prevalence are related to
differences in both nongenetic and genetic risk factors, with
socioeconomic status as one of the strongest factors. Other factors
may include the intake of sugar-sweetened beverages, intake of fast
food, and having a television in the bedroom (O’Connor et al.,
2016).
In addition to calculating and plotting BMI at least once a year, other
actions are recommended to screen and assess all children for obesity
prevention or early intervention with counseling.
• Assess family history (e.g., parents, siblings, grandparents) for type
2 diabetes and cardiovascular disease risk factors, such as
hypertension.
• Conduct a medical history and physical examination to identify any
existing obesity-related comorbidities.
• Assess dietary intake, such as the usual foods and beverages
consumed and pattern of intake.
• Assess frequency, duration, and intensity of moderate and vigorous
physical activity, in both structured and unstructured settings.
• Determine hours of screen time.
• Assess family attitudes about weight and physical activity.
• Assess for socioeconomic stressors.
• Assess willingness to change.
Obesity Prevention Strategies

The low success in treating obesity makes prevention crucial. Early
prevention strategies include (Hagan et al., 2017) the following:
• Encouraging women to attain healthy BMI before becoming
pregnant and gaining the recommended amount of weight during
pregnancy
• Smoking cessation prior to pregnancy
• Exclusive breastfeeding for the first 6 months of life
• Continuation of breastfeeding is at least until the age of 1 in
combination with complementary foods
Formula-fed infants consume more protein per kilogram of body
weight than do breastfed infants. This may predispose the formula-
fed infant to obesity later in life.
Prevention strategies for toddlers include the following:

• A transition to nutrient-dense foods with weaning
• Eliminating sedentary entertainment
• Active play for physical activity
• Parental role modeling of healthy eating and physical activity
behaviors
Obesity prevention strategies for children and adolescents with a

healthy BMI include permanent lifestyle modifications (Box 13.10) aimed
at the following:
• Consuming a nutrient-dense healthy eating pattern
• Decreasing sedentary behaviors
• Increasing physical activity
• Obtaining adequate sleep
Treatment Strategies for Obesity in Youth

The goals of obesity treatment are to improve long-term physical and
psychosocial health by establishing permanent healthy lifestyle behaviors
and changes to the environment where the child or adolescent lives (Hagan
et al., 2017). Stages of obesity treatment are outlined in Box 13.11.
BOX Lifestyle Modification Obesity

13.10 Prevention Strategies
Healthier Nutrition
Healthy Eating Behaviors
• Eat family meals as often as possible with parents role modeling

healthy eating.
• Eat more home-prepared meals.
• Use other things instead of food or screen time as rewards.
• Limit eating out.
• Eat breakfast daily.
• Keep healthy foods and beverages available and in plain sight, such as
water pitchers, fruits, vegetables, and other low-calorie snacks.
• Decrease the size of serving spoons, plates, bowls, and glasses.
• Limit before bed snacks.
Healthy Choices
• Promote a healthy eating pattern that emphasizes nutrient-dense foods

such as fruits, vegetables, whole grains, low-fat or nonfat dairy, lean
meats, legumes, and seafood.
• Limit sugar-sweetened beverages and those containing artificial
sweeteners.
• Limit foods containing refined carbohydrates.
• Limit calorie-dense foods, such as fried foods, baked goods, and pizza.
• If high-calorie snacks and sweets are purchased for a special occasion,
buy them immediately before the event and remove them immediately
afterward.
Reduce Sedentary Behaviors

• Avoid screen time in infants and toddlers younger than 18 months of
age.
Limit screen time in children 18 months to 4 years to no more than 1
• hour/day (American Academy of Pediatrics Council on
Communications and Media, 2016).
• Limit total entertainment screen time to less than 2 hours/day for older
children and adolescents (Golden et al., 2016).
• Do not allow a television in bedrooms.
• Turn off the TV and other screens during mealtimes.
Increase Physical Activity

Meet national physical activity guideline of at least 60 minutes of
physical activity each day with most of it in moderate-to-vigorous
aerobic activity (see Box 13.8).
Adequate Sleep
Counsel parents on age-appropriate sleep durations based on age.
Source: Daniels, S. R., Hassink, S. G., & Committee on Nutrition. (2015). The role of the
pediatrician in primary prevention of obesity. Pediatrics, 136(1), e275–e292.
https://doi.org/10.1542/peds.2015-1558; Golden, N. H., Schneider, M., Wood, C., & Committee
on Nutrition, Committee on Adolescence and Section on Obesity. (2016). Preventing obesity
and eating disorders in adolescents. Pediatrics, 138(3), e20161649.
https://doi.org/10.1542/peds.2016-1649
BOX Staged Approach for Obesity Treatment

13.11 in Childhood and Adolescence
Stage 1: Prevention Plus
• For youth with overweight or obesity.

• Existing healthy eating behaviors are continued and reinforced.
• Lifestyle modifications focus on basic specific goals, such as at least 5
fruits and vegetables a day, less than 1 hour of screen time/day, at least
1 hours of moderate-to-vigorous physical activity/day, elimination of
sugar-sweetened beverages, practicing healthy eating behaviors (e.g., 3
daily meals, family meals).
• Goal is to improve BMI status.
• Office-based visits.
• Brief motivational interviewing on selected behaviors (e.g., more fruits
and vegetables) to motivate the youth and family.
• Advance to Stage 2 if lack of improvement after 3 to 6 months.
Stage 2: Structured Weight Management
• Continued focus on lifestyle modifications.

• Monthly office-based visits with youth and family (e.g., physician,
nurse, or dietitian).
• More structured timing and content of daily meals and snacks for the
whole family.
• Reduce nonacademic screen time to less than 1 hour/day.
• Increase amount of moderate and vigorous physical activity.
• Self-monitoring, such as logging screen time, physical activity, and
intake.
• Progress to Stage 3 if no improvement in BMI (e.g., maintenance or
decrease) after 3 to 6 months.
Stage 3: Comprehensive Multidisciplinary Intervention
• A dedicated pediatric multidisciplinary structured behavioral program

that includes more structured physical activity, diet, and behavior
modification.
• Use dedicated pediatric weight management program with weekly
visits for 8 to 12 weeks followed by monthly follow-up.
• Strong family involvement is encouraged especially for children less
than 12 years.
• Only advance to Stage 4 after considering patient’s maturity and
ability to understand risks and willingness to maintain physical activity
and appropriate diet and behavioral monitoring.
Stage 4: Tertiary Care Intervention
• Intended for overweight or obese youth with comorbidities or for

severely obese youth.
• Comprehensive multidisciplinary program is conducted under medical
supervision at a pediatric weight-management center with a focus on
resolving or improving comorbidities.
• Treatments options may include very-low-calorie diets (less than 1000
cal/day) or meal replacements, pharmacologic treatment, or bariatric
surgery.
Source: Barlow, S. E., & the Expert Committee. (2007). Expert committee recommendations
regarding the prevention, assessment, and treatment of child and adolescent overweight and
obesity: Summary report. Pediatrics, 120(Suppl 4), S164–S192.
https://doi.org/10.1542/peds.2007-2329C; Hagan, J. F., Shaw, J. S., & Duncan, P. M. (Eds.).
(2017). Bright futures: Guidelines for health supervision of infants, children, and adolescents.
American Academy of Pediatrics.
Consider Luis. He and his mother enroll in a 12-week-long

weight management program at their community center. The
program began by stressing healthy behaviors, including
types of food to eat. What eating strategies would you
encourage them to adopt? What recommendations would
you make about exercise, physical activity, and sedentary
activity?
The Parent’s Role

Parental role modeling of a healthy lifestyle is vital to initiating and
sustaining changes in eating and physical activity behaviors.
• Parents often recognize that they need to set an example for their
children but lack the time to do so.
• Parents who are overweight may feel they cannot set a good
example because they do not practice what they preach.
• Other barriers to parents taking action are (1) a belief that children
will outgrow their excess weight, (2) a lack of knowledge about how
to help children control their weight, and (3) a fear they will cause
eating disorders in their children.
• Parents should be encouraged to not talk about weight but rather
about healthy eating and healthy physical activity (Golden et al.,
2016).
Family involvement in the treatment of obesity has been shown to be

more effective than an adolescent-only approach (Golden et al., 2016).
• Family-centered motivational interviewing can be effective
technique to promote healthy behaviors by inspiring parents to serve
as role models by serving healthy meals, eating with their children,
avoiding talk about weight, engaging in regular physical activity,
and limiting their own sedentary behaviors.
• Even in adolescence, parents are still the primary role models for
eating and physical activity behaviors and have a direct impact on
the adolescent’s food and activity environment (Daniels & Hassink,
2015).
• Parents and other family members should be encouraged to
implement the same changes as the child.
• Dieting is a risk factor for both obesity and eating disorders, so
emphasis should be on healthy lifestyle, not restrictive eating.
Motivational Interviewing
a goal-oriented, client-centered counseling style that facilitates and engages intrinsic motivation to
change behavior.
Recall Luis. He has not lost weight but has grown taller, so
there has been some improvement in his BMI. His mom
continues counseling to improve her parenting skills, which
she now admits influenced her son’s overeating. She has had
a hard time eating vegetables herself and tends to graze,
although they are eating family dinners almost every day.
How would you respond to her question of how long this
“diet thing” needs to continue?
How Do You Respond?

Does early introduction of solid foods help infants
sleep through the night? A frequently given reason for
introducing solids before 4 months of age is the
unsupported belief that it will help infants to sleep
through the night. A major objection to the early
introduction of solids is that it may interfere with
establishing sound eating habits and may contribute to
overfeeding because infants less than 4 months old are
unable to communicate satiety by turning away and
leaning back.
Does diet contribute to acne prevalence? Although the
pathogenesis of acne is complex and not completely
understood, several dietary components are being
investigated. In a study based on self-reported acne
among young adults, participants with moderate-to-severe
acne reported a higher dietary glycemic index and higher
intakes of total sugar, added sugar, fruit/fruit juice,
number of milk servings/day, saturated fat, and trans fats
than participants with no or mild acne (Burris et al.,
2014). Studies have found an association between vitamin
D deficiency and acne and that vitamin D
supplementation reduces acne inflammation (Stewart &
Bazergy, 2018). Studies on the association between
increased BMI and acne are mixed (DiLandro et al.,
2012; Halvorsen et al., 2012; Stewart & Bazergy, 2018).
Further research is needed to clarify the link between diet
and acne and determine if nutrition therapy can play a
role in acne treatment.
REVIEW CASE STUDY
Andrew is 16 years old and sedentary. He is 5 ft 8 in. tall, weighs 218

pounds, and has a BMI of 33. He has been overweight for most of his life,
as is most of his extended paternal family. His mother has tried
“everything” over the years to get him to lose weight, from putting him on
her own weight loss diet to hiding foods he shouldn’t have, such as soft
drinks and chips, to limit his access. He has a part-time job in a fast-food
restaurant and is able to leave the school property at lunchtime to have
lunch where he works. He is not good at sports but loves to play video
games and watch movies. He hates that he’s so big but feels hopeless about
changing. His normal day’s intake is shown on the right:
• Using the BMI-for-age percentile for boys, what is Andrew’s weight

status? Is it an appropriate approach to limit Andrew’s calories to
outgrow his current weight status?
• How many calories should Andrew consume daily? Based on the
MyPlate intake levels, which food groups is he consuming the
appropriate amounts of? Which groups is he overeating? Which groups is
he not eating enough of? What are the sources of empty calories in his
diet?
• What specific goals would you encourage Andrew to set regarding his
intake, activity, and weight?
• What would you suggest his mother do to support better eating habits and
a healthier weight?
Breakfast: Two doughnuts and a large glass of apple juice

Lunch: A double cheeseburger, large fries, and a large shake
Snacks: Frozen mini pizzas, a large soft drink, and a handful of cookies
Dinner: The same as lunch on nights he works; if he’s home, he eats
whatever is available, often pizza or sandwiches and chips, ice cream,
and a soft drink
Snacks: Chips and salsa and a soft drink
STUDY QUESTIONS
1 Which statement indicates the mother understands the nurse’s

instructions about breastfeeding?
a. “Breastfeeding should only last 5 minutes on each breast.”
b. “Sometimes, babies cry just because they are thirsty, so a bottle of
water should be offered before breastfeeding begins to see if the infant
is just thirsty.”
c. “The longer the baby sucks, the less milk I will have for the next
feeding.”
d. “The first breast offered should be alternated with each feeding.”
2 A mother asks why toddlers shouldn’t drink all the milk they want.
Which of the following is the nurse’s best response?
a. “Consuming more than the recommended amount of milk can displace
the intake of iron-rich foods from the diet and increase the toddler’s
risk of iron deficiency anemia.”
b. “Consuming more than the recommended amount of milk increases the
risk of milk allergy.”
c. “Too much milk can lead to overhydration.”
d. “Consuming more than the recommended amount of milk will provide
too much calcium.”
3 The nurse knows her instructions about introducing solids into the
infant’s diet have been effective when the mother states,
a. “Babies should be introduced to solid foods at 1 to 3 months of age.”
b. “New foods should be given for at least 3 days so that allergic
responses can be easily identified.”
c. “Infants are more likely to accept infant cereal for the first time if it is
mixed with breast milk or formula and given from a bottle.”
d. “The appropriate initial serving size for solids is 1 to 2 tbsp.”
4 Which of the following would be the best snack for a 2-year-old?
a. Popcorn
b. Banana slices
c. Fresh cherries
d. Raw celery
5 Which foods are youth ages 5 to 18 most likely to eat in inadequate
amounts? Select all that apply.
a. Whole grains
b. Vegetables
c. Fruits
d. Meat
6 The client asks if her 10-year-old daughter needs a weight loss diet.
a. “Rather than a diet at this age, you should just forbid her to eat sweets
and empty calories.”
b. “Because prevention of overweight is more effective than treatment,
you should start to limit her calorie intake by only serving low-fat and
artificially sweetened foods.”
c. “Ten-year-old girls are about to enter the growth spurt of puberty, and
it is natural for her to gain weight before she grows taller. Diets are not
recommended for children, although healthy eating and moderation are
always appropriate.”
d. “She needs extra calories for the upcoming growth spurt, so you
should be encouraging her to eat more than she normally does.”
7 Calorie requirements during adolescence
a. are higher than during adulthood because of growth and developmental
changes.
b. peak early (e.g., ages 12 and 13) and then fall until adulthood is
reached.
c. are lower than during childhood.
d. do not change from middle childhood.
8 Which is a nutrient of concern particularly for adolescent girls?
a. Vitamin A
b. Protein
c. Zinc
d. Folic acid
CHAPTER SUMMARY NUTRITION

FOR INFANTS, CHILDREN, AND
ADOLESCENTS
The goals of nutrition and physical activity for children are to promote
optimal physical and cognitive development, a healthy weight, an
enjoyment of food, and a decreased risk of chronic disease. Nutritional
requirements are less precise for youth than they are for adults due to
variations in growth and activity.
Infancy: Birth to 1 year

Excluding fetal growth, growth in the first year of life is more rapid than at
any other time in the life cycle.
• Nutrient needs: Proportionately infants require more calories and

nutrients than adults. Adequate growth means the infant is consuming
adequate nutrition.
• Breast feeding: Exclusive breastfeeding is recommended for the first 6
months and should continue through the first year or longer if desired.
• Infant formula: Most are made from cow milk to resemble breast milk.
• Complementary foods: Complementary foods are added when the
infant is developmentally ready, usually around 6 months of age.
• Foods that provide iron should be added first, such as iron-fortified
infant cereals or pureed meats.
• New foods are added one at a time for about 3 days so that any allergic
reaction can be identified.
• There is no evidence that delaying the introduction of allergenic foods
such as peanuts, eggs, and fish beyond 6 months of age prevents
allergies.
• By 12 months of age, infants should be eating a variety of table foods
and various textures.
Nutrition during Early
Childhood
Adequate nutrition during early childhood focuses on promoting normal
growth through the appropriate amount and types of foods within an
environment that allows the child to self-regulate.
• Parental influence: Parents are the primary gatekeepers of their
children’s nutritional intake. They should make healthy foods available
and not introduce foods into their children’s diet that have no value other
than calories.
• Developmental milestones: The dramatic decrease in growth rate that
occurs after the first year of life causes a decrease in appetite and
unpredictable food intake. Picky eating is normal. Adult role modeling is
important.
• Calorie and nutrient needs: Daily calorie need for ages 12 to 23
months range from 800 to 1000. From 2 to 5 years of age, total daily
calories range from 1000 to 1600 depending on activity.
• Feeding guidelines: Calorie-appropriate, nutrient-dense eating patterns
are recommended across the life span.
• Beverages used at 12 months are whole milk and water. Sweet and
caffeinated beverages should not be offered.
• A variety of nutrient-dense foods should be consumed in 3 meals and
2 to 3 nutrient-dense snacks/day.
• Healthy child-feeding practices are critical for helping children
develop healthy eating habits later in life.
Nutrition for Children (6–10

years) and Adolescents (11–18
years)
Childhood growth rate is slow and steady. It abruptly and dramatically
increases with pubescence until the rate is nearly as rapid as that of early
infancy.
Calorie needs: They increase during adolescence to support the rapid
• rate of growth. Timing and duration of the growth spurt vary among
individuals.
• Nutrient needs: They reach adult levels at the 14- to 18-year-old age
group.
• Promoting healthy habits: Parental influence on eating behaviors is still
important but waning. Eating family dinners is strongly encouraged.
• Diet quality: The unhealthy eating pattern of youth causes diet quality to
be low. Youth underconsume fruit, vegetables, whole grains, seafood,
and dairy, resulting in inadequate intakes of fiber, vitamin C, vitamin D,
vitamin E, potassium, and magnesium. Additional nutrients of concern
for adolescent girls are calcium, iron, and folic acid. Youth overconsume
refined grains, saturated fat, added sugars, and sodium.

Maintaining healthy weight during childhood and adolescence is crucial for
overall health and well-being during these periods and into adulthood:
• Prevalence of overweight and obesity has been increasing for 4 decades.
• Chronic conditions related to obesity previously seen only in adults are
now affecting an increasingly number of adolescents and even children.
Obesity also impairs quality of life.
• All youth should be screened for obesity beginning at age 6 using BMI
for age percentiles.
• The low success in treating obesity makes prevention crucial. Early
prevention strategies include preventing excessive weight gain during
pregnancy, exclusive breastfeeding for the first 6 months of life, allowing
children to self-regulate how much they consume, and parental role
modeling of healthy eating and physical activity.
• Primary prevention in youth who have a healthy weight focuses on
maintaining weight to prevent overweight and obesity. A healthy eating
pattern, limiting screen time, promoting adequate physical activity, and
ensuring adequate sleep are stressed.
• Treatment strategies for overweight and obese youth are staged and
range from a more structured lifestyle approach to intense intervention
that may include a very low-calorie diet, pharmacologic treatment, or
bariatric surgery.
• Family involvement in treatment of obesity may be more effective than
an adolescent-only approach.
Figure sources: shutterstock.com/Marcel Jancovic, shutterstock.com/Monkey Business Images, and
shutterstock.com/Nina Buday

book at
Websites
Academy of Nutrition and Dietetics: Kids Eat Right provides science-based resources for families at
www.eatright.org/kids
American Academy of Pediatrics Bright Futures, Promoting Healthy Nutrition at
https://brightfutures.aap.org/Bright%20Futures%20Documents/BF4_HealthyNutrition.pdf
American Academy of Pediatrics Institute for Healthy Childhood Weight at https://ihcw.aap.org
provides obesity prevention and management and treatment resources
Children’s Nutrition Research Center at Baylor College of Medicine at www.bcm.edu/cnrc/
Dietary Guidelines for Americans, 2020–2025 at https://dietaryguidelines.gov
Ellyn Satter Institute for information on ways to make feeding a positive and joyful experience at
https://www.ellynsatterinstitute.org/
Healthychildren.org for dietary recommendations, parenting skills advice, etc. at
https://www.healthychildren.org
KidsHealth at www.kidshealth.org
Let’s Move provides links to many government and private efforts to raise a healthier generation of
children at www.letsmove.gov
MyPlate Kid’s Place provides a variety of activities and resources at www.myplate.gov/kids
National Institutes of Health, National Heart, Lung, and Blood Institute: We Can! contains dietary
recommendations, physical activity recommendations, and monitoring tools at
http://www.nhlbi.nih.gov/health/educational/wecan/
Nutri-eSTEP nutrition screen designed to screen toddlers 18 to 35 months and preschoolers 3 to 5
years at www.nutritionscreen.ca
References
Abrams, S. (2015). Is it time to put a moratorium on new infant formulas that are not adequately
investigated? The Journal of Pediatrics, 166, 756–760.
https://doi.org/10.1016/j.jpeds.2014.11.003
American Academy of Pediatrics. (2020, September 16). Choosing an infant formula. The AAP
Parenting Website. https://www.healthychildren.org/English/ages-stages/baby/formula-
feeding/Pages/Choosing-an-Infant-Formula.aspx
American Academy of Pediatrics Council on Communications and Media. (2016). Media and young
minds. Pediatrics, 138(5), e20162591. https://doi.org/10.1542/peds.2016-2591
Burris, J., Rietkerk, W., & Woolf, K. (2014). Relationships of self-reported dietary factors and
perceived acne severity in a cohort of New York young adults. Journal of the Academy of
Nutrition and Dietetics, 114, 384–392. https://doi.org/10.1016/j.jand.2013.11.010
Centers for Disease Control and Prevention. (2010). Growth charts. National Center for Health
Statistics. https://www.cdc.gov/growthcharts/
Daniels, S. R., & Hassink, S. G. (2015). The role of the pediatrician in primary prevention of obesity.
Pediatrics, 136(1), e275–e292. https://doi.org/10.1542/peds.2015-1558
DiLandro, A., Cazzaniga, S., Parazzini. F., Ingordo, V., Cusano, F., Atzori, L., Cutri, F., Musumeci,
M., Zinetti, C., Pezzarossa, E., Bettoli, V., Caproni, M., Lo Scocco, G., Bonci, A., Bencini, P.,
Naldi, L., & GISED Acne Study Group. (2012). Family history, body mass index, selected
dietary factors, menstrual history, and risk of moderate to severe acne in adolescents and young
adults. Journal of the American Academy of Dermatology, 67(6), 1129–1135.
https://doi.org/10.1016/j.jaad.2012.02.018
Federal Interagency Forum on Child and Family Statistics. (2019). America’s children: Key national
indicators of well-being, 2019. U.S. Government Printing Office.
Golden, N., Schneider, M., Wood, C., & AAP Committee on Nutrition. (2016). Preventing obesity
and eating disorders in adolescents. Pediatrics, 138(3), e20161649.
https://doi.org/10.1542/peds.2016-1649
Greer, F. R., Sicherer, S. H., Burks, A. W., AAP Committee on Nutrition, & AAP Section on Allergy
and Immunology. (2019). The effects of early nutritional interventions on the development of
atopic disease in infants and children: The role of maternal dietary restriction, breastfeeding,
hydrolyzed formulas, and timing of introduction of allergenic complementary foods. Pediatrics,
143(4), e20190281. https://doi.org/10.1542/peds.2019-0281
Halvorsen, J., Vleugels, R., Bjertness, E., & Lien, L. (2012). A population-based study of acne and
body mass index in adolescents. Archives of Dermatology, 148(1), 131–132.
https://doi.org/10.1001/archderm.148.1.131
Muth, N. (2019, September 19). Recommended drinks for young children ages 0–5. The American
Academy of Pediatrics AP Parenting Website. https://www.healthychildren.org/English/healthy-
living/nutrition/Pages/Recommended-Drinks-for-Young-Children-Ages-0-5.aspx
O’Connor, E. A., Evans, C. V., Burda, B. U., Walsh, E. S., Eder, M., & Lozano, P. (2016). Screening
for obesity and intervention for weight management in children and adolescents: A systematic
evidence review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 150.
Agency for Healthcare Research and Quality AHRQ Publication No. 15-05219-EF-1.
Ogata, B., & Hayes, D. (2014). Position of the Academy of Nutrition and Dietetics: Nutrition
guidance for healthy children ages 2 to 11 years. Journal of the Academy of Nutrition and
Provincial Health Services Authority. (2016, November). Pediatric Nutrition Guidelines (Six Months
to Six Years). https://www.health.gov.bc.ca/library/publications/year/2017/pediatric-nutrition-
guidelines.pdf
Rossen, L. M., Simon, A. E., & Herrick, K. A. (2016). Types of infant formulas consumed in the
United States. Clinical Pediatrics, 55(3), 278–285. https://doi.org/10.1177/0009922815591881
Satter, E. (2016). Ellyn Satter’s division of responsibility in feeding. The Ellen Satter Institute.
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Singh, A., Mulder, C., Twisk, J., van Mechelen, W., & Chinapaw, J. (2008). Tracking of childhood
overweight into adulthood: A systematic review of the literature. Obesity Reviews, 9(5), 474–488.
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Skinner, A. C., Ravanbakht, S. N., Skelton, J. A., Perrin, E. M., & Armstrong, S. C. (2018).
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Stewart, T., & Bazergy, C. (2018). Hormonal and dietary factors in acne vulgaris versus controls.
Dermato-Endocrinology, 10(1), e1442160. https://doi.org/10.1080/19381980.2018.1442160
and beverages: Mean amounts consumed per individual, by gender and age. What We Eat in
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U.S. Department of Health and Human Services. (2018). Physical activity guidelines for Americans
(2nd ed.). https://health.gov/sites/default/files/2019-
U.S. Preventive Services Task Force. (2017). Screening for obesity in children and Adolescents. U.S.
Preventive Services Task Force Recommendation Statement. Journal of the American Medical
Association, 317(23), 2417–2426. https://doi.org/10.1001/jama.2017.6803
Chapter Nutrition for Older
14 Adults
Clara Wellington
Clara, 74 years old, lives alone in her own home. She
is relatively healthy and has a home health aide come
2 hours per week to help her with light housekeeping.
Her only medication is an occasional antacid for
gastroesophageal reflux disease. She is 5 ft 5 in., and
for all of her adult life, she has weighed 135 pounds.
At her most recent doctor visit, she was down 7
pounds from the previous visit 6 months ago.
Learning Objectives
1 Give examples of physiologic changes that occur with aging and that
have an impact on nutrition.
2 Discuss why older adults may need more protein than younger adults.
3 Explain why older adults may need supplements of calcium, vitamin D,
and vitamin B12.
4 Describe the characteristics of the Mediterranean diet and why it may
promote healthy aging.
5 Describe the characteristics of the MIND diet and how it differs from the
MedDiet.
6 Discuss criteria that may be used to screen for malnutrition in older
adults.
7 Debate the benefits of using a liberal diet in long-term care facilities.
8 Propose strategies for enhancing food intake in long-term care residents.
9 Explain the effects Alzheimer’s disease may have on nutritional status.
Approximately 1 out of 7 Americans, or 15.2% of the population, is 65
years or older (U.S. Department of Health and Human Services [USDHHS]
& Administration on Aging [AOA], 2018). The older population is not only
increasing, it is also getting increasingly older. In 2016, nearly 82,000
adults were over the age of 100 years (USDHHS & AOA, 2018). Despite
the misconceptions and stereotypes people have of older adults, they are a
heterogeneous group that varies in age, marital status, social background,
financial status, health status, and living arrangements.
With the exception of Chapter 12 (pregnancy and lactation) and Chapter
13 (infants, children, and adolescents), this book implicitly addresses
nutrition as it pertains to adults. Yet adulthood represents a wide age range,
from young adults at 18 years to the “oldest old.” Adults over 50 years, and
especially those over 70 years, have different nutritional needs and concerns
than do younger adults. This chapter focuses on how aging affects nutrition
for older adults.
AGING AND OLDER ADULTS
Aging is a gradual, inevitable, complex process of progressive physiologic,

cellular, cultural, and psychosocial changes that begin at conception and
end at death. As cells age, they undergo degenerative changes in structure
and function that eventually lead to impairment of organs, tissues, and body
functioning. Table 14.1 outlines changes related to aging and their
association with nutrition.
Table Changes Related to Aging and

14.1 Their Nutritional Implications
Changes Related to Aging Association with Nutrition

Changes in physiology and
function Increases risk of osteoporosis;
increased need for calcium.
Loss of bone density. Loss of muscle mass and strength
Loss of muscle mass, strength, becomes evident in the early
and physical function; 60s; 20%–40% of muscle
increased risk of sarcopenia. strength may be lost by age 70.
Lowers body mass index (BMI)
and calorie requirements,
making it more difficult to
meet micronutrient
requirements.
Increase in body fat related to
Sarcopenia and frailty increase risk
decreased physical activity.
of malnutrition.
Changes in body fat distribution
Lowered need for calories.
related to hormonal changes.
Increased deposition of abdominal
fat increases the risk of
metabolic syndrome, which
increases the risk of heart
disease and diabetes.
Digestive system changes
Difficulty chewing related to loss If intake is limited to soft, easy-to-
of teeth and periodontal chew foods, some essential
disease. Jaw bone nutrients may be deficient.
deterioration may be related to Meat intake is most commonly
osteoporosis affected when chewing is
impaired.
Decrease in gastric acid secretion Less gastric acid can impair iron
Decreases in digestive enzyme and vitamin B12 absorption.
secretion, GI motility, and Increased risk of digestive
organ function disorders including
Appetite and thirst dysregulation constipation
occurs Decreased awareness of hunger;
decreased sense of thirst
Delayed gastric emptying increases risk of dehydration.
Feeling of fullness persists longer
after eating, slowing the return
of hunger.
Changes in the nervous system
and cognition Independence and quality of life
Increased risk of cognitive decline are affected. Decreased ability
to prepare food, forgetting to
eat, and inability to access food
are the earliest signs of mild
cognitive impairment or pre-
Alzheimer’s disease.
Changes in immune system
functioning Infections increase metabolism,
Immune response dysfunction calorie needs, and nutrient
with increased susceptibility to requirements; malnutrition can
infection and chronic occur, which further impairs
inflammation immune function.
Changes in kidney function
Decreased kidney function related Impaired kidney function may
to decrease in kidney mass, alter vitamin D metabolism,
blood flow, and glomerular lower vitamin D levels, and
filtration rate contribute to osteoporosis.
Sensory changes
Increased risk of nutrition Impaired socialization can impair
deficiencies because: appetite and intake in older
Hearing loss adults.
Vision loss Food purchasing, preparation, and
Diminished senses of taste and eating are more difficult.
smell Eating becomes less appealing.
Changes in income Food budget may decrease.
Fixed income related to retirement
Changes in health
Nutrient requirements, intake,
Older adults have a high digestion, metabolism, or
prevalence of cardiovascular excretion may be altered,
disease, type 2 diabetes, increasing the risk of
hypertension, bone and joint malnutrition.
problems, and Disability conditions may impair
neurodegenerative conditions, food purchasing, preparation,
which increase the risk of or eating.
fragility and disability Medications may affect appetite,
Reliance on medication ability to smell or taste, or the
digestion, absorption,
metabolism, and excretion of
nutrients.
Alcohol abuse; alcohol may be Alcohol abuse can cause
used to relieve boredom, impairments in nutrient intake,
loneliness, depression, or pain. absorption, metabolism, and
excretion.
Psychosocial changes
Social isolation related to death of Loneliness can lead to disinterest

a spouse, death of friends, in living and eating and may
living alone, impaired mobility lead to malnutrition.
Poor self-esteem related to change May lead to poor intake.
in body image, lack of Health care facility residents are at
purpose, feelings of increased risk of malnutrition.
aimlessness.
Move to a health care facility
Source: Amarya, S., Singh, K., & Sabharwal, M. (2015). Changes during aging and their association
with malnutrition. Journal of Clinical Gerontology and Geriatrics, 6(3), 78–84.
https://doi.org/10.1016/j.jcgg.2015.05.003
NUTRITIONAL NEEDS OF OLDER

ADULTS
Age-related changes in metabolism, body composition, and nutrient

absorption are among the factors that alter calorie needs and nutrient
requirements among older adults. Dietary Reference Intake (DRI)
references separate older adulthood into two categories: ages 51 to 70 years
and older than 70. Generally, most DRIs remain constant throughout
adulthood. However, because health status, physiologic functioning,
physical activity, and nutritional status may vary more among older adults
(especially those older than 70) than among individuals in any other age
group, recommendations may not be appropriate for all older individuals at
all times.
Calories
Estimated calorie needs per day decrease with age (Fig. 14.1). The decrease
results from a decrease in energy spent on all three components of energy
expenditure, namely, basal metabolic rate (BMR), physical activity, and the
thermic effect of processing food (Institute of Medicine, 2005).
• BMR represents the largest component of total energy expenditure
and is closely correlated to the amount of lean body mass. The
progressive loss of muscle mass that occurs with aging lowers
BMR.
• Calories spent on physical activity may decrease due to changes in
health or functional limitations. Individual variations exist.
• Although calorie needs decrease in older adults, most nutrient
requirements do not change, making the concept of nutrient density
even more important.
Lean Body Mass

all body components except stored fat; the fat-free mass of the body.
Protein
For more than 70 years, the Recommended Dietary Allowance (RDA) for
protein has been set at 0.8 g/kg/day for healthy adults aged 19 years and
older (Institute of Medicine, 2005). This level of intake is an estimate of the
minimum amount of protein that must be consumed to avoid loss of body
nitrogen. However, the data were gathered almost entirely in college-aged
men, which are likely not applicable to older adults (Traylor et al., 2018).
Furthermore, critics cite numerous shortcomings in nitrogen balance
techniques to estimate protein need, such as the difficulty in accurately
measuring all sources of nitrogen excretion (Wolfe et al., 2017). It is
recommended that nitrogen balance no longer be used as the gold standard
for assessing adequacy of protein intake (Institute of Medicine, 2005).
A body of data from studies using isotope tracers supports
recommending protein intakes greater than the RDA for older people
(Traylor et al., 2018).
• Observational studies also show that higher protein intakes are
associated with greater muscle mass and better muscle function with
aging (Houston et al., 2008; Isanejad et al., 2016).
• One reason why older adults need more protein than younger adults
is that they have a declining anabolic response to protein intake; that
is, their threshold for the amount of protein needed to stimulate
protein synthesis is higher.
• Protein need may also be higher due to inflammatory and catabolic
effects of chronic and acute diseases that commonly occur with
aging.
• In addition to the total amount of protein consumed per day, other
aspects of protein intake may also affect muscle mass and strength
during aging, such as the distribution over the day, the amount per
meal, and protein quality.
Figure 14.1 ▲ Estimated calorie needs per day for men and women
ages 51 to 76 years and older.
The PROT-AGE Study Group, composed of an international panel of

experts, developed evidence-based recommendations for optimal protein
intake for older adults (Bauer et al., 2013). They recommend the following:
• A higher protein intake is needed than the current RDA and higher
amounts are needed when health is compromised:
• healthy older adults: 1.0 to 1.2 g/kg protein/day
• older adults with an acute or chronic disease: 1.2 to 1.5 g/kg/day
• older adults with severe illness or injury or with marked
malnutrition: as much as 2.0 g/kg/day
• Protein should be evenly distributed throughout the day (e.g., 25–30
g protein per meal, the equivalent of 3–4 oz of protein foods), to
maximally stimulate muscle protein synthesis.
• At least 2.5 g of leucine per meal is recommended for healthy older
adults. Leucine is an essential amino acid that plays a key role in
stimulating skeletal muscle synthesis. The best sources of leucine
are eggs, dairy, meat, poultry, and fish.
• Protein quality may also be an important factor in the maintenance
of muscle mass. Current evidence suggests that plant proteins (e.g.,
in soy and wheat) result in lower muscle protein synthesis than
animal proteins, possibly because of the relative lack of leucine in
plants compared to animal-based proteins (Gingrich et al., 2019).
Recall Clara. She currently weighs 128 pounds. How much

protein should she have per day? She complains that meats
are too difficult to chew. What sources of protein may be
easier for Clara to consume? Which sources of protein are
most economical and easiest to prepare for someone living
alone? If she is willing to eat in between meal snacks, what
would you recommend?
More research is needed to determine protein and leucine thresholds, the

causes of anabolic resistance to low protein intakes in older adults, and who
best benefits from protein interventions to prevent or manage sarcopenia
(Rodriguez, 2015). Researchers are also considering whether increasing
protein intake earlier in life, such as during middle age, will promote long-
term muscle health.
Fiber
The recommendation for fiber decreases for adults age 50 years and older
because the Adequate Intake (AI) for fiber is based on total calorie intake.
• At age 51, the AI for fiber decreases to 30 g/day for men and 21
g/day for women.
• The AI is based on median intake levels observed to protect against
coronary heart disease (CHD) (Institute of Medicine, 2005).
• However, fiber also helps prevent constipation, a condition older
adults are more prone to due to decreased abdominal muscle tone, a
decrease in physical activity, or as a side effect of drug therapy.
Older adults may benefit from increasing their fiber intake despite
the lower AI for their age group.
• Fiber sources that promote laxation include wheat bran, whole
grains, nuts, and the skins and seeds of fruits and vegetables.
Micronutrients
The most notable changes in DRIs for older adults are for vitamin D,
calcium, vitamin B12, and iron.
Vitamin D
After age 70, the RDA for vitamin D increases from 15 mcg/day (600 IU)
to 20 mcg/day (800 IU) for both men and women. Vitamin D is well known
for its role in maintaining skeletal health. Epidemiologic evidence suggests
that low vitamin D levels may be involved in age-related diseases, such as
cognitive decline, depression, osteoporosis, cardiovascular disease,
hypertension, type 2 diabetes, and cancer (Meehan & Penckofer, 2014).
• Various risk factors place older adults at increased risk for vitamin D
deficiency, such as inadequate intake, limited sun exposure,
decreased ability to synthesize vitamin D on the skin, and impaired
activation by the liver and kidneys.
There are few dietary sources of vitamin D: fortified milk and other
• vitamin D–fortified foods, egg yolks, fatty fish, and beef liver.
• Supplements of vitamin D may be necessary to achieve adequacy.
The Endocrine Society recommends that adults consume at least the
RDA of vitamin D for their age and states that 1500 to 2000 IU/day
may be required to achieve serum levels >30 ng/mL of vitamin D,
the level they believe is optimal to prevent deficiency and maximize
bone health (Holick et al., 2011).
Calcium
Consuming adequate amounts of calcium, vitamin D, and other nutrients is
critical for optimum bone health. Low bone mineral density and
osteoporosis are common in the United States, especially in older adults,
and can lead to fractures and increased risk of morbidity and mortality.
• After age 70, the RDA for calcium increases for men from 1000 to
1200 mg/day. For women, the increase to 1200 mg/day occurs at age
51.
• Calcium is preferably obtained from food. Generally, three daily
servings of milk, yogurt, or cheese plus nondairy sources of calcium
are needed to ensure an adequate calcium intake. Nondairy sources
of calcium include calcium-fortified orange juice, soy milk, and
breakfast cereals and certain greens (bok choy, collard greens, kale,
turnip greens).
• People who are unwilling or unable to consume adequate calcium
through food sources need calcium supplements.
Vitamin B12
Vitamin B12 holds the distinction of being the only vitamin not found in
plants; naturally, it occurs only in animal products such as meat, fish,
poultry, eggs, milk, and milk products. Although the RDA for vitamin B12
does not change with aging, the recommended source does: Adults over the
age of 50 are advised to meet their B12 requirement mostly from fortified
foods (e.g., fortified ready-to-eat cereal) or supplements (Institute of
Medicine, 1998). Vitamin B12 status tends to decline with age, possibly due
to a decrease in gastric acidity, which impairs the freeing of vitamin B12
bound to protein in foods, a necessary step in the process of absorption.
The best option for a client concerned about an osteoporosis

diagnosis after fracturing their hip is medication to treat
osteoporosis. Once bone loss has occurred, medications are
necessary.
Iron
The recommendation for iron for men does not change with aging. In
women, the requirement for iron decreases after menopause due to the
cessation of monthly blood loss. However, iron deficiency may occur in
older adults secondary to low stomach acid, the use of antacids, or chronic
blood loss from diseases or medications. Iron intake may be low in adults
who do not regularly eat red meat.
Vitamin and Mineral Supplements

In theory, older adults should be able to obtain adequate amounts of all
essential micronutrients through well-chosen foods. However, according to
2015 to 2016 data, mean intakes of vitamin A, vitamin D, vitamin E,
calcium, magnesium, and potassium fall below recommended amounts for
adults age 50 years and older (U.S. Department of Agriculture [USDA] &
Agricultural Research Service [ARS], 2018).
• Supplement use is high among older adults. A 2017 study showed
that 70% of adults age 60 and older used one or more dietary
supplements in the previous 30 days, with multivitamin or mineral
the most common supplement used (Gahche et al., 2017).
As noted earlier, supplements of vitamin D, calcium, and vitamin
• B may be necessary for older adults.
12
• Low-dose multivitamin and mineral supplements can help achieve

adequate micronutrient intakes, especially when food selection is
limited.
HEALTHY AGING
Genetic and environmental “life advantages”—such as genetic potential for

longevity, intelligence, motivation, curiosity, good socialization, religious
affiliation, marriage and family, avoidance of substance abuse, availability
of health care, adequate sleep, and sufficient rest and relaxation—have
positive effects on both length and quality of life. Although there is no
universally agreed upon definition of healthy or successful aging, criteria
often cited include no major chronic diseases, no cognitive impairment, no
physical disabilities, and no mental health limitations (Sun et al., 2009).
The goal of healthy aging is not only to prolong life but more
importantly to extend healthy active years (Shlisky et al., 2017).
Unfortunately, chronic diseases become more prevalent with age and are
often considered an inevitable consequence of aging. The fact that many
chronic diseases are occurring at younger ages points to a cause other than
aging, namely, nutrition and lifestyle factors. According to the World
Health Organization (WHO), at least 80% of all heart disease, stroke, and
type 2 diabetes as well as over 40% of all cancer would be prevented
through a healthy diet, regular physical activity, and avoidance of tobacco
(World Health Organization, 2005).
Healthy Eating
Across the human life span, healthy eating patterns and diet quality are
linked to health promotion and disease prevention. A healthy eating pattern
provides the appropriate amount of calories from a variety of foods
•
across food groups,
• emphasizes nutrient-dense foods: fruit, vegetables, whole grains,
seafood, eggs, legumes, nuts, low-fat and fat-free dairy, and lean
meats and poultry, and
• limits saturated fats, sodium, refined starches, and added sugars.
Healthy Eating Index

The Healthy Eating Index (HEI-2015), the tool used to measure how
closely intake aligns with the Dietary Guidelines for Americans
recommendations, shows that adults aged 60 and older have the highest diet
quality among all age groups, scoring 63 out of a possible 100 points (U.S.
Department of Agriculture [USDA] & U.S. Department of Health and
Human Services [USDHHS], 2020). However, this score is still low and
indicates that older adults are not meeting the recommendations for food
group and nutrient intakes. Older adults can improve their intake by
• consuming more vegetables, fruits, dairy, whole grains, and seafood
• consuming less added sugars, saturated fat, and sodium.

The healthy eating patterns featured in the Dietary Guidelines, namely, the
Healthy U.S.-Style, Healthy Mediterranean-Style, and Healthy Vegetarian
Eating Patterns, are all appropriate across the life span. Healthy eating
patterns that have been investigated for specifically promoting healthy
aging include the Mediterranean diet (MedDiet) and the Mediterranean–
DASH Intervention for Neurodegenerative Delay (MIND) diet. Both diets
have been independently associated with better cognitive function and
lower risk of cognitive impairment (McEvoy et al., 2017). Both are rich in
plants and have features that overlap. Table 14.2 compares the general
guidelines for each eating pattern.
The Mediterranean Diet
The Mediterranean diet (MedDiet) describes the traditional eating habits of
people living in the olive-growing areas of the Mediterranean region before
the mid-1960s (Trichopoulou et al., 2014). Historically, Mediterranean
countries have been among the healthiest countries in the world, with
relatively low rates of cardiovascular diseases and cancer and greater
longevity (Trichopoulou et al., 2014). Interest in the traditional MedDiet
began in the late 1950s, when it was proposed that the low incidence of
coronary heart disease (CHD) in Mediterranean countries may be linked to
the low saturated fat content of the MedDiet. Compared to other healthy
eating patterns, the MedDiet
• is relatively high in total fat (e.g., 40% of total calories), with a high
ratio of monounsaturated fat to saturated fat coming primarily from
virgin olive oil, nuts, and fatty fish.
• includes a moderate intake of red wine consumed during meals.
Table A Comparison of the

Mediterranean Diet and
14.2 MIND Diet
Mediterranean Diet MIND Diet

Consists primarily of minimally Composed of specific foods that
processed foods, such as provide nutrients that may help
whole grains, legumes, delay neuron aging, such as
vegetables, fruit, nuts, and vitamin E, DHA, B vitamins,
fish vitamin C, and vitamin D
Relatively high fat intake (e.g.,
40% of total calories) with a 10 “brain healthy” food
high ratio of monounsaturated components to emphasize:
fat to saturated fat due to the • Green leafy vegetables: at least 1
liberal use of olive oil serving/day
• All other vegetables: at least 1
serving/day
Main meals contain the
• Berries: at least 2 servings/week
following:
• Nuts: 5 or more servings/week
• 1–2 servings of grains, • Olive oil: use as main cooking
preferably whole grains oil
• 2 or more servings of • Whole grains: at least 3
vegetables, at least one of servings/day
which is raw • Fish: at least 1 serving/week
• 1–2 servings of fruit • Beans: at least 4 servings/week
• Poultry: 2 or more servings/week
Daily
• Wine: no more than 1 glass/day
• 2 servings of low-fat yogurt,
cheese, and other fermented 5 unhealthy groups to avoid or
daily products limit:
• Use olive oil as the principal • Butter/margarine: less than 1
source of fat tbsp/day
• Add a variety with spices, • Cheese: less than 1 ounce/week
herbs, garlic, and onions • Red meat: no more than 3
• A reasonable intake of olives, servings/week
nuts, and seeds as healthy • Fried food/fast food: less than
snacks once/week
• Moderate consumption of wine • Pastries and sweets: no more
during meals than 4 times/week
Weekly
• Eat a variety of plant and

animal proteins
• 2 or more servings of fish
• 2 servings of white meat
• 2–4 eggs
• Less than 2 servings of lean red
meat
• Less than 1 serving processed
meat
Occasionally
Sweets in small amounts and only
for special occasions
Source: Bach-Faig, A., Berry, E., Lairon, D., et al. (2011). Mediterranean diet pyramid today. Science
and cultural updates. Public Health Nutrition, 14(12A), 2274–2284.
https://doi.org/10.1017/S1368980011002515; Di Fiore, N. (2015, March 16). Diet may help
prevent Alzheimer’s: MIND diet rich in vegetables, berries, whole grains, nuts. Rush University
Medical Center. https://www.rush.edu/news/diet-may-help-prevent-
alzheimers">https://www.rush.edu/news/diet-may-help-prevent-alzheimers
Potential Age-Related Benefits

Increasing evidence suggests that high adherence to a MedDiet promotes
good health during aging (Assmann et al., 2018). For instance, studies link
close adherence to a MedDiet to:
• lower the risk of mild cognitive impairment and Alzheimer’s disease
(AD) (Shlisky et al., 2017),
• less age-related brain shrinkage (Luciano et al., 2017),
• prolonged survival (study participants who most closely followed a
MedDiet were significantly less likely to die over the 8-year study
period [Bonaccio et al., 2018]),
• reduced risk of frailty, even among very old elderly (Rahi et al.,
2018),
• greater chance of living beyond 70 years with greater health and
well-being (Samieri et al., 2013).
Components Attributed to Benefits

The EPIC study credited a high intake of plants, moderate alcohol intake,
low meat intake, and liberal use of olive oil with reducing total mortality
among a prospective cohort consuming the MedDiet (Trichopoulou et al.,
2009). The benefits of the MedDiet may be related to its high alpha-
linolenic acid content, high antioxidant content, high fiber content, low
glycemic load, or some other components or combination of components
(Trichopoulou et al., 2014).
Mind Diet
The Mediterranean-DASH Intervention for Neurodegenerative Delay or
MIND diet is a combination of the MedDiet and DASH diets, which are
two diets shown to lower blood pressure and reduce the risk of
cardiovascular disease and diabetes. The goal of the MIND diet is to
specifically reduce the risk of dementia and decline in brain health that
usually occurs with aging (Pike, 2019). Fifteen foods are specifically
named, with 10 that are encouraged and 5 that should be limited. The
MIND diet differs from the MedDiet in that (Hosking et al., 2019):
• it recommends daily and weekly servings of specific foods and food
groups rather than an eating pattern.
• it specifies berry intake but not other fruits. Both the MedDiet and
the DASH diet recommend a high intake of fruit in general but not
berries specifically.
• green leafy vegetables comprise a separate category due to their
high content of nutrients that are thought to lower the risk of
cardiovascular disease and cognitive decline. Other vegetables are
also recommended daily but grouped into one category. The
MedDiet and DASH diet encourage a liberal intake of fruit and
vegetables of all varieties.
Potential Age-Related Benefits

Created in 2015, the MIND diet is relatively new. The handful of study
results indicate:
• The diet substantially slows cognitive decline with age (Morris et
al., 2015a).
• Greater adherence to the MIND diet has been linked to a 53%
decrease in the rate of Alzheimer’s disease (AD) (Morris et al.,
2015b). Even modest adherence to the MIND diet may have
substantial benefits for the prevention of AD.
Components Attributed to Benefits

A diet that promotes vascular health is inherently protective against
vascular dementia. In addition to those benefits, certain foods and food
components emphasized in the MIND diet have been directly linked to
improved neurological function or reduced AD markers in the brain
(Mosconi et al., 2014). The MIND diet is high in vitamin E, DHA, B
vitamins, vitamin C, and vitamin D, all of which have been found to help
delay neuron aging (Mohajeri et al., 2015).
BOX Key Physical Activity Guidelines for

14.1 Older Adults
These guidelines are the same for adults and older adults:
• Adults should move more and sit less throughout the day. Some
physical activity is better than none. Adults who sit less and do any
amount of moderate to vigorous physical activity gain some health
benefits.
• For substantial health benefits, adults should do at least 150 minutes (2
hours and 30 minutes) to 300 minutes (5 hours) a week of moderate-
intensity aerobic physical activity or 75 minutes (1 hour and 15
minutes) to 150 minutes (2 hours and 30 minutes) a week of vigorous-
intensity aerobic physical activity or an equivalent combination of
moderate- and vigorous-intensity aerobic activity. Preferably, aerobic
activity should be spread throughout the week.
• Additional health benefits are gained by engaging in physical activity
beyond the equivalent of 300 minutes (5 hours) of moderate-intensity
physical activity a week.
• Adults should also do muscle-strengthening activities of moderate or
greater intensity that involve all major muscle groups on 2 or more
days a week, as these activities provide additional health benefits.
Guidelines only for older adults:
• As part of their weekly physical activity, older adults should do

multicomponent physical activity that includes balance training as well
as aerobic and muscle-strengthening activities.
• Older adults should determine their level of effort for physical activity
relative to their level of fitness.
• Older adults with chronic conditions should understand whether and
how their conditions affect their ability to do regular physical activity
safely.
• When older adults cannot do 150 minutes of moderate-intensity
aerobic activity a week because of chronic conditions, they should be
as physically active as their abilities and conditions allow.
Source: U.S. Department of Health and Human Services. (2018). Physical Activity Guidelines for
Americans (2nd ed.). https://health.gov/sites/default/files/2019-
Physical Activity
Older adults are urged to follow the same physical activity guidelines as
those for younger adults in order to reap similar health benefits (Box 14.1).
Regular physical activity also reduces the risk of falls and fall-related
injuries in older adults. Other benefits include (U.S. Department of Health
and Human Services [USDHHS], 2018)
• lower risk of all-cause mortality, cardiovascular disease,
hypertension, type 2 diabetes, dyslipidemia, certain cancers, and
dementia.
delayed progression of certain chronic illnesses, hypertension, and
• type 2 diabetes,
• weight loss, particularly when combined with a lower calorie intake,
and improved weight maintenance,
• improvements in cognition, quality of life, sleep, bone health, and
physical function,
• reduced risk of anxiety and depression.
NUTRITION AND HEALTH

CONCERNS OF OLDER ADULTS
How people rank their own health is an important indicator of overall health
and a significant predictor of mortality (United Health Foundation, 2019).
In 2017, 45% of community-dwelling adults aged 65 and older ranked their
health as excellent or very good yet most older adults have at least one
chronic health condition (USDHHS & AOA, 2018).
Malnutrition
Although older adults generally perceive themselves as healthy, many are at
risk of malnutrition. A recent meta-analysis revealed an overall malnutrition
prevalence of 2.3% and risk of malnutrition prevalence of 19% in
community-dwelling older adults (Verlaan et al., 2017). The quality and
quantity of food intake, food insecurity, and acute or chronic physical or
mental health conditions may be contributing factors (Saffel-Shrier et al.,
2019). Loss of appetite, which may arise from physiologic, psychosocial,
and medical factors, is a key predictor of malnutrition in older adults.
Malnutrition impairs quality of life and is a strong predictor of short-
term mortality in older adults (Gentile et al., 2013). Common symptoms of
malnutrition, such as confusion, fatigue, and weakness, are often attributed
to other conditions and are misdiagnosed or unrecognized as malnutrition
(Marshall et al., 2016). Selected risk factors for malnutrition in older adults
are shown in Box 14.2.
Nutrition Screening for Malnutrition

Nutrition screening, a simple process to quickly identify the risk of
malnutrition, is appropriate in any setting where older adults receive
services or care, as in hospitals, long-term care facilities, community-based
care, home health, and physician office. Although there are many screening
tools that can be used to screen for malnutrition in older adults, the
Academy of Nutrition and Dietetics recommends the Malnutrition
Screening Tool (MST) be used to screen adults for malnutrition
(undernutrition) regardless of age, medical history, or setting (Skipper et al.,
2020).
The MST asks only three questions:
• Have you lost weight without trying?
• If yes, how much weight have you lost?
• Have you been eating poorly because of a decreased appetite?
BOX Selected Risk Factors to Assess for

12.2 Malnutrition in Older Adults
Physical and Medical Conditions
• Chronic diseases that directly or indirectly affect intake by leading to:

• Decreased appetite
• Impaired taste
• Impaired ability to eat, prepare, or purchase food
• Restrictive diets
• Dysphagia
• Acute or chronic diseases that cause:
• Increased nutrient needs through inflammation
• Altered nutrient digestion (e.g., chronic pancreatitis) or absorption
(e.g., celiac disease)
• Impaired nutrient utilization (e.g., uncontrolled diabetes) or
excretion (e.g., chronic kidney disease)
• Geriatric syndromes, such as pressure ulcers, falls, functional
decline, delirium, incontinence, sleeping problems, dizziness, and
self-neglect
Physical Assessment
• Loss of subcutaneous fat

• Muscle loss
• Oral impairments, such as loss of teeth, ill-fitting dentures, or dry
mouth
• Dysphagia
• Impaired sense of taste or smell
• Constipation or diarrhea
Nutrition Assessment Findings
• Unintentional weight loss

• Inadequate intake as per diet history, although food recall may be
inaccurate, especially in adults with cognitive impairment
• Nutrition risk identified through:
• Nutrition screening
• Use of multiple medications, including prescriptions, over-the-
counter medications, vitamins, and supplements; assess for side
effects that affect appetite or intake
Mental Health Status
• Cognition and dementia

• Mood and anxiety disorders
• Depression
Functioning
• Gait, strength, and balance
• Ability to perform ADLs and IADLs
Social Domain
• Social networks
• Financial constraints
• Living arrangements
Environment
• Housing, such as ability to use stairs to gain access to the outside

• Adequacy of transportation to purchase food
• Accessibility to grocery stores
Source: DiMaria-Ghalili, R. (2014). Integrating nutrition in the comprehensive geriatric
assessment. Nutrition in Clinical Practice, 29, 420–427.
https://doi.org/10.1177/0884533614537076
Criterion is scored to determine malnutrition risk.

• An individual who is eating well with little or no weight loss is
deemed not at a nutritional risk.
• An individual who is eating poorly and/or has recent weight loss is
determined to be at nutritional risk.
• The MST has been shown to have a moderate degree of validity,
agreement, and interrater reliability in identifying malnutrition. The
strength of evidence for the MST is good/strong with good
generalizability.
• See Chapter 15 for the actual MST tool.
Interventions to Improve Intake and Weight

Regardless of living situation, ongoing screening that identifies risk of
actual or potential malnutrition should be followed by a nutrition
assessment that leads to an individualized plan to improve overall intake.
• One option is to increase the nutrient density of foods eaten by
adding ingredients that provide calories and/or protein (Box 14.3).
The effect is to increase the nutritional value while the volume of
food served remains the same.
• Homemade or commercial oral nutrition supplements are an
effective option to increase overall nutrient intake for nursing home
residents as well as for community-dwelling older adults.
• Smoothies, milk shakes, and protein powder–based milk drinks
can be consumed between meals. Liquids leave the stomach more
quickly than solids and are less likely to interfere with the next
meal.
• Commercial supplements offer convenience but are more
expensive.
• Taste fatigue may occur over time. Consider altering the amount,
timing, flavors, or types to maintain acceptance.
• Monitor overall intake to ensure that supplements are adding to
instead of replacing food intake.
Additional Considerations for Community-Dwelling Adults

Among community-dwelling adults, eating with others may help improve
the intake and nutritional status of those who live alone. Efforts should be
made to eat with friends and relatives whenever possible. Federally funded
nutrition programs, such as congregate meals and Meals on Wheels, are
also options.
• These programs are designed to provide low-cost, nutritious, hot
meals; education about food and nutrition; opportunities for
socialization and recreation; and information on other health and
social assistance programs.
• The congregate meal program provides a hot, balanced, midday
meal and the opportunity to socialize in senior citizen centers and
other public or private facilities. Those who choose to pay may do
so; otherwise, the meal is free.
• Meals on Wheels is a home-delivered meal program for older adults
who are unable to get to congregate meal centers because they live
in an isolated area or have a chronic illness or physical limitations.
Usually, a hot meal is delivered before midday with a bagged lunch
to be eaten as the evening meal. Modified diets, such as
carbohydrate-controlled diets and low-sodium diets, are provided as
needed.
BOX Examples of Foods Made More

14.3 Nutrient/Calorie Dense
• Mashed potatoes made with extra butter, whole milk, and/or cheese
• Milk fortified with nonfat dry milk powder to make “double strength”
milk that can be used in cereal, soups, milk-based desserts, milk
shakes
• Casseroles, soups, rice, noodles, or sandwiches with added cheese or
chopped fine hard-cooked eggs
• Fruit, plain cake, or other desserts topped with vanilla Greek yogurt
• Oatmeal made with added butter, nonfat dry milk, and sugar
• Coffee with half and half, whole milk, and/or honey
• Scrambled eggs with added cheese
Think of Clara. Clara agreed to go to the senior center for

noontime meals but stopped going after a few days because
she got lost driving there and fears she may be developing
dementia. She is now receiving Meals on Wheels but eats
only 50% of each meal. Her weight continues to decline.
Could she be considered at risk for malnutrition? What other
options or strategies may help improve Clara’s intake?
Additional Considerations for Long-Term Care Residents
Preventing malnutrition is a quality-of-life issue. To meet the needs of
individual residents, a holistic approach is advocated that includes the
individual’s personal goals, overall prognosis, risk–benefit ratio, and quality
of life.
• Mealtime should be made as enjoyable as possible. Noise and
distractions in the dining room should be minimized.
• Family involvement increases resident intake.
• Honor individual food preferences whenever possible.
• Encourage independence in eating and supervise dining areas so that
proper feeding techniques are used when residents are assisted or
fed by certified nursing assistants.
• For residents with functional or cognitive impairments, specialized
utensils and dishes, finger foods, and tactile prompts may facilitate
independence.
• A liberalized eating pattern, which is a healthy diet of nutrient-dense
foods that contains neither excessive nor restrictive amounts of
cholesterol, sodium, and added sugar, may help improve intake and
lower the risk of weight loss (Box 14.4)
• The liberal diet can be modified to meet the requirements of
residents with increased needs, such as those who have pressure
ulcers. Using foods that are made more nutrient dense or adding
extra meat and/or milk will provide increased amounts of calories,
protein, and fluid.
• Restrictive diets should be used only when a significant
improvement in health can be expected, as in the case of ascites or
constipation.
• Consistently and accurately record food intake. Intakes less than
75% and weight loss of 5% in 30 days warrant investigation.
BOX Sample Liberal Eating Pattern for Older

14.4 Adults
Breakfast
• Orange juice
• Oatmeal
• One soft-cooked egg
• One slice buttered whole wheat toast
• Low-fat milk
• Coffee/tea
Lunch
• Turkey sandwich made with two slices whole-wheat bread, tomato,
romaine lettuce, and low-fat salad dressing
• Vegetable soup
• Sliced strawberries over angel food cake
• One cup low-fat milk
• Coffee/tea
Dinner
• Roast pork
• Oven-roasted potatoes
• Baked acorn squash
• Fresh-fruit salad
• Ice cream
• Coffee/tea
Snack
• One cup low-fat yogurt
Obesity
For adults of any age, underweight is defined as a BMI less than 18.5,
overweight at BMI of 25 to 29.9, and obesity at BMI of 30 or more.
• Only 0.9% of community-dwelling adults aged 60 and older are
estimated to be underweight (Fryar et al., 2018).
• In contrast, an estimated 40.2% of men and 43.5% of women aged
65 to 74 years are obese (Centers for Disease Control and
Prevention [CDC], 2017). Obesity exacerbates most chronic health
conditions, such as sarcopenia, frailty, disability, and diabetes
(Saffel-Shrier et al., 2019).
Certainly, obesity is not unique to older adults. The question of what is

appropriate obesity treatment for older adults is where controversy lies.
• Loss of weight is not synonymous with—nor does it have the same
benefit as—loss of fat.
• Intentional weight loss causes loss of muscle—even when the goal
is fat loss. In fact, calorie restriction or diet-alone-induced weight
loss contributes to the development of sarcopenia and bone loss and
thus to a higher risk of functional impairment and disability (Batis et
al., 2015).
• Other challenges include the difficulty of changing behavior with
advancing age.
• Many older people may not feel a need to make changes at this
point in life.
• Active participation in physical activity may be difficult because
of medical problems, financial limitations, or impaired hearing or
vision.
• Diminished sense of taste, living alone, depression, and a limited
food budget may impede changes in intake.
• Because of these challenges, there has been no consensus on
optimal therapy, including the use of high-protein diets, which do
not ensure preservation of muscle during weight loss in older
adults (Coker & Wolfe, 2017).
Sarcopenia
Sarcopenia is a progressive and generalized skeletal muscle disorder
characterized by accelerated loss of muscle mass and insidious functional
decline (Cruz-Jentoft & Sayer, 2019).
Sarcopenia
age-related progressive loss of lean mass and muscle strength associated with morbidity, reduced
quality of life, frailty, disability, and increased rates of mortality.
• Adverse outcomes include physical disability, frailty, falls, fractures,

poor quality of life, and death (Cruz-Jentof et al., 2014). It has
become one of the most important challenges to healthy aging
(Chen et al., 2016).
• Estimates of sarcopenia prevalence in community-dwelling older
adults range from 9.9% to 40.4% depending on the definition used
(Mayhew et al., 2019).
• Sarcopenia should be considered in all older adults with observed
declines in physical function, strength, or overall health and
especially in older adults who are bedridden, who cannot rise
independently from a chair, or who have a slow gait (Evans, 2010).
• In part, sarcopenia may be caused by nutritional deficiencies, such
as an inadequate intake of protein (Cruz-Jentof et al., 2014). It is not
known whether protein and/or amino acid supplementation are
effective treatment interventions. High-quality clinical trials are
needed to identify effective prevention and treatment strategies.
• Sarcopenic obesity refers to obesity with low skeletal muscle
function and mass. There is no consensus on its definition and
diagnostic criteria and effective prevention and treatment strategies
remain inadequate. Optimal dietary options and medical nutritional
support to preserve muscle mass in obese people remain largely
undefined (Barazzoni et al., 2018).
Frailty
An international definition of frailty is as follows: a medical syndrome with
multiple causes and contributors that is characterized by diminished
strength, endurance, and reduced physiological function that increases an
individual’s vulnerability for dependency and/or death (Saffel-Shrier et al.,
2019).
• Frailty has a prevalence of nearly 10% among community-dwelling
older adults, is more common in women than men, and increases
sharply with age (Collard et al., 2012).
• Multiple factors contribute to frailty, including malnutrition, chronic
diseases, and psychological factors. Although sarcopenia may be a
component of frailty, frailty is more multidimensional than
sarcopenia alone (Fielding et al., 2011).
• Criteria used to identify frailty include weight loss and loss of
muscle mass, weakness, poor endurance, exhaustion, slowness, and
low activity. Three or more positive findings may indicate the
presence of frailty (Fried et al., 2001).
• Although there are numerous screening tools to identify frailty, there
is no international standard measurement (Dent et al., 2016).
• Several simple validated screening tools are available to enable
physicians to quickly identify adults with physical frailty syndrome
who are in need of a more in-depth assessment. One example is the
simple FRAIL questionnaire screening tool (Fig. 14.2).
• Frailty screening is recommended for all adults age 70 years and
older and anyone with significant weight loss (5% or more over the
last year) due to chronic illness (Morley et al., 2013).
Nutrition Therapy for Frailty

Nutrition therapy recommendations for frailty varies with weight status.
• Frailty related to weight loss can be partially prevented or treated
with protein–calorie supplementation (Morley et al., 2013).
• Frailty associated with obesity may be lessened with intentional
weight loss (Porter Starr et al., 2016).
• Vitamin D supplements for older adults who are deficient in vitamin
D may reduce the risk of falls, hip fractures, and mortality and may
improve muscle function (Morley et al., 2013).
Figure 14.2 ▲ The FRAIL questionnaire. (Source: Morley, J., Vellas, B.,
van Kan, G., Anker, S. D., Bauer, J. M., Bernabei, R., Cesari, M., Chumlea,
W., Doehner, W., Evans, J., Fried, L., Guralnik, J., Katz, P., Malmstrom, T.,
McCarter, R., Robledo, L., Rockwood, K., von Haehling, S., Vanewoude,
M., & Walston, J. (2013). Frailty consensus: A call to action. Journal of the
American Medical Directors Association, 14(6), 392–397.
https://doi.org/10.1016/j.jamda.2013.03.022).
Alzheimer’s Disease
Several of the leading causes of death among adults aged 45 to 64 are also
the leading causes of death among adults aged 65 and older, such as heart
disease, cancer, chronic lower respiratory diseases, and diabetes. A leading
cause of death among adults aged 65 and older that is not one of the 10
leading causes of death among people aged 64 and younger is Alzheimer's
Disease (AD). AD ranks as the fifth leading cause of death among adults
aged 65 and older and the third leading cause among adults aged 85 and
older (Heron, 2019).
AD is an irreversible, progressive brain disorder that gradually destroys
memory and cognition. It appears to result from a complex series of events
in the brain that occur over decades. Disruptions in nerve cell
communication, metabolism, and repair eventually cause many nerve cells
to stop functioning, lose connections with other nerve cells, and die,
resulting in gradual atrophy of the brain. Like CHD, AD is at least partially
a vascular problem, but plaques and tau tangles that form with AD are filled
with beta-amyloid, an indissoluble protein, not fat and cholesterol.
The cause of early-onset AD is usually a genetic mutation. Suspected
causes of late-onset AD include a combination of genetic, environmental,
and lifestyle factors (National Institute on Aging [NIA] & National
Institutes of Health [NIH], 2019). Increased age and family history of AD
are known risk factors for AD; cardiovascular disease, stroke, hypertension,
and diabetes may also increase the risk (NIA, NIH, 2019). As stated
previously, the MedDiet and MIND diet may decrease the risk of cognitive
impairment and AD (McEvoy et al., 2017; Morris et al., 2015b; Shlisky et
al., 2017). However, it is a multifactorial disease, and a cure does not exist.
Effect on Nutritional Status

AD can have a devastating impact on an individual’s nutritional status.
• Compared with healthy older adults, older adults diagnosed with
cognitive impairment or AD may have lower intakes of all nutrients
(Bernstein & Munoz, 2012).
• Early in the disease, impairments in memory and judgment may
make shopping, storing, and cooking food difficult. The client may
forget to eat or may forget that they have already eaten and
consequently may eat again.
• Changes in the sense of smell may develop, a preference for sweet
and salty foods may occur, and unusual food choices are not
uncommon.
• Agitation and fidgeting increases energy expenditure, and weight
loss is common.
• Choking may occur if the client forgets to chew food sufficiently
before swallowing or hoards food in the mouth.
• Eating of nonfood items may occur, and eventually self-feeding
ability is lost.
• Clients in the latter stage of AD no longer know what to do when
food is placed in the mouth. When this occurs, a decision regarding
the use of other means of nutritional support (e.g., nasogastric or
percutaneous endoscopic gastrostomy tube feedings) must be made.
Recall Clara. Clara is admitted to a memory care facility.

What symptoms did she display that are characteristic of the
progressive decline in function seen in adults with AD? Her
intake continues to be approximately 50% at each meal. She
pushes food around her plate and hides it under the plate.
She also prefers wandering the halls to sitting. She has a
health care proxy who explicitly states that she does not
want artificial food or fluids should there be no hope of
recovery. How can you best care for Clara?
NURSING
PROCESS Older Adult
Harold Hausman is a regular participant of the monthly congregational

nursing program sponsored at his church. He is a sedentary 82-year-old
widower who lives alone. You have noticed that he has lost weight over
the past several months. He has asked you to answer a few questions he
has about the low-sodium, low-cholesterol diet his doctor
recommended.
Assessment
Assessment
Medical– • medical history that may have nutritional

Psychosocial implications, such as hyperlipidemia,
History hypertension, cardiovascular disease, or GI
complaints
• ability to understand, attitude toward health
and nutrition, and readiness to learn
• attitude about his present weight and recent
weight loss
• usual activity patterns
• medications that may affect nutrition
• use of prescribed and over-the-counter drugs
• functional limitations such as impaired ability
to shop, cook, and eat
• psychosocial and economic issues such as
who does the shopping and cooking, adequacy
of food budget, need for food assistance, and
level of family and social support
Anthropometric • height, current and usual weight

Assessment • percentage of weight change
• determine BMI
Biochemical and • cholesterol level, if available

Physical • blood pressure
Assessment • dentition and ability to swallow
Assessment
Dietary Assessment • Why did your doctor give you this low-
sodium, low-cholesterol eating plan?
• How many daily meals and snacks do you
usually eat?
• What is a normal day’s intake for you?
What changes have you made in
implementing this eating plan? For instance,
• did you stop using the saltshaker at the table
or are you reading labels for sodium content?
Did you change the type of butter/margarine
you use? The type of salad dressing?
• Do you prepare food with added fat, or do you
bake, broil, steam, or boil your food?
• Do any cultural, religious, or ethnic
considerations influence your eating habits?
• Do you use vitamins, minerals, or nutritional
supplements? If so, which ones, how much,
and why are they taken?
• Do you use alcohol, tobacco, and caffeine?
• How is your appetite?
Analysis
Possible Nursing Malnutrition risk related to restrictive diet and

Analysis eating alone as evidenced by weight loss.
Planning
Assessment
Client Outcomes The client will

• attain/maintain a “healthy” weight
consume, on average, a varied and balanced
eating pattern that meets the recommended
• number of servings from the 2000-calorie
MyPlate meal plan
• implement healthy low-sodium, low-
cholesterol changes to his usual intake
without compromising nutritional or caloric
adequacy
Nutrition Therapy Encourage a varied and balanced eating pattern

that meets the recommended number of
servings from each of the major MyPlate
food groups for a 2000-calorie eating
pattern.
Client Teaching Instruct the client on:

• The role of nutrition in maintaining health and
quality of life, including the following:
• A balanced eating pattern consisting of a
variety of nutrient-dense foods helps
maximize the quality of life.
• Avoiding excess salt is prudent for all
people. Recommendations on sodium
intake should be made on an individual
basis according to the client’s cardiac and
renal status, appetite, and use of
medications.
Assessment
Although it is wise to avoid high-fat,
nutrient-poor foods such as most cakes,
• cookies, pastries, pies, chips, full-fat dairy
products, and fried foods, observing too
severe fat restriction compromises calorie
intake and may result in undesirable weight
loss.
• Eating plan essentials, including the
importance of
• choosing a variety of foods to help ensure
an average adequate intake (limiting food
choices or skipping a food group increases
the risk of both nutrient deficiencies and
excesses)
• eating enough food to avoid unfavorable
weight loss
• eating enough high-fiber foods such as
whole-grain breads and cereals, dried peas
and beans, and fresh fruits and vegetables
• drinking adequate fluid regularly
throughout the day
• Behavioral matters, including
• the importance of discussing the rationale
for the low-sodium, low-cholesterol diet
with his physician, particularly because he
has had an unfavorable weight loss
• how to read labels to identify low-sodium
foods
• Physical activity goals that may help improve
appetite and intake
Assessment
Evaluation
Evaluate and • Monitor weight and blood pressure.

Monitor • Provide periodic feedback and reinforcement
on food intake and questions about the eating
plan.
How Do You Respond?

Can diet help alleviate osteoarthritis pain? The most
compelling link between diet and osteoarthritis (OA) is
body weight. Currently, weight loss and increased
physical activity are the strongest evidence-based lifestyle
modifications for arthritis (Thomas et al., 2018). Obesity
not only increases the load on weight-bearing joints
(Messier et al., 2014); it also leads to low-grade systemic
inflammation, which can exacerbate symptoms (Hauner,
2005). Although a 10% weight loss may be enough to
reduce pain and improve physical functioning and
mobility, the ultimate goal should be to attain and
maintain normal BMI (Thomas et al., 2018). While
observational studies suggest that consuming omega-3
fatty acids from fish, using monounsaturated oils in place
of polyunsaturated oils, and consuming adequate amounts
of vitamins D, A, C, and E may help alleviate arthritis
symptoms, the evidence is limited (Thomas et al., 2018).
However, even if those strategies do not directly improve
arthritis symptoms, they may improve overall intake and
health.
REVIEW CASE STUDY
Annie is an 80-year-old widow who lives alone. She has a long history of
hypertension and diabetes and suffers from the complications of CHD and
neuropathy. She has diabetic retinopathy, which has left her legally blind.
She has never been compliant with a diabetic eating plan but takes insulin
as directed. She is 5 ft 5 in. tall and weighs 170 pounds, down from her
usual weight of 184 pounds 5 months ago.
Annie reluctantly agreed to receive Meals on Wheels, so she does not
have to prepare lunch and dinner except on weekends. Her daughter buys
groceries for Annie every week, and her grocery list generally consists of
milk, oatmeal, two cans of soup, two bananas, a bag of chocolate candy, a
layer cake, two doughnuts, and mixed nuts. Her weekend meals consist of
whatever she has available to eat.
• What is Annie’s BMI? How would you assess her weight status?
• Is her recent weight loss significant? Is it better for her to lose weight,
maintain her present weight, or try to regain what she has lost?
• What would you recommend Annie eat for breakfast? For snacks? For
weekend meals? Would you discourage her from eating sweets?
• What arguments would you make for her to eat better?
STUDY QUESTIONS
1 A 68-year-old man who has steadily gained excess weight over the years
complains that it is too late for him to make any changes in diet or
exercise regimen that would effectively improve his health, particularly
the arthritis in his knees. Which of the following would be the nurse’s
best response?
a. “Unfortunately, you’re right. You cannot benefit from a change in diet
and exercise now.”
b. “It is too hard for older people to change their habits. You should just
continue what you’ve been doing and know that it’s a quality of life
issue to enjoy your food.”
c. “It may not help to change your intake and exercise, but it certainly
wouldn’t hurt. Why don’t you give it a try and see what happens?”
d. “It is not too late to make changes, and losing weight through diet and
exercising are the best lifestyle interventions for osteoarthritis.”
2 The nurse knows their instructions about vitamin B12 are effective when a
65-year-old client verbalizes they will
a. consume more meat.
b. consume more fruits and vegetables.
c. eat vitamin B12–fortified cereal.
d. drink more milk.
3 A client complains that she is not eating any more than she did when she
was 30 years old and yet she keeps gaining weight. Which of the
following would be the nurse’s best response?
a. “As people get older, they lose muscle mass, which lowers their calorie
requirements, and physical activity often decreases too. You can
increase the number of calories you burn by building muscle with
resistance exercises and increasing your activity.”
b. “You may not think you are eating more calories but you probably are
because the only way to gain weight is to eat more calories than you
burn.”
c. “Weight gain is an inevitable consequence of getting older that is
related to changes in your body composition. Do not worry about it
because older people are healthier when they are heavier.”
d. “Weight gain among older adults is inevitable and untreatable.
Concentrate on eating a healthy eating pattern and do not focus on
weight.”
4 Which mineral is likely to be consumed in inadequate amounts by older
adults?
a. iron
b. calcium
c. iodine
d. sodium
5 The MedDiet differs from other healthy eating plans in that it
a. prohibits dairy intake.
b. is higher in fat content, primarily from olive oil, nuts, and fatty fish.
c. does not include fruit.
d. does not limit sweets.
6 Why are older adults at increased risk of vitamin D deficiency? Select all
that apply.
a. inadequate intake
b. impaired activation by the liver and kidneys
c. decreased ability to synthesize vitamin D on the skin
d. decreased GI absorption
7 What is a source of leucine that may help stimulate protein synthesis?
a. milk
b. nuts
c. legumes
d. grains
8 The MIND diet differs from the MedDiet in that it
a. prohibits the intake of alcohol.
b. prohibits the intake of red meat.
c. does not make a recommendation regarding fish intake.
d. lists green leafy vegetables as a separate recommendation from other
vegetables.
CHAPTER SUMMARY NUTRITION

FOR OLDER ADULTS
The population of older adults is increasing and is getting older. Older
adults represent a heterogeneous group that varies in health, activity, and
nutritional status.
Aging and Older Adults

Aging causes changes numerous changes in physiology and function,
digestion, nervous system functioning, kidney function, senses, income,
health, and psychosocial status. These changes can alter nutrient intake,
digestion, metabolism, excretion, or nutrient requirements.
Nutritional Needs of Older

Adults
• Calories: Requirements decrease because fewer calories are expended

on basal metabolic rate and on physical activity. Nutrient density
becomes more important.
• Protein: The RDA for protein appears to be too low for older adults to
maintain muscle mass. Need may increase to at least 1.0 to 1.2 g/kg/day
for healthy older adults.
• Fiber: Although the AI decreases due to a decrease in calorie intake,
older adults may benefit from increasing fiber to maintain regularity.
• Micronutrients: Most micronutrient needs remain constant throughout
adulthood except that:
• Vitamin D and calcium requirements increase.
• Vitamin B12 should be consumed from fortified foods or supplements.
• Iron requirement decreases for women after menopause.
• Vitamin and mineral supplements: A healthy eating pattern should
provide adequate amounts of micronutrients, but numerous
micronutrients are under-consumed by older adults. A multivitamin and
mineral supplement can help meet micronutrient requirements.
Healthy Aging
Healthy aging is generally considered as being free of major chronic
diseases, cognitive impairment, physical disabilities, and mental health
limitations. Healthy eating, physical activity, and not smoking greatly
influence aging.
• Healthy eating: Healthy eating means consuming the appropriate

amount of calories; consuming a mostly plant-based, nutrient-dense
eating pattern; and limiting the intake of added sugars, solid fats, and
sodium.
• Healthy eating index: Older adults eat healthier than other age groups
yet underconsume vegetables, fruits, whole grains, seafood, and dairy
products. Older women also consume less protein foods than
recommended. Average intakes of refined grains, added sugars, saturated
fat, and sodium exceed recommendations.
• Healthy eating patterns: Certain eating patterns may be associated with
better cognitive function and lower risk of cognitive impairment.
• The MedDiet is a plant-based diet that is high in fat from olive oil,
nuts, and fish. Alcohol, in the form of red wine, is consumed in
moderate amounts with meals.
• The MIND diet, a hybrid of the MedDiet and the DASH diet, was
specifically designed to reduce the risk of dementia and the decline in
brain health that usually occurs with aging. It features 10 foods to
emphasize and 5 to avoid.
• Physical activity: Older adults receive the same benefits as younger
adults from regular physical activity; in addition, it may reduce the risk
of falls. Adaptations may be necessary based on physical functioning.
Nutrition and Health Concerns
of Older Adults
Older adults generally consider themselves to be healthy even though most
have at least one chronic disease.
Malnutrition
Older adults are at disproportionate risk for inadequate intake and protein–
calorie malnutrition.
• Unintentional weight loss and loss of appetite may be used to screen
for malnutrition.
• Nutrition interventions that may improve intake and weight are: eating
with others, increasing the nutrient density of foods consumed, and
oral nutrition supplements between meals.
• Additional nutrition interventions for community dwelling adults:

Congregate meals and Meals on Wheels provide low-cost, nutritious
hot meals and opportunities for socialization.
• Additional nutrition interventions for long-term care residents: making
mealtimes enjoyable, promoting independence in eating, using
appropriate feeding strategies, and providing a liberal diet with few
dietary restrictions may help prevent malnutrition and improve quality
of life.
• Obesity: Obesity is a more prevalent weight issue than underweight.
The appropriate obesity treatment for older adults is controversial.
• Sarcopenia: A progressive and generalized skeletal muscle disorder
characterized by accelerated loss of muscle mass and insidious
functional decline.
• In part, sarcopenia may be caused by nutritional deficiencies, such as
an inadequate intake of protein.
• It is not known whether protein and/or amino acid supplementation
can effectively treat sarcopenia.
• Sarcopenic obesity refers to obesity with low skeletal muscle function
and mass.
• Frailty: a condition characterized by weight loss and loss of muscle
mass, weakness, poor endurance, exhaustion, slowness, and low activity.
• Frailty can occur in people who are obese.
• Nutrition therapy varies from protein–calorie supplements, planned
weight loss, and vitamin D supplementation.
• Alzheimer’s disease: A disease that is not a leading cause of death until
after age 65. It has a devastating effect on nutritional intake.
Figure sources: shutterstock.com/Oleksandra Naumenko, shutterstock.com/rkl_foto,
shutterstock.com/wavebreakmedia

book
athttps://thePoint.lww.com/activate
Websites
Administration on Aging, Administration for Community Living at https://acl.gov/about-
acl/administration-aging
Alzheimer’s Association at www.alz.org
American Association of Retired Persons at www.aarp.org
The American Geriatrics Society at www.americangeriatrics.org
America’s Health Rankings, United Health Foundation Senior Report at
https://www.americashealthrankings.org/learn/reports/2019-senior-report
Arthritis Foundation at www.arthritis.org
A guide to completing the MNA-SF at www.mna-elderly.com/forms/mna_guide_english_sf.pdf
National Institute of Aging Information Office at www.nia.nih.gov
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UNIT THREE
Nutrition in Clinical Practice

Hospital Nutrition:
Chapter Identifying Nutrition
15 Risk and Feeding
Clients
Miguel Hernandez
Miguel Hernandez is a 46-year-old man admitted to
the hospital for a laminectomy. Over the past month,
he has experienced considerable pain to the point
where he restricts his activity and has lost his
appetite. He is 5 ft 10 in. tall and weighs 193 pounds,
down from his usual weight of 209 pounds. He has a
history of type 2 diabetes. The plan is for him to be
discharged the day after surgery to ensure his blood
glucose levels are controlled.
Learning Objectives
Upon completi1on of this chapter, you will be able to:
1 List six characteristics that may be used to diagnose malnutrition.

2 Describe the purpose of a nutrition screen.
3 Explain nutrition therapy guidelines for clients at nutrition risk.
4 Discuss information obtained during a nursing history and physical that
can be used to assess for malnutrition.
5 Suggest strategies to promote an optimal intake in clients.
6 Modify a menu to an altered consistency diet (e.g., clear liquid, pureed
diet, mechanically altered diet).
7 Give examples of therapeutic diets and their uses.
8 Describe the characteristics of different categories of oral nutrition
supplements.
Through all degrees of health and illness, understanding and applying
nutrition knowledge and skills enable all members of the health care team
to effectively evaluate nutrition status and provide appropriate care
(DiMaria-Ghalili et al., 2014). Client care is improved when evidence-
based nutrition care is synchronized with and reinforced by all health
professionals, including physicians, nurses, pharmacists, occupational
therapists, physical therapists, speech and language pathologists, and
psychologists. Although the dietitian is the primary nutrition authority, it
takes an interdisciplinary team to provide optimal nutrition care.
This chapter serves as the introduction to clinical nutrition, covering the
prevalence of malnutrition among hospitalized clients and how it is
identified and treated, how nutrition is integrated throughout the nursing
care process, and the optimal approach for feeding clients, namely, oral
diets and oral nutritional supplements (ONS).
MALNUTRITION
The primary focus of clinical nutrition is to prevent or treat malnutrition (or

protein–calorie undernutrition in this context). Malnutrition is a common
and often unrecognized problem among hospitalized clients. Whether
clients are admitted with malnutrition or it develops during the course of
hospitalization, malnutrition is estimated to affect 20% to 50% of adult
hospitalized clients in the United States (Jensen et al., 2013). Among clients
undergoing surgery, an estimated 24% to 65% are at nutrition risk
(Wischmeyer et al., 2018). In practice, as few as 5% to 8% of clients
receive a documented or coded diagnosis of malnutrition during their
hospitalization (Tobert et al., 2018).
Malnutrition
literally, bad nutrition. In practice, malnutrition refers specifically to protein–calorie
undernutrition.
Malnutrition is a major contributor to morbidity and mortality, impaired

function, decreased quality of life, increased frequency and length of
hospital stay, and higher health care costs (White et al., 2012). Suboptimal
nutritional status is also a strong independent predictor of poor
postoperative outcomes (Wischmeyer et al., 2018). The deleterious effect of
malnutrition not only affects virtually all organ systems but can also impair
cognitive ability, leaving clients unable to make independent, informed
consent when they are in a severely compromised nutritional state (Russo et
al., 2016).
Diagnosis of Malnutrition
The Academy of Nutrition and Dietetics and the American Society of
Parenteral and Enteral Nutrition (ASPEN) have proposed that clients who
have at least two of the following six criteria are malnourished (White et al.,
2012):
• inadequate calorie intake
• unintentional weight loss
• loss of muscle mass
• loss of subcutaneous fat
• localized or generalized fluid accumulation that may mask weight
loss
• diminished functional status as measured by handgrip strength
Malnutrition is classified as severe or non-severe (moderate) based on

specific thresholds and/or descriptions for each of the above criteria.
The etiology-based approach for defining malnutrition involves
assessing the client for the presence of inflammation, a potent contributor to
disease-related malnutrition (Fig. 15.1) (Malone & Hamilton, 2013).
Figure 15.1 ▲ Etiology-based malnutrition definitions. (Source: White,

J., Guenter, P., Jensen, G., Malone, A., & Schofield, M., Academy of
Nutrition and Dietetics Malnutrition Work Group, ASPEN Malnutrition
Task Force, and the ASPEN Board of Directors. [2012]. Consensus
statement of the Academy of Nutrition and Dietetics and American Society
for Parenteral and Enteral Nutrition: Characteristics recommended for the
identification and documentation of adult malnutrition (undernutrition).
Journal of the Academy of Nutrition and Dietetics, 112[5], 730–738.
https://doi.org/10.1016/j.jand.2012.03.012)
• Starvation-related malnutrition occurs when food is not available

due to environmental or social circumstances. Inflammation is
absent. It usually develops slowly and may be caused by abuse,
neglect, famine, poverty, or disordered eating (Skipper, 2012).
• Chronic disease–related malnutrition may occur in clients with
diseases such as congestive heart failure or chronic obstructive
pulmonary disease. A mild to moderate degree of inflammation
impedes appetite, intake, or nutrient utilization.
• Acute disease–related or injury-related malnutrition may occur in
clients with critical illness, multi-trauma, or major infection due to a
marked inflammatory response. These clients may be adequately
nourished upon admission but are at high risk for malnutrition due
to the nature of their illness.
Timely identification and treatment of malnutrition is critical to

improving client outcomes (Field & Hand, 2015). The process of
identification begins with nutrition screening and continues with a nutrition
assessment and individualized nutrition care plan as needed. Figure 15.2
illustrates the interdisciplinary approach to nutrition care.
Figure 15.2 ▲ The Alliance to Advance Patient Nutrition approach to
interdisciplinary nutrition care. (Source: Tappenden, K. A., Quatrara, B.,
Parkhurst, M. L., Malone, A. M., Fanjiang, G., & Ziegler, T. R. [2013].
Critical role of nutrition in improving quality of care: An interdisciplinary
call to action to address adult hospital malnutrition. Journal of the Academy
of Nutrition and Dietetics, 113[9], 1219–1237.
https://doi.org/10.1016/j.jand.2013.05.015)
Nutrition Screening
Nutrition screening is used to identify clients at risk for malnutrition and
those who are likely to benefit from further assessment and intervention.
Note that when a client is found not to be at risk for malnutrition, it does not
mean the client is without health risks. For instance, a client admitted with
symptoms of a myocardial infarction may not have malnutrition but may
still be at high risk for morbidity and mortality related to the admitting
diagnosis.
Nutrition Screening
a quick look at a few variables to judge a client’s relative risk for nutritional problems. Nutrition
screening can be general for malnutrition or custom designed for a particular population (e.g.,
pregnant women).
Screening Protocol
The Joint Commission, a nonprofit organization that sets health care
standards and accredits health care facilities that meet those standards,
specifies that nutrition screening must be conducted within 24 hours after
admission to a hospital or other health care facility.
• Because the standard applies 24 hours a day, seven days a week,
staff nurses are usually responsible for completing the screen as part
of the admission process.
• Each facility is able to determine the criteria it uses for screening,
who completes nutrition screening, and when rescreening is
required.
• Clients identified as at risk for malnutrition are referred to a dietitian
for further nutrition assessment, diagnosis, and intervention.
• Clients determined to be at low risk are rescreened within a
specified time frame to identify if changes in risk have developed
(Field & Hand, 2015).
Screening Tools
A number of screening tools are available.
• Tools vary in their intended population (e.g., adults or older adults),
intended setting (e.g., hospital or community settings), levels of
agreement, reliability, generalizability, complexity, and validity
(Skipper et al., 2020).
• To be useful, screening tools should be quick, simple, valid
(sensitive and specific), and reliable and done regularly to identify
changes in risk (Field & Hand, 2015).
• Criteria that often comprise a screening tool are recent weight loss,
recent food intake, and current body mass index (BMI); disease
severity may also be included (Rasmussen et al., 2010).
• An example of a widely used validated tool for screening adults,
including older adults, in inpatient and outpatient settings is the
Malnutrition Screening Tool (MST) (Fig. 15.3). It consists of only
two criteria that are scored to determine at risk status.
• The Academy of Nutrition and Dietetics recommends the MST as
the single tool to screen adults for malnutrition (undernutrition)
regardless of their age, medical history, or the setting (Skipper et al.,
2020).
Figure 15.3 ▲ Malnutrition Screening Tool. (Source: Ferguson, M.,
Capra, S., Bauer, J., & Banks, M. [1998, August 30]. Development of a
valid and reliable malnutrition screening tool for adult acute hospital
patients. Nutrition, 15[6]. 458–464. https://doi.org/10.1016/S0899-
9007(99)00084-2)
Think of Miguel. Based on findings from his health

assessment, is he at nutrition risk according to the MST (Fig.
15.3)?
NUTRITION ASSESSMENT
Clients found to be at risk for malnutrition through screening are referred to

a dietitian for a comprehensive nutritional assessment to identify specific
risks or confirm the existence of malnutrition. Nutrition assessment
encompasses the nutrition care process and its four steps (Fig. 15.4). While
nurses use the same problem-solving model to develop nursing or
multidisciplinary care plans that may integrate nutrition, the nutritional care
plan created by dietitians is specific for nutrition problems. Box 15.1
identifies activities of the dietitian.
an in-depth analysis of a person’s nutritional status. In the clinical setting, nutritional assessments
focus on at-risk clients with suspected or confirmed protein–energy malnutrition.
Nutrition Therapy for Clients at Nutritional Risk

An adequate intake of calories and protein is the focus of nutrition therapy
for clients at nutritional risk. When protein intake is inadequate, loss of lean
body mass occurs and recovery and quality of life are impaired. Calories are
essential for sparing protein from being used for energy, yet glucose without
protein (e.g., simple IV solutions of dextrose and water) cannot promote
anabolism (Wischmeyer et al., 2018). Both calories and protein are needed
to maintain lean body mass and weight.
Dietitians may use the following general guidelines to calculate a
nutrition prescription that is then individualized according to the client’s
nutritional status and response to feedings:
• Calories: A simple method of estimating calorie needs is to
multiply a person’s weight in kilograms by a factor appropriate for
the medical condition. A range frequently used is 25 to 30
cal/kg/day. Calories per kilogram are adjusted upward or downward
as appropriate for the client’s condition or response to nutrition
therapy.
• Other predictive equations are available to estimate resting energy
expenditure (REE) such as the Mifflin-St Jeor equation (see
Chapter 8). REE is then multiplied by factors to account for
activity and degree of physiologic stress.
• Indirect calorimetry, which measures oxygen consumption and
carbon dioxide production, is the reference standard for
determining calorie expenditure in critically ill patients and in
patients who fail to respond to presumed adequate nutrition
support (Mtaweh et al., 2018). It provides a more accurate
estimate of energy needs than predictive equations, but it is not
always available, necessary, or feasible.
• Protein: Ensure adequate protein intake.
• Actual protein need varies with the client’s medical condition. For
instance, clients with cancer may need 1.2 to 1.5 g protein/kg/day
to help maintain or restore lean body mass (Arends et al., 2017)
and postsurgical clients may need 1.5 to 2.0 g/kg/day
(Wischmeyer et al., 2018). Protein is more of a priority for
postsurgical clients than is total calorie intake.
• To achieve an adequate protein intake, high-protein ONS may be
recommended 2 to 3 times/day.
• Feeding method: Clients who are unable to consume at least 50%
of their protein and calorie goals orally may require enteral nutrition
support.
• Parenteral nutrition is considered only if the oral and enteral
routes are inadequate or unavailable.
Figure 15.4 ▲ The nutrition care process. Like the nursing process, the
nutrition care process is a problem-solving method used to evaluate
and treat nutrition-related problems.
Activities of the Dietitian

BOX
15.1
• Dietitians interview clients and/or families to obtain a nutrition

history which can help differentiate nutrition problems caused by
inadequate intake from those related to disease.
• A nutrition history may include information on
• current dietary habits,
• recent changes in intake or appetite,
• usual snack and meal pattern,
• alcohol intake,
• food allergies and intolerances,
• ethnic, cultural, or religious diet influences, and
• nutrition knowledge and beliefs.
• They calculate estimated calorie and protein requirements based
on the assessment data and determine whether the diet ordered is
adequate and appropriate for the client.
• They determine nutrition diagnoses that define the nutritional
problem, etiology, and signs and symptoms. While a nursing
analysis statement may be malnutrition risk a nutrition diagnosis
would be more specific, such as, “inadequate protein-energy
intake.”
• Dietitians determine the appropriate malnutrition diagnosis code
for the client for hospital reimbursement purposes.
• They determine the appropriate nutrition intervention, such as a
nutrition prescription detailing specific recommendation
regarding diet, calorie intake, or feeding method, nutrition
education, and coordination of nutrition care.
Think of Miguel. Using the general guidelines, how many

calories does he need? How much protein? Does a regular
oral diet provide Miguel with all the protein he needs? Is he
a good candidate for ONS?
NURSING
PROCESS Malnutrition
Neil Stein is 42 years old, 5 ft 11 in. tall, and has weighed 185 pounds
for most of his adult life. He was diagnosed with acute myelogenous
leukemia 7 weeks ago and spent 31 days in the hospital for the first
round of chemotherapy. He is admitted to the hospital for a week of
chemotherapy that starts with his admission. His admitting weight is
162 pounds. He appears thin and fatigued. He complains of nausea,
anxiety, taste changes, and poor appetite. His weight loss and loss of
appetite qualify him for a diagnosis of malnutrition.
Assessment
Medical– • Medical history that may have nutritional

Psychosocial implications, such as diabetes or GI disorders
History • Medications that may affect nutrition
• Current treatment plan
• Other symptoms Neil is experiencing related
to leukemia or its treatment
Anthropometric • Current BMI

Assessment • Percent weight loss
Biochemical and • Check abnormal laboratory values for their

Physical nutritional significance.
Assessment • Assess body fat, muscle mass, handgrip.
• Assess blood pressure.
Assessment
Dietary Assessment • How many meals do you consume daily?

• Do you avoid any foods?
• What foods do you eat most often?
• Do you feel hungry?
• Do you use ONS?
• How do you compensate for taste alterations?
• Does he understand the importance of eating
an adequate intake?
• Did you have any dietary restrictions before
being diagnosed with leukemia?
Analysis
Possible Nursing Malnutrition risk related to poor intake and other

Analysis side effects from cancer and cancer treatment as
evidenced by weight loss
Planning

• maintain his weight,
• consume three meals each day,
• consume three ONS each day, and
• verbalize the importance of consuming an
adequate calorie and protein intake.
Assessment
Nutrition Therapy • Provide a regular diet as prescribed.

• Encourage alternate selections when the menu
does not offer desirable foods.
• Encourage consumption of the ONS.
Client Teaching • Instruct the client on the following:
• Eating plan essentials:
• The importance of eating an adequate
intake to maintain weight
• The importance of consuming adequate
protein to restore lean body mass
• The importance of consuming the ONS
• Behavioral matters:
• Relying entirely on ONS, which can
provide complete nutrition, if unable to
consume solid foods
• Thinking of food as medicine, not as a
pleasurable option
Evaluation
Evaluate and • Monitor weight and intake.

Monitor • Assess tolerance to regular diet.
• Monitor tolerance to ONS.
• Need for additional nutrition counseling.
NUTRITION IN THE NURSING
PROCESS
Nutrition has been an integral component of nursing care since Florence

Nightingale noted nutrition as the second most important area for nursing
(Nightingale, 1992). Until the dietetics profession was founded, nurses were
responsible for preparing and serving food to the sick. Today, nurses play a
vital role in creating a culture that values nutrition and in achieving‐
successful nutrition-related client outcomes (Tappenden et al., 2013).
Nurses are often responsible for nutrition screening, integrate nutrition into
nursing care plans, and obtain assessment data that dietitians use in
completing nutrition assessments. The following sections are intended to
help nurses provide quality nursing care that includes basic nutrition, rather
than help nurses become dietitians.
Nursing Assessment
Dietitians may obtain much of their preliminary assessment data about the
client from the nursing history and physical examination, such as skin
integrity, problems chewing, swallowing, or self-feeding, use of
supplements and over-the-counter medications, and living situation.
Dietitians rely on nurses for ongoing monitoring and documentation of
changes in intake, weight, and function.
Medical–Psychosocial History
The chief complaint and medical history may reveal disease-related risks
for malnutrition and the presence of inflammation (see Fig. 15.1).
• Medical conditions often associated with malnutrition include
AIDS, alcoholism, cancer, cardiovascular disease, celiac disease,
chronic kidney disease, diabetes, liver disease, and dementia and
other mental illness.
• Among surgical clients, the risk of malnutrition is often most
significant after major gastrointestinal (GI) and oncologic surgery
(Wischmeyer et al., 2018).
• Box 15.2 lists psychosocial factors that may affect intake or
requirements and may help identify nutrition counseling needs.
Height, Weight, and Body Mass Index

Weight status, as determined by BMI, is an important factor in a person’s
overall health and risk for disease.
Body Mass Index (BMI)

an index of weight in relation to height that is calculated mathematically by dividing weight in
kilograms by the square of height in meters. BMI interpretations are as follows:
<18.5 Underweight
18.5–24.9 Healthy weight
25–29.9 Overweight
≥30 Obese
• An accurate BMI is dependent upon accurate measures of height

and weight. Because it is relatively quick and easy to measure
height and weight and requires little skill, actual measures, and not
estimates, should be used whenever possible.
• A client’s stated height and weight should be used only when there
are no other options.
• Although malnutrition can occur at any BMI, people at extremes of
BMI may be at increased risk of poor nutritional status (White et al.,
2012).
BOX Psychosocial Factors That May Affect

Intake, Nutritional Requirements, or
15.2 Nutrition Counseling
Psychological Factors
• Depression
• Anxiety
• Eating disorders
• Psychosis
Social Factors
• Illiteracy
• Language barriers
• Limited knowledge of nutrition and food safety
• Lack of caregiver or social support system
• Social isolation
• Lack of or inadequate cooking arrangements
• Limited or low income
• Limited access to transportation to obtain food
• Advanced age (older than 80)
• Lack of or extreme physical activity
• Use of tobacco or recreational drugs
• Limited use or knowledge of community resources
Weight Loss
Unintentional weight loss is a well-validated indicator of malnutrition
(White et al., 2012).
• The significance of weight change is determined after the
percentage of weight loss in a given period of time is calculated
(Table 15.1).
• The client’s weight can be unreliable or invalid due to hydration
status. Edema, anasarca, fluid resuscitation, heart failure, and
chronic liver or kidney disease can falsely inflate weight.
Percentage of Weight Loss
a calculation where the amount of weight lost is divided by usual body weight then multiplied by
100.
(amount of weight loss/usual body weigh) × 100 = percentage of weight loss
Remember Miguel. What is his percent weight loss? How

would you classify it? What is his BMI? Does his BMI
indicate a risk of malnutrition? Do the screening findings
support a diagnosis of malnutrition?
Table Interpretation of Weight Loss

15.1 by Malnutrition Etiology
Moderate Severe
Etiology of Malnutrition Malnutrition Malnutrition
Starvation or chronic 5%/1 month >5%/1 month
disease 7.5%/3 months >7.5%/3 months
10%/6 months >10%/6 months
20%/1 year >20%/1 year
Acute disease or injury 1%–2%/1 week >2%/1 week
5%/1 month >5%/1 month
7.5%/3 months >7.5%/3 months
Source: Malone, A., & Hamilton, C. (2013). The Academy of Nutrition and Dietetics/The American
Society for Parenteral and Enteral Nutrition consensus malnutrition characteristics: Application in
practice. Nutrition in Clinical Practice, 28(6), 639–650.
https://doi.org/10.1177/0884533613508435
Dietary Intake
An intake of food that is less than estimated requirements is a characteristic
of malnutrition. However, like other data, a food intake history obtained
from the client or caregiver may not be reliable.
• Simply asking a client “How is your appetite?” will not provide
sufficient information regarding their dietary intake. A better
question is, “Has the type or amount of food you usually eat
changed recently?” with a follow-up question to explain their
answer (“How did it change?” or “Why do you think it has
changed?” are examples).
• Another question to avoid while obtaining a nursing history is, “Are
you on a diet?” To most people, the word diet is synonymous with
weight loss. They may fail to mention that they use nutrition therapy
to limit sodium, modify fat, or count carbohydrates. A better
question is, “Do you avoid any particular foods?” or “Do you watch
what you eat in any way?”
• Depending on the circumstances, valuable information may be
gained by asking the client what concerns they have about what or
how they eat, how illness has affected their choice or tolerance of
food, and if they have enough food to eat.
Physical Findings
Physical findings occur only with overt malnutrition, not with subclinical
malnutrition, and can vary among population groups because of genetic and
environmental differences. Physical findings that may indicate risk for
malnutrition include the following:
• loss of subcutaneous fat, such as in the orbital region, upper arm,
and thoracic regions
• loss of muscle mass, such as in the quadriceps, trapezium, and
deltoid muscles
• localized or generalized fluid retention in the lower and upper
extremities, face and eyes, and/or scrotal area
• Fluid accumulation may also be caused by other conditions like
congestive heart failure or chronic kidney disease.
• diminished handgrip strength as measured by a dynamometer
• other physical findings as listed in Box 15.3
• Most findings cannot be considered diagnostic because the
evaluation of normal versus abnormal findings is subjective, and
the signs of malnutrition may be nonspecific. For instance, dull,
dry hair may be related to severe protein deficiency, overexposure
to the sun, or the use of harsh hair products.
Laboratory Data
Currently, there is no universally agreed-upon biochemical indicators to
diagnose malnutrition.
• While albumin has traditionally been used as an indicator of
malnutrition, it is neither specific nor sensitive enough to be a
marker for malnutrition (Nelson et al., 2015).
• The major cause of low albumin and other visceral proteins is
inflammation, not malnutrition (Cederholm et al., 2015).
Inflammation is considered an etiologic factor of malnutrition, not a
diagnostic feature.
• However, albumin is often part of a nutrition screen because it is a
good indicator of disease severity and outcome and a strong
predictor of surgical risk and mortality (Wischmeyer et al., 2018).
BOX Physical Findings Suggestive of

15.3 Malnutrition
• Hair that is dull, brittle, dry, or falls out easily

• Swollen glands of the neck and cheeks
• Dry, rough, or spotty skin that may have a sandpaper feel
• Poor or delayed healing of wounds or sores
• Depressed mood
• Abnormal heart rate, heart rhythm, or blood pressure
• Enlarged liver or spleen
• Loss of balance and coordination
Nursing Analysis
Nursing analyses relate directly to nutrition when the pattern of nutrition
and metabolism is the problem. For example, risk of malnutrition related to
poor intake as evidenced by weight loss is a nursing analysis. Other nursing
analyses may not be as specific for nutrition but may involve nutrition as
part of the nursing care plan, such as teaching the client how to increase
fiber intake to relieve constipation.
Nutrition-Related Client Outcomes

Whenever possible, the client should actively participate in goal setting,
even if the client’s perception of need differs from yours. In matters that do
not involve life or death, it is best to first address the client’s concerns. For
example, your primary consideration for a client who has undergone six
months of chemotherapy may be their significant weight loss, whereas the
client’s major concern may be fatigue. The two concerns are undoubtedly
related, but your effectiveness as a change agent is greater if you approach
the problem from the client’s perspective. Commitment to achieving the
goal is greatly increased when the client believes they own the goal.
• The goal for all clients is to consume adequate calories, protein, and
nutrients using foods they like and tolerate, as appropriate.
• If possible, additional short-term goals may be set to alleviate
symptoms or side effects of disease or treatments and to prevent
complications or recurrences if appropriate.
• After short-term goals are met, attention can expand to promoting
healthy eating to reduce the risk of chronic-diet-related diseases
such as obesity, diabetes, hypertension, and heart disease.
Nutrition Interventions
Nutrition care plans include a nutrition prescription based on the client’s
nutrition diagnoses and estimated needs. Specific nutrition intervention
strategies focus on the etiology of the problem. The nurse is involved in
implementing nutrition interventions, basic nutrition education/reinforcing
nutrition teaching, and communicating with other members of the health
care team.
Implementation
The nutrition prescription may detail recommendations regarding calories,
protein, other nutrients, specific foods, or the method of feeding. The
nurse’s role may be to
• ensure that dietitian-prescribed interventions occur in a timely
manner,
• facilitate nursing interventions to treat clients who have or are at risk
of malnutrition,
• ensure clients receive automated nutrition intervention (e.g., food,
oral supplements) if there is a delay between nutrition screening and
nutrition assessment,
• promote optimal intake of food and ONS (Box 15.4).
Educate and Reinforce

Include nutrition in all discussions with clients and their family members.
• Reinforce the importance of obtaining adequate nutrition.
• Review basic principles of the eating plan and avoid the term diet.
• Counsel the client about drug–nutrient interactions.
• Emphasize things “to do” instead of things “not to do.”
• Keep the message simple.
• Respond to questions.
• Review written handouts with the client.
• Advise the client to avoid foods that are not tolerated.
BOX
Strategies to Promote an Optimal Intake
15.4
• Avoid disconnecting enteral or parenteral nutrition for client
repositioning, ambulation, procedures, etc.
• Advocate discontinuation of intravenous therapy as soon as
feasible.
• Advocate aggressively for diet progressions.
• Replace meals withheld for diagnostic tests.
• Promote congregate dining, if appropriate.
• Question diet orders that appear inappropriate.
• Display a positive attitude when serving food or discussing
nutrition.
• Help the client select appropriate foods. Offer standby choices for
clients who do not like menu selections.
• Gently motivate the client to eat.
• Encourage clients who feel full quickly to eat the most nutrient-
dense items first: meat and milk rather than juice, soup, or coffee,
etc.
• Order snacks and ONS.
• Request assistance with feeding or meal setup.
• Get the client out of bed to eat, if possible.
• Encourage good oral hygiene.
• Screen the client from offensive sights and remove unpleasant
odors from the room.
• Downgrade the consistency of the diet (e.g., provide a soft diet) if
the client has difficulty chewing or swallowing.
Communicate
Dietitians rely on nurses for their observations and feedback.
• Communicate concerns regarding eating, nutrition, or client
knowledge.
• Communicate changes in the client’s condition that may indicate
nutrition risk.
• Include nutrition discussions into handoff of care and nursing care
plans.
Nutrition-Related Monitoring
Monitoring the client’s acceptance and tolerance to the nutrition
prescription allows for timely revision of the plan as needed. Nurses are in
an ideal position to monitor the client’s nutrition because of their close,
ongoing contact with the client and their family.
• Observe intake of food and supplements whenever possible.
• Document appetite and take action when the client does not eat.
• Order supplements if intake is low or needs are high.
• Initiate calorie counts.
• Request a nutritional consult.
• Assess tolerance (i.e., absence of side effects).
• Monitor weight.
• Monitor progression of nothing by mouth status and restrictive diets.
• Monitor the client’s grasp of the information and motivation to
change.
• Rescreen clients within established time frame.
FEEDING HOSPITALIZED CLIENTS
The goal of nutrition intervention for all hospitalized clients, whether or not
they have been diagnosed with malnutrition, is to provide sufficient calories
and nutrients to meet the client’s estimated needs in a form the client can
tolerate and utilize.
Private and government regulatory agencies stipulate meal timing,
frequency, and nutritional content and require that hospital menus be
supervised by a qualified dietitian. Many hospital food service departments
offer a room service, cook-to-order menu. Compared to more traditional
food service menus, a restaurant-style service gives clients greater control
over what and when they eat. Restaurant-style service has also been shown
to improve calorie and protein intake, reduce plate waste, and improve
client satisfaction (McCray et al., 2018).
Oral Diets
Oral diets are the easiest and most preferred method of providing nutrition.
In most facilities, clients choose what they want to eat from a menu
representing the diet ordered by the physician. Oral diets may be
categorized as regular, modified consistency, or therapeutic. Often,
combination diets are ordered, such as a pureed, low-sodium diet or a high-
protein, soft diet. The actual foods allowed on a diet varies among
institutions and the diet manual in use.
Although hospital diets provide adequate amounts of calories and
protein, most clients do not consume complete meals. A recent study found
that 32.1% of adult hospitalized clients ate a quarter of their meal or less
(Sauer et al., 2019).
• Appetite may be impaired by fear, pain, or anxiety.
• Hospital food may be refused because it is unfamiliar, tasteless (e.g.,
cooked without salt), inappropriate in texture (e.g., pureed meat),
religiously or culturally unacceptable, or served at times when the
client is unaccustomed to eating.
• Clients may underestimate the importance of nutrition in their
recovery process.
Regular Diet
Regular diets are used to achieve or maintain optimal nutritional status in
clients who do not have impaired ability to eat or tolerate an oral intake or
altered nutritional needs. No foods are excluded, and portion sizes are not
limited. The nutritional value of the diet varies significantly with the actual
foods chosen by the client.
Regular diets are adjusted to meet age-specific needs throughout the life
cycle. For instance, a regular diet for a child differs from that of an adult.
Regular diets are also altered to meet specifications for vegetarian or kosher
eating.
Sometimes, physicians order a diet as tolerated (DAT) on admission or
after surgery. This order is interpreted according to the client’s appetite and
ability to eat and tolerate food. The nurse has the authority to advance the
DAT.
Remember Miguel. He is ordered on a regular diet for his

first meal postoperatively. Why wasn’t he ordered on a
carbohydrate-controlled diet due to his history of type 2
diabetes? When his tray arrives, Miguel doesn’t want to eat
it, stating that his throat is sore and the foods provided are
not items he normally eats. What steps would you take to
encourage Miguel to eat?
Modified Consistency Diets

Modified consistency diets include clear liquid and mechanically altered
diets (Table 15.2). Clear liquid diets are most commonly used in preparation
for colonoscopy.
• Traditionally, a clear liquid diet was ordered as the first
postoperative meal based on the rationale that a gradual progression
from a clear liquid diet to a regular diet maximized tolerance when
eating resumed.
• It is now known that early resumption of oral feeding after major
surgery, including GI surgery, is associated with a decrease in
postoperative complications, length of stay, and mortality (Warren et
al., 2011).
• It is recommended that clear liquid diets not be routinely used
postoperatively because they do not provide adequate nutrition or
protein (Wischmeyer et al., 2018). The current recommendation is
that a high-protein diet of food and/or high-protein ONS be initiated
on the day of surgery in most cases (Wischmeyer et al., 2018).
Table Characteristics of Modified

15.2 Consistency Diets
Diet Characteristics Foods Allowed Indications

Clear liquid
A short-term, highly restrictive • Clear broth or • In preparation
diet composed only of fluids bouillon for bowel
or foods that are transparent • Coffee, tea, surgery or
and liquid at body and colonoscopy
temperature (e.g., gelatin). It carbonated • Acute
requires minimal digestion beverages, as gastrointestinal
and leaves a minimum of allowed and disorders
residue. Inadequate in as tolerated • Transitional
calories and all nutrients • Fruit juices: feeding after
except vitamin C if vitamin clear (apple, parenteral
C–fortified juices are used. cranberry, nutrition
grape) and • Routine use of
strained a clear liquid
(orange, diet after
lemonade, surgery is not
grapefruit) recommended
• Fruit ice (Wischmeyer
made from et al., 2018).
clear fruit
juice
• Gelatin
• Popsicles
• Sugar, honey,
hard candy
• Commercially
prepared clear
liquid
supplements
Pureed diet
A diet composed of foods that All foods are • Used after oral
are blended, whipped, or allowed, but or facial
mashed to pudding-like consistency surgery
consistency. is changed • For wired jaws
All foods should be smooth, not to liquid. • Chewing and
sticky, and free of lumps. swallowing
Requires minimal chewing problems
ability.
Most foods can be liquefied by
combining equal parts of
solids and liquids; fruits and
vegetables need less liquid.
Broth, gravy, cream soups,
cheese, tomato sauce, milk,
and fruit juice are preferable
to water for blenderizing
due to their higher calorie
and nutritional value.
Liquids may be thickened to
improve ease of swallowing.
Mechanically altered diet
A regular diet modified in • Milk Used for clients
texture only and excludes • Yogurt who have
most raw fruits and • Pudding limited
vegetables and foods chewing
• Cottage
containing seeds, nuts, and ability such
cheese
dried fruit. as clients
• Mashed, soft who
Gravies, sauces, milk, and water
ripened fruit
are used to soften foods that • are edentulous
(peaches,
are chopped, ground, • have ill-fitting
pears,
mashed, or cooked soft. dentures
bananas)
Sticky foods such as peanut • have
butter are avoided. • Cooked,
mashed soft undergone
vegetables surgery to the
(peas, carrots, head, neck, or
yams) mouth
• Ground meats
• Soft
casseroles
• Smooth
cooked
cereals
• Soft bite-
sized pasta
• Bread
products
made into a
slurry with
the addition
of gravy or
syrup
Soft diet
A regular diet that features soft- • Soft-cooked • Used to limit
textured foods that are easy vegetables gastrointestinal
to chew and swallow. Hard, • Shredded irritation and
sticky, dry, or crunchy foods lettuce minimize gut
are excluded. • Canned fruit activity for
healing
• Soft, peeled
purposes
fresh fruit
• Not intended
• Well-
for long-term
moistened,
use because it
thin-sliced,
can cause
tender, or
constipation
ground meats;
poultry; or
fish
• Eggs
• Milk
• Yogurt
• Mashed
potatoes
• White rice
• Well-cooked
pasta
• Well-
moistened
cereals
without dried
fruits or nuts
Mechanically altered diets contain foods that are pureed,

chopped/ground, or soft for clients who have difficulty chewing or
swallowing. Dysphagia diets are another variation of modified consistency
diets that are covered in Chapter 19.
Therapeutic Diets
Therapeutic diets differ from a regular diet in the amount of one or more
nutrients or food components for the purpose of preventing or treating
disease or illness. The number or timing of meals may also be altered. Table
15.3 outlines the characteristics and indications of selected therapeutic
diets.
Oral Nutrition Supplements

Oral nutrition supplements (ONS) are often used for inadequate intake or to
treat malnutrition. They provide calories, protein, and micronutrients to
help limit weight loss and promote recovery of lost lean body mass (Bally
et al., 2016). ONS use has been shown to reduce readmission rates and
health care costs (Philipson et al., 2013).
Table Selected Therapeutic Diets:

15.3 Characteristics and Indications
Type of Diet Characteristics Indications

Heart
healthy • Limited in saturated • High-serum low-density
(cardiac) fats (less than 7%– lipoprotein (LDL)
10% total calories), cholesterol
trans fats, and • Prevention or treatment of
sodium (less than cardiovascular disease
2300 mg/day)
• Encourages whole
grains, fruits,
vegetables,
unsaturated fats, and
appropriate calories
to attain/maintain
healthy weight
Consistent
carbohydrate • Consistent total daily • Type 1 and type 2
carbohydrate content diabetes
with emphasis on • Gestational diabetes
heart-healthy food • Impaired glucose
choices tolerance
• Calories are based • Impaired fasting glucose
on attaining and
maintaining healthy
weight
• A high fiber intake is
encouraged and
sodium may be
limited
Fat restricted
• Limits total fat: • Malabsorption syndromes
Limitations vary • Liver disease
from less than 25–50 • Pancreatic disease
g/day
• Chronic cholecystitis
• Gastroesophageal reflux
High fiber A general diet with To prevent or treat
low-fiber foods
replaced by foods • constipation
high in fiber with a • diabetes
goal of 25–35 g or • irritable bowel syndrome
more per day • hypercholesterolemia
• obesity
Low fiber
• Limits fiber by • Before surgery to
eliminating skins, minimize fecal residue
membranes, and • During acute phases of
seeds from fruits and intestinal disorders such
vegetables as ulcerative colitis,
• Allows grains with Crohn’s disease, and
less than 2 g diverticulitis
fiber/serving • Radiation therapy to the
• Excludes nuts, seeds, pelvis and lower bowel
and dried fruits • Recent intestinal surgery
• Lactose may also be • New colostomy or
restricted ileostomy
High calorie, A diet rich in calorie-
high protein dense and/or • To meet increased
protein-dense foods nutritional requirements
• Also used in clients with
poor intakes
Renal Stages 1–4 chronic kidney
• Slightly lower in disease
protein
• Emphasizes heart-
healthy fats
• Adequate in calories
• Sodium, potassium,
and phosphorus
levels adjusted
depending on the
stage of chronic
kidney disease
Potassium Potassium may be • Low-potassium diets may
modified increased or be used in the treatment
restricted by of certain renal diseases
manipulating in conjunction with
potassium-rich certain medications or in
foods, such as adrenal insufficiency
• fruits • High-potassium diets may
• vegetables be used in conjunction
• whole grains with certain medications
• milk and with certain renal
diseases
• meats
• legumes
Sodium Sodium limit may be
restricted set at 1500 mg/day or • May be prescribed for
2000 mg/day hypertension and
congestive heart failure
• Acute and chronic renal
disease
• Liver disease
Gluten free • Sources of gluten (a • Celiac disease (celiac
protein in wheat, sprue, nontropical sprue,
rye, and barley) are gluten-sensitive
eliminated from the enteropathy)
diet • Dermatitis herpetiformis
• Gluten-free grains, rash
such as corn, potato,
rice, soy, and quinoa,
are encouraged as
sources of complex
carbohydrates
Lactose Limits foods with
restricted lactose (“milk sugar”) • Lactose intolerance
to the amount tolerated • Lactase insufficiency that
by the individual may occur secondary to
certain inflammatory
gastrointestinal disorders
such as ulcerative colitis
and Crohn’s disease
Table Oral Nutrition

15.4 Supplements
Categories of supplements include clear liquid supplements, milk-based
drinks, commercially prepared liquid supplements, specially prepared
foods, and bariatric meal replacements (Table 15.4). Liquid supplements are
easy to consume, are generally well accepted, and tend to leave the stomach
quickly making them a good choice for snacks that are between meals.
ONS compliance in hospitalized clients has been estimated at 67%
(Hubbard et al., 2012). Despite uncertain compliance, ONS have been
found to provide clinical benefits (Sriram et al., 2017). Actions that help
promote compliance include obtaining taste preferences, explaining the
potential benefits, serving supplements cold, and rotating different types of
supplements and flavors to help forestall or prevent taste fatigue that tends
to occur over time. Acceptance should be closely monitored and the
percentage consumed documented.
Recall Miguel. He vomited after eating. Would he be a

candidate for an ONS? What category of ONS would be
appropriate for him? Would an ONS be appropriate for him
after discharge?
How Do You Respond?
Should I save my menus from the hospital to help me
plan meals at home? This is not a bad idea if the in-
house and discharge food plans are the same. The menus
should serve only as a guide. If shrimp was not included
on the hospital menu then that doesn’t mean it should be
avoided. Likewise, if the client hated the orange juice
served every morning, they shouldn’t think they need to
continue drinking it. Hospital menus are more rigid than
at-home eating plans by necessity.
REVIEW CASE STUDY
Mildred is an 80-year-old woman who lives independently in her own

home. She was brought to the emergency department due to worsening
generalized weakness that resulted in a fall with probable hip fracture. She
has a history of lower GI bleeding and presents with anemia. She is alert
and oriented. Her BMI is 16.8. Three months ago, she weighed 135 pounds,
and she currently weighs 104 pounds. She states that she has not had an
appetite for several months. Her health has been stable since her last
hospital admission for GI bleeding two years ago.
• Using Figure 15.3, what is Mildred’s nutrition screening score?

• What is her percent weight change?
• Mildred is admitted and ordered a regular diet. What nutrition
interventions would you initiate to help maximize Mildred’s intake?
• The nutrition diagnosis is underweight related to loss of appetite and poor
intake as evidenced by BMI of 16.8. What criteria will you monitor that
will enable the dietitian to evaluate Mildred’s progress?
STUDY QUESTIONS
1 Nurses are in an ideal position to

a. screen clients for risk of malnutrition.
b. order therapeutic diets.
c. conduct nutrition assessments.
d. calculate a client’s calorie and protein needs.
2 Which of the following criteria would most likely be on a nutrition
screen in the hospital?
a. prealbumin
b. weight loss
c. serum potassium value
d. cultural food preferences
3 Which of the following statements regarding nutrition screening is false?
a. A nutrition screen is completed only when a client is suspected of
having a nutritional problem.
b. A nutrition screen must be completed within 24 hours after admission
to a hospital or other health care facility.
c. The purpose of nutrition screening is to detect the risk of malnutrition.
d. Health care facilities are free to choose their own screening criteria and
to determine how quickly a client must be rescreened.
4 Which of the following statements is accurate regarding the physical
signs and symptoms of malnutrition?
a. Physical signs of malnutrition appear before changes in weight or
laboratory values occur.
b. Physical signs of malnutrition are suggestive, not definitive, for
malnutrition.
c. Physical signs have a clear threshold that identifies what is considered
abnormal.
d. All races and sexes exhibit the same intensity of physical changes in
response to malnutrition.
5 Which of the following strategies may help promote an adequate oral
intake in hospitalized clients? Select all that apply.
a. Tell the client that you wouldn’t want to eat the food either, but it is
important for their recovery.
b. Encourage the client to select their own menu.
c. Offer standby alternatives when the client cannot find anything on the
menu they want to eat.
d. Advance the diet as quickly as possible, as appropriate.
6 A pureed diet is the most appropriate diet in which of the following
situations?
a. It is appropriate as an initial oral diet after surgery to establish
tolerance.
b. It is appropriate as a transition between a full liquid diet and a regular
diet.
c. It is appropriate for clients who need a low-fiber diet.
d. It is appropriate for clients who have had their jaw wired.
7 Your client has a question about the ONS they receive twice a day. What
is the best response?
a. “Ask your doctor when they make their rounds.”
b. “What is your question? If I can’t answer it, then I will get the dietitian
to talk with you.”
c. “You need to drink it to get better. You can discontinue it after
discharge but you need it now.”
d. “If I see the dietitian around, then I will tell them to stop by to see
you.”
8 Which of the following statements is true regarding albumin?
a. Albumin is a reliable and sensitive indicator of protein status and can
help diagnose malnutrition.
b. Albumin levels rise in response to inflammation.
c. Albumin and other visceral proteins are good indicators of disease
severity and outcome but not malnutrition.
d. An increase in albumin level means nutrition therapy is effectively
treating malnutrition.
CHAPTER SUMMARY Hospital

Nutrition: Identifying Nutrition Risk and
Feeding Clients
Malnutrition
Malnutrition is common and often unrecognized among hospitalized
clients. It is a major contributor to morbidity and mortality.
• Diagnosis: The presence of more than two of the following
characteristics indicates malnutrition: inadequate calorie intake,
unintentional weight loss, loss of muscle mass, loss of subcutaneous
fat, localized or generalized fluid accumulation, and diminished
functional status as measured by handgrip strength.
• Nutrition screening is used to identify people at risk for
malnutrition. It is usually the responsibility of the nurse to perform
a nutrition screening.
• Health care facilities determine their own screening criteria, who
completes the screen, and how quickly a rescreen is required.
• Screening tools should be quick, easy, valid, and reliable. Most use
weight loss, food intake, and BMI to evaluate malnutrition risk.
A dietitian completes a nutrition assessment on clients found to be at risk
for malnutrition. Steps include assessment, diagnosis, intervention, and
monitoring and evaluation. Nurses may directly or indirectly be involved in
any or all steps.
• Nutrition therapy for malnutrition: General guidelines often
suggest 25 to 30 cal/kg/day and 1.2 to 2.0 g protein/kg/day
depending on the client’s status and response to therapy. High-
protein ONS consumed 2 to 3 times per day can help meet protein
needs. If necessary, enteral nutrition is provided. Parenteral nutrition
is considered only if the oral and enteral routes are inadequate or
unavailable.
Nutrition in the Nursing

Process
Nutrition may be integrated throughout the steps of the nursing process.
• Nursing assessment: Dietitians rely on nurses for much of the
initial information about the client and for ongoing monitoring and
documentation of changes in intake, weight, and function.
• Medical–Psychosocial history can identify disease-related
nutrition risks.
• Height, weight, BMI: Accurate measures are vital. Risk of poor
nutritional status increases at either extreme of BMI.
• Weight loss: The percentage of unintentional weight loss over a
specified period of time is used to diagnose malnutrition.
• Dietary intake: Loss of appetite indicates risk.
• Physical findings: Loss of muscle, fat, and decreased handgrip may
indicate malnutrition.
• Lab data: There is no universally agreed-upon biochemical
indicators to diagnose malnutrition.
• Nursing analyses: Nursing analyses may be specifically related to
nutrition (e.g., underweight) or may include nutrition in the etiology
of the problem (e.g., constipation related to lack of dietary fiber).
• Nutrition-related client outcomes: The goal for all clients is to
consume adequate calories, protein, and nutrients using foods they
like and can tolerate, as appropriate. Alleviating symptoms or side
effects may be additional short-term goals.
• Nutrition interventions: Nurses are involved with promoting an
adequate nutritional intake, providing or reinforcing basic nutrition
education, and communicating with the dietitian.
• Nutrition-related monitoring: Nurses monitor the client’s intake,
weight, and tolerance to the diet.
Feeding Hospitalized Clients

Private and government regulatory agencies stipulate meal timing,
frequency, and nutritional content and require that hospital menus be
supervised by a qualified dietitian.
• Oral diets are the preferred method of providing nutrition.
• Regular diets are for clients who do not have altered nutrient
needs. No foods are excluded.
• Modified consistency diets include clear liquid and
mechanically altered diets, such as pureed, chopped/ground, or
soft diets.
• Therapeutic diets differ in the amount of one or more nutrients or
food components for the purpose of preventing or treating disease
or illness.
• ONS are used to prevent or treat malnutrition. They are quick,
easy, and provide clinical benefits. A wide range of flavors and
types are available.
Figure sources: shutterstock.com/sfam_photo and shutterstock.com/Monkey Business Images

book at
Websites
Oral nutrition supplement product information at www.abbottnutrition.com; nestlehealthscience.us
Screening and assessment tools from the American Society for Parenteral and Enteral Nutrition at
https://www.nutritioncare.org/Guidelines_and_Clinical_Resources/Toolkits/Malnutrition_Toolkit/
Screening_and_Assessment_Tools/
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Chapter Enteral and Parenteral
16 Nutrition
Sandy Arnold
Sandy is a 21-year-old downhill skier who is training
for international competition. She has been
hospitalized for the last 7 days after a skiing accident,
where she sustained multiple fractures and internal
injuries. She is intubated, a nasointestinal (NI)
feeding tube is placed, and the enteral nutrition (EN)
order is written for 2200 mL/day of a standard
formula that provides 1.0 cal/mL, 44 g protein/L, and
842 g water/L. The formula is to be given over 18
hours. She has no medical history. She is 5 ft 8 in. and
weighs 130 pounds upon admission.
Learning Objectives
1 Describe the difference between standard enteral formulas and

hydrolyzed formulas.
2 Choose the most appropriate enteral formula for a given client.
Discuss the advantages and disadvantages of various enteral nutrition
3
delivery methods.
4 Give examples of barriers that prevent clients from receiving the
prescribed amount of enteral formula.
5 List ways to maximize tube-feeding tolerance.
6 Identify signs of tube-feeding intolerance and recommend appropriate
interventions.
7 Explain the benefits of using enteral nutrition over parenteral nutrition
when enteral nutrition is not contraindicated.
8 List indications for using parenteral nutrition.
9 Discuss the components of parenteral nutrition.
10 List potential metabolic complications of parenteral nutrition.
Oral diets are the safest, easiest, and most preferred method of feeding
clients. Clients who are unable to consume adequate nutrition may be fed in
part or in total via enteral or parenteral nutrition (PN). This chapter
describes enteral feeding routes, formulas, delivery methods, and potential
complications. The indications for PN, its composition, and potential
complications are presented.
ENTERAL NUTRITION
Enteral nutrition (EN) has long been considered the standard of care for
providing nutrition support for clients who are unable to consume adequate
calories and protein orally and have at least a partially functional
gastrointestinal (GI) tract that is accessible and safe to use. EN may
supplement an oral diet or may be the sole source of nutrition. Indications
for EN include dysphagia, mechanical ventilation, chronic history of poor
oral intake, critical illness, head and neck surgeries, and malnutrition with
inadequate oral intake. EN is contraindicated when the GI tract is
nonfunctional or inaccessible, in severe short bowel syndrome, intractable
vomiting and/or diarrhea, GI ischemia, bowel obstruction, high-output
fistula, peritonitis, and paralytic ileus. Figure 16.1 illustrates the process of
selecting an appropriate method of feeding based on GI function.
Enteral Nutrition (EN)

the delivery of nutrients by tube, catheter, or stoma into the gastrointestinal tract beyond the oral
cavity; commonly known as tube feeding.
Figure 16.1 ▲ Selecting the appropriate type and method of feeding.
EN is preferred over PN because it is a cost-effective method of

delivering nutrition support and is associated with less septic morbidity and
fewer infectious (Academy of Nutrition and Dietetics, 2020a). Even in
critically ill clients, it is practical and safe to use EN instead of PN
(McClave et al., 2016).
Estimating Nutritional Needs

Calculations of the client’s calorie and protein requirements are used to
determine the appropriate type and volume of formula necessary to meet the
client’s needs. The following general guidelines may be used and revised
according to the client’s response to nutrition therapy:
• Calories: 25 to 30 cal/kg/day may be used as the initial estimate of
need.
• Protein: Normal protein Recommended Dietary Allowance (RDA)
is 0.8 g/kg body weight. Older clients and ill clients may need 1.2 to
2.0 g/kg/day. Protein needs are likely even higher for burn or multi-
trauma clients (McClave et al., 2016).
• Fluid: Common guidelines are 30 to 40 mL/water/kg/day or
approximately 2.5 L/day for women and 3 L/day for men. These
guidelines are not evidence based, nor do they account for
conditions that impact fluid needs, such as GI fluid losses related to
vomiting, diarrhea, and ostomy drains.
• Protein: Box 16.1 gives an example of calorie and protein
calculations compared to nutrients provided via an EN prescription.
BOX Comparing Client Needs to Nutrients

16.1 Provided via Enteral Nutrition Order
Example: A healthy client who weighs 165 pounds (75 kg) is ordered on
standard formula that provides 1 cal/mL and 40 g protein/L. The initial
rate is 50 mL/h, which will be advanced at 20 mL/h every 4 hours until
the goal rate of 90 mL/h is achieved. The assumption is that the formula
will infuse for 22 hours/day to allow time off to administer medications.
Calculation Guidelines
• Calories: 25 to 30 cal/kg/day
• Normal protein RDA is 0.8 g/kg body weight
Client Need Calculations

Estimated calories: 1875 to 2250 cal/day
75 kg × 25 cal/kg = 1875 cal
75 kg × 30 cal/kg = 2250 cal
Estimated protein: 60 g
75 kg × 0.8 g/kg = 60 g protein/day
Nutrients Provided via Enteral Nutrition Order
• Calories
Initially: 50 mL/h × 22 h = 1100 mL
1100 mL × 1 cal/mL = 1100 cal
Goal rate: 90 mL/h × 22 h = 1980 mL
1980 mL × 1 cal/mL = 1980 cal/day
• Protein
Initially: 1.1 L × 40 g/L = 44 g
Goal rate: 1.98 L × 40 g/L = 79.2 g protein/day
Recall Sandy. What was Sandy’s body mass index (BMI) on

admission? Calculate her estimated calorie, protein, and
fluid needs. Will she obtain adequate calories and protein
from the formula as prescribed?
Formula Selection
Formula selection is based on the client’s nutritional needs and medical
conditions. Standard formulas are the most commonly used formulas and
are appropriate for most clients who require EN. Variations of standard
formulas can meet the needs of clients who have elevated calorie and/or
protein needs. Hydrolyzed formulas are intended for clients with impaired
GI function. Disease-specific formulas are also available.
Standard Formulas
Standard formulas, also known as polymeric or intact formulas, are made
from whole proteins found in foods (e.g., milk, meat, eggs) or protein
isolates.
Standard Formulas
tube-feeding formulas that contain whole molecules of protein; known as intact or polymeric
formulas.
• Because they contain complex molecules of protein, carbohydrates,

and fat, standard formulas are intended for clients who have normal
digestion and absorption.
• Blenderized formulas are a type of standard formula that are made
from a mixture of whole foods (such as chicken, vegetables, fruits,
and oil) and fortified with vitamins and minerals. They may be
homemade or commercially made and appeal to people who want a
more natural formula.
• Many standard formulas can be consumed as an oral supplement.
• Standard formula variations include high-protein, high-calorie,
fiber-enriched as well as disease-specific formulas (Table 16.1).
Hydrolyzed Formulas
Hydrolyzed or elemental formulas contain very little residue and are
intended for clients with impaired digestion or absorption, such as people
with inflammatory bowel disease, cystic fibrosis, and pancreatic disorders.
Hydrolyzed
broken down or predigested.
• They contain nutrients that are partially hydrolyzed (e.g., semi-
elemental formulas that contain peptides and free amino acids) or
completely hydrolyzed (e.g., elemental formulas that contain 100%
free amino acids).
• Carbohydrates and fat in hydrolyzed formulas are also in simple
forms that require little or no digestion, such as carbohydrates in the
form of maltodextrin or fructose and fat in the form of fatty acid
esters or medium-chain triglyceride (MCT) oil.
• Table 16.2 features selected hydrolyzed enteral formulas.
Table Examples and Selected

Characteristics of Standard
16.1 Formulas

Characteristics of Hydrolyzed
16.2 Enteral Nutrition Formulas
Disease-specific Formulas
A variety of disease-specific formulas are available to meet the altered
nutrient needs of clients with certain illnesses, such as diabetes/glucose
intolerance, immunocompetence, kidney disease, and respiratory
insufficiency (Table 16.3).
• Expert consensus suggests avoiding the routine use of all specialty
formulas in critically ill clients in a medical intensive care unit
(ICU) and disease-specific formulas in the surgical ICU (McClave
et al., 2016).
• However, immune-modulating formulas containing arginine should
be considered in clients with severe trauma and postop clients in the
surgical ICU (McClave et al., 2016).

Characteristics of Disease-Specific
16.3 Enteral Nutrition Formulas
Formula Characteristics
As illustrated in Tables 16.1 to 16.3, enteral formulas differ in their calorie
density, amount of protein/L, water content, and micronutrient density.
Additional salient points are summarized in Box 16.2.
Feeding Route
The choice of enteral access or placement of the feeding tube is highly
dependent on the anticipated length of time for which tube feeding will be
used. Table 16.4 summarizes the advantages and disadvantages of various
feeding routes.
BOX Additional Points Regarding Enteral

16.2 Formula Characteristics
Calorie Density: determines the volume of formula needed to meet the

client’s estimated needs.
• Most routine formulas provide 1.0 to 1.2 cal/mL, which is adequate for
most clients needing EN support.
• High-calorie formulas provide 1.5 to 2.0 cal/mL and are appropriate
for clients who need a fluid restriction or those who are intolerant of
higher volumes of formula.
Macronutrient Content: varies with the intended use of the formula.
• Diabetes-specific formulas contain lower percentages of carbohydrate

and provide fiber.
• Respiratory insufficiency formulas are high in fat to reduce respiratory
quotient.
• Formulas for clients with malabsorption contain negligible to low
amounts of fat in the form of MCTs. Depending on the actual fat
content, some clients may not meet their essential fatty acid
requirement.
Water Content: varies with the caloric concentration.
• Generally, formulas that provide 1.0 cal/mL provide approximately

850 mL of water per liter.
• The water content of high-calorie formulas is lower at 690 to 720
mL/L.
• Adults generally need at least 30 mL/kg/day, so most clients who
received EN need additional free water to meet fluid requirements.
• Free water is administered when water is used to flush the tube and as
a bolus administration specifically for the purpose of meeting fluid
requirements.
Micronutrient Density: the amount of formula needed to meet 100% of
adult Dietary Reference Intakes (DRIs) for vitamins and minerals.
• Generally, the amount of formula needed to meet nutrient DRIs ranges

from 1000 to 1500 mL/day.
• When an enteral feeding is the client’s sole source of nutrition, it is
important to ensure nutritional adequacy within the volume of formula
the client receives.
Residue Content: composed of fiber, undigested food, intestinal
secretions, and other cells.
• Standard formulas come in low-residue or fiber-enriched varieties.

• Hydrolyzed formulas are essentially residue free because they are
completely absorbed.
Fiber Content: Fiber stimulates peristalsis, increases stool bulk, and is
degraded by GI bacteria to short-chain fatty acids that promote repair and
maintenance of the intestinal lining. EN formulas containing fiber may
improve digestive health and normal bowel function in noncritically ill
clients (Brown et al., 2015).
• Fiber-enriched standard formulas provide 10 to 15 g fiber per liter in

the form of oat, soy, pea, guar gum, or other fibers.
• Blenderized formulas are made from whole foods and thus contain
natural sources of fiber, generally about 4 g fiber per liter.
Other ingredients:
• Virtually all formulas are lactose and gluten free.

• Formulas may also be kosher and halal.
Osmolality: the measure of particles in solution; determined by the
concentration of sugars, amino acids, and electrolytes.
• Osmolality was once thought to contribute to diarrhea and GI

intolerance in enterally fed clients, but this idea is not supported by
evidence.
• Enteral formulas have lower osmolality than many common liquids
(e.g., broth, soda, juices, sherbet) and medications that are routinely
ordered for clients (e.g., acetaminophen elixir, sugar-free KCl elixir,
liquid multivitamin).
Table Advantages and Disadvantages

of Various Feeding Routes
16.4
Transnasal Routes
feeding routes that extend from the nose to either the stomach or the small intestine.
Ostomy Routes
a surgically created opening (stoma) made to deliver feedings directly into the stomach or
intestines.
Delivery Methods
The type of delivery method to be used depends on the type and ___location of
the feeding tube, the type of formula being administered, and the client’s
tolerance.
Intermittent Tube Feedings

Intermittent feedings are administered five to eight times daily in large
volumes (250–500 mL) over 30 to 45 minutes or longer.
Intermittent Feedings
tube feedings administered in equal portions at selected intervals.
• A gravity or an enteral feeding pump may be used.

• Feedings may be spaced throughout an entire 24-hour period or may
be scheduled only during waking hours to give clients time for
uninterrupted sleep.
• Intermittent feedings are generally used for gastric-fed, stable clients
and home tube feedings.
• They offer the advantage of resembling a more normal pattern of
intake and allow the client more freedom of movement between
feedings.
Think of Sandy. The doctor has ordered 2200 mL/day of a‐

standard formula that provides 1.0 cal/mL to be given over
18 hours. The formula provides 842 g water/L. What will the
infusion rate be? Will she meet her fluid requirement
without additional free water?
Bolus Feedings
Bolus feedings are a variation of intermittent feedings.
Bolus Feedings
rapid administration of a large volume of formula.
• A relatively large volume of formula (≥250 mL) is given over 10 to

20 minutes 4 to 6 times/day by gravity via a syringe.
• They are used only for gastric feedings in stable clients and
ambulatory clients.
• They are more likely to cause symptoms of GI intolerance (nausea,
vomiting, abdominal pain) than the other delivery methods.
Continuous Drip Method
Continuous drip feedings are the most commonly used administration
method in hospitalized clients, especially those who are critically ill, are at
risk for gastroesophageal reflux, have a history of aspiration pneumonia, or
require intestinal feedings. They are also used for clients who cannot
tolerate intermittent or bolus feedings.
• The prescribed amount of formula volume is given at a constant rate
over a specified period of time, usually 16 to 24 hours.
• An infusion pump is usually used. Feedings into the jejunum require
a pump.
• This method is associated with smaller residual volumes and lower
risk for aspiration when compared to other delivery methods.
Cyclic Feedings
Cyclic feedings are a variation of continuous drip feedings and deliver a
constant rate of formula over 8 to 20 hours, often during sleeping hours.
• Because there is “time off,” the rate of infusion tends to be higher
than with continuous feedings.
• A pump is usually used.
• Cyclic feedings are usually well tolerated and often used to maintain
a reliable source of nutrition while transitioning from total EN to an
oral intake or in noncritical, undernourished clients unable to meet
their nutritional needs orally.
Feeding Systems
EN is delivered through either open or closed feeding systems.
Open System
With an open system, formula from the original can or bottle is poured into
a feeding reservoir that is either a feeding bag or a syringe (for a bolus
feeding).
• Ready-to-use formulas may safely hang for 8 to 12 hours.
• Reconstituted formulas should hang for 4 hours or less.
Closed Systems
A closed or ready-to-hang system uses a sterile, prefilled container of
formula (usually 1 L) that is spiked with a feeding tube and then delivered
via an infusion pump.
• Closed systems may also be used to deliver bolus feedings by
setting the infusion pump to deliver boluses at predetermined times.
• Although closed systems are more expensive, they may hang for 24
to 48 hours when label instructions are followed.
• Closed systems have a lower risk of microbial contamination and
require less time to prepare, hang, and manage than an open-system
client (Foster et al., 2015).
Initiating and Advancing the Feeding

There are no prospective randomized studies to determine the optimal rate
to initiate feedings or how quickly they should be advanced (Parrish &
McCray, 2019a).
• The EN order may specify starting a continuous feeding at 20 to 50
mL/h and advancing by 10 to 25 mL/h every 4 to 24 hours as
tolerated until goal rate is reached.
• Intermittent or bolus feedings generally start at 120 mL every 4
hours and advance by 30 to 60 mL every 8 to 12 hours (Parrish &
McCray, 2019a).
• Stable clients generally tolerate rapid rate advancement to reach
goal rate and may even tolerate beginning enteral feedings at the
goal rate.
• Expert consensus suggests that clients who are at high nutrition risk
or severely malnourished should be advanced toward goal rate as
quickly as tolerated over 24 to 48 hours with appropriate monitoring
• The sooner the goal rate is achieved, the sooner the client’s
nutritional needs are met.
• Regardless of the access route, enteral formulas are initiated at full
strength. The previous practice of diluting hypertonic feedings has
not been shown to improve tolerance, prolongs the period of
inadequate nutrition support, and may increase the risk of bacterial‐
contamination.
To maximize tolerance, perform the following:

• Confirm backrest elevation is greater than 30° to 45°.
• Check gastric residual volume (GRV) every 8 hours or as per
order.
• Conditions where GRV checks may be useful in clients who
receive EN into the stomach include head injury, abdominal
surgery, obtunded or vegetative state, and critical illness
following surgery or trauma (Parrish & McCray, 2019b).
• There is no standard definition of GRV and little agreement on
how frequently GRV should be checked and whether the GRV
should be returned to the stomach (Parrish & McCray, 2019b).
• Consider continuous feedings if client receives bolus feedings.
• Consider post-pyloric feedings if client receives feedings into the
stomach.
Gastric Residual Volume
the volume of feeding that remains in the stomach from a previous feeding.
Water Flushes
Flushing the tube periodically helps meet water requirements and ensures
patency (openness). The often-cited standard for maintaining tube patency
in adults is to flush with a minimum of 20 to 30 mL of warm water
(Campbell, 2015):
• every 4 to 6 hours during continuous feedings (including cyclic
feedings)
• before and after every bolus or intermittent feeding
• before and after checking gastric residuals
• before and after giving medication
• If more than one medication is given at the same time, then give 5
mL of water between each
Monitoring
Monitoring ensures that the client is tolerating the EN regimen and that it is
meeting the client’s needs. As per facility protocol, the nurse may monitor
the following:
• daily weights
• daily intake and output
• GRV
• character and frequency of bowel movements
• electrolyte levels
• tube placement
• tube site for infection
• tube-feeding tolerance
Tube-Feeding Intolerance
Although EN is an effective way to provide nutritional support to clients
who are unable to consume adequate nutrition orally, many clients fail to
receive the amount of EN ordered and do not receive the full benefit of
nutrition support. For instance, cessation of EN occurs in >85% of ICU
clients for 8% to 20% of the infusion time (McClave et al., 2016).
Numerous barriers interfere with delivery of the EN prescriptions (Box
16.3) (Parrish & McCray, 2019b). Client intolerance accounts for one third
of the time EN is halted, but only half of this represents true intolerance
• Hospitalized clients often have significant GI issues, but they may
arise from causes other than EN, such as the underlying disease
process or inadequate/inappropriate medications.
• There is little evidence to support using bowel sounds or GRVs as a
measurement of EN tolerance (Parrish & McCray, 2019b).
• Further assessment is needed to identify the cause of the issue and
effectively intervene.
• Box 16.4 outlines signs of intolerance and suggested interventions.
BOX Barriers to Delivering Optimal Enteral

16.3 Nutrition
• “Holds”—or periods of time when the tube feeding is withheld—for

surgery, bedside procedures, respiratory procedures, diagnostic
procedures, extubation
• Issues with enteral access, such as clogged tubes, dislodged tubes,
staffing unavailable to place tubes
• Inaccurate calculation of client nutrient needs
• Certain medical issues, such as hypotensive episodes or GI bleeding
• Perceived or actual tube-feeding intolerance
• Client psychosocial barriers such as fear of advancing formula,
anxiety, depression
BOX Signs of Tube-Feeding Intolerance and

16.4 Suggested Interventions
Abdominal distress: distention, pain, abdomen is firm or tense.

• Hold feeding.
• Check for constipation.
Nausea
• Give antiemetics.
• Minimize narcotics.
Emesis
• Hold feeding.
Constipation
• EN does not cause constipation: underlying risk factors include the use
of certain medications, immobility, and poor bowel habits or secondary
to an underlying condition such as irritable bowel syndrome,
neurologic disorders, or endocrine disorders.
• Minimize the use of narcotics or consider a narcotic antagonist to
promote intestinal contractility.
Diarrhea
• EN is rarely the cause and does not indicate the need to hold EN
(Parrish & McCray, 2019a).
• Assess normal stooling pattern prior to illness.
• Assess for causes:
• Medications are a common, but often unrecognized, cause of
diarrhea in tube-fed clients (Parrish & McCray, 2019a). Liquid
medications that contain sorbitol or other sugar alcohols can cause
osmotic diarrhea when consumed in excess of the individual’s
tolerance threshold. Examples of liquid medications with sugar
alcohols include Tylenol Elixir, multivitamin/mineral liquid,
potassium chloride elixir, and proton pump inhibitor suspensions.
• Other medications known to cause diarrhea include antibiotics,
lactulose, magnesium supplements, and phosphate.
• Other causes include infections (particularly Clostridium difficile)
and underlying diseases such as inflammatory bowel disease,
pancreatic insufficiency, and diabetes enteropathy.
• Monitor stool frequency, volume, and consistency.
Sources: Parrish, C., & McCray, S. (2019a). Part II enteral feeding: Eradicate barriers with root
cause analysis and focused intervention. Practical Gastroenterology.
https://med.virginia.edu/ginutrition/wp-content/uploads/sites/199/2019/02/Parrish-Barriers-in-
EN-February-2019.pdf; Parrish, C., & McCray, S. (2019b). Part I enteral feeding barriers:
Pesky bowel sounds & gastric residual volumes. Practical Gastroenterology.
https://med.virginia.edu/ginutrition/wp-content/uploads/sites/199/2019/02/Parrish-Bowel-
Sounds-and-GRVs-January-2019.pdf
Aspiration
EN is generally considered safe, but there can be various complications.
Potential metabolic complications include fluid imbalance, electrolyte
imbalances, and altered glucose levels. The tube may become clogged,
become dislodged, or cause irritation at the insertion site. Aspiration is the
most serious potential complication with gastric feedings.
• Factors contributing to aspiration risk include inability to protect the
airway, presence of an NG tube, mechanical ventilation, client age
of 70 years or older, reduced level of consciousness, poor oral care,
inadequate amount of nurses for the number of clients, supine
positioning, neurologic deficits, gastroesophageal reflux, and use of
bolus EN (McClave et al., 2016).
• Aspiration risk is reduced by switching from bolus gastric feedings
to continuous infusion and delivering EN into the small bowel
instead of the stomach.
• Elevate the head of the bed to 30° to 45°. Position the client upright
in a chair if doing so is not contraindicated.
• Confirm the tip of the feeding tube is properly placed before the
feeding starts. Verify that feeding tube is correctly placed at least
every 4 hours during continuous feedings or in the time frame
according to institutional protocol.
Recall Sandy. She developed diarrhea after 2 days on a tube

feeding. What are the possible causes? What would you
recommend to resolve her diarrhea?
Giving Medications by Tube

Although many medications are frequently given through feeding tubes to
clients who are unable to swallow, they should never be given while a
feeding is being infused. Some drugs become ineffective if added directly to
the enteral formula. Adding acidic drugs to the formula may cause the
protein to coagulate and clog the tube. It is important to stop the feeding
before administering drugs and to make sure the tube is flushed with 10 to
30 mL of water before and after the drug is given. If more than one drug is
given, then flush the tube between doses with 5 mL of water. Drugs
absorbed from the stomach should never be given through an NI tube.
Transition to an Oral Diet

The goal of diet intervention during the transition period between EN and
oral diet is to ensure adequate nutritional intake while promoting an oral
diet. The tube feeding should be stopped for 1 hour before each meal to
begin the transition process. Gradually increase meal frequency until six
small oral feedings are accepted. Actual intake should be recorded and
evaluated daily. Tube feedings may be limited to only during night when
oral calorie intake consistently reaches 500 to 700 cal/day. The tube feeding
may be totally discontinued when the client consistently consumes two
thirds of protein and calorie needs and 1000 mL fluid orally for 3
consecutive days.
Consider Sandy. Her condition improves, and she

desperately wants to have the feeding tube removed. She
knows she must demonstrate that she can orally consume a
“fair” intake. What measures can you take to encourage and
maximize her oral intake?
NURSING
PROCESS Enteral Nutrition
Support
Vince is 48 years old, is 6 ft tall, and has weighed 170 to 175 pounds
throughout his adult life. Two weeks ago, he was admitted to the ICU
after an industrial accident caused first- and second-degree burns over
20% of his body. He was initially fed via an NG tube and then started
on an oral diet. Vince was able to achieve only 40% of the calorie goal
set by the dietitian, so he has reluctantly agreed to be fed by tube for 8
hours during the night to supplement his daytime oral intake.
Assessment
Assessment
Medical–
Psychosocial • Medical history that may have nutrition
History implications, such as diabetes or GI disorder.
• Medications that may affect nutrition.
• Current treatment plan.
• Level of tube-feeding acceptance, including fears
or apprehension about being tube fed during the
night.
• If Vince may need a tube feeding after discharge,
assess living situation: availability of running
water, electricity, refrigeration, cooking and
storage facilities, employment, social support
system, and financial status.
Anthropometric • Height, current weight, BMI

Assessment • Percentage of weight loss
Biochemical • Check laboratory values: hemoglobin, hematocrit,

and Physical glucose, electrolytes, and other abnormal values
Assessment for their nutritional significance.
• Check tube for proper positioning: Check external
length of tube every 4 hours to monitor tube
placement.
• Monitor hydration status.
• Ask if the client has any physical complaints
associated with oral food intake or tube feeding,
such as nausea or bloating.
• Observe abdomen for distention.
• Measure GRVs if indicated.
• Monitor stool frequency, volume, and
consistency.
Assessment
Dietary • How many calories and how much protein are

Assessment being provided via the tube feeding?
• Do the nocturnal tube feedings affect the amount
of food consumed orally during the day?
• Is protocol being followed for administering the
tube feeding and documenting administration and
tolerance?
• Is Vince able and willing to learn how to use tube
feeding at home if necessary?
Analysis
Possible Malnutrition risk related to hypermetabolism

Nursing secondary to thermal injuries as evidenced by oral
Analyses calorie intake of 40% of goal.
Planning
Client The client will

Outcomes • meet calorie and protein goals via combination of
oral and tube feeding,
• be free of any signs or symptoms of aspiration
and other complications, and
• discontinue tube feedings when oral intake is
consistently two thirds of calorie and protein goal
Nutrition • Administer tube feeding as ordered.

Therapy • Encourage oral intake.
Assessment
Client Teaching Instruct the client

on the importance of tube feedings for
supplemental nutrition until oral intake meets at
least two thirds of goal,
•
• on the signs and symptoms of intolerance of tube
feeding and to alert the nurse if any problems
arise,
• not to adjust the flow rate unless otherwise
instructed, and
• on formula preparation, administration, and
monitoring as well as the rationales and
interventions for tube-feeding complications, if
home EN is indicated.
Evaluation
Evaluate and • Monitor weight.

Monitor • Monitor calorie and protein intake.
• Monitor flow rate and administration.
• Monitor for signs and symptoms of intolerance:
complaints of abdominal distress, nausea, emesis,
constipation, and diarrhea.
PARENTERAL NUTRITION
Parenteral Nutrition (PN) was developed in the 1960s when researchers

from the University of Pennsylvania discovered how to deliver nutrients
into the bloodstream via central venous access, thereby bypassing the GI
tract (Koretz, 2007). PN may be provided via a central or a peripheral vein
and may be the sole or supplemental source of nutrition. The term PN
implies central PN unless otherwise specified.
Parenteral Nutrition (PN)

the delivery of nutrients by vein; parenteral literally means “outside the intestinal tract.”
Indications for Parenteral Nutrition

PN is used in adult clients who are malnourished or at risk for malnutrition
when a contraindication to EN exists. It is also used when the client does
not tolerate adequate EN or lacks sufficient bowel function to maintain or
restore nutritional status (Worthington et al., 2017). Conditions that are
likely to require PN include impaired absorption or loss of nutrients (e.g.,
short bowel syndrome, radiation enteritis), mechanical bowel obstruction
(e.g., stenosis or strictures), the need for bowel rest (e.g., ischemic bowel,
severe pancreatitis), motility disorders (e.g., prolonged ileus), and the
inability to achieve or maintain enteral access (e.g., active GI bleeding). It
is recommended that PN not be used solely on the basis of medical
diagnosis or disease state (Worthington et al., 2017).
Disadvantages and Contraindications of

Although PN is a life-sustaining treatment, clinical practice guidelines
uniformly support the use of EN as the preferred route for nutrition support
when possible (Worthington et al., 2017). PN is invasive, costly, and
associated with numerous mechanical and infectious complications.‐
Potential metabolic complications that impact nutrition are listed in Box
16.5.
• PN is never an emergency procedure, and it should be discontinued
as soon as possible.
• It should not be used to solely treat poor oral intake and/or cachexia
associated with advanced malignancy (Worthington et al., 2017).
• PN is not indicated when the prognosis does not warrant aggressive
nutrition support (Academy of Nutrition and Dietetics, 2020b).
Access Sites
PN may be infused via peripheral or central veins.
Peripheral Parenteral Nutrition

Peripheral parenteral nutrition (PPN) is not widely used because solutions
infused into peripheral veins must have lower osmolarity (i.e., they must
have low concentrations of dextrose and amino acids) to prevent phlebitis
and increased risk of thrombus formation (Worthington et al., 2017).
BOX Potential Metabolic Complications of

16.5 Parenteral Nutrition
Hyperglycemia, hypoglycemia
Electrolyte imbalances
Liver dysfunction
Elevated liver enzymes
Hypertriglyceridemia
Steatosis, cholestasis, gallstones
Refeeding syndrome
Metabolic bone disease (from long-term use)
• Because the caloric and nutritional value of PPN is limited, it is best

suited for clients who need short-term nutrition support (≤7–10
days).
• It is intended to prevent, rather than correct, nutritional deficits.
• PPN is contraindicated in clients who need a fluid restriction, such
as in clients with renal failure, liver failure, or congestive heart
failure.
Central Parenteral Nutrition

• Central PN is administered via central venous catheters (CVCs).
Their distal tip lies in the distal vena cava or right atrium. Using a
large-diameter central vein allows for the infusion of a hypertonic
formula because it is quickly diluted. Smaller veins are not able to
handle such concentrated solutions.
• CVC catheter types include non-tunneled, peripherally inserted
central catheter, tunneled, or implanted ports.
Central PN
the infusion of nutrients into the bloodstream by way of a central vein. Central PN solutions are
nutritionally complete.
Parenteral Nutrition Solutions

PN solutions are a complex mixture of protein, carbohydrate, fat,
electrolytes, vitamins, and trace elements in sterile water. Established
clinical guidelines define the ratio of carbohydrates, amino acids, and lipids.
• PN regimens can be individualized to meet specific requirements or
standardized to cover nutrition needs of a larger client population
(Yu et al., 2017).
• PN admixture formulations come with and without lipids.
• Total nutrient admixture (TNA) or “3 in 1” solution contains all
the macronutrients (dextrose, amino acids, and intravenous fat
emulsions [IVFE]) in one intravenous solution. Commercial
preparations of electrolytes, vitamins, and trace elements are
added to provide total nutrition.
• A “2 in 1” solution contains everything in the “3 in 1” solution
except the IVFE. IVFE is infused separately for calories and to
prevent fatty acid deficiency on a daily or intermittent basis.
Calories
The client’s total calorie needs are determined according to recommended
guidelines (ASPEN, 2019b).
• Stable clients: 20 to 30 cal/kg/day
• Critically ill, trauma, and septic clients: 20 to 30 cal/kg/day
• Obese clients: 22 to 25 cal/kg of ideal body weight/day
Protein
Protein is provided as a solution of crystalline essential and nonessential
amino acids with the amounts of specific amino acids varying
insignificantly among manufacturers.
• Protein usually provides 15% to 20% of total calories in PN
formulas.
• Recommended protein amounts are 0.8 to 1.5 g/kg/day for stable
clients and 1.2 to 2.5 g/kg/day for critically ill clients or those with
trauma or sepsis (ASPEN, 2019b).
• Because protein has minimal metabolic consequences, amino acids
can be initiated at the goal rate.
Carbohydrate
Glucose in the form of dextrose monohydrate is the main source of
calories in PN.
Dextrose Monohydrate
a molecule of glucose combined with a molecule of water.
• Dextrose provides 3.4 cal/g.

• Dextrose concentrations for central PN range from 25% to 70%.
Only concentrations at 10% or less are used for PPN to avoid
damage to the peripheral vein. The amount and concentration
provided varies with the client’s nutritional needs, the amount of
intravenous lipid emulsion (IVLE) given, and tolerance.
• Dextrose infusion rate starts at a moderate dose and progresses
gradually.
• The goal recommendation for dextrose is 4 to 5 mg/kg/min in stable
clients and <4 mg/kg/min in critically ill clients (ASPEN, 2019b).
• Carbohydrate is an important energy source but giving a client too
much can have negative consequences.
• Hyperglycemia contributes to severe infection, organ dysfunction,
and death in critically ill clients (Cotogni, 2017).
• To achieve glycemic control in clients with hyperglycemia, short-
acting insulin is given either by intravenous (IV) pump infusion
or by adding it to the infusion bag.
• A high carbohydrate load may also lead to excessive carbon
dioxide production, which may complicate weaning from
mechanical ventilation. The trend toward less aggressive feeding
has decreased the incidence of this complication.
Fat
IVLEs provide essential fatty acids and calorie-dense nonprotein calories in
an isotonic solution.
• In the United States, soybean oil has been the mainstay of PN lipid
formulations since the 1970s. Within the last decade, newer-
generation lipid products have been developed using various
combinations of fats, namely, MCT oil, olive oil, and fish oil, to
alter the content of fatty acids that may play a role in immunity and
inflammation (Raman et al., 2017).
• IVLEs are available in 10%, 20%, and 30% concentrations and
supply 1.1, 2.0, and 3.0 cal/mL, respectively.
• The recommendations for IVLEs are to dose at <1 g/kg/day in
critically ill and septic clients and not greater than 1 g/kg/day in
stable clients (ASPEN, 2019b).
• Lipids are a significant source of calories and so are useful when
volume must be restricted or when dextrose must be lowered
because of persistent hyperglycemia.
• Allergy contraindications with standard soybean IVLEs include
hypersensitivities to egg, soy, or peanut proteins (Raman et al.,
2017).
• IVLEs should be avoided or used with caution in clients with severe
hyperlipidemia, severe liver insufficiency, or recent myocardial
infarction, stroke, or embolism.
Micronutrients
The American Society for Parenteral and Enteral Nutrition (ASPEN) has
put forth recommendations for PN micronutrient dosing for adults,
neonatal, and pediatric clients (ASPEN, 2019b).
• Standard electrolyte packages include sodium, potassium, chloride,
calcium, magnesium, acetate, and phosphorus.
• Most PN multivitamin products in the United States contain 13
vitamins that provide the daily requirements for parenteral vitamins
when administered at full daily dose. Both fat and water soluble
vitamins are provided.
• The trace elements typically added to PN solutions include
chromium, copper, manganese, selenium, and zinc. Iron destabilizes
other ingredients in PN solutions, so a special form of it is injected
separately as needed.
• Shortages of vitamins, electrolytes, and other PN nutrition
components have critically impacted hospitals and home infusion
companies throughout the United States over the last several years
(ASPEN, 2019a).
BOX Nursing Management Considerations for

16.6 Parenteral Nutrition
Once PN solutions are prepared, they must be used immediately or
•
refrigerated.
• Remove PN bag from refrigerator at least 1 to 2 hours before hanging
to allow solution to warm to room temperature. Do not place in hot
water or microwave.
• Verify PN orders with the label on the bag.
• Once hung, the solution is infused or discarded within 24 hours.
• Inspect the solution for “creaming,” which occurs as larger fat droplets
aggregate and rise to the surface. This reaction is reversible with
mixing. If the fat in the formula has coalesced or is “oiling out,” the
mixture is unusable. The PN order may need to be adjusted to prevent
reoccurrence.
• Monitor the flow rate to avoid complications and ensure adequate
intake.
• Perform physical assessment per protocol.
• Monitor laboratory data and clinical signs to prevent the development
of nutrient deficiencies or toxicities.
• Measure and record fluid intake and output.
• Monitor weight. Weight gain >1 kg/day indicates fluid overload.
• Some clients may feel hungry while receiving PN and should be
allowed to eat, if possible. If oral intake is contraindicated, give mouth
care.
• Begin weaning the client from PN to EN or oral intake as soon as
possible. Gradual weaning is necessary to prevent rebound
hypoglycemia.
• Clients who have permanently nonfunctional GI tracts require PN
indefinitely. For home PN to be successful, clients and their families
must be physically and emotionally prepared. Intensive counseling
focuses on preparation and administration of the solution, catheter and
equipment care, and assessment skills as well as the psychological
impact of permanent PN.
Note. EN = enteral nutrition; PN = parenteral nutrition.
Initiation and Administration
PN is initiated and administered according to client characteristics and
facility protocol. Nutrition-related nursing management considerations
appear in Box 16.6. Recommendations for initiating PN are based on the
client’s status (Worthington et al., 2017):
• after 7 days for well-nourished, stable adult clients who have been
unable to receive 50% or more of their estimated requirements via
oral and/or EN
• within 3 to 5 days in clients who are nutritionally at risk and
unlikely to achieve desired intake orally or via EN
• as soon as feasible for clients with existing moderate or severe
malnutrition in whom oral intake or EN is not possible or adequate
• delayed initiation in a client with severe metabolic instability until
the client’s condition has improved
Infusions may be continuous or cyclical.
• PN is typically infused continuously over 24 hours. Continuous
infusions are given to clients who are malnourished or critically ill.
• Cyclical PN infusions given over a period of 8 to 16 hours or more
are widely used in clients who require long-term PN and/or PN on
an outpatient basis.
• Compared to continuous infusions, cyclic infusions cause
metabolic changes that must be considered: the body must adapt
to changes in blood levels of nutrients (e.g., glucose) that occur
when the infusion stops and higher infusion rates are required to
compensate for the off periods.
• Cyclical PN is often used as a transition between PN and EN or
an oral intake. During the switch from continuous to cyclic PN,
the infusion time may be gradually decreased by several hours
each day, as ordered, and assessment is ongoing for signs of
glucose intolerance.
Cyclical PN Infusions
infusing PN at a constant rate for 8 to 16 hours/day.
Refeeding Syndrome
When PN was first introduced, it was widely and enthusiastically embraced
as state-of-the-art therapy. The prevailing school of thought was that “if
some is good, more is better” and overfeeding was common practice
(Koretz, 2007). At that time, PN was called “hyperalimentation”—literally
excessive nourishment. The practice of overfeeding has been replaced with
a more conservative, lower-in-calories approach because it is now known
that overfeeding, particularly overfeeding carbohydrates in nutritionally
debilitated clients, can lead to a life-threatening complication known as the
refeeding syndrome.
Refeeding Syndrome
a potentially fatal complication that occurs from an abrupt change from a catabolic state to an
anabolic state and an increase in insulin caused by a dramatic increase in carbohydrate intake.
• Refeeding syndrome is characterized by metabolic and

physiological shifts of fluid, electrolytes, and minerals from the
extracellular fluid to intracellular fluid from the infusion of
dextrose. The spike in insulin following the infusion of dextrose
promotes anabolism; cells quickly draw potassium, phosphate, and
magnesium out of the bloodstream.
• The resulting decrease in serum electrolyte levels can lead to fluid
retention, heart failure, and respiratory failure.
• Symptoms include edema, cardiac arrhythmias, muscle weakness,
and confusion.
• Thiamin deficiency occurs from the increased metabolism of
carbohydrates and may cause acidosis, hyperventilation, and
neurological impairments.
• The risk of refeeding syndrome can be minimized by ensuring
normal electrolyte levels prior to initiating PN and beginning PN at
a 25% of estimated daily needs and advancing the infusion slowly.
A higher-protein, low-carbohydrate regimen is recommended.‐
Supplemental thiamin is provided.
• Monitoring of glucose and electrolyte levels is essential.
Transitioning from Parenteral Nutrition

The transition from PN to EN and/or an oral intake begins only after GI
function is adequate. PN is usually tapered as EN feedings or oral intake
resumes; the transition rate is influenced by how long the client has been
dependent on PN and their overall health. When the client is able to
consume 50% to 75% of calorie, protein, and micronutrient requirements
through EN and/or an oral intake, PN may be discontinued (Worthington et
al., 2017).
How Do You Respond?

My client claims they can taste their tube feeding. Can
they? Except for clients who experience gastric reflux,
clients cannot truly taste a tube feeding. However, the
appearance and aroma of the formula may influence the
client’s acceptance and perception of palatability. If the
formula’s appearance is offensive, cover the feeding
reservoir or remove it from the client’s field of vision, if
possible.
What are modular enteral nutrition formulas?
Modular formulas are an infrequently used option to
improve a client’s intake. They are powdered or liquid
products usually composed of a single nutrient, such as
carbohydrate (e.g., hydrolyzed cornstarch), protein (e.g.,
whey protein), or fat (e.g., MCT oil). These products can
be added to enteral formulas, food, or beverages to boost
calorie or nutrient density. For instance, a client with
chronic kidney failure may receive carbohydrate-fortified
mashed potatoes to increase calorie intake without adding
protein or altering taste. The disadvantages of adding a
modular product EN is ineffective quality control
(calculation errors), risk of bacterial contamination, and
higher costs than standard formulas. They also increase
the risk of clogged tubes and nutrient imbalances.
REVIEW CASE STUDY
Eugene is a 73-year-old man who weighs 168 pounds and is 5 ft 10 in. tall.
He has had progressive difficulty swallowing related to supranuclear palsy.
He has no other medical history other than hypertension, which is
controlled by medication. He denies that the disease interferes with his
ability to eat, even though he coughs frequently while eating and has lost 20
pounds over the last 6 months. He is currently hospitalized with pneumonia,
and a swallowing evaluation concluded that he should have NPO. He has
agreed to an NG tube because he believes the “problem” will be short term
and he will be able to resume a normal oral diet after he is discharged from
the hospital. Based on his age and activity, and considering his weight and
health status, the dietitian has determined he needs 2000 cal/day and
approximately 90 g protein per day to help maintain muscle mass.
• What type of formula would be most appropriate for him? How much
formula would he need to meet his calorie requirements? How much
formula would he need to meet his vitamin and mineral requirements?
• What type of delivery would you recommend? What would the goal rate
be?
• If the doctor convinces him to agree to having a percutaneous endoscopic
gastrostomy (PEG) tube placed, what formula and feeding schedule
would you recommend for use at home? What does his family need to be
taught about tube feedings?
STUDY QUESTIONS
1 Which tube is appropriate for a short-term enteral feeding?

a. gastrostomy
b. PEG
c. NG
d. jejunostomy
2 What is the underlying difference between standard and hydrolyzed
formulas?
a. Standard formulas cannot meet the needs of clients who have high
protein needs.
b. Standard formulas contain intact nutrients. Hydrolyzed formulas
contain nutrients in more readily absorbable form.
c. Standard formulas can be infused in the stomach or intestine.
Hydrolyzed formulas can be infused only into the stomach.
d. Standard formulas are nutritionally complete. All hydrolyzed formulas
intentionally lack one or more nutrients.
3 Which type of enteral formula would be most appropriate for a client
experiencing malabsorption related to inflammatory bowel disease?
a. a standard intact formula
b. a fiber-enriched intact formula
c. a hydrolyzed formula for malabsorption
d. a client with malabsorption cannot receive EN
4 Which of the following conditions indicate that IVLEs should be used
with caution or avoided? Select all that apply.
a. recent myocardial infarction
b. hyperglycemia
c. severe hyperlipidemia
d. allergy to eggs
5 Which tube-feeding delivery method is most likely to cause symptoms of
GI intolerance?
a. intermittent feedings
b. bolus feedings
c. cyclic feedings
d. continuous drip feedings
6 Which of the following statements is true?
a. Medications may be the primary cause of diarrhea in tube-fed clients.
b. Diarrhea is most commonly caused by infusing EN at too high a rate.
c. Diarrhea indicates the tube feeding should be held.
d. Diluting the formula and gradually increasing the concentration helps
avoid diarrhea.
7 Which of the following conditions are likely to require PN? Select all
that apply.
a. paralytic ileus
b. severe short bowel syndrome
c. dysphagia
d. coma
8 When oral or EN is not possible or adequate, when should PN be
initiated in clients who are moderately to severely malnourished?
a. as soon as feasible
b. within 2 to 3 days
c. within 3 to 5 days
d. within 7 days
CHAPTER SUMMARY ENTERAL
AND PARENTERAL NUTRITION
Enteral Nutrition
Enteral nutrition (EN) is commonly referred to as tube feeding. EN is
preferred whenever the GI tract is at least partially functional, accessible,
and safe to use. The client’s nutritional needs are estimated before selection
decisions are made.
Formula Selection
• Standard formulas contain intact nutrients and are suitable for most
clients who need EN.
• Hydrolyzed formulas are composed of nutrients in simple form for
clients with altered digestion and/or absorption.
• Disease-specific formulas are specially designed for clients with certain
disorders, such as diabetes, pulmonary disorders, and immune disorders.
• Formula characteristics differ in caloric density, amount of protein/L,
water content, micronutrient density, and other features.
• Feeding routes are NG, NI, gastrostomy, and jejunostomy.
Delivery Methods
• Intermittent: 250 to 500 mL given 4–8 times/day

• Bolus: variation of intermittent; >250 mL given 4–6 times/day via
gravity using a syringe
• Continuous drip: consistent rate over 16 to 24 hours
• Cyclic: variation of continuous drip given over 8 to 20 hours
Feeding Systems
• Open system: Formula is poured from original container into feeding

reservoir.
• Closed system: Formula is in ready-to-hang form
Initiating and Advancing the

Feeding
• The optimal rate to initiate feedings and how quickly they should be
advanced are not known.
• Formulas are infused at full strength.
• Stable clients may be able to tolerate starting feeding at goal rate.
Water flushes keep the tube clear, meet fluid requirements, and are
completed before and after medication and feedings.
Monitoring is necessary to ensure tolerance and nutritional adequacy. Real

or perceived tube-feeding intolerance is a common reason for holding
EN.
• Tube-feeding complications include altered fluid balance, electrolyte
imbalances, altered glucose levels, mechanical problems with the tube,
and aspiration of gastric feedings.
Medications by tube must be given separately and after flushing the tube
with water. Many medications contain sorbitol, which may cause diarrhea.
Transition to oral diet: EN may be discontinued when oral intake provides
two thirds of protein and calorie needs.
Parenteral nutrition (PN) is the delivery of a nutritionally complete sterile
solution into a major vein.
• Indications: clients who are unable to absorb adequate nutritional

enterally.
• Disadvantages are that it is invasive, costly, associated with numerous
metabolic, mechanical, and infections complications.
• Access sites: may be delivered peripherally (PPN) or via central vein
(PN). PPN solutions must be isotonic and therefore are limited in
calories.
• PN solutions: TNAs (“3 in 1”) contain all 3 macronutrients in one IV
solution. “2 in 1” solutions contain everything except IVFE, which can
be administered separately, often by piggyback infusion. Electrolytes,
vitamins, and trace minerals are added to parenteral solutions.
Composition
• Protein: crystalline essential and nonessential amino acids that can be

initiated at goal rate.
• Carbohydrate: dextrose monohydrate that is initiated at low rate and
progressed slowly.
• Fat: IVLEs prevent essential fatty acid deficiency and are a concentrated
source of calories.
• Micronutrients: Electrolytes, multivitamins, and trace minerals are
added.
Initiation and Administration
• as per facility protocol

• infused continuously to begin PN and appropriate for malnourished and
critically ill clients
• cyclic PN is widely used by clients who need PN permanently
Refeeding Syndrome: a life-threatening complication from the abrupt

change from a catabolic to an anabolic state from the increase in
carbohydrate in debilitated clients.
• prevention strategies: correct electrolyte levels before beginning PN,
initiate at a low rate, advance PN slowly.
Transitioning from PN: PN may be discontinued when oral/enteral intake

provides 50% to 75% of client needs.
Figure sources: shutterstock.com/nampix, shutterstock.com/Bignai, and shutterstock.com/Martin
Carlsson

book at
Websites
American Society for Parenteral and Enteral Nutrition at www.nutritioncare.org
Enteral product information at www.abbottnutrition.com; https://www.nestlehealthscience.us/
European Society for Parenteral and Enteral Nutrition at www.ESPEN.org
The Oley Foundation, a nonprofit organization to help clients, families, and clinicians involved with
home parenteral or enteral nutrition at www.oley.org
References
Academy of Nutrition and Dietetics. (2020a). Nutrition care manual: Enteral nutrition.
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American Dietetic Association, 107(6), 988–996. https://doi.org/10.1016/j.jada.2007.03.015
McClave, S., Taylor, B., Martindale, R., Warren, M., Johnson, D. R., Braunschweig, C., McCarthy,
M., Davanos, E., Rice, T., Cresci, G., Gervasio, J., Sacks, G., Roberts, P., Compher, C., & the
Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition.
(2016). Guidelines for the provision and assessment of nutrition support therapy in the adult
critically ill client: Society of Critical Care Medicine (SCCM) and American Society for
Parenteral and Enteral Nutrition (A.S.P.E.N.). Journal of Parenteral and Enteral Nutrition, 40(2),
159–211. https://doi.org/10.1177/0148607115621863
Parrish, C., & McCray, S. (2019a). Part II enteral feeding: Eradicate barriers with root cause analysis
and focused intervention. Practical Gastroenterology. https://med.virginia.edu/ginutrition/wp-
content/uploads/sites/199/2019/02/Parrish-Barriers-in-EN-February-2019.pdf
Parrish, C., & McCray, S. (2019b). Part I enteral feeding barriers: Pesky bowel sounds & gastric
residual volumes. Practical Gastroenterology. https://med.virginia.edu/ginutrition/wp-
content/uploads/sites/199/2019/02/Parrish-Bowel-Sounds-and-GRVs-January-2019.pdf
Raman, M., Almutairdi, A., Mulesa, L., Alberda, C., Beattie, C., & Gramlich, L. (2017). Parenteral
nutrition and lipids. Nutrients, 9(4), 388. https://doi.org/10.3390/nu9040388
Worthington, P., Balint, J., Bechtold, M., Bingham, A., Chan, L.-N., Durfee, S., Jevenn, A., Malone,
A., Mascarenhas, M., Robinson, D., & Holcombe, B. (2017). When is parenteral nutrition
appropriate? Journal of Parenteral and Enteral Nutrition, 41(3), 324–377.
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https://doi.org/10.1177/0884533617701883
Chapter Nutrition for Obesity
17 and Eating Disorders
Emma Guido
Emma is 33 years old, stands 5 ft 1 in. tall, and
weighs 160 pounds. Since the age of 21 years, her
weight has ranged from 100 to 160 pounds. Her goal
is to weigh 110 pounds. She is a certified personal
trainer but changed professions because it was
“fueling bad behaviors.” She does not have a medical
history, although she admits to being hospitalized at
one point because of very low potassium levels. She
wants to achieve “more normal” eating behaviors.
Learning Objectives
1 Discuss the value and shortcomings of using body mass index (BMI) and
abdominal waist circumference to quantify and classify obesity.
2 Assess a person’s level of disease risk based on BMI and waist
circumference.
3 Discuss the three components of lifestyle therapy for weight
management.
4 Identify general calorie targets for weight-loss diets for men and women.
5 Discuss the potential health benefits that may be realized when a
Mediterranean diet or Dietary Approaches to Stop Hypertension diet is
used for weight loss.
6 Give examples of evidence-based diets that are associated with weight
loss if calorie intake is appropriately lowered.
7 Give examples of lifestyle behaviors of people who are successfully able
to maintain weight loss.
8 Explain when weight-loss medications are appropriate in weight-loss
treatment.
9 Describe a general diet progression after bariatric surgery.
10Suggest possible nutritional interventions for nutritional complications
that may occur after bariatric surgery.
11 Contrast nutrition therapies for anorexia nervosa, bulimia nervosa, and
binge-eating disorder.
Obesity is a complex chronic condition that typically develops over an
individual’s lifetime. At its most basic level, obesity is a problem of
excessive calorie intake. A far less common weight issue is disordered
eating manifested as anorexia nervosa (AN) or bulimia nervosa.
Historically, the studies of obesity and eating disorders have been separate,
with the former rooted in medicine and the latter the focus of psychiatry and
psychology. Yet there are commonalities between them, such as questions
of appetite regulation, concerns with body image, and similar etiologic risk
factors.
This chapter focuses on obesity—its causes, complications, and
treatment approaches, including nutrition therapy, behavioral intervention,
physical activity, pharmacology, and surgery. Eating disorders and their
nutrition therapy are described.
OBESITY
Obesity can be defined as abnormal or excessive body fat accumulation that
leads to adverse health consequences. The cause of obesity seems obvious:
excessive calorie intake compared to calorie expenditure over a period of
time (i.e., people eat more calories than they use). Although we know how
obesity occurs, why it occurs is not fully understood despite intensive study.
Certainly, dietary patterns and inactivity are among the primary
contributing factors. However, the causes are multifactorial and complex. It
is likely that obesity results from a dynamic interaction of genetic,
physiological, behavioral, sociocultural, and environmental factors (Bray et
al., 2016). Examples of these factors are outlined in Table 17.1.
Measures of Obesity
Body mass index (BMI) and waist circumference are ways to quantitatively
define and classify obesity and assess the risk of disease (Table 17.2).
Table Factors That May Contribute

17.1 to Obesity
Causative Factors Examples

Genetic • More than 50 genes are strongly
associated with obesity (Sicat, 2018).
• Rarely, single gene defects (e.g., leptin
deficiency) cause severe obesity in early
childhood related to very high levels of
hunger.
• More commonly, predisposition occurs
from multiple genes (e.g., fat mass and
obesity-associated gene [FTO]) that may
promote hunger, lower satiety, or lower
control overeating.
Physiological
• Hypothyroidism
Diseases • Cushing syndrome
Metabolic/hormonal • Leptin helps regulate energy balance and

suppresses appetite; leptin resistance may
Side effect of promote higher intake of calories and
medications prevent sustained weight loss
Mental disorders • During dieting and weight loss, ghrelin
levels increase (ghrelin stimulates appetite,
particularly for high-fat, high-sugar foods)
• Antidepressants
• Antipsychotics
• Corticosteroids
• Insulin
• Depression
• Binge-eating disorder
• Bulimia nervosa
Sociocultural/behavioral • Preference for foods high in fat and/or
carbohydrates
• “Value meals,” increased intake of food
away from home
• Increase in sedentary occupations
• Increase in sedentary leisure time
• Labor-saving devices (e.g., motorized
walkways)
• Lack of adequate sleep
Environmental • Communities not conducive to physical
activity
• Distances between homes and
work/shopping too far for walking
• Living near high concentration of fast-
food restaurants
Source: Sicat, J. (2018, July 23). Obesity and genetics: Nature and nurture. Obesity Medicine
Association. https://obesitymedicine.org/obesity-and-genetics; AACE Obesity Resource Center.
(n.d.) What is the disease of obesity? Obesity pathophysiology.
https://www.aace.com/sites/default/files/pdfs/disease_state_resources/nutrition_and_‐
obesity/slide_library/1.2.obesity-pathophysiology.pdf; van der Valk, E., van den Akker, E., Savas,
M., Kleinendorst, L., Visser, J. A., Van Haelst, M. M., Sharma, A. M., & van Rossum, E. F. C.,
(2019). A comprehensive diagnostic approach to detect underlying causes of obesity in adults.
Obesity Reviews, 20, 795–804. https://doi.org/10.1111/obr.12836
Classification of Overweight and

Table Obesity by Body Mass Index, Waist
17.2 Circumference, and Associated
Disease Risks
Body Mass Index

BMI is calculated by dividing weight in kilograms by height in meters
squared.
• It often correlates with the degree of body “fatness,” but it does not
differentiate for gender, ethnicity, muscle mass, and frame size
(Welcome, 2017).
• BMI should be considered a screening tool to identify obesity, not a
diagnostic method (Bray et al., 2016).
• The classification of underweight, normal weight, overweight, and
obesity begins at lower levels for Asians than at the ranges given in
Table 17.2.
Waist Circumference
Waist circumference is a measure of central obesity.
• Although it is not used routinely to diagnose overweight and
obesity, waist circumference is a strong predictor of obesity-related,
long-term health problems and correlates well with metabolic
disease risk (Welcome, 2017).
• Like BMI, suggested cutoff points for health risk based on waist
circumferences are lower for Asians (≥35 in. for men and ≥31 in. for
women) than for Caucasians (International Diabetes Federation,
2006).
Overweight
a BMI of 25 or greater.
Obesity
a BMI of 30 or greater.
Obesity Prevalence
Obesity is a worldwide epidemic and a global public health challenge.
According to the World Health Organization, more people are obese than
underweight in every region of the world except parts of sub-Saharan
Africa and Asia (World Health Organization [WHO], 2018). Worldwide,
obesity has almost tripled from 1975 to 2016. In 2016, more than 1.9 billion
adults aged 18 and older were overweight, 650 million of whom were
obese.
From 1960–1962 to 2015–2016, obesity and severe obesity increased
dramatically in both men and women (Fig. 17.1) (Fryar et al., 2018). In
2015–2016, the prevalence of obesity among American adults was 39.8%,
or approximately 93.3 million adults (Hales et al., 2017). Obesity
prevalence has increased in all age groups and in all racial and ethnic
groups. Overall, obesity prevalence is higher among the following:
• adults ages 40 to 59 than among adults aged 20 to 39
• women than men (Fig. 17.2)
• Hispanic adults compared to other races (Fig. 17.2)
Figure 17.1 ▲ Trends in adult overweight, obesity, and extreme obesity
among men and women aged 20 to 74 years, 1960–1962 to 2015–2016.
(Source: Carroll, M., Fryar, C., & Ogden, C. [2018, September]. NCHS
Health E-Stats. Centers for Disease Control and Prevention.
https://www.cdc.gov/nchs/data/hestat/obesity_adult_15_16/obesity_adult_1
5_16.pdf)
Note. Data are age adjusted by the direct method to U.S. Census 2000 estimates using age groups 20–
39, 40–59, and 60–74. Overweight is a body mass index (BMI) of 25.0–29.9 kg/m2; obesity is a BMI
at or above 30.0 kg/m2; and severe obesity is a BMI at or above 40.0 kg/m2. Pregnant women are
excluded from the analysis.
Consider Emma. What is her current BMI? Does it present

a health risk? What was her BMI when she weighed 100
pounds? Was that a healthier weight?
Obesity Complications
Overweight and obesity are associated with increased risk of all-cause
mortality (Aune et al., 2016). High BMI is a major risk factor for
cardiovascular disease, diabetes, musculoskeletal disorders, and some
cancers (Box 17.1) (WHO, 2018). Most of the world’s population live in
countries where overweight and obesity kill more people than underweight
(WHO, 2018). Obesity also increases the risk of the following:
• morbidity from hypertension, dyslipidemia, type 2 diabetes,
coronary heart disease, stroke, gallbladder disease, osteoarthritis,
sleep apnea, respiratory problems, and some cancers (Jensen et al.,
2014)
• complications during and after surgery
• complications during pregnancy, labor, and delivery
Where excess body fat is stored also influences the risk of comorbidities.
• Central obesity, as part of the metabolic syndrome, increases the
risk of coronary heart disease and type 2 diabetes (see Chapters 21
and 22).
• Central obesity also increases the risk of stroke, sleep apnea,
hypertension, dyslipidemia, insulin resistance, inflammation, and
some types of cancer (Tchernof & Després, 2013). This risk is
usually confirmed at any degree of total body fatness.
• Evidence shows that as waist circumference increases, so does risk
of obesity comorbidities (Jensen et al., 2014).
Metabolic Syndrome
a cluster of interrelated symptoms, including obesity, insulin resistance, hypertension, and
dyslipidemia, which together increase the risk of cardiovascular disease and diabetes.
Central Obesity
waist circumference exceeding 35 in. in women or 40 in. in men.
Figure 17.2 ▲ Age-adjusted prevalence of obesity among adults aged
20 and over, by sex and race and Hispanic origin: United States, 2015–
2016. (Source: Hales, C., Carroll, M., Fryar, C., & Ogden, C. [2017,
October]. NCHS data brief. Centers for Disease Control and Prevention.
https://www.cdc.gov/nchs/data/databriefs/db288.pdf)
Note. All estimates are age adjusted by the direct method to the 2000 U.S. census population using
the age groups 20–39, 40–59, and 60 and over. Access data table for figure at
https://www.cdc.gov/nchs/data/databriefs/db288_table.pdf#2.
1
Significantly different from non-Hispanic Asian persons.
2
Significantly different from non-Hispanic White persons.
3
Significantly different from Hispanic persons.
4
Significantly different from women of the same race and Hispanic origin.
BOX Potential Complications of

17.1 Overweight/Obesity
Metabolic complications:
• Prediabetes
• Metabolic syndrome
• Type 2 diabetes mellitus
• Nonalcoholic fatty liver disease and nonalcoholic steatohepatitis
Cardiovascular complications:
• Dyslipidemia
• Hypertension
• Cardiovascular disease
Certain cancers:
• Postmenopausal breast
• Colorectal
• Endometrial
• Esophagus
• Kidney
• Pancreas
• Possibly linked to cancers of: gallbladder, liver, cervix, ovary, and
aggressive prostate cancer
• Possibly linked to non-Hodgkin’s lymphoma and multiple myeloma
Organ-specific, hormonal, and mechanical complications:
• Polycystic ovary syndrome and infertility in women

• Hypogonadism in men
• Obstructive sleep apnea
• Asthma/respiratory disease
• Osteoarthritis
• Urinary stress incontinence
• Gastroesophageal reflux disease
Psychological complications:
• Depression
• Anxiety
• Binge-eating disorder
• Stigmatization
Source: Garvey, W. T., Mechanick, J., Brett, E., Garber, A., Hurley, D., Jastreboff, A., Nadolsky,
K., Pessah-Pollack, R., Plodkowski, R., & Reviewers of the AACE/ACE Obesity Clinical
Practice Guidelines. (2016). American association of clinical endocrinologists and American
college of endocrinology comprehensive clinical practice guidelines for medical care of
patients with obesity. Endocrine Practice, 22(supplement 3), 1–203.
https://doi.org/10.4158/EP161365.GL; Simon, S. (2019). The link between weight and cancer
risk. https://www.cancer.org/latest-news/the-link-between-weight-and-cancer-risk.html; Sarwer,
D., & Polonsky, H. (2016). The psychosocial burden of obesity. Endocrinology and Metabolism
Clinics of North America, 45(3), 677–688. https://doi.org/10.1016/j.ecl.2016.04.016
MANAGEMENT OF OVERWEIGHT
AND OBESITY
While prevention may be key to reversing the obesity epidemic, prevention

strategies tested in schools, work places, and communities have shown little
effect, emphasizing the need for effective treatment (Bray et al., 2016).
Treatment guidelines have been issued by leading health organizations such
as the American Heart Association/American College of Cardiology/The
Obesity Society (Jensen et al., 2014) and the American Association of
Clinical Endocrinologists and American College of Endocrinology (Garvey
et al., 2016). Assessment begins with identifying clients who need to lose
weight. Table 17.3 identifies who should lose weight based on BMI and the
presence/severity of weight-related complications.
Evaluating Readiness to Lose Weight

Objectively identifying who may benefit from weight loss is not the only
criterion to be considered before beginning treatment; assessing the client’s
level of readiness to make changes is crucial. Because clients at the two
earliest stages of the transtheoretical stages of behavior change model are
ambivalent about behavior change, clients in those stages are not likely to
benefit from weight-loss counseling (Fig. 17.3) (Wee et al., 2005). Even
worse, counseling before readiness may preclude subsequent attempts at
weight loss, when the client may be more likely to succeed. The question
that needs to be answered is, Is the client committed to making permanent
changes for long-lasting success?
Table Obesity Treatment Based on

Body Mass Index and
17.3 Complications
Figure 17.3 ▲ Stages of change.
Treatment Goals
As indicated in Table 17.3, treatment goals for weight management focus
on preventing or ameliorating weight-related complications through weight
loss, not “curing” overweight and obesity. In reality, achieving a permanent
decrease in BMI to 25 or less is seldom achieved. The goal of losing large
amounts of weight may be unrealistic, overwhelming, and, from a health
perspective, not necessary to achieve medically significant health benefits.
• A sustained weight loss of as little as 3% to 5% of body weight can
cause clinically significant reductions in triglycerides, blood
glucose, and hemoglobin A1c and lowered risk of type 2 diabetes
(Jensen et al., 2014).
• Greater weight loss leads to greater benefits, such as lowering blood
pressure, improving low-density lipoprotein (LDL) cholesterol and
high-density lipoprotein (HDL), and reducing the need for
medications to control blood pressure, blood glucose, and lipids
• A 5% to 10% weight loss within 6 months is recommended.
• For some people, even modest weight loss may be unattainable, so a
more appropriate goal may be to prevent additional weight gain.
Although this may sound like a passive approach, it requires active
intervention, not simply maintenance of the status quo.
Think of Emma. Would you identify her as a candidate for

weight loss? If so, what would a reasonable weight goal be?
WEIGHT-LOSS THERAPIES
Weight-loss therapies include lifestyle/behavioral therapy (healthy calorie-

reduced eating plan, physical activity, and behavioral interventions),
weight-loss medications, and bariatric surgery.
Lifestyle/Behavioral Therapy
Lifestyle/behavioral therapy serves as the foundation of weight
management for all people who are overweight or obese regardless of
complications (see Table 17.3). It is a three-pronged approach that includes
a healthy, calorie-reduced eating plan, an increase in physical activity, and
behavioral interventions to facilitate adherence to eating and activity
changes (Box 17.2). Lifestyle/behavioral therapy alone will cause a
substantial proportion of clients to lose enough weight to improve health
Interestingly, it is recommended that people with a healthy BMI use
similar approaches to prevent overweight and obesity: Eat a healthy eating
pattern, increase physical activity, and participate in health education.
Healthy Calorie-Reduced Eating Plan

Reducing calorie intake is the main component of any weight-loss
intervention (Garvey et al., 2016). A hypocaloric eating plan may be
achieved by any of the following methods (Jensen et al., 2014):
• choosing a general target to create a calorie deficit, such as 1200 to
1500 cal/day for women and 1500 to 1800 cal/day for men
• prescribing a calorie level that is 500 to 750 cal/day less than
estimated need; a 500-cal/day deficit theoretically causes a 1-pound
weight loss/week (see Box 17.3)
• adopting an ad lib approach that does not necessarily prescribe a
specific calorie level but achieves a calorie deficit by restricting or
eliminating particular food groups, as seen in a low-carbohydrate or
low-fat eating plan
Components of Evidence-Based
BOX
Lifestyle/Behavior Therapy for Obesity
17.2 Treatment
Eating Plan
• Reduce total calorie intake by 500 to 750.
• Individualize plan according to personal and cultural preferences.
• Use a healthy meal pattern: Mediterranean, DASH, low-carb, low-fat,
volumetric, high-protein, vegetarian.
• Meal replacements may aid weight loss.
• VLCD for limited circumstances and with medical supervision.
Physical Activity
• Increase aerobic activity.
• Engage in resistance training exercises.
• Decrease sedentary time.
Behavioral Interventions
Any number of the following:
• Self-monitoring, such as with food intake, exercise, and weight.

• Goal setting, such as regarding food intake, physical activity, or
behavioral changes.
• Problem-solving strategies, such as planning appropriate behaviors for
high-risk situations.
• Stimulus control, such as restructuring the environment to avoid
triggers for overeating.
• Behavioral contracting to promote behavior change.
• Stress reduction to decrease the risk that food will be used to reduce
stress.
• Cognitive restructuring such as changing inaccurate beliefs.
• Motivational interviewing to resolve ambivalent feelings and find
internal motivation.
• Mobilization of social support structures, which is important for long-
term weight-loss success.
• Education via face-to-face meetings, group sessions, or remote
technologies.
Source: American Association of Clinical Endocrinologists, American College of Endocrinology.
AACE/ACE Algorithm for medical care of patients with obesity. https://pro.aace.com/disease-
state-resources/nutrition-and-obesity/treatment-algorithms/obesity-algorithm#/start
BOX One Pound of Body Fat Equals

17.3 Approximately 3500 Calories
• To lose 1 pound per week: reduce intake by 3500 cal/week or 500

cal/day (3500 calories ÷ 7 days/week).
• To lose 2 pounds per week: reduce intake by 7000 cal/week or 1000
cal/day (7000 cal ÷ 7 days/week.).
The “Best” Weight Loss Diet

The question of which diet is the “best” diet for weight loss has been
debated for decades. Attention has focused on the relevance of the
macronutrient composition of the diet—the proportion of carbohydrates,
protein, and fat—in achieving and maintaining weight loss.
• Data are insufficient to support any particular macronutrient
distribution for the specific purpose of promoting weight loss
(Garvey et al., 2016). In other words, when designed to provide
fewer calories for weight loss, numerous evidence-based dietary
approaches can be effective (Table 17.4). From a weight-loss
standpoint, calories matter more than the percent contribution of
carbohydrates, protein, and fat. Table 17.5 illustrates the amount
from each food group in a low-fat, balanced, and low-carbohydrate
1500-calorie eating plan.
• Because most low-calorie diets lead to clinically important weight
loss if the diet is followed, the “best” diet is the one the client will
adhere to (Johnston et al., 2014).
• However, in terms of overall health, certain meal patterns or
approaches may be beneficial for certain populations, as described
in the following section.
The Dietary Approaches to Stop Hypertension Diet
The Dietary Approaches to Stop Hypertension (DASH) diet may be
preferable for clients with hypertension.
• It lowers blood pressure even when weight loss is not the goal
(Svetkey et al., 1999).
• It has also been shown to be an effective weight-loss meal pattern
when modified to provide a calorie deficit of 500 cal/day (Appel et
al., 2003).
• The DASH diet is rich in fruit, vegetables, low-fat dairy products,
and whole grains; moderate in poultry, fish, and nuts; and low in fat,
red meat, and added sugar.
• For more on the DASH diet, see Chapters 7 and 22.
The Mediterranean Diet

The Mediterranean diet may be beneficial for clients with cardiometabolic
risk (e.g., high glucose, high triglycerides, low HDL cholesterol, central
obesity, and hypertension) (Garvey et al., 2016).
• A Mediterranean-Style Eating Pattern is associated with a decrease
in BMI, hemoglobin A1c, fasting glucose, and fasting insulin (Huo
et al., 2014).
• The PREvención con Dieta MEDiterránea study showed that better
conformity with the traditional Mediterranean-Style Eating Pattern
is associated with better cardiovascular disease (CVD) outcomes,
including reductions in the rates of coronary heart disease, ischemic
stroke, and total CVD (Martinez-Gonzalez et al., 2019).
• The Mediterranean-Style Eating Pattern is rich in fruit, vegetables,
nuts, legumes, unprocessed cereals, and olive oil; moderate in fish
and wine with meals; and low in meat, meat products, and dairy
products. It is a relatively high-fat diet (e.g., 40% of total calories),
particularly monounsaturated fat, largely due to the liberal use of
olive oil.
• For more on the Mediterranean diet, see Chapters 2 and 14.
Evidence-Based Dietary
Table Approaches Associated with
17.4 Weight Loss if Low-Calorie Intake
Is Achieved
Dietary Approach Descriptiona
Diet from the Food group approach without formal
European prescribed calorie restriction
Association for
the Study of
Diabetes
Guidelines
Higher-protein diet Prescribed calorie restriction of 25% protein,
30% fat, and 45% carbohydrate
Higher-protein zone- Five meals a day, each composed of 30%
type diet protein, 30% fat, and 40% carbohydrate
without prescribed calorie restriction
Lacto-ovo vegetarian- Prescribed calorie restriction
style diet
Low-calorie diet Prescribed calorie restriction
Low-carbohydrate Initial carbohydrate intake of <20 g/day
diet without prescribed calorie restriction
Low-fat vegan-style 10%–25% of calories from fat without
diet prescribed calorie restriction
Low-fat diet 20% of calories from fat without prescribed
calorie restriction
Low–glycemic load With or without prescribed calorie restriction
diet
Lower-fat, high-dairy Less than 30% fat, four servings of dairy per
diet day, with or without increased fiber and/or
low-glycemic index foods with prescribed
calorie restriction
Dietary Approach Descriptiona
Macronutrient- Prescribed calorie restriction with 15%–25%
targeted diets protein, 20%–40% fat, and 35%, 45%,
55%, or 65% carbohydrates
Mediterranean-style Prescribed calorie restriction
diet
Moderate-protein diet 12% protein, 30% fat, 58% carbohydrates
without prescribed calorie restriction
The American Heart Prescribed calorie restriction of 1500–1800
Association–style cal/day with <30% fat, <10% saturated fat
step 1 diet
In diets without a prescribed calorie restriction, calorie deficits result from restricting or eliminating
a
specific foods or food groups.

Source: Jensen, M., Ryan, D., Apovian, C., Ard, J. D., Comuzzie, A. G., Donato, K. A., Hu, F.,
Hubbard, V., Jakicic, J., Kushner, R., Loria, C., Millen, B., Nonas, C., Pi-Sunyer, X., Stevens, J.,
Stevens, V., Wadden, T., Wolfe, B., & Yanovski, S. Z. (2014). 2013 AHA/ACC/TOS guideline for
the management of overweight and obesity in adults. A report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines and the Obesity
Society. Journal of the American College of Cardiology, 63(25), 2985–3023.
https://doi.org/10.1016/j.jacc.2013.11.004.
Table Sample 1500-Calorie Eating Plans

for Low-Fat, Balanced, and Low-
17.5 Carb Diets
Meal Replacement Approach
Consuming liquid meal replacements or prepackaged foods is one approach
that may promote more weight loss than standard low-calorie diets and
behavior counseling (Rock et al., 2016).
• Prepacked foods overcome several barriers to dietary adherence,
including portion control, convenience, and reduced decision-
making.
• Commercial diet programs, such as Jenny Craig and Nutrisystem,
feature one to two meals per day of vitamin- and mineral-fortified,
low-calorie meals, which may be in the form of a shake, frozen
entrée, or meal bar.
• In overweight and obese women, the use of liquid and bar meal
replacements is associated with greater weight loss at up to 6
months compared to a balanced low-calorie diet of conventional
food (Jensen et al., 2014).
• Long-term studies are needed to determine how meal replacements
impact weight-loss maintenance.
Very-Low-Calorie Diet
Very-low-calorie diets (VLCDs) provide <800 cal/day, usually in the form
of a liquid shake that is enriched with high biologic value protein and 100%
of the daily value for micronutrients.
• Initial weight loss is quick and substantial, but VLCDs are
associated with gallstones and sudden death and greater weight
regain compared with weight loss achieved through a more
moderate calorie restriction (Hemmingsson et al., 2012).
• VLCDs should be used only in limited circumstances in a medical
care setting, with the provision of medical supervision and high-
intensity lifestyle intervention (Jensen et al., 2014).
• VLCDs are a common method to reduce weight prior to bariatric
surgery to reduce overall surgical risk in people with severe obesity
(Yolsuriyanwong et al., 2019).
Physical Activity
Evidence-based lifestyle therapy for the treatment of obesity includes the
following physical activity recommendations (Garvey et al., 2016):
• Aerobic physical activity progressing to 150 minutes/week or more
performed on 3 to 5 separate days/week. Greater amounts of
exercise are associated with better long-term weight-loss
maintenance (Vanderwood et al., 2011; Wadden et al., 2011).
• Resistance training of single-set exercises involving the major
muscle groups performed 2–3 times/week. Resistance training
exercises help promote fat loss while preserving muscle mass during
weight-loss therapy.
• Reduce sedentary behavior, which in general means any waking
behavior with low energy output done while sitting, reclining, or
lying down.
• Physical activity should be individualized according to the client’s
preferences and physical limitations.
• Evidence-based strategies that may improve physical activity levels
include receiving guidance within small groups led by a health
professional or trainer; using a “buddy system” for support; and
technology-based approaches, such as pedometers and other
wearable activity monitors, and virtual coaching through text
messaging, telephone, or the Internet (United States Department of
Health and Human Services, 2018).
Behavioral Interventions
Behavioral interventions are intended to promote adherence to nutrition and
physical activity prescriptions through activities such as self-monitoring,
goal setting, and stimulus control (Box 17.2). Box 17.4 lists specific
strategies to promote adherence to a reduced-calorie eating plan.
BOX Behavior Change Ideas

17.4
Change the Environment
• Keep food only in the kitchen, not scattered around the house.
• Stay out of the kitchen except when preparing and cleaning up after
meals.
• Avoid tasting food while cooking; don’t take extra portions to get rid
of a food.
• Place the low-calorie foods in the front of the refrigerator; keep the
high-calorie foods hidden.
• Remove temptation to better resist it: “Out of sight, out of mind.”
• Plan meals and snacks to help eliminate hasty decisions and impulses
that may sabotage healthy eating.
Eat Wisely
• Wait 10 minutes before eating when you feel the urge; hunger pangs
may go away if you delay eating.
• Never skip meals.
• Eat before you’re starving and stop when satisfied, not stuffed.
• Eat only in one designated place and devote all your attention to
eating. Activities such as reading and watching television can be so
distracting that you may not even realize you ate.
• Serve food directly from the stove to the plate instead of family style,
which can lead to second helpings.
• “Right size” portions by estimating portion sizes according to common
household items, such as using the size of a woman’s palm to estimate
a 3 oz serving of meat.
• Eat the low-calorie foods first.
• Drink water with meals.
• Use a small plate to give the appearance of eating a full plate of food.
• Chew food thoroughly and eat slowly.
• Put utensils down between mouthfuls.
• Leave some food on your plate to help you feel in control of food
rather than feeling that food controls you.
• Eat before attending a social function that features food; while there,
select low-calorie foods to nibble on.
• Give yourself permission to enjoy an occasional planned indulgence
and do so without guilt; don’t let disappointment lead to an eating
binge.
• Eat satisfying foods and do not restrict particular foods.
• Replace sugar-sweetened beverages with water.
Shop Smart
• Never shop while hungry.

• Shop only from a list; resist impulse buying.
• Buy food only in the quantity you need.
• Don’t buy foods you find tempting.
• Stock on fruits and vegetables for low-calorie snacking.
Practice Healthy Habits
• Keep busy with hobbies or projects that are incompatible with eating
to take your mind off eating.
• Brush your teeth immediately after eating.
• Keep food and activity records.
• Keep hunger records.
• Get more sleep if fatigue triggers eating.
• Weigh yourself regularly.
Recall Emma. In an effort to lose weight, she has been

weighing and measuring her food and tracking her total
daily intake, which averages between 900 and 1100 cal/day.
Her food records show that she eats grains and protein foods
but no vegetables, fruits, or dairy. What would you tell
Emma about appropriate calories and weight-loss diets?
What would you tell her about healthy eating?
Comprehensive Lifestyle Programs

Comprehensive lifestyle programs are structured multidisciplinary
programs that include all three lifestyle therapies: hypocaloric eating plan,
physical activity prescriptions, and behavioral interventions. Multiple
studies show that structured comprehensive programs produce substantially
greater weight loss than standard or usual care (Garvey et al., 2016).
Frequent contact between health care professionals and accommodations
for personal and cultural client preferences may contribute to improved
success.
• Overweight and obese adults who want to lose weight should be
advised to participate in a comprehensive lifestyle program for at
least 6 months. Such programs help participants adhere to a lower-
calorie diet and increase physical activity through the use of
behavioral strategies (Jensen et al., 2014).
• Longer-duration programs (longer than 1 year) result in greater
weight loss and are more effective in preventing weight regain
(Millen et al., 2014).
• Electronically delivered weight-loss programs are useful but may
result in smaller weight loss than in-person interventions (Raynor &
Champagne, 2016).
• Commercial weight-loss diets that include comprehensive lifestyle
intervention, such as Weight Watchers, can be used provided there is
peer-reviewed published evidence of their safety and efficacy
(Raynor & Champagne, 2016).
Weight Maintenance after Loss

Although losing weight may be difficult, keeping it off is even harder.
Calorie expenditure is lower after weight loss because a lighter/smaller
body requires fewer calories than a heavier/larger body when performing
the same activity. Metabolic changes that occur during weight loss may also
contribute to the risk of regain. Evidence shows that weight loss causes an
adaptive thermogenesis which is a lowering of calorie expenditure beyond
what can be predicted by changes in body weight and composition (Camps
et al., 2013). This metabolic adaptation is a survival mechanism to conserve
energy during periods of famine. After weight loss, adaptive thermogenesis
may be responsible for a decrease in calorie expenditure of 20 to 200
cal/day—meaning someone who has lost significant weight may burn up to
200 fewer calories per day compared to someone of the same weight who
has not experienced weight loss. Camps et al. (2013) found that people with
a larger weight loss show a greater decrease in resting metabolic rate and
that adaptive thermogenesis may persist for up to 44 weeks after weight
loss. Adaptive thermogenesis was no longer observed when weight was
regained to preloss or higher weight. The disproportionate decrease in
calorie expenditure after weight loss could be one of the factors
contributing to the high rate of regain (Camps et al., 2013).
Typically, clients who participate in a lifestyle intervention program
reach maximum weight loss at 6 months, followed by a plateau and gradual
regain over time (Jensen et al., 2014). Weight regain is most likely to occur
in people who ease up on physical activity, increase their fat intake, use less
dietary restraint, and weigh themselves less often. Better long-term weight
maintenance is associated with larger initial weight loss and longer duration
of maintenance (Thomas et al., 2014). Long-term weight-loss maintenance
is possible but requires sustained behavior change (Thomas et al., 2014),
namely, high levels of physical activity (>200 minutes/week), continuation
of a low-calorie eating plan, and weekly self-monitoring of weight (Jensen,
2014).
The National Weight Control Registry (NWCR), founded in 1994 to
identify and investigate behavioral and psychological characteristics of
people who are successful in maintaining significant weight loss, is
currently tracking more than 10,000 people in the registry. The average
participant has lost an average of 66 pounds and kept it off for 5½ years.
Participants are surveyed annually to examine the behavioral and
psychological characteristics of weight maintainers and to identify the
strategies they use to maintain their weight loss. Characteristics of
successful weight maintainers appear in Box 17.5.
BOX Successful Weight Maintenance

17.5
The main strategies used by participants in the National Weight Control

Registry (NWCR) to successfully maintain long-term weight loss are the
following:
• High levels of physical activity (about 1 hour/day), walking being the

exercise of choice for most people
• Eating a low-calorie, low-fat diet
• Eating breakfast every day
• Weighing themselves at least once a week
• Limiting TV viewing to <10 hours/week
• Maintaining a consistent pattern across weekdays and weekends
Source: National Weight Control Registry. (n.d.). NWCR facts.
http://nwcr.ws/Research/default.htm
Weight-Loss Medications
While lifestyle modification alone is effective in achieving some weight
loss, virtually all obesity medication studies show that adding weight-loss
medication to lifestyle therapy consistently produces greater weight loss
and weight-loss maintenance than lifestyle therapy alone (Garvey et al.,
2016). Similarly, data show that weight-loss medication alone does not
result in as much weight loss as when medications are combined with
lifestyle therapy (Garvey et al., 2016).
• Weight-loss medications are approved by the Food and Drug
Administration (FDA) for clients with a BMI ≥ 30 without weight-
related complications or ≥27 in clients with at least one weight-
related complication (Mechanick et al., 2019).
• Weight-loss medications are used long term for chronic management
of obesity. Short-term use (3–6 months) has not been shown to
produce long-term health benefits (Garvey et al., 2016).
• In clients with weight-related complications that can be ameliorated
by weight loss, it is recommended that lifestyle therapy and weight-
loss medications be combined at the initiation of treatment.
• Weight-loss medications are increasingly used in clients who have
had bariatric surgery but have failed to lose adequate weight or have
had weight regain (Mechanick et al., 2019).
• Table 17.6 features the drugs approved by the U.S. FDA for the
treatment of obesity.
• Evidence is generally lacking on the usefulness of dietary
supplements in promoting weight loss (Box 17.6).
U.S. Food and Drug

Table Administration–Approved Drugs
17.6 for Long-Term Obesity
Treatments
BOX Selected Weight-Loss Supplements
17.6
• Acai: No definitive evidence exists that it promotes weight loss; little

information exists regarding its safety when consumed in supplement
form.
• Bitter orange: Evidence is insufficient to support its use for any health
purpose. Safety concerns have been raised, especially in people with
cardiac issues or hypertension.
• Ephedra (ma huang): There is little evidence of its effectiveness
except for short-term weight loss. It is associated with serious adverse
events, such as cardiovascular complications and death. Sale has been
banned in the United States since 2004.
• Green tea: There is not enough reliable data to assess its effect on
weight loss. A few, small studies found that the loss of weight in
overweight or obese adults who had taken a green tea preparation was
very small, not statistically significant, and not likely to be clinically
important.
• Hoodia: No reliable evidence supports its use for any health condition.
Safety has not been studied.
Source: National Institutes of Health, National Center for Complementary and Integrative Health.
(2015). Weight-control and complementary and integrative approaches: What the science says.
https://nccih.nih.gov/health/providers/digest/weightloss-science#acai
Weight-Loss Devices
A relatively new approach in treating obesity is the use of FDA-approved
nonsurgical procedures using certain devices. For instance, various
endoscopic bariatric therapies work by reducing stomach capacity, such as
the insertion of an intragastric balloon to occupy space in the stomach.
Three gastric balloons have been approved by the FDA for clients with a
BMI of 30 to 40. Although the devices are associated with short-term
weight loss, their effectiveness and safety in long-term obesity management
remain uncertain (Mechanick et al., 2019).
Recently, the popular press has touted FDA approval for a new weight-
loss pill called Plenitytm that expands in the stomach to provide a feeling of
fullness. However, the FDA approved Plenitytm as an adjunct to diet and
exercise and as “a transient, space-occupying devise for weight
management and/or weight loss for people with BMI of 25–40” (U.S. Food
and Drug Administration, 2019). It is composed of hydrogel that acts like a
fiber supplement to absorb water thereby causing the stomach to lose about
25% of its available volume. The “device” then passes from the body via
the GI tract. Preliminary studies show promise, but long-term safety and
usefulness are yet to be determined.
Bariatric Surgery
Bariatric surgery is the most effective treatment for obesity. Weight-loss
surgeries are considered both bariatric and metabolic surgeries. In addition
to leading to significant weight loss, these surgeries cause significant
improvements in glycemic-control metrics in clients with type 2 diabetes
and in cardiovascular outcomes, such as hypertension, dyslipidemia,
myocardial infarction, and stroke (Mechanick et al., 2019). The underlying
mechanisms of the beneficial effects are complex and include changes in GI
anatomy and motility, diet and behavior, gut hormones (e.g., ghrelin), bile
acid flow, and gut bacteria (Dagan et al., 2017). Candidates for bariatric
surgery are listed in Box 17.7.
Surgical procedures for obesity restrict the stomach’s capacity or
combine a reduced stomach capacity with malabsorption by bypassing part
of the small intestine. The type of procedure used is based on individualized
goals, local expertise, client preferences, and other variables. Laparoscopic
procedures are preferred over open procedures because they are associated
with lower early postoperative morbidity and mortality (Mechanick et al.,
2019). Vitamin and mineral deficiencies are one of the disadvantages of
bariatric surgery. They are most likely to develop after the first year of
surgery. Clients take vitamin and mineral supplements for the rest of their
lives.
Seventy percent of total bariatric surgeries in the United States are
laparoscopic sleeve gastrectomy (SG), 5% are laparoscopic gastric bypass,
and 3% are adjustable gastric banding (Mechanick et al., 2019).
BOX Candidatesa for Bariatric Surgery

17.7
Candidates for bariatric surgery are clients with
• BMI ≥40 without medical complications in whom bariatric procedures

would not be associated with excessive risk,
• BMI ≥35 and ≥1 severe obesity-related complications remediable by
weight loss such as type 2 diabetes, high risk for type 2 diabetes,
poorly controlled hypertension, nonalcoholic fatty liver disease,
obstructive sleep apnea, osteoarthritis of the knee or hip, and urinary
stress incontinence, and
• BMI 30–34.9 and type 2 diabetes with inadequate glucose control
despite optimal lifestyle and medical therapy.
• Bariatric surgery should also be considered to achieve optimal health
and quality-of-life outcomes when the amount of weight loss needed to
prevent or treat clinically significant obesity-related complications
cannot be obtained using only structured lifestyle change with medical
therapy.
BMI criterion may be adjusted for ethnicity (e.g., lowered for Americans of Asian descent).
a
Source: Mechanick, J., Apovian, C., Brethauer, S., Garvey, T., Joffe, A., Kim, J., Kushner, R.,
Lindquist, R., Pessah-Pollack, R., Seger, J., Urman, R., Adams, S., Cleek, J., Correa, R.,
Figaro, M., Flanders, K., Grams, J., Hurley, D., Kothari, S., … Still, S. (2019). Clinical practice
guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients
undergoing bariatric procedures-2019 update: Cosponsored by American Association of
Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American
Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American
Society of Anesthesiologists. Endocrine Practice, 25(supplement 2), 1–75.
https://journals.aace.com/doi/pdf/10.4158/GL-2019-0406
Sleeve Gastrectomy
Sleeve Gastrectomy (SG) removes approximately 80% of the stomach
longitudinally, resulting in a small pouch resembling a sleeve (hence the
name) or long thin banana (Fig. 17.4).
• The pyloric sphincter and intestines remain intact so the food
pathway is not altered.
• Removal of most of the stomach results in increases in gut hormone
levels that induce satiety, inhibit food intake, increase insulin
sensitivity, and slow gastric emptying (Weight Management Dietetic
Practice Group et al., 2015).
• Weight loss is somewhat less than that produced by Roux-en-Y
Gastric Bypass (RYGB), but it is achieved at lower cost, lower
morality, lower rates of complications, and fewer metabolic
complications (Raynor & Champagne, 2016).
• Common micronutrient deficiencies after SG include calcium, iron,
vitamin B12, thiamin, and vitamin D (Weight Management Dietetic
Practice Group et al., 2015).
Roux-en-Y Gastric Bypass

Roux-en Y Gastric Bypass (RYGB) has long been considered the gold
standard procedure for obesity (Raynor & Champagne, 2016). The GI tract
is permanently altered as a small pouch is created at the top of the stomach
and the jejunum is attached via a small hole in the pouch. Food bypasses
most of the stomach, the entire duodenum, and a small portion of the
proximal jejunum (Fig. 17.5). Removal of the pyloric sphincter increases
the risk of dumping syndrome.
Dumping Syndrome
symptoms (e.g., nausea, abdominal cramping, diarrhea, hypoglycemia) that occur from rapid
emptying of an osmotic load from the stomach into the small intestine.
• Weight loss and/or improvement in obesity-related comorbidities

such as diabetes and hyperlipidemia are greater for RYGB than the
currently more popular procedure SG (Lager et al., 2017).
• Mortality rate and rate of complications are higher in RYGB than
the other two surgeries (Raynor & Champagne, 2016).
• The most common micronutrient deficiencies after RYGB include
calcium, iron, folate, vitamin B12, thiamin, and vitamin D (Weight
Management Dietetic Practice Group et al., 2015).
Figure 17.4 ▲ Sleeve gastrectomy.
Figure 17.5 ▲ Roux-en-Y gastric bypass.
Laparoscopic Adjustable Gastric Banding

Laparoscopic adjustable gastric banding (LAGB) works purely by
restricting the capacity of the stomach.
• An inflatable band encircles the uppermost stomach to create a 15-
to 30-mL capacity gastric pouch with a limited outlet between the
pouch and the main section of the stomach (Fig. 17.6).
• The outlet diameter can be adjusted by inflating or deflating a small
bladder inside the “belt” through a small subcutaneous reservoir.
The size of the outlet can be repeatedly changed as needed.
• Clients must understand the importance of eating small meals,
eating slowly, chewing food thoroughly, and progressing the diet
gradually from liquids, to pureed foods, to soft foods.
• The popularity of LAGB has decreased in the United States,
primarily due to inferior weight loss, complex follow-up, a lower
remission rate of diabetes, and a high rate of reoperation due to
complications (Raynor & Champagne, 2016).
• Common micronutrient deficiencies after LAGB include calcium,
iron, thiamin, and vitamin D.
Figure 17.6 ▲ Laparoscopic adjustable gastric banding.
Nutrition Therapy for Bariatric Surgery

Bariatric surgery is not a magical cure for weight loss but rather an adjunct
to comprehensive lifestyle treatment that includes diet, physical activity,
and behavioral intervention. Bariatric surgery requires dramatic and
dynamic changes in intake. Nutrition therapy is important presurgically,
postsurgically, and long term for weight management and overall health.
Presurgical Phase
Preoperative nutrition counseling addresses presurgical weight loss and
behavior change. Modest presurgical weight loss has been associated with
surgical advantages, such as shortened surgery time and improved glycemic
state (Dagan et al., 2017).
• There is no consensus regarding how long a diet should be followed.
Recommendations for the duration of the diet range from 2 to 6
weeks (Dagan et al., 2017).
• Likewise, the ideal macronutrient distribution of the presurgical diet
is not known, although a low-carbohydrate diet may be more
effective in promoting short-term weight loss and improved insulin
sensitivity (Dagan et al., 2017).
• Despite short-term benefits of preoperative weight loss, evidence is
inconclusive regarding the long-term benefits.
• Vitamin and mineral deficiencies should be identified and corrected
before surgery. Studies show vitamin B12, iron, folic acid, vitamin D,
and thiamin are the most common presurgical nutrient deficiencies
(Dagan et al., 2017).
• Clients are screened for problematic eating behaviors that are
barriers to postsurgical success, such as binge eating, emotional
eating, and boredom eating (Tempest, 2012).
• Preoperative counseling also gives clients a realistic expectation of
the postoperative phase, dispelling any notions that the surgery
guarantees success.
Initial Postsurgical Phase: The First 2 Months after Surgery

General nutrition and eating behavior guidelines after bariatric surgery are
listed in Box 17.8.
• The initial postsurgical diet begins with small portions of room-
temperature clear liquids and progresses in texture and consistency
over the first 2 months.
• There is no evidence to support a specific protocol of postsurgical
diet stages, though many guidelines are available.
• A sample diet progression is outlined in Box 17.9.
• Although nutrition complications can occur any time after bariatric
surgery, they are most likely in the initial 2 months (Table 17.7).
Later Postsurgical Phase: 2 Months to 1 Year after Surgery

About 2 months after surgery, clients are ready to follow a regular healthy
eating pattern.
• Eating nutrient-dense foods helps clients distinguish between
physical and emotional hunger.
• Three meals with one to two snacks daily comprise the structured
pattern.
• Food portions and speed of eating are monitored to promote weight
loss and maintenance (Weight Management Dietetic Practice Group
et al., 2015).
General Postsurgical Nutrition

BOX
Guidelines and Eating Behavior
17.8 Recommendations
Nutrition Guidelines
• Fluids: Throughout all diet stages, consume adequate fluid to prevent

dehydration (at least 1.5 L/day).
• Protein: Recommendations vary. Client may need 60–80 g/protein/day
or 1.1 to 1.5 g/kg ideal body weight (using an “ideal” body weight as
what the patient’s weight would be at a BMI of 25).
• Limit carbohydrates during early postop period (50 g/day) and
gradually increase to 130 g/day.
• Avoid concentrated sugars (e.g., sugar-sweetened beverages, sugar,
honey, and sweet foods) to decrease the risk of dumping syndrome (for
post RYGB) and because they are empty calories.
• Eating fiber (after 1 month postsurgery) promotes weight loss and
enhances healthy eating.
• Fat recommendations do not differ from those of the general
population.
• Avoid carbonated beverages (e.g., seltzer water).
• Progression to solid foods is important because solids provide greater
satiety than liquids.
Eating Behavior Recommendations
• Consume 4 to 6 meals/day. Avoid eating small amounts throughout the

day (known as “grazing”) because it reduces long-term success.
• Eat protein foods before eating other foods in the meal.
• Eat slowly.
• Take small bites.
• Chew food thoroughly so that it becomes the consistency of
applesauce.
• Stop eating when satiated instead of stopping only when feeling
satiated (or “full”).
• Avoid fluids 15 minutes before and for at least 30 minutes after eating
solids.
Source: Dagan, S., Goldenshluger, A., Globus, I., Schweiger, C., Kessler, Y., Sandbank, G., Ben-
Porat, T., & Sinai, T. (2017). Nutritional recommendations for adult bariatric surgery patients:
Clinical practice. Advances in Nutrition, 8, 382–394. https://doi.org/10.3945/an.116.014258
BOX Sample Postsurgical Diet Progression

17.9
For 24 to 48 hours after surgery
• Consume room-temperature clear liquids, such as water, decaffeinated

herbal tea, and broth at a rate of about 2 to 4 oz/hour during waking
hours.
• Gradually increase volume to at least 8 cups/day.
• Consume in small portions (one-half cup/serving).
At 3 to 7 days postsurgery,
• add full liquids, such as milk, soy drinks, and plain yogurt.
• Bariatric protein powder supplements mixed with water or milks
may be used as “meal replacements.”
At 1 to 2 week postsurgery,
• progress to mashed/pureed diet using smooth foods,

• slowly progress texture as tolerated, and
• avoid liquids with solids and for 30 minutes after eating.
At 2 weeks postsurgery,
• add soft foods, such as scrambled eggs, soft-cooked vegetables, and

soft-peeled fruit;
• add crackers.
One month postsurgery,
• add solid foods, including legumes, fresh vegetables, fresh fruit, and
bread;
• protein should be emphasized; and
• consume fiber-rich foods to promote weight loss.
At 2 months postsurgery,
• consume a regular, well-balanced eating pattern, such as the DASH

diet.
Long-term nutritional and lifestyle recommendations:
• Continue with a healthy eating pattern, such as the DASH diet or
Mediterranean diet.
• Engage in 150 minutes/week of aerobic exercise and gradually
increase to 300 minutes/week.
• Do resistance training exercises 2 to 3 times/week.
• Avoid smoking and tobacco products as a general health practice, not
one specific to bariatric surgery.
• Avoid or reduce alcohol intake after RYGB due to increased alcohol
absorption and longer time to eliminate alcohol.
• Other postsurgical clients who want to drink alcohol should eat 15 to
30 minutes before consuming.
• Avoid complete fasting (e.g., for religious reasons) for 12 to 18 months
after bariatric surgery (until vomiting risk decreases). Clients who
participate in fasting after that period should be sure to fully hydrate
before fasting.
• Take lifelong vitamin and mineral supplements as prescribed.
Source: Dagan, S., Goldenshluger, A., Globus, I., Schweiger, C., Kessler, Y., Sandbank, G., Ben-
Porat, T., & Sinai, T. (2017). Nutritional recommendations for adult bariatric surgery patients:
Clinical practice. Advances in Nutrition, 8, 382–394. https://doi.org/10.3945/an.116.014258
Success of Bariatric Surgery

Evidence shows that bariatric surgery results in greater weight loss and is
more effective in inducing remission of type 2 diabetes than nonsurgical
treatments (Courcoulas et al., 2015). The Longitudinal Assessment of
Bariatric Surgery Study looked at RYGB and LAGB and found (Courcoulas
et al., 2018) the following:
• Long-term health improvements vary with the procedure.
• RYGB produces high rates of comorbid disease remission, most
of which are evident by the first 2 years after surgery. Some
decline in disease remission occurs from years 3 to 7, especially
for diabetes and hypertension.
Table Potential Nutrition
Complications after Bariatric
17.7 Surgery
Complication Possible Causes Possible Interventions

Dehydration • Inadequate fluid intake • Encourage client to
related to separating consume at least 1.5
solids from liquids and L fluid/day
avoidance of sugar- • Encourage client to
sweetened beverages and consume fluid even
carbonated beverages if the sensation of
• Excessive losses through thirst is absent
vomiting or severe • Intravenous
diarrhea hydration if
necessary
• Antiemetics
Diarrhea • Lactose intolerance • Increase fluid intake
• Drinking fluids with • Reduce intake of
meals lactose, fat, sugar
• Infection alcohols, and fiber
• Dumping syndrome
• Intake of sugar alcohols
• LAGB, RYGB, and SG
do not cause diarrhea
Dumping • Rapid emptying of • Avoid refined
syndrome hyperosmolar load carbohydrates, such
(high-sugar and high- as juice, soda,
carbohydrate foods) into concentrated
the small bowel followed sweets, foods with
by a shift of added sugars (sugar,
intravascular fluid into honey, and high-
the intestinal lumen fructose corn syrup)
Most often occurs with Increase intake of
RYGB protein, fiber, and
• • complex
carbohydrates
• Separate liquids and
solids by at least 30
minutes
Protein • Poor oral intake • Exact protein
malnutrition • Prolonged vomiting or requirements after
(associated with diarrhea bariatric surgery are
malabsorptive unknown
• Acquired food
procedures) • Suggested goals
intolerance for protein-
rich foods may be 60–80 g
protein/day or 1–1.5
g protein/kg ideal
body weight/day
Constipation • Use of narcotics • Assess fluid and
• Inadequate fluid intake fiber intake for
• Low-fiber intake adequacy
• Calcium or iron • Reduce iron dosage
supplementation to the lowest
possible dose
• Stool softener or
laxative may be
needed
Eating issues, • Altered taste • Avoid foods not
such as food • Eat or drink too much or tolerated
intolerances, too rapidly • Remind client to eat
regurgitation and drink mindfully
• Failure to chew food
without nausea and slowly
thoroughly
or true
• Improperly moistened • Avoid problem
vomiting, food
food foods until tolerance
gets “stuck”
improves
Source: Weight Management Dietetic Practice Group, Cummings, S., & Isom, K. (Eds.). (2015).
Academy of nutrition and dietetics pocket guide to Bariatric surgery (2nd ed.). American Academy
of Nutrition and Dietetics; Dagan, S., Goldenshluger, A., Globus, I., Schweiger, C., Kessler, Y.,
Sandbank, G., Ben-Porat, T., & Sinai, T. (2017). Nutritional recommendations for adult bariatric
surgery patients: Clinical practice. Advances in Nutrition, 8, 382–394.
https://doi.org/10.3945/an.116.014258
• The only comorbid conditions with lower prevalence 7 years after
LAGB are low HDL cholesterol and high triglyceride.
• The greater the amount and speed of the initial weight loss the better
the long-term weight outcomes.
• Seventy-five percent of RYGB participants maintained at least
20% of weight loss through 7 years.
• Fifty percent of LAGB participants maintained at least 16% of
weight loss through 7 years.
• Weight regain may be more common after SG than RYGB;
however, poor reporting and a lack of a consensus definition of
weight regain hamper comparisons (Lauti et al., 2017).
• Postoperative behavioral intervention appears to result in greater
weight loss than surgery alone (Stewart & Avenell, 2016). Even
cognitive behavior therapy via telephone for clients 6 months
postsurgery has been shown to result in significant improvements in
binge eating, emotional eating, depressive symptoms, and anxiety
symptoms (Sockalingam et al., 2017).
Nutrition for Weight Maintenance

A healthy lifestyle is vital to optimize and sustain long-term weight loss
after bariatric surgery. Weight maintenance requires that clients eat
mindfully with attention to hunger and satiety cues. Factors associated with
successful weight maintenance after bariatric surgery include the following:
• compliance to nutrition recommendations
• eating regularly scheduled meals instead of “grazing”
• heeding satiety cues
• realistic expectations
• regular moderate aerobic physical activity
• tracking food intake
• monitoring weight
• adequate sleep
• meal planning
• limiting fluids with and immediately after meals
• avoiding alcohol
• periodic assessment to identify and treat eating or other psychiatric
disorders
NURSING
PROCESS Obesity
Rosa is 37 years old, 5 ft 4 in. tall, and the mother of two children.
Before her first child was born 10 years ago, her normal weight was 140
pounds. She gained 35 pounds during pregnancy and didn’t regain her
normal weight before her second pregnancy a year later. She is now at
her heaviest weight of 180 pounds. She complains of fatigue and thinks
her weight contributes to her asthma. She admits to “out of control
eating” and has tried several diets but has been unable to take weight off
and keep it off. Her doctor told her she has prehypertension and
encouraged her to lose weight to lower both her blood pressure and
serum glucose levels. The fear of needing medication for hypertension
or diabetes has motivated her to lose weight.
Assessment
Medical– • Medical history and comorbidities, such as
Psychosocial hypertension, dyslipidemia, cardiovascular
Data disease, diabetes, sleep apnea, osteoarthritis, and
esophageal reflux
• Medications that may promote weight gain or
interfere with weight loss, such as steroid
hormones, psychotropic drugs, mood stabilizers,
antidepressants, and antiepileptic drugs
• Level of motivation to lose weight including
previous history of successful and unsuccessful
attempts to lose weight, social support, and
perceived barriers to success
Anthropometric • Height, current weight, BMI

Assessment • Weight history
• Waist circumference
Assessment
Biochemical • Lab values related to possible comorbidities, such

and Physical as total cholesterol, LDL cholesterol, HDL
Assessment cholesterol, triglycerides, glucose, hemoglobin
A1c
Triiodothyronine (T3) and thyroxine (T4) for
thyroid function
•
• Blood pressure
Assessment
Dietary • How many daily meals and snacks do you usually

Assessment eat?
• Do you skip meals?
• What is a typical day’s intake?
• How do you think your usual intake needs to
change to be healthier or to help you lose weight?
• What will be hardest for you to change? What
will be easiest?
• What triggers cause you to overeat?
• How many servings of fruits and vegetables do
you eat daily?
• How much sweetened soda do you drink daily?
• Do you limit any particular foods?
• How many meals per week do you eat out?
• What triggers your “out of control” eating?
• Do you take vitamins, minerals, or supplements to
help with weight loss? If so, what?
• What is your goal weight?
• How much aerobic physical activity do you do on
a daily basis?
• Do you do resistance training exercises?
• How much of your day is spent on sedentary
activities?
• How much alcohol do you consume?
• Do you have any cultural, religious, or ethnic
food preferences?
• Do you have any food allergies or intolerances?
Analysis
Assessment
Possible Obesity related to excess calorie intake as evidenced

Nursing by a BMI of 31.
Analyses
Planning
Outcomes • gradually increase physical activity (aerobic and
resistance training) while reducing sedentary
activity,
• consume a nutritionally adequate, hypocaloric
diet consisting of healthy carbohydrates, healthy
fats, and lean protein,
• eat three meals per day,
• practice behavior change to modify undesirable
eating habits,
• self-monitor food intake, physical activity, and
weight loss,
• lose 1–2 pounds/week on average until 10% of
initial weight is lost,
• verbalize the components of a hypocaloric
healthy eating pattern.
Nutrition • Decrease calorie intake to 1500 a day in three
Therapy meals using an evidence-based dietary approach
selected by the client.
• Encourage ample fluid intake, preferably water
and other noncalorie drinks, to promote excretion
of metabolic wastes.

Assessment
The interrelationship between a hypocaloric diet,
increased physical activity, and behavior change
in managing weight
•
• The eating plan essentials with emphasis on high-
satiety foods, such as whole grains, fruit and
vegetables, low-fat or nonfat dairy, and lean
protein
• Behavioral matters, including
• eating only in one place while sitting down
• putting utensils down between mouthfuls
• Monitoring hunger on a scale of 1 to 10, with 1
corresponding to “famished” and 10
corresponding to “stuffed”: Encourage clients to
eat when the hunger scale is at about 3 and to stop
when satisfied (not full) at about 6 or 7
• Weighing oneself at least once a week
• Periodically keeping a record of food intake and
activity
• Planning splurges instead of eating on impulse:
Planned splurges involve making a conscious
decision to eat something, enjoying every
mouthful of the food, and then moving on from
the experience without feelings of guilt or failure
• Changing eating attitudes by
• replacing negative self-talk with positive talk,
• replacing the attitude of “always being on a
diet” with an acceptance of eating healthier and
less as a way of life
• Consulting a physician or dietitian if questions
concerning the eating plan or weight loss arise
Evaluation
Assessment
Monitor • Evaluate food and activity records to assess
adherence; suggest changes in the meal plan as
needed.
• Provide periodic feedback and reinforcement.
• Monitor biochemical data for improvements
attributable to weight loss.
EATING DISORDERS: ANOREXIA

NERVOSA, BULIMIA NERVOSA,
BINGE-EATING DISORDER, AND
EATING DISORDERS NOT
OTHERWISE SPECIFIED
Eating disorders are serious psychological disorders. They are characterized

by severe disturbances in eating behaviors (Box 17.10) that can have a
profound effect on health and/or psychosocial functioning. Other
characteristics include obsessive ideation about body size and weight and
body dysmorphic disorder or distorted body image. Table 17.8 compares
anorexia nervosa (AN) and bulimia nervosa (BN). Binge-eating disorder
(BED) is the other eating disorder defined in the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM-5) (American Psychiatric
Association [APA], 2013).
Eating disorders result from complex interaction of genetic,
developmental, family influences, and sociocultural factors; however, the
etiology of eating disorders in not known. Studies indicate that genetic
heritability may account for 50% to 80% of the risk of developing anorexia
and BN (Trace et al., 2013). Dieting may be the initial impetus in the
development of eating disorders. Other risk factors include early childhood
eating and GI problems, increased concern about weight and size, negative
self-evaluation, sexual abuse, and other traumas (Ozier & Henry, 2011).
Major stressors, such as the onset of puberty, parental divorce, death of a
family member, and ridicule of being or becoming fat, may be precipitating
factors. Athletes may develop eating disorders to improve their
performance. People with eating disorders often have anxiety and
depression. Each person’s recovery process is unique; therefore, treatment
plans are highly individualized.
BOX Examples of Disordered Eating

17.10 Behaviors
• Calorie restriction for weight loss

• Avoidance of specific foods, especially high-calorie foods that are
perceived to be fattening
• Eating a limited variety of foods
• Restricting dietary fat intake
• Inflexibility with food
• Filling up on low-calorie foods, such as fruits and vegetables
• Excessive use of artificial sweeteners
• Use of nonnutritive beverages such as water and diet soft drinks to
suppress appetite
• Excessive caffeine intake
• Abnormal timing of meals and snacks
• Over-involvement in food preparation
• Collecting recipes and menus
• Excessive use of condiments
• Overestimating portion sizes
• Confusion about how much to eat
Source: Hart, S., Marnane, C., McMaster, C., & Thomas, A. (2018). Development of the
“Recovery from Eating Disorders for Life” Food Guide (REAL Food Guide)-a food pyramid
for adults with an eating disorder. Journal of Eating Disorders, 6, 6.
https://doi.org/10.1186/s40337-018-0192-4
Table A Comparison of Anorexia

17.8 Nervosa and Bulimia Nervosa
Anorexia Nervosa Bulimia Nervosa

Major • Preoccupation with • Preoccupation with
characteristics food food
• Irrational fear of • Irrational fear of
normal body weight normal body weight
• Body image • Body image
distortion distortion
• Self-worth based on • Self-worth based on
size and shape size and shape
• Compulsive pursuit • Binge eating
of thinness accompanied by a
• Terrified of gaining lack of sense of
weight or becoming control
fat
Onset
• Usually develops • Usually develops
during adolescence or during adolescence or
young adulthood young adulthood
Overall adult
prevalence • 0.6% • 0.3%
• Lifetime prevalence 3 • 5 times higher among
times higher in women than men
women than men
Typical eating
and exercise • Semi-starvation with • Gorging (e.g., 1200–
behaviors compulsive exercise 11,500 calories in a
• Onset of disorder is short amount of time)
usually preceded by followed by purging:
dieting behavior • Self-induced
vomiting
• Excessive exercise
• Abuse of laxatives
• Diuretics
• Enemas
• Fasting
• “Dieting” is a way of
life but bingeing may
occur several times
per day and may be
planned
Weight Significantly low body
weight (e.g., <85% • Fluctuations are
ideal body weight) normal
compared to what is • Weight may be
minimally expected normal or slightly
for age, sex, above normal
developmental
trajectory, and
physical health
Emotional
symptoms • Denial of the • Displays mood
condition can be swings
extreme • Full recognition of
• Body image the behavior as
disturbance abnormal
Pronounced Ongoing feelings of
emotional changes isolation, guilt,
depression, and low
• Low self-esteem •
• 56% of survey self-esteem
respondents met • 94% of survey
criteria for at least respondents met
one of the core DSM- criteria for at least
5 disorders with any one of the core DSM-
anxiety disorder, the 5 disorders with any
most common anxiety disorder, the
cormorbidity most common
(National Institute of cormorbidity
Mental Health, 2017) (National Institute of
Mental Health, 2017)
Physical
consequences • Hypotension • Hypotension
• Bradycardia • Bradycardia
• Electrolytes • Electrolytes
imbalances, which imbalances, which
can be life can be life
threatening threatening
• Hypothermia • Erosion of teeth
• Loss of GI functions: enamel
decreased peristalsis, • Swollen salivary
delayed gastric glands in cheeks
emptying, atrophy of • Sores, scars, or
GI lining, diarrhea calluses on knuckles
Lanugo (fine, downy or hands
hair on extremities)
•• Hormonal
imbalances:
amenorrhea or
delayed onset of
menstruation,
osteoporosis
Nutrient
deficiencies • Protein–calorie • Varies
malnutrition
• Various micronutrient
deficiencies
Source: Eating disorders. (2020). Available at www.nutritioncaremanual.org. and learn at
Nationaleatingdisorders.org/learn (n.d.); National Institute of Mental Health. (2017, November).
Eating disorders. https://www.nimh.nih.gov/health/statistics/eating-disorders.shtml
Body Dysmorphic Disorder

excessive preoccupation with a real or imagined defect in physical appearance.
Anorexia Nervosa (AN)

a condition of self-imposed fasting or severe self-imposed dieting.
Bulimia Nervosa (BN)

an eating disorder characterized by recurrent episodes of bingeing and purging.
A multidisciplinary approach that includes nutrition counseling,

behavioral interventions, psychotherapy, family counseling, and group
therapy is most effective. Antidepressant drugs effectively reduce the
frequency of problematic eating behaviors but do not eliminate them. Most
eating disorders are treated on an outpatient basis; however, life-threatening
consequences of malnutrition in severe cases of AN may necessitate
inpatient treatment (Rocks et al., 2014). Treatment can be complex and
protracted.
Anorexia Nervosa
AN is characterized by restriction of food intake, intense fear of gaining
weight, and a distorted body image (Fig. 17.7) (APA, 2013). Eating issues
may include self-imposed starvation, avoidance of social eating,
disassociation from internal hunger cues, and food rituals that delay or
extend a meal, such as repeated cutting or reheating of food. Denial of the
condition can be extreme.
Figure 17.7 ▲ A woman suffering from anorexia sees herself as
overweight.
Malnutrition and low body weight may result in major impairment in

health (Resmark et al., 2019). There is no proven treatment for AN, and
rates of relapse and chronicity are high. For instance, it may take years for
clients with AN to achieve a first remission or to recover permanently. It is
estimated that 25% of adult clients develop a chronic form of the disorder
and 33% of clients suffer long-term residual symptoms (Resmark et al.,
2019).
Nutrition Therapy for Anorexia Nervosa

Although nutritional and weight restoration is a core focus of most AN
programs, there has been very little research on this area of AN (Marzola et
al., 2013). The American Psychiatric Association (APA) guidelines for AN
state that the goals of nutritional rehabilitation for seriously underweight
clients are to (Marzola et al., 2013)
• restore weight,
• normalize eating pattern,
• achieve normal perceptions of hunger and satiety, and
• correct biological and psychological sequelae of malnutrition.
APA guidelines for anorexia nervosa are as follows:
• Provide initial calorie intake of 1000 to 1600 cal/day or 30 to 40
cal/kg with gradual progression to 70–100 cal/kg/day is used
(Marzola et al., 2013). The “low and slow” calorie initiation is for
the purpose of reducing the risk of refeeding syndrome. Monitoring
of vitals, electrolytes, and cardiac function is required to prevent
refeeding syndrome.
• The necessity of this conservative approach has been challenged;
newer guidelines state that an initial low-calorie intake with gradual
increase is not required for safe weight gain in clients with mild to
moderate AN (Resmark et al., 2019). However, recommended initial
calorie amounts were not specified.
• Weight gain targets suggested 2 to 3 pounds/week for hospitalized
clients and 0.5 to 1 pound/week for people in outpatient programs
(Marzola et al., 2013).
• Clients who refuse to eat may need nasogastric feeding.
Refeeding Syndrome
a potentially life-threatening condition characterized by severe shifts in fluid and electrolytes,
especially phosphorus, from the extracellular to intracellular fluid when refeeding begins in a
person who is severely malnourished and depleted in total body phosphorus. Thiamin deficiency
may also occur secondary to increased metabolism of carbohydrates.
Additional considerations (Marzola et al., 2013) are as follows:

• For weight maintenance, clients with AN may need 50 to 60 cal/kg,
amounts higher than those required by the general population. The
high need may be due to exercise and changes in metabolism.
• During refeeding, treatment should focus on correcting disordered
eating patterns, such as irregular eating, vegetarianism, and
restricted variety of foods.
Strategies to promote compliance and feelings of trust include
• involving the client in formulating individualized goals and meal
plans;
• offering rewards linked to the quantity of calories consumed, not to
weight gain;
• having the client record food intake and exercise activity; diet
diversity may be predictive of weight maintenance in clients with
AN (Schebendach et al., 2008);
• meal planning tips and eating behavior strategies for AN (see Box
17.11).
BOX Meal Planning Tips and Eating Behavior

17.11 Strategies for Anorexia Nervosa
Meal Planning Tips
• Eat a meal or snack every 3 to 4 hours even if not hungry during
initial phase of treatment.
• Eat sources of protein, fat, and complex carbohydrates, preferably
whole grains, at every meal and snack.
• If a small amount of food causes a feeling of fullness, recognize
that it does not mean you have overeaten. Fullness is a temporary
feeling.
• Consume the planned amounts of all foods. Do not
overconsume fruits and vegetables, which may then displace
the intake of other more calorically dense foods. Gradually
increase portion sizes of “safe” foods.
• Gradually increase variety of foods and food groups consumed.
• Drink water and other beverages to meet fluid needs but avoid all
diet drinks.
• Supplements may be prescribed to meet nutrient needs until
intake is adequate.
Eating Behaviors
• Avoid ritualistic eating behaviors that may impair the ability to
recognize hunger or satiety.
• Learn to trust that there are no “good foods” or “bad foods” but
that all foods can fit into a healthy meal plan.
• Reduce obsessive thoughts about food, eating, weight, and body
image. Instead, develop alternative activities and rewards to
replace these thoughts.
• Be patient with learning to self-nourish.
• Use a hunger scale to identify internal cues for hunger, satiety,
and fullness.
• Understand that weight restoration is necessary for recovery,
which will allow the body and mind to function more effectively.
Source: Academy of Nutrition and Dietetics. (2020). Nutrition
• care manual. Anorexia nervosa meal planning tips.
https://www.nutritioncaremanual.org/client_ed.cfm?
ncm_client_ed_id=64
Bulimia Nervosa
BN is characterized by binge-eating episodes followed by behaviors to
prevent weight gain, such as self-induced vomiting, fasting, or excessive
exercise. Although the mortality rate associated with BN is less than that of
AN, it is still increased due to severe electrolyte and acid–base imbalances
related to recurrent vomiting or stimulant laxative abuse (Westmoreland et
al., 2016). The diagnostic criteria are as follows (APA, 2013):
• Recurrent episodes of binge eating occur, which are characterized
by eating a large amount of food within any 2-hour period that is
accompanied by a feeling of lack of control overeating.
• Recurrent behaviors to prevent weight gain from bingeing occur,
such as self-induced vomiting; laxative, diuretic, or diet pill abuse;
or excessive exercise.
• Binge and purge episodes occur on average at least once a week for
3 months but may occur several times a day
• Self-evaluation is strongly based on body shape and weight.
Nutrition Therapy for Bulimia Nervosa

People with BN are usually within their normal weight range, although
some may be overweight; weight fluctuations are common. The major goals
of nutrition therapy are to stabilize weight by decreasing bingeing and
purging and achieve normal perceptions of hunger, fullness, and satiety.
• Nutritional counseling focuses on identifying and correcting food
misinformation and fears and includes discussing normal weight
fluctuations, hunger and satiety cues, meal planning, establishing a
normal pattern of eating, and identifying the dangers of dieting.
People with BN must understand that gorging is only one aspect of a
•
complex pattern of altered behavior; in fact, excessive dietary
restriction is a major contributor to the disorder.
• Although most clients with BN want to lose weight, dieting and
recovery from an eating disorder are incompatible. Normalization of
eating behaviors is a primary goal.
• Nutrition strategies for BN are listed in Box 17.12.
BOX Meal Planning Tips and Eating Goals for

17.12 Bulimia Nervosa
Daily Meal Planning Tips

• Eat three meals and 2 to 3 snacks daily to regain structure.
• Eat every 4 to 5 hours while learning to recognize hunger cues.
• Use a hunger scale to identify internal cues for hunger, satiety,
and fullness.
• Eat slowly.
• All foods are acceptable. Restricting foods can lead to binge
eating.
• Strive for variety, balance, and moderation in food choices.
• Eat protein, fat, and high-fiber foods at each meal and snack for
satiety and bulk.
• Eat fruit and vegetables when able to do so without feeling an
uncomfortable fullness.
• Consume adequate but not excessive water and fluid to meet
needs.
Recognize and identify eating habits, feelings, or situations that may
trigger binges or out-of-control eating, such as
• certain food triggers,
• body image concerns,
• social settings or being alone,
• frustration, stress, or particular emotions, and
• feeling full.
Identify alternative activities to manage feelings that may lead to
bingeing, such as
• moderate physical activity,
• journaling or talking to a friend,
• listening to music,
• diversionary activities such as homework or gardening, and
• creating art.
• Source: Academy of Nutrition and Dietetics. (2020). Nutrition
care manual. Anorexia nervosa meal planning tips.
ncm_client_ed_id=65
Recall Emma. She admits that she has seen a counselor for
an eating disorder and that she binges and purges when she’s
“bad.” She recognizes that bingeing and purging are not
normal behaviors and admits to feeling out of control when a
binge begins. Restrictive dieting always precedes her periods
of bingeing. She purges with vomiting and laxatives, which
caused her to be hospitalized for hypokalemia. Is counting
calories a good strategy for Emma? What strategies would
you recommend to help Emma normalize her eating
behaviors?
Binge-Eating Disorder
BED, previously referred to as compulsive overeating, was included as its
own category of eating disorder in the DSM-5. Before then, it was not
recognized as a separate disorder and was diagnosable only under the catch-
all category of Eating Disorder Not Otherwise Specified. The diagnostic
criteria for BN include recurrent episodes of binge eating with an episode‐
characterized by eating significantly more food in a short period of time
than most people would eat under similar circumstances, with episodes
marked by of lack of control (APA, 2013). Unlike BN, people with BED do
not purge. Binge eating occurs on average, at least once a week for 3
months. Episodes produce significant distress regarding binge eating and
are associated with three or more of the following:
• eating more quickly than normal
• eating until comfortably full
• eating large amounts of foods when not physically hungry
• eating alone because of embarrassment of how much is eaten
• feeling disgusted with oneself, depressed, or very guilty after
overeating
BED differs from common overeating in that it is more severe, is
associated with more subjective distress regarding the eating behavior, and
is accompanied with physical and psychological problems. People with
BED may be of normal weight, but it is often associated with obesity and its
comorbid nutritional and medical complications. Risk factors include
childhood obesity, parental obesity, high degree of body dissatisfaction,
dysfunctional attitudes regarding weight and shape, poor self-esteem, and
impaired social functioning (Academy of Nutrition and Dietetics, 2020).
Comorbidities include major depressive disorder, anxiety disorders, and
alcoholism. BED is more prevalent than AN and BN combined (National
Institute of Mental Health, 2017).
Psychotherapy, particularly cognitive behavior therapy, and medication
are the main treatment modalities for BED (Westerberg & Waitz, 2013).
The focus of nutrition therapy is to normalize eating behaviors with
emphasis on recognizing internal hunger and satiety cues (Box 17.13).
Reducing binge eating may be followed by participation in a weight-control
program.
BOX Binge-Eating Disorder Meal Planning

17.13 Tips
• Use a hunger rating scale to identify hunger, satiety, and fullness.
For instance, on a scale of 1 to 10, 1 represents “starving,” 10
represents “stuffed,” and satiety may be 6 or 7. A workable range
may be to eat at a 3 or 4 and stop at 6 or 7.
• Identify signs of hunger, such as empty stomach, stomach noise,
feeling irritable, headache, and feeling weak or light-headed.
• Eat slowly and allow 20 to 30 minutes for each meal to let the
brain to signal that the body has eaten enough.
• Make eating its own activity; avoid TV and other electronics,
reading, cooking, and driving while eating.
• Eat seated and avoid eating alone.
• Enjoy the food.
• Know that you can have more when hunger returns.
• Do not label any foods “forbidden.”
• Identify triggers and alter your environment accordingly.
• Source: Academy of Nutrition and Dietetics. (2020). Nutrition
care manual. Binge-eating disorder meal planning tips.
ncm_client_ed_id=63
Eating Disorders Not Otherwise Specified

The prevalence of eating disorders not otherwise specified (EDNOS) is
unknown because there is no simple definition of EDNOS. This group
represents people who diet frequently, who use unhealthful methods to lose
weight such as restricting food, and people who meet some, but not all, of
the criteria for the diagnosable eating disorders (Academy of Nutrition and
Dietetics, 2020).
How Do You Respond?

If 1200 calories can promote a 1- to 2-pound loss per
week, will a more drastic calorie reduction speed the
weight-loss process?
People often think that the greater the calorie deficit, the
quicker the weight loss. In reality, cutting calories too
much may result in higher proportions of lean tissue loss.
This leads to a lowering of basal energy expenditure and
reduced exercise tolerance, making weight loss and
maintenance more difficult (Blackburn et al., 2010).
REVIEW CASE STUDY
“I hate being fat.”

Client history: C.C. is a 43-year-old mother of three who has
experienced gradual weight gain after the birth of each of her children. She
is 5 ft 7 in. tall, weighs 189 pounds, works full time, and does not engage in
regular exercise. She has prediabetes and prehypertension and appears
eager to make lifestyle changes to improve her health and be a better
nutritional role model for her children. She has successfully lost weight in
the past through Weight Watchers but eventually got bored and regained all
of the weight she lost. Her usual intake is no breakfast, snacks at a vending
machine twice a day, fast food for lunch, and dinner with the family. Her
dinner usually consists of about 6 oz of meat, potatoes, sometimes a
vegetable, bread with butter, and dessert. C.C. admits to a weakness for
sweets but wants to try a low-carbohydrate diet because she heard it is the
best and easiest way to lose weight.
• What is C.C.’s weight status based on her BMI?
• What would be an appropriate calorie diet for her to lose weight?
• What would you tell her about the “best and easiest” way to lose
weight?
• What foods does she eat that provide carbohydrates? Compared to
the low-carbohydrate eating plan outlined in Table 17.4, what food
groups would she need to increase? Decrease?
• What other lifestyle changes would you recommend for her?
• Create a nursing care plan complete with nursing diagnosis, client
goal, interventions, and monitoring recommendations.
STUDY QUESTIONS
1 The client asks if it is okay to follow a low-carbohydrate, ketogenic-type

diet in the short term to get started on weight-loss efforts. Which of the
a. “No, low-carbohydrate diets are not healthy and would only sabotage
your weight-loss efforts.”
b. “A ketogenic-type diet can help you lose weight as can many other
types of diets. The important factor that determines whether you lose
weight is the number of calories you eat, not the proportion of
carbohydrates, protein, and fat you eat.”
c. “A low-carbohydrate diet is better than any other type of diet and is a
good choice for you to use.”
d. “A low-fat diet is easier. Try that instead.”
2 What behavioral factors are associated with successful long-term weight
maintenance after weight loss? Select all that apply.
a. high levels of daily physical activity
b. weighing oneself at least weekly
c. consuming a low-calorie, low-fat diet
d. eating only two meals/day
3 The client asks if meal replacements, such as Jenny Craig products, are a
good idea to help with weight loss. Which of the following would be the
a. “They are a great way to control portions and can help you adhere to
your hypocaloric meal plan when used as suggested.”
b. “They are gimmicks that fail to teach you how to control your own
intake. They are not recommended.”
c. “Most people gain weight while using them. You should stay away
from them.”
d. “They are not nutritionally balanced so you actually have to overeat in
order to meet your nutritional requirements if you use them.”
4 A 32-year-old client has learned that their BMI has increased to 28 since
their last annual physical. They are determined to lose weight and asks if
they can use weight-loss medication instead of going on a diet because
they have had trouble following diets. Which is the best response?
a. “You are not a candidate for weight-loss medications because they can
only be prescribed for people with complications related to weight,
such as diabetes.”
b. “You are an ideal candidate for weight-loss medications. Tell the
doctor you are interested in them when they arrive.”
c. “For people with a BMI of 28 and no weight-related complications,
weight-loss medications are considered only if you are unsuccessful at
losing weight with lifestyle therapy. See how successful you can be
with lifestyle therapy.”
d. “Weight-loss medications are associated with serious risks so they are
reserved for people with BMI > 35.”
5 Which of the following calorie level ranges is considered appropriate for
weight-loss diets for most women?
a. 1800 to 2000 cal/day
b. 1200 to 1500 cal/day
c. 1000 to 1200 cal/day
d. 800 to 1000 cal/day
6 The nurse knows the instructions on how to reduce the risk of dumping
syndrome after RYGB surgery are effective when the client verbalized
they will
a. avoid high-sugar foods and fluids with meals and for 30 minutes
afterward.
b. eat less fat.
c. limit complex carbohydrates.
d. eat larger, less frequent meals.
7 What is the priority when instituting nutrition therapy to a client
diagnosed with BN?
a. Teach the client about nutrient and calorie requirements.
b. Halt weight loss.
c. Reduce bingeing and purging.
d. Provide sufficient calories for weight gain.
8 What is the priority when instituting nutrition therapy for a client
diagnosed with AN?
a. Teach the client about nutrient and calorie requirements.
b. Restore weight.
c. Motivate the client by offering rewards linked to weight gain.
d. Halt purging behaviors.
CHAPTER SUMMARY Nutrition for

Obesity and Eating Disorders
Obesity can be defined as abnormal or excessive body fat accumulation that
leads to adverse health consequences. It is a chronic, complex condition
with potentially many contributing factors.
Measures of obesity: BMI and waist circumference are screening
•
tools, not diagnostic measures, to quantify and classify obesity.
• Obesity prevalence: Obesity is a worldwide epidemic. In the

United States, approximately 40% of adults are obese. The
prevalence has increased in both genders, in all age groups, and
among all races and ethnicities.
• Obesity complications: Overweight and obesity increase the risk of
all-cause mortality. High BMI is a major risk factor for
cardiovascular disease, diabetes, musculoskeletal disorders, and
some cancers. Central obesity is linked to increased risk of obesity
comorbidities.
Management of Overweight and Obesity
The treatment of obesity is based on BMI and the presence/severity of

complications. Clients’ readiness to lose weight should be evaluated before
initiating a weight-loss attempt. Although restoration of healthy or normal
BMI is ideal, as little as 3% to 5% of body weight loss results in clinical
improvements, especially in glycemic metrics. Over 6 months, 5% to 10%
weight loss is recommended.
Weight-Loss Therapy:
Lifestyle/Behavioral Therapy
Lifestyle therapy serves as the foundation of weight management for all

people, regardless if other therapies are also used.
Healthy, calorie-reduced eating plan: Generally, low-calorie diets
provide 1200 to 1500 cal/day for women and 1500 to 1800 cal/day for
men. A variety of eating patterns can produce weight loss as long as the
appropriate amount of calories is consumed. The best diet is the one the
client will stick to. Certain populations may benefit from certain low-
calorie eating patterns.
• The DASH diet lowers blood pressure and may be preferable for
people with hypertension.
• The Mediterranean diet improves glycemic metrics and decreases
the risk of cardiovascular disease.
Physical activity: Recommendations include increasing aerobic
activity, resistance training, and reducing sedentary time.
• Behavioral therapy: Behavioral therapy is used to improve
adherence to diet and exercise changes. Strategies include self-
monitoring, goal setting, stimulus control, and cognitive structuring.
• Comprehensive lifestyle programs: Comprehensive lifestyle
programs run by a multidisciplinary team help participants adhere to
diet, exercise, and behavioral changes. At least 6 months of
participation is recommended, with longer durations producing
better results.
• Weight maintenance after loss: Long-term weight-loss
maintainers tend to continue to eat a low-calorie and low-fat diet,
exercise about 1 hour/day, weigh themselves weekly, and limit TV
viewing.
Weight-Loss Medications
Medications are approved for obesity treatment in people who have a BMI
≥30 or ≥27 with at least one weight-related complication. They work best
when combined with lifestyle modification; lifestyle modification produces
greater loss when medications are used. Medications are a long-term
intervention. Weight-loss devices, such as endoscopically place intragastric
balloons, are additional options.
Bariatric Surgery
Bariatric surgeries are the more effective and long-lasting treatment for
obesity. They can result in significant weight loss, treat type 2 diabetes, and
improve cardiometabolic risk factors. Nutrient deficiencies are common
and lifelong supplementation with micronutrients is necessary.
• Sleeve gastrectomy is performed more often than other bariatric
surgeries. It significantly reduces gastric capacity. It produces less
weight loss than gastric bypass but has lower rates of complications.
• Roux-en-Y gastric bypass promotes weight loss by restricting
gastric capacity and bypassing part of the small intestine where
nutrient absorption takes place. Weight loss and complications are
greater than with other procedures.
• Adjustable gastric banding restricts the capacity of the stomach. The
outlet diameter can be adjusted repeatedly as needed. It produces
inferior weight loss, requires follow-up, has a lower remission rate
of diabetes, and has a high rate of reoperation due to complications.
• Nutrition for bariatric surgery: Surgery is not a magic cure for
weight loss but rather an adjunct to lifestyle therapy.
• Presurgery: Weight loss may help improve surgical outcomes,
although the long-term benefits are not known. Preoperative
nutrition counseling prepares clients for dietary changes needed and
helps them set realistic expectations for weight loss.
• Postsurgery: Oral intake progresses from room-temperature clear
liquids to a regular healthy eating plan by around 2 months. Protein
needs are elevated; fluid is not consumed with meals or for 30
minutes afterward to reduce the risk of dumping syndrome. Clients
are urged to chew food thoroughly, avoid sugars, eat slowly and
mindfully, and stop eating when satisfied.
• Long-term maintenance: A healthy diet, such as the DASH or
Mediterranean diet, along with exercise and micronutrient
supplements is needed.
Eating Disorders
Eating disorders are psychological disorders characterized by severe

disturbances in eating behaviors that can profoundly affect health and
psychological functioning.
• Anorexia nervosa: AN is virtually self-imposed starvation as part
of a compulsive pursuit of thinness. Restoration of weight is the
primary goal; little is known about the optimal approach. Oral
feedings are preferred; nasogastric feedings may be necessary in
hospitalized clients who refuse to eat.
• Bulimia nervosa: BN is binge eating characterized by a lack of
sense of control and accompanied by purging via self-induced
vomiting, laxative abuse, diuretics, or fasting. Body weight may be
normal or slightly above normal. Weight stabilization and
normalization of eating behaviors are the primary goals.
• Binge-eating disorder refers to binge eating without purging
accompanied by physical and psychological problems. Clients may
be normal weight but most are obese. The focus of nutrition therapy
is normalization of eating behaviors with an emphasis on
recognizing hunger and satiety cues.
• Eating Disorders Not Otherwise Specified refers to disordered
eating behaviors that meet some—but not all—of the criteria for the
diagnosable eating disorders
Figure sources: shutterstock.com/New Africa, shutterstock.com/Monkey Business Images,
shutterstock.com/Den Rise

book at
Websites
• For reliable information on weight, dieting, physical fitness, and
obesity
• Calorie Control Council at www.caloriecontrol.org
• Division of Nutrition, Physical Activity, and Obesity, National
Center for Chronic Disease Prevention and Health Promotion at
www.cdc.gov/nccdphp/dnpa
• National Heart, Lung, and Blood Institute Obesity Education
Initiative at www.nhlbi.nih.gov/about/oei/index.htm
• Obesity Society at www.obesity.org
• Weight-Control Information Network at
http://www.niddk.nih.gov/health-information/health-
communication-programs/win/Pages/default.aspx
• For free intake/diet analysis
• FitDay at www.fitday.com
• For eating disorders
• Anorexia Nervosa & Related Eating Disorders (ANRED) at
www.anred.com
• National Eating Disorders Association at
www.nationaleatingdisorders.org
• Overeaters Anonymous, Inc. at www.oa.org
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Chapter Nutrition for Clients
18 with Critical Illness
Franny Werts
Franny is a 70-year-old woman recently admitted to
the hospital after sustaining five thoracic spine
compression fractures from falling backward down a
flight of stairs. She is confused and a neurologic
consult is ordered. Shortly after admission, she
developed a fever and tachycardia. Pneumonia was
suspected, and she was diagnosed with sepsis and
transferred to the intensive care unit (ICU). She is 5 ft
tall and weighs 112 pounds, with a body mass index
(BMI) of 22.
Learning Objectives
1 Explain how the stress response affects metabolism.
2 Explain why enteral nutrition, when feasible, is superior to parenteral
nutrition in clients who are critically ill.
3 Calculate the calorie and protein requirements of a client with critical
illness.
4 Explain why underfeeding calories may be preferable in the early phase
of critical illness.
5 Discuss the cause and signs of refeeding syndrome.
6 Teach a client how to increase protein and calorie intake.
7 Devise a high-calorie, high-protein menu with small frequent meals.
Critical illness generally refers to any acute, life-threatening illness or
injury that requires treatment in the ICU, such as trauma (e.g., gunshot
wounds, motor vehicle accidents, severe burns), certain diseases (e.g.,
pancreatitis, acute renal failure), extensive surgery, or infection. It is
typically associated with a state of catabolic stress characterized by a
systemic inflammatory response and carries the risk of increased infectious
morbidity, multiple-organ dysfunction, prolonged hospitalization, and
disproportionate mortality (McClave et al., 2016).
Once considered adjunct therapy, nutrition support is now thought to
help mitigate the metabolic response to stress, prevent oxidative cellular
injury, and favorably dampen exaggerated immune responses. Early enteral
nutrition (EN), appropriate macro- and micronutrient delivery, and tight
glycemic control may reduce the severity of the illness, reduce
complications, decrease length of stay in the ICU, and improve outcomes
Nutrition Support
the provision of nutrition via enteral feeding tubes or parenteral catheters.
This chapter discusses the stress response and nutrition therapy for
critical illness. Nutrition therapy for burns and acute respiratory distress
syndrome (ARDS) is presented.
STRESS RESPONSE
Disruptions to homeostasis elicit a body-wide stress response characterized

by hormonal and inflammatory changes to promote healing and resolve
inflammation. The ebb and flow phases generally describe the course of the
stress response (Box 18.1). The intensity of the stress response depends to
some extent on the cause and/or severity of the initial injury; for instance,
the larger the body surface area burned, the greater the intensity of the stress
response that follows.
BOX Overview of the Stress Response Phases

18.1
Initial shock or ebb phase is marked by hemodynamic instability:
• Typical duration: 24 to 48 hours postinjury until the client is

hemodynamically stable
• Characteristics:
• shock with hypovolemia and diminished tissue oxygenation
• decreased cardiac output, oxygen consumption, and body
temperature
• increase in heart rate
• increased blood glucose level
• increase in acute phase proteins
• immune system activated
• Treatment goals: Restore blood flow to organs, maintain adequate
oxygenation to all tissues, stop bleeding, and replace fluids.
The catabolic flow phase is marked by metabolic instability and
catabolism. It lasts 3 to 10 days.
• Spike in circulating levels of hormones that direct the “fight-or-flight

response” (e.g., glucagon, catecholamines, cortisol) promotes the
breakdown of stored nutrients to meet energy needs:
• glucose from glycogen
• amino acids from skeletal muscle tissue
• fatty acids from adipose
• Characteristics:
• insulin resistance
• increased cardiac output, oxygen consumption, body temperature,
basal metabolic rate (BMR), and total body protein catabolism
(negative nitrogen balance)
• length of this phase is dependent on the severity of injury or
infection and whether complications develop
• Nutrition goals: achieve and maintain fluid and electrolyte balance;
minimize body protein catabolism; and meet calorie, protein, and
micronutrient needs.
The anabolic flow phase is characterized by a positive nitrogen balance
as protein synthesis begins. Adequate calories, protein, and nutrients are
needed for anabolism.
Hormonal Response
Hormones released in response to stress include the following:
• catecholamines, glucagon, and cortisol
• The metabolic effects from these hormones is to release stored
macronutrients to meet the increased demands for energy. Their
combined effects contribute to hyperglycemia.
• Excess cortisol is damaging when stress is prolonged. It inhibits
protein synthesis even when protein intake is high, promotes insulin
resistance, contributes to hyperglycemia, and suppresses immune
responses.
• aldosterone and antidiuretic hormone, which conserve water and
sodium to help maintain blood volume
Stress Response
a complex series of hormonal and metabolic changes that occur to enable the body to adapt to
stressors.
Inflammatory Response
In reaction to infection or tissue injury, the immune system mounts a quick,
acute-phase response to destroy infection agents, prevent further tissue
damage, and promote healing. Inflammation causes positive acute-phase
proteins, such as C-reactive protein, to increase in concentration. Negative
acute-phase proteins, such as albumin, prealbumin, and transferrin, decrease
in response to inflammation. Cytokines and other immune system
molecules are responsible for regulating acute-phase proteins; they also
produce changes in other cells that cause systemic symptoms of
inflammation, such as anorexia, fever, lethargy, and weight loss.
Acute-Phase Response
trauma- or inflammation-induced release of inflammatory mediators that cause changes in the
levels of plasma proteins and clinical symptoms of inflammation.
Cytokines
a group name for more than 100 different proteins involved in immune responses. Prolonged
production of proinflammatory cytokines promotes accelerated catabolism.
Potential Complications of the Stress Response

The inflammatory response to infection and tissue damage is a desired
reaction that is generally self-limiting (Sharma et al., 2019). However, when
the response is exaggerated and prolonged, the beneficial response becomes
damaging.
• The body mounts an antiinflammatory response to counter the
proinflammatory response.
• A disproportionate shift toward an antiinflammatory state can lead
to endothelial damage and organ failure, immune suppression,
metabolic abnormalities, and loss of body mass.
• The weakened immune system is unable to destroy pathogens, and
the host becomes increasingly immunocompromised.
Sepsis
Sepsis is defined as “life-threatening organ dysfunction caused by a
dysregulated host response to infection” (Singer et al., 2016, p. 804).
• Sepsis is the primary cause of death from infection (Singer et al.,
2016).
• Septic shock is a subset of sepsis in which underlying circulatory
and cellular metabolism abnormalities are severe enough to
substantially increase the risk of death (Singer et al., 2016).
Sepsis
an abnormal systemic host response to infection that causes life-threatening organ dysfunction.
Malnutrition
Hypermetabolism and catabolism caused by the inflammatory response
can quickly deplete protein stores. It is well understood that inflammation
related to critical illness is a potent contributor to malnutrition (Malone &
Hamilton, 2013).
• Malnutrition is independently associated with high mortality risk,
longer length of hospital stay, and higher cost of hospitalization
(Lim et al., 2012).
• Although it is difficult to actually define malnutrition in critically ill
clients, it is estimated to affect 39% to 78% of clients with critical
illness (Lew et al., 2017).
• Because baseline nutrition status is a strong predictor of clinical
outcomes, timely initial screening is imperative to identify clients
with malnutrition or high risk for malnutrition who benefit from
early nutrition support (Sharma et al., 2019).
Hypermetabolism
higher-than-normal metabolism.
NUTRITION SUPPORT
Nutrition plays a key role in modulating inflammatory responses,
maintaining immune function, slowing skeletal muscle catabolism,
promoting tissue repair, supporting the functional integrity of the gut, and
maintaining the pulmonary mucosal barrier (Sharma et al., 2019). However,
best practices for providing nutrition care in the ICU remain unclear
(Morrissette & Stapleton, 2020). Several factors contribute to the relative
lack of strong ICU nutrition research: Sample sizes are small, the surrogate
markers (e.g., improved weight) for improved clinical outcomes (e.g., lower
infection rates) may not necessarily correlate, ICU clients are a
heterogeneous population with different underlying diseases (Sharma et al.,
2019), and our understanding of specific nutritional needs during severe
physiologic and metabolic stress is poor (Morrissette & Stapleton, 2020).
Nutrition Support Goals

The goal of nutrition support is to reduce infectious morbidity, ventilator-
dependent days, and length of stay in the ICU (McClave et al., 2016).
Additional goals are to minimize body protein catabolism, promote wound
healing, and provide the appropriate amount and combination of nutrients to
limit or modulate the stress response and complications.
Nutrition Support
An oral diet is preferred over EN or parenteral nutrition (PN) in clients who
are able to eat without risk of vomiting or aspiration (Singer et al., 2019).
An oral intake that meets 70% of client need from days 3 to 7 is considered
adequate.
When oral intake is not adequate, early EN is preferred over early PN
(Singer et al., 2019). EN is preferred because it helps maintain gut integrity
and has been shown to reduce infectious complications and length of ICU
and hospital stay (Singer et al., 2019). It is recommended that EN be
initiated as soon as fluid resuscitation is complete and the client is
hemodynamically stable, preferably within the first 24 to 48 hours
(McClave et al., 2016). When EN is not feasible or adequate, the use of PN
is indicated, especially in clients with moderate to severe malnutrition or at
risk of malnutrition. Guidelines for nutrition support in critically ill clients
are summarized in Box 18.2. Additional points are presented as follows.
Enteral Formula Selection

For most clients, a standard polymeric (intact macronutrients) formula that
provides 1.0 to 1.5 cal/mL may be used to initiate nutrition support in the
ICU.
• For obese clients, a low-caloric density formula with a reduced
nonprotein calorie-to-nitrogen ratio is suggested (proportionately
lower in calories from carbohydrates and fats than in protein
content).
• For clients in the surgical ICU or with severe trauma, an immune-
modulating formula that provides arginine, fish oils, and/or
glutamine may be considered.
• No benefit has been shown for routine use of other specialty
formulas and disease-specific formulas in the ICU, such as
pulmonary formulas for acute respiratory failure and hepatic
formulas for critically ill clients with acute or chronic liver disease.
BOX Summary of Nutrition Support

18.2 Guidelines in Critical Illness
Method of Feeding
• An oral diet is recommended if it is feasible.

• EN is strongly recommended over PN when appropriate.
• Either gastric or small bowel feedings are appropriate. Consider small
bowel feedings if client is at high risk for aspiration or has intolerance
to gastric feedings.
Calories
• It is recommended that IC be used to determine calorie requirements.
• In the absence of IC predictive equations, a simple weight-based
formula may be used:
• 25 to 30 cal/kg/day of admission weight for clients with BMI <30
• 11 to 14 cal/kg/day of actual body weight for clients with BMI in
the range of 30 to 50
• 22 to 25 cal/kg/day of ideal body weight for clients with BMI >50
Protein
• Positive outcomes in critical illness may be more dependent on
adequate protein intake than adequate total calorie intake.
• Protein recommendations are as follows:
• 1.2 to 2.0 g/kg/day of actual weight for adults with BMI <30; higher
amounts may be necessary for certain illnesses, such as burns.
• at least 2.0 g/kg/day of ideal body weight for clients with BMI of 30
to 40.
• Up to 2.5 g/kg/day of ideal body weight for clients with BMI ≥40.
Other
• It is recommended that supplemental enteral glutamine not be

routinely added to an EN regiment in critically ill clients based on
randomized controlled trials that showed added glutamine had no
significant benefit on mortality, infections, or hospital length of stay.
• Antioxidant vitamins (including vitamins E and C) and trace minerals
(including selenium, zinc, and copper) may improve client outcomes,
especially in clients with burns, with trauma, and requiring mechanical
ventilation.
• Fluid requirements are highly individualized according to losses that
occur through exudates, hemorrhage, emesis, diuresis, diarrhea, and
fever.
• Clients with persistent diarrhea may benefit from the use of the fiber-
containing formula, a semi-elemental formula in place of a standard
formula, or a soluble fiber supplement.
Source: McClave, S., Taylor, B., Martindale, R., Warren, M., Johnson, D. R., Braunschweig, C.,
McCarthy, M., Davanos, E., Rice, T., Cresci, G., Gervasio, J., Sacks, G., Roberts, P., Compher,
C., and the Society of Critical Care Medicine and American Society for Parenteral and Enteral
Nutrition. (2016). Guidelines for the provision and assessment of nutrition support therapy in
the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society
for Parenteral and Enteral Nutrition (A.S.P.E.N.). Journal of Parenteral and Enteral Nutrition,
40(2), 159–211. https://doi.org/10.1177/0148607115621863.
Recall Franny. She was given intravenous (IV) fluids and is

hemodynamically stable. A nasoduodenal feeding tube is
inserted for EN to begin immediately. Is this the best feeding
method and route for Franny?
Calories
Indirect calorimetry (IC) is considered the gold standard for determining
calorie requirements, but it may not be routinely performed due to limited
availability, lack of expertise for interpreting results, or costliness of the
device.
Indirect Calorimetry (IC)
an indirect calculation of energy expenditure based on analysis of the oxygen and carbon dioxide
of inspired and expired air.
When IC is not an option, calorie needs can be estimated by either a

predictive equation or a simple weight-based equation (see Box 18.2).
Although there are more than 200 predictive equations, their accuracy rates
range from 40% to 75% when compared to IC and none stand out as being
the most accurate for ICU clients (McClave et al., 2016). Regardless of the
method used to estimate calorie requirements, calorie expenditure should be
reevaluated more than once a week so that intake can be optimized
Calorie Targets
It has been widely debated whether initially limiting the number of calories
provided during critical illness may modulate the inflammatory response
and thus improve mortality and clinical outcomes. To avoid overfeeding, it
is recommended that early full EN and PN not be given to critically ill
patients but shall be achieved within 3 to 7 days (Singer et al., 2019).
However, clients who are severely malnourished or at high nutrition risk
should advance toward goal as quickly as tolerated over 24 to 48 hours and
should be monitored for refeeding syndrome (Box 18.3) (McClave et al.,
2016).
Over the past 10 years, several large randomized controlled trials have
studied whether calorie-restricted or full-target enteral feedings are optimal
for ICU clients who are relatively well nourished (Morrissette & Stapleton,
2020).
BOX Refeeding Syndrome

18.3
Refeeding syndrome: Refeeding syndrome is an ill-defined disorder that

generally occurs when carbohydrate is reintroduced into the diet of
severely malnourished clients, such as clients with
• chronic alcoholism,
• chronic undernutrition or malnutrition of calories and/or protein,
• morbid obesity with recent massive weight loss,
• prolonged fasting,
• long-term use of simple IV hydration, and
• cardiac and cancer cachexia.
It may develop in critically ill clients who receive aggressive

nutrition repletion, either via a PN or EN diet or via an oral diet.
Symptoms range from a mild decrease in serum electrolytes that
respond quickly to repletion to life-threatening changes in metabolic and
organ systems.
The sudden availability of carbohydrate stimulates insulin secretion
•
and increases the need for thiamin and minerals involved in
carbohydrate metabolism.
• Hypophosphatemia, hypokalemia, and hypomagnesemia can occur as
cells rapidly remove these minerals from the bloodstream.
• Edema and heart failure can result from sodium and fluid retention
• Thiamin deficiency can cause acidosis, hyperventilation, and
neurologic impairments.
• For mild refeeding syndrome, initiation of EN is not affected as long
as electrolyte abnormalities are corrected.
• In severe refeeding syndrome, thiamin supplementation, ongoing
electrolyte replacement, and slower advancement of EN may be
needed.
• Initial provision of 100% or 70% of calculated calories, or any

amount in between, is reasonable in most relatively young and well
nourished clients (Morrissette & Stapleton, 2020).
• More research is needed to determine whether (Morrissette &
Stapleton, 2020):
• the short- and long-term outcomes in less well-nourished clients
are affected by the number of calories initially provided,
• briefly delaying the provision of EN would yield different results
than instituting early feedings.
Consider Franny. Calculate her estimated calorie needs.

What is an appropriate calorie target for her as the tube
feeding begins? What is an appropriate protein intake for
her?
Refeeding Syndrome
a potentially fatal complication that occurs from an abrupt change from a catabolic state to an
anabolic state and increase in insulin caused by a dramatic increase in carbohydrate intake.
Protein
Protein is the most important macronutrient for wound healing, supporting
immune function, and maintaining lean body mass (McClave et al., 2016).
• For most critically ill clients, the increased need for protein is
proportionately higher than the increased need for calories.
• Optimizing protein intake rather than total calorie intake has been
shown to decrease infections, the duration of mechanical ventilation,
length of hospitalization, and mortality (Nicolo et al., 2016).
• Study data are lacking on the optimal dose of protein for critically ill
clients (Heyland et al., 2018). The recommendations for protein (see
Box 18.2) are not universally agreed upon, and there may be more
uncertainty over protein requirements than calorie needs.
Micronutrients
It is recommended that a combination of antioxidant micronutrients (e.g.,
vitamins C and E, selenium, zinc, copper) be provided in safe doses (e.g.,
5–10 times the Dietary Reference Intakes) based on trials that showed that
antioxidant and trace element supplementation was associated with a
significant decrease in overall mortality (McClave et al., 2016). Research is
needed to define normal antioxidant status for critically ill clients and
determine optimal supplementary dosage, frequency, duration, and route of
administration.
Think of Franny. As her signs and symptoms of

inflammation and infection begin to resolve, her appetite
improves but only for tea and toast. She wants the feeding
tube removed but isn’t hungry enough to eat a whole tray of
food. What steps will you take to help maximize Franny’s
oral intake? How many calories should she be consistently
consuming before the feeding tube can be removed?
Nutrition during Recovery
Clients are typically transitioned to an oral diet as soon as possible, usually
following extubation. The goal of nutrition therapy is to maximize intake to
preserve lean body mass.
• Oral intake is commonly inadequate after extubation for a variety of
reasons, which may include residual pain after endotracheal tube
removal, delays in ordering a diet, restrictive diets, client fatigue,
anorexia, gastrointestinal (GI) upset, and nothing-by-mouth orders
for tests or procedures.
• Monitoring oral intake and individualizing nutrition therapy are vital
to optimize recovery.
• A high-calorie, high-protein diet with small frequent meals may
help maximize intake (Box 18.4).
• A nutrient-dense diet provides nutrients important for wound
healing and recovery (Table 18.1).
• Oral nutrition supplements can provide significant protein, calories,
and nutrients. Supplemental EN may be necessary.
Table Nutrients Important for Wound

18.1 Healing and Recovery
Rationale for
Nutrient Increased Need Possible Deficiency Outcome
Rationale for
Protein • to replace lean • significant weight loss
body mass lost • impaired/delayed wound healing
during the • shock related to decreased blood
catabolic phase volume
after stress
• edema related to decreased serum
• to restore blood albumin
volume and
• diarrhea related to decreased
plasma proteins
albumin
lost during
exudates, • anemia
bleeding from • increased risk of infection related
the wound, and to decreased antibodies, impaired
possible tissue integrity
hemorrhage • increased mortality
• to replace losses
resulting from
immobility
(increased
excretion)
• to meet
increased needs
for tissue repair
and resistance to
infection
Calories • to spare protein • signs and symptoms of protein
• to restore normal deficiency due to use of protein to
weight meet energy requirements
• extensive weight loss
Rationale for
Water • to replace fluid • signs, symptoms, and
lost through complications of dehydration such
vomiting, as poor skin turgor, dry mucous
hemorrhage, membranes, oliguria, anuria,
exudates, fever, weight loss, increased pulse rate,
drainage, decreased central venous pressure
diuresis
• to maintain
homeostasis
Vitamin • important for • impaired/delayed wound healing
C capillary related to impaired collagen
formation, tissue formation and increased capillary
synthesis, and fragility and permeability
wound healing • increased risk of infection related
through collagen to decreased antibodies
formation
• needed for
antibody
formation
Thiamin, • requirements • decreased enzymes available for
niacin, increase with energy metabolism
riboflavin increased
metabolic rate
Rationale for
Folic • needed for cell • decreased or arrested cell division
acid, proliferation and, • megaloblastic anemia
vitamin therefore, tissue
B12 synthesis
• important for
maturation of red
blood cells
• impaired folic
acid synthesis
related to some
antibiotics;
impaired vitamin
B12 absorption
related to some
antibiotics
Vitamin • important for • decreased immune function and
A immune function increased risk of infectious
• plays a role in morbidity and mortality
protein synthesis • impaired epithelial cells alter
and cell digestion and absorption of
differentiation; nutrients and increase the risk of
important for infections of the respiratory tract,
epithelial cells GI tract, urinary tract, vagina, and
inner ear
Vitamin • important for prolonged prothrombin time
K normal blood
clotting
• impaired
intestinal
synthesis related
to antibiotics
Rationale for
Iron • to replace iron • signs, symptoms, and
lost through complications of iron deficiency
blood loss anemia such as fatigue, weakness,
pallor, anorexia, dizziness,
headaches, stomatitis, glossitis,
cardiovascular and respiratory
changes, possible cardiac failure
Zinc • needed for • impaired/delayed wound healing
protein synthesis • impaired immune response
and wound
healing
• needed for
normal
lymphocyte and
phagocyte
response
BOX A Sample High-Calorie, High-Protein

18.4 Menu
Breakfast
• orange juice
• cheese and mushroom omelet
• wheat toast with butter and jelly
• milk
• coffee with whipped cream added
Snack
smoothie made with Greek yogurt, instant breakfast mix, whole milk, and
strawberries
Lunch
• New England clam chowder

• chicken salad sandwich on a croissant
• milk
• ice cream with chocolate sauce and whipped cream
Snack
Greek yogurt
Dinner
• meat loaf with gravy

• baked potato with sour cream
• broccoli with cheese sauce
• spinach salad with hard-cooked eggs, onions, walnuts, and vinaigrette
dressing
• milk
• carrot cake with cream cheese frosting
Snack
melon topped with fruited Greek yogurt
BURNS
Extensive burns are a severe form of metabolic stress. The extensive

inflammatory response causes rapid fluid shifts and large losses of fluid,
electrolytes, protein, and other nutrients from the wound. Fluid and
electrolyte replacement to maintain adequate blood volume and blood
pressure is the priority of the initial postburn period. Persistent and
prolonged increases in metabolism and catabolism can lead to significant
loss of lean body mass and weight with increased risks of impaired wound
healing, organ dysfunction, and infection. Paralytic ileus, anorexia, pain,‐
infection or other complications, emotional trauma, and medical–surgical
procedures may complicate nutrition support.
Although nutrition support is a critical component of burn treatment,
there is a lack of consensus regarding the optimal timing, route, amount,
and composition of nutritional support (Clark et al., 2017).
Oral Nutrition
For burns covering less than 20% of total body surface area (TBSA), an
oral high-protein, high-calorie diet can adequately meet protein and calorie
requirements of most clients.
Enteral Nutrition
EN is recommended for burn clients who have functional GI tracts but who
are unable to orally meet their estimated calorie needs. McClave et al.
(2016) recommend
• Small frequent meals of calorie- and protein-dense foods (Box 18.5)
and oral nutrition supplements help maximize intake.
• Daily calorie counts may be used to monitor intake.
• When calorie and protein intake is less than 75% of estimated need
for greater than 3 days, EN may be indicated for supplemental or
total nutrition. Supplemental EN given during the night is useful
when nutritional needs are not met through food alone.
Ways to Increase Protein and Calorie

BOX
Density of Foods
18.5
Ways to Increase Protein Density
• Add skim milk powder to milk.

• Substitute milk for water in recipes.
• Melt cheese on sandwiches, casseroles, hot vegetables, or potatoes.
• Spread peanut butter on apples or crackers or mix into hot cereals.
• Sprinkle nuts on cereals, desserts, or salads; mix into casseroles or stir-
fry.
• Coat breaded meats with eggs first; add chopped hard-cooked eggs to
casseroles.
• Top fruit with yogurt or Greek yogurt.
• Use plain yogurt or plain Greek yogurt in place of sour cream.
• Add commercially available whey protein powder to water, milk,
shakes, or smoothies.
Ways to Increase Calorie Density
• Spread cream cheese on hot bread.

• Add butter or olive oil to hot foods: potatoes, vegetables, cooked
cereal, rice, pasta, pancakes, and soups.
• Use gravy over potatoes, meat, or vegetables.
• Use mayonnaise in place of salad dressing.
• Use whipped cream on desserts and in coffee and tea.
• Add honey to cooked cereals, fruit, coffee, or tea.
• Add marshmallows to hot chocolate.
• initiating EN within 4 to 6 hours of injury if possible; early initiation

is associated with improved structure and function of the GI tract
and fewer episodes of infection and may also blunt the
hypermetabolic response to burns;
• placing a nasoenteric tube into the small bowel to facilitate early
EN; and
• using PN only when EN is not feasible or tolerated.
Nutrient Recommendations
Nutrient needs vary with the TBSA burned, the client’s baseline nutritional
status, the stage of treatment, and if the client develops complications.
Frequent monitoring is necessary to assess the adequacy of nutrition.
Calorie Requirements
IC is recommended as the most accurate method to assess calorie
requirements in burn clients. No predictive equations have found to be
precise in estimating calorie needs of clients with >20% TBSA burns.
• If IC is not available or feasible, calorie needs may be estimated by
the weight-based formula of 25 to 30 cal/kg (Academy of Nutrition
and Dietetics, 2020).
• Calorie needs do not immediately decrease with wound closure;
hypermetabolism may last for years after the injury (Clark et al.,
2017).
Protein
Providing high doses of protein does not reduce the catabolism of body
protein stores but does promote protein synthesis and reduces negative
nitrogen balance (Clark et al., 2017).
• Recommended protein intake is 1.5 to 2.0 g/kg/day for adults, which
is 2 to 2.5 times above the recommended dietary allowances (RDA)
for healthy people (McClave et al., 2016).
• Adequacy of protein intake is evaluated by wound healing and
adherence of skin grafts.
Micronutrients
Micronutrient supplementation after burns is common practice in order to
fight oxidative stress, support the immune system, and promote wound
healing. However, research is needed to achieve a consensus on which
nutrients, their dosages, and duration of supplementation are optimal for
clients with severe burns. McClave et al. (2016) state that antioxidant
vitamins (including vitamins E and C) and trace minerals (including
selenium, zinc, and copper) may improve client outcomes in burn clients.
Nutrition after Discharge

A high-calorie, high-protein diet is usually recommended for about a year
after discharge, even though data on the optimal diet after the acute
postburn phase are virtually nonexistent (Clark et al., 2017). Clients should
be encouraged to engage in strength training exercise to counter the
continued loss of muscle mass and regularly weigh themselves.
ACUTE RESPIRATORY DISTRESS

SYNDROME
Acute respiratory distress syndrome (ARDS) is a severe lung disease. Acute

lung injury (ALI) is a less severe form of lung disease. Both diseases are
characterized by inflammation of the lung parenchyma and increased
pulmonary capillary permeability, leading to impaired gas exchange.
Pulmonary edema interferes with ventilation and damages the alveoli.
Oxygen levels fall in the blood and tissues, leading to impaired cellular
function and possibly cell death. Hypercapnia can cause acidosis. Breathing
is labored and heart rate increases. Cyanosis, confusion, and drowsiness
may develop. Heart arrhythmias and coma may result.
Nutrition Therapy for Clients with Acute
Respiratory Distress Syndrome
ARDS and ALI are most often observed as part of systemic inflammatory
processes, such as sepsis, pneumonia, trauma, burn, aspiration, and
pancreatitis (Academy of Nutrition and Dietetics, 2020). The underlying
inflammatory condition increases calorie and protein requirements and the
risk for malnutrition.
Enteral Nutrition
EN is used if the GI tract is functional. Intestinal feedings may be preferred
because they lower the risk of aspiration.
• EN products specially formulated for clients with pulmonary
disorders are high in fat and low in carbohydrate based on the
rationale that lesser amounts of carbohydrate reduce CO2
production.
• This assumption has been shown to be erroneous; increasing the
ratio of fat to carbohydrate only lowers CO2 production in the
client who is overfed (McClave et al., 2016).
• When the appropriate number of calories is provided, the
macronutrient composition of the formula is much less likely to
affect CO2 production (McClave et al., 2016).
• It is recommended that these high-fat formulas not be used in ICU
clients with acute respiratory failure.
• Clients with acute respiratory failure who require fluid restriction
may benefit from calorie-dense EN formulas (e.g., those providing
1.5–2.0 cal/mL) that provide more nutrition in less volume than
standard formulas (McClave et al., 2016).
• A meta-analysis of studies that examined the effects of omega-3
fatty acids and/or antioxidants in adults with ARDS was unclear as
to whether these components improve oxygenation, long-term
survival, length of ICU stay, or the number of ventilator-dependent
days (Dushianthan et al., 2019).
Calories and Protein
The goal for ARDS is to provide adequate calories and protein to prevent
weight loss. However, evidence regarding the calorie needs of clients with
ARDS is conflicting (Loi et al., 2017).
• IC is the gold standard for estimating calorie requirements, but it is
costly and may not be as accurate in intubated clients with high
oxygen requirements (Loi et al., 2017).
• Less accurate methods of estimating calorie requirements include
predictive equations or the weight-based formula of 25 to 30 cal/kg.
• Overfeeding is avoided because it increases CO2 production and
may complicate respiratory function and ventilator weaning.
• Either permissive underfeeding or full calorie delivery is appropriate
because these two strategies yield similar outcomes over the first
week of hospitalization in clients with ARDS (McClave et al., 2016)
• However, some studies suggest that permissive underfeeding (low
calories and protein) or tropic EN (low calories) with slow
progression may be more beneficial than aggressive full feeding
in clients with ARDS and ALI (Patel et al., 2018; Rice et al.,
2011).
• Protein requirements generally range from 1.5 to 2.0 g/kg/day.
NURSING
PROCESS Metabolic Stress
Yin is a frail, 74-year-old man admitted to the hospital with multiple

serious but non–life-threatening injuries resulting from a car accident.
His BMI is 18. A regular diet is ordered with oral nutrition supplements
provided 3 times/day. He consumes 25% to 50% of most meals and
supplements and states he has no appetite.
Assessment
Medical– • current diagnoses and medications
psychosocial • medical history, including hyperlipidemia,
history hypertension, cardiovascular disease, renal
impairments, diabetes, GI complaints
• medications that affect nutrition, such as lipid-
lowering medications, cardiac drugs,
antihypertensives
• extent of injuries, significance of GI trauma, if
appropriate
• hemodynamic status, signs and symptoms of
hemorrhaging
• neurologic status (e.g., confusion, disorientation),
ability to eat, ability to self-feed
• GI symptoms, such as distention, complaints of
nausea, anorexia
• psychosocial and economic issues prior to injury,
such as whether finances, loneliness, or isolation
impaired his food intake; determine who does
food shopping and preparation and whether the
client is a candidate for the Meals on Wheels
program
Anthropometric • height, current weight, BMI

Assessment • recent weight history, usual weight
Biochemical • check abnormal labs for their nutritional

and Physical significance
Assessment • input and output
• clinical symptoms of malnutrition such as wasted
appearance
Assessment
Dietary • Do you have any difficulty chewing or

Assessment swallowing?
• Do you have nausea or any other symptoms that
interfere with your ability to eat?
• Are you able to feed yourself?
• Do you follow a special diet at home?
• Do you have enough food to eat at home?
• Do you have any food intolerances or allergies?
food preferences?
• Do you take vitamins, minerals, or supplements?
If so, what?
• How much alcohol do you consume?
Analysis
Possible Malnutrition risk related to anorexia and
Nursing underweight status as evidenced by oral intake of
Analysis 25% to 50% and BMI of 18 on admission.
Planning

Outcomes • maintain normal fluid and electrolyte balance,
• meet 75% of his goal for calories and protein via
oral diet with supplements,
• describe the principles and rationale of a high-
calorie, high-protein diet, and
• avoid complications of undernutrition, such as
weight loss, poor wound healing, and infections.
Assessment
Nutrition • Provide regular diet with oral nutrition
Therapy supplements as ordered.
• Encourage the client to eat calorie- and protein-
dense foods first during mealtime.
• Offer standby menu choices as needed.
• Motivate the client to consume oral nutrition
supplements.

• the importance of protein and calories in
promoting wound healing and recovery and
overall health.
• the eating plan essentials, including
• how to increase calories and protein in the diet,
• to eat small frequent meals to maximize intake.
Evaluation
Evaluate and • Monitor fluid and electrolyte balance and other
Monitor biochemical values.
• Monitor percentage of food consumed.
• Monitor weight.
• Monitor for complications, such as delayed
wound healing or infection.
• Observe for tolerance to oral diet.
• Suggest changes in the meal plan as needed.
• Provide periodic feedback and reinforcement.
How Do You Respond?

Do flavored waters marketed to improve immune
function really work? There are several flavored waters
available on grocery store shelves that feature descriptive
terms such as defend, protect, or immunity on the label.
All of these products contain added vitamins and/or
minerals, such as vitamins A, C, D, E, B vitamins, or
zinc. Some provide calories from sweeteners, while
others are calorie free. Although certain vitamins and
minerals are important for normal immune system
functioning, it is a huge leap to conclude that any of these
products provide health benefits beyond those obtained
from a normal mixed diet. In general, consuming more
than required of any nutrients necessary for immune
system functioning does not boost immune function—
unless the immune system was impaired because of a
nutrient deficiency. Manufacturers are free to put in
whatever nutrients they desire in whatever amounts they
choose; scientific evidence of benefit or need is not‐
required to make a function claim.
REVIEW CASE STUDY
Samuel was recently discharged after being hospitalized for burns he had
suffered in an industrial accident that covered 18% TBSA. He is 38 years
old, 5 ft 9 in. tall, and currently weighs 134 pounds. His pre-burn weight
was 150 to 155 pounds. He received three meals a day plus three high-
protein shakes while in the hospital. He is motivated to regain weight, but
he refuses to drink any more of the shakes—they are too sweet and taste
artificial. The dietitian told him he should be eating at least 2000 calories
and include protein-dense foods at each meal and snack, but he lives alone
and doesn’t have the appetite for that amount of food.
His usual pre-burn intake appears in the box on the right.
• Evaluate Samuel’s current BMI and usual adult weight. What would be
an appropriate goal weight?
• What specific strategies would you recommend that Samuel implement
to improve his overall intake?
• Is 2000 calories an appropriate amount of daily calories for Samuel?
What sources of protein did he usually consume?
• Devise a sample menu for Samuel that takes into account the calories and
protein he needs, living arrangements, and lack of appetite.
Breakfast: coffee with creamer, two doughnuts

Lunch: two hot dogs on buns, french fries, diet soft drink
Dinner: frozen pizza, ice cream, beer
STUDY QUESTIONS
1 When should nutrition support be initiated in a hemodynamically stable,

fluid resuscitated, critically ill client?
a. within 24 hours
b. within 24 to 48 hours
c. within 3 to 7 days
d. within the first week
2 Which of the following strategies will increase protein density?
a. using whipped cream to replace milk in coffee
b. spreading cream cheese on hot bread
c. using plain yogurt to replace sour cream
d. using mayonnaise to replace salad dressing
3 Why is EN preferred over PN for a client with burns with a functional GI
tract?
a. EN can provide higher amounts of calories and protein.
b. EN is less likely to interfere with oral intake.
c. EN is less expensive.
d. EN has a lower risk of infectious complications.
4 Which of the following strategies will increase calorie density?
a. using butter instead of margarine on toast
b. adding brown sugar to cereal instead of white sugar
c. using gravy over meat
d. substituting whole wheat bread for white bread
5 What is the primary intervention in the initial postburn period?
a. PN
b. supplements of trace elements
c. fluid and electrolytes
d. a low-carbohydrate diet to decrease CO2 production
6 Why may underfeeding critically ill clients be beneficial?
a. It provides less work for the GI tract to do.
b. All methods of measuring a person’s energy expenditure overestimate
calorie requirements, so a lower calorie load is prudent.
c. It may modulate the inflammatory response.
d. It provides less strain on the respiratory system.
7 What causes refeeding syndrome in clients who are fed after being in a
catabolic state?
a. a dramatic increase in fluid intake
b. a dramatic increase protein intake
c. a dramatic increase in fat intake
d. a dramatic increase in carbohydrate intake
Which of the following metabolic abnormalities is associated with
8 refeeding syndrome?
a. hyperphosphatemia
b. thiamin deficiency
c. hyperkalemia
d. hypermagnesemia

Clients with Critical Illness
Stress Response
Critical illness is any acute, life-threatening illness or injury that requires
treatment in the ICU. It is characterized by a systemic inflammatory
response and associated with a state of catabolic stress. Stress elicits
hormonal and inflammatory responses designed to promote healing and
resolve inflammation.
Hormonal Response
This response promotes release of glucose, amino acids, and fatty acids
from body reserves to meet increased demands for energy. Other hormones
conserve water and sodium to help maintain blood volume.
Inflammatory Response
To destroy infectious agents, this response prevents further tissue damage
and promotes changes in acute phase proteins. The inflammatory response
is desired and generally selflimiting. Sometimes, this response becomes
exaggerated, prolonged, and damaging to the host.
Sepsis
Sepsis is a life-threatening syndrome of abnormal inflammatory response
that causes organ dysfunction; the primary cause of death from infection.
Malnutrition
Inflammation of critical illness is a potent contributor to malnutrition.
Malnutrition is difficult to diagnose in critically ill people. Baseline
nutrition status is a strong predictor of clinical outcomes; nutrition
screening is imperative to identify clients with malnutrition or at high risk
for malnutrition, who benefit from early nutrition support.
Nutrition Support
EN is the preferred route for feeding critically ill clients if an oral diet is not
feasible because it helps maintain gut integrity, modulates stress, and
lessens disease severity. PN is indicated when EN is not feasible or
inadequate.
Nutrition Support Goals. The goals are to reduce infectious morbidity,
ventilator-dependent days, length of stay in ICU, and body protein
catabolism.
• Enteral formula selection: A standard polymeric (intact
macronutrients) formula that provides 1.0 to 1.5 cal/mL is generally
appropriate.
Calories. Requirements can be determined by indirect calorimetry,
predictive equations, or simple weight-based formulas. All methods have
disadvantages. Initial provision of 100% or 70% of calculated calorie
needs, or any amount in between, is reasonable in most clients.
Protein. Protein requirement increases more than calorie requirement and
may be more important than calories. Recommendations are not universally
agreed upon.
Micronutrients. Antioxidant micronutrient supplements (e.g., vitamins C
and E and selenium, zinc, and copper) are recommended in doses 5 to
10 times the DRI.
Nutrition during Recovery. Oral intake may resume after extubation.
A high-calorie, high-protein diet is encouraged. Oral nutrition supplements
or supplemental EN may be necessary.
Burns
Severe burns represent the most severe form of metabolic stress. Loss of
lean body mass can be significant.
Oral Nutrition. Clients with burns covering <20% TBS may be able to
meet their nutrient needs with a high-calorie, high-protein diet with oral
nutrition supplements. Supplemental EN may be necessary.
Enteral Nutrition. This should be initiated within 4 to 6 hours after
injury if possible. PN is indicated only when EN is not feasible or tolerated.
Nutrient Recommendations
• Calorie recommendation: Calorie needs can be estimated by IC,
predictive equations, or weight-based formulas.
• Protein recommendation: 1.5 to 2.0 g/kg/day.
• Micronutrients: Antioxidant vitamins (e.g., vitamins C and E) and
trace minerals (e.g., selenium, zinc, and copper) may improve
outcomes in clients with burns.
Nutrition after Discharge. Increased calorie needs may persist for a
year after injury. A high-protein, high-calorie diet with oral nutritional
supplements is recommended. Clients should regularly weigh themselves to
monitor adequacy of intake.
Acute Respiratory Distress

Syndrome
ARDS is an inflammatory lung disease often part of systemic inflammatory
processes such as sepsis, pneumonia, trauma, burn, and pancreatitis.
Nutrition Therapy. Calorie and protein needs are elevated. Mechanical
ventilation makes nutrition support necessary.
• Routine standard formulas are recommended; calorie-dense versions
may be appropriate for clients who require a fluid restriction.
• Calorie needs are not easily or accurately determined. The weight-
based formula of 25 to 30 cal/kg may be used. Overfeeding should
be avoided; permissive underfeeding may be used for the initial
feeding period in well-nourished clients.
• Protein recommendation: 1.5 to 2.0 g/kg.
• It is not known if omega-3 fatty acids and/or antioxidants benefit
adults with ARDS.
Figure sources: shutterstock.com/Arne Beruldsen, shutterstock.com/Chaikom,
shutterstock.com/nampix

book at
Websites
American Association of Critical-Care Nurses at www.aacn.org
American Burn Association at www.ameriburn.org
American Society for Parenteral and Enteral Nutrition at https://www.nutritioncare.org/
Society of Critical Care Medicine at www.sccm.org
Surviving Sepsis Campaign at www.survivingsepsis.org
References
Academy of Nutrition and Dietetics. (2020). Nutrition care manual.
https://www.nutritioncaremanual.org
Clark, A., Imran, J., Madni, T., & Wolf, S. (2017). Nutrition and metabolism in burn patients. Burns
& Trauma, 5, s41038-017-0076-x. https://doi.org/10.1186/s41038-017-0076-x
Dushianthan, A., Cusack, R., Burgess, V. A., Grocott, M., & Calder, P. (2019). Immunonutrition for
acute respiratory distress syndrome (ARDS) in adults. Cochrane Database of Systematic
Reviews, Issue 1. Art. No.: CD012041. https://doi.org/10.1002/14651858.CD012041.pub2
Heyland, D. K., Stapleton, R., & Compher, C. (2018). Should we prescribe more protein to critically
ill patients? Nutrients, 10, 462. https://doi.org/10.3390/nu10040462
Lew, C., Yandell, R., Fraser, R., Chua, A., Chong, M., & Miller, M. (2017). Association between
malnutrition and clinical outcomes in the intensive care unit: A systematic review. Journal of
Parenteral and Enteral Nutrition, 41(5), 744–758. https://doi.org/10.1177/0148607115625638
Lim, S., Ong, K., Chan, Y., Loke, W., Ferguson, M., & Daniels, L. (2012). Malnutrition and its
impact on cost of hospitalization, length of stay, readmission and 3-year mortality. Clinical
Nutrition, 31(3), 345–350. https://doi.org/10.1016/j.clnu.2011.11.001
Loi, M., Wang, J., Ong, C., & Lee, J. (2017). Nutritional support of critically ill adults and children
with acute respiratory distress syndrome: A clinical review. Clinical Nutrition ESPEN, 17, 1–8.
https://doi.org/10.1016/j.clnesp.2017.02.005
Malone, A., & Hamilton, C. (2013). The Academy of Nutrition and Dietetics/The American Society
for Parenteral and Enteral Nutrition consensus malnutrition characteristics: Application in
https://doi.org/10.1177/0884533613508435
McClave, S., Taylor, B., Martindale, R., Warren, M., Johnson, D. R., Braunschweig, C., McCarthy,
M., Davanos, E., Rice, T., Cresci, G., Gervasio, J., Sacks, G., Roberts, P., Compher, C. and the
Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition.
(2016). Guidelines for the provision and assessment of nutrition support therapy in the adult
critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for
Parenteral and Enteral Nutrition (A.S.P.E.N.). Journal of Parenteral and Enteral Nutrition, 40(2),
159–211. https://doi.org/10.1177/0148607115621863
Morrissette, K. M., & Stapleton, R. D. (2020). Mounting clarity on enteral feeding in critically ill
patients. American Journal of Respiratory and Critical Care Medicine, 201(7), 758–760.
https://doi.org/10.1164/rccm.202001-0126ED
Nicolo, M., Heyland, D., Chittams, J., Sammarco, T., & Compher, C. (2016). Clinical outcomes
related to protein delivery in a critically ill population: A multicenter, multinational observation
study. Journal of Parenteral and Enteral Nutrition, 40(1), 45–51.
https://doi.org/10.1177/0148607115583675
Patel, J., Martindale, R., & McClave, S. (2018). Controversies surrounding critical care nutrition: An
appraisal of permissive underfeeding, protein, and outcomes. JPEN, 42(3), 508–515.
doi.org/10.1177/0148607117721908
Rice, T., Mogan, S., Hays, M., Bernard, G., Jensen, G., & Wheeler, A. (2011). Randomized trial of
initial tropic versus full-energy enteral nutrition in mechanically ventilated patients with acute
respiratory failure. Critical Care Medicine, 39(5), 967–974.
https://doi.org/10.1097/CCM.0b013e31820a905a
Sharma, K., Mogensen, K., & Robinson, M. (2019). Pathophysiology of critical illness and role of
nutrition. Nutrition in Clinical Practice, 34(1), 12–22. https://doi.org/10.1002/ncp.10232
Singer, P., Blaser, A., Berger, M., Alhazzani, W., Clader, P. C., Casaer, M. P., Hiesmayr, M., Mayer,
K., Montejo, J. C., Pichard, C., Preiser, J.-C., van Zanten, A. R. H., Oczkowski, S., Szceklik, W.,
& Bischoff, S. (2019). ESPEN guideline on clinical nutrition in the intensive care unit. Clinical
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JAMA, 315(8), 801–810. https://doi.org/10.1001/jama.2016.0287
Nutrition for Clients
Chapter with Upper
19 Gastrointestinal Tract
Disorders
Bertha Parker
Bertha is an 84-year-old female who was diagnosed
with type 2 diabetes 30 years ago. She has multiple
chronic health problems, including mild to moderate
dementia and gastroparesis. During a recent
hospitalization for uncontrolled diabetes, she was
given a swallowing evaluation after nurses observed
hoarseness and coughing during and after
swallowing.
Learning Objectives
1 Give examples of ways to promote eating in people with anorexia.

2 Describe nutrition interventions that may help maximize intake in people
who have nausea.
3 Describe the five levels of food textures in the international dysphagia
diet.
4 Describe the five levels of liquid consistencies in the international
dysphagia diet.
5 Discuss nutrition and lifestyle recommendations for someone with
gastroesophageal reflux disease.
6 Teach a client about the role of nutrition therapy in the treatment of
peptic ulcer disease.
7 Summarize nutrition strategies for clients with gastroparesis.
8 Give examples of nutrition therapy recommendations for people
experiencing dumping syndrome.
Nutrition therapy is used in treating many digestive system disorders. For
many disorders, diet merely plays a supportive role in alleviating symptoms
rather than altering the course of the disease. For other gastrointestinal (GI)
disorders, nutrition therapy is the cornerstone of treatment. Frequently,
nutrition therapy is needed to restore nutritional status that has been
compromised by dysfunction or disease.
This chapter begins with disorders that affect eating and covers
disorders of the upper GI tract (mouth, esophagus, and stomach) that have
nutritional implications. Table 19.1 outlines the roles these sites play in the
mechanical and chemical digestion of food. Problems with the upper GI
tract affect nutrition mostly by affecting food intake and tolerance to
particular foods or textures. Nutrition-focused assessment criteria for upper
GI tract disorders are listed in Box 19.1.
The Role of the Upper

Table Gastrointestinal Tract in the
19.1 Mechanical and Chemical
Digestion of Food
Mechanical
Site Digestion Chemical Digestion
Mechanical
Mouth • Chewing Saliva contains lingual lipase, which
breaks down has a limited role in the digestion
food into of fat, and salivary amylase, and
smaller begins the process of starch
particles. digestion. Food is not held in the
• Food mixes mouth long enough for
with saliva for significant digestion to occur
ease in there.
swallowing.
Esophagus • Propels food None.
downward into
the stomach.
• Lower
esophageal
sphincter
relaxes to move
food into
stomach.
Mechanical
Stomach • Churns and • Secretes gastric acid (composed of
mixes food hydrochloric acid, potassium
with gastric chloride, and sodium chloride),
juices to reduce which
it to a thin • denatures protein molecules to
liquid called make peptide bonds more
chyme. accessible to enzymes,
• Forward and • activates pepsinogen into the
backward enzyme pepsin, which begins to
mixing motion digest protein into polypeptides,
at the pyloric • frees vitamin B12 from the
sphincter
protein it is bound to in food, a
pushes small
necessary step for absorption.
amounts of
chyme into the Enhances the solubility of iron to
duodenum. promote its absorption.
Gastric juices (HCl, lipase, pepsin)
• inactivate swallowed
microorganisms to protect against
bacterial infections in the GI tract.
• Secretes gastric lipase, which has a
limited role in fat digestion.
• Secretes intrinsic factor, necessary
for the absorption of vitamin B12.
• Absorbs some water, electrolytes,
certain drugs, and alcohol.
BOX Nutrition-Focused Assessment for Upper

19.1 Gastrointestinal Tract Disorders
GI symptoms that interfere with intake, such as anorexia, early satiety,
• difficulty chewing and swallowing, nausea and vomiting, heartburn
• Changes in eating made in response to symptoms
• Complications that affect nutritional status, such as weight loss,
aspiration pneumonia, diarrhea
• Usual pattern of eating and frequency of meals and snacks
• Use of tobacco, over-the-counter drugs for GI symptoms, and alcohol
• Food allergies or intolerances, such as high-fat foods, citrus fruits,
spicy food
• Use of nutritional supplements, including vitamins, minerals, fiber, and
herbs
• Client’s willingness to change their eating habits
DISORDERS THAT AFFECT EATING
Anorexia
Anorexia is a common symptom of many physical conditions and a side
effect of certain drugs. Emotional issues, such as fear, anxiety, and
depression, frequently cause anorexia. The aim of nutrition therapy is to
stimulate the appetite to maintain adequate nutritional intake. The following
interventions may help:
• Serve food attractively and season according to individual taste. If
decreased ability to taste is contributing to anorexia, enhance food
flavors with tart seasonings (e.g., orange juice, lemonade, vinegar,
lemon juice) or strong seasonings (e.g., basil, oregano, rosemary,
tarragon, mint).
• Schedule procedures and medications when they are least likely to
interfere with meals, if possible.
• Control pain, nausea, or depression with medications as ordered.
• Provide small, frequent meals.
• Withhold beverages for 30 minutes before and after meals to avoid
displacing the intake of more nutrient-dense foods.
• Offer liquid supplements between meals for additional calories and
protein if meal consumption is low.
• Limit fat intake if fat is contributing to early satiety.
Anorexia
lack of appetite; it differs from anorexia nervosa, a psychological condition characterized by
denial of appetite.
Nausea and Vomiting

Nausea and vomiting may be related to a decrease in gastric acid secretion,
a decrease in digestive enzyme activity, a decrease in GI motility, gastric
irritation, or acidosis. Other causes include bacterial and viral infection;
increased intracranial pressure; equilibrium imbalance; liver, pancreatic,
and gallbladder disorders; and pyloric or intestinal obstruction. Drugs and
certain medical treatments may also contribute to nausea.
The short-term concern of nausea and vomiting is fluid and electrolyte
balance, which can be maintained by intravenous administration and/or
clear liquids. Dehydration and weight loss are concerns with prolonged or
intractable vomiting.
Intractable Vomiting
vomiting that is difficult to manage or cure.
Nutrition intervention for nausea is a commonsense approach. Food is

withheld until nausea subsides.
• When the client is ready to resume an oral intake, clear liquids are
offered and intake is progressed to a regular diet as tolerated.
• Small, frequent meals of readily digested carbohydrates are usually
best tolerated:
• dry toast
• saltine crackers
• plain rolls
• pretzels
• angel food cake
• oatmeal
• canned peaches and canned pears
• banana
• High-fat foods are avoided if they contribute to nausea.
• fats: nuts, nut butters, oils, margarine, butter, salad dressings,
creams (liquid, sour, whipped)
• fatty meats, including many processed meats (bologna, pastrami,
hard salami), bacon, sausage
• milk and milk products containing whole or 2% milk
• rich desserts, such as cakes, pies, cookies, pastries
• many savory snacks, such as potato chips, cheese puffs, and
tortilla chips
• Other strategies that may help are to
• encourage the client to eat slowly and not to eat if they feel
nauseated,
• promote good oral hygiene with mouthwash and ice chips,
• limit liquids with meals because they can cause a full, bloated
feeling,
• encourage a liberal fluid intake between meals with whatever
liquids the client can tolerate, such as clear soup, juice, gelatin,
ginger ale, and popsicles,
• serve foods at room temperature or chilled (hot foods may
contribute to nausea),
• avoid spicy foods if they contribute to nausea,
• encourage the client to sit up for at least 1 hour after eating, and
• use ginger (tea, ginger ale, crystallized ginger), anecdotally,
which may help relieve nausea.
DISORDERS OF THE ESOPHAGUS
Symptoms of esophageal disorders range from difficulty swallowing and

the sensation that something is stuck in the throat to heartburn and reflux.
Dysphagia and gastroesophageal reflux disease (GERD) are discussed next.
Dysphagia
Swallowing is a complex series of events characterized by three basic
phases (Fig. 19.1). Dysphagia is objectively defined as an abnormal delay
in the transit of liquids or solid during the oropharyngeal or esophageal
phases of swallowing. It can have a profound impact on intake, hydration
status, and nutritional status and greatly increases the risk of aspiration and
its complications of bacterial pneumonia and bronchial obstruction. The
two major types of dysphagia are oropharyngeal dysphagia and esophageal
dysphagia; clients can have one or both types.
Oropharyngeal Dysphagia
Oropharyngeal dysphagia occurs when there is difficulty in the initial stage
of swallowing that involves transferring food from the mouth into the
esophagus. It is most often caused by neurologic or muscular disorders,
such as stroke, myasthenia gravis, Parkinson’s disease, multiple sclerosis,
upper esophageal sphincter dysfunction, muscular dystrophy, radiation
injury, amyotrophic lateral sclerosis, and head and neck tumors.
Figure 19.1 ▲ Swallowing phases and symptoms of impairments.
Dysphagia
impaired ability to swallow.
Esophageal Dysphagia
Esophageal dysphagia is difficulty passing food down the esophagus. It is
caused by either a motility disorder (e.g., achalasia, diffuse esophageal
spasm) or a mechanical obstruction (e.g., peptic stricture, esophageal
cancer, lower esophageal rings). It is characterized by the sensation of food
sticking in the throat or in the chest for several seconds after swallowing.
Signs and Symptoms

Signs and symptoms of dysphagia include
• eating meals slowly,
• choking, coughing, or throat clearing while eating or after eating,
• frequent heartburn,
• drooling,
• being hoarse, and
• unintended weight loss.
Texture and Consistency Modification

One of the most common interventions for dysphagia is texture
modification (Steele et al., 2015). The appropriate texture modification for
dysphagia depends on the particular issue.
• Thickened liquids are generally safer for people with dysphagia
because they flow more slowly than thin liquids, allowing the
airway time to close.
• However, very thick liquids and solid food may pose a risk for
people with diminished tongue strength or pharyngeal muscle
strength if food remains in the pharynx after a swallow.
• Pureed food may be appropriate for clients who are unable to bite or
chew food or have reduced tongue control.
• People who have some basic chewing ability but are unable to bite
off pieces of food safely may benefit from solid food that is minced
and moist (International Dysphagia Diet Standardization Initiative
[IDDSI], 2019).
A swallow evaluation is done by a speech pathologist, who identifies
the appropriate food texture and liquid consistency and recommends
feeding techniques based on the client’s individual status. Texture and
consistency changes are made as the client’s ability to swallow improves or
deteriorates.
Consider Bertha. Based on her symptoms, which phase of

swallowing is impaired? What may be the cause of Bertha’s
impairment? What other symptoms may she display?
Nutrition Therapy for Dysphagia

The goal of nutrition therapy for dysphagia is to modify the texture of foods
and/or viscosity of liquids to promote safe and efficient swallowing,
allowing the client to achieve adequate nutrition and hydration while
decreasing the risk of aspiration. A new global standardized dysphagia
guideline was developed by the International Dysphagia Diet
Standardization Initiative board (IDDSI, 2019).
• The guidelines use new standardized terminology and definitions to
describe texture-modified foods and thickened liquids for people
with dysphagia of all ages, in all care settings, and all cultures.
• A continuum of 8 levels is identified by numbers, description titles,
and color codes (Fig. 19.2). An upright triangle is used to describe
each level of liquids (levels 0–4), and an inverted triangle features
food (levels 3–7). Note that the foods and liquids in level 3 and level
4 share the same characteristics; using the same number and color to
identify both food and liquid within each of these 2 levels
demonstrates this equivalence in texture (IDDSI, 2019). Table 19.2
describes the characteristics of foods in levels 4 to 7 and gives
examples of foods included.
• Test instructions are provided to evaluate the consistency or texture
for each of the 8 levels.
For instance, levels 0 to 4 flow tests provide an objective
• measurement for liquid thickness based on their rate of flow using
a syringe filled to 10 mL of liquid and released over 10 seconds
(Fig. 19.3) Videos of the flow test can be found at
https://iddsi.org/framework/drink-testing-methods/
• Tests to evaluate the texture of foods in levels 4 (pureed) to 7
(regular) involve a fork to measure thickness (level 4), size of
food pieces (levels 5), or firmness (levels 6 and 7) (Fig. 19.4).
• The standardized terminology will make client transitions from one
facility to another safer and easier regarding appropriate texture.
However, there is no expectation that every facility will offer all 5
levels of food texture and all 5 levels of liquid levels.
Table International Dysphagia Diets 4 to

7: Characteristics and Examples
19.2 of Foods Included
Level Characteristics Examples of Foods Included

4: • Usually eaten with a • Foods pureed in a blender
Pureed spoon, although eating using extra gravy, sauce, or
with a fork is possible. milk, such as
• Cannot be drunk from a • scrambled or baked eggs
cup or sucked through a • soft pasta dishes
straw. • meat dishes (e.g., beef
• No chewing required. stew, chicken curry)
• Pureed to smooth. • potatoes
• Can be piped, layered, or • vegetables
molded and holds its own • cooked oatmeal
shape.
• fruit
• Not sticky.
• Smooth soup
• Liquid does not separate
• Smooth yogurt
from solid.
5: • Can be eaten with a fork
Minced or spoon. • Smooth soups
and • Tender, soft, and moist. • Egg (scrambled, poached,
moist boiled) finely mashed with
• Needs very little chewing.
sauce added
• Small visible lumps are
• Finely minced or chopped
allowed.
meat served in thick,
• Lumps are easy to mash smooth gravy
with the tongue.
• Mashed potatoes, mashed
• Usually requires a smooth pasta or rice in a thick
sauce, gravy, or custard, sauce
which should be very
• Mashed or finely chopped
thick.
fruit without excess liquid
• No mixed textures (e.g.,
• Finely mashed or finely
thick and thin) such as
chopped cooked vegetables
cereal in milk or
without excess liquid
separation of liquid from
food (e.g., watermelon). • Thick, smooth cooked
cereal
• Yogurt, pudding, custard
• Soft cheese, hummus
6: Soft • Soft, tender, and moist; • Cooked tender and bite-
and bite requires chewing but not sized pieces of meat and
sized biting. fish or meat and fish finely
• Can be mashed with a minced in a thick smooth
fork; no knife is required sauce or gravy
for cutting. • Egg (scrambled, poached,
• Usually requires a smooth boiled, fried)
sauce, gravy, or custard, • Soft and chopped pieces of
which should be very fruit without excess liquid
thick. • Steamed or boiled bite-
• No mixed textures (e.g., sized pieces of vegetables
thick and thin) such as that are tender
cereal in milk or Cereals that are fully
separation of liquid from softened with excess liquid
food (e.g., watermelon). • drained away
• Pancakes with syrup
7: • Normal foods of soft, • Tender meats and fish
Regular tender texture. • Fruit soft enough to break
and • May include thin and apart into smaller pieces
easy to thick textured food and • Steamed or boiled
chew liquids together (e.g., soup vegetables until tender
with solids). • Cereal with texture
• Foods may range in size; softened
no size limit or • Rice
recommendation.
• Can be cut or broken apart
easily with the side of a
fork or spoon. A knife is
not required to cut this
food.
• Can bite off pieces of
food.
Eliminates hard, tough,
chewy, fibrous, stringy
• foods with seeds or
gristle.
7: • Normal with various • All foods included
Regular textures.
• Size not restricted.
• Includes hard, tough,
chewy, fibrous, stingy,
dry, crispy, crunchy, or
crumbly bits.
• Includes foods that
contain seeds or husks.
• Includes mixed
consistency foods.
Viscosity
the condition of being resistant to flow; having a heavy, gluey quality.
Figure 19.2 ▲ International dysphagia diet: Simplified version of food

and liquid levels. (Source: The International Dysphagia Diet ‐
Standardisation Initiative 2016 https://iddsi.org/framework)
Figure 19.3 ▲ International dysphagia diet: Characteristics and testing
information for liquids. (Source: The International Dysphagia Diet
Figure 19.4 ▲ International dysphagia diet: Characteristics and testing
information for foods. (Source: The International Dysphagia Diet
Promoting Intake
Meeting nutrient and fluid needs is a challenge in clients with dysphagia.
• Texture modifications often dilute the nutritional value of the diet
and make food and beverages less appealing.
• Emotionally, dysphagia can affect quality of life; clients with
dysphagia may feel panic at mealtime, avoid eating with others, and
stop eating even when they still feel hungry.
• Acceptability of pureed food is a common concern. Pureed foods
can be molded into the appearance of “normal” food by using
commercial thickeners and molds designed for pureed foods (Fig.
19.5). Molded food may (Farrer et al., 2016) or may not (Lepore et
al., 2014) be preferred over scooped pureed food.
• Various feeding techniques that may facilitate safe swallowing are
listed in Box 19.2.
Figure 19.5 ▲ Examples of pureed and molded foods.
BOX Various Feeding Techniques to Facilitate

19.2 Safe Swallowing
Depending on the client’s level of impairment, do the following:
• Serve small, frequent meals to help maximize intake.

• Encourage clients to rest before mealtime. Postpone meals if the client
is fatigued.
• Position the client in a 90° upright position.
• Give mouth care immediately before meals to enhance the sense of
taste.
• Instruct the client to think of a specific food to stimulate salivation. A
lemon slice, lemon hard candy, or dill pickles may also help to trigger
salivation, as may moderately flavored foods.
• Reduce or eliminate distractions at mealtime.
• Limit disruptions, if possible, and do not rush the client; allow at least
30 minutes for eating.
• If the client has one-sided facial weakness, place the food on the other
side of the mouth. Tilt the head forward to facilitate swallowing.
• Use adaptive eating devices, such as built-up utensils and mugs with
spouts, if indicated. Syringes should never be used to force liquids into
the client’s mouth because this can trigger choking or aspiration.
Unless otherwise directed, do not allow the client to use a straw.
• Encourage small bites and thorough chewing.
• When possible, offer foods that are naturally at the appropriate texture
for the client’s ability, such as yogurt, applesauce, and puddings.
• Ensure the client remains sitting upright for 15 to 20 minutes after
eating.
• Consider oral nutrition supplements in the appropriate texture, as
needed.
• Discourage the client from consuming alcohol because it reduces
cough and gag reflexes.
Fluid Intake
Thickened beverages are often poorly accepted, making it difficult to
maintain an adequate fluid intake. Potential complications include
dehydration, decreased compliance with swallowing guidelines, and
decreased quality of life.
The Frazier Free Water Protocol allows certain clients with dysphagia
the option to consume water in between meals.
• A recent systematic review of mostly rehabilitation clients with
oropharyngeal dysphagia who required thickened liquids or were to
remain NPO found that the free water protocol did not result in
increased risk of having lung complications and that fluid intake
may increase (Gillman et al., 2017).
• Large-scale studies are needed to evaluate the advantages and
disadvantages of the free water protocol in the acute care settings
(Kenedi et al., 2019).
Recall Bertha. The speech-language pathologist has

recommended that Bertha be placed on a diet of level 4
pureed foods and level 3 moderately thick liquids. She
refuses to eat “baby” food and will not drink thickened
liquids. What foods are the appropriate texture in their
normal state? Can Bertha meet her nutrient requirements
from these foods alone without consuming foods in pureed
form? She desperately wants a cup of black tea. How would
you respond to her request for tea?
Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) occurs when gastric contents
back up into the esophagus or mouth, producing the common symptoms of
heartburn, regurgitation, and chest pain. Approximately 20% of American
adults experience at least weekly symptoms of GERD, making it the most
prevalent GI disorder in the United States (Richter & Rubenstein, 2018).
Quality of life is impaired when GERD affects daily functioning and sleep.
GERD can lead to dysphagia, bleeding from erosive esophagitis,
esophageal adenocarcinoma, and Barrett’s esophagus (Richter &
Rubenstein, 2018). The frequency and severity of heartburn do not correlate
with the degree of esophageal damage (Richter & Rubenstein, 2018).
Gastroesophageal Reflux Disease (GERD)

the backflow of gastric acid into the esophagus; GERD occurs when symptoms of reflux happen
two or more times a week.
Proton pump inhibitors (PPIs) are the main drug therapy for GERD, but
recent observations associating their use with increased risk of acute and
chronic kidney disease, Clostridium difficile infection, dementia, rebound
gastric acid hypersecretion, and osteoporotic fractures emphasize the
importance of nondrug therapies (Sethi & Richter, 2017), namely, lifestyle
and nutrition therapy.
Nutrition Therapy for Gastroesophageal Reflux Disease

Clients with GERD are often advised to adhere to the following nutrition
therapy and lifestyle recommendations. Box 19.3 features a simplified list.
• Avoid certain items known to trigger symptoms: citrus, alcohol, and
carbonated beverages.
• Eliminate any foods not tolerated.
• Anecdotally, GERD symptoms are linked to eating fat,
nonvegetarian foods; fried foods; and chocolate; however,
objective studies showing clinical improvement in GERD
symptoms from eliminating these foods are lacking (Sethi &
Richter, 2017).
• Although coffee is often blamed for causing GERD symptoms, a
meta-analysis found no significant association between coffee
intake and GERD symptoms (Kim et al., 2014).
• Encourage clients to keep a food record to identify particular
foods not tolerated.
• Lose weight if overweight.
• Epidemiologic data show that obesity is an important risk factor
for GERD (Chang & Friedenberg, 2014).
• Clients with increased body mass index (BMI) have been found
to have more acid reflux, more severe and more frequent reflux
symptoms, and endoscopic findings of erosive esophagitis (Ness-
Jensen et al., 2016).
• Weight gain of as little as 3.5 BMI units is associated with a
threefold increase risk of developing reflux symptoms (de Bortoli
et al., 2016). Furthermore, a 10% weight loss was associated with
significant decrease in reflux symptoms.
• Regular aerobic physical activity may help in the management of
GERD (Sethi & Richter, 2017).
• Additional lifestyle interventions that may reduce symptoms are to
(Sethi & Richter, 2017)
• avoid meals within 3 hours of lying down,
• avoid nighttime snacking, and
• elevate the head of the bed during sleep.
BOX Nutrition and Lifestyle Modifications for

19.3 Gastroesophageal Reflux Disease
• Avoid certain foods known to trigger symptoms: citrus, alcohol, and

carbonated beverages.
• Engage in aerobic physical activity regularly.
• Avoid meals within 3 hours of lying down.
• Avoid nighttime snacking.
• Elevate the head of the bed during sleep.
The client with GERD should not lie down for at least 3 hours after
eating. Instead, the client should be encouraged to eat small meals as
a way to help control their GERD symptoms.
DISORDERS OF THE STOMACH
Peptic ulcer disease (PUD), gastroparesis, and gastrectomy are disorders of

the stomach that use nutrition therapy to help control symptoms.
Peptic Ulcer Disease

The majority of peptic ulcers occur in the stomach or proximal duodenum.
The main risk factors for both gastric and duodenal ulcers are Helicobacter
pylori infection and the use of nonsteroidal antiinflammatory drugs
(NSAIDs). However, most people infected with H. pylori or using NSAIDs
do not develop the disease, which indicates that individual susceptibility is
important (Kuna et al., 2019). H. pylori appears to secrete an enzyme that
depletes gastric mucus, making the mucosal layer more susceptible to
erosion. For these clients, eradicating the bacteria—typically with a
combination of antibiotics and acid-suppressing drugs—generally cures the
ulcer. Eating spicy food does not cause ulcers.
Peptic Ulcer
erosion of the GI mucosal layer caused by an excess secretion of, or decreased mucosal resistance
to, hydrochloric acid and pepsin.
The most common symptom of peptic ulcers is epigastric pain, which is

described as gnawing or burning that is usually worse at night or when the
stomach is empty. However, not all people with peptic ulcers experience
epigastric pain. Less frequent symptoms include bloating, early satiety, and
nausea. The most common and severe complication of PUD is GI bleeding,
which can be life threatening. From a nutritional standpoint, pain or early
satiety may impair intake and lead to weight loss. Blood loss can lead to
iron deficiency. Long-term use of medications to decrease gastric acid
production may impair the absorption of calcium, iron, and vitamin B12.
Nutrition Therapy for Peptic Ulcer Disease

Nutrition and diet have not been found to play a role in causing or
preventing peptic ulcers (National Institute of Diabetes and Digestive and
Kidney Diseases, 2014).
• Although certain foods can increase production of stomach acid,
good evidence that they worsen peptic ulcers is lacking.
• As with GERD, clients are advised to avoid any foods not
individually tolerated. Commonly avoided foods include black
pepper, caffeine, coffee (decaffeinated and regular), tea
(decaffeinated and other), mint, chocolate, and tomatoes.
• Probiotics may be a helpful adjunct to antibiotic therapy in
eradicating H. pylori (Boltin, 2016). However, the optimal species
and treatment dosage are not known.
• Alcohol and smoking do contribute to ulcers and should be avoided.
Gastroparesis
Gastroparesis, or delayed gastric emptying, is a chronic motility disorder of
the stomach that can cause nausea, vomiting, bloating, early satiety, and
upper abdominal pain (Camilleri et al., 2013). Symptoms vary greatly
among individuals and can come and go over time. Potentially life-‐
threatening complications include electrolyte imbalances, dehydration,
malnutrition, and poor glycemic control. Quality of life can be greatly
affected. Although gastroparesis is most commonly associated with
diabetes, it may also occur secondary to gastric bypass surgery, neurologic
and connective tissue disorders (e.g., Parkinson’s disease, multiple
sclerosis, scleroderma), post–viral syndrome, or may be idiopathic.
Nutrition Therapy for Gastroparesis

Gastroparesis can lead to poor oral intake, an inadequate calorie intake, and
micronutrient deficiencies (Camilleri et al., 2013). The goal of nutrition
therapy is to maintain an adequate oral intake. Clients may be advised to do
the following (Parrish & McCray, 2011; University of Virginia Digestive
Health Center, 2017):
• Consume smaller, more frequent meals. Four to eight meals per day
may be necessary to achieve an adequate intake.
• Consume more liquid calories because emptying of liquids is often
preserved in gastroparesis even when solid emptying is impaired.
• Tolerance for solid food may deteriorate as the day progresses,
making liquids a better option as the day progresses.
• Pureed foods (e.g., solid food pureed with milk or broth) or oral
nutrition supplements may serve as an important source of
calories and protein.
• Consume solid foods that are low in fat if fat in solid food worsens
symptoms. Fat in liquids is often well tolerated and can be a
valuable source of calories and nutrients. Limit foods high in fibers
because they may delay gastric emptying and promote bezoar
formation, particularly if the client has a history of bezoar
formation. Foods to avoid include bran and whole grain cereals, nuts
and seeds, fruits (e.g., apples, berries, oranges, kiwi, coconut, figs),
dried fruits, certain vegetables (e.g., green beans, peas, broccoli,
brussels sprouts, corn, potato peels, sauerkraut, tomato skins), and
popcorn.
• Avoid carbonated beverages, which can aggravate gastric distention.
• Chew foods thoroughly, especially meats.
• Sit upright for at least 1 hour after eating.
• Control blood glucose levels if client has diabetes.
• Avoid alcohol and smoking because both can alter gastric emptying.
• Enteral (jejunal feeding) or parenteral nutrition may be necessary in
severe gastroparesis.
Bezoar
a solid mass of indigestible material that may become trapped in the stomach, although it can also
occur in the small intestine.
Consider Bertha. She has experienced gastroparesis

intermittently for years. Nausea, vomiting, and pain are her
most common symptoms. She continues to have symptoms
of gastroparesis while on a pureed diet with moderately
thick liquids. What other interventions may help reduce
Bertha’s symptoms? What are nutritional concerns with
prolonged vomiting related to gastroparesis?
Gastrectomy
Gastrectomy is the surgical removal of part or all of the stomach, which
may be done to treat malignancy, refractory PUD, or GI bleeding. Similar
components of gastrectomy surgeries are used in bariatric surgeries, which
are surgeries to treat obesity (see Chapter 17). Partial gastrectomies leave a
portion of the stomach that is then surgically connected to the duodenum or
jejunum. Total gastrectomies remove all of the stomach so that the lower
esophagus connects directly to the small intestine. With either type of
gastrectomy, a smaller or absent stomach increases the risk of
malabsorption due to rapid gastric emptying and shortened transit time.
A common complication after gastric surgery is dumping syndrome.
Rapid emptying of stomach contents into the intestine causes fluid from the
plasma and extracellular fluid to shift into the intestines to dilute the
hyperosmolar bolus. The large volume of hypertonic fluid in the jejunum
and an increase in peristalsis lead to cramping, diarrhea, and abdominal
pain. Weakness, dizziness, and tachycardia occur as the volume of
circulating blood decreases. These symptoms occur within 10 to 20 minutes
after eating and characterize the early dumping syndrome.
An intermediate dumping reaction occurs 20 to 30 minutes after eating
as undigested food is fermented in the colon, producing gas, abdominal
pain, cramping, and diarrhea (Academy of Nutrition and Dietetics, 2020).
Malabsorption of calories and nutrients produces weight loss and increases
the risk of malnutrition. Malabsorption of micronutrients may lead to iron
deficiency anemia, vitamin B12 deficiency, and bone disease.
Late dumping syndrome occurs 1 to 3 hours after eating and is
especially common after consuming simple sugars (Academy of Nutrition
and Dietetics, 2020). The rapid absorption of carbohydrate causes a quick
spike in blood glucose levels; the body compensates by oversecreting
insulin. Blood glucose levels drop rapidly, and symptoms of hypoglycemia
develop, such as shakiness, sweating, confusion, and weakness.
Nutrition Therapy for Clients with Dumping Syndrome

Nutrition intervention can control or prevent symptoms of dumping
syndrome. Unlike most initial postoperative feedings, clear liquid diets are
not used because sugars contribute to the concentration of particles entering
the intestine.
• Clients begin oral feedings with sips of water and broth.
• After tolerance is established, an anti-dumping regimen is followed
(Box 19.4).
• Over time, the diet is liberalized as the remaining portion of the
stomach or duodenum hypertrophies to hold more food and allows
for more normal digestion.
• Liquid multivitamin and mineral supplements are recommended,
and vitamin B12 injections, nasal gel spray, or oral supplements may
be necessary depending on the extent of surgery.
• Clients who are unable to tolerate the normal diet progression may
require nutrition support.
BOX
Anti-Dumping Syndrome Diet Guidelines
19.4
Diet Guidelines
• Clients are started on small, frequent meals consisting of only one or
two foods per meal or snack, one of which is a protein. Protein is
consumed at each feeding because it slows gastric emptying.
• Food must be thoroughly chewed.
• Liquids are provided 30 minutes to 1 hour after consuming solids, not
with meals, because they promote quick movement through the GI
tract.
• Items avoided include
• foods containing simple sugars such as sweet desserts, candy,
sweetened beverages, canned fruit in heavy syrup, sweetened
yogurt, ice cream, sherbet,
• foods containing sugar alcohols (e.g., sorbitol, xylitol), such as
dietetic candy, sugarless gum and mints, and certain fruits (apples,
pears, peaches, prunes),
• gassy vegetables such as broccoli, cauliflower, cabbage, and corn,
• fried meats, fish, and poultry; high fat luncheon meats, sausage, hot
dogs, and bacon; tough or chewy meats; dried peas and beans; nuts,
• high-fiber foods,
• carbonated beverages, caffeinated beverages, alcohol, and
• lactose.
• Clients are advised to lie down after eating.
• Functional fibers, such as pectin and guar gum, may be used to delay
gastric emptying and treat diarrhea (Academy of Nutrition and
Dietetics, 2020).
Recommended Foods
• Breads and cereals: refined plain breads, crackers, rolls, unsweetened

cereal, rice, and pasta that provide <2 g fiber per serving.
• Vegetables: well-cooked or raw vegetables without seeds or skins,
strained vegetable juice, lettuce.
• Fruits: banana, soft melons, unsweetened canned fruit.
• Milk and milk products: lactose-free and unsweetened 1% or fat-free
yogurt, and milk alternatives (e.g., plain soy milk).
• Meat and meat alternatives: tender, well-cooked meat, fish, poultry,
egg, and soy without added fat; smooth nut butters.
• Fats: oils, butter, margarine, cream cheese, mayonnaise.
• Beverages: decaffeinated coffee and tea; sugar-free soft drinks.
• Other: allowed foods made with artificial sweeteners such as
NutraSweet, sucralose, acesulfame potassium.
Sample Menu (When Recovered Enough to Eat Six Times a

Day)
Breakfast
1 poached egg
1 slice white toast with butter
1 hour later: 1 cup decaffeinated coffee with half and half
Mid-Morning Snack
1 cup plain lactose-free yogurt
1 hour later: 1 cup plain unsweetened soy milk
Lunch
½ cup lactose-free cottage cheese with two unsweetened, canned peach
halves
dinner roll with butter
1 hour later: 8 oz sugar-free ginger ale
Mid-Afternoon Snack
2 oz cheddar cheese
4 saltine crackers
Dinner
3 oz baked chicken
½ cup white rice with butter
½ cup cooked carrots with butter
1 hour later: caffeine-free tea
Bedtime Snack
1 cup lactose-free yogurt without added sugar
NURSING
PROCESS Gastroesophageal Reflux
Disease
Jason is 28 years old and complains of frequent painful heartburn. He

takes antacids on a daily basis and has lost 14 pounds over the past few
months. His strategy to avoid pain is to avoid eating. He is 5 ft 8 in. tall,
currently weighs 170 pounds, and has an appointment to see his doctor.
In the meantime, he has come to you, the corporate nurse on staff where
he works, to see what he can do to help control his heartburn.
Assessment
Assessment
Medical– • medical history that would contribute to GERD,
Psychosocial such as hiatal hernia
History • symptoms that may affect nutrition, such as
difficulty swallowing or nausea and vomiting
• use of medications that may decrease lower
esophageal sphincter pressure, such as
anticholinergic agents, diazepam, or theophylline
• use of medications that may damage the mucosa,
such as NSAIDs or aspirin
• history of smoking
• level of activity
Anthropometric BMI, weight loss percentage
Assessment
Biochemical abnormal lab values, if available, especially
and Physical hemoglobin and hematocrit because low values may
Assessment indicate bleeding
Assessment
Dietary • How many meals do you eat daily?
Assessment • Would you say your meals are small, medium, or
large in size?
• Are there any particular foods that cause
heartburn, especially alcohol, coffee, tea, caffeine,
pepper, mint, chocolate, or fatty foods?
• What foods do you avoid?
• Can you correlate your symptoms to
• lying down after eating?
• wearing tight clothes?
• eating right before bed?
• Do you take vitamins, minerals, herbs, or other
supplements?
• Do you have ethnic, religious, or cultural food
preferences?
Analysis
Possible Malnutrition risk related to avoidance of eating to
Nursing avoid post-prandial heartburn, as evidenced by a 14-
Analysis pound weight loss
Planning
Outcomes
• report relief from symptoms,
• consume adequate calories and nutrients,
• use less medication to control symptoms,
• explain nutrition and lifestyle modifications for
controlling GERD symptoms, and
• exhibit normal laboratory values.
Assessment
Nutrition
Therapy • Eat a balanced eating pattern that promotes
healthy weight loss to achieve BMI of <25.
• Avoid items known to trigger symptoms: citrus,
alcohol, carbonated beverages.
• Avoid eating within 3 hours of bedtime.
• that nutrition interventions may help control

symptoms but do not treat the underlying
problem,
• to avoid citrus, alcohol, and carbonated
beverages,
• to keep a food journal so food intolerances can be
identified and avoided,
• to lose weight gradually to achieve a healthy
weight of BMI <25,
• on lifestyle modifications that may help improve
symptoms, such as elevating the head of the bed,
not eating within 3 hours of bedtime, and
engaging in regular physical activity.
Evaluation
Evaluate and
Monitor • Monitor for improvement in symptoms.
• Evaluate adequacy and appropriateness of intake.
• Monitor weight.
• Monitor for medication usage.
How Do You Respond?
Are there any foods that can treat heartburn?
Evidence linking the use of specific foods with relief of
heartburn is largely anecdotal, but as long as the use of
natural remedies does not preclude necessary medical
treatment, there is little risk in trying unproven food
remedies. Such unproven remedies include consuming
probiotics, vinegar, coconut water, almonds, and teas such
as ginger and persimmon. Clients who are on long-term
PPI therapy should not suddenly discontinue drug
treatment; gradual tapering and doctor supervision are
advised.
REVIEW CASE STUDY
Barbara is a 72-year-old woman with a “type A” personality who was

diagnosed with a peptic ulcer more than 40 years ago. At that time, her
doctor told her to follow a bland diet and eat three meals per day with three
snacks per day of whole milk to “quiet” her stomach. She meticulously
complied with the diet to the point of becoming obsessive about not eating
anything that may not be “allowed.” She lost 15 pounds by following the
bland diet because her intake was so restricted. She recently began
experiencing ulcer symptoms and has put herself back on the bland diet,
convinced it is necessary in order to recover from her ulcer.
Yesterday, she ate the following as shown on the right:
• Barbara’s 1600-calorie MyPlate plan calls for 1.5 cups of fruit, 2 cups of
vegetables, 5 grains, 5 oz of meat/beans, 3 cups of milk, and 5 teaspoons
of oils. How does her intake compare? What food groups is she
undereating? Overeating? What are the potential nutritional
consequences of her current diet?
• What other information would be helpful for you to know in dealing with
Barbara?
• Barbara clearly wants to be on a bland diet. What would you tell her
about diet recommendations for PUD? What recommendations would
you make to improve her symptoms and meet her nutritional
requirements while respecting her need to follow a “diet”?
Breakfast: 1 poached egg, 2 slices dry white toast, 1 cup whole milk
Morning Snack: 1 cup whole milk
Lunch: three fourths cup cottage cheese with one half cup canned
peaches
Afternoon snack: 1 cup whole milk
Dinner: 3 oz boiled chicken, one half cup boiled plain potatoes, one half
cup boiled green beans, one half cup gelatin
Evening snack: 1 cup whole milk
STUDY QUESTIONS
1 The client asks if coffee is bad for their peptic ulcer. Which of the
following is the nurse’s best response?
a. “Coffee does not cause ulcers and drinking it probably does not
interfere with ulcer healing. You may try eliminating it from your diet
to see what impact it has on your symptoms and then decide whether
or not to avoid it.”
b. “Both caffeinated and decaffeinated coffee can cause ulcers and
interfere with ulcer healing. You should eliminate both from your
diet.”
“You need to eliminate caffeinated coffee from your diet, but it is safe
c. to drink decaffeinated coffee.”
d. “You can drink all the coffee you want; it does not affect ulcers.”
2 Which of the following statements indicates that the client needs further
instruction about GERD?
a. “I know a bland diet will help prevent the heartburn I get after eating.”
b. “Lying down after eating can make GERD symptoms worse.”
c. “Carbonated beverages can trigger GERD symptoms.”
d. “Losing excess weight can help prevent symptoms of GERD.”
3 Which of the following snacks would be best for a client who wants to
eat but is experiencing nausea?
a. cheese
b. peanuts
c. banana
d. a milkshake
4 The nurse knows their instructions have been effective when the client
with dumping syndrome verbalizes they should
a. avoid lying down after eating.
b. drink liquids between, not with, meals.
c. consume foods sweetened with sugar alcohols (e.g., sorbitol or xylitol)
instead of sugar.
d. avoid protein.
5 A client with dumping syndrome asks why it is so important to avoid
sugars and sweets. Which of the following is the nurse’s best response?
a. “Sugars and sweets provide empty calories, so they should be limited
in everyone’s diet.”
b. “Sugars draw water into the intestines and cause cramping and
diarrhea.”
c. “Sugar should be avoided because it promotes inflammation and
delays healing.”
d. “Avoiding sugars and sweets helps ensure that they will not displace
the intake of protein, which you need for healing.”
6 Which of the following foods is not appropriate for a client on a level 4
pureed diet?
a. vanilla yogurt
b. regular scrambled eggs
c. smooth hummus
d. chocolate pudding
7 What is the characteristic of level 2 mildly thick liquid?
a. It is thicker than water but can flow through a standard straw.
b. It drips slowly in dollops through the prongs of a fork.
c. It holds its shape on a spoon.
d. It is “sippable” from a cup but takes effort to drink through a standard
straw.
8 The best dessert for a client with gastroparesis is
a. chocolate cake
b. strawberry shortcake
c. blueberry pie
d. angel food cake

Clients with Upper Gastrointestinal Tract
Disorders
Nutrition therapy for GI disorders may help minimize or prevent
symptoms. For some GI disorders, nutrition therapy is the cornerstone of
treatment.
Disorders That Affect Eating
Anorexia is the lack of appetite. Small, frequent meals, limiting fat intake,
and seasoning food to taste may help improve appetite.
Nausea and vomiting can cause fluid and electrolyte imbalance in the
short term and dehydration and weight loss in the long term. Intake may
improve with
• good oral hygiene,

• limiting liquids with meals but otherwise encouraging a liber fluid
intake,
• serving room-temperature or cold foods, and
• avoiding high-fat foods.
Disorders of the Esophagus

Dysphagia is an impairment in the swallowing process. Modifying the
texture of food and consistency of liquids promotes safe and efficient
swallowing. The international dysphagia diet defines the levels of food and
liquids and describes objective tests to ensure proper texture and
consistency.
GERD occurs when gastric contents back up into the esophagus.
• Clients should
• avoid citrus, alcohol, carbonated beverages, and any other food not
individually tolerates,
• lose weight if overweight,
• engage in regular aerobic physical activity,
• refrain from eating within 3 hours of bedtime, and
• elevate the head of the bed during sleep.
Disorders of the Stomach

PUD is caused by H. pylori bacteria or nonsteroidal inflammatory
medication use, not by food.
• Clients should avoid any foods not tolerated, smoking, and alcohol.
• Probiotics may help, but further research is needed.
Gastroparesis is a chronic motility disorder that can cause nausea,
vomiting, early satiety, and pain. Nutrition therapy recommendations
include
• eating small frequent meals and limiting fat in solid foods if not
tolerated,
• consuming more liquid calories because emptying of liquids is often
preserved in gastroparesis even when solid emptying is impaired,
• limiting fiber and foods that contribute to bezoar formation,

• chewing foods thoroughly, and
• avoiding alcohol and smoking.
Gastrectomy can cause dumping syndrome after eating. Symptoms
may improve by
• eating small meals,
• avoiding liquids with meals and afterward,
• avoiding simple sugars and sugar alcohols, and
• eating protein at each meal.
Figure sources: shutterstock.com/Photographee.eu, shutterstock.com/zstock, shutterstock.com/Brent
Hofacker

book at
Websites
American Gastroenterological Association at www.gastro.org
The Helicobacter Foundation at www.helico.com
National Digestive Diseases Information Clearinghouse (NDDIC), a service of the National Institute
of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health at
http://digestive.niddk.nih.gov
Nutrition Issues in Gastroenterology at https://practicalgastro.com/category/disorders/nutrition/
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with Disorders of the
Chapter Lower Gastrointestinal
20 Tract and Accessory
Organs
Stephanie Schlau
Stephanie is an 18-year-old college freshman who
was diagnosed with type 1 diabetes 12 years ago. She
has an insulin pump, is of healthy weight, and has no
other significant medical history. She went to the
student health center on campus with complaints of
fatigue, abdominal cramping, and diarrhea.
Learning Objectives
1 Modify a regular diet to be high in fiber.

2 Instruct a client on the nutrition therapy recommendations for diarrhea.
3 Give examples of appropriate nutrition interventions for various
symptoms and complications of malabsorption syndrome.
4 Modify a regular diet to be low in lactose.
5 Identify sources of gluten.
6 Discuss nutrition interventions for clients with short bowel syndrome.
7 Describe nutrition interventions for a nonalcoholic liver disease.
Summarize nutrition therapy interventions recommended for clients with
8 cirrhosis.
9 Compare a low-fat diet to a regular diet.
The lower gastrointestinal (GI) tract consists of the small and large
intestines, rectum, and anus. Most nutrient absorption occurs in the first 100
cm of the jejunum; B12 and bile salts are absorbed in the last 100 cm of the
ileum; magnesium is absorbed in the terminal ileum and proximal colon;
and fluid and sodium absorption occurs throughout the bowel (fig 20.1).
The large intestine is primarily responsible for water and electrolyte
absorption and the elimination of solid wastes. The accessory organs—liver,
gallbladder, and pancreas—are involved in nutrient metabolism or
digestion. With many disorders of the lower GI tract and accessory organs,
nutrition therapy is used to improve or control symptoms; replenish losses;
and promote healing, if applicable. For one GI disorder, celiac disease,
nutrition therapy is the sole mode of treatment.
Figure 20.1 ▲ The sites of nutrient absorption.

This chapter presents nutrition therapy for altered bowel elimination,
malabsorption syndromes, disorders of the large intestine, and disorders of
the accessory organs. Box 20.1 lists nutrition-focused assessment criteria
for lower GI disorders.
BOX Nutrition-Focused Assessment for Lower

20.1 Gastrointestinal Disorders
• GI symptoms that interfere with intake

• anorexia
• early satiety
• pain
• abdominal distention
• Changes in eating made in response to symptoms
• Complications that affect nutritional status
• weight loss
• diarrhea
• blood loss
• Usual pattern of eating and frequency of meals and snacks
• Weight, weight stability
• Use of the following:
• tobacco
• over-the-counter drugs for GI symptoms
• alcohol
• caffeine
• Food allergies or intolerances, such as high-fat foods, milk, and high-
fiber foods
• Use of nutritional supplements:
• vitamins
• minerals
• fiber
• herbs
• Client’s willingness to change their eating habits
ALTERED BOWEL ELIMINATION
Constipation
Criteria for diagnosing constipation include having fewer than three bowel
movements per week, passing stools that are hard, and excessive straining
during defecation. Inadequate fiber intake, physical inactivity, and low food
intake increase the risk of constipation. Constipation can occur secondary to
irregular bowel habits, psychogenic factors, chronic laxative use, metabolic
and endocrine disorders, and bowel abnormalities (e.g., tumors, hernias,
strictures). Certain medications, such as analgesics that contain opiates,
antidepressants, diuretics, aluminum hydroxide, and iron and calcium
supplements, cause constipation. Contrary to popular belief, daily bowel
movements are not necessary provided the stools are not hard and dry.
Nutrition Therapy for Constipation

To treat constipation, it is standard practice to recommend that fiber intake
be increased (Box 20.2).
BOX
High-Fiber Diet
20.2
• A high-fiber diet is a regular diet that substitutes whole grains for

refined grains and is high in other fiber-rich foods—namely, fresh
fruits, vegetables, and dried peas and beans.
• Unprocessed bran and bran-based cereals may be added as tolerated.
• A high-fiber diet is used for constipation and diverticulosis. It may
also promote weight loss and helps lower serum cholesterol levels and
improve glucose tolerance in diabetes.
• All healthy Americans are urged to increase their intake of fiber.
• The diet should not be used in cases of intestinal inflammation or
stenosis, postgastrectomy, or pseudo-obstruction.
Guidelines to Achieve a High-Fiber Diet

• Substitute whole grains for refined grains.
Use In place of
Whole wheat bread White bread
Brown rice White rice
Whole wheat pasta White pasta
Bran or whole-grain cereal Refined cereals
Whole wheat flour White flour
• Eat more dried peas or beans.
• Eat more fresh fruit; leave the skin on whenever possible. Apples,
blackberries, blueberries, figs, dates, kiwifruit, mango, oranges, pears,
prunes, strawberries, and raspberries are high-fiber fruits
• Eat more vegetables. Cooked asparagus, green beans, broccoli,
Brussels sprouts, cabbage, carrots, celery, corn, eggplant, parsnips,
peas, snow peas, Swiss chard, and turnips are good choices.
• Other foods with fiber include popcorn, nuts, sunflower seeds, and
sesame seeds.
Sample Menu
Breakfast Lunch Dinner Snacks
Prune juice Split pea soup Roast chicken Low-fat popcorn
Bran flakes with Ham sandwich Brown rice Dried fruits and
milk on whole nuts
Whole wheat wheat bread Tossed salad Raw carrots and
toast with with lettuce with fresh celery with
jelly and tomato vegetables dip
Fresh orange Fresh Steamed
sections strawberries broccoli
Date cookie Whole wheat
Milk roll with
butter
Milk
Blueberries over
ice cream
Potential Problems Recommended Interventions
Flatus, distention, cramping, and Initiate a high-fiber diet gradually
osmotic diarrhea related to to develop the client’s tolerance. If
increasing fiber content of the diet symptoms of intolerance persist,
too much or too quickly reduce fiber content to maximum
amount tolerated by the client.
Client Teaching
Instruct the client on the following:
• A variety of foods high in fiber should be eaten; numerous forms of
fiber exist, and each performs a different action in the body (see
Chapter 3).
• A diet rich in insoluble fiber increases stool bulk and speeds passage
of food through intestines.
• Increasing fiber intake gradually may be better tolerated than
increasing fiber intake quickly.
• Fiber intake may be increased by making subtle changes in eating and
cooking habits such as eating more fresh fruits and vegetables,
especially with the skin on.
• Whole wheat bread should be eaten instead of “wheat” bread
whenever possible. Ingredient labels that include enriched wheat flour
are not 100% whole wheat.
• Wheat bran cereals are not truly “whole wheat” because they contain
only the bran portion of the wheat kernel; but they are very high in
fiber.
• Coarse, unprocessed wheat bran, also called Miller’s bran, can be
incorporated into the diet by mixing it with juice or milk; by adding it
to muffins, quick breads, casseroles, and meat loaves before baking; or
by sprinkling it over cooked cereals, applesauce, eggs, or other foods.
• Wheat bran should be added to the diet gradually (up to 3 tbsp/day) to
decrease the likelihood of developing flatus and distention.
• A meatless main dish made with dried peas and beans is a high-fiber
alternative to traditional entrées.
• Snacks of fresh or dried fruits, nuts, and seeds provide fiber.
• Certain foods (in addition to being high in fiber) have laxative effects:
prunes and prune juice, figs, and dates.
• At least eight 8 oz glasses of fluid should be consumed daily.
• Fiber increases stool weight, bulk, and fecal water content and
stimulates peristalsis to promote a more rapid transit time.
• Insoluble fiber found in whole grains, bran, and the skins and seeds
of fruit and vegetables is more effective at treating constipation than
soluble fiber.
• Although a goal of 25 to 38 g/day, which is the adequate intake for
fiber, may be recommended, those levels are based on the amount of
fiber needed to protect against coronary heart disease, not for
optimal bowel function. The amount of fiber needed to alleviate
constipation varies among individuals and is usually determined by
trial and error.
• A gradual increase in fiber is recommended to avoid symptoms of
intolerance such as gas, cramping, and diarrhea. If these side effects
do occur, they are usually temporary and subside within several
days.
• To achieve maximum benefit, fiber intake should be spread
throughout the day.
Fiber supplements, such as Metamucil, Fiberall, and Citrucel, may
• be necessary if adequate fiber cannot be consumed through food.
Other interventions to promote bowel regularity include the following:
• ensuring an adequate fluid intake of at least 64 oz/day; without
enough water, a high-fiber diet can worsen constipation, abdominal
pain, bloating, and gas (Academy of Nutrition and Dietetics [AND],
2020)
• increasing aerobic exercise
• consuming probiotics or prebiotics daily, such as yogurt containing
live bacterial cultures, acidophilus milk, and kefir
Probiotics
live microorganisms found in food that, when consumed in adequate amounts, are beneficial to
health.
Prebiotics
nondigestible food components that stimulate the growth of probiotic bacteria within the large
intestine.
Diarrhea
Diarrhea is a common symptom of many GI disorders, infectious diseases,
and antibiotic use (Box 20.3). It is also a frequent side effect of
chemotherapy and radiation. Diarrhea is characterized by an increase in the
frequency of bowel movements and/or water content of stools, which alters
either the consistency or volume of fecal output. A rapid transit time
decreases the time available for water, sodium, and potassium to be
absorbed through the colon; the result is more water and electrolytes in the
stools and the potential for dehydration, hyponatremia, hypokalemia, acid–
base imbalance, and metabolic acidosis. Chronic diarrhea can lead to
malnutrition related to impaired digestion, absorption, and intake.
Types of Diarrhea and their causes

BOX
20.3
Osmotic Diarrhea
Osmotic diarrhea occurs when there is an increase in particles in the
intestine, which draws water in to dilute the high concentration.
• Causes include maldigestion of nutrients (e.g., lactose intolerance),

excessive intake of sorbitol or fructose, dumping syndrome, tube
feedings, and some laxatives.
• Treating the underlying cause cures osmotic diarrhea.
Secretory Diarrhea
Secretory diarrhea is related to an excessive secretion of fluid and
electrolytes into the intestines.
• Causes include bacterial, viral, protozoan, and other infections; certain

medications; and some GI disorders, such as Crohn’s Disease and
celiac disease.
• An excessive amount of bile acids or unabsorbed fatty acids in the
colon can also cause secretory diarrhea.
• Antibiotics are the primary component of treatment when the cause is
infection.
• Symptoms may be treated with medications that decrease GI motility
or thicken the consistency of stools, such as the soluble fiber psyllium
(Metamucil).
Antibiotic-Acquired Diarrhea
Antibiotic-acquired diarrhea is caused by the disruption in GI microbiota
or irritation to the GI mucosa as a side effect of antibiotic therapy.
• Most cases are mild and self-limiting.

• Overgrowth of Clostridium difficile is the most clinically significant
form; severe cases may cause watery diarrhea of up to 10 to 15
times/day. Pseudomembranous colitis is a severe complication.
Nutrition Therapy for Diarrhea

Nutrition therapy for diarrhea is largely supportive and depends on the
severity of diarrhea and the underlying cause.
• Encourage a liberal fluid intake to replenish losses. Oral rehydration
solutions, such as Pedialyte and Speedlyte, may be used.
• Clear liquids are avoided because they have high osmolality related
to their high sugar content, which may promote osmotic diarrhea.
• Temporary avoidance of foods that stimulate GI motility may
improve diarrhea:
• alcohol
• caffeine
• items high in simple sugars, such as milk (lactose), fruit
(fructose), and carbonated beverages (sucrose)
• high-fiber foods, such as whole grains
• gas-producing foods, such as bran, nuts, beans, corn, broccoli,
and cabbage
• sugar alcohols (e.g., sorbitol in “dietetic” products)
• Probiotics may help lessen diarrhea, especially diarrhea related to
use of antibiotics. Because it is not known which strains or doses of
probiotics may be most beneficial, it may be prudent to obtain
probiotics from food sources, such as yogurt, kefir, and acidophilus
milk, instead of supplements.
• Clients with intractable diarrhea may need complete bowel rest (i.e.,
parenteral nutrition [PN]).
Lactose
the disaccharide (double sugar) in milk composed of glucose and galactose.
Recall Stephanie. Her vital signs and temperature are
within normal limits. The physician assistant diagnoses viral
gastritis and advises her to eat a bland diet until her
symptoms abate. Is a bland diet the best option for
Stephanie? What specific foods would you recommend she
consumes? What foods should she avoid?
MALABSORPTION DISORDERS
Malabsorption occurs secondary to nutrient maldigestion or from

alterations to the absorptive surface of the intestinal mucosa. Generally,
malabsorption related to maldigestion involves one or few nutrients,
whereas malabsorption that stems from an altered mucosa is more
generalized, resulting in multiple nutrient deficiencies and weight loss.
Characteristics of malabsorption vary with the underlying disorder, ranging
from minimal to widespread and serious (Box 20.4).
BOX General Characteristics of

20.4 Malabsorption
• Malabsorption may be suspected in clients who have weight loss,

growth failure, postprandial abdominal pain, bloating, and flatulence.
• Watery diarrhea and distention are symptoms of malabsorption from
carbohydrate maldigestion (e.g., lactose intolerance).
• The passage of less frequent stools that are oily, bulky, and foul
smelling is a symptom of malabsorption related to fat maldigestion
(e.g., pancreatitis).
• The excretion of fat in the stools means that essential fatty acids, fat-
soluble vitamins, and certain minerals are also lost through the stools.
• Nutrient deficiencies can cause metabolic complications, such as
osteomalacia and bone pain related to the deficiencies of calcium,
vitamin D, and magnesium.
• Appetite may be poor, and nutrient needs may be elevated for healing.
• The risk for malnutrition can be high.
Malabsorption
a broad term that describes altered or inadequate nutrient absorption from the GI tract.
The goal of nutrition therapy for malabsorption syndromes is to control

steatorrhea, promote normal bowel elimination, restore optimal nutritional
status, and promote healing, when applicable. Nutrition therapy is
individualized according to symptoms and complications; possible diet
modifications appear in tab 20.1. Specific malabsorption syndromes are
discussed in the following sections—namely, lactose malabsorption,
inflammatory bowel disease (IBD), celiac disease, and short bowel
syndrome (SBS).
Steatorrhea
excess fat in the stools that are loose, foamy, and foul smelling.
Table Nutrition Therapy for

20.1 Malabsorption Symptoms
Dietary
Symptoms Interventions Rationale
Dietary
Anorexia Small, frequent To maximize
meals intake
Oral nutrition Liquid
supplements supplements
are easy to
Enteral consume, are
nutrition if nutritionally
anorexia is dense, and
severe leave the
and/or stomach
prolonged quickly.
To meet calorie
and nutrient
needs until the
client is able to
consume an
adequate oral
intake
Dietary
Diarrhea Low-fiber diet To minimize
Ensure stimulation to
adequate the bowel
fluid and Increased losses
electrolytes. of fluid and
Avoid lactose electrolytes in
the stool
Lactase activity
may be lost
during acute
episodes of
malabsorption
due to altered
integrity and
function of
intestinal villi
cells; lactase
deficiency may
persist into
remission.
Nutrient deficiencies Nutrient-dense To replenish
diet losses, facilitate
healing, and
Vitamin meet increased
supplements; needs related to
water- the metabolism
soluble of a high-
forms of the calorie, high-
fat-soluble protein diet
vitamins Dietary sources
may be may not be
necessary. adequate to
meet need.
Oral, nasal, or
Dietary
parenteral
vitamin B12
Water-soluble
Calcium forms do not
supplements require normal
fat absorption
Other mineral to be absorbed,
supplements as do fat-
soluble
vitamins in
their natural
form.
Bacterial
overgrowth,
pancreatic
insufficiency,
and ileal
disease or
resection
impair vitamin
B12 absorption.
Serum calcium
may be low
related to low
serum albumin
or calcium
malabsorption
related to poor
vitamin D
absorption or
the binding of
calcium with
unabsorbed fats
which forms
Dietary
unabsorbable
soaps.
Magnesium levels
are often low in
some
malabsorption
syndromes;
losses of zinc
are high in
clients with
fistulas.
Steatorrhea Limit fat To avoid
Medium-chain aggravating fat
triglyceride malabsorption
(MCT) oil MCT oil is
may be used absorbed
for calories. without
undergoing
digestion.
Tissue damage (e.g., resulting Increase Calories and
from inflammation or calories protein are
surgery) and/or weight loss (2000–3500 needed to
cal/day) facilitate
Increase healing and
protein (1.2– restore weight.
1.5
g/kg/day)
Dietary
Hyperoxaluria (Calcium Reduce fat Lowering fat
normally binds with oxalate If previous allows more
in the GI tract. Loss of history of calcium
calcium due to fat oxalate available to
malabsorption leaves kidney bind with
increased amounts of oxalate stones exists, oxalate,
available for absorption into limit oxalate rendering it
the blood, resulting in an intake (e.g., unavailable for
increased risk of oxalate tea and absorption
kidney stones in susceptible fruit).
people).
Lactose Malabsorption
Lactose malabsorption refers to impaired lactose digestion and absorption
related to reduced activity of lactase, the enzyme that splits lactose into its
component simple sugars glucose and galactose. Without adequate lactase,
lactose reaches the large intestine, where microbiota ferment the sugar,
which may cause bloating, cramping, flatulence, and diarrhea. Particles of
undigested lactose increase the osmolality of intestinal contents, increasing
the likelihood of osmotic diarrhea. Symptoms range from mild to severe,
depending on the amount of lactase actually produced and the amount of
lactose consumed. The occurrence of symptoms in people with lactose
malabsorption is known as lactose intolerance (Misselwitz et al., 2019).
Lactose malabsorption may be caused by the following:
• congenital lactase deficiency, a rare pediatric condition
characterized by a complete lack of lactase that results in severe
symptoms of failure to thrive in infants (Misselwitz et al., 2019).
• lactase nonpersistence (LNP), a common condition in which
lactase activity reaches a peak at birth but decreases during
childhood (Misselwitz et al., 2019).
Worldwide prevalence is estimated at 68%; it is lowest in Nordic
• countries (<5% in Denmark) and highest in Korean and Han
Chinese populations (approaches 100%) (Misselwitz et al., 2019).
• LNP is not synonymous with lactose intolerance, which by
definition requires evidence of lactose malabsorption and the
development of symptoms, which is not currently done in practice
(Misselwitz et al., 2019).
• In comparison to LNP, Caucasians from Northern Europe or
Northern European descent retain high lactase levels during
adulthood, which is termed lactase persistence. Both lactase
persistence and nonpersistence are normal human conditions
(Misselwitz et al., 2019).
• Secondary lactose malabsorption may occur in people who normally
digest lactose but experience a GI condition that alters the integrity
and function of intestinal villi cells, where lactase is secreted.
• The lactase deficiency that results is usually temporary.
• GI conditions that may cause lactase deficiency include infectious
gastroenteritis, IBD, and celiac disease.
• The loss of lactase may also develop secondary to malnutrition
because the rapidly growing intestinal cells that produce lactase
are reduced in number and function.
• Symptoms of secondary lactose malabsorption tend to be more
severe and occur more quickly after eating lactose than when
lactose malabsorption is caused by LNP.
Lactose Malabsorption
incomplete digestion of lactose.
Lactose Intolerance
GI symptoms of lactose malabsorption that occur after a blinded, placebo-controlled lactose
challenge.
Lactase Nonpersistence
reduced activity of lactase at the jejunal brush border, which is common in the majority of human
adults. Low lactase activity may cause symptoms after lactose is consumed.
Lactase Persistence
persistence of a high level of lactase into adulthood that enables adequate digestion of larger
amounts of lactose.
Nutrition Therapy for Lactose Malabsorption

Nutrition therapy for lactose malabsorption is to reduce lactose to the
maximum amount tolerated by the individual, which is dose related (Box
20.5).
BOX
Low-Lactose Diet
20.5
• Lactose is the sugar in milk; limit or avoid milk and foods made
with milk.
• Individual tolerance varies; eat dairy foods as tolerance allows.
• Lactose tolerance may improve by introducing a small serving of
a lactose-containing food and increasing the amount consumed
daily.
• Lactose is better tolerated with meals, not alone. Chocolate milk
may be better tolerated than plain milk.
• These ingredients are derived from milk but are lactose-free:
casein, lactate, lactalbumin, lactic acid.
• Avoid products whose ingredient list contains butter, cream, milk,
milk solids, or whey and products with ingredient lists that state,
“May contain milk.”
• Consider lactase enzyme supplements.
• Choose nondairy sources of calcium to ensure an adequate intake,
such as canned salmon with bones; calcium-fortified tofu, orange
juice, and soy milk; shellfish; “greens” such as turnip, collard,
and kale; dried peas and beans; broccoli; and almonds.
Lactose-Free Milk Low-Lactose Dairy Possible Hidden

and Nondairy Foods Foods Sources of Lactose
Milk labeled lactose Aged cheese, such as Bread
free cheddar, Swiss, and Baked goods
Cheese and yogurt parmesan Breakfast cereals
labeled lactose free Cream cheese Instant potatoes and
Almond, rice, or soy Ricotta cheese soups
milk Cottage cheese Margarine
Soy yogurt, soy Yogurt Lunch meats
cheese, soy sour Salad dressings
cream Mixes for pancakes,
Almond milk cheese biscuits, and
cookies
Powdered meal-
replacement
supplements
• People with lactose nonpersistence may be asymptomatic when they

consume doses up to 12 g of lactose (e.g., 1 cup of milk) or more
when consumed with food (Misselwitz et al., 2019). Chocolate milk
may be better tolerated than plain milk, although the reason is
unclear (Heaney, 2013).
• Tolerance to lactose may improve by consuming probiotics that
produce lactase in the gut (Heaney, 2013).
• For people who want to consume milk or lactose-containing foods
beyond their limit, lactose-reduced milk and lactase enzyme tablets
or liquid may be used.
• For clients with secondary lactose malabsorption related to GI
disorders, a lactose-restricted diet is indicated at least until the
disorder is resolved and sometimes for a prolonged period
thereafter. Because lactose is used as an ingredient in many foods
and drugs, a lactose-free diet is not realistic.
Recall Stephanie. Her symptoms resolved when she limited

her intake to chicken broth, Gatorade, and tomato juice, but
when she resumed her normal eating pattern, her symptoms
returned. She has unintentionally lost a few pounds. She
decided to keep a food diary to see if her symptoms
correlated to food. She concluded that milk is a problem and
has eliminated all milk and dairy products from her eating
pattern. What nutrients may she be lacking in by eliminating
all dairy? Is it appropriate for her to eliminate all dairy?
Does eliminating dairy effectively eliminate all sources of
lactose?
Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) predominantly refers to Crohn’s disease
(CD) and ulcerative colitis (UC). Although the exact cause is unknown, a
combination of altered immune system functioning, genetics, and
environmental factors may be involved. CD and UC are characterized by
cycles that alternate between active and quiescent states; they share
common symptoms and treatments (tab 20.2).
According to the European Society for Clinical Nutrition and
Metabolism (Forbes et al., 2017),
• the increasing incidence of IBD in Western countries supports the
hypothesis that lifestyle may play a role in its development;
• smoking, antibiotic use, and diet are potentially reversible risk factors
for IBD;
• a diet rich in fruits, vegetables, and omega-3 fatty acids and low in
omega-6 fatty acids is associated with a decreased risk of developing
IBD and is therefore recommended; and
• vitamin D and zinc may lower the risk of CD but not UC.
Table Comparison between Crohn’s

Disease and Ulcerative Colitis
20.2
Crohn’s Disease Ulcerative Colitis
Area affected Can occur anywhere Confined to the rectum
along the GI tract but and colon
most commonly occurs
in the ileum and colon.
Disease pattern Inflammation is Inflammation is
discontinuous, with continuous,
normal tissue between beginning at rectum
patches of inflamed and usually
tissue. extending into the
All layers of the bowel colon.
are affected. Affects only the
mucosal layer.
Main symptoms Diarrhea, abdominal pain, Diarrhea, abdominal
weight loss pain, rectal bleeding
Weight loss, fever, and
weakness are
common when most
of the colon is
involved.
Complications Fistulas, abscesses Tissue erosion and
Stricture of the ileum ulceration
Bowel perforation Toxic megacolon
Bowel obstructions may Greatly increased risk
occur from scar tissue of: cancer
formation.
Toxic megacolon
Increased risk of intestinal
cancer
Crohn’s Disease Ulcerative Colitis
Nutritional Impaired bile acid Anemia related to
complications reabsorption may cause blood loss
malabsorption of fat, Dehydration and
fat-soluble vitamins, electrolyte
calcium, magnesium, imbalances related to
and zinc. diarrhea
Malnutrition may occur Protein depletion from
from nutrient losses through
malabsorption, inflamed tissue
decreased intake, or
intestinal resections.
Anemia related to blood
loss or malabsorption
Vitamin B12 deficiency
related to B12
malabsorption from the
ileum due to
inflammation
Medical Antidiarrheals, Antidiarrheals,
treatment immunosuppressants, immunosuppressants,
immunomodulators, and anti-
biologic therapies, and inflammatory agents
anti-inflammatory
agents
Surgical Most common procedure Most common
intervention is ileostomy; disease procedure is total
often recurs in the colectomy; surgery
remaining intestine. prevents recurrence.
IBD increases the risk of malnutrition, more so in clients with CD than

UC (Forbes et al., 2017).
• Malnutrition may be caused by poor intake, increased nutrient
excretion, drug–nutrient interactions, and, in clients with CD,
previous surgical resection of the bowel.
• Because malnutrition worsens client prognosis, complication rates,
and quality of life, malnutrition screening should occur at the time of
diagnosis and regularly thereafter (Forbes et al., 2017).
Nutrition Therapy for Active Inflammatory Bowel Disease

Currently, evidence is lacking on the effects of experimental diets, such as
specific carbohydrate, gluten-free, paleolithic, and the Fermentable Oligo-,
Di-, and Monosaccharides, and Polyols (FODMAP) diet, on promoting
remission in clients with active disease (Forbes et al., 2017).
• Actual nutrient needs vary among individuals and with the presence
and severity of symptoms, the presence of complications, and the
nutritional status of the client. tab 20.1 outlines dietary interventions
that may be appropriate based on symptoms.
• Restrictions are kept to a minimum to encourage an adequate intake.
Diets should be modified according to individual tolerance.
• Low-fiber diets are frequently recommended to reduce the volume
and bulk of stool and slow intestinal transit time (Box 20.6).
• Calorie expenditure does not increase as a direct result of IBD,
therefore calorie needs are not elevated above normal (Forbes et al.,
2017). However, many clients with CD are malnourished and
underweight and require additional calories for repletion.
• During active disease, protein needs increase to 1.2 to 1.5 g/kg.
Protein need returns to normal during remission.
• Micronutrient deficiencies are common. A multivitamin may correct
most deficiencies but additional iron, zinc, and vitamin D may be
needed (Forbes et al., 2017).
• Enteral nutrition (EN) is considered when oral intake is inadequate. A
routine polymeric is recommended. Disease-specific modified
formulas (e.g., fortified with glutamine or omega-3 fatty acids) are
not recommended.
• PN is considered only when enteral feeding is contraindicated.
• Any dietary restrictions followed during active disease are liberalized
to tolerance during periods of remission.
BOX Low-Fiber Diet

20.6
• This diet restricts fiber to decrease the volume and frequency of stools.
• This diet is a short-term diet to be used when the bowel is inflamed,
such as in the acute stages of diverticulitis, UC, and CD. It may also be
used for esophageal and intestinal stenosis, in preparation for or after
bowel surgery, or for new colostomy or ileostomy.
General Guidelines to Achieve a Low-Fiber Diet
• Choose refined white flour products with less than 2 g fiber/serving

such as white bread and rolls, white pasta, white rice, refined, low-
fiber cereals.
• Eat only well-cooked vegetables that do not have skins or seeds.
• Choose fresh ripe banana or melon; canned or cooked fruit except
pineapple; fruit juices without pulp (except prune juice).
• Eat plain desserts made without nuts or coconut, such as plain cakes,
puddings (rice, bread, and plain), cookies, and ice cream.
• Avoid foods high in fiber:
• whole-grain breads and cereals
• most raw vegetables, vegetables with seeds, gassy vegetables,
cooked greens or spinach
• all fresh fruits except banana and melons; fruit juice with pulp,
prune juice, any fruits sweetened with sorbitol
• dried peas and beans
• anything containing nuts, seeds, or coconut; popcorn
Additional Recommendations
• Avoid milk and milk products that contain lactose if lactose intolerance
is suspected. Low-lactose and lactose-free alternatives include
acidophilus milk, yogurt, soy milk, and almond milk.
• Avoid high-fat protein foods (sausage, bacon, many cold cuts).
• Avoid items that stimulate GI motility: alcohol, caffeine, sorbitol, and
xylitol.
• Probiotic foods may help, such as yogurt with live bacterial cultures,
acidophilus milk, and kefir.
Sample Menu
Pulp-free orange Chicken noodle Roast chicken Saltine crackers
juice soup White rice Rice cakes
Poached egg Tuna sandwich Cooked carrots Tomato juice
White toast with on white Italian bread Fresh banana
jelly bread with with olive oil Soy milk
mayonnaise Frozen yogurt
Canned peach
halves
Milk if tolerated
Constipation related to low fiber Persistent diarrhea related to poor
content of diet; insufficient fiber tolerance of even small amounts
intake causes decrease in stool of fiber contained in a low-fiber
bulk and slowing of intestinal diet; tolerance of fiber varies
transit time. among clients and conditions.
Liberalize diet to allow more fiber; Further reduce fiber content by
this diet is intended to be short eliminating all fruits and
term. vegetables except strained fruit
juice.
Client Teaching
• Reducing fiber slows passage of food through the bowel.

• Fiber is a component of plants and, therefore, is found in fruits,
vegetables, whole grains, dried peas and beans, and nuts.
• This diet is intended to be short term.
• Food preparation techniques to reduce fiber include removing skins,
seeds, and membranes of fruits and vegetables that are high in fiber
and cooking allowed vegetables until they are very tender.
Nutrition Therapy during Remission of Inflammatory Bowel

Disease
No specific diet is routinely recommended for maintaining remission of
IBD. Of note (Forbes et al., 2017):
• IBD patients tend to choose a diet low in fiber and vegetables.
• A lactose-restricted diet is recommended for patients with secondary
lactose malabsorption, which is mainly prevalent in clients with
proximal CD.
• Limited, controlled data suggest clients with CD eliminate the
following items but only when they are poorly tolerated: lactose,
dairy products, spices, herbs, fried foods, and gassy and high-fiber
products.
• Cohort studies in clients with UC suggest those who habitually
consume more meat and alcohol have a higher rate of relapse.
• General advice may be to follow a Mediterranean-Style Eating
Pattern rich in fruit and vegetables, unless there are known strictures.
Celiac Disease
Celiac disease is a chronic, genetic autoimmune disorder characterized by
chronic inflammation of the proximal small intestine mucosa related to a
permanent intolerance to certain gluten-forming proteins found in wheat,
barley, and rye. When ingested, these proteins trigger an immune response
that damages the villi that line the mucosa of the small intestine.
• Once thought to be a pediatric disease, improved diagnostic testing
has helped establish celiac disease as a systemic autoimmune disease
that can develop at any age (Leonard et al., 2017).
• People at risk of celiac disease are those who have an autoimmune
disease (e.g., type 1 diabetes), Down syndrome, or a first-degree
relative with celiac disease.
BOX Types of Clinical Presentations in Celiac

20.7 Disease
Intestinal Presentation
• More common in children younger than 3 years of age. Symptoms
include diarrhea, anorexia, abdominal distention, and failure to thrive.
• Older children and adults may experience diarrhea, bloating,
constipation, abdominal pain, or weight loss. However, malabsorption
syndrome is rare. When it does occur, it can cause weight loss,
sarcopenia, and electrolyte abnormalities.
• More frequently, adults present with symptoms of IBS or nausea with
occasional vomiting.
Extraintestinal presentation: attributed to a combination of chronic
inflammation, nutrient deficiencies, and possibly an adaptive immune
response spreading from the intestinal mucosa to other tissues and organs
(Leonard et al., 2017).
• Common in children and adults.

• Symptoms include iron deficiency anemia, bone disease, dermatitis
herpetiformis, neurologic disorders, fatigue, and reproductive
alterations (e.g., late menarche, amenorrhea, recurrent miscarriages,
early menopause).
Subclinical Form
• Clients have symptoms below the clinical threshold for identification.
• Often only recognized after adherence to a gluten-free diet produces
beneficial effects.
Potential Form
• It is characterized by positive serological and genetic markers but with
normal intestinal mucosa and minimal signs of inflammation.
• It can manifest with classic and non-classic symptoms or be entirely
asymptomatic.
• It is not known if a gluten-free diet should be prescribed.
Refractory Celiac Disease

• It is characterized by persistent malabsorption symptoms and atrophy
of intestinal villi despite strict adherence to a gluten-free diet for at
least 6 to 12 months.
Nonceliac Gluten Sensitivity

• Clinical symptoms occur after eating gluten and disappear or improve
when gluten is eliminated from the diet.
• Symptoms include abdominal pain, bloating, bowel irregularity
(diarrhea, constipation, or both).
• Extraintestinal symptoms include “foggy brain,” headache, joint and
muscle pain, fatigue, depression, leg or arm numbness, dermatitis, and
anemia (Leonard et al., 2017).
Source: Caio, G., Volta, U., Sapone, A., Leffler, D., DeGiorgio, R., Catassi, C., & Fasano, A.
(2019). Celiac disease: A comprehensive current review. BMC Medicine, 17, 142.
https://doi.org/10.1186/s12916-019-1380-z; Leonard, M., Sapone, A., Catassi, C., & Fasano, A.
(2017). Celiac disease and nonceliac gluten sensitivity: A review. Journal of the American
Medical Association, 318(7), 647–656. https://doi.org/10.1001/jama.2017.9730
The significant variation in presenting symptoms in clients makes the

diagnosis of celiac disease challenging (Caio et al., 2019).
• Clients may present with GI symptoms, extraintestinal symptoms, or
both (Box 20.7).
• The gold standard for diagnosis is a combination of mucosal changes
identified by duodenal biopsy and positive serological tests; biopsy
remains necessary, because no antibody test currently available is
100% sensitive or specific (Caio et al., 2019).
• Testing for celiac disease needs to occur before a gluten-free diet is
implemented because once the diet is initiated, testing for celiac
disease is no longer accurate (Leonard et al., 2017).
Complications of celiac disease include hyposplenism, intestinal

lymphoma, small bowel adenocarcinoma, and ulcerative jejunoileitis (Caio
et al., 2019). Complications are suspected when symptoms (e.g., diarrhea,
abdominal pain, weight loss, fever) persist or return despite adherence to a
gluten-free diet.
Nutrition Therapy for Celiac Disease

The only effective treatment for celiac disease is a lifelong gluten-free diet
(Box 20.8). The gluten-free diet has been shown to promote mucosal
healing, reduce serum levels of celiac antibodies, improve nutrient
deficiencies and bone health, and increase body fat, although it is not
successful in all clients (Cichewicz et al., 2019). The response to the diet
may be slow, particularly in people diagnosed in adulthood.
• Gluten occurs naturally in barley, wheat, and rye. Wheat products are
the predominant complex carbohydrate in the typical American diet.
• Oats is considered a source of gluten in the United States due to
possible contamination with other grains, unless it is specifically
labeled as gluten free.
• The diet is difficult to comply with because of the pervasiveness of
gluten in processed foods and medications and confusion over
identifying sources of gluten on food labels.
• Special gluten-free products (e.g., breads, pastry) made with rice,
corn, or potato flour have different textures and tastes than “normal”
products and may not be well accepted. They may also cost more
than similar gluten-containing products.
• It is difficult to actually achieve a gluten-free diet because minute
amounts of gluten may be present in gluten-free foods. As defined by
the Food and Drug Administration (FDA), foods labeled as “gluten-
free” must contain <20 ppm of gluten (U.S. Food and Drug
Administration [FDA], 2018). According to the FDA (2018), this is
the lowest level that can be consistently detected in foods using valid
scientific analytical tools.
Gluten
a general name for the storage proteins gliadin (in wheat), secalin (in rye), and hordein (in barley).
BOX
Gluten-Free Diet
20.8
• Celiac disease and NCGS are the only indications for a gluten-free
diet. There is no evidence that a gluten-free diet is part of a healthier
lifestyle or is helpful in treating overweight or obesity (Leonard et al.,
2017).
• Gluten, a protein fraction found in wheat, rye, and barley, is
eliminated. All products made from these grains or their flours are
eliminated. Oats are at high risk of gluten contamination, so only oats
labeled gluten free are suitable.
• Many foods are naturally gluten free: milk, butter, cheese; fresh,
frozen, and canned fruits and vegetables; fresh meat, fish, poultry,
eggs; dried peas and beans; nuts; corn; and rice.
Naturally Gluten- Gluten-Containing Foods Not
Free Grains and Grains to Eliminate Recommended (May
Other Starch- Contain Wheat,
Containing Foods Barley, or Rye)
Amaranth Wheat—all forms, Beer
Arrowroot Buckwheat including Bouillon cubes
Cassava wheat flours, such as Brown rice syrup
Chia bread flour, Chips/potato chips
Corn, cornstarch bromated flour, cake Candy
Flax flour, durum flour, Cold cuts, hot dogs,
Gums enriched flour, salami, sausage
Acacia (gum Arabic) graham flour, pastry Communion wafer
Carob bean gum flour, phosphated Flavored or herbal
Carrageenan flour, plain flour, coffee
Cellulose self-rising flour, Flavored or herbal tea
Guar semolina, white French fries
Locust bean flour Gravy
Xanthan Wheat starch, wheat Imitation fish
Legumes, legume bran, wheat germ, Licorice
flours cracked wheat, Malt, malted syrup,
Millet hydrolyzed wheat malt beverages,
Nut flours protein, farina, malt vinegar
Certified gluten-free matzo Meat substitutes
oats Wheat sources of Rice and corn cereals
Potatoes, potato flour Dextrin (may contain barley
Quinoa Caramel color malt)
Rice, all plain; wild Maltodextrin Rice mixes
rice; rice flour Modified food starch Sauces
Soy “Ancient” types of Seasoned or dry-
Sorghum wheat: Einkorn, roasted nuts
Tapioca emmer, spelt, kamut Seasoned tortilla chips
Teff Barley Self-basting poultry
Yucca Rye Soups
Malt Soy sauce
Vegetables in sauce
Naturally Gluten- Gluten-Containing Foods Not
Free Grains and Grains to Eliminate Recommended (May
Other Starch- Contain Wheat,
Containing Foods Barley, or Rye)
Triticale (a cross
between wheat and
rye)
Oats not certified
gluten-free
Sample Menu

Orange juice Cuban black Tomato juice Plain nuts
Gluten-free beans with Roast chicken Rice cake
cornflakes brown rice Quinoa pilaf Banana
Milk Pure corn tortilla Steamed Apple slices
Coffee Milk broccoli with peanut
Plain yogurt Corn bread butter
topped with made without
chopped wheat flour
almonds Blueberries over
Coffee/tea ice cream
made without
gluten
stabilizers
Additional Considerations
• Clients may be discouraged and overwhelmed when faced with a
lifelong restricted diet. Provide support, encouragement, and thorough
diet instructions.
• The client may have temporary lactose malabsorption and may require
a lactose-restricted diet.
Increased expense related to Encourage the client to use as
buying special gluten-free foods many “normal” items as
possible such as corn, grits,
quinoa, rice, and rice cereals;
they are easy to obtain and less
expensive than special products.
Inadequate intake of several Encourage a varied diet of allowed
nutrients (B vitamins, calcium, foods and enriched gluten-free
zinc, and iron) related to the products over non-enriched;
lower content of these nutrients recommend a gluten-free, age-
in gluten-free products appropriate multivitamin and
compared to the enriched and mineral supplement.
fortified grains and cereals they
replace
Inadequate intake of fiber related Encourage fiber from legumes,
to the absence of whole wheat nuts, fruits, vegetables, and
products gluten-free whole grains such as
flax seed, millet,
uncontaminated oats, quinoa,
brown rice, and amaranth.
Client Teaching
Instruct the client on the importance of adhering to the diet even when no
symptoms are present. “Cheating” on the diet can damage intestinal villi
even if no symptoms develop.
To permanently eliminate all flours and products containing wheat,
rye, barley, triticale, and malt, the client should do the following:
• Read labels. By law, foods labeled gluten free must contain <20 ppm
of gluten.
• Check with the manufacturer before using products of questionable
composition. While all food products must be clearly labeled to
indicate the presence of wheat, other sources of gluten are less obvious
(e.g., malt flavorings and extracts from barley).
• Use corn, potato, rice, arrowroot, and soybean flours and their
products.
• Use the following as thickening agents: arrowroot starch, cornstarch,
tapioca starch, rice starch, and sweet rice flour.
• Eat an otherwise normal, well-balanced diet adequate in nutrients and
calories. Lactose is restricted only if not tolerated. Weight gain may be
slowly achieved.
Provide the client with the following aids:
• A detailed list of foods allowed and not allowed.

• Information regarding support groups; see “Websites” section at the
end of this chapter.
• Gluten-free recipes.
The crucial benefits of adhering to a gluten-free diet are accompanied

by some disadvantages, such as the following (Caio et al., 2019):
• Impaired quality of life: This diet requires a major lifestyle change: it
is very restrictive, necessitates conscientious label reading, and is
difficult to adhere to while eating out.
• Psychological problems, which may include fear of involuntary or
inadvertent gluten consumption.
• Nutrient deficiencies: Adults diagnosed with celiac disease are likely
to have a nutrient deficiency, such as folate, B12, zinc, and iron
• Increased risk of metabolic syndrome and cardiovascular disease.
• Possible severe constipation related to elimination of wheat,
specifically whole wheat. Other allowed grains and starchy foods that
provide fiber are less commonly consumed.
Nonceliac Gluten Sensitivity

Nonceliac gluten sensitivity (NCGS) is a condition in which people do not
have the diagnostic features of celiac disease but develop celiac-like
symptoms in response to eating gluten and experience improvement or
disappearance of symptoms when gluten is eliminated from the diet.
• No specific biomarkers have been identified and validated for NCGS,
and symptoms alone cannot reliably differentiate celiac disease from
NCGS because symptoms overlap between the two conditions
• Treatment is a gluten-free diet, although it is not known if long-term
strict avoidance of all gluten is necessary, because NCGS may be
transient (Fasano et al., 2015).
• It is recommended that a gluten-free diet be followed for 12 to 24
months before repeating testing for gluten tolerance (Leonard et al.,
2017).
• Some clients with NCGS choose to follow a gluten-free diet
indefinitely.
Think of Stephanie. Despite conscientiously following a

low-lactose eating pattern, her symptoms persisted, and her
weight loss continued. She is eventually seen by a
gastroenterologist who diagnoses celiac disease and iron
deficiency anemia. Is there a connection between type 1
diabetes and celiac disease? Should she continue to restrict
lactose from her eating pattern? How will nutrition
counseling for a college student who lives in a dorm differ
from counseling for an adult living in her own home?
Stephanie knows she should eat fiber to help regulate her
blood glucose levels; what sources of fiber would be
appropriate on a gluten-free diet?
Short Bowel Syndrome

Short bowel syndrome (SBS), the most frequent cause of intestinal failure,
is intestinal malabsorption related to a functional small intestine length of
less than 200 cm (Pironi, 2016). This functional definition is necessary due
to the variations in the length of small bowel remaining and the ability of
the remaining small bowel to compensate for the shortened length (Parrish
& DeBaise, 2017). There are three anatomical types of SBS depending on
the portion and length of bowel that remains (Box 20.9).
Short Bowel Syndrome (SBS)
a complex condition resulting from extensive surgical resection of the intestinal tract resulting in
an inadequate absorptive surface that may lead to maldigestion and malabsorption.
BOX Characteristics of the Anatomical Types

20.9 of Short Bowel Syndrome
End jejunostomy
• Ileum and colon are completely removed; losses of sodium and fluid
are large.
• Malabsorption of macronutrients, vitamin B12, and bile salts occurs.
• Acid hypersecretion.
• Rapid gastric and intestinal transit.
• Long-term PN is usually required depending on the length of small
bowel remaining.
Jejunocolic anastomosis
• Ileum and part of the colon are removed; the benefits of having even a
part of the colon remain are related to its ability to absorb fluid,
electrolytes, and fatty acids; slow transit time; and stimulate intestinal
adaptation.
• Vitamin B12 and bile salt malabsorption occurs because the ileum is
removed.
• Rapid intestinal transit.
• Long-term PN may be required depending on the length of small
bowel remaining.
Jejunoileal anastomosis
• Part of the small intestine is removed but the colon remains intact;
rarest type.
• Vitamin B12 and bile salt absorption are preserved.
• Transit is normal.
• Long-term PN may not be required.
SBS is a challenging and often disabling malabsorptive disorder

associated with significant morbidity and mortality and decreased quality of
life (Parrish & DeBaise, 2017). Loss of the ileum, especially the terminal
ileum, is more detrimental than loss of jejunum, because it is the only site
for absorption of intrinsic factor–bound vitamin B12 and bile salts.
Disruption of enterohepatic circulation of bile salts leads to severe fat
malabsorption and steatorrhea. Clients with a small bowel <100 cm that
ends in a jejunostomy may need permanent PN and hydration to survive.
The most common causes of SBS in adults are complications from
abdominal surgery (e.g., bariatric surgery), radiation enteritis, CD,
ischemia, or trauma (Parrish & DeBaise, 2017). The complications,
prognosis, and treatment depend on the length, health, and area of the
remaining bowel. Symptoms include diarrhea/malabsorption, steatorrhea,
electrolyte imbalances, weight loss, dehydration, fat-soluble vitamin
deficiencies, oxalate kidney stones, metabolic acidosis, metabolic bone
disease, and impaired wound healing related to malnutrition (Pironi, 2016).
Advances in the treatment of SBS have led to the reduction or
elimination of PN in many formerly PN-dependent clients (Parrish &
DeBaise, 2017). Early initiation of EN therapy postsurgically is critical for
promoting optimal intestinal adaptation (the process whereby the absorptive
capacity of the small bowel increases), which occurs mainly during the first
2 years after surgery. Strategies that may promote independence from PN
include (Parrish & DeBaise, 2017)
• early introduction of enteral and oral feedings to stimulate intestinal
adaptation and optimize absorption,
• the use of medications to control symptoms and improve quality of
life,
• intestinal growth factors (e.g., somatropin and teduglutide), and
• surgery when appropriate (e.g., to relieve obstruction or add bowel
into continuity).
Course of Nutrition Therapy

• Initially after surgery, most clients with SBS require PN.
• As soon as possible in the early post-op period, an intact EN formula
should be added to the treatment regimen for maximum bowel
stimulation and adaptation (Matarese, 2013). However, PN remains
the major source of nutrition and hydration.
• As adaptation occurs, EN combined with oral feedings may promote
weaning off PN.
• When the client can consume oral nutrition without excessive stool or
ostomy output and can maintain or gain weight, the amount of PN is
gradually decreased.
Nutrition Therapy Interventions

Nutrition interventions are highly individualized. Few comparative studies
on diet composition are available due to the complexity of SBS and the
heterogenous sample (AND, 2020). Diet recommendations are typically
based on clinical experience and observational studies. General eating and
nutrition guidelines are summarized in Box 20.10.
BOX General Eating and Nutrition Guidelines

20.10 for Short Bowel Syndrome
Eating Guidelines
• Eat 6 to 8 small meals or snacks.
• Chew food thoroughly.
• Avoid liquids with solids and for 30 minutes after eating to help reduce
diarrhea.
• If coffee, tea, and iced tea are allowed, limit intake to less than 4
ounces per day.
• Avoid the following:
• Food and beverages containing simple sugars, such as desserts,
sugar-sweetened beverages, fruit juices, fruit drinks, oral nutrition
supplements, and sweetened cereals.
• Food and beverages containing sugar alcohols (sorbitol, xylitol,
mannitol). Artificial sweeteners, such as Splenda, Equal, and Stevia,
may be used.
• Alcohol.
• Lactose if not tolerated.
General Nutrition Guidelines

• Consume a high-quality protein at each meal and snack. Protein should
supply approximately 20% of total calories.
• The percent contribution of carbohydrate and fat is based on whether
or not the colon is present.
• For clients with any remaining colon, a low-fat, high-carbohydrate
diet is recommended. Excess fat can promote steatorrhea and
increase oxalate absorption, which may increase the risk of oxalate
kidney stones. Oxalate intake may need to be limited.
• For clients without a colon (end jejunostomy or ileostomy), a diet
low in carbohydrates and higher in salt is recommended. Fat intake
does not increase stoma output and can help meet calorie needs.
• Oral rehydration solutions may be more beneficial than water,
especially in clients with an end jejunostomy.
• Clients not receiving PN may need oral vitamin and mineral
supplements, possibly 2 to 3 times/day to compensate for
malabsorption. Depending on the extent of small and large bowel,
remaining micronutrients of greatest concern are calcium, fat-soluble
vitamins, vitamin B12, zinc, and selenium.
Source: Parrish, C., & DiBaise, J. (2017). Managing the adult client with short bowel syndrome.
Gastroenterology & Hepatology, 13(10), 600–608; Academy of Nutrition and Dietetics. (2020).
Nutrition care manual. https://www.nutritioncaremanual.org/
CONDITIONS OF THE LARGE

INTESTINE
Irritable Bowel Syndrome

Irritable bowel syndrome (IBS), one of the most frequently diagnosed GI
conditions, is a chronic functional disorder characterized by abdominal pain
with diarrhea, constipation, or both in the absence of any other disease that
may cause these symptoms (Chey et al., 2015). Bloating and distention are
other common complaints. IBS can greatly impair quality of life and work
productivity.
The cause of IBS is unclear and not likely to be singular. Factors that
may contribute to its pathogenesis include disruption of the brain–gut axis,
gut dysmotility, visceral hypersensitivity, low-grade mucosal inflammation,
increased intestinal permeability, and altered microbiota (Hayes et al.,
2014). Life stressors (changes in employment, relocation, etc.) can trigger
or worsen symptoms as can excessive use of laxatives or antidiarrheal
drugs, lack of regular sleep, and inadequate fluid intake (University of
Virginia Nutrition, 2016). Over 80% of IBS clients report food-related
symptoms (Böhn et al., 2013).
Nutrition Therapy for Irritable Bowel Syndrome

FODMAP is an acronym for Fermentable Oligo-, Di-, and
Monosaccharides, and Polyols, which are carbohydrates that are poorly
absorbed and rapidly fermented, resulting in diarrhea, gas, and abdominal
pain in susceptible individuals (Staudacher et al., 2014).
• Dietary restriction of FODMAPs has been shown to be an effective
treatment for IBS symptoms, with 50% to 76% of clients
experiencing clinical benefits (Böhn et al., 2013).
• It is recommended that high-FODMAP foods are restricted for 4 to 6
weeks (Box 20.11).
• After symptom improvement is achieved, reintroduction of individual
FODMAPs is encouraged to keep restrictions to a minimum and
increase the likelihood of nutritional adequacy.
• A long-term FODMAP diet (6–18 months) has been shown to be not
only effective for IBS management but also nutritionally adequate
and generally well accepted by clients (O’Keeffe et al., 2018).
BOX Low–Fermentable Oligo-, Di-, and

20.1 Monosaccharides, and Polyols Diet
Incomplete digestion of fructose and other short-chain carbohydrates

distends the bowel via osmotic effects and rapid fermentation and leads
to the production of short-chain fatty acids and gas. In some people with
IBS, FODMAPs may result in IBS symptoms (Staudacher et al., 2011).
However, because there are no defined cutoff values for high- and low-
FODMAP foods, there are discrepancies in identifying foods to avoid.
FODMAPs are found in the following:
• Honey and certain fruits that are high in free fructose. These items
cause symptoms.
• Fruits that contain equal or greater amounts of glucose compared to
fructose may be tolerated in measured amounts because glucose
promotes the absorption of fructose. That is why fructose from white
sugar and high-fructose corn syrup (HFCS), which are composed of
equal parts of glucose and fructose, is generally completely absorbed.
In contrast, fructose from a pear, which contains approximately 4 times
more fructose than glucose, is poorly absorbed.
• Wheat, onions, leeks, garlic asparagus, artichokes, and inulin
(fructans)
• Milk, yogurt, and ice cream (lactose)
• Legumes (galacto-oligosaccharides)
• Certain fruits and sugarless gums, mints, and dietetic foods that
contain sugar alcohols such as sorbitol, mannitol, or xylitol
Guidelines to Achieve a Low–FODMAP Diet

• Keep a record of the amount and types of food and beverages
consumed and the type, severity, and onset of symptoms to help
identify intolerances.
• Avoid products that list fructose, crystalline fructose (not HFCS),
honey, and sorbitol on the label.
• Avoid sugar alcohols found in “diet” or “dietetic” foods.
• Limit beverages with HFCS to ≤12 oz/day. Consume with food for
improved tolerance.
• Fresh or frozen fruit may be better tolerated than canned fruit.
• Cooked vegetables may be better tolerated than raw.
• Fructose and sorbitol may be ingredients in medications. Check with
the pharmacist.
• Tolerance is dose related; whereas small amounts of FODMAPs may
be tolerated, eating beyond a person’s threshold causes symptoms to
develop.
• Keep in mind that not all FODMAP-containing foods worsen IBS
symptoms in all clients.
• After a period of 6 to 8 weeks, clients who are able to control their
symptoms with complete exclusion of FODMAPs are encouraged to
gradually reintroduce eliminated foods, to keep restrictions to a
minimum.
Foods Low in High-FODMAP Questionable
FODMAP Foods to Avoid Foods/Foods to
Limit
Fruit Bananas, Fruit: apples, pear, Fruit canned in
blackberries, guava, heavy syrup,
blueberry, honeydew other fruits
grapefruit, melon, mango,
honeydew, Asian pear,
kiwifruit, papaya, quince,
lemons, star fruit,
limes, watermelon
mandarin Stone fruit:
orange, apricots,
melons peaches,
(except cherries, plums,
watermelon), nectarines
oranges, Fruits high in
passion fruit, sugar: grapes,
pineapple, persimmon,
raspberries, lychee
rhubarb, Dried fruit
strawberries, Fruit juice
tangelos Dried fruit bars
Fruit pastes and
sauces: tomato
paste, chutney,
plum sauce,
sweet and sour
sauce, barbecue
sauce
Fruit juice
concentrate
Limit
Vegetables Bamboo shoots, Onion, leek, garlic, Avocado, corn,
bok choy, shallots, mushrooms,
carrots, asparagus, tomatoes,
cauliflower , a
artichokes, other beans
celery, cabbage,
cucumber , a
Brussels sprouts,
eggplant , a
cauliflower,
green beans , a
mushrooms,
green sugar snap peas,
peppers ,a
snow peas
leafy greens, Legumes and
parsnip, lentils
pumpkin,
spinach,
sweet
potatoes,
white
potatoes,
other root
vegetables
Other All meats Wheat and wheat Items
All fats products (e.g., containing
Oats wheat pasta, HFCS if not
Rice cereals, cakes tolerated
Lactose-free cookies, and
yogurt and crackers)
hard cheeses Rye and rye
Eggs products
Aspartame Milk, ice cream,
(Equal, yogurt
NutraSweet) containing
Saccharin
(Sweet’N
Low) Limit
Sugar
lactose, and
Glucose
other sources of
Maple syrup
lactose
Fortified wines:
sherry, port, etc.
Chicory-based
coffee substitute
Honey, agave
nectar
Certain additives
identified on
food labels, such
as inulin (often
labeled as
chicory root
extract), fructo-
oligosaccharides,
sorbitol,
mannitol, xylitol,
maltitol, isomalt
Desserts sweetened
with fructose or
sorbitol (e.g., ice
cream, cookies,
popsicles)
a
Possible gas-forming foods that may need to be avoided.
Anecdotally, the following interventions may help reduce symptoms

(University of Virginia Nutrition, 2016):
• Eat smaller, more frequent meals.
• Reduce fat intake, which can be achieved by selecting lean meats,
avoiding fried foods, choosing low-fat or nonfat dairy products, and
avoiding high-fat snacks and sweets.
• Avoid caffeine, chocolate, and alcohol.
• Slowly increase soluble fiber intake (e.g., oatmeal, lima beans, peas,
sweet potato) while consuming adequate fluid.
Other nutrition therapy interventions are often used for IBS with
varying effectiveness.
• Probiotics may be effective in improving overall IBS symptoms and
quality of life, but more studies are needed to determine what type,
strain, dose, and treatment duration are optimal (Zhang et al., 2016).
• Peppermint oil improves cramping but may cause GERD or
constipation (Chey et al., 2015).
• Other unproven but safe supplements often used include chamomile
tea, evening primrose oil, and fennel seeds (University of Virginia
Nutrition, 2016).
Diverticular Disease
Diverticular disease (DD) is characterized by the presence of diverticula
and includes the conditions of diverticulosis and diverticulitis.
Diverticulitis can be uncomplicated (inflammation of ≥1 diverticula) or
complicated if abscess, perforation, fistula formation, or obstruction occurs
(Pearlman & Akpotaire, 2019).
Diverticulosis
the presence of colonic diverticula, without inflammation or symptoms.
Diverticula
pouches that protrude outward from the muscular wall of the intestine usually in the sigmoid
colon.
Diverticulitis
macroscopic inflammation of diverticula with related acute or chronic complications.
It was a long-standing belief that low-fiber diets caused DD by
increasing pressure within the intestinal lumen leading to mucosal
herniation and the formation of diverticula. However, there is a lack of
evidence to support this idea (Pearlman & Akpotaire, 2019). Dietary factors
that have been shown to increase the risk of diverticulitis include red meat
intake, particularly unprocessed red meat (Cao et al., 2018), and obesity and
weight gain in adulthood (Ma et al., 2018).
Nutrition Therapy for Diverticular Disease

Some evidence suggests a high-fiber diet may decrease the risk of
diverticulitis recurrence and/or symptomatic DD (Dahl et al., 2018). Based
on very low evidence, the American Gastroenterology Association suggests
a high-fiber diet or fiber supplements in clients with a history of acute
diverticulitis (Stollman et al., 2015).
• Even though the certainty and magnitude of benefit are difficult to
determine, a high-fiber diet or supplements are unlikely to pose a
substantial risk (Stollman et al., 2015).
• A “prudent diet” (cholesterol-lowering diet rich in fruits, vegetables,
whole grains, legumes, poultry, and fish) may decrease the risk of
diverticulitis. Interestingly, recent intake seems to be as effective as
past intake, suggesting that it is not too late to adopt a prudent diet
(Stollman, 2017).
• It is common practice for clients to be told to avoid nuts, seeds, and
popcorn based on the theory that these can become trapped in
diverticula and cause diverticulitis. However, there is no scientific
evidence that proves nuts and seeds cause flares of diverticulitis
(Kim, 2019).
• The efficacy of probiotics in different phases of DD is not fully
understood (Ojetti et al., 2018).
Ileostomies and Colostomies

The surgical creation of a stoma causes temporary or permanent alteration
in the transit of food and/or elimination of stool (de Oliveira et al., 2018).
Medical conditions that may necessitate an ileostomy or colostomy include
colorectal cancer, congenital disorders, trauma, IBD, intestinal obstruction,
and diverticulitis. The process of nutrient absorption is interrupted at the
point of the stoma.
• Ileostomies are created in the small intestine, the site of nutrient
absorption. Nutrients that may be lost include calcium, magnesium,
iron, vitamins B12, the fat-soluble vitamins, folic acid, water, protein,
fat, and bile salts. A normal, mature ileostomy should only make
about 1200 mL of output each day (Bridges et al., 2019). Stools are
liquid to semiliquid.
• Colostomies are created in the colon; there is little or no nutrient loss.
Colostomies usually only put out 200 to 600 mL/day (Bridges et al.,
2019). Stools range from semiliquid to hard.
Ileostomy
a surgically created opening (stoma) on the surface of the abdomen from the ileum.
Colostomy
a surgically created opening on the surface of the abdomen from the colon.
Nutrition Therapy for Ileostomies and Colostomies

Specific dietary guidelines for people with a stoma are lacking. Restrictions
should be kept to a minimum. Common sense eating strategies that may be
beneficial include the following (Bridges et al., 2019):
• Eat 4 to 6 small meals per day.
• Chew food thoroughly.
• Eat food you normally eat, but avoid mushrooms, nuts, corn, coconut,
celery, and dried fruit for the first 2 weeks after surgery. Slowly
reintroduce these foods, as desired, in moderation.
• Eat a source of protein at each meal and snack.
• Use salt liberally.
Consume adequate fluid. At least 80 oz/day may be needed to protect
•
kidney function.
High Output Stomas

An estimated 16% of stomas will suffer from a high output (Arenas
Villafranca et al., 2015), which is generally defined as ≥1500 mL/day.
• Causes of high output stoma include SBS, intra-abdominal sepsis,
enteritis, paralytic ileus, and medications.
• Clients with prolonged high output are at greater risk of dehydration,
acute kidney injury, and malnutrition (Ahmad et al., 2019).
• A diet similar to that recommended for SBS may be indicated, at least
until the output is under control (see Box 20.10).
• Fluid requirement is individualized to ensure a urine output of at least
1200 mL/day (Bridges et al., 2019).
DISORDERS OF THE ACCESSORY

GASTROINTESTINAL ORGANS
The liver, pancreas, and gallbladder are known as accessory organs of the
GI tract. Although food does not come in direct contact with these organs,
they play vital roles in the digestion of macronutrients. Liver disease,
pancreatitis, and gallbladder disease are discussed next.
Liver Disease
The liver is a highly active organ involved in the metabolism of almost all
nutrients. After absorption, almost all nutrients are transported to the liver,
where they are “processed” before being distributed to other tissues. The
liver synthesizes plasma proteins, blood clotting factors, and nonessential
amino acids and forms urea from the nitrogenous wastes of protein.
Triglycerides, phospholipids, and cholesterol are synthesized in the liver, as
is bile, an important factor in the digestion of fat. Glucose is synthesized,
and glycogen is formed, stored, and broken down as needed. Vitamins and
minerals are metabolized, and several are stored in the liver. Finally, the
liver is vital for detoxifying drugs, alcohol, ammonia, and other poisonous
substances.
Liver damage can have profound and devastating effects on the
metabolism of almost all nutrients. It can range from mild and reversible
(e.g., fatty liver) to severe and terminal (e.g., hepatic coma). Liver failure
can occur from chronic liver disease or secondary to critical illnesses.
The objectives of nutrition therapy for liver disease are to avoid or
minimize permanent liver damage, restore optimal nutritional status,
alleviate symptoms, and avoid complications. Adequate protein and calories
are needed to promote liver cell regeneration. However, regeneration may
not be possible if liver damage is extensive.
Fatty Liver Disease

Fatty liver disease is characterized by abnormal fat deposition in the liver.
Fatty liver occurs in the majority of clients with alcoholic liver disease.
Nonalcoholic fatty liver disease (NAFLD) is a spectrum of diseases ranging
in severity from simple hepatic steatosis, which is often asymptomatic and
benign, to nonalcoholic steatohepatitis (NASH), its progressive subtype,
characterized by inflammation and liver cell damage. Complications such
as advanced fibrosis, cirrhosis, and hepatocellular carcinoma may result.
Steatohepatitis
fat accumulation in the liver with inflammation.
Cirrhosis
irreversible liver disease that occurs when damaged liver cells are replaced by functionless scar
tissue, seriously impairing liver function and disrupting normal blood circulation through the
liver.
First described in 1980, NAFLD is estimated to be the most common

cause of chronic liver disease, affecting 80 to 100 million American adults,
among whom nearly 25% will progress to NASH (Perumpail et al., 2017).
NASH has been recognized as one of the leading causes of cirrhosis in
American adults, and NASH-related cirrhosis is the second indication for
liver transplants in the United States (Younossi et al., 2016).
• NAFLD is strongly associated with obesity and metabolic syndrome
—a cluster of symptoms that include central obesity, insulin
resistance, type 2 diabetes, hypertension, and abnormal blood lipid
levels.
• Clients with NAFLD are twice as likely to die of cardiovascular
disease as liver disease, largely because of their shared risk factors
such as diabetes, hypertension, and obesity (Friedman et al., 2018).
• A high intake of calories, saturated fat, refined carbohydrates, sugar-
sweetened beverages, and fructose have all been associated with
weight gain, obesity, and NAFLD (EASL-EASD-EASO, 2016).
Treatment of NAFLD focuses on controlling the underlying risk factors,
such as obesity, diabetes, and hyperlipidemia (Romero-Gómez et al., 2017).
• Lifestyle interventions, such as a healthy eating plan and physical
activity, are well-established treatment strategies for these conditions.
• Sustained weight loss is the most effective treatment for NAFLD and
should serve as the cornerstone of treatment.
Nutrition Therapy for Nonalcoholic Fatty Liver Disease

Clinical Practice Guidelines for the treatment of NAFLD suggest the
following lifestyle interventions (EASL-EASD-EASO, 2016):
• Reduce calories by 500 to 1000/day to promote gradual weight loss.
• A target weight loss of 7% to 10% is recommended.
• A Mediterranean diet has been shown to reduce liver fat even when
weight loss is not achieved. It is the most recommended dietary
pattern for NAFLD.
• Avoid fructose (e.g., high fructose corn syrup) in beverages and food.
• Limit alcohol.
• Coffee exerts a protective effect in NAFLD; there are no liver-related
restrictions on coffee intake.
Both aerobic and resistance training reduce liver fat. One hundred
• fifty to 200 minutes/week of moderate-intensity aerobic physical
activities is recommended. Benefits are dose related. Resistance
straining is encouraged.
• Clients who are unable to achieve weight loss and metabolic
improvements with lifestyle modification and drug therapy may
consider bariatric surgery.
Hepatitis
Although fatty liver and alcohol toxicity can cause hepatitis, the most
frequent causes are infection from hepatitis viruses A, B, and C. Early
symptoms of hepatitis include anorexia, nausea and vomiting, fever, fatigue,
headache, and weight loss. Later, symptoms such as dark-colored urine,
jaundice, liver tenderness, and, possibly, liver enlargement may develop. In
many cases, particularly those caused by hepatitis A, liver cell damage that
occurs from acute hepatitis is reversible with proper rest and adequate
nutrition.
Hepatitis
inflammation of the liver that may be caused by viral infections, alcohol abuse, and hepatotoxic
chemicals such as chloroform and carbon tetrachloride.
Nutrition Therapy for Hepatitis

A healthy diet adequate in calories, protein, and micronutrients is
recommended for clients with acute hepatitis (first 6 months of illness).
Food restrictions are usually not necessary. For clients with chronic
hepatitis (illness that persists beyond 6 months), diet modifications are
based on symptoms (AND, 2020).
• Limit sodium to 2 g/day if there is fluid retention.
• Consume 4 to 6 small meals and/or snacks to promote an adequate
intake.
• Consume 1.0 to 1.2 g protein/kg.
• Follow a carbohydrate-controlled eating pattern appropriate for
diabetes if hyperglycemia develops.
• Limit fat to <30% of total calories if steatorrhea develops.
Cirrhosis
Scarring from chronic hepatitis can lead to cirrhosis. Liver damage
progresses slowly, and some clients are asymptomatic. Early nonspecific
symptoms include fever, anorexia, weight loss, and fatigue. Glucose
intolerance is common. Later, portal hypertension, dyspepsia, diarrhea or
constipation, jaundice, esophageal varices, hemorrhoids, ascites, edema,
bleeding tendencies, anemia, hepatomegaly, and splenomegaly may
develop.
Malnutrition affects an estimated 20% of clients with compensated
cirrhosis and >50% of clients with decompensated liver disease (European
Association for the Study of the Liver [EASL], 2019).
• Malnutrition is associated with the progression of liver failure and
with a higher rate of complications such as infection, hepatic
encephalopathy, and ascites.
• Whether malnutrition can be reversed in cirrhotic clients is
controversial.
• Although commonly assumed to mean “undernutrition,” overweight
and obesity are increasingly seen in cirrhotic clients due to the
increase in NAFLD (EASL, 2019).
• Obesity and sarcopenic obesity may worsen the prognosis of clients
with cirrhosis.
Hepatic Encephalopathy
the CNS manifestations of advanced liver disease characterized by irritability, short-term memory
loss, and impaired ability to concentrate.
Nutrition Therapy for Cirrhosis

According to the EASL (2019), a varied healthy eating pattern is
recommended for all clients with cirrhosis. Fruit and vegetables to tolerance
are encouraged. Other points are as follows (EASL, 2019):
• Other than alcohol, no food is contraindicated because no food
actually damages the liver.
• Emphasis should be placed on consuming appropriate calories and
adequate protein:
• Nonobese clients should consume 35 cal/kg/day of actual body
weight and at least 1.2 to 1.5 g protein/kg.
• Clients with obesity should consume a hypocaloric diet that is 500
to 800 cal/day less than their estimated need to promote gradual
weight loss of greater than 5% to 10% of body weight. Protein
intake should not fall below 1.5 g/kg/ideal body weight to preserve
body protein stores.
• Three meals plus 3 snacks daily are recommended. The last snack
should be substantial because of overnight fasting.
• Oral nutrition supplements can help achieve an adequate intake.
• Clients with ascites should limit sodium intake to 2 g/day. Effort
should be made to ensure overall calorie intake is not reduced due to
lower diet palatability.
• Micronutrient supplements may be necessary.
Following are additional considerations for clients with hepatic
encephalopathy (EASL, 2019):
• Optimal calorie and protein intake should not be lower than the
recommendations for clients with cirrhosis.
• Protein restriction is generally considered detrimental.
• Protein in plants and dairy products may be better tolerated than
meats.
• Supplements of branch-chain amino acids may provide
neuropsychiatric benefits.
• Clients who are unable to consume an adequate oral intake need EN
or PN.
Nutrition Therapy for Liver Transplantation

Liver transplantation is a treatment option for clients with severe and
irreversible liver disease. Many clients awaiting a transplant are
malnourished. Moderate-to-severe malnutrition increases the risk of
complications and death after transplantation. Whenever possible, nutrient
deficiencies and imbalances are corrected before the transplantation to
promote a positive outcome.
Following are the presurgical recommendations (EASL, 2019):
• Provide 30 cal/kg/day and 1.2 g protein/kg body weight/day for
clients with adequate nutritional status. Increase calories to 35 cal/kg
and protein to 1.5 g/kg in clients who need nutritional repletion.
• Use standard nutritional regimens because specialized nutrition
formulas (e.g., branch-chain amino acid–enriched or immune-
enhancing formulas) have not been shown to improve morbidity or
morality.
Following are the postsurgical recommendations (EASL, 2019):
• Initiate oral or EN within 12 to 24 hours after surgery, or as soon as
possible. PN is used if EN is contraindicated or impractical.
• Provide 35 cal/kg body weight and 1.5 g protein/kg body weight after
the acute post-op period.
• Provide 25 cal/kg/day and 2.0 g protein/kg/day for patients with
obesity receiving EN or PN.
• Be aware that long-term survivors of liver transplant are at high risk
of overweight or obesity and comorbidities of metabolic syndrome.
Pancreatitis
The pancreas is responsible for secreting enzymes needed to digest dietary
carbohydrates, protein, and fat. Until they are needed, these enzymes are
held in the pancreas in their inactive form. Inflammation of the pancreas
causes digestive enzymes to be retained in the pancreas and converted to
their active form, where they literally begin to digest the pancreas. Because
the pancreas also produces insulin, people with pancreatitis may also
develop hyperglycemia related to insufficient insulin secretion.
Pancreatitis
inflammation of the pancreas.
Acute Pancreatitis
Severe acute pancreatitis can be triggered by drugs, alcohol, gallstones, or
hypertriglyceridemia (McClave, 2019). Inflammation and a subsequent
series of events can injure the intestinal mucosa, causing a breakdown of
barrier defenses, impaired immune function, development of a virulent
pathobiome, gut-derived sepsis, and multiple organ failures (McClave,
2019). Innovative treatment strategies have emerged from a better
understanding of intestinal failure and the loss of the commensal
microbiome (McClave, 2019). For instance, shorter use of antibiotics and
minimal use of narcotics are suggested because both of these drugs may
stimulate virulent pathogen activity.
Pathobiome
the set of host-associated microbial organisms associated with impaired or potentially impaired
health due to interactions between microbial members and the host.
Commensal Microbiome
a living relationship in which one organism derives food or other benefits from the host organism
without helping or hurting it.
Nutrition Therapy for Acute Pancreatitis

Current approaches in nutrition therapy are intended to help mitigate
disease severity and reduce complications (McClave, 2019).
Recommendations for clients with mild-to-moderate acute pancreatitis are
as follows (McClave, 2019):
• Encourage an oral diet. Allowing the client to decide when to
advance to an oral diet reduces hospital length of stay. Clear liquid
diets are not necessary.
• Emulsifying agents found in processed food, such as
carboxymethylcellulose or polysorbate 80, should be avoided because
they have been shown to reduce the mucus layer of the intestinal tract
and promote low-grade virulence of microbiota.
Recommendations for clients with severe acute pancreatitis
necessitating intensive care unit (ICU) admission are as follows (McClave,
2019):
• Early initiation of EN via nasogastric route is recommended. EN
initiated within 24 to 48 hours is more likely to reduce infection,
length of hospital stay, and multiple organ failure than delayed
feedings.
• After tolerance to a polymeric formula is established and goal rate is
achieved, it is recommended that a whole food formula be used
instead. Whole food formulas may reduce systemic infection,
decrease growth of pathogens, and lead to greater bacterial diversity
in the colon.
• The provision of prebiotics and probiotics may be considered.
Chronic Pancreatitis
Acute pancreatitis that is not resolved or recurs frequently can lead to
chronic pancreatitis (CP), an inflammatory disorder that causes irreversible
pancreatic damage, resulting in both exocrine and endocrine dysfunction.
• Diabetes, steatorrhea, and malabsorption can result.
• Diarrhea may occur in up to 70% of clients with CP (Sikkens et al.,
2012).
• Malnutrition is common and multifactorial and may be due to altered
endocrine and exocrine function, significant abdominal pain, delayed
gastric emptying, increased metabolism, and often continued alcohol
consumption (O’Brien & Omer, 2019).
• Malnutrition significantly affects quality of life and is a component of
client disability.
Nutrition Therapy for Chronic Pancreatitis

The commonly experienced problems of inadequate intake and
maldigestion/malabsorption contribute to the challenge of nutrition therapy
for CP (O’Brien & Omer, 2019).
• Most clients can be managed with an oral diet and pancreatic enzyme
replacement.
Low-fat diets are often recommended to reduce abdominal pain but
• consideration should be given to the long-term impact this can have
on calorie intake and the client’s weight.
• A carbohydrate-controlled diet is indicated for clients with diabetes.
• Oral nutrition supplements can help promote an adequate intake of
protein and calories.
Gallbladder Disease
The gallbladder plays an important but not vital role in digestion in that it
stores and releases bile, which prepares fat for digestion. As bile is held in
the gallbladder, water is slowly removed, making it more concentrated and
increasing the likelihood that solids (either cholesterol crystals or bilirubin)
will precipitate out into hard clumps known as gallstones. Incomplete
emptying of the gallbladder may also be involved in gallstone formation.
Interestingly, data show that people with obesity who follow a very low-fat
diet to achieve weight loss are at higher risk of gallstones and that diets
higher in fat may help reduce the risk of gallstones in people trying to lose
weight (Stokes et al., 2014).
• While some people with cholelithiasis are asymptomatic, others
experience severe abdominal pain, nausea, and vomiting.
• For some people, eating a fatty meal precipitates symptoms; for
others, symptoms develop during sleep.
• Gallstones that obstruct the cystic duct can lead to cholecystitis, and
less commonly, obstructive jaundice, cholangitis, acute pancreatitis,
and gangrene of the gallbladder (Madden et al., 2017).
Surgical removal of the gallbladder is the only definitive therapy for
acute cholecystitis and the gold standard for treating symptomatic
gallstones (Altomare et al., 2017).
• After the gallbladder is removed, secondary bile acids are
continuously secreted directly into the small bowel, leading to
diarrhea and probably changes in the gut microflora (Altomare et al.,
2017).
• A postcholecystectomy syndrome characterized by nausea, bloating,
diarrhea, and abdominal pain has been reported to occur in 5% to
40% of people who have had a cholecystectomy (Sagar et al., 2015).
Cholelithiasis
formation of gallstones.
Cholecystitis
inflammation of the gallbladder.
Nutrition Therapy
Clients with symptomatic gallstones are often advised to consume a low-fat
diet (<30% total calories from fat) based on the rationale that limiting fat
intake reduces stimulation to the gallbladder and minimizes pain. However,
there is no published evidence of the benefits of a low-fat diet compared to
a regular diet (Madden et al., 2017).
Likewise, there are no evidence-based nutrition therapy
recommendations for clients who have had a cholecystectomy. The
following advice is commonly given:
• Consume a low-fat diet and reduce the amount of fat at each meal to
allow the body time to adapt to the gallbladder’s absence (Box
20.12).
• Increase soluble fiber intake, which may help normalize bowel
function. Soluble fiber is found in canned fruit; fresh fruit without
skins, peels, membranes, and/or seeds; oatmeal; and barley.
• Consider prebiotics and probiotics, especially if the client has
diarrhea.
• Consume small meals if reflux is a problem.
• Avoid any foods not tolerated, which may or may not include spicy
foods and caffeine.
• Consider micronutrient supplements, particularly of fat-soluble
vitamins, to replenish nutrients malabsorbed due to diarrhea.
Low-Fat Diet
BOX
20.12
• Total fat is limited to reduce symptoms of steatorrhea and pain in
clients who are intolerant to fat, such as for people with cholecystitis,
chronic pancreatitis, radiation enteritis, and SBS.
Guidelines to Achieve a Low-Fat Diet

• Select only very lean meats, fish, and skinless poultry; egg whites; and
low-fat egg substitutes.
• Bake, broil, or boil foods instead of frying.
• Use milk and dairy products that provide less than 1 g fat/serving and
use low-fat cheese with not more than 3 g fat/serving.
• Enjoy all fruits and vegetables that are prepared without added fat.
• Choose grain products that are prepared without added fat (e.g., avoid
muffins, waffles, biscuits, cakes, cookies, doughnuts, pastries, other
baked goods, chips, cheese crackers).
• Choose low-fat and fat-free desserts: sherbet, fruit ices, gelatin, angel
food cake, vanilla wafers, graham crackers, nonfat ice cream and
frozen yogurt, and fruit whips with gelatin.
• Use fats and oils sparingly, including oils, soft margarines, salad
dressings, and avocados.
Sample Menu

Orange juice Fat-free 2 oz broiled lean Pretzels
Oatmeal with vegetable chicken Fat-free yogurt
fat-free milk soup Brown rice Fresh fruit
Whole wheat 2 oz of fat-free Tossed salad
toast with ham on whole with
jelly wheat bread vegetables
with lettuce and fat-free
and fat-free dressing
mayonnaise Steamed
Fresh broccoli
strawberries Whole wheat
Fat-free milk roll with 1 tsp
butter
Blueberries
Fat-free milk

Noncompliance related to Encourage the client to eat a
decreased palatability and variety of foods and to use
satiety from the reduction in fat nonfat and fat-free versions of
intake familiar foods.
Persistent symptoms of steatorrhea Encourage use of butter-flavored
or pain after eating that are sprinkles and sprays to season
related to fat intolerance hot vegetables and potatoes.
Inadequate intake of iron related to Decrease fat content by
the limited allowance of meat eliminating fats and oils and
(red meat is the best absorbed reducing the amount of low-fat
source of iron in the diet) meat allowed.
Monitor Hgb and Hct; recommend
iron supplements as needed.
Encourage a liberal intake of high-
iron foods such as fortified
cereals and grains and dried peas
and beans; advise the client to
consume a rich source of
vitamin C at each meal to
maximize iron absorption.
Client Teaching
Ensure that the client understands the following:
• The total amount of dietary fat must be reduced regardless of the

source.
• Sources of fat may be visible (e.g., butter, margarine, shortening, fat on
meat, salad dressings) or invisible (e.g., marbled meat, whole milk and
whole-milk products, egg yolks, nuts).
• Careful selections when eating out can greatly reduce fat intake.
• Choose juice or broth-based soup instead of cream soup as an
appetizer.
Use lemon, vinegar, low-calorie dressing (if available), or fresh-
• ground pepper on salad, or request that the dressing be brought on
the side.
• Order plain baked or broiled foods.
• Avoid warm bread and rolls, which absorb more butter than those at
room temperature.
• Order fresh fruit, gelatin, or sherbet for dessert.
• Request milk for coffee or tea in place of cream and nondairy
creamers.
• Various food preparation techniques reduce fat content
• Trim fat from meat and remove skin from chicken before cooking.
• Place meats to be baked or roasted on a rack to allow the fat to
drain.
• Rinse oil-packed tuna and salmon.
• Bake, broil, steam, or sauté foods in a vegetable cooking spray or
allowed fats.
• Cook with bouillon, lemon, vinegar, wine, herbs, and spices instead
of adding fat.
• Make fat-free soup stock and gravies by preparing the stock a day
ahead and refrigerating it overnight. The fat will harden and can
easily be removed from the surface.
• Purchase “select” grade meats because they are lower in fat than
“choice” and “prime” grades.
NURSING
PROCESS Crohn’s Disease
Andrew is a 20-year-old man who is admitted to the hospital for

suspected CD. His chief complaints are crampy abdominal pain,
diarrhea, weight loss, fatigue, and anorexia. He has unintentionally lost
15 pounds since his symptoms began 2 weeks ago. He is prescribed
intravenous fluids, sulfasalazine, prednisone, an antidiarrheal
medication, and a diet as tolerated.
Assessment
Medical– • Medical and surgical history
Psychosocial • Use of prescribed and over-the-counter
History medications
• Support system
Anthropometric • Height, current weight, usual weight;
Assessment percentage weight loss; body mass index
Biochemical and • Hemoglobin (Hgb), hematocrit (Hct)
Physical • Serum electrolyte levels
Assessment
• Blood pressure
• Signs of dehydration (poor skin turgor, dry
mucous membranes, etc.)
Dietary • How has your intake changed since you began
Assessment experiencing symptoms?
• Do you know if any particular foods cause
problems? Did you have any food intolerances
or allergies before your symptoms began?
• How many meals per day are you eating?
• How much fluid are you drinking in a day?
• Have you ever followed any kind of diet
before?
• Do you take vitamins, minerals, or other
supplements?
• Do you use alcohol?
• Who prepares your meals?
Analysis
Assessment
Possible Nursing Malnutrition risk related to anorexia and diarrhea
Analyses as evidenced by unintentional 15-pound weight
loss in 2 weeks
Planning
• consume adequate calories and protein to
restore normal weight,
• experience improvement in symptoms
(diarrhea, abdominal pain, fatigue, anorexia),
• maintain normal fluid balance, and
• describe the principles and rationale of
nutrition therapy for CD and implement the
appropriate interventions.
Nutrition Therapy • Provide a low-fiber, high-protein, lactose-
restricted diet as tolerated.
• Provide lactose-free commercial supplements
between meals to enhance protein and calorie
intake.
• Encourage high fluid intake, especially of
fluids high in potassium such as tomato juice,
apricot nectar, and orange juice.
• Promote gradual return to normal diet as
tolerated.
Assessment
• on the purpose and rationale of a low-fiber,
lactose-restricted diet; advise the client that
after the disease goes into remission, dietary
restrictions are limited only to items not
individually tolerated,
on the importance of consuming adequate
protein, calories, and fluid to promote healing
• and recovery,
• to maximize intake by eating small, frequent
meals,
• to avoid colas and other sources of caffeine
because they stimulate peristalsis,
• to eliminate individual intolerances, and
• to communicate any side effects he experiences
from the medications.
Evaluation
Evaluate and • Percentage of food consumed
Monitor • Weight
• Symptoms (diarrhea, abdominal pain, fatigue,
anorexia). If client does not tolerate an oral
diet, determine whether a defined formula EN
feeding is appropriate.
• Fluid and electrolyte balance
• Client knowledge of principles and rationale of
nutrition therapy for CD
How Do You Respond?

Is it a good idea to detox or cleanse the gut? Not only is
it unnecessary to detox or cleanse the gut, it is also
potentially harmful based on the regimen used, such as
consuming only juices or water for several days, fasting,
taking specific supplements, irrigating the colon, or using
enemas or laxatives. The body naturally eliminates toxins
through the lungs, kidneys, colon, lymph system, and the
liver. There is no convincing evidence that detox or
cleansing actually removes toxins from the body or
improves health.
Are “live active cultures” the same thing as
probiotics? Live active cultures are microorganisms
associated with foods that are often used to ferment food.
For instance, live active cultures in yogurt refer to the
mixture of bacterial species, such as Lactobacillus
acidophilus, Lactobacillus bulgaricus, and Lactobacillus
casei, that ferment milk into yogurt. Some live active
cultures do not survive the fermentation process and
therefore do not provide health benefits when consumed.
In contrast, probiotics are live microorganisms in foods
that have been shown to benefit health when consumed in
adequate amounts. Some yogurts contain therapeutic
doses of probiotics to provide a health benefit, such as to
prevent or treat acute diarrhea.
REVIEW CASE STUDY
Brittany is a 33-year-old woman who was recently diagnosed with IBS. She
alternates between episodes of diarrhea and constipation and complains of
distention and abdominal pain. Her doctor suggested she eat more fiber and
take Metamucil. She dislikes whole wheat bread. She is reluctant to take a
fiber supplement; she knows fiber helps people with constipation, and
because she also has diarrhea, she believes it will only make her problem
worse. She is thinking about adding yogurt to her usual diet to see if that
helps. She drinks an “irritable bowel syndrome–friendly tea” that is
supposed to help, but she hasn’t noticed any improvement.
Her usual intake is as follows:
• What does Brittany need to know about fiber and bowel function? What
would you say to her about eating more fiber? About taking a fiber
supplement? About yogurt? And about “irritable bowel syndrome–
friendly tea?”
• What else do you need to know about Brittany to help relieve her
symptoms?
• What other diet interventions could she implement to try to improve her
symptoms?
• What foods does Brittany consume that are high in FODMAPs?
Breakfast: orange juice, white toast with peanut butter, coffee

Snacks: small bag of chips from the vending machine
Lunch: fast-food hamburger on a bun, small French fries, and diet coke
Snacks: cheese and crackers, glass of wine
Dinner: beef or chicken, mashed potatoes, broccoli, tossed salad with
Italian dressing, ice cream, coffee
Snacks: milk and cookies, apples
STUDY QUESTIONS
1 When developing a teaching plan for a client who has chronic diarrhea,
which of the following items would the nurse suggest the client avoid?
a. tomato juice
b. whole wheat pasta
c. saltine crackers
d. soy milk
2 Which statement indicates the client with cirrhosis needs further
instruction about what to eat?
a. “As with alcohol, certain foods, such as white sugar and white bread,
must be avoided because they damage the liver.”
b. “I should eat 3 meals/day and 3 snacks, especially a bedtime snack.”
c. “I may need to limit sodium due to fluid retention.”
d. “I need to be sure I eat enough protein.”
3 Which statement indicates the client following a low FODMAP
understands instruction about the diet?
a. “A low-FODMAP diet is the same thing as a gluten-free diet.”
b. “I understand that I can eventually try adding sources of FODMAPs
into my diet to test for tolerance.”
c. “The low-FODMAP diet effectively controls symptoms of IBS in all
people who adhere to the diet.”
d. “FODMAPs are only found in certain fruits and vegetables so as long
as I am careful in choosing those, I can eat items from all other food
groups without concern.”
4 The nurse knows their instructions have been effective when the client
with celiac disease verbalizes that an appropriate breakfast is
a. eggs and toast
b. grits with berries
c. bran flakes cereal with milk
d. buttermilk pancakes with syrup
5 Which of the following would be most effective in modifying a regular
diet to a high-fiber diet?
a. romaine in place of ice berg lettuce
b. bran cereal in place of cornflakes
c. rice in place of mashed potatoes
d. black beans in place of garbanzo beans
6 Which of the following may be the best tolerated source of calcium for a
client who is lactose intolerant?
a. calcium-fortified orange juice
b. pudding
c. cottage cheese
d. refined breads and cereals
7 A client with fat malabsorption is at risk for which of the following?
a. calcium oxalate kidney stones
b. constipation
c. fatty liver disease
d. type 2 diabetes
8 Which of the following strategies would help a client achieve a low-fat
diet?
a. Substitute margarine for butter.
b. Eat nonfat frozen yogurt in place of nonfat frozen ice cream.
c. Substitute whole wheat bread for white bread.
d. Prepare chicken by roasting instead of frying.

Clients with Disorders of the Lower
Gastrointestinal Tract and Accessory Organs
Most nutrient absorption occurs in the first half of the small intestine.
Conditions that affect the small intestine can impair the absorption of one
or many nutrients. The large intestine absorbs water and electrolytes.
Disorders of the colon can cause problems with fluid and electrolyte
balance.
Altered Bowel Elimination

Constipation. Increasing fiber, particularly insoluble fiber in whole
grains and bran, can alleviate or prevent most cases of constipation. The
amount of fiber needed to promote bowel regularity varies among people.
Diarrhea. Short-term acute diarrhea usually does not require nutrition

therapy.
• Avoid clear liquids.
• Avoid items that stimulate peristalsis, such as caffeine, alcohol, high-
fiber foods, gassy foods, and sugar alcohols.
Malabsorption Disorders
Lactose Malabsorption. A deficiency or lack of the enzyme lactase
causes symptoms of lactose intolerance: cramping, bloating, and diarrhea
after consuming lactose.
• Lactose is the naturally occurring sugar in milk.
• Lactase decreases after childhood in many populations.
• Secondary lactose malabsorption occurs secondary to other GI
disorders.
• Lactose is restricted to the amount individually tolerated.
Inflammatory Bowel Disease. A group of chronic immune disorders
characterized by alternating periods of exacerbation and remission.
• Nutrition may be impacted by poor intake, malabsorption, increased
requirements related to systemic inflammation, drug–nutrient
interactions, and previous surgeries.
• During exacerbation: no specific diet is recommended. Low fiber,
high protein, increased calories for weight restoration, if appropriate,
and supplemental micronutrients may be advised. EN or PN is used if
oral intake is inadequate or contraindicated. Restrictions are
liberalized as symptoms improve.
• During remission: no specific diet is known to help maintain
remission. Many clients consume a low-fiber, low vegetable intake. A
Mediterranean diet may be recommended.
Celiac Disease. Chronic autoimmune disorder characterized by
inflammation of the proximal small bowel from permanent intolerance to
the gluten-containing proteins. Malabsorption of macro- and micronutrients
occurs.
• The only treatment is a lifelong gluten-free diet. Gluten is found in
wheat, barley, rye, and oats and products made from these grains.
• The diet is highly restrictive, can be difficult to follow, and may cause
constipation and nutrient deficiencies.
• NCGS causes celiac-like symptoms but without other diagnostic
features of celiac disease. It is not known if permanent elimination of
gluten from the diet is necessary.
Short Bowel Syndrome. Occurs when the small bowel is surgically
shortened to the extent that nutrient absorption is not adequate to meet the
client’s needs.
• Symptoms include diarrhea, steatorrhea, electrolyte imbalances,
dehydration, weight loss, and malnutrition.
• Adaptation occurs during the first 2 years after surgery. Adaptation is
promoted with early EN.
• Some clients need PN indefinitely.
• Dietary tolerance varies with the length of small bowel remaining and
the health of the remaining bowel.
• An oral diet limits fluid with meals, simple sugars, sugar alcohols, and
possibly lactose. Oral rehydration solutions, small frequent meals, and
liberal intake of sodium are encouraged. Clients should chew food
thoroughly.
Conditions of the Large

Intestine
Irritable Bowel Syndrome. A functional disorder characterized by
diarrhea, constipation, or alternating periods of each.
• A low-FODMAP diet improves symptoms in many people. After 4 to
6 weeks on the diet, sources of FODMAPs are reintroduced to keep
dietary restrictions to a minimum. High-FODMAP foods are not
objectively defined or universally agreed upon.
• Other strategies that may help include eating small frequent meals;
limiting fat intake; avoiding caffeine, chocolate, and alcohol; and
increasing soluble fiber intake gradually.
Diverticular Disease. A spectrum of conditions related to diverticula.
• There is no evidence to support the idea that a low-fiber diet causes
DD.
• Some evidence suggests a high-fiber diet may decrease the risk of
diverticulitis or its reoccurrence.
• Red meat intake and obesity and weight gain during adulthood
increase the risk of diverticulitis.
• A prudent diet may help prevent diverticulitis.
• It is not necessary for clients to avoid nuts, seeds, or popcorn.
• The value of using probiotics has not been determined.
Ileostomies and Colostomies. Surgical creation of a stoma in the
small intestine or colon. Ileostomies have a greater impact on nutritional
status than do colostomies.
• There are no dietary guidelines for after an ileostomy or colostomy.
• General recommendations include eating small frequent meals and
snacks that contain a source of protein; chewing food thoroughly;
avoiding foods that may cause a blockage, such as mushrooms, nuts,
corn, celery, and dried fruit; and consuming adequate fluid and
sodium.
• Output ≥1500 mL/day is considered high output. Following the diet
for SBS may be beneficial.
Disorders of the Accessory

Gastrointestinal Organs
Liver Disease
Fatty liver disease: occurs from alcohol abuse or secondary to
obesity/metabolic syndrome.
• Sustained weight loss is the most effective treatment for NAFLD.
• Alcohol is avoided.
• A Mediterranean diet may help reduce fat in the liver even if weight
loss does not occur. It is the most recommended dietary pattern for
NAFLD.
• Coffee exerts a protective effect in NAFLD and is not restricted.
• Bariatric surgery may be considered if lifestyle therapy fails to achieve
healthy weight.
Hepatitis: inflammation of the liver frequently caused by certain viruses.

• Acute hepatitis: A healthy diet is recommended.
• Chronic hepatitis: Small frequent meals and an increased protein
intake is recommended. Additional diet modifications are based on
symptoms, such as a low-sodium diet for ascites, carbohydrate
controlled for diabetes, and low-fat diet for steatorrhea.
Cirrhosis: an irreversible late stage of liver disease characterized by

scarring secondary to hepatitis or alcohol abuse.
• Other than alcohol, no food is contraindicated because no food
actually damages the liver.
• Adequate calories and protein are emphasized. Clients with obesity
should gradually lose weight.
• Three meals plus 3 snacks daily are recommended with a substantial
late night snack.
• Oral nutrition supplements can help achieve an adequate intake.
• Sodium is limited if necessary and if it does not compromise adequate
intake.
• Micronutrient supplements may be necessary.
Following are considerations for clients with hepatic encephalopathy:
• Calorie and protein intake should not be lower than the
recommendations for clients with cirrhosis.
• Protein restriction is detrimental; however, plant and dairy proteins
may be better tolerated than meats.
• Supplements of branch-chain amino acids may provide
neuropsychiatric benefits.
• EN or PN may be necessary.
Pancreatitis
• Acute pancreatitis: inflammation of the pancreas that may be caused
by drugs, alcohol, gallstones, or hypertriglyceridemia.
• An oral diet is recommended as soon as the client is able to eat.
• Emulsifiers in processed food should be avoided because they reduce
the mucus layer of the GI tract.
• Clients in ICU should be placed on EN within 24 to 48 hours. After
tolerance and goal rate are achieved, the polymeric formula should be
replaced by a whole food formula.
• Probiotics may be considered.
Chronic pancreatitis: results from recurring or unresolved acute

pancreatitis characterized by irreversible anatomical changes and
damage.
• Most clients can be managed with an oral diet and pancreatic enzyme
replacement.
• Low-fat diets may be used to reduce abdominal pain but may
detrimentally impact calorie intake and the client’s weight.
• A carbohydrate-controlled diet is indicated for clients with diabetes.
• Oral nutrition supplements may be used.
Gallbladder disease: includes cholelithiasis, cholecystitis, and

cholecystectomy.
• Clients with symptomatic gallstones may be advised to consume a
low-fat diet (less than 30% total calories from fat) based on the
rationale that limiting fat intake reduces stimulation to the gallbladder
and minimizes pain. This is not supported by evidence.
• There are no evidence-based nutrition therapy recommendations for
clients who have had a cholecystectomy. Strategies that may be
recommended include a low-fat diet, an increased intake of soluble
fiber, the use of pre- and probiotics, small meals, and eliminating
individual food intolerances.
Figure sources: shutterstock.com/PERLA BERANT WILDER, shutterstock.com/ChameleonsEye,
shutterstock.com/mkldesigns, and shutterstock.com/Zern Liew

book at
Websites
Celiac Disease Foundation at www.celiac.org
Crohn’s and Colitis Foundation of America at www.ccfa.org
Gluten Intolerance Group at www.gluten.net
National Digestive Diseases Information Clearinghouse at http://digestive.niddk.nih.gov
United Ostomy Associations of America, Inc. at www.uoa.org
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21 with Diabetes Mellitus
Darius Jackson
Darius is the first man in his family to reach the age
of 60 years without having a stroke or myocardial
infarction. He has had hypertension for decades and
was recently diagnosed with type 2 diabetes with a
hemoglobin A1c of 9.2%. He was immediately
prescribed metformin and a basal insulin regimen of
10 units/day and told to lose weight.
Learning Objectives
1 Discuss strategies recommended to prevent diabetes.

2 Describe the nutrient and dietary recommendations for managing
diabetes.
3 Name eating patterns that are associated with a decrease in A1c levels.
4 Explain meal-planning approach recommendations for adults based on
pharmacological therapy.
5 List the characteristics of a consistent carbohydrate diet.
6 Explain carbohydrate choice lists.
7 Describe the plate method of meal planning.
8 Determine the number of carbohydrate choices a serving of food
provides by using the “Nutrition Facts” label.
9 Discuss diabetes nutrition therapy in youth and older adults.
Diabetes is one of the most costly and burdensome chronic diseases of our
time and is expected to increase in prevalence due at least in part to an
aging population, increasing prevalence of overweight and obesity, and
growing minority populations that are at higher risk of diabetes. Nutrition
therapy is a vital component of diabetes prevention and management.
Although medical nutrition therapy is the ___domain of the registered dietitian
nutritionist, all health-care team members need to be knowledgeable in the
basic principles of diabetes nutrition therapy so they can facilitate basic
meal planning, dispel misconceptions, and reinforce diabetes nutrition
education.
This chapter describes nutrition therapy for the treatment of type 1 and
type 2 diabetes and also the prevention and treatment of type 2 diabetes.
Gestational diabetes is presented in Chapter 12.
DIABETES
Diabetes mellitus is a heterogeneous group of metabolic disorders

characterized by hyperglycemia and abnormal insulin metabolism. Absent
or ineffective insulin impairs the metabolism of all three macronutrients,
resulting in high blood glucose levels, increased levels of fatty acids and
triglycerides in the blood, and muscle wasting (tab 21.1). Diagnostic criteria
for diabetes appear in tab 21.2.
Table Actions of Insulin and Effects

of Its Insufficiency
21.1
Nutrient Action of Insulin Results of Insulin Insufficiency
Glucose Promotes uptake of Decreases uptake of glucose into
glucose into cells muscle and adipose
Promotes formation Decreases glycogen formation in
of glycogen in the liver and muscle
liver and muscle Increases glycogen breakdown in
Promotes liver and muscle
conversion of Increases gluconeogenesis (the
excess glucose formation of glucose from a
into triglycerides noncarbohydrate source, such as
for storage amino acids or glycerol)
Hyperglycemia
Protein Promotes uptake of Decreases uptake of amino acids into
amino acids into muscle
tissue protein Decreases protein synthesis
Increases protein breakdown
Fat Promotes formation Increases production of ketones in
of adipose from the liver
excess fat Decreases formation of triglycerides
in adipose
Increases triglyceride breakdown in
adipose
Increases serum triglyceride and fatty
acid levels
Table Diagnostic Criteria for

21.2 Diabetes and Prediabetes
The statistics of diabetes prevalence are staggering (Centers for Disease
Control and Prevention [CDC], 2020a, 2020b). Crude estimates for 2018
were as follows:
• 34.1 million Americans aged 18 or older had diabetes (13% of all
U.S. adults).
• 7.3 million adults aged 18 or older who met laboratory criteria for
diabetes were not aware of or did not report having diabetes.
• 88 million adults aged 18 or older had prediabetes.
Type 1 Diabetes
Type 1 diabetes, formerly known as insulin-dependent diabetes mellitus, is
characterized by the absence of insulin. It accounts for 5% to 10% of
diabetes cases. Although type 1 can occur at any age, it is most often
diagnosed before the age of 18 years. Type 1 diabetes occurs from an
autoimmune response that damages or destroys pancreatic beta cells,
leaving them unable to produce insulin. Interaction between genetic
susceptibility and environmental factors, such as viral infection, is thought
to be responsible. The classic symptoms of polyuria, polydipsia, and
polyphagia appear abruptly. Sometimes, the first sign of the disease is
ketoacidosis. There is no known way to prevent type 1 diabetes. All people
with type 1 diabetes require exogenous insulin.
Type 1 Diabetes
diabetes characterized by the absence of insulin secretion.
Polyuria
excessive urine excretion.
Polydipsia
excessive thirst.
Polyphagia
excessive appetite.
Ketoacidosis
the accumulation of ketone bodies leading to acidosis related to incomplete breakdown of fatty
acids from carbohydrate deficiency or inadequate carbohydrate utilization.
Type 2 Diabetes
Type 2 diabetes, previously referred to as non–insulin-dependent diabetes,
accounts for 90% to 95% of diagnosed cases of diabetes. Although it is
most often diagnosed after the age of 45 years, the rising prevalence of
obesity in youth has led to an increase in type 2 diabetes in young adults
and adolescents (Sattar et al., 2019).
Unlike type 1 diabetes, in which there is a relatively abrupt and absolute
end to insulin production, type 2 diabetes is a slowly progressive disease
characterized by a combination of peripheral insulin resistance and relative
insulin deficiency. When cells do not respond to insulin as they should, the
pancreas compensates by secreting higher than normal levels of insulin but
not high enough to lower serum glucose to normal levels. Impaired fasting
glucose and impaired glucose tolerance occur despite high levels of
circulating insulin. Over time, chronic hyperinsulinemia leads to a
decrease in the number of insulin receptors on the cells and a further
reduction in tissue sensitivity to insulin. Insulin production progressively
falls to a deficient level, and frank type 2 diabetes develops. Because
hyperglycemia develops gradually in type 2 diabetes and is often not severe
enough for clients to recognize any of the classic diabetes symptoms, type 2
diabetes may go undiagnosed for years. Undiagnosed clients are at
increased risk of developing microvascular and macrovascular
complications (American Diabetes Association [ADA], 2020a).
Although the exact cause of type 2 diabetes is unknown, genetic and
environmental factors, such as being 45 years of age or older; overweight;
physically inactive; or a member of a high-risk racial or ethnic group, such
as people who are African American, Latino, Native American, Asian
American, or Pacific Islander; and having a history of gestational diabetes,
are contributing factors (ADA, 2020a). Metabolic syndrome (MetS) is a
cluster of risk factors, such as central obesity, insulin resistance,
dyslipidemia, and hypertension that, when combined, increases the risk of
type 2 diabetes fivefold and cardiovascular disease (CVD) threefold
(O’Neill & O’Driscoll, 2015).
Insulin Resistance
decreased cellular response to insulin.
Impaired Fasting Glucose

fasting plasma glucose levels of 100 to 125 mg/dL.
Impaired Glucose Tolerance

2-hour values in the oral glucose tolerance test of 140 to 199 mg/dL.
Hyperinsulinemia
elevated blood levels of insulin.
Metabolic Syndrome (MetS)

a clustering of interrelated risk factors that includes hypertension, low high-density lipoprotein
(HDL) cholesterol, high triglycerides levels, elevated serum glucose, and central or abdominal
obesity, as indicated by waist circumference.
Consider Darius. He is 5 ft 10 in. tall. At the time of

diagnosis, he weighed 205 pounds. He wants to lose weight
to get off insulin. What is his body mass index (BMI)? What
risk factors does he have for type 2 diabetes? How much
weight should he initially lose? Is it possible for him to
manage his diabetes without insulin?
Prediabetes
Prediabetes describes the condition where glucose levels are not high
enough to reach the criteria for diabetes but are too high to be considered
normal (tab 21.2). Rather than viewed as a clinical entity, prediabetes
should be considered an increased risk for diabetes and CVD (ADA,
2020a). Prediabetes is associated with MetS.
Because of the strong link between excess weight and insulin
resistance/type 2 diabetes, modest weight loss is the primary focus of
diabetes prevention. Several major randomized controlled trials show that
lifestyle and behavioral therapy that includes an individualized hypocaloric
meal plan, a healthy eating pattern (e.g., Mediterranean-style, Dietary
Approaches to Stop Hypertension [DASH] diet, or vegetarian diet), and
physical activity is highly effective in preventing type 2 diabetes and
improving cardiometabolic markers such as blood pressure, lipid levels, and
inflammation (ADA, 2020b). One such trial is the Diabetes Prevention‐
Program that is summarized in Box 21.1.
BOX The Diabetes Prevention Program: What

21.1 It Was and What It Showed
What it was: It was a major, multicenter, randomized controlled trial in a

diverse group of overweight people with impaired glucose tolerance.
• The 2 major goals of the intensive, behavioral lifestyle intervention

were to achieve a minimum weight loss of 7% at a rate of 1 to
2 pounds/week and 150 minutes/week of physical activity of the
intensity of brisk walking.
• All participants were given the same goals.
• The program was individual based, not group based.
• The core curriculum was 16 sessions completed in 24 weeks.
What is showed:
• The program lowered the incidence of type 2 diabetes by 58% over

3 years (Knowler et al., 2002).
• Average weight loss among study participants was a modest 5% to 7%
of initial weight.
• Participants were also benefited from improvements in their lipid
profiles, blood pressure, and markers of inflammation (Haffner et al.,
2005; Ratner et al., 2005).
• A 10-year follow-up on the original participants showed that the
lifestyle intervention group maintained a decreased risk of diabetes
over time (Diabetes Prevention Program Research Group, 2009).
Long-Term Diabetes Complications

Sustained hyperglycemia, regardless of what type of diabetes causes it,
alters glucose metabolism in virtually every tissue. Damage to small vessels
(microvascular) can lead to retinopathy, nephropathy, and neuropathy. Large
blood vessel (macrovascular) damage increases the risk of CVD. In fact,
atherosclerotic cardiovascular disease (ASCVD) (coronary heart disease,
cerebrovascular disease, or peripheral arterial disease) is the leading cause
of morbidity and mortality for people with diabetes (ADA, 2020c). Other
diabetes complications include impaired wound healing, gangrene,
periodontal disease, and increased susceptibility to other illnesses.
Intensive glucose control has been shown to
• significantly lower the rates of development and progression of
microvascular complications in clients with type 1 diabetes
(Diabetes Control and Complications Trial Research Group, 1993),
• significantly lower the rates of microvascular complications in
clients with short-duration type 2 diabetes (UK Prospective Diabetes
Study [UKPDS] Group, 1998), and
• provide a cardiovascular benefit when initiated early the course of
type 1 diabetes (Nathan et al., 2005).
LIFESTYLE MANAGEMENT
Diabetes is a progressive disease that requires lifelong treatment. Lifestyle
management, encompassing effective behavior management and
psychological well-being, is fundamental to achieving treatment goals for
people with diabetes (ADA, 2020d). Lifestyle management components
discussed in the following section are diabetes self-management
education and support (DSMES), medical nutrition therapy, and physical
activity. Lifestyle strategies not discussed here are smoking cessation and
psychosocial care (ADA, 2020d).
Diabetes Self-Management Education and Support (DSMES)
the process of facilitating the knowledge, skill, and ability needed to self-manage diabetes and the
support needed to implement and maintain skills on an ongoing basis.
Diabetes Self-Management Education and

Support
It is recommended that all people with diabetes participate in DSMES at
diagnosis and thereafter as needed to learn and sustain the knowledge,
skills, and ability needed to manage diabetes self-care (ADA, 2020d).
Examples of self-care behaviors include healthy eating, being active,
monitoring glucose and eating, taking medication, problem-solving, and
healthy coping. Critical times to assess, provide, and fine-tune DSMES are
at diagnosis, annually, when new complicating factors arise (e.g., a change
in health or physical ability), and during transitions (e.g., changes in living
situation or insurance coverage) (ADA, 2020d).
Although DSMES has been shown to lower A1c, improve quality of
life, reduce all-cause mortality risk, and reduce health-care costs, only 5%
to 7% of people eligible for DSMES through Medicare or a private
insurance plan actually receive it (ADA, 2020d). Initial and ongoing
diabetes education is vital to empowering clients with the tools necessary to
optimize self-care.
Medical Nutrition Therapy

Individualized medical nutrition therapy is recommended for all people
with type 1 or type 2 diabetes and prediabetes whether or not medication is
used and regardless of weight status. Because atherosclerotic
cardiovascular disease (ASCVD) is the most common cause of death
among adults with diabetes, nutrition therapy for diabetes includes
strategies to reduce the risk of ASCVD. The goals of nutrition therapy for
adults with diabetes are to (ADA, 2020d)
Atherosclerotic Cardiovascular Disease (ASCVD)
diseases of the cardiovascular system caused by atherosclerosis, which is the accumulation of
plague within arteries. ASCVD includes acute coronary syndromes, myocardial infarction, stable
or unstable angina, coronary or other arterial revascularization, stroke, transient ischemic attack,
or peripheral arterial disease.
• Promote and support healthful eating patterns to

• improve overall health;
• attain and maintain body weight goals;
• achieve individualized goals for glucose, lipids, and blood
pressure;
• delay or prevent diabetes complications;
• individualize a nutrition plan consistent with the clients’ preferences
and culture, health literacy, access to healthy foods, willingness and
ability to change, and barriers to change;
• preserve pleasure in eating; and
• provide practical tools for developing healthy eating patterns rather
than concentrating on individual macronutrients, micronutrients, or
single foods.
Weight Management
Losing and maintaining weight are recommended for all overweight and
obese people with type 1, type 2, or prediabetes. There is strong evidence
that weight loss is highly effective in preventing the progression from
prediabetes to type 2 diabetes and in managing cardiometabolic health in
type 2 diabetes (Evert et al., 2019). Overweight and obesity are also
becoming increasingly prevalent in people with type 1 diabetes.
• For people with prediabetes: A weight loss goal of 7% to 10% of
body weight is recommended to prevent the progression to type 2
diabetes (ADA, 2020d).
• For people with type 1 diabetes who are overweight or obese:
Improvements in A1c and lipid levels are benefits of sustained
weight loss. The use of insulin complicates weight loss efforts
(ADA, 2020d).
• For many overweight and obese people with type 2 diabetes: A
modest weight loss of 5% of body weight is recommended to
achieve clinical improvements in glycemic control, blood pressure,
and/or blood lipid levels (Macleod et al., 2017).
• Weight loss benefits are dose related; more intense weight loss
goals (e.g., >15%) may be indicated (ADA, 2020d).
• A deficit of 500 to 750 cal/day or total calorie intake of 1200 to
1500 cal/day for women and 1500 to 1800 cal/day for men is
appropriate for most people.
• The “best” weight-loss eating pattern is one the client will be able
to maintain.
• Additional strategies may be appropriate in carefully selected
patients (ADA, 2020e):
• Very low-calorie diets (<800 cal/day) and meal replacements
used for a short term.
• Adjunct use of weight loss medications (see Chapter 17).
• Metabolic surgery may be an option of adults who do not
achieve durable weight loss and improvement in comorbidities
(see Chapter 17).
Nutrients and Dietary Recommendations

• People with diabetes generally have the same nutritional
requirements as the general population, and dietary
recommendations to promote health and well-being in the general
public—lose weight if overweight, eat a variety of nutrient-dense
foods; limit saturated fat, trans fat, sodium, and added sugars; eat
more fiber—are also appropriate for people with diabetes. An ideal
macronutrient composition for all people with diabetes has not been
determined, nor is there a universal “diabetic diet” that is
recommended for all people with diabetes (ADA, 2020d).
• The ADA’s nutrition therapy recommendations are summarized in
Box 21.2.
BOX Nutrition Therapy Recommendations for

21.2 People with Diabetes
Carbohydrate
• Although the rise in glucose that occurs after eating is primarily
determined by the amount of carbohydrates consumed (and the amount
of available insulin), the ideal amount of carbohydrate intake for
people with diabetes is unknown (ADA, 2020d).
• Growing evidence shows that lowering overall carbohydrate intake
improves glycemic control for people with diabetes and prediabetes;
however, “low carb” is not definitively defined (Evert et al., 2019).
• Consistent with recommendations for the general population, nutrient-
dense and high-fiber sources of carbohydrate should be chosen
whenever possible over refined or processed carbohydrates with added
sodium, fat, and sugar.
• The majority of carbohydrate calories should come from fruit,
vegetables, whole grains, and legumes.
• Study results are mixed on whether using low-glycemic index eating
patterns improves glucose levels.
Fiber
• Fiber intake should be at least as much as the amount recommended
for the general population (14 g fiber/1000 calories) with at least ½ of
all grain choices being whole grains.
Added Sugar
• Sugar-sweetened beverages, including fruit juices, should be avoided
to help control glucose levels and weight and reduce the risk of CVD
and fatty liver.
• The intake of foods with added sugar should be minimized to avoid
displacing the intake of nutrient-dense foods.
Protein
• Usual protein intake (typically 1.0–1.5 g/kg/day or 15%–20% of total
calorie intake) seems to be appropriate for clients who do not have
diabetic kidney disease.
• For people with diabetic kidney disease, the RDA for protein
(0.8 g/kg) should be maintained. Lowering protein intake beyond this
amount does not improve glycemic control, CVD risk factors, or the
rate of glomerular filtration rate decline (ADA, 2020d).
Fat
• The ideal total fat intake for people with diabetes is not known; the
type of fat consumed is more important than the total amount.
• A Mediterranean-Style Eating Pattern that is rich in polyunsaturated
and monounsaturated fats can improve glucose control and lower CVD
risks and may be an effective alternative to a low-fat, high-
carbohydrate eating pattern (ADA, 2020d).
• Recommendations to eat less saturated fat and trans fat are appropriate
for the general population, including people with diabetes.
• Eating omega-3 fatty acids in fatty fish (docosahexaenoic acid and
eicosapentaenoic acid) and nuts and seeds (alpha-linolenic acid) is
recommended to prevent or treat CVD. The routine use of omega-3
supplements is not supported by evidence.
Sodium
• The general population, including people with diabetes, is advised to
limit sodium intake to <2300 mg/day (Evert et al., 2019).
• Limiting intake to <1500 mg is generally not recommended, even for
those with hypertension (ADA, 2020d).
Micronutrients and Herbal Supplements
• Unless there is an underlying nutrient deficiency, there is no clear
evidence that taking supplements of micronutrients (e.g., vitamins and
minerals) or herbal supplements provides benefits for people with
diabetes (ADA, 2020d).
Alcohol
• Moderate alcohol intake has minimal long-term detrimental effects on
blood glucose control in people with diabetes (ADA, 2020d).
• Adults with diabetes who choose to drink alcohol should follow the
same guidelines as for those people who do not have diabetes: limit
intake to one drink per day or less for women and two drinks per day
or less for men.
• Delayed hypoglycemia is a risk, especially in people who take insulin
or insulin secretagogues.
• Consuming alcohol with food can minimize the risk of nocturnal
hypoglycemia (Evert et al., 2019).
• Nonnutritive sweeteners, such as saccharin, aspartame, acesulfame
potassium, and sucralose, may be acceptable alternatives to caloric
sweeteners for people with diabetes when used in moderation (ADA,
2020d).
• Using them does not guarantee weight loss.
• People are encouraged to consume water in place of sugar-sweetened
and nonnutritive-sweetened beverages.
Source: American Diabetes Association. (2020d). Facilitating behavior change and well-being to
improve health outcomes: Standards of medical care in diabetes—2020. Diabetes Care,
43(suppl 1), S48–S65. https://doi.org/10.2337/dc20-S005; Evert, A., Dennison, M., Gardner,
C., Garvey, W. T., Lau, K. H., MacLeod, J., Mitri, J., Pereira, R. F., Rawlings, K., Robinson, S.,
Saslow, L., Uelmen, S., Urbanski, P. B., & Yancy, W. S. (2019). Nutrition therapy for adults
with diabetes or prediabetes: A consensus report. Diabetes Care, 42(5), 731–754.
https://doi.org/10.2337/dci19-0014
Eating Patterns
Personal preferences (e.g., culture, religion, economics), health status,
metabolic goals, and ability to sustain the eating pattern should be used to
determine the best eating pattern for the individual.
• No single eating pattern has been proven to be consistently better
than any other.
• Eating patterns associated with a decrease in A1c include the
Mediterranean diet, vegetarian and vegan diets, DASH diet, and
low-carb and very low-carb diets (Evert et al., 2019).
• Total calorie intake is important regardless of the type of eating
pattern selected.
• Regardless of the specific eating pattern chosen,
• nutrient-dense foods are emphasized: fruit, vegetables, legumes,
lean proteins, nuts, and whole grains;
• added sugars and refined grains are minimized; and
• whole foods are chosen over highly processed foods.
Meal-Planning Approaches
Managing carbohydrate intake is a primary strategy for achieving glycemic
control (MacLeod et al., 2017). Meal-planning approaches to manage
carbohydrate intake include carbohydrate counting, the plate method, and
food lists. Any of these approaches can be used to implement a healthy
eating pattern, such as Mediterranean-style, DASH, vegetarian or vegan, or
low-carbohydrate eating patterns. Meal-planning approach
recommendations are based on the client’s pharmacological treatment (tab
21.3) and consider the client’s literacy and numeracy abilities, preferences,
and management goals (Evert et al., 2019; McLeod et al., 2017).
Table Meal-Planning Approach

Recommendations for Adults
21.3 Based on Pharmacological
Therapy
Meal-Planning
Pharmacological Approach Rationale for
Therapy Recommendation Recommendation
Multiple daily Carbohydrate Shown to result in significant
injections of counting using decreases in A1c and
insulin or insulin-to- significant increases in
insulin pump carbohydrate quality of life with
therapy ratios continued maintenance of
these improvements for up
to 44 months with no
significant change in weight
using this approach
Fixed insulin Emphasis on In people using fixed insulin
doses or consistency in doses or insulin
insulin the timing and secretagogues, consistent
secretagogues amount of carbohydrate intake can
carbohydrate improve glycemic control
intake using and lower the risk of
any of the hypoglycemia
following:
Carbohydrate
counting
Plate method with
portion control
and a
simplified meal
plan
Food lists and
carbohydrate
choices
Meal-Planning
Pharmacological Approach Rationale for
Therapy Recommendation Recommendation
No diabetes Any of the Monitoring carbohydrate
medication following: intake remains vital for
(e.g., treated Carbohydrate glycemic control
with lifestyle counting A simple healthful eating plan
alone) or Plate method with approach may be best suited
medications portion control for clients with type 2
other than and a diabetes who have low
secretagogues simplified meal health literacy or numeracy
plan skills
Food lists and
carbohydrate
choices
Source: MacLeod, J., Franz, M., Handu, D., Gradwell, E., Brown, C., Evert, A., Reppert, A., &
Robinson, M. (2017). Academy of Nutrition and Dietetics Nutrition Practice Guidelines for type 1
and type 2 diabetes in adults: Nutrition intervention evidence reviews and recommendations.
Carbohydrate Counting
Carbohydrate counting has become a mainstay meal-planning approach and
is fundamental to diabetes self-management in clients on insulin. In clients
with type 1 diabetes, it has been shown to significantly decrease A1c
concentration compared to other meal-planning approaches (Fu et al.,
2016).
• Foods containing carbohydrates are counted as carbohydrate
choices. One carbohydrate choice provides 15 g of carbohydrate per
specified serving size.
• Clients are given a meal plan based on their calorie needs that
specifies the number of carbohydrate choices to consume at each
meal and snack.
• Clients choose whatever carbohydrate sources they want (Box 21.3)
as long as they adhere to their choice allotment.
• Clients are taught how to estimate portion sizes and how to use the
“Nutrition Facts” label for an accurate estimation of carbohydrate
content when available (fig 21.1).
• Box 21.4 features characteristics of a consistent carbohydrate diet
and the number of carbohydrate choices recommended based on
total calorie allotment.
• Guidance is provided on the amount and types of protein foods and
fat to consume. Although only carbohydrates are “counted,” patients
are encouraged to maintain a consistent intake of protein and fat
because they also require insulin for metabolism, provide calories,
and are essential nutrients.
• The two levels of carbohydrate counting are basic and advanced.
Figure 21.1 ▲ Label reading for carbohydrate counting.
BOX
21.3
Carbohydrates that count as 1 carbohydrate choice (15 g

carbohydrate) when consumed in a specified amount. Amounts vary
by item.
• Bread, rolls, crackers
• Grains (e.g., rice) and cereals (cooked and ready to eat)
• Pasta
• Starchy vegetables (e.g., corn, peas, potatoes)
• Fruit—fresh, frozen, canned, or juice
• Milk and yogurt
• Sweets and desserts (e.g., brownie, ice cream, granola bar)
Nonstarchy vegetables provide 5 g carbohydrate in a typical serving.
Three servings are counted as 1 carbohydrate choice.
• Fresh, canned, or frozen varieties of nonstarchy vegetables such as
asparagus, carrots, green beans, summer squash, and tomatoes
• Vegetable juice
• Salad greens
BOX Consistent Carbohydrate Diet

21.4
Characteristics
• Total calorie intake is individualized.
• The number of carbohydrate choices may differ between meals (e.g.,
more for dinner than for breakfast) but should be consistent from day
to day.
No foods are omitted. If sugar-sweetened foods are used, the serving
• size is based on carbohydrate content of the item and the grams of
carbohydrate allotted.
• Clients should consume a variety of carbohydrate sources (e.g.,
starches, vegetables, fruit, milk) and variety within each food group to
ensure an adequate nutritional intake.
• Typical ranges of carbohydrate choices for meals and snacks are as
follows:
Total Calories/Day Carbohydrate Carbohydrate

Choices/Meal Choices/Snack (If
Desired)
1200–1500 (for weight 3 (45 g) 1 (15 g)
loss)
1600–2000 (for weight 4 (60 g) 1–2 (15–30 g)
control)
2100–2400 (for active 5 (75 g) 1–2 (15–30 g)
people)
Basic Carbohydrate Counting

Basic carbohydrate counting is a structured approach with a focus on
consistency in the timing and amount of carbohydrates consumed.
• This approach is recommended for clients who take fixed doses of
insulin, take oral diabetes medications, or manage their diabetes
with lifestyle changes alone.
• Clients use a meal pattern that is consistent from day to day.
• Although the daily amount and timing of carbohydrate consumption
remain constant, there should be variety in the type of carbohydrates
chosen.
• Two sample menus that count carbohydrates in an 1800-calorie meal
pattern are featured in Box 21.5.
BOX Carbohydrate Counting: Samples of
21.5 1800-Calorie Menus
Sample Menu Carbohydrate Sample Menu Carbohydrate

Choices Choices
Breakfast
½ cup orange 1 A parfait
juice consisting of
1 low-fat waffle 1 1¼ cup whole 1
strawberries
Topped with ¾ 1 ½ cup granola 2
cup
blueberries
1 cup nonfat 1 6 oz artificially 1
milk sweetened
vanilla Greek
yogurt
1 tsp light Coffee
margarine
Lunch
6-in. submarine 3 Hamburger on a 2
with 2 oz hamburger
meat and bun
light
mayonnaise
1 apple 1 1 cup oven- 1
baked French
fries
Calorie-free soft Lettuce and
drink tomato
Sample Menu Carbohydrate Sample Menu Carbohydrate
Choices Choices
Light
mayonnaise
1 cup nonfat 1
milk
Dinner
2 taco shells 1 2/3 cup 2
(each 5 in spaghetti
diameter) noodles
2 meatballs
3 oz taco meat ½ cup spaghetti 1
sauce
2 cups 1 Tossed salad
combined 1 slice Italian
lettuce, bread
tomato, onion
1/3 cup rice 1 1 tsp butter 1
1 cup cubed 1 Calorie-free soft
papaya drink
Bedtime Snack
½ cup shredded 1 3 cups added 1
wheat popcorn
1 cup nonfat 1 Calorie-free
milk flavored
seltzer water
Total 14 13
carbohydrate
choices/day
Note. 4 carbohydrate choices/meal, 1–2 carbohydrate choices per snack.
Think of Darius. He has been counseled on basic

carbohydrate counting and has a meal pattern that allows
him four carbohydrate choices per meal and two for a
bedtime snack. His usual dinner is 4 pieces of thick crust
cheese and pepperoni pizza and a sugar-free soft drink. He
was shocked to learn that each piece of pizza counts as 2½
carbohydrate choices. How can Darius continue to enjoy
pizza and still adhere to his meal plan?
Advanced Carbohydrate Counting

Advanced carbohydrate counting is more flexible than basic carbohydrate
counting in that it gives the client the freedom to choose how much
carbohydrate they want to eat at each meal and the responsibility to
calculate the corresponding insulin dose.
• Advanced carbohydrate counting is best suited to clients who take
multiple daily injections of insulin (e.g., basal insulin 1 to
2 times/day and bolus insulin at meals) or use an insulin pump.
• Clients are taught how to determine their bolus insulin dose
according to the amount of carbohydrate consumed based on a given
insulin-to-carbohydrate ratio (ICR). For instance, if a meal
provides 45 g of carbohydrate and the individual’s ICR is 1:15, the
amount of bolus insulin needed is 3 units of rapid-acting insulin (45
divided by 15 = 3).
• Insulin pumps are programmed with the individual’s ICR; the client
simply inputs the amount of carbohydrates they will eat, and the
pump calculates and secretes the appropriate bolus dose.
• Patients are able to adjust the bolus insulin dose to compensate for
deviations in preprandial glucose levels.
Basal Insulin
insulin injected once or twice a day to regulate glucose levels between meals. Types include the
intermediate-acting insulin NPH (e.g., Humulin N, Novolin N), long-acting insulin
(e.g., glargine/Lantus), and ultra-long–acting insulin (e.g., degludec/Tresiba).
Bolus Insulin
the rapid-acting insulin injected, such as aspart (Novolog), lispro (Humalog), and glulisine
(Apidra), at mealtimes to counteract the rise in blood glucose after eating.
Insulin-to-Carbohydrate Ratio (ICR)

the number of units of rapid-acting insulin needed to handle a specific number of grams of
carbohydrate consumed. An ICR of 1:15 means that 1 unit of rapid-acting insulin is needed for
each 15 g of carbohydrate consumed.
Plate Method for Meal Planning

The plate method for meal planning with portion control serves as a simple
approach to meal planning.
• This approach is suited to people who have difficulty understanding
health and math concepts. It may also be an effective strategy for
older adults.
• A 9" dinner plate is used to illustrate healthy balance and portion
control (fig 21.2).
• Additional guidance is provided on healthy foods to emphasize (e.g.,
whole grains, lean meats) and nutrients to limit (e.g., salt, added
sugar, saturated fat).
• Accurate estimation of portion sizes is stressed (see sections Food
Lists for Diabetes and Estimating Portion Size).
Figure 21.2 ▲ The plate method of meal planning.
Food Lists for Diabetes

The Choose Your Foods: Food Lists for Diabetes is a meal-planning
approach that groups foods into lists that, per serving size given, are similar
in carbohydrate, protein, fat, and calories based on rounded averages (ADA
& Academy of Nutrition and Dietetics, 2019).
• Its three major categories are carbohydrates, protein, and fats.
• The carbohydrate list includes sub-lists for starch, fruit, milk,
nonstarchy vegetables, and sweets/desserts/other carbohydrates.
• The protein list has sub-lists for lean, medium-fat, high-fat, and plant-
based proteins.
• The fat list is divided into 3 sub-lists based on whether they
predominately provide saturated, monounsaturated, or saturated
fat.
• An individualized meal plan specifies the number of servings allowed
from each list for each meal and snack.
• Any food (in the serving size specified) can be exchanged for any
other within each list.
• Information is provided on the serving sizes, calories, and number of
carbohydrate choices per serving of various alcohol beverages; so
clients who choose to drink alcohol know how to count it in their
meal plan.
• As with carbohydrate counting, accurate portion sizes are vital to
maintaining a consistent carbohydrate and calorie intake.
• The food lists can be helpful for people who want, or need, structured
meal-planning guidance and are able to understand complex details.
• The food list approach is not better than carbohydrate counting for
maintaining glycemic control, is less flexible, and may not be
appropriate or acceptable for all age, ethnic, and cultural groups.
Estimating Portion Sizes

Correctly estimating portion sizes is a crucial component of all meal-
planning approaches, especially carbohydrate counting. Inaccurate portion
size estimates have the potential to cause weight gain or loss and hypo- or
hyperglycemia. Food models or measuring cups can help teach appropriate
portion sizes to patients. Other strategies that may help include urging
patients to
• measure foods once per week to reinforce serving sizes and correct
quantification;
• note how a portion size looks on the plate or where it comes to in
their bowls or cups;
• create a cheat sheet of the carbohydrate content of foods they usually
eat;
• check the nutritional content of restaurant items online before
ordering food out; and
• use standard household items to approximate size; for instance, the
size of a baseball is approximately 1 cup and the size of a deck of
cards is approximately 3 oz of meat.
Promoting Behavior Change

The diagnosis of diabetes often triggers anxiety and uncertainty. People
often see “diet” as the most difficult part of treatment. Even people with
healthy eating patterns may need to adjust their intake to improve glycemic
control. Giving someone a list of dos and don’ts can add to a resentful
client’s frustration. Before recommending changes, it is useful to ask the
following:
• What are your goals?
• What behaviors do you want to change?
• What changes can you make in your present lifestyle?
• What obstacles may prevent you from making changes?
• What changes can you make right now?
• What changes would be most difficult for you to make?
Mastering the intricacies of nutrition therapy for diabetes—what, when,

and why—occurs over a continuum, from learning basic facts to
assimilating and implementing more advanced information (fig 21.3).
Figure 21.3 ▲ An illustration of knowledge and skills attained in
stepwise fashion. Actual progression and concepts learned vary among
individuals.
• Individuals differ in how much information they want or need to

know and in how motivated they are to improve their eating
behaviors.
• Ideally, positive changes occur progressively over time in stepwise
fashion with the client actively involved in goal setting, self-
monitoring, and record keeping.
• In reality, motivation to change eating behaviors may be initially high
but commitment and diligence may wane when clients realize that
“cheating” does not cause immediate illness.
• Periodic and ongoing follow-up is necessary.
Diabetes Medications
People with type 1 diabetes require exogenous insulin. Most people with
type 1 diabetes should be treated with multiple daily injections of prandial
and basal insulin, or continuous subcutaneous insulin infusion (ADA,
2020f). Rapid-acting insulin analogs are recommended for most people
with type 1 diabetes to reduce the risk of hypoglycemia.
For people with type 2 diabetes, metformin is recommended at the time
of diagnosis, along with lifestyle modifications, unless there are
contraindications (ADA, 2020f).
• It is recommended that metformin be continued as long as it is
tolerated and that other agents, including insulin, should be added to
metformin as needed.
• Clients who continue to lose weight, who have persistent symptoms
of hyperglycemia, or whose A1c or blood glucose levels are very
high may be candidates for early introduction of insulin.
• Because of the progressive nature of the disease, it is common for
most people with type 2 diabetes to eventually need the greater
potency of injectable medications (ADA, 2020f).
General nutrition-related considerations regarding the use of

antidiabetic medications are as follows:
• Although the exact cause is unknown, metformin is associated with
vitamin B12 deficiency.
• Macrocytic anemia, neurologic changes (e.g., paresthesia of the
hands and feet, decreased sense of position, depression), and
gastrointestinal (GI) changes (e.g., anorexia, indigestion, diarrhea
or constipation) may develop. Neurological impairments can be‐
permanent without adequate vitamin B12 supplementation.
• Annual testing of vitamin B12 levels should be considered in people
taking metformin, especially in those with anemia or peripheral
neuropathy (Evert et al., 2019).
• People who take medications that can cause hypoglycemia (e.g.,
insulin, insulin secretagogues) should
• carry a readily absorbable source of carbohydrate with them at all
times to treat hypoglycemia (see section Hypoglycemia);
• keep an appropriate source of carbohydrate on the nightstand in
case hypoglycemia develops during the night.
• In people who are overweight or obese, a side effect of weight loss
may be considered positive whereas weight gain is a negative effect.
Physical Activity
Exercise has been shown to improve glycemic control, lower ASCVD risk
factors, contribute to weight loss, and improve well-being (ADA, 2020d).
• Moderate-to-high amounts of aerobic activity are associated with
lower cardiovascular and overall mortality risks in both type 1 and
type 2 diabetes (ADA, 2020d).
• Physical activity is as important for people for type 1 diabetes as it is
for the general population, but its role in preventing diabetes
complications and managing glucose levels is not as clear as it is for
those with type 2 diabetes (ADA, 2020d).
• Physical activity recommendations for adults with diabetes are
similar to those of the general population (ADA, 2020d) (Box 21.6).
Exercise
a specific form of physical activity that is structured and intended to improve physical fitness.
Physical Activity
all movement that increases calorie expenditure.
BOX Physical Activity Suggestions and

21.6 Considerations for Adults with Diabetes
Activity Suggestions
• Engage in 150 minutes or more per week of moderate-intensity
physical activity. One way to achieve this goal is to exercise at least 20
to 25 minutes every day.
• Engage in activities that work all major muscle groups (e.g., legs, hips,
back, abdomen, chest, shoulders, and arms) on 2 or more days a week.
• Stretching exercises promote flexibility and balance.
• Consume adequate fluid during activity to avoid dehydration.
• Wear cotton socks and properly fitting athletic shoes. Check feet for
blisters and other injuries after exercising.
• Check blood glucose level before engaging in physical activity,
especially if insulin is used.
• If serum glucose is <100 mg/dL, consuming an extra 15 to 30 g of
carbohydrate may be necessary to avoid hypoglycemia.
• If serum glucose is >240 mg/dL, it may not be safe to engage in
physical activity, particularly if ketones are present in the urine
because ketoacidosis may occur during activity.
• Check blood glucose levels after exercising.
Source: Centers for Disease Control and Prevention. (2018, April 24). Get active!
https://www.cdc.gov/diabetes/managing/active.html
ACUTE DIABETES COMPLICATIONS

Untreated or poorly controlled diabetes can lead to acute life-threatening
complications related to high blood glucose concentrations. Conversely,
hypoglycemia caused by overuse of medication, too little food, or too much
exercise can also be life threatening.
Diabetic Ketoacidosis
People with type 1 diabetes are susceptible to diabetic ketoacidosis (DKA),
characterized by hyperglycemia (glucose levels >250 mg/dL) and
ketonemia.
• DKA is caused by a severe deficiency of insulin or from physiologic
stress, such as illness or infection.
• It is sometimes the presenting symptom when type 1 diabetes is
diagnosed.
• Hyperventilation, diabetic coma, and death are possible.
• DKA rarely develops in people with type 2 diabetes because only
very little insulin is needed to prevent ketosis. If DKA does occur in
people with type 2 diabetes, infection or illness is usually to blame.
Hyperosmolar Hyperglycemic State

Hyperosmolar hyperglycemic state (HHS) is characterized by
hyperglycemia (>600 mg/dL) without significant ketonemia.
• HHS occurs most commonly in people with type 2 diabetes because
they have enough insulin to prevent ketosis.
• Dehydration and heat exposure increase the risk; illness or infection
is usually the precipitating factor.
• Older people may be particularly vulnerable because they have a
diminished sense of thirst or may be unable to replenish fluid losses
due to illness or physical impairments.
• HHS develops relatively slowly over a period of days to weeks.
• The best protection against HHS is regular glucose monitoring.
Hypoglycemia
Hypoglycemia (blood glucose level <70 mg/dL) occurs from taking too
much insulin or some oral medications and inadequate food intake, delayed
or skipped meals, extra physical activity, or consumption of alcohol without
food.
• Symptoms include weakness, shakiness, dizziness, cold sweat,
clammy feeling, headache, confusion, irritability, and light-
headedness.
• Readily absorbable forms of carbohydrate, such as pure sugars, are
used to quickly raise blood glucose levels; items like chocolate candy
bars, which contain fat that slows gastric emptying time and delays
the rise in blood glucose, are not recommended.
• Mild hypoglycemia is treated with the “15–15 Rule” (Box 21.7)
• Regular blood glucose monitoring and exercising with someone are
recommended.
• Frequent bouts of hypoglycemia may mean the care plan needs to be
revised or further education is needed.
• Clients with long-standing diabetes may develop hypoglycemic
unawareness. This occurs because the body no longer signals
hypoglycemia. Consistent monitoring of blood glucose is especially
important for people who are not cognizant of hypoglycemic
symptoms.
BOX The “15-15 Rule”

21.7
Eat 15 g of readily absorbable carbohydrate if blood glucose is

<70 mg/day.
Wait 15 minutes. If glucose level is still <70 mg/dL, repeat the process.
When glucose is back to normal, eat a meal or snack.
Each of the following provides approximately 10 to 15 g of readily
absorbable sugar:
4 glucose tablets
½ cup fruit juice
4 to 6 oz regular soft drink (not diet)
1 tbsp sugar, honey, or corn syrup
5 to 6 Life Savers
8 SweeTARTS
16 Skittles
1 fruit roll-up
2 tbsp raisins
1 tube (0.68 oz) of Cake Mate decorator gel
SICK-DAY MANAGEMENT
Acute illnesses, even mild ones such as a cold or flu, can significantly raise
blood glucose levels. Unless otherwise instructed by the physician, clients
should maintain their normal medication schedule, monitor their blood
glucose levels every 2 to 4 hours, maintain an adequate fluid intake, and
continue with their normal meal plan. Softer foods such as soup, crackers,
applesauce, and fruit juice may help maintain an adequate intake. If the
client cannot tolerate solids, carbohydrate targets can be met by consuming
sweetened liquids, which are generally a well-tolerated source of
carbohydrates and fluid. A daily intake of 150 to 200 g of carbohydrates,
approximately 50 g (approximately three carbohydrate choices) every 3 to
4 hours, is recommended. Examples of items that may be best tolerated
during illness are as follows (each serving specified provides approximately
one carbohydrate choice [15 g of carbohydrate]):
• 6 oz regularly sweetened ginger ale
• 8 oz sports drink
• ½ cup ice cream
• ½ cup apple juice
• 1 frozen 100% juice bar
• ¼ cup sherbet or sorbet
• ½ cup gelatin
• 1 cup cream soup made with water
Consider Darius. He developed the flu and was advised to

drink plenty of fluids; continue with his four carbohydrates
per meal pattern by using regular ginger ale, fruit juice, and
ice cream; and increase his monitoring of blood glucose and
ketones. He is reluctant to consume regular ginger ale and
ice cream because he knows sugar is bad for him. How do
you respond?
Diabetes in the Hospital

Consistent carbohydrate meal plans are used by many hospitals; these
menus also typically feature heart-healthy selections that limit saturated fat,
trans fat, and sodium.
• The American Diabetes Association does not endorse any single meal
plan or specified percentages of macronutrients (ADA, 2020g).
• The following hospital diets previously designated for clients with
diabetes are obsolete: “no concentrated sweets,” “no sugar added,”
“low sugar,” and “liberal diabetic” diets. These diets do not reflect the
current nutrient recommendations for diabetes, are unnecessarily
restrictive in sugar, and may give clients the false impression that
glycemic control is achieved by limiting sugar.
• Enteral formulas designed for clients with diabetes appear to be
superior to standard formulas in controlling postprandial glucose,
A1c, and the insulin response (ADA, 2020g).
Recall Darius. He is admitted to the hospital with
pneumonia and uncontrolled diabetes. He is ordered a soft
diet without any carbohydrate restrictions. He is confused by
the lack of restriction and announces he is no longer going to
count carbohydrates because it is too confusing and difficult.
What strategies are available to help Darius eat a
hypocaloric meal plan to promote weight loss and manage
diabetes?
LIFE-CYCLE CONSIDERATIONS
There are unique nutrition therapy challenges for managing diabetes in

children and adolescents as well as in older adults. Special considerations
for these groups are presented in the following sections.
Children and Adolescents

Diabetes management in children and adolescents is complicated by the
impact of growth on nutrient needs, irregular eating patterns, and erratic
activity levels. Other unique challenges include the ability to provide self-
care, supervision in childcare and school settings, neurological vulnerability
to hypoglycemia and hyperglycemia in young children, and possible
adverse neurocognitive effects of diabetic ketoacidosis (ADA, 2020h).
Young children are unable to recognize or articulate hypoglycemia.
Psychosocial issues and family stresses can impact diabetes management.
Youth with type 1 diabetes may have subclinical CVD within the first
decade of diagnosis (ADA, 2020h). Current standards for diabetes
management reflect the need to lower glucose as safely as possible (ADA,
2020h). Lower A1c in adolescence and young adulthood is associated with
lower risk and rate of microvascular and macrovascular complications
(ADA, 2020h). Individualized nutrition therapy for youth is an essential
component of diabetes management.
Nutrition Therapy Recommendations and Considerations for

Type 1 Diabetes
• Family habits, food preferences, religious or cultural preferences,
schedules, physical activity, and the youth’s and family’s literacy and
numeracy skills are all considered when determining the nutrition
plan of care.
• Either carbohydrate counting or experience-based estimation can be
used to monitor carbohydrate intake (ADA, 2020h).
• Failure to provide adequate calories and nutrients results in poor
growth, as do poor glycemic control and inadequate insulin
administration.
• Excessive weight gain occurs from excessive calorie intake,
overtreatment of hypoglycemia, or excess insulin administration.
• Neither withholding food nor having a child eat when not hungry is
an appropriate strategy to manage glucose levels.
• Increased use of basal-bolus regimens, insulin pumps, frequent
blood glucose monitoring, goal setting, and improved client
education in youth are associated with more children achieving
blood glucose targets (ADA, 2020h).
• Advanced carbohydrate counting and intensive insulin regimens
can provide flexibility for erratic eating, activity, and growth.
Type 2 Diabetes in Youth

Type 2 diabetes in youth has increased over the past 20 years and estimates
suggest an incidence of ~5000 new cases per year in the United States
(ADA, 2020h). Nutrition-related considerations are as follows (ADA,
2020h):
• Evidence suggests type 2 diabetes in youth differs not only from type
1 but also from type 2 diabetes in adults in that there is a faster
decline in beta-cell function and accelerated development of diabetes
complications (ADA, 2020h).
• Risk factors for type 2 diabetes in youth include adiposity, family
history of diabetes, female sex, low socioeconomic status, and certain
ethnicities and racial minorities.
• Youth who are overweight or obese should participate with their
families in a comprehensive lifestyle program with the goal of losing
7% to 10% of excess weight.
• Lifestyle intervention focuses on an increase in physical activity and
healthy eating patterns that emphasize nutrient-dense foods and
minimize calorie-dense foods, especially sugar-sweetened beverages.
• Distinguishing between type 1 and type 2 diabetes can be difficult
due to the increasing prevalence of overweight and obesity among
youth, including those with type 1 diabetes.
Diabetes in Later Life

In general, older adults are at greater nutritional risk than younger adults
due to a variety of changes that may occur with aging, such as oral and GI
changes (e.g., difficulty chewing, decreased nutrient absorption), central
nervous system changes (e.g., cognitive impairments, depression), sensory
losses (e.g., decreased sense of smell and taste), reliance on medications,
social isolation, and decreased appetite. Older adults with diabetes may be
at even greater nutritional risk than the general older population related to
the following:
• Higher rates of comorbidities: hypertension, coronary heart disease,
and stroke.
• Higher risk of reduced muscle strength, poor muscle quality, and
accelerated loss of muscle mass, resulting in sarcopenia (ADA,
2020i).
• Frailty because diabetes is also an independent risk factor for frailty.
Frailty impairs physical functioning and increases the risk of poor
health outcomes (ADA, 2020i).
An optimal nutrient and protein intake, along with aerobic physical
activity and resistance training, is encouraged for all older adults who can
safely engage in such activities (ADA, 2020i). Glycemic goals may be
based on the health of the client, including their remaining life expectancy.
NURSING
PROCESS Type 2 Diabetes
Mark is 52 years old and is sedentary. His doctor has been monitoring
his fasting blood glucose and cholesterol levels for several years, urging
Mark to eat better and exercise or he would eventually need medications
to bring down both his glucose and cholesterol levels. Mark was
unmotivated to change until he was recently diagnosed with type 2
diabetes. His mother went blind from type 2 diabetes, and he now
realizes he must make lifestyle changes to manage his diabetes. He
admits to knowing little about diabetes management and is seeking
nutrition information. He is 5 ft 9 in. tall and weighs 190 pounds.
Assessment
Medical– • Medical history and comorbidities, including
Psychosocial hyperlipidemia, hypertension, ASCVD, renal
History impairments, neuropathy, and GI complaints.
• Use of prescribed and over-the-counter
medications that may affect nutrition.
• Psychosocial and economic issues such as the
living situation, cooking facilities, adequacy of
food budget, education, need for food assistance,
and level of family and social support.
• Usual activity patterns.
Assessment
Anthropometric • Height, current weight, usual weight; recent
Assessment weight history.
• BMI.
• Waist circumference to identify abdominal
obesity.
Biochemical • Hemoglobin A1c, fasting glucose levels, glucose
and Physical tolerance results.
Assessment • Lipid profile.
• Measures of renal function, if available.
• Blood pressure.
Assessment
Dietary • How many meals and snacks do you usually eat
Assessment in a day? Do you ever skip meals? Do you eat at
regular intervals? When do you eat snacks?
• What is a typical day’s intake?
• Have you ever tried to follow a diet or improve
your eating habits?
• What changes can you make in your present
lifestyle?
• What obstacles may prevent you from making
changes?
• What changes would be difficult to make?
• What questions do you have about nutrition for
diabetes?
• How is your appetite?
• Do you have any food intolerances or allergies?
Do you ever have GI symptoms that affect what
you eat?
• How do you feel about your weight?
food preferences?
• Who prepares your meals?
• Do you take vitamins, minerals, or other
supplements?
Analysis
Possible Food- and nutrition-related knowledge deficit
Nursing related to a new diagnosis of type 2 diabetes as
Analysis evidenced by request for information.
Planning
Client Short term
Outcomes
Assessment
The client will do the following:
• Explain carbohydrate counting.
• Begin strategies to shift toward a nutritionally
adequate, balanced, and varied diet that has the
following:
• Four carbohydrate choices at each meal and
two at a bedtime snack that are composed of a
variety of fruits, vegetables, whole grains, and
low-fat or nonfat milk
• 4 to 6 oz of protein/day
• Small amounts of healthy fats
• Little saturated fat and minimal trans fats
• Lose 1 to 2 pounds/week.
• Eat three meals plus a bedtime snack at
approximately the same times every day.
• Keep periodic food records that include the
timing of meals and snacks and type and amount
of food eaten.
• Walk 10 minutes three times a day at least 3 days
a week.
Long term
• Lose 13 pounds in 6 months (7% of initial
weight).
• Sustain his lower weight.
• Achieve hemoglobin A1c and preprandial and
postprandial blood glucose levels within target
levels established by his physician.
• Improve lipid profile.
• Prevent or delay chronic complications.
Assessment
• Increase physical activity to at least 30 minutes
daily five times per week.
Nutrition Introduce basic concepts: characteristics of a healthy
Therapy eating pattern, sources of carbohydrates, appropriate
serving sizes for carbohydrates, and how many
carbohydrate choices are prescribed for each meal
and snack.
The role of nutrition therapy in managing blood
glucose levels, including the following:
• Nutrition therapy is essential and nutrition is
important even when no symptoms are apparent.
• Modest weight loss can achieve glycemic goals.
• If medication is prescribed, it is used in addition
to nutrition therapy, not as a substitute.
• Ongoing or follow-up counseling is necessary to
make adjustments and expand skills and
knowledge to optimize diabetes management.
Eating plan essentials, including the importance of
the following:
• Eating meals and snacks at regular times every
day.
• Eating a varied, nutrient-dense eating pattern that
limits refined foods and foods processed with
added sugar, fat, or sodium.
• Eating approximately the same amount of food
every day, especially the same amount of
carbohydrates.
• Eating enough high-fiber foods such as whole-
wheat bread, whole-grain ready-to-eat cereals,
Assessment
whole-wheat pasta, brown rice, oats, vegetables,
fruit, and dried peas and beans.
• Avoiding sugar-sweetened beverages and limiting
empty calorie foods
Behavioral matters, including the following:
• How to read labels to determine the amount of
carbohydrate choices a serving of food provides.
• Not skipping meals or snacks.
• How to order from a restaurant menu.
• Physical activity goals.
• Having a source of glucose handy at all times.
• The importance of monitoring food intake.
• Where to get additional information.
Evaluation
Evaluate and • Food intake records for consistency in meal
Monitor timing, the number and quality of carbohydrate
choices per meals and snacks, and overall quality
and adequacy of food choices made.
• Appetite/satiety.
• Weight.
• Laboratory data as available.
• Need for nutritional counseling.
• Progress toward physical activity goals.
How Do You Respond?

Are “dietetic” products like candy and cookies worth
the added expense? Dietetic products are not necessarily
calorie free or specifically intended for people with
diabetes. Foods that are labeled “dietetic” may be made
without sugar, without salt, with a particular type of fat,
or for particular food allergies. Read the ingredient label
and check with a nutrition counselor before adding a
dietetic food to the diet—or avoid dietetic foods
altogether because they are expensive and usually do not
taste as good as the foods they are intended to replace.
Can I save some carbs from breakfast and lunch for a
special dinner? Carbohydrate intake should stay
relatively consistent, not light for 2 meals so it can be
heavier at the other. This is particularly true for people on
fixed insulin regimens or who take insulin secretagogues.
Instead of skimping during the day to add carbs at dinner,
on occasion it is fine to forgo some healthy carb dinner
choices (e.g., fruit, grains, milk) for a small portion of
special dessert. It is better to make reasonable
adjustments on occasion than to just add extra carbs.
REVIEW CASE STUDY
Keisha is a 42-year-old black woman with a BMI of 29. She was recently
diagnosed with diabetes and hypertension. Her mother and two sisters also
have type 2 diabetes. She is the mother of three children and had gestational
diabetes with her last two pregnancies. Although she knows she should
exercise, she doesn’t have time in her busy schedule.
The doctor gave her a 1500-calorie diet and told her if her glucose does
not improve, she will have to go on medication and possibly insulin. She
has tried the “diet” but finds it too restrictive: It tells her to eat things she
doesn’t like (such as milk) and won’t let her eat the things she loves
(like sweetened tea and fast foods). She is scared of the potential for
needing insulin and the complications associated with diabetes.
• What risk factors does Keisha have for type 2 diabetes?
• Is a 1500-calorie diet appropriate for her? Should it promote weight loss
or maintain her current weight?
• What would you tell Keisha about weight and diabetes management?
• What would you tell her about drinking milk? What about sweetened tea
and fast foods?
• What approaches would you take to improve compliance yet increase her
satisfaction with eating?
• What other lifestyle changes would you propose to Keisha to manage
diabetes and reduce the risk of complications?
STUDY QUESTIONS
1 Which statement indicates the client understands nutrition

recommendations regarding carbohydrate intake?
a. “People with diabetes should not eat sugars and foods that contain
sugars.”
b. “It is important to consume the proper balance of starch, sugar, and
fiber at each meal.”
c. “It is important to consume the correct amount of carbohydrate at each
meal and snack.”
d. “People with diabetes should avoid starchy foods.”
2 The client with type 1 diabetes asks if they can have a glass of wine with
dinner on the weekends. Which of the following would be the nurse’s
best response?
a. “It is better to have wine between meals than with meals so that it
doesn’t interfere with your normal food intake.”
b. “People with diabetes cannot have alcohol because it raises blood
glucose levels very quickly.”
c. “A mixed drink would be better than wine because the mixer will help
slow the absorption of the alcohol.”
d. “An occasional glass of wine with dinner will not cause problems. Be
sure to limit yourself to one serving.”
3 When developing a teaching plan for a client who is taking insulin, which
of the following foods would the nurse suggest the client carry with him
to treat mild hypoglycemia?
a. Crackers
b. Peanuts
c. Chocolate drops
d. Life Savers
4 The best approach for monitoring carbohydrate intake is to use
a. the food list system
b. carbohydrate counting
c. the plate method
d. the approach that best helps the individual control blood glucose levels
5 How many carbohydrate choices are provided in a serving of food that
supplies 19 g of carbohydrate?
a. 1
b. 2
c. 3
d. 4
6 The nurse knows her instructions about label reading have been effective
when the client verbalizes that to determine the amount of carbohydrate
in a serving you must
a. use only the grams of added sugars
b. use only the grams of total carbohydrate
c. add the grams of total carbohydrate and grams of added sugars
together
d. add the grams of total carbohydrate, grams of added sugars, and grams
of dietary fiber together
7 What is the priority for preventing diabetes in people who are at high
risk?
a. Eat a low-carbohydrate diet.
b. Consume a consistent amount of carbohydrate at every meal.
c. Achieve moderate weight loss through increased activity and lowered
calorie intake.
d. Eat a low-sugar diet.
8 Which types of food provide carbohydrates? (Select all that apply.)
a. Vegetables
b. Fruit
c. Milk
d. Animal proteins

Clients with Diabetes Mellitus
Diabetes is a group of diseases characterized by hyperglycemia related to
an absent or ineffective secretion of insulin. The metabolism of all three
macronutrients is affected, resulting in high blood glucose levels, increased
levels of fatty acids and triglycerides in the blood, and muscle wasting. The
prevalence is increasing.
Type 1 Diabetes. Characterized by an absolute absence of insulin.
• 5% to 10% of diabetes cases are type 1.
• Most often diagnosed before the age of 18 years.
Caused by an autoimmune response that damages or destroys
• pancreatic beta cells. Interaction between genetic and environmental
factors (e.g., viral infection) may be responsible.
Type 2 Diabetes. Characterized by defective insulin secretion and
insulin resistance.
• 90% to 95% of diabetes cases are type 2.
• Most often diagnosed after age 45; prevalence among younger people
is increasing.
• Exact cause is unknown, but genetic and environmental factors, such
as overweight and inactivity, are contributing factors.
Prediabetes. Characterized by glucose levels that are not high enough to

reach the criteria for diabetes but are above normal.
• Almost 40% of people >18 years of age have prediabetes.
• Rather than viewed as a clinical entity, it should be considered an
increased risk for diabetes and CVD.
• Strongly associated with obesity, especially central obesity,
dyslipidemia with high triglycerides and/or low HDL cholesterol, and
hypertension.
• Lifestyle and behavioral therapy, including an individualized
hypocaloric meal plan, is highly effective in preventing type 2 diabetes
and improving cardiometabolic markers.
Long-Term Diabetes Complications. Sustained hyperglycemia alters
glucose metabolism in virtually every cell.
• Damage occurs in micro- (e.g., retinopathy, nephropathy, neuropathy)
and macro- (e.g., cardiovascular) vessels.
• Other complications include impaired wound healing, gangrene,
periodontal disease, and increased susceptibility to other illnesses.
Lifestyle Management
Diabetes is a progressive disease that requires lifelong treatment. Lifestyle
management, which includes DSMES, medical nutrition therapy, and
physical activity, is the cornerstone of diabetes management.
Diabetes Self-Management Education and Support. Imparts the
skills and knowledge necessary for clients to manage their diabetes.
• Recommended for all people at the time of diabetes diagnosis.
• Support is ongoing and necessary in response to changes in health,
age, or life circumstances.
• Only a small percentage of clients participate in DSMES.
Medical Nutrition Therapy. Individualized nutrition therapy is
recommended for all people with type 1 or type 2 diabetes and prediabetes.
• A major goal is to promote healthy eating to improve overall health;
manage weight; achieve glucose, lipid, and blood pressure goals; and
prevent/delay diabetes complications.
• Weight Management. Losing and maintaining weight are
important for overweight and obese people with type 1, type 2, or
prediabetes. Weight loss can prevent the progression of prediabetes
to type 2 diabetes. Five to ten percent weight loss leads to
improvements in glycemic control, blood pressure, and blood lipid
levels.
• Nutrient and Dietary Recommendations. Nutrient needs of
people who have diabetes are not different from the general
population. There is no “diabetic diet” with prescribed percentages
of calories for each macronutrient.
• Eating patterns. No single eating pattern has been proven to be
consistently better than any other. Patterns associated with a
decrease in A1c include the Mediterranean diet, vegetarian and
vegan diets, DASH diet, and low-carb and very low-carb diets.
• Carbohydrates. Low-carb eating patterns are beneficial for people
with diabetes and prediabetes; however, “low carb” is not
definitively defined. High-fiber sources are recommended; added
sugar intake should be minimized.
• Protein. Usual protein intake is appropriate unless the client has
diabetic kidney disease, in which case intake should be lowered to
the recommended dietary allowance (RDA) of 0.8 g/kg body
weight.
• Fat. The type of fat is more important than the total amount.
Unsaturated fats are encouraged; saturated and trans fats are
restricted.
• Sodium. People with diabetes have the same guideline as the
general population—limit intake to 2300 mg/day.
• Micronutrient and herbal supplements. Micronutrient
supplements are not helpful except if the client has a deficiency. No
herbal supplements are recommended to improve glycemic control.
• Alcohol. Moderate alcohol has minimal acute or long-term effects
on blood glucose. If consumed, it should be accompanied by food to
decrease the risk of hypoglycemia.
Meal-Planning Approaches
• Carbohydrate counting
• 15 g of carbohydrates equal one carbohydrate “choice.”
• Clients follow a meal plan that specifies the number of carbohydrate
choices per meal and snack.
• Clients choose how to satisfy their choice allotment.
• Basic carb counting uses a consistent daily meal plan; advanced
counting adjusts the carbohydrate allotment based on premeal
glucose and insulin dosage.
• Plate method: Uses a dinner plate to illustrate proportion and balance.
• Food lists for diabetes: Similar to carbohydrate counting but the meal
plan also includes servings of protein and fat.
• Estimating portion sizes: Accuracy in portion sizes is vital to avoid
undesirable weight changes or hypo- and hyperglycemia.
Promoting Behavior Change. “Diet” is often considered the most
difficult part of managing diabetes. Behavior change should occur over a
continuum based on how much information the client needs or wants to
know.
Physical Activity. Physical activity guidelines for people with diabetes
are similar to those of the general public. Aerobic exercise, resistance
training, and a decrease in sedentary time are recommended.
Acute Diabetes Complications

Diabetic ketoacidosis. Characterized by glucose >250 mg/dL and
ketonemia; usually occurs in only people with type 1 diabetes.
Hyperosmolar hyperglycemic state. Characterized by glucose
>600 mg/dL without significant ketonemia; occurs most commonly in
people with type 2 diabetes. Regular glucose monitoring helps to prevent it.
Hypoglycemia. Characterized by glucose < 70 mg/dL that occurs from
too much insulin/medication, inadequate food intake, extra physical
activity, or alcohol consumed without food. A quickly absorbed simple
sugar is needed to raise glucose.
Sick-Day Management
General advice during acute illness: Maintain the usual medication
schedule, monitor blood glucose levels closely, consume adequate fluids,
eat the usual amount of carbohydrate, and use sugar-sweetened fluids (e.g.,
sugar-sweetened soft drinks, ice cream, sherbet) if liquids are tolerated over
solids.
Life-Cycle Considerations
Children and Adolescents. Diabetes management is complicated by
growth needs, irregular eating patterns, emotional immaturity, and erratic
activity levels. Glycemic goals are set by balancing the long-term benefits
of lowering A1c against the risks of hypoglycemia and the burdens of
intensive regimens.
Nutrition recommendations:
• Individualize the meal plan.
• Use carbohydrate counting/experience-based portion estimation to
achieve consistency in intake.
• Overweight and obese youth with type 2 diabetes should participate
with their families in a lifestyle intervention program with the goal of
losing 7% to 10% of body weight.
Older adults. Aging increases nutritional risk; diabetes adds to the risk.
An adequate nutrient intake, especially of protein, along with aerobic
physical activity and resistance training, is recommended, especially for
older adults who are frail.
Figure sources: shutterstock.com/Raihana Asral, shutterstock.com/Zern Liew,
shutterstock.com/oksana2010

book at
Websites
American Diabetes Association at www.diabetes.org
Joslin Diabetes Center at www.joslin.org
National Institute of Diabetes and Digestive and Kidney Diseases at www.niddk.nih.gov
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Chapter with Cardiovascular
22 Disorders
Jacob Holzhausen
Jacob is 49 years old and wants to eat healthier and
lose weight. He is 6 ft 1 in. tall, weighs 298 pounds,
and does not exercise. His physician advised him to
get down to 250 pounds and told him to follow a
2000-calorie diet. He has prediabetes, hypertension,
and hypercholesterolemia. He lives alone and doesn’t
cook. Instead, he normally eats fast-food meals. He
admits to being a heavy beer drinker.
Learning Objectives
1 List the metrics that define cardiovascular health.

2 Discuss the characteristics that define an optimal healthy diet score.
3 Summarize the characteristics of a Dietary Approaches to Stop
Hypertension (DASH) diet.
4 Describe the characteristics of a Mediterranean-style eating pattern.
5 Compare the DASH diet with the traditional Mediterranean-style eating
pattern.
6 Summarize nutrition interventions recommended for the primary and
secondary prevention of hypertension.
7 Discuss diet-related recommendations for hypercholesterolemia.
8 Discuss diet-related recommendations for metabolic syndrome.
9 List the top six sources of sodium in the U.S. diet.
Cardiovascular disease (CVD) is a general term that refers to heart and
blood vessel conditions such as coronary heart disease (CHD), stroke,
hypertension, and heart failure (HF). Atherosclerotic cardiovascular disease
(ASCVD) refers to cardiac conditions caused by atherosclerosis, a
progressive disease characterized by the buildup of fatty plaques that can
develop in the arteries that supply blood to the heart, brain, kidneys, and
extremities. The majority of CVD, including CHD and stroke, are ASCVD.
ASCVD is the leading cause of morbidity and mortality worldwide
(Arnett et al., 2019). In the United States, heart disease remains the leading
cause of death as it has been for decades (Heron, 2019). ASCVD is largely
a result of modifiable risk factors, including lifestyle (Lachman et al.,
2016). A healthy lifestyle throughout life, namely, a healthy eating pattern,
adequate physical activity, and avoidance of tobacco, is the most important
way to prevent atherosclerotic vascular disease, HF, and atrial fibrillation
(Arnett et al., 2019) and is vital to the secondary prevention of CVD and its
risk factors, including obesity, hypercholesterolemia, hypertension, and
diabetes.
This chapter discusses cardiovascular health, healthy eating patterns
recommended for cardiovascular health, and nutrition therapy for primary
and secondary CVD and its nutrition-related risk factors.
CARDIOVASCULAR HEALTH
In 2010, the American Heart Association introduced a new concept of

cardiovascular health based on 7 metrics, commonly referred to “Life’s
Simple 7” (Virani et al., 2020). These metrics include four health behaviors
(diet quality, physical activity, tobacco use, body mass index [BMI]) and
three health factors (blood cholesterol, blood pressure, blood glucose).
Because cardiovascular health occurs along a continuum and an ideal
cardiovascular health profile is rare, a range of values are used to score
each metric as ideal, intermediate, and poor. (tab 22.1 lists the ideal for each
metric and the percentage of adults who achieve each ideal.)
Ideal Cardiovascular Health
the absence of clinically evident CVD and the simultaneous presence of optimal levels of all 7
metrics without the use of medication to control blood glucose, blood cholesterol, and blood
pressure.
Multiple independent studies show a strong protective association

between cardiovascular health metrics and many conditions, including
premature all-cause mortality, CVD mortality, and HF; subclinical measures
of atherosclerosis such as carotid arterial wall stiffness; impaired physical
function and frailty; and cognitive decline and depression (Virani et al.,
2020). Research shows that even a moderately unhealthy lifestyle is
associated with a significantly lower risk of CVD events compared to those
with a very unhealthy lifestyle, suggesting that even small improvements
may result in a substantial reduction in the risk of CVD (Lachman
et al., 2016).
Cardiovascular Health Among American Adults

Among American adults aged 20 and older (Virani et al., 2020),
• less than 20% met the criteria for 5 or more ideal metrics;
• ideal score prevalence improved from 1999–2000 to 2015–2016 for
smoking, total cholesterol, blood pressure, and physical activity
• ideal score prevalence during that same period declined for BMI and
diabetes.
As indicated in tab 22.1, the metric scored as ideal by the lowest

percentage of Americans is in achieving a healthy eating pattern (0.3%),
and achieving a low sodium intake is the primary dietary characteristic least
often attained (Virani et al., 2020).
“Life’s Simple 7”: Definition of

Table Ideal Cardiovascular Health
22.1 Metrics and Prevalence of Each
Metric of for Adults ≥20 Years Old
% of
Adults
Who
Achieve
Ideal Ideal
Health Behaviors
Current smoking Never or quit >12 months 78.8
BMI <25 28.7
Physical activity ≥150 minutes/week moderate or 41.5
≥75 minutes/week vigorous or
≥150 minutes/week
moderate + 2x vigorous
Healthy diet 4–5 primary components

pattern:
% of
Adults
Who
Achieve
Ideal Ideal
≥4.5 c/day fruits 0.3
and 10.2
vegetables 18.0
≥2 servings/week 7.1
of fish 53.3
≥3 servings/day 0.7
of whole
grains
≤36 oz/week
sugar-
sweetened
beverages
≤1500 mg/day
sodium
Health Factors
Total cholesterol <200 mg/dL 49.4
Blood pressure <120/<80 mm Hg 41.0
Fasting plasma <100 mg/dL 58.4
glucose
Source: Virani, S. S., Alonso, A., Benjamin, E. J., Bittencourt, M. S., Callaway, C. W., Carson, A. P.,
Chamberlain, A. M., Chang, A. R., Cheng, S., Delling, F. N., Djousse, L., Elkind, M. S. V.,
Ferguson, J. F., Fornage, M., Khan, S. S., Kissela, B. M., Knutson, K. L., Kwan, T. W., Lackland,
D. T., … Tsao, C. W. on behalf of the American Heart Association Council on Epidemiology and
Prevention Statistics Committee and Stroke Statistics Subcommittee. (2020). Heart disease and
stroke statistics—2020 update: A report from the American Heart Association. Circulation,
141(9), e139–e596. https://doi.org/10.1161/CIR.0000000000000757
The “ideal” eating pattern, scaled to 2000 calories and a Dietary

Approaches to Stop Hypertension (DASH)—type eating pattern, is defined
as achieving 4 of the 5 primary characteristics of
• ≥4.5 cups fruit and vegetables/day
• ≥2 servings of fish/week
• <1500 mg sodium/day
• <36 oz sugar-sweetened beverages/week
• ≥3 servings of whole grains/day
Secondary diet metrics include

• ≥4 servings/week of nuts/legumes/seeds
• ≤2 servings/week of processed meats
• <7% total calories from saturated fat
Saturated Fat or Fatty Acids

fatty acids in which all the carbon atoms are bonded to as many hydrogen atoms as they can hold,
so no double bonds exist between carbon atoms; animal fats (meat and dairy), coconut oil, palm
oil, and palm kernel oil are the biggest sources.
Recall Jacob. A diet history reveals that his typical first

meal of the day is two egg-and-sausage breakfast
sandwiches along with coffee, cream, and sugar. Lunch is
two peanut butter and jelly sandwiches on white bread with
chips and soda. Dinner is a submarine sandwich, pizza, or
tacos. During the evening, he eats chips and salsa while
drinking three to four beers. How does his usual intake
compare to the ideal diet metrics? What specific suggestions
would you make to improve his usual intake?
Heart-Healthy Eating Patterns

Historically, nutrients, not eating patterns, were the focus of dietary
recommendations, such as lowering sodium to prevent or treat hypertension
and lowering cholesterol and saturated fat to treat hypercholesterolemia.
Currently, the emphasis is on healthy eating patterns to promote overall
health and reduce the risk of all chronic diseases, including CVD, CVD risk
factors, certain cancers, and age-related decline.
While “Life’s Simple 7” uses a DASH-type diet as the ideal, plant-
based and Mediterranean-style eating patterns are also linked to lower risk
of ASCVD (Arnett et al., 2019). Both the DASH diet and Mediterranean-
style eating pattern have the characteristics recommended for the primary
prevention of CVD (Arnett et al., 2019). Both patterns
• emphasize the intake of vegetables, fruit, legumes, nuts, whole
grains, vegetable oils, and fish
• limit the intake of red and processed meat, refined grains, added
sugars, butter, high sodium foods, and commercial trans fat
• are higher in fiber, vitamins, antioxidants, minerals, phytonutrients,
and unsaturated fat and lower in glycemic index, glycemic load,
salt, and trans fat than the typical Western diet (Mozaffarian, 2016).
Trans Fats
fatty acids with hydrogen atoms on opposite sides of the double bond. Most trans fats in the diet
come from partially hydrogenated fats.
Unsaturated Fat or Fatty Acids

fatty acids in which one or more double bonds exist between carbon atoms. A fatty acid with one
double bond is classified as a monounsaturated fat. Polyunsaturated fats have two or more double
bonds between carbon atoms.
With attention to cultural considerations, as appropriate (Box 22.1), the

DASH diet and Mediterranean-style eating pattern come close to being
“one size fits all.” Although the DASH diet is most often recommended for
hypertension and the Mediterranean-style eating pattern is often
recommended for CVD and diabetes, the “best” diet for an individual is the
one the client can adhere to. tab 22.2 summarizes the DASH diet and
Mediterranean-style eating pattern. A sample menu comparison of DASH
diet and Mediterranean-style eating pattern menus appears in tab 22.3.
Additional points appear in the following section.
Dietary Approaches to Stop Hypertension Diet

DASH was a multicenter feeding study that set out to test whether eating
whole “real” foods rather than individual nutrients would lower blood
pressure as a result of some combination of nutrients, interactions among
individual nutrients, or other food factors (Appel et al., 1997).
• The results clearly showed that the eating pattern substantially
lowers both systolic and diastolic blood pressures as well as low-
density lipoprotein cholesterol (LDL-C).
BOX Cultural Considerations

22.1
For all cultural groups, emphasize the positive aspects of their eating
styles and suggest ways to lower saturated fat and sodium content of
traditional foods.
African American Tradition

Traditional soul foods tend to be high in saturated fat and sodium. On the
positive side, there is a heavy emphasis on vegetables and complex
carbohydrates.
Suggested changes in cooking techniques include the following:
• Using nonstick skillets sprayed with cooking spray when pan-frying
eggs, fish, and vegetables
• Using small amounts of liquid smoke flavoring in place of bacon, salt
pork, or ham
• Using more seasonings, such as onion, garlic, and pepper, in place of
some of the salt
• Using turkey ham or turkey sausage in place of bacon
• Using “lite” or sugar-free syrups
Mexican American Tradition

The traditional diet is primarily vegetarian with a heavy emphasis on
fruits, vegetables, rice, and dried peas and beans. Processed foods are
used infrequently.
Cooking techniques rely on frying and stewing with liberal amounts
of oil or lard. An alternative is to sauté or stew with small amounts of
canola or olive oil.
High-fat meats and lard are commonly used. Using less meat,
choosing lower-fat varieties, trimming visible fat, and substituting oil for
lard are heart-healthy alternatives.
Chinese American Tradition

Traditional Chinese cooking relies heavily on vegetables and rice with
plants providing the majority of calories. Meat is used more as a
condiment than an entrée. Cooking techniques tend to preserve nutrients.
Sauces add little fat.
Sodium intake is highly related to heavy use of soy sauce,
monosodium glutamate (MSG), and salted pickles. Reduced-sodium soy
sauce is available, but it is still high in sodium. Because of the difficulty
in eliminating the use of soy sauce, a more practical approach is to
gradually use less.
Native North American/Indigenous People of Alaska

Traditions
Widely diverse eating styles make useful generalizations difficult.
In general,
• Encourage traditional cooking methods such as baking, roasting,
boiling, and broiling.
• Encourage the use of traditional meats, such as fish, deer, and caribou.
• Remove fat from canned meats.
• Use vegetable oil for frying instead of lard or shortening.
Jewish Tradition
Many traditional foods are high in sodium such as kosher meats (salt is
used in the koshering process), herring, lox, pickles, canned chicken
broth or soups, and delicatessen meats (e.g., corned beef, pickled tongue,
pastrami).
Pareve (neutral) nondairy creamers are often used as a dairy
substitute in meals containing meat, but they are high in saturated fat.
Encourage light and fat-free versions.
Encourage methods to lower fat in traditional recipes such as the
following:
• Baking instead of frying potato pancakes
• Limiting the amount of schmaltz (chicken fat) used in cooking
• Using reduced-fat or fat-free cream cheese on bagels
• Using low-fat or nonfat cottage cheese, sour cream, and yogurt in
kugels and blintzes
Table A Summary of the DASH Diet

and Mediterranean-Style Eating
22.2 Pattern
DASH Diet Mediterranean Diet

Origin Designed to see if a Traditional eating
healthy eating pattern, pattern of people
not specifically living in countries
individual nutrients, that border the
could lower high blood Mediterranean Sea.
pressure. As an eating pattern of
the poor, it consisted
of locally grown,
seasonally fresh
foods.
Most notable Primary and secondary Lower risk of CVD
health prevention of (Estruch et al.,
benefits hypertension (Appel et 2018).
al., 1997). Lower risk of recurrent
CHD events and all-
cause mortality
(Shikany et al.,
2018).
Improvements in
hemoglobin A1c,
fasting glucose, and
fasting insulin (Huo
et al., 2014).
Characteristics A uniform definition
High in fruit, vegetables, does not exist. In
whole grains, lean general, the
protein, and low-fat traditional diet:
dairy products. (Boucher, 2017;
Estruch et al., 2018)
Is rich in olive oil, fruit,
Moderate in whole grains, nuts, vegetables,
poultry, fish, and nuts. legumes, and grains
Low in saturated fat, red (mostly whole
meat, sweets, and grains)
sugar-sweetened Includes the liberal use
beverages of herbs and spices
(e.g., sofrito) instead
of salt to flavor
foods
Includes the frequent
intake of fish and
seafood
Includes poultry and
eggs in moderation
and red wine with
meals
Is lower in dairy
products, red meat,
processed meats, and
sweets
Most salient Low in fat and saturated High in fat (e.g., up to
nutritional fat. 40% of total calories
attributes High content of potassium, predominately from
calcium, and olive oil, fish, and
magnesium. nuts).
Relatively low in
saturated fat.
Selected U.S.
News & #2 (tie with Flexitarian #1
World diet) #1 (ties with DASH
Report #1 (ties with diet)
2020 Mediterranean diet) #1
Rankingsa #2 (tie with Flexitarian #1
Best diets diet) #1
overall #2 (tie with Flexitarian #2
Best diets for diet)
healthy #6
eating #3
Best plant-
based diets
Best diabetes
diets
Easiest to
follow
Best heart-
healthy
diets
U.S. News & World Report. (2020). Best diets overall. https://health.usnews.com/best-diet/best-
a
diets-overall
A Comparison of Dietary
Table Approaches to Stop Hypertension
22.3 Diet and Mediterranean-Style
Eating Pattern Menus
DASH Diet
(Approximately Mediterranean-Style
2000 calories) Eating Pattern
DASH Diet
Breakfast 2 slices whole-wheat toast ½ cup cooked oatmeal
2 tbsp peanut butter topped with Greek
1 banana yogurt, dates, ground
1 cup fat-free milk flax seed, and almonds
Banana
Lunch 3 oz turkey on 2 slices of Sautéed white beans and
whole-wheat bread zucchini, tomatoes,
with mustard onions, and garlic on a
Large salad made of bed of greens drizzled
lettuce, tomato, onions, with olive oil
cucumber, carrots, and 1 slice whole-wheat bread
mushrooms with 1 T dipped in olive oil
low-fat salad dressing Orange slices
1 orange
1 cup fat-free milk
Dinner 3 oz grilled chicken breast 3 oz pan-seared trout
½ cup brown rice Tabouli (bulgur, parsley,
½ cup roasted winter tomatoes, green onions,
squash and cucumbers with a
1 small corn bread muffin splash of fresh lemon
1 tsp soft margarine juice and olive oil)
1 medium pear Roasted eggplant
1 cup fat-free milk Red wine
Pear
Snacks Walnuts Walnuts
Fruit Fruit
Fresh vegetables with Fresh vegetables with
hummus hummus
DASH Diet
Comparison Compared to Compared to DASH diet
Mediterranean-style Higher in olive oil, nuts,
eating pattern legumes, wine
Higher in dairy and grains Lower in dairy and grains
Lower in fat
• Reductions in blood pressure were similar in men and women and
similar in magnitude to the effects seen with drug monotherapy for
mild hypertension. It is likely that several aspects of the diet, not
just one nutrient or food, lowered blood pressure (Appel et al.,
2006).
• Especially noteworthy is that the decrease in blood pressure
occurred without lowering sodium intake and without lowering
calories to produce weight loss.
• A second study, DASH-sodium, was designed to test whether
limiting sodium on a DASH diet would yield even better results. It
showed that at each sodium level, blood pressure was lower on the
DASH diet than on the control diet and that the greatest blood‐
pressure reductions occurred in Black Americans; middle-aged and
older people; and people with hypertension, diabetes, or chronic
kidney disease (Sacks et al., 2001).

Arguably, the healthiest and best-studied eating pattern is a Mediterranean-
style pattern (fig 22.1). A large, strong, plausible, and consistent body of
prospective evidence confirms the benefits of the Mediterranean-style
eating pattern on cardiovascular health (Martinez-González et al., 2019).
Figure 22.1 ▲ Mediterranean Diet Pyramid: A lifestyle for today.
(©2010 Foundacion dieta mediterranea. The use and promotion of the
pyramid is recommended without any restriction.)
• The PREDIMED study showed that in people at high cardiovascular

risk, the incidence of major cardiovascular events was lower among
those who consumed a non-calorie–restricted Mediterranean diet
supplemented with extra-virgin olive oil or nuts than among those
assigned to a low-fat diet (Estruch et al., 2018).
• A large meta-analysis shows that the Mediterranean-style eating
pattern is associated with lower risks of CVD incidence and
mortality, including CHD and myocardial infarction (MI) (Grosso
et al., 2017). The protective effects of the diet appeared to be most
attributable to olive oil, fruits, vegetables, and legumes.
• The Mediterranean-style eating pattern is associated with lower risk
of all-cause mortality than standard diets (Arnett et al., 2019), a
lower risk of Metabolic Syndrome (MetS) (Godos et al., 2016), and
with improved glycemic control and CVD risk factors in people
with type 2 diabetes (Esposito et al., 2017).
Think of Jacob. Is 2000 calories an appropriate weight loss

diet for a male? What factors should be considered when
deciding whether Jacob should be counseled to adhere to a
DASH diet or a Mediterranean-style eating pattern? Can
either pattern be adjusted to the appropriate calorie level?
Jacob says he prefers a Mediterranean-style eating pattern
because it includes wine, which he will drink in place of
beer. What does Jacob need to know about alcohol and his
CVD risks?
Nutrition for Cardiovascular Disease Risks

Diet has traditionally been considered a main determinant of cardiovascular
health (Martinez-González et al., 2019) and is a major factor in the
development or treatment of several other cardiovascular health metrics,
namely, hypertension, hypercholesterolemia, obesity (Chapter 17), and
diabetes (Chapter 21). These risk factors are often interrelated. For instance,
poor diet increases the risk of obesity, which increases the risk of
hypertension, type 2 diabetes, and ASCVD (Arnett et al., 2019). A heart-
healthy lifestyle is the foundation of ASCVD risk reduction (Grundy et al.,
2019). A heart-healthy lifestyle is also recommended for the secondary
prevention of ASCVD, hypertension, obesity, and diabetes. Nutrition
recommendations for selected CVD risks are presented in the following
section.

Although nutrition for obesity is covered in Chapter 17, the high prevalence
of overweight and obesity and its association with heart disease and its risks
(e.g., diabetes, hypertension, MetS) warrant inclusion of the topic here.
• It is recommended that all people who are overweight or obese lose
weight to improve ASCVD risk profile (Arnett et al., 2019).
• Although a 5% loss of body weight may not result in ideal BMI
range, it is associated with moderate improvement in blood pressure,
LDL-C, triglyceride levels, and glucose levels in people who are
overweight or obese and lowers or delays the development of type 2
diabetes (Arnett et al., 2019).
• Comprehensive weight loss programs are recommended to attain
and maintain weight loss. They consist of the following:
• A hypocaloric diet, such as 1200–1500 cal/day for women and
1500–1800 cal/day for men.
• At least 150 minutes/week of aerobic physical activity (e.g., brisk
walking) for initial weight loss. Higher levels of activity are
recommended long term.
• Self-monitoring of intake, weight, and physical activity.
• BMI should be calculated annually or more frequently to identify
who may benefit from weight loss.
• Measuring waist circumference may be useful to identify clients
who are at greater cardiometabolic risk.
Hypertension
Hypertension is a major risk factor for CVD and stroke (Virani et al., 2020).
The ideal blood pressure metric used in “Life’s Simple 7” is defined as less
than 120/ less than 80 for adults aged 20 and older. The 2017 Hypertension
Clinical Practice Guidelines defines hypertension as systolic blood pressure
130 mm Hg or more or diastolic blood pressure 80 mm Hg or more (Carey
et al., 2018).
Some of the diet-related components that have been associated with
hypertension include overweight and obesity, excess intake of sodium, and
inadequate intakes of potassium, calcium, magnesium, protein (particularly
from vegetables), fiber, and fish fats (Whelton et al., 2018). Because poor
diet, physical inactivity, and excessive alcohol intake, alone or in
combination, are the underlying cause of a large proportion of hypertension,
correcting these behaviors is an important approach to preventing and
managing hypertension (Whelton et al., 2018).
Recommended interventions for the prevention and treatment of
hypertension are as follows (Carey et al., 2018):
• Consume a heart-healthy eating pattern (e.g., DASH diet) (Tables
22.2 and 22.3)
• Limit sodium intake.
• The top six sources of sodium in a typical American eating
pattern are identified as (American Heart Association, 2020):
• Bread and rolls
• Pizza
• Sandwiches
• Cold cuts and cured meats
• Soup
• Burritos and tacos
• Given that more than 75% of the sodium in a typical American
diet comes from processed foods (Box 22.2), it is difficult for
people who regularly consume processed, prepackaged, and
restaurant foods to lower their sodium intake.
• Box 22.3 outlines strategies to lower sodium intake and client
teaching points.
• Increase potassium intake unless otherwise contraindicated (e.g., use
of medications that reduce potassium excretion). High potassium
foods include:
• Dried apricots, raisins, and prunes
• Potatoes, both sweet and white (especially when baked with the
skin on)
• Leafy greens
• Lentils and legumes
• Certain fruit and vegetable juices: prune juice, tomato puree or
juice, carrot juice, orange juice, and vegetable juice
• Milk and yogurt
• Seafood
• Abstinence from or moderation in alcohol intake (≤2 drinks/day for
men, ≤1 drink/day for women).
Hypercholesterolemia
Serum cholesterol and the lipoproteins that carry it (low-density lipoprotein
[LDL], very-low-density lipoprotein [VLDL], and high-density lipoprotein
[HDL]) are known to be related to ASCVD (Grundy et al., 2019).
• The ideal total cholesterol metric is defined as less than 200 mg/dL.
• LDL and VLDL are atherogenic. Optimal LDL level is less than
100 mg/dL.
• HDL is seemingly not atherogenic (Grundy et al., 2019).
Recommended HDL level is at least 40 mg/dL for men and at least
50 mg/dL for women.
BOX The Effect of Food Processing on Sodium

22.2 Content
Examples of the Impact Food Processing Has on

Sodium Intake
Food Groups Sodium
(mg)
Whole and other grains and grain products
Cooked cereal, rice, pasta, unsalted, ½ cup 0–5
Ready-to-eat cereal, 1 cup 0–360
Bread, 1 slice 110–175
Vegetables
Fresh or frozen, cooked without salt, ½ cup 1–70
Canned or frozen with sauce, ½ cup 140–460
Tomato juice, canned, ½ cup 330
Low-fat or fat-free milk and milk products
Milk, 1 cup 107
Yogurt, 1 cup 175
Natural cheeses, 1½ oz 110–450
Processed cheeses, 2 oz 600
Nuts, seeds, and legumes
Peanuts, unsalted, ½ cup 0–5
Peanuts, salted, ½ cup 120
Beans, cooked from dried or frozen, without salt, ½ cup 0–5
Beans, canned, ½ cup 400
Lean meats, fish, and poultry
Fresh meat, fish, poultry, 3 oz 30–90
Ham, lean, roasted, 3 oz 1020
Tuna (canned water pack), no salt added, 3 oz 35–45
Tuna-canned water pack, 3 oz 230–350
Convenience and Fast Foods Sodium
(mg)
1 packet dry onion soup mix 3132
1 tsp salt 2325
1 fast-food single cheeseburger with condiments and bacon 1314
One 6-in., fast-food tuna salad sub 1293
1 large fast-food taco 1233
2 fast-food pancakes with syrup 1104
1 cup canned macaroni and cheese 1061
1 fast-food beef chimichanga 910
1 cup canned soup 800+
1 slice of 14" pizza 640
Historically, nutrition recommendations for reducing CVD risk are
dietary cholesterol restriction (U.S. Department of Health and Human
Services [USDHHS] & U.S. Department of Agriculture [USDA], 2010).
Newer guidelines, including the 2020–2025 Dietary Guidelines for
Americans (U.S. Department of Agriculture [USDA] & U.S. Department of
Health and Human Services [USDHHS], 2020) and the American Heart
Association/American College of Cardiology (AHA/ACC) guideline on the
management of blood cholesterol (Grundy et al., 2019), do not make
specific recommendations regarding cholesterol intake. The National
Academies recommends that dietary cholesterol intake be as low as
possible without compromising the nutritional adequacy of the diet
(National Research Council, 2005). The issue is cloudy (Carson et al.,
2020).
• Observational studies from several countries generally do not
indicate a significant association between cholesterol intake and
CVD risk.
• Most meta-analysis of intervention studies shows cholesterol intakes
that exceed the current average levels of intake are associated with
elevated total cholesterol or LDL-C.
BOX Strategies to Lower Sodium Intake and

22.3 Client Teaching Points
In General
• Eat more meals at home. Cook in batches and freeze for use on busy
days.
• Avoid or limit convenience foods, such as boxed mixes, frozen
dinners, and canned goods.
• Compare labels to find items lowest in sodium.
• Don’t add salt when cooking.
• Making changes gradually may be easier.
Grains and Cereals
• Find lower-sodium varieties by comparing labels.
• Cook rice and pasta without adding salt.
• Eat cereals without added salt, such as oatmeal, shredded wheat, and
puffed whole-grain cereal.
• Avoid instant flavored rice, pasta, and cereal mixes.
Vegetables
• Eat more fresh or frozen vegetables without salt added.
• Rinse canned vegetables before using.
• Switch to pasta sauce without added salt or dilute regular bottled pasta
sauce with equal parts of no-salt-added tomato sauce.
• Substitute fresh vegetables for pickles and other pickled foods.
Fruits
• Fresh, frozen, and canned fruits are salt free; enjoy.
Milk and Milk Products

• Use cheese sparingly, especially processed cheeses.
Protein Foods
• Choose fresh poultry, fish, and lean meat instead of canned, smoked,
deli, or other processed varieties.
• Limit frozen dinners.
• Limit cured meat intake, such as sausages and hot dogs. Compare
labels to find lower-sodium varieties.
• Limit imitation crab and lobster products.
• Limit soy substitutes, such as imitation ground beef or chicken.
• Use no-salt-added nut butters.
Fats and Oils

• Use homemade vinegar and oil dressings instead of bottled salad
dressings.
Miscellaneous
• Use herbs and spices instead of salt to season foods.
• Replace garlic and onion salts with garlic and onion powders.
• Use reduced-salt or no-salt-added condiments such as ketchup, soy
sauce, and mayonnaise.
• Use no-salt-added broth to make soup instead of using canned soup.
When Eating Out

• Request that food not be salted, if possible.
• Avoid fast-food restaurant meals, which usually are high in sodium. If
you have to go, order a child-sized meal.
• Order sandwiches without mayonnaise, sauces, or condiments; load
with lettuce, tomato, and onion.
Client Teaching
Provide general information:
• Reducing sodium intake will help the body rid itself of excess fluid
and help lower high blood pressure.
• Sodium appears in the diet in the form of salt and, to some degree, in
almost all foods and beverages.
• Most unprocessed, unsalted foods are low in sodium.
• The majority of the sodium in a typical American diet comes from
processed foods.
• Sodium-containing compounds are used extensively as preservatives
(sodium propionate, sodium sulfite, and sodium benzoate),
leavening agents (sodium bicarbonate, baking soda, and baking
powder), and flavor enhancers (e.g., salt, MSG) and are found in
foods that may not taste salty.
• Salt substitutes replace sodium with potassium or other minerals.
“Low-sodium” salt substitutes are not sodium free and may contain
half as much sodium as regular table salt. Use neither type without a
physician’s approval.
• The preference for salty taste eventually will decrease.
• When an occasional food containing ≥300 mg/serving is eaten, balance
it out with low-sodium foods the rest of the day.
Teach the client food preparation techniques to minimize sodium intake:
• Prepare foods from “scratch” whenever possible.
• Experiment with sodium-free seasonings, such as herbs, spices, lemon
juice, vinegar, and wine. Fresh ingredients are more flavorful than
dried ones.
• Try a commercial “salt alternative” for sodium-free flavor
enhancement.
• Consult a low-sodium cookbook or online low-sodium recipes.
Teach the client how to read labels:
• Salt, MSG, baking soda, and baking powder contain significant
amounts of sodium. Other sodium compounds such as sodium nitrite,
benzoate of soda, sodium saccharin, and sodium propionate add less
sodium to the diet.
• Sodium labeling terms are reliable:
• “Sodium-free” and “salt-free” foods provide <5 mg sodium/serving.
• “Very low sodium” provides <35 mg sodium/serving.
• “Low sodium” provides <140 mg sodium/serving.
• A variety of low- and reduced-sodium products are available, such as
bread and bread products, cereal, crackers, cakes, cookies, pastries,
soups, bouillon, canned vegetables, tomato products, meats, entrées,
processed meats, hard and soft cheeses, condiments, nuts and peanut
butter, butter, margarine, salad dressings, and snack foods. The
difference in flavor between some low-sodium products and their high-
sodium counterparts is barely noticeable; others taste flat and may
need to have herbs or spices added.
• It is difficult to study the relationship between cholesterol intake and
CVD because most sources of cholesterol are usually high in
saturated fat.
The evidence-based diet-related recommendations featured in the 2013

AHA/ACC guidelines on lifestyle management to lower cardiovascular risk
(Eckel et al., 2014) are still supported for the general public and for clients
at risk for ASCVD (Grundy et al., 2019).
• Dietary guidance should focus on heart-healthy eating patterns, such
as the DASH diet and the Mediterranean-style eating pattern
(Carson et al., 2020). These patterns are inherently low in
cholesterol.
• The emphasis on vegetables, fruit, whole grains, legumes, healthy
protein sources (low-fat dairy, low-fat poultry, fish, seafood, and
nuts), and nontropical vegetable oils provides a relatively high ratio
of polyunsaturated fatty acids to saturated fatty acids.
• Because egg yolks are relatively high in cholesterol, it is advisable
to limit intake in healthy individuals to up to a whole egg daily
(Carson et al., 2020).
• Lacto-ovo vegetarians may include more eggs.
• Because of the nutritional benefits and convenience of eating
eggs, older clients with normal cholesterol may include up to
2 eggs/day within the context of a heart-healthy eating pattern.
• People with diabetes should be cautious about consuming high-
cholesterol foods.
Metabolic Syndrome
Metabolic syndrome (MetS) is a multicomponent risk factor for CVD and
type 2 diabetes (Virani et al., 2020).
• MetS consists of a cluster of metabolic abnormalities, namely,
elevated triglycerides, low HDL-C, high blood pressure, high fasting
blood glucose levels, and central obesity (Alberti et al., 2009).
• Although multiple definitions for MetS have been proposed,
generally three abnormal findings out of five qualify a person for
MetS (tab 22.4).
• Because MetS is closely linked to excess weight and particularly to
central obesity, the prevalence has increased sharply among adults
and children in tandem with the increase in overweight and obesity
(Grundy et al., 2019).
In all age groups, lifestyle therapy is the main intervention for the
primary and secondary prevention of MetS.
• A Mediterranean-style eating pattern is recommended (tab 22.2):
• A meta-analysis of epidemiological studies and clinical trials
indicates that adherence to the Mediterranean-style eating pattern
is associated with lower MetS prevalence and progression and has
a beneficial effect on the components of MetS, namely,
abdominal obesity, lipid levels, glucose metabolism, and blood
pressure (Kastorini et al., 2011).
• Calories should be appropriate to maintain weight or lose weight if
overweight or obese.
Consider Jacob. Does he meet the criteria for having MetS?

Does his diet contribute to his risk of MetS? What should be
Jacob’s highest dietary priority? How would you respond
when he asks if he can use meal replacements for two meals
a day so he doesn’t have to think about what to eat?
Table Diagnostic Criteria for

22.4 Metabolic Syndrome
Risk Factor Defining Level

Risk Factor Defining Level
Metabolic syndrome is confirmed by the presence of any three of the
following five risks:
Central obesity
Men >40-in. waist
Women >35-in. waist
Or population- and country-specific definitions,
especially Asians and non-Europeans who have
predominantly lived outside the United States
Elevated ≥150 mg/dL
triglycerides Or taking medication for high triglyceride levels
Low HDL-C
Men <40 mg/dL in men
Women <50 mg/dL in women
Or taking medication for low HDL-C
Elevated blood ≥130 mm Hg systolic blood pressure
pressure ≥85 mm Hg diastolic blood pressure
Or taking antihypertensive medication with a history
of hypertension
Elevated fasting ≥100 mg/dL
glucose Or taking medication to control blood sugar level
Note. HDL-C = high-density lipoprotein cholesterol.
Source: Alberti, K., Eckel, R., Grundy, S., Zimmet, P. Z., Cleeman, J. I., Donato, K. A., Fruchart, J. -
C., James, W. P. T., Loria, C. M., & Smith, S. C., Jr. (2009). Harmonizing the metabolic syndrome:
A joint interim statement of the International Diabetes Federation Task Force on Epidemiology
and Prevention; National Heart, Lung, and Blood Institute: American Heart Association; World
Heart Federation: International Atherosclerosis Society; and International Association for the
Study of Obesity. Circulation, 120, 1640–1645.
SECONDARY PREVENTION OF
CARDIOVASCULAR DISEASES
Secondary prevention of CVD focuses on the management of care for
clients who have a history of ASCVD, such as a history of myocardial
infarction, angina, prior stenting or bypass surgery, stroke or transient
ischemic attack, or symptomatic peripheral arterial disease. The goal is to
prevent recurrent events, improve symptoms, and improve quality of life.
Treatment approaches include drug therapy (e.g., lipid-lowering
medications, antihypertensives, antiplatelets), cardiac rehabilitation, and
lifestyle intervention, including a healthy eating pattern.
Healthy Eating Pattern

Yet again, evidence points to the benefits of a Mediterranean-style eating
pattern. The Lyon Diet Heart Study, a secondary prevention trial in clients
with recent MI, showed rates of CHD events and death were reduced for up
to 4 years after an initial event in those assigned a Mediterranean-style
eating pattern (de Lorgeril et al., 1999). Likewise, Lopez-Garcia et al.
(2014) found an inverse relationship between adherence to a
Mediterranean-style eating pattern and all-cause mortality in men and
women with CVD, showing that a healthy eating pattern can still be
beneficial at an advanced stage of the atherosclerotic process. However,
individual preference should determine whether a DASH diet or
Mediterranean-style eating pattern is used because both patterns are heart
healthy and can be adjusted for appropriate calories and sodium content.
Heart Failure
Heart failure (HF) is a complex progressive syndrome characterized by
specific symptoms—particularly dyspnea, fatigue, and fluid retention—that
result from any structural or functional impairment of the heart’s ability to
adequately pump blood. Malnutrition among clients with advanced HF,
known as cardiac cachexia, may occur from decreased sensation of hunger,
diet restrictions, fatigue, shortness of breath, nausea, anxiety, or
malabsorption related to gastrointestinal edema. Sarcopenia, characterized
by progressive and generalized loss of skeletal muscle mass and strength,
can also be common in clients with HF (Someya et al., 2016).
Cachexia
a wasting syndrome characterized by loss of lean tissue, muscle mass, and bone mass.
HF is treated with drug therapy and lifestyle modifications including a

healthy eating pattern, weight management, physical activity, and smoking
cessation. High adherence to a Mediterranean-style diet has been associated
with a lower risk of HF and mortality from HF in men (Tektonidis et al.,
2016).
Nutrition Therapy for Heart Failure

Evidence-based nutrition therapy guidelines from the Academy of Nutrition
and Dietetics (Kuehneman et al., 2018) includes the following:
• Calorie intake is individualized according to the client’s weight and
health status.
• In stable clients, weight loss may be recommended to improve
quality of life or comorbidities such as diabetes or hypertension.
• Protein intake should be at least 1.1 g/kg of actual body weight to
prevent catabolism. Clients who are malnourished may need 1.1 to
1.4 g/kg actual body weight/day.
• Sodium and fluid intake are individualized within the ranges of
2000 to 3000 mg sodium/day and 1 to 2 L fluid/day.
• These levels of sodium and fluid intake are associated with
improvements in renal function, lab values, symptoms, and
quality measures (e.g., readmission rate, length of stay, mortality
rate).
• This level of sodium intake exceeds the current DRI of
1500 mg/day for adults although is less than the typical American
intake.
• There is a lack of evidence to support or refute sodium restriction
for HF clients (Mahtani et al., 2018).
• Due to interactions between supplements and medications, it is
unclear whether certain supplements, such as coenzyme Q10, n-3
fatty acids, vitamin D, iron, and thiamin, are appropriate for clients
with HF.
NURSING PROCESS Heart Failure
Mrs. Gigante is a 79-year-old widow admitted with moderate-to-severe

HF, with a long-standing history of hypertension and one previous MI.
She lives alone and complains of poor appetite and fatigue. She appears
frail and has experienced progressive unintentional weight loss despite
significant lower extremity edema. She is diagnosed with cardiac
cachexia.
Assessment
Medical– • Medical history and comorbidities
Psychosocial including diabetes, hypertension, MI,
History alcohol abuse, and other CHD risk factors
• Use of medications that affect nutrition,
such as diuretics, antihypertensives,
antidiabetics, and lipid-lowering
medications; adherence to prescribed drug
therapy
• Additional symptoms that interfere with
intake, such as shortness of breath or
nausea
• Psychosocial and economic issues, such as
living situation, ability to cook and shop,
financial status, education, and eligibility
for the Meals on Wheels program
Assessment
Anthropometric • Height, weight; BMI
Assessment • Recent weight history, especially rapid
weight gain
Biochemical and • General appearance; signs of muscle
Physical wasting
Assessment • Blood pressure
• Measure of edema
• Laboratory values related to
comorbidities, such as total cholesterol,
LDL, HDL, and triglyceride levels
• Intake and output
• Lung sounds respirations for breathing
effort
Dietary Assessment • How many meals and snacks do you
usually eat?
• What is your usual 24-hour food intake
like?
• What foods are most appealing to you?
• Are there certain times of the day when
your appetite is best?
• What symptoms interfere with eating?
• Do you have any cultural, religious, or
ethnic influences on your food preferences
or eating habits?
• Do you take any vitamins, minerals, and
nutritional supplements? If so, what are
the reasons?
• Do you use alcohol or caffeine?
Analysis
Assessment
Possible Nursing Evident malnutrition related to poor appetite,
Analysis eating alone, and fatigue as evidenced by
progressive unintentional weight loss and
muscle wasting.
Planning
• Consume a varied and nutritious diet with
adequate calories and protein. Eat small,
frequent meals to maximize intake.
• Consume appropriate amounts of fluid and
sodium.
Nutrition Therapy • Provide regular diet with in-between meal
oral nutrition supplements as ordered.
• Encourage the client to eat calorie- and
protein-dense foods first during mealtime.
• Monitor intake.
Assessment

• The importance of protein and calories to
improve nutritional status and overall
health.
• The eating plan essentials, including
• how to increase calories and protein in
the diet
• the benefits of consuming oral nutrition
supplements between meals to
maximize intake, especially when
fatigued
• to rest before meals
• to avoid excessive sodium
• The availability of a Meals on Wheels–
type program. Explain that Meals on
Wheels can provide her with the
appropriate diet after discharge to ensure
that she gets the proper foods that can be
supplemented with oral nutrition
supplements as needed. (Notify the
discharge planner that the client may be a
candidate for Meals on Wheels.)
Evaluation
Assessment
Evaluate and • Monitor percentage of food consumed.
monitor • Monitor weight daily for rapid weight
gain.
• Monitor edema and other signs of fluid
retention.
• Monitor tolerance to oral diet.
• Suggest changes in the meal plan as
needed.
• Provide periodic feedback and
reinforcement.
How Do You Respond?

Are there any supplements that lower the risk of heart
disease? There is a lack of convincing evidence to
support the use of supplements to lower CVD risk;
however, it is difficult to study the effects of supplements
because people who use supplements generally have a
healthier lifestyle and eating pattern and randomized
studies are rarely performed (Bronzato & Durante, 2018).
Results of the Physician’s Healthy Study II showed that
taking a daily multivitamin did not reduce major
cardiovascular events, MI, stroke, or CVD mortality in
male physicians after more than a decade of treatment and
follow-up (Sesso et al., 2012). The U.S. Preventive
Services Task Force (U.S. Preventive Services Task Force
[USPSTF], 2014) states that there is not enough evidence
to determine whether taking multivitamins, paired
vitamin and mineral supplements, or most single vitamins
or minerals will help prevent CVD. Evidence from most
randomized controlled trials does not support the use of
vitamin E supplementation for the primary or secondary
prevention of CVD (Wang & Xu, 2019). More research is
needed to clarify the following (Bronzato & Durante,
2018):
• Low–vitamin D levels have been linked to coronary
artery disease (CAD), HF, and arterial fibrillation.
• CoQ10 deficiency has been associated with myocardial
dysfunction and to statin myopathies.
• Probiotics may be involved in lowering blood pressure
and lipid levels
Because hard evidence on the benefits of supplements

is lacking at this time, it is safer to obtain nutrients and
phytonutrients from food instead of supplements. The
DASH diet and Mediterranean-style eating patterns fit the
bill once again.
Why should I eat less sodium if my blood pressure is
normal? Even for people who are normotensive,
lowering sodium intake will blunt the rise in blood
pressure that occurs with aging (Appel et al., 2011). In
addition to its effect on blood pressure, a high sodium
intake also increases the risk of fibrosis in the heart,
kidneys, and arteries; kidney damage, gastric cancer, and
possibly osteoporosis by increasing the excretion of
calcium. Reducing sodium intake is considered an
important public health effort to prevent CVD, stroke, and
kidney disease (Appel et al., 2011).
REVIEW CASE STUDY

Matt is 34 years old. His waist circumference is 42 and BMI is 30; both
have steadily increased over the last few years when he accepted a position
with his company that requires frequent travel. It is hard for him to exercise,
and he eats out often. He is a “steak and potatoes” kind of guy who
wouldn’t dream of eating lunch or dinner without meat as the centerpiece of
the meal. At his most recent annual employee physical, Matt’s total
cholesterol level was 245 mg/dL, his HDL level was 33, fasting glucose
level was 92, and his blood pressure was 154/85 mm Hg. His father died of
a heart attack at age 49 years. Matt feels doomed by genetics and is resistant
to going on medication because of the potential side effects. He is willing to
try to change his diet and lifestyle but is skeptical that it will help.
• What risks does Matt have for heart disease? What criteria does he have
for MetS?
• Knowing that he is willing to change his diet and lifestyle, what
additional information would you ask of Matt before devising a teaching
plan?
• What diet recommendations would you prioritize in helping Matt initiate
a healthy eating pattern? What suggestions could you offer him to help
him meet these recommendations?
• How would you respond to Matt’s skepticism that lifestyle factors will
probably not lower his risk of heart disease?
STUDY QUESTIONS
1 Which statement indicates the client understands the instruction about a

DASH-style diet?
a. “The most important thing about a DASH diet is to eat less cholesterol.
No egg yolks for me.”
b. “I need to eat more fruits, vegetables, and low-fat dairy products.”
“As long as I don’t add salt to my food while cooking or at the table, I
c. will be able to achieve a low-sodium diet.”
d. “I need to use olive oil liberally in food preparation and eat nuts every
day.”
2 The client asks if he can use butter on a heart-healthy diet. Which of the
a. “No, butter does not fit into a heart-healthy diet.”
b. “Butter is not limited in a heart-healthy diet because most people only
use small amounts.”
c. “You can fit in small amounts of butter if you are willing to reduce
saturated fat elsewhere, such as eating red meat less often.
d. “Butter is considered a dairy product and you can have up to
3 servings/day. ”
3 When developing a teaching plan for a client on a low-sodium diet,
which of the following foods would the nurse advise the client to limit?
a. Cold cuts
b. Canned fruit
c. Eggs
d. Milk
4 The nurse knows that instructions for a Mediterranean-style eating
pattern have been effective when the client expresses a need to eat more
a. fish and nuts
b. lean red and deli meats
c. dairy products
d. sweets that are fat free instead of full fat
5 Which of the following are characteristics of an “ideal” healthy eating
pattern for someone consuming 2000 cal/day. Select all that apply.
a. ≥4.5 cups of fruits and vegetables/day
b. ≥3 servings of whole grains/day
c. ≥2 servings of fish/week
d. <1500 mg sodium/day
6 A client asks how to alter a diet to lower high cholesterol levels. Which
of the following is the nurse’s best response?
a. “Alcohol lowers serum cholesterol, but limit consumption to a
moderate intake.”
b. “Eliminate egg yolks and butter.”
c. “Eat less processed foods.”
d. “The issue of reducing cholesterol intake to lower serum cholesterol is
murky. Eat a DASH diet or Mediterranean-style eating pattern to lower
your risk of ASCVD.”
7 The client understands that lifestyle therapy is the cornerstone of primary
and secondary prevention of MetS. What does the client need to know
about nutrition therapy for MetS?
a. Because the primary goal is to lose weight, it doesn’t matter what kind
of hypocaloric diet is chosen.
b. The DASH diet has been shown to be most effective at improving
MetS risk factors.
c. A Mediterranean-style eating pattern has been shown to be most
effective at improving MetS risk factors.
d. Low-fat diets are the best for MetS because it is beneficial to eat less
of all types of fat in the diet.
8 Which statement indicates the client does not understand the nutrition
recommendations for hypertension?
a. “Weight loss will help lower my blood pressure.”
b. “Sodium restriction is not necessary as long as I eat enough potassium
in fruits and vegetables.”
c. “Alcohol intake should be limited to 1 drink/day for women and
2 drinks/day for men.”
d. “The DASH diet is probably better for high blood pressure than the
Mediterranean-style eating pattern.”
Clients with Cardiovascular Disorders
The American Heart Association defines cardiovascular health with seven
metrics: eating pattern, physical activity, tobacco use, BMI, blood
cholesterol, blood pressure, and blood glucose.
Cardiovascular health among American adults: Americans achieve the
ideal most often for tobacco use and least often for eating pattern.
Healthy eating pattern: The “ideal” intake is to achieve 4 of the 5 primary
characteristics of a healthy pattern:
• ≥4.5 cups fruit and vegetables per day
• ≥2 servings of fish/week
• <1500 mg sodium/day
• <36 oz sugar-sweetened beverages/week
• ≥3 servings of whole grains/day
DASH diet: A heart-healthy diet rich in fruits, vegetables, low-fat dairy,

and whole grains and low in fat, red meat, and sweets. This diet has been
shown to lower blood pressure in normo- and hypertensive adults.
Mediterranean-style eating pattern: The traditional eating pattern of
populations living along the Mediterranean basin. It is high in olive oil,
fruit, nuts, vegetables, and grains; moderate in fish and poultry; low in
dairy, red meat, processed meats, and sweets; and moderate in wine
consumed with meals. This heart-healthy eating pattern is associated
with reduced risks of CVD and diabetes.
Nutrition for CVD risks: Diet is a primary determinant of cardiovascular

health and a major factor in the development or treatment of all the other
cardiovascular health metrics, namely, hypertension, hypercholesterolemia,
obesity, and diabetes.
Overweight and obesity: To reduce the risk of CVD, weight loss is

recommended for all people who are overweight or obese. A 5% loss of
body weight may result in moderate improvements in blood pressure,
LDL-C, triglyceride, and glucose levels. Central obesity indicates greater
cardiometabolic risks.
Hypertension: Diet-related lifestyle recommendations for the primary or
secondary prevention of hypertension include losing weight if
overweight, following a DASH diet, reducing sodium intake, consuming
adequate potassium, and using alcohol in moderation, if at all.
Hypercholesterolemia: Previously, the general public and clients with high
cholesterol levels were advised to restrict their intake of cholesterol.
Currently, the recommendation is to eat a heart- healthy diet (e.g., DASH
or Mediterranean style) because they are inherently low in cholesterol
and saturated fat. For most people, eating an egg a day is acceptable.
Metabolic syndrome: A multicomponent risk factor for both ASCVD and
type 2 diabetes characterized by at least three of the following: high
triglycerides, low HDL cholesterol, high blood pressure, elevated fasting
glucose, and central obesity. Lifestyle therapy is the cornerstone of
treatment. A Mediterranean-style eating pattern with appropriate calories
for weight loss is recommended.
Secondary Prevention of
Cardiovascular Diseases
Lifestyle modifications, including regular physical activity and weight
management, are fundamental to treating existing CHD.
Healthy eating pattern: Both the Mediterranean-style eating pattern and
DASH diet are heart healthy. The “best” pattern is the one the client can
adhere to. Calories should be adjusted to promote weight loss, if
overweight or obese.
Heart failure: HF is treated with drug therapy and lifestyle modifications
including a healthy eating pattern, weight management, physical activity,
and smoking cessation. Greater adherence to a Mediterranean-style eating
pattern is associated with a lower risk of HF. Calories are adjusted for
weight status; higher amounts of protein are indicated. The ideal intake of
sodium is controversial; 2000 to 3000 mg/day may be appropriate with a
fluid restriction, if necessary.
Figure sources: shutterstock.com/Alexander Raths, shutterstock.com/Double Brain,
shutterstock.com/JenJ_Payless

book at
Websites
American Heart Association at www.americanheart.org
Heart and Stroke Foundation of Canada at www.hsf.ca
Mediterranean-style eating pattern at https://oldwayspt.org/
National Heart, Lung and Blood Institute at www.nhlbi.nih.gov
To estimate your risk of heart disease, go to http://cvdrisk.nhlbi.nih.gov/
References
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23 with Kidney Disorders
Sonja Fern
Sonja is 46 years old, is 6 ft 1 in. tall, and weighs
218 pounds. She has intentionally lost 25 pounds in
the last month after donating one of her kidneys. She
was extremely moved by the significance of being
healthy enough to help a friend through organ
donation and recognizes that she must proactively
protect her remaining kidney to preserve her own
health. She had borderline hypertension before the
surgery, is a previous heavy smoker, but has no other
medical history. She has adopted a lacto-ovo
vegetarian eating pattern and occasionally eats fish.
Learning Objectives
1 Explain general nutrition recommendations for nephrotic syndrome.

2 Discuss nutrition and lifestyle interventions that may help prevent
chronic kidney disease (CKD).
Explain why sodium, protein, phosphorus, and potassium are restricted
3
as kidney disease progresses.
4 Summarize the importance of consuming adequate calories when protein
intake is restricted.
5 Give examples of foods to eat or avoid when sodium, protein,
phosphorus, and potassium are restricted.
6 Review characteristics of the Mediterranean-Style Eating Pattern that
may benefit clients with CKD.
7 Explain how nutrient recommendations differ for clients with CKD after
renal replacement therapy begins.
8 Explain nutrient recommendations for posttransplant clients.
9 Summarize nutrition and lifestyle strategies that may help prevent kidney
stones from forming.
The kidneys play many vital roles in maintaining overall health (Box 23.1);
impairments in kidney function can cause widespread disruptions in
metabolism, bone health, fluid balance, nutritional status, and nutrient
requirements. Kidney diseases are the ninth leading cause of death in the
United States (Kochanek et al., 2019). Fifteen percent of U.S. adults are
estimated to have chronic kidney disease (CKD) and 9 out of 10 adults
with CKD do not know they have it (Centers for Disease Control and
Prevention [CDC], 2019). Kidney diseases vary in severity, chronicity, and
etiology.
Chronic Kidney Disease (CKD)

an estimated GFR <60 mL/min/1.73 m2 for ≥3 months with evidence of kidney damage as
indicated by albuminuria.
BOX Kidney Functions

23.1
Filter blood and form urine to

• regulate extracellular fluid volume and osmolarity, electrolyte
concentration, and acid–base balance;
• excrete nitrogenous wastes from protein metabolism (e.g., urea,
creatinine), toxic substances, and drugs;
Help regulate blood pressure by secreting renin, an enzyme that activates
the precursor of angiotensin, a hormone involved in blood pressure
regulation
Stimulate the production of RBC in the bone marrow by producing
the hormone erythropoietin
Help regulate calcium balance and bone formation by converting
vitamin D to its active form
Nutrition is implicated in several of the chronic disease risk factors for

CKD and is an integral component of kidney disease management. This
chapter presents the role of nutrition in maintaining kidney health and
nutrition therapy for the treatment of nephrotic syndrome, CKD, acute
kidney injury (AKI), and urolithiasis.
NUTRITION IN MAINTAINING
KIDNEY HEALTH
The typical American diet, characterized by a high intake of red meat,

saturated fat, trans fat, added sugar, and processed foods and a low intake of
fruits, vegetables, whole grains, and fish, increases the risk of several
chronic diseases, such as obesity, diabetes, hypertension, and cardiovascular
disease (CVD). Each of these chronic diseases increases the risk of kidney
disease. Furthermore, the Nurse’s Health Study showed that people who
consume a typical American-Style Eating Pattern are more likely to have
moderate to severely increased levels of urinary albumin excretion and are
more likely to have a rapid decline in glomerular filtration rate (GFR)
compared to people who do not eat a western diet (Lin et al., 2011).
Glomerular Filtration Rate (GFR)

the rate at which the kidneys form filtrate estimated from the amount of creatinine excreted per
24 hours. Normal GFR is about 120 to 130 mL/min.
Preventing CKD and its complications is possible by managing risk

factors to slow its progression (CDC, 2017). Given their shared risks,
general suggestions to reduce the risk of CKD are consistent with
recommendations for promoting cardiovascular health (Chapter 22).
• Consume a healthy eating pattern, such as a Dietary Approaches to
Stop Hypertension (DASH) diet or Mediterranean-Style Eating
Pattern.
• Do not use tobacco.
• Control blood glucose levels.
• Maintain normal blood pressure.
• Maintain normal serum cholesterol.
Healthy Eating Pattern

Known to reduce the risk of CVD, the DASH diet and Mediterranean-Style
Eating Patterns have also been shown to reduce the incidence of CKD
disease (Huang et al., 2013b; Rebholz et al., 2016). Both patterns are
inherently low in cholesterol, saturated fat, and processed foods (e.g.,
sodium) and can be adjusted to provide the appropriate number of calories
for achieving or maintaining healthy weight. Unlike recommendations for
cardiovascular health, a healthy eating pattern for healthy kidneys also
includes avoiding an excessive intake of protein. Protein metabolism
generates nitrogenous wastes that the kidney must excrete. Increasing the
proportion of plant sources of protein is recommended (Kalantar-Zadek &
Fougue, 2017).
Nitrogenous Wastes
wastes produced from nitrogen—namely, ammonia, urea, uric acid, and creatinine.
Dash Diet
A prospective cohort study has found that participants who consumed an
eating pattern similar to the Dietary Approaches to Stop Hypertension
(DASH) diet had a lower risk for kidney disease, independent of
demographic characteristics, kidney disease risk factors, and baseline
kidney function (Rebholz et al., 2016).
• The DASH diet is high in fruits, vegetables, whole grains, nuts and
legumes, and low-fat dairy products and low in red and processed
meats, sugar-sweetened beverages, and sweets (see Chapter 22).
• Benefits may be attributed to its effect on lowering blood pressure
and reducing inflammation.
• In addition, researchers specifically found that high intakes of nuts,
legumes, and low-fat dairy products were associated with a lower
risk for kidney disease, whereas high red and processed meat intake
was associated with a higher kidney disease risk.

Strong adherence to a Mediterranean-Style Eating Pattern is associated with
lower prevalence of CKD and lower mortality risk (Huang et al., 2013b).
• The Mediterranean-Style Eating Pattern is a plant-based pattern that
emphasizes whole grains, fruit, vegetables, nuts, legumes, and olive
oil; frequent intake of fish; limited amounts of red meat, processed
meats, and sweets; and wine in moderation with meals.
• The Mediterranean-Style Eating Pattern may help preserve kidney
function through favorable effects on endothelial function,
inflammation, lipid levels, and blood pressure (Chauveau et al.,
2018).
• Strong adherence to a Mediterranean-Style Eating Pattern has also
been shown to lower the risk of two major risk factors for CKD,
namely, CVD (Estruch et al., 2018) and type 2 diabetes (Salas-
Salvado et al., 2016).
NEPHROTIC SYNDROME
Nephrotic syndrome refers to a collection of symptoms caused by

alterations in the kidney’s glomerular basement membrane that result in
large urinary losses of albumin and other plasma proteins. It can arise from
any kidney disease that damages the glomeruli, such as diabetes,
autoimmune diseases (e.g., lupus, IgA nephropathy), infection, and certain
chemicals.
Nephrotic Syndrome
a collection of symptoms that occur when increased capillary permeability in the glomeruli allows
serum proteins to leak into the urine.
• Hypoalbuminemia, proteinuria, hyperlipidemia, and edema are

major features of nephrotic syndrome.
Hypoalbuminemia
low blood levels of albumin, the most abundant plasma protein.
Proteinuria
protein in the urine; also known as albuminuria.
Hyperlipidemia
abnormally high level of lipids in the blood, such as low-density lipoprotein cholesterol and
triglycerides.
• The majority of the urinary protein excreted is albumin;

hypoalbuminemia, along with sodium and fluid retention, leads to
edema.
• Possible complications related to the loss of other plasma proteins
include anemia (loss of transferrin), increased risk of infection (loss
of immunoglobulins), vitamin D deficiency (loss of vitamin D–
binding protein), and increased blood clotting (loss of anti–blood
clotting proteins).
• Hyperlipidemia (elevated serum levels of cholesterol and
triglycerides) increases the risk of atherosclerosis, myocardial
infarction, and stroke and may play a role in the increased risk of
thrombosis associated with nephrotic syndrome (Agrawal et al.,
2018). The dyslipidemia of nephrotic syndrome also causes kidney
injury and may contribute to the development of CKD.
• Protein–calorie malnutrition may develop.
• In some cases, treating the underlying disorder corrects nephrotic
syndrome. In others, especially diabetes, nephrotic syndrome may
be the beginning of CKD.
Nutrition Therapy for Nephrotic Syndrome

The primary objective of nutrition therapy for nephrotic syndrome is to
reduce proteinuria (Academy of Nutrition and Dietetics, 2020).
• The recommended protein intake for nephrotic syndrome in adults is
0.8 to 1.0 g/kg/day (adult Recommended Dietary Allowance [RDA]
is 0.8 g/kg/day.) (Cadnapaphornchai et al., 2014). Although
nephrotic syndrome is characterized by increased urinary losses of
plasma proteins, a high-protein diet is contraindicated because it
exacerbates urinary protein losses, promoting further kidney
damage.
• Sodium intake should be restricted to ≤2 g/day to help control
edema and blood pressure (Cadnapaphornchai et al., 2014).
• A low-fat, low-cholesterol diet is recommended because it improves
dyslipidemia. However, no study has proven that this intervention
improves prognosis (Nishi et al., 2016).
• Adequate calories, such as 35 cal/kg, are required to spare protein
and maintain weight.
• Supplements of vitamin D are provided when vitamin D deficiency
is diagnosed.
CHRONIC KIDNEY DISEASE

Normal kidney function is defined as an estimated glomerular filtration
rate (eGFR) of at least 90 mL/min 1.73 m2, although 60 to 89 may be
normal for some people, including adults over the age of 60. CKD is
diagnosed when eGFR is <60 for 3 months or longer.
Estimated Glomerular Filtration Rate (eGFR)

determined through an equation that takes into account serum creatinine level, age, gender, and
race; used interchangeably with the term glomerular filtration rate (GFR).
CKD, a generally progressive and irreversible loss of kidney function, is

categorized into five stages based on eGFR. Stages 1 and 2 are the mildest
stages, whereas stage 5 represents advanced CKD. The decision to begin
dialysis or perform a transplant is made not only on the basis of residual
kidney function, but also on the basis of symptoms of uremia (e.g.,
anorexia, hyperazotemia, hyperphosphatemia, metabolic acidosis,
malnutrition, etc.) that are no longer manageable (Cupisti et al., 2018).
Chronic Kidney Disease Risk Factors

Diabetes (Chapter 21) and hypertension (Chapter 22) are responsible for 3
out of 4 of new cases of kidney failure (CDC, 2020). Other risk factors
include CVD, obesity, advancing age, and a family history of CKD.
Individuals of African-American, Native American, or Hispanic ethnicities
are at increased risk for CKD. CKD increases the risk of early death, heart
disease, and stroke. Not all clients with CKD progress to kidney failure.
Control of risk factors, annual testing, lifestyle changes, and medication
may help prevent CKD and lower the risk of kidney failure (CDC, 2020).
Think of Sonja. What is her body mass index (BMI)? What

risk factors for CKD did she have or currently has? What
interventions would you suggest to help her maintain kidney
health? Is a lacto-ovo eating pattern adequate and
appropriate?
Disease Progression
CKD and its progression are closely linked to increased inflammatory
response of the body (Pluta et al., 2017). As kidney function deteriorates,
especially in advanced stages, the ability to excrete adequate amounts of
nitrogenous wastes, sodium, fluid, potassium, phosphorus, and hydrogen
ions becomes increasingly impaired. Interrelated and multifactorial
metabolic and clinical complications develop, and the disruption to
homeostasis is profound (Box 23.2).
BOX Complications of Chronic Kidney

23.2 Disease
• Sodium and fluid retention → hypertension, edema, shortness of

breath, heart failure, and oxidative stress.
• Impaired synthesis of renin contributes to hypertension.
• Phosphorus retention → secondary hyperparathyroidism → renal bone
disease, vascular calcification, accelerated progression of kidney
disease due to vascular injury, and increased risk of cardiovascular
mortality.
• Decreased excretion of the fixed acid load → metabolic acidosis.
• Metabolic acidosis → anorexia, nausea, and vomiting; it also
stimulates protein and muscle catabolism, bone demineralization,
insulin resistance, and hyperkalemia. Associated with more rapid
kidney disease progression and increase in overall risk of death.
• Impaired synthesis of erythropoietin → anemia; GI absorption of iron
is also impaired and iron intake may be inadequate.
• Alterations in carbohydrate, protein, and fat metabolism may
contribute to hypoglycemia, cachexia, and CVD (de Boer &
Utzschneider, 2017).
• Accumulation of nitrogenous wastes (from food intake and muscle
protein catabolism) → uremic syndrome, characterized by anemia,
bone disease, hormonal imbalances, bleeding impairment, impaired
immunity, fatigue, decreased mental acuity, muscle twitches, cramps,
anorexia, nausea, vomiting, diarrhea, itchy skin, and gastritis.
• Uremic syndrome → PEW → decreased physical activity, onset of a
micro-inflammatory state, and higher rates of hospitalization and
mortality.
• Inflammation, oxidative stress, and vascular calcification contribute to
accelerated onset of cardiovascular risk.
• Cardiovascular death is 2 to 3 times higher in clients with CKD
compared with the general population (Saglimbene et al., 2020).
Fixed Acid
Acid produced in the body from sources other than carbon dioxide that are not excreted by the
lungs. These acids are mostly produced from the metabolism of sulfur in dietary protein; plant
foods yield bicarbonate. Dietary acid load must be excreted by the kidney to maintain acid–
base balance.
Source: Cupisti, A., Brunori, G., Di Iorio, B. R., D’Alessandro, C., Pasticci, F., Cosola, C.,
Bellizzi, V., Bolasco, P., Capitanini, A., Fantuzzi, A. L., Gennari, A., Piccoli, G. B.,
Quintaliani, G., Salomone, M., Sandrini, M., Santoro, D., Babini, P., Fiaccadori, E., Gambaro,
G., … Gesualdo, L. (2018). Nutritional treatment of advanced CKD: Twenty consensus
statements. Journal of Nephrology, 31(4), 457–473. https://doi.org/10.1007/s40620-018-0497-z
• Complications increase in frequency and severity as CKD

progresses; however, complications can occur at any stage and can
lead to death before CKD progresses to end-stage renal disease
(ESRD).
• Complications may arise not only from diminishing kidney function,
but also from CVD or treatments.
• Significant weight loss relatively early in the course of CKD is
associated with a substantially higher risk for death after dialysis is
initiated (Ku et al., 2018). More studies are needed to determine if
optimizing weight and nutritional status before the initiation of
dialysis will improve ESRD outcomes.
• Protein energy wasting (PEW), similar to cachexia, has a prevalence
of 11% to 54% among clients during Stages 3 to 5 of CKD (Carrero
et al., 2018): However, there is a lack of consensus on how to define
PEW in this population and how to measure proposed criteria, such
as skeletal muscle depletion, reduced food intake, and abnormal lab
values (e.g., serum albumin) (Koppe et al., 2019).
• CKD is associated with an increase in atherosclerosis from its early
stages and the progression of CKD is associated with the
progression of atherosclerosis
• Among the emerging risk factors for atherosclerosis in CKD are
altered bone mineral metabolism, vascular calcification, uremic
toxins, inflammation, oxidative stress, and endothelial
dysfunction (Valdivielso et al., 2019).
Nutrition Therapy
The goal of nutrition therapy in CKD is to promote optimal nutritional
status; prevent and or improve signs, symptoms, and complications of
CKD; and possibly delay the initiation of dialysis (Cupisti et al., 2018).
Indeed, nutrition therapy can help manage uremia, electrolyte and acid–base
imbalances, water and sodium retention, mineral and bone disorders, and
protein–energy malnutrition (Kalantar-Zadek & Fougue, 2017). Control of
blood pressure and glucose levels remains the crucial strategy in all stages
of kidney disease.
Although the potential benefits of nutrition therapy in CKD are
recognized, there is lack of consensus on actual nutrient recommendations;
variations exist among experts, the level of existing kidney function, and
comorbidities. Generally, all clients with CKD are urged to eat a heart-
healthy eating pattern and to avoid excessive intakes of protein and sodium;
additional restrictions for phosphorus and potassium are added as necessary
(tab 23.1). Salient points about these and other nutrients of concern are
presented in the following section. As restrictions become more numerous
and severe, overall diet quality may be compromised (Campbell & Carrero,
2016). Box 23.3 provides a general guide for food selection.
Table General Nutrient

Recommendations for Chronic
23.1 Kidney Disease
BOX Eating Tips for People with Chronic

23.3 Kidney Disease
These recommendations are intended for all people with CKD.
• Choose heart-healthy options.
• Grill, broil, bake, roast, or stir-fry instead of deep-fat frying.
• Use nonstick cooking spray or olive oil instead of butter.
• Trim fat from meat and remove poultry skin before eating.
• Choose lean protein sources: loin or round cuts of meat, skinless
white-meat poultry, fish, legumes, and low-fat milk, yogurt, and
cheese.
• Limit alcohol to moderate intake: no more than 1 drink/day for
women and no more than 2 drinks/day for men.
• Control the type and amount of protein chosen.
• Eat small portions of protein.
• Use a mix of animal proteins (chicken, fish, meat, eggs, dairy) and
plant proteins (legumes, nuts).
• Choose foods with less sodium to help control blood pressure.
• Avoid salting food during cooking or at the table.
• Buy fresh food more often.
• Use spices, herbs, and sodium-free seasonings instead of salt.
• Check the Nutrition Facts label to comparison shop. A Daily Value
of ≥20% means the food is high in sodium.
• Look for foods that are labeled sodium free, salt free, very low
sodium, low sodium, reduced or less sodium.
• Rinse canned vegetables, beans, and meats before eating.
• Avoid processed meats and salted snacks and crackers.
• Avoid high-sodium condiments, such as soy sauce, teriyaki sauce,
and bottled salad dressings.
Additionally, these recommendations may be appropriate as kidney
function deteriorates.
• Choose foods with less phosphorous.
• Many packaged foods have added phosphorus. Look for phosphorus
or words beginning with “phos” on ingredient lists.
• Foods higher in phosphorus include
• meat, poultry, and fish;
• bran cereals and oatmeal;
• chocolate, hot chocolate, and cocoa;
• some whole grains;
• dairy foods: milk, cheese, ice cream, milk, pudding, and yogurt;
• lentils;
• nuts, peanut butter, and seeds; and
• cola and beer.
• Foods lower in phosphorus include
• fresh fruit and vegetables;
• breads, pasta, rice;
• corn and rice cereals;
• non-enriched rice milk; and
• light-colored soft drinks.
• Choose foods that have the appropriate amount of potassium.
• Avoid salt substitutes unless approved by the health care provider.
• Drain canned fruits and vegetables before eating.
• Foods higher in potassium include
• oranges, orange juice, avocado, banana, kiwifruit, prunes, prune
juice, dried fruit, mango, nectarine, papaya, and pumpkin;
• artichokes, avocado, brussels sprouts, okra, winter squash,
potatoes, greens (except kale), tomatoes, and vegetable juice;
• brown and wild rice, bran cereals;
• milk and yogurt;
• whole-wheat bread and pasta; and
• legumes and nuts.
• Foods lower in potassium include
• apples, black berries, blueberries, cherries, grapes, grape juice,
pears, pineapple, raspberries, and strawberries;
• carrots, green beans, cabbage, celery, corn, cucumber, eggplant,
kale, lettuce, green peas, and zucchini squash;
• white bread, pasta, and rice;
• cooked rice and wheat cereals; grits; and
• unenriched rice milk.
Adapted from National Institute of Diabetes and Digestive and Kidney
Diseases. (2016, October). Eating right for chronic kidney disease.
https://www.niddk.nih.gov/health-information/kidney-disease/chronic-
kidney-disease-ckd/eating-nutrition
Consider Sonja. A diet history revealed she uses soy

protein–based entrees, which she recently realized are high
in sodium. Her typical pattern also includes 1 serving of
yogurt per day, 1 serving of vegetables, 1 to 2 servings of
fruit, and occasionally whole-wheat bread. She dislikes milk
and gave up sugar-sweetened beverages. She drinks two
“large” glasses of wine 3 to 4 days/week and admitted a
weakness for white bread and potatoes. When she is
stressed, she goes to the vending machine and buys two
candy bars and hides them in her clothes so her coworkers
won’t know she is eating. Does her usual intake qualify as a
healthy eating pattern? What are the positive features of her
current pattern? What specific changes can she make in her
intake to improve her diet quality? Is her alcohol intake
considered moderate? What options would you suggest in
place of high-sodium soy entrees?
Heart-Healthy Eating Pattern: Mediterranean Style

The Mediterranean diet has recently been suggested for adults with CKD
Stages 1 to 5 not on dialysis or posttransplantation, with or without altered
lipid levels, to improve lipid profiles (Ikizler et al., 2020).
• Emerging evidence in clients with CKD suggests that eating patterns
rich in fruits and vegetables, such as the Mediterranean-Style Eating
Pattern, may help delay the progression of CKD and prevent
complications (Kelly et al., 2017).
• Better adherence to the Mediterranean-Style Eating Pattern has been
consistently associated with a lower risk of ESRD in community-
dwelling adults aged 51 to 70 years (Smyth et al., 2016).
• The potential mechanisms by which the Mediterranean-Style Eating
Pattern may benefit clients with CKD are summarized in Box 23.4.
Selected Potential Mechanisms by Which

BOX
the Mediterranean-Style Eating Pattern
23.4 May Benefit Clients with Chronic
Kidney Disease
• The amount of protein is similar to a controlled protein diet for CKD,

supplying approximately 0.8 g/kg/day; but it mostly comes from heart-
healthy vegetables, fish, and white meat.
• Red and processed meats are limited, which limits saturated fat,
sodium, and phosphate intake.
• Half of the relatively high fat content is from monounsaturated fat due
to the use of extra virgin olive oil; its polyphenols and vitamin E exert
anti-inflammatory and antioxidant properties.
• Most of the carbohydrates are from high-quality, nutrient-dense
sources, such as fruit, vegetables, whole grains, and nuts, which results
in a low-glycemic index intake that may improve glucose control,
hyperinsulinemia, insulin resistance, and blood lipid levels.
• Moderate intake of wine is included, which has anti-inflammatory and
antioxidant properties due to the content of polyphenols (e.g.,
resveratrol) in red wine and phenols in white wine.
• Unrefined, minimally processed foods, which are lower in phosphorus
and sodium than highly processed foods, are emphasized.
• Thirty to 50 g of fiber/day is provided, which positively affects the
microbiome, constipation, uremic toxins, inflammation, and the risk of
diabetes and heart disease.
• Its high content of fruits and vegetables is controversial.
• On the plus side, they provide potassium which may help control
blood pressure and have a low dietary acid load which may slow the
decline in kidney function.
• However, their high potassium content may increase the risk of
CKD progression.
Source: Chauveau, P., Aparicio, M., Bellizzi, V., Campbell, K., Hong, X., Johansson, L., Kolko,
A., Molina, P., Sezer, S., Wanner, C., ter Wee, P. M., Teta, D., Fouque, D., Carrero, J. J., &
European Renal Nutrition (ERN) Working Group of the European Renal Association-European
Dialysis Transplant Association (ERA-EDTA). (2018). Mediterranean diet as the diet of choice
for patients with chronic kidney disease. Nephrology Dialysis Transplantation, 33, 725–735.
https://doi.org/10.1093/ndt/gfx085
Protein
A high-protein diet, usually defined as >1.2 g protein/kg body weight/day,
is known to cause significant alterations in the function and health of
kidneys (Ko et al., 2017). Conversely, low-protein diets can slow the
progression of CKD but contribute to the state of malnutrition usually seen
in CKD clients (Noce et al., 2016).
• Although it is agreed upon that excesses and deficiencies of protein
should be avoided, the ideal intake of protein for clients with CKD
is not known.
• Clients with CKD and diabetes may be allowed slightly higher
amounts of protein than clients without diabetes to improve
glycemic control.
• Where keto acid analogs are available, a very-low-protein diet
supplemented with essential amino acids and keto acid mixtures
may be considered for adults without diabetes, not on dialysis, and
with an eGFR <20 mL/min/1.73 m2.
• Keto acid analogs are widely used for managing CKD in Europe,
Asia, and other areas of the world. Their use in the United States
is limited because of lack of availability.
• These supplements ensure a sufficient balance of essential amino
acids.
• Crucial to the success of this type of regimen is a high level of
client motivation, intensive education and support, and ongoing
nutrition counseling.
• Low-protein diets (0.6–0.8 g protein/kg body weight/day) are not
always prescribed in the United States as a means of slowing the
progression of CKD, in part because of the risk of malnutrition and
difficulty with compliance (Kalantar-Zadeh et al., 2016).
• Most clients on a low-protein diet consume more protein than
prescribed (Cupisti et al., 2018).
Sodium
Sodium restriction is recommended to control fluid retention and
hypertension and to improve cardiovascular risk profile, even though it is
not clear that it slows disease progression (Kalantar-Zadeh & Fouque,
2017).
• Generally, <2300 mg/day is recommended (Ikizler et al., 2020).
• For reference, the Chronic Disease Risk Reduction Intake for
sodium for healthy Americans aged 14 and older is 2300 mg/day—
meaning that all people should reduce their intake of sodium if it is
>2300 mg (National Academies of Sciences, Engineering, and
Medicine, 2019).
• Evidence supporting a sodium intake of <1500 mg for clients with
renal insufficiency is lacking, given the risk of hyponatremia and
adverse outcomes.
Phosphorus
Elevated parathyroid hormone highlights the importance of managing
phosphorus intake even in clients who do not have hyperphosphatemia
(Kalantar-Zadeh & Fouque, 2017).
• Phosphorus and protein share many sources, so a low-protein diet is
lower in phosphorus than the typical American diet.
• Phosphorus absorption is higher from animal sources than from
plants.
• Phosphate additives, widely used as food preservatives, are
commonly found in frozen, convenience, and prepackaged foods.
Because inorganic phosphate additives are better absorbed than
naturally occurring phosphorus in foods, processed food intake
should be minimized.
• “Nutrition Facts” labels are not required to list phosphorus content,
making it difficult for clients to estimate phosphorus intake.
• Because serum phosphate levels are difficult to control through
dietary restriction alone, ample use of phosphate binders may be
prescribed with meals and snacks to avoid excessively stringent
protein restriction to control hyperphosphatemia (Kalantar-Zadeh &
Fouque, 2017).
Potassium
Clients with CKD are at risk of hyperkalemia due to reduced urinary
excretion. Other contributing factors include metabolic acidosis,
catabolism, and the use of ACEIs or ARBs to control blood pressure.
• Potassium restriction is often recommended for clients with
hyperkalemia, especially clients in advanced stages of kidney
disease. However, excessive potassium restriction may translate to
less heart-healthy/more atherogenic eating patterns (e.g., fewer
fruits, vegetables, and whole grains) and worsen constipation, which
may result in higher gastrointestinal (GI) absorption of potassium
(Kalantar-Zadeh & Fouque, 2017).
• In clients with hyperkalemia, limiting potassium intake to <3 g/day
is recommended with the caveat that fruit, vegetable, and high-fiber
intake not be compromised (Kalantar-Zadeh & Fouque, 2017).
Other Dietary Concerns

Calories, calcium, fiber, fat, and micronutrient supplements are other
dietary concerns for clients with CKD.
Calories
Generally, 25 to 35 cal/kg/day are suggested depending on BMI, sex, level
of physical activity, CKD stage, concurrent illness, and age.
• Adequate calories are needed to ensure that dietary protein is used
for repair rather than being metabolized as a source of energy.
• Calorie intake is often inadequate due to anorexia, nausea,
depression, and taste and smell abnormalities related to uremic
toxicity (Cupisti et al., 2018).
• Specially formulated low-protein foods made from carbohydrates
are available to boost calorie intake while providing negligible
amounts of protein, potassium, sodium, and phosphorus. However,
they tend to be expensive and lack palatability.
• Fats and simple sugars are considered “free” foods because they
provide protein-free calories with only small amounts of potassium,
sodium, and phosphorus when used in recommended amounts.
Suggestions include the following:
• Adding honey or sugar to cereals or beverages.
• Adding oils or trans fat–free margarine to cooked rice, pasta,
cereals, or vegetables.
• Using jam or jelly on toast or crackers
• Snacking on hard candy, gummies, lollipops, jelly beans, and
marshmallows.
Calcium
Kidney disease alters calcium metabolism in several ways. The decrease in
vitamin D activation in the kidneys decreases calcium absorption from the
GI tract, although passive diffusion of calcium ion absorption continues.
Urinary calcium excretion decreases, but calcium is released from the bone
secondary to hyperparathyroidism.
• It is recommended that calcium intake from all sources be 800 to
1000 mg/day in clients with moderate-to-advanced CKD, a
recommendation not too different than the normal RDA.
Milk products, a rich source of calcium, are generally restricted
•
because they are also high in phosphorus.
Fiber
Advanced CKD is characterized by dysbiosis of intestinal microbiota,
which contributes to uremic toxicity and cardiovascular damage (Cupisti et
al., 2018).
Dysbiosis
an imbalance in the natural microflora of the gut, a condition thought to contribute to the cause or
persistence of diseases.
• Adequate fiber intake could reduce dysbiosis and circulating uremic

toxins (Cupisti et al., 2018).
• High-fiber grains may promote a more favorable microbiome and
help prevent constipation, but most are higher in phosphorus and
potassium than refined grains. Some low-phosphorus grains that
provide fiber include
• bulgur,
• high-fiber white bread,
• unsalted popcorn, and
• Grape Nut Flakes.
Fat
A low-protein diet results in a higher proportion of calories from
carbohydrates and fat (Kalantar-Zadeh & Fouque, 2017).
• Pure fats are a concentrated source of calories and do not provide
protein, phosphorus, and potassium. Like simple sugars; they are
considered “free” foods.
• Because people with CKD are at high risk of CVD, heart-healthy
unsaturated fats (e.g., olive oil, soy oil, or canola oil) are preferred
over saturated fats (e.g., butter and stick margarine). Soy oil and
canola oil also provide omega-3 fatty acids.
Micronutrient Supplements
Micronutrient imbalances may occur in clients with CKD from inadequate
intake, impaired GI absorption, or altered metabolism.
• Iron is the most problematic mineral deficiency (Kalantar-Zadeh &
Fouque, 2017).
• When assessment of micronutrient intake is determined to be
inadequate, daily multivitamin supplements may be prescribed
(Ikizler et al., 2020).
• Clients at any stage of CKD may be prescribed vitamin D
supplements to correct impaired vitamin D metabolism resulting
from decreased kidney function.
• At any stage of CKD, routine supplementation of selenium or zinc is
not suggested because there is little evidence of benefit (Ikizler et
al., 2020).
Renal Meal Plan

In contrast to the general guide for food selection outlined in Box 23.3, a
renal meal plan is a more restrictive approach to managing the intake of
specific nutrients. This detailed approach is particularly useful for CKD
clients with diabetes who require a consistent carbohydrate intake. The
meal plan varies with the stage of CKD and the client’s calorie needs. Keep
in mind that these generalizations listed as follows may differ from
guidelines from other sources.
• Food lists and a meal plan are used to achieve relative consistency
in the intake of nutrients of concern: protein, sodium, phosphorus,
and potassium.
• Subgroups exist based on nutrient content.
• Box 23.5 outlines food choice lists for diabetes and CKD Stages 1 to
4, with examples of representative foods.
• An individualized meal plan specifies how many servings from each
list or sublist should be consumed at each meal and snack.
An example of the total daily amount of food from each food group
•
allowed for someone with Stage 4 CKD is as follows:
• 4 oz of meat
• ½ c of milk
• 2 servings of fruit (1 low potassium, 1 high potassium)
• 3 servings of vegetables (1 each of low, medium, and high
potassium)
• 5 servings of bread, cereal, and grains
• 6 servings of fats
• 2 desserts/sweets
• Client adherence to traditional nutrition therapy for CKD is
estimated to be approximately 31% (Cupisti et al., 2018). Strategies
to help promote dietary adherence are listed in Box 23.6.
Food Choice Lists for Diabetes and

BOX
Chronic Kidney Disease Stages 1–4:
23.5 Examples of Representative Foods
Protein choice categories

• Meat, poultry, and fish
• Meat alternatives: eggs, nuts, and tofu
• Legumes: prepared from dried beans; not canned varieties
• Protein foods with higher amounts of sodium and phosphorus: bacon,
sausage, canned fish, processed cheese, canned legumes, deli meats,
and vegetarian meat alternatives
Dairy choice categories
• Dairy foods: low-fat or fat-free milk, low-fat or fat-free yogurt
• Dairy foods with higher amounts of calories, carbohydrates, and fat:
eggnog, ice cream, whole milk, sweetened pudding, and regular
sweetened or frozen yogurt
• Dairy alternatives: unenriched, unsweetened almond milk, rice milk,
and soy milk; nondairy creamer
Bread, cereal, and grain choice categories
• Bread, cereal, or grain food: bread, many cooked cereals, crackers,
pasta, popcorn, rice, and tortilla
• Additional grain choices: biscuits, muffins, oatmeal, dry cereal,
pancake, waffle, and sandwich cookie
• Desserts and sweets: hard candies, jellybeans, sugar cookies, and low-
fat vanilla wafers
Fruit choice categories
• Low-potassium fruits: apple, apple juice, applesauce, blackberries,
blueberries, grapes, papaya nectar, pear, and strawberries
• Medium-potassium fruits: cantaloupe cherries, fig, grapefruit, mango,
and fresh papaya
• High-potassium fruits: apricot, avocado, bananas, dates, kiwifruit,
orange, orange juice, prune juice, and raisins
Vegetable choice categories
• Low-potassium vegetables: canned beets, cabbage, carrots,
cauliflower, corn, eggplant, green beans, mushrooms, and onions
• Medium-potassium vegetables: asparagus, broccoli, celery, kale, green
peas, summer squash, and zucchini
• High-potassium vegetables: artichokes, brussels sprouts, okra,
potatoes, spinach, sweet potatoes, tomatoes, and winter squash
Fat choice categories
• Healthier, unsaturated fats: trans fat–free margarine, low-fat or nonfat
mayonnaise, and oils (canola, corn, olive, peanut, soybean, sunflower)
• Saturated fats—limit use: bacon fat, butter, half and half, cream
cheese, whipped cream, lard, sour cream, and whipped cream topping
Note. Lists are not complete or universally agreed upon
Source: Academy of Nutrition and Dietetics. (n.d.). Diabetes and chronic kidney disease stages
1–4: nutrition guidelines. https://www.nutritioncaremanual.org/
Strategies to Promote Dietary Adherence

BOX
to Chronic Kidney Disease Diet
23.6
• Provide positive messages about what to eat rather than emphasizing

food restrictions.
• Encourage social support from family and friends.
• Foster the client’s perception as successfully adhering to the plan;
people who are more confident in their ability to adhere to the eating
plan make better choices.
• Provide feedback on self-monitoring and laboratory data; correlation
of records with laboratory data enables the client to see cause and
effect, reinforces the importance of nutrition therapy, and opens the
door for problem-solving.
• Encourage clients to
• eat a good breakfast if appetite decreases as the day progresses,
which may occur secondary to uremia;
• try highly seasoned or strongly flavored foods if uremia has caused
a change in the sense of taste;
• eat a consistent intake of carbohydrate with regularly timed meals to
control blood glucose levels, if appropriate; and
• seek physician approval before using any vitamin, mineral, or
supplement.
• Provide pointers to help clients limit their intake of protein, which may
be less than 5 to 6 oz/day for most men and less than 4 oz/day for most
women.
• Urge clients to think of meat as a side dish, not the main entrée.
• Because too little or too much protein can cause uremic symptoms
to return, encourage clients to initially, and periodically thereafter,
weigh or measure protein portion sizes for accuracy.
• Encourage the use of low-protein breads, cereals, cookies, and
pastas. Acceptability varies greatly among low-protein products, so
if a client does not like one brand, it does not mean they will not like
another.
• Urge clients to spread protein allowance over the whole day instead
of saving it all for one meal.
Nutrition Therapy during Dialysis

Clients undergoing dialysis are at considerable increased risk of morbidity
and mortality related to persistent inflammation, malnutrition, and
metabolic abnormalities (Huang et al., 2013a). The goal of nutrition therapy
is to match dietary intake with renal replacement therapy (RRT) while
preventing nutrition deficiencies (Beto et al., 2014). The diet is complex
and dynamic. Nutrient recommendations are used as a guideline; the client’s
actual needs are based on individual assessment.
In general, clients undergoing dialysis have the same nutrient
recommendations as those listed for advanced CKD (tab 23.1) with the
following exceptions:
• Protein recommendation increases to 1.0 to 1.2 g/kg/day or higher to
account for the loss of serum proteins and amino acids in the
dialysate (Ikizler et al., 2020).
Dialysate
the dialysis solution used to extract wastes and fluid from the blood.
• Achieving a high protein intake within the confines of other

restrictions, especially phosphorus restrictions, can be
challenging.
• Total calcium intake should be <800 mg/day.
• For people on hemodialysis, fluid allowance equals the volume of
any urine produced plus 1000 mL (Kalantar-Zadeh & Fouque,
2017).
• Fluid intake is monitored by weight gain: Anuric hemodialysis
clients should not gain more than approximately 2 pounds/day
between treatments.
• For many clients on hemodialysis, limiting fluid intake is the
biggest challenge. Teaching how to control their intake and thirst
is vital.
• Strategies to relieve thirst are listed in Box 23.7.
• Peritoneal dialysis clients usually have fewer problems with fluid
retention.
BOX Strategies to Relieve Thirst

23.7
• Very cold items are better at relieving thirst.
• Use ice or popsicles within the fluid allowance.
• Rinse your mouth without swallowing using refrigerated water.
• Rinse your mouth occasionally with refrigerated mouthwash.
• Try frozen low-potassium fruit, such as grapes.
• Suck on the following:
• Hard candy
• Mints
• Lemon wedge
• Chew gum.
• Eat bread with applesauce or jelly and margarine.
• Control blood glucose levels, as appropriate.
• Use small drinking glasses instead of large ones.
• Apply petroleum jelly to the lips.
Kidney Transplantation
Kidney failure poses a significant challenge to maintaining adequate
nutritional status and muscle mass. In fact, up to 20% of people have
protein–calorie malnutrition and loss of muscle mass at the time of kidney
transplant (Nolte Fong & Moore, 2018). After transplantation, the use of
immunosuppressive drugs requires ongoing nutrition therapy to reduce the
risks of obesity, hyperlipidemia, hypertension, diabetes, and osteoporosis
(Hong et al., 2019). Arterial sclerosis, such as ischemic heart disease and
stroke, is the leading cause of death in kidney transplant clients; therefore, a
heart-healthy eating pattern is indicated. Unfortunately, nutrition practice
guidelines for posttransplant clients are scarce (Nolte Fong & Moore,
2018).
• In the immediate postoperative period, calorie and protein needs are
increased due to the stress and catabolism related to surgery. During
the first 1 to 2 months of posttransplant, the need for protein may be
1.3 to 2.0 g/kg of body weight (Hong et al., 2019).
• Protein and calorie needs gradually decrease after the initial
postoperative period. Table 23.2 outlines nutrient recommendations
after transplant.
• Relaxation of dietary restrictions and an increase in appetite
secondary to steroids increase the likelihood of posttransplant
weight gain, particularly visceral fat gain.
• Visceral fat gain increases the risk of developing new-onset
diabetes, dyslipidemia, and CVD (Nolte Fong & Moore, 2018).
• Calorie intake should be adjusted to maintain desirable weight.
• Ongoing nutrition assessment and counseling are needed to maintain
adequate nutritional status and adjust the diet as needed to prevent
or alleviate side effects caused by the use of immunosuppressive
drugs (Hong et al., 2019).
• The DASH diet and Mediterranean-Style Eating Patterns are
suitable for posttransplant clients; however, longitudinal studies
have not been conducted in this population (Nolte Fong & Moore,
2018). Both patterns are heart healthy, which is important to
decrease the risk of obesity, hypertension, diabetes, and
hyperlipidemia.
ACUTE KIDNEY INJURY

Acute kidney injury (AKI) is characterized by a sudden decrease (up to
48 hours) in kidney function. Common life-threatening complications
include volume overload, hyperkalemia, acidosis, and uremia. AKI seldom
exists as an isolated organ failure but rather is often a complication of
sepsis, critical illness, burns, cardiac surgery, trauma, and multiple-organ
failure.
Table Nutrient Recommendations for

23.2 Adults after Transplantation
Nutrient Posttransplantation
Protein 0.8–1.0 g/kg of BW/day with 50% high biological value
Limit protein with chronic graft dysfunction
Energy Initially 30–35 cal/kg
Thereafter, 25–35 kcal/kg of BW/day to achieve or
maintain desirable body weight
Carbohydrate Emphasize complex carbohydrate intake
Fat Emphasize unsaturated fat intake
Sodium Initial restriction if blood pressure/fluid status dictates
After acute period, allowance based on blood pressure
and/or edema
Potassium No restriction unless hyperkalemia is present and then
individualized
Calcium 1200–1500 mg (prolonged use of steroids increases the
risk of osteoporosis)
Phosphorus Initial supplementation may be needed to restore normal
blood levels
Thereafter, DRI level
Fiber Same as general population: 25–35 g/day
Fluid No restriction; matched to urine output if appropriate
Source: Beto, J. A., Ramirez, W. E., & Bansal, V. K. (2014). Medical nutrition therapy in adults with
chronic kidney disease: Integrating evidence and consensus into practice for the generalist
registered dietitian nutritionist. Journal of the Academy of Nutrition and Dietetics, 114(7), 1077–
1087; Hong, S., Kim, E., & Rha, M. (2019). Nutritional intervention process for a patient with
kidney transplantation: A case report. Clinical Nutrition Research, 8(1), 74–78.
https://doi.org/10.7762/cnr.2019.8.1.74
PEW may affect up to 40% of AKI clients in the intensive care unit
(ICU) and represents a major negative prognostic factor (Fiaccadori et al.,
2013). The pathogenesis of PEW in AKI is complex and involves many
factors, including a systemic inflammatory response, loss of kidney
homeostatic function, insulin resistance, and oxidative stress (Fiaccadori et
al., 2013). Dialysis may contribute to nutrient losses.
Nutrition Therapy
There is a consensus that nutritional support should be individualized
according to the severity of hypercatabolism and the underlying disease,
comorbidities, the use of dialysis, and the client’s preexisting nutritional
status (Ostermann et al., 2019). However, evidence-based guidelines are
limited and high-quality trials have not been performed. Still, studies on
general ICU populations regarding the type and timing of nutrition are
likely to be applicable to critically ill clients with AKI (Ostermann et al.,
2019). The following recommendations are based on expert opinion, the
lowest grade of evidence (Ostermann et al., 2019).
• Calorie recommendation are generally 20 to 30 cal/kg.
• Hypocaloric feedings (not greater than 70% of energy
expenditure) progressing gradually to 80% to 100% of estimated
need by day 3 are recommended for general ICU clients and may
also be appropriate for clients with AKI.
• Protein recommendations vary depending on whether dialysis is
used in these critically ill clients; without dialysis: gradually
increase to 1.3 g/kg/day or possibly 1.7 g/kg/day.
• On intermittent RRT: 1.0 to 1.5 g/kg/day.
• On continuous RRT: up to 1.7 g/kg/day.
An oral diet is the preferred route; enteral nutrition within 24 to
•
48 hours is recommended if oral intake is inadequate.
KIDNEY STONES
Kidney stones form when insoluble crystals precipitate out of urine. They
vary in size from sand-like “gravel” to large, branching stones. Although
they form most often in the kidney, they can occur anywhere in the urinary
system. Dehydration or low urine volume, urinary tract obstruction, gout,
chronic inflammation of the bowel, and intestinal bypass or ostomy surgery
are medical conditions that increase the risk for kidney stone formation.
Kidney stones are common, with an estimated prevalence in the United
States of approximately 7.1% in women and 10.6% in men (Scales et al.,
2012). The prevalence of stones has consistently increased over the last
50 years and that trend is expected to continue based on the rising
prevalence of obesity, diabetes, and metabolic syndrome, which are
considered risk factors for stone formation (Khan et al., 2016). A twin study
estimated that 56% of the risk of stones is hereditary, implying that
approximately 50% of stones could be prevented by modifiable risk factors
(Ferraro et al., 2017).
Stone Composition
Approximately 80% to 85% of kidney stones contain calcium, and most
calcium stones are composed primarily of calcium oxalate (Noori et al.,
2014). Because dietary calcium favorably binds with dietary oxalate in the
intestines to form an insoluble compound that the body cannot absorb, an
adequate calcium intake helps reduce the risk of calcium oxalate stones.
Oxalate
a salt of oxalic acid. Oxalate has no known function in the body and is normally excreted in urine.
Excess oxalate can bind with calcium in the urine to form calcium oxalate kidney stones.
Nutrition Therapy
Nutrition therapy cannot dissolve a kidney stone, although increasing fluid
intake may help promote its excretion. However, nutrition and lifestyle may
help prevent stones from forming. A study of 3 large prospective cohort
studies found that the following actions were associated with a more than a
50% decrease in the incidence of kidney stones (Ferraro et al., 2017).
• Maintain a normal BMI
• Obesity and weight gain increase the risk of stone formation, and
the magnitude of the increased risk may be greater in women than
in men (Taylor et al., 2005).
• Drink an adequate amount of fluid—at least 2 L/day
• A well-accepted strategy for reducing the recurrence of stones is
to increase fluid intake to dilute the urine, thereby reducing the
risk of stone formation regardless of the composition (Ferraro et
al., 2013).
• Consume a DASH-style eating pattern that is high in fruits,
vegetables, and low-fat dairy products.
• In a randomized controlled trial, the DASH diet, despite its high
oxalate content, decreased the risk of stone formation by 35%
(Noori et al., 2014).
• The effectiveness of the DASH diet may be due to its ample
content of calcium, magnesium, and potassium. The result is
more calcium to bind with oxalate in the intestine and a favorable
increase in urinary pH.
• The study data do not support the common practice of restricting
dietary oxalate (a single component), particularly if that means a
lower intake of fruits, vegetables, and whole grains (a healthy
eating pattern).
• Consume adequate calcium
• Consuming 1200 mg calcium/day combined with a low intake of
animal protein and lower sodium intake has been associated with
a 51% decrease in stone recurrence compared to a low calcium
intake (about 400 mg/day) in people affected with idiopathic
calcium stones (Borghi et al., 2002).
• Avoid frequent intake of sugar-sweetened beverages
• Frequent consumption of sugar-sweetened beverages (soft drinks
and punch) has been reported to increase the risk of kidney stones
by 30% to 40% (Ferraro et al., 2013).
Recall Sonja. An increase in her stress level has caused her

to give up on her lacto-ovo vegetarian eating pattern. Her
blood pressure is increasing, and her weight loss has stalled.
To make matters worse, she recently went to an ambulatory
care center with excruciating back pain and was diagnosed
with kidney stones, which she passed hours after receiving
IV fluids. She is worried she will have more kidney stones
that may eventually damage her only kidney. What would
you tell her about reducing her risk of stone recurrence?
What should her nutritional priorities be to maintain kidney
health? What other lifestyle interventions would you
recommend?
NURSING PROCESS Chronic Kidney

Disease
Carlos is 66 years old and has had type 2 diabetes for 20 years. He is
5 ft 7 in. tall and weighs 172 pounds. His hemoglobin A1c is 8.2; he
takes insulin twice daily. He has a history of hypertension and mild
anemia and complains of sudden weight gain and “swelling.” His blood
urea nitrogen (BUN) and creatinine have been steadily increasing over
the last several years, and his GFR is currently 63. During his last
appointment, the doctor told Carlos to watch his sugar intake and avoid
salt. At this visit, Carlos states he has never followed a “diet” before and
does not want to start now. The doctor has asked you to talk to Carlos
about his diet.
Assessment
Medical– • Medical history including
Psychosocial
cardiovascular disease, hypertension,
History diabetes, and renal disease
• Medications that affect nutrition such
as diuretics, insulin, and lipid-
lowering medications
• Physical complaints such as fatigue,
taste changes, anorexia, and nausea
• Psychosocial and economic issues
such as living situation, cooking
facilities, financial status,
employment, and education
• Understanding of the relationship
between diet and diabetes,
hypertension, renal function
Anthropometric
• Current height, weight, and BMI
Assessment
• Recent weight history
Biochemical and
• Blood values of the following:
Physical
• BUN and creatinine
Assessment
• Sodium, potassium, and other
electrolytes
• Glucose
• Lipid profile
• Hemoglobin and hematocrit
• eGFR
• Blood pressure
Dietary Assessment
• What kind of nutrition counseling
have you had in the past?
Assessment
How many meals and snacks do you
usually eat?
•
• What is a typical day’s intake for
you?
• What gives you the most difficulty in
changing your eating habits to limit
sugar and salt?
• Do you have any eating issues, such
as difficulty chewing or swallowing?
• What kind of protein do you eat most
often? What is a typical serving size?
Is it spread out over the day?
• How often do you eat sweets and
sugar-sweetened beverages?
• How often do you eat high-sodium
foods, such as cold cuts, bacon,
frankfurters, smoked meats, sausage,
canned meats, chipped or corned
beef, buttermilk, cheese, crackers,
canned soups and vegetables,
convenience products, pickles, and
condiments?
• Do you use a salt substitute?
• Do you regularly eat fruits and
vegetables? How many servings of
each do you consume in an average
day?
• How much fluid do you drink daily?
What is your favorite beverage?
• Do you have any cultural, religious,
and ethnic food preferences?
Assessment
• Do you have any food allergies or
intolerances?
• Do you use vitamins, minerals, or
nutritional supplements? If so, what,
how much, and why do you use
them?
• Do you drink alcohol?
• How often do you eat out?
Analysis
Possible Nursing Food and nutrition-related knowledge deficit
Analysis related to lack of interest in making dietary
changes as evidenced by his denial for the
need to change his eating habits
Planning
Client Outcomes
• Understand the rationale for reducing
sugar and salt intake.
• Implement the appropriate dietary
strategies to achieve a lower intake of
sugar and salt.
• Achieve adequate glucose control.
• Achieve and maintain normal blood
pressure.
• Delay or prevent further kidney damage.
Nutrition Therapy Provide a 2000-calorie carbohydrate-
controlled diet with 2300 mg sodium, as
ordered.
Assessment

• The role of nutrition therapy in the
treatment of CKD.
• Eating plan essentials including the
following:
• The rationale for consuming a heart-
healthy eating pattern.
• Maintaining a consistent carbohydrate
intake that is adequate in calories.
• Limiting high-sodium foods, not adding
salt during cooking or at the table.
• Behavioral matters including the
following:
• How to estimate portion sizes to
improve accuracy.
• Weighing oneself at approximately the
same time every day with the same
scale while wearing the same amount of
clothing. Unexpected weight gain or
loss should be reported to the physician.
• That heart-healthy cookbooks and
cookbooks for diabetes may help increase
variety and interest in eating.
• Changing eating attitudes.
• Learn to view the diet as an integral
component of treatment and a means of
life support.
• Adhering to the diet can improve the
quality of life and decrease the
workload on the kidneys.
Evaluation
Assessment
Evaluate and Monitor food intake or records (if
Monitor available) for compliance to limiting sugar
•
and salt.
• Monitor weight.
• Monitor lab values, blood glucose, blood
pressure, and urine output.
• Provide periodic feedback and
reinforcement.
How Do You Respond?

Does cranberry juice prevent urinary tract infections?
Cranberry, particularly in the form of cranberry juice, has
long been associated with preventing and treating of
urinary tract infections (UTIs) (Dong et al., 2018).‐
Proanthocyanidins, one of the active phytonutrients in
cranberry, have been shown to inhibit the adhesion of
certain strains of Escherichia coli (the primary bacteria
associated with UTIs) to the lining of the urinary tract.
Unfortunately, study results are often conflicting, and
standardization of doses, form (tablets, capsules), length
of trial, and the amount of active ingredient used are not
always reported (Dong et al., 2018). Given that the use of
cranberry is without adverse effects and that it may be
beneficial, clients who are prone to urinary tract
infections and like cranberry juice should be encouraged
to consume it regularly.
Are omega-3 fish oil supplements beneficial for people
on hemodialysis? Omega-3 fatty acids in fish and fish oil
can modify abnormal lipid levels, decrease platelet‐
aggregation, and improve blood pressure, heart rate,
oxidative stress, and inflammation (Saglimbene et al.,
2020). Given these effects, their use is recommended for
secondary cardiovascular prevention in the general
population (Siscovick et al., 2017).
The potential benefits linked to omega-3 fatty acids,
namely, improved lipid levels, less inflammation, and
reduced blood pressure, suggest they may be beneficial
for clients with CKD. However, study results using
omega-3 fatty acids in clients with CKD are often
conflicting (Svensson & Carrero, 2017). For instance,
results from a recent meta-analysis of randomized
controlled trials indicate that supplements of omega-3
fatty acids may decrease cardiovascular mortality in
clients treated with hemodialysis but were uncertain
whether they reduce the progression to ESRD in clients
with CKD not yet receiving RRT (Saglimbene et al.,
2020). More high-quality studies are needed.
REVIEW CASE STUDY
Dorothea is a 72-year-old Black woman who is 5 ft 5 in. tall and weighs

149 pounds. She has coronary heart disease and a long-standing history of
hypertension with progressive loss of kidney function. She recently started
receiving hemodialysis and is gaining about 4 pounds/day between
treatments. She has convinced herself that because she is on dialysis, she
can eat and drink whatever she wants and “the machine will take care of it.”
Yesterday, she ate the following as shown on the right.
• What risk factors does Dorothea have for CKD?

• Based on her treatment with hemodialysis, what nutrients may she need
to restrict or increase?
• Why is she gaining 4 pounds/day between treatments? What is a more
reasonable goal? What would you suggest she do to achieve the goal?
• Evaluate her protein intake and recommend changes she could make to
achieve her protein goals.
• What foods is she eating that are not heart healthy? What substitutions
would you recommend?
• Evaluate her sodium intake and recommend changes she could make to
limit her sodium intake.
• What foods is she eating that are high in potassium? What alternatives
would you suggest?
• What would you tell Dorothea about the use of dialysis and her theory
about eating anything she wants?
• Which is the lesser risk: getting enough calories and protein by eating
non-heart-healthy foods or adhering to the sodium and other restrictions
but not getting enough calories and protein?
Breakfast: Grits with cheese, bacon, biscuit with butter, and coffee
Lunch: Hamburger on bun with ketchup and mustard, potato chips,
banana, and sweetened tea
Dinner: Fried chicken, macaroni and cheese, collard greens, pound cake,
and sweetened tea
STUDY QUESTIONS
1 Which statement indicates the client understands the instructions about

nutrition therapy for nephrotic syndrome?
a. “I know I need to eat a high-protein diet to replace the protein lost in
urine.”
b. “I need to limit my intake of fruit and vegetables that are high in
potassium.”
c. “I should limit my sodium intake by not using salt in cooking or at the
table and avoiding foods high in sodium such as processed foods, fast
foods, and convenience foods.”
d. “I should lose weight to decrease the workload on my kidneys.”
2 A healthy client with a family history of CKD asks how they can
decrease their risk of developing kidney disease. Which of the following
would be the nurse’s best response?
a. “If you have a positive family history, there is no way for you to lower
your risk of CKD.”
b. “We don’t know how to lower the risk of CKD so the best thing you
can do is to have your kidney function monitored regularly.”
c. “Limit your intake of plants because they are high in potassium and
phosphorus, 2 nutrients that make your kidneys work harder.”
d. “Eat a heart-healthy eating pattern; CVD and CKD share the same
lifestyle risks.
3 When developing a teaching plan for a client who must restrict
potassium, which fruits and vegetables would the nurse recommend for
their low potassium content?
a. Avocado, tomatoes, and potatoes
b. Kiwifruit, prune juice, and acorn squash
c. Apple, blueberries, and green beans
d. Mango, spinach, and raisins
4 The nurse knows their instructions about preventing future kidney stones
have been effective when the client verbalizes he should
a. avoid milk, cheese, and other sources of calcium.
b. limit fruit and vegetables.
c. lose weight to maintain healthy body weight.
d. eat a high-protein diet.
How do the protein recommendations for adults with CKD without
5 diabetes differ from those who have diabetes?
a. Protein is more restricted for people who do not have diabetes.
b. Protein is more restricted for people who have diabetes.
c. The protein recommendations do not differ for people with diabetes or
without diabetes.
d. There are no specific protein recommendations for people with
diabetes because carbohydrates and fat are the priority concerns.
6 A client on hemodialysis asks if they can use popsicles to help relieve
their thirst. Which of the following is the nurse’s best response?
a. “That’s a great idea as long as you deduct the equivalent amount of
fluid from your total daily fluid allowance.”
b. “Popsicles are empty calories. You are better off drinking just plain
water.”
c. Popsicles are great at relieving thirst, and because they are solid, they
do not count as fluid, so you can eat them as desired.”
d. “Hot things are better at relieving thirst than cold things. Try small
amounts of hot tea or coffee to relieve your thirst.”
7 What characteristics of a Mediterranean-Style Eating Pattern may be
beneficial to clients with CKD? Select all that apply.
a. It is low in red and processed meats, which limits saturated fat,
sodium, and phosphate intake.
b. It includes a moderate intake of wine, which has anti inflammatory and
antioxidant properties.
c. It is low in fat, which helps protect against CVD.
d. Its protein content is similar to a controlled protein diet recommended
for people with CKD.
8 The client asks if they will need to follow a diet after they recover from a
kidney transplant. Which of the following is the nurse’s best response?
a. “You will always have to limit protein and phosphorus intake to help
preserve the health of the new kidney.”
b. “After recovery, all restrictions are lifted and you can eat anything you
want.”
c. “You may need to modify some aspects of your diet because of side
effects from the medications you will be taking, and you should
continue to eat a heart-healthy diet to decrease the risks of diabetes,
hypertension, heart disease, and obesity.”
d. “All the restrictions you followed before dialysis will resume after you
recover from the transplant.”

Clients with Kidney Disorders
The kidneys are vital for maintaining overall health; impairments in kidney
function can cause widespread disruptions in metabolism, bone health, fluid
balance, nutritional status, and nutrient requirements.
Nutrition in Maintaining
Kidney Health
The typical American diet increases the risk of obesity, diabetes,
hypertension, and CVD; each of these chronic diseases increases the risk of
kidney disease. Heart-healthy nutrition and lifestyle interventions are likely
also kidney healthy.
Healthy Eating Pattern. Certain eating patterns have been shown to
reduce the incidence of CKD disease.
The DASH Diet. Benefits may be attributed to its effect on lowering blood
pressure and reducing inflammation.
Mediterranean-Style Eating Pattern. May help preserve kidney function
through favorable effects on endothelial function, inflammation, lipid
levels, and blood pressure.
Nephrotic Syndrome
Hypoalbuminemia, proteinuria, hyperlipidemia, and edema are major
features of nephrotic syndrome.
Nutrition Therapy. The primary objective of nutrition therapy is to reduce
proteinuria. Protein intake should be adequate but not excessive. Sodium
may be restricted. It is not known if restricting cholesterol and fat improves
prognosis. Calories should be adequate and vitamin D supplements may be
necessary.
Chronic Kidney Disease

CKD is a progressive, irreversible loss of kidney function.
Risk Factors for CKD. Diabetes and hypertension are the major risk
factors. Others include CVD, obesity, advancing age, family history, and
certain ethnic backgrounds.
Disease Progression. Loss of kidney function leads to impaired excretion
of nitrogenous wastes, sodium, fluid, potassium, phosphorus, and hydrogen
ions. Interrelated and multifactorial metabolic and clinical complications
develop.
Nutrition Therapy. Varies in complexity according to the stage of CKD,
comorbidities, and the client’s nutritional status. Control of blood glucose
and blood pressure is primary. Limiting sodium and protein and eating heart
healthy are encouraged for all stages of CKD; additional restrictions for
phosphorus and potassium are added as necessary. Actual nutrient
recommendations vary among experts.
Mediterranean-Style Eating Pattern. Recommended for adults at all
stages of CKD (but not on dialysis or posttransplant); may improve lipid
levels and posttransplant may help delay the progression of CKD and
prevent complications.
Protein. Low-protein diets can slow the progression of CKD but may
contribute to the malnutrition.
Sodium. Restricted to control of blood pressure and edema.
Phosphorus. Restricted due to elevated parathyroid hormone, even when
serum phosphorus is not high. Dietary control is difficult; phosphate
binders allow for greater phosphorus intake.
Potassium. Serum levels become elevated due to impaired excretion,
metabolic acidosis, catabolism, and certain antihypertensive medications.
Many healthy foods, such as fruits, vegetables, whole grains, and legumes,
are high in potassium.
Calories. Must be adequate to promote protein sparing.
Calcium. Restricted due to abnormal metabolism. Milk is restricted
because it is also a rich source of phosphorus.
Fiber. Adequate intake is encouraged to improve intestinal dysbiosis,
which contributes to uremic toxicity and cardiovascular damage.
Fat. Unsaturated fats are emphasized over saturated fats due to the high
risk of CVD.
Micronutrient Supplements. Micronutrient imbalances may occur in
clients from inadequate intake, impaired GI absorption, or altered
metabolism. Daily supplements may be prescribed.
Renal Meal Plan. Food lists based on nutrient content are used to create a
daily meal pattern. The diet is complex and multiple sublists are common.
Nutrition Therapy during Dialysis. With the exception of protein and
fluid, dietary recommendations remain similar during dialysis. Protein
intake is liberalized to account for losses in the dialysate and fluid is
restricted.
Kidney Transplantation. The use of immunosuppressive drugs requires
ongoing nutrition therapy to reduce the risks of obesity, hyperlipidemia,
hypertension, diabetes, and osteoporosis.
Acute Kidney Injury. Usually occurs in combination with critical illness.
Nutrient recommendations for critical illness are probably appropriate.
Protein recommendations vary depending on whether dialysis is used.
Kidney Stones
The prevalence of stones has consistently increased over the last 50 years
and is related to the rising prevalence of obesity, diabetes, and metabolic
syndrome, which are risk factors for stone formation.
Stone Composition. Eighty to eighty-five percent of stones contain
calcium. Adequate calcium is needed to bind with oxalate in the intestines
so it is not absorbed and filtered through the kidneys.
Nutrition Therapy for Kidney Stones. Many stones can be prevented by
maintaining healthy body weight, drinking adequate fluid, eating a healthy
eating pattern such as the DASH diet, consuming adequate calcium, and
avoiding frequent consumption of sugar-sweetened beverages.
Figure sources: shutterstock.com/ratmaner, shutterstock.com/Vitalii Vodolazskyi, and
shutterstock.com/VILevi

book at
Websites
American Association of Kidney Patients at www.aakp.org
American Kidney Fund at www.kidneyfund.org
National Institute of Diabetes and Digestive and Kidney Diseases at www.niddk.nih.gov
National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) at
http://kidney.niddk.nih.gov
National Kidney Disease Education Program (NKDEP) at www.nkdep.nih.gov
National Kidney Foundation at www.kidney.org
Oxalosis and Hyperoxaluria Foundation at www.ohf.org
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A randomized controlled trial comparing DASH (Dietary Approaches to Stop Hypertension)-
style and low-oxalate diets. American Journal of Kidney Diseases, 63(3), 456–463.
Ostermann, M., Macedo, E., & Oudemans-van Straaten, H. (2019). How to feed a patient with acute
kidney injury. Intensive Care Medicine, 45, 1006–1008. https://doi.org/10.1007/s00134-019-
05615-z
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(2017). Beneficial effects of 6-month supplementation with omega-3 acids on selected
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Rebholz, C., Crews, D., Grams, M., Steffen, L. M., Levey, A. S., Miller, E. R., III, Appel, L. J., &
Coresh, J. (2016). DASH (Dietary Approaches to Stop Hypertension) diet and risk of subsequent
kidney disease. American Journal of Kidney Diseases, 68(6), 853–861.
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Teixeira-Pinto, A., Craig, J. C., & Strippoli, G. F. M. (2020). Effects of omega-3 polyunsaturated
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Chapter with Cancer or
24 HIV/AIDS
Patrick Hannon
Patrick is 50 years old, is 6 ft tall, and considers
himself healthy. His normal adult weight is
258 pounds. He is a “meat-and-potatoes” kind of guy
and admits to being sedentary. His beverage of choice
is sweetened tea, which he prefers over water. His
wife convinced him to have a routine colonoscopy—
since it is recommended at age 50 years—which led
to a diagnosis of stage 3 colon cancer. He had a
partial colectomy and lymph node removal. He is
undergoing adjuvant chemotherapy.
Learning Objectives
1 Evaluate a person’s usual intake according to nutrition guidelines for

cancer prevention.
2 Summarize how cancer and cancer therapies can affect nutritional status.
3 Give examples of ways to modify the diet to alleviate side effects of
anorexia, nausea, fatigue, taste changes, mouth sores, dry mouth, and
diarrhea.
4 Discuss ways to increase a client’s calorie and protein intake.
5 Explain how HIV/AIDS affects nutritional status.
6 List food safety practices.
7 Teach a person living with HIV/AIDS guidelines for a healthy eating
pattern.
Cancer and HIV/AIDS are combined in this chapter because they can have
similar effects on nutritional status, whether from the disease itself or from
disease treatments. Although nutrition therapy cannot cure either disease, it
has the potential to maximize the effectiveness of drug therapy, alleviate the
side effects of the disease and its treatments, and improve overall quality of
life.
This chapter presents nutrition recommendations for cancer prevention,
the effects of cancer and cancer treatments on nutrition, and nutrition
therapy for clients being treated for cancer, for those with advanced cancer,
and for cancer survivors. Also presented are the nutritional consequences of
HIV and AIDS and nutrition therapy recommendations.
CANCER
Cancer is a group name for more than 100 different types of malignancies
characterized by the uncontrolled growth of cells. Individual cancers differ
in where they develop, how quickly they grow, the type of treatment they
respond to, and how much they affect nutritional status. In the United
States, 40 out of 100 men and 39 out of 100 women will develop cancer
during their lifetime (American Cancer Society [ACS], 2020). Cancer was
responsible for 21.3% of all deaths in 2016 and 2017, making it the second
leading cause of death in the United States (Heron, 2019).
Nutrition in Cancer Prevention
In 2014, an estimated 42% of incident cancers and almost 50% of all cancer
deaths were attributed to potentially modifiable risk factors (Islami et al.,
2018). Tobacco cessation is inarguably the leading behavioral strategy for
reducing the risk of cancer (Box 24.1). For nontobacco users, the most
important modifiable determinants of cancer risk are body weight, dietary
choices, and levels of physical activity.
Figure 24.1 depicts cancer prevention recommendations by the
American Institute for Cancer Research (AICR). These recommendations
are similar to those published by the American Cancer Society and the
American Heart Association (Chapter 2, Table 2.3). A large systematic
review of 10 large prospective studies showed that high versus low
adherence to ACS or AICR nutrition and physical activity cancer
prevention guidelines consistently and significantly reduced the overall risk
of cancer incidence and mortality (Kohler et al., 2016). Risk reduction
ranged from 10% to 45% for cancer incidence and 14% to 61% for cancer
mortality. For people who most closely adhered to cancer prevention
recommendations, consistent reductions in incidence were shown for breast
cancer (19%–60%), endometrial cancer (23%–60%), and colorectal cancer
in both men and women (27%–52%).
BOX Percent of Cancer Deaths Attributed to

24.1 Various Lifestyle Factors
Risk Factor %
Cancer
Deaths
Risk Factor %
Cancer
Deaths
Cigarette smoking 29%

Excess body weight 7%–
Alcohol intake 8%
Poor diet (e.g., low intake of fruit, vegetables, fiber, and dietary 4%–
calcium and consumption of red and processed meat) 6%
Physical inactivity 4%–
5%
2%–
3%
Source: Islami, F., Sauer, A., Miller, K., Siegel, R., Fedewa, S. A., Jacobs, E. J., McCullough, M.
L., Patel, A. V., Ma, J., Soerjomataram, I., Flanders, W. D., Brawley, O. W., Gapstur, S. M., &
Jemal, A. (2018). Proportion and number of cancer cases and deaths attributable to potentially
modifiable risk factors in the US. CA: A Cancer Journal for Clinicians, 68(1), 31–54.
Figure 24.1 ▲ 10 Cancer prevention recommendations as an
overarching “package.” (Source: Reproduced from World Cancer
Research Fund/American Institute for Cancer Research. Diet, Nutrition,
Physical Activity and Cancer: A Global Perspective. Continuous Update
Project Expert Report 2018. Available at dietandcancerreport.org.)
Despite evidence showing nutrition and physical activity guidelines

consistently and significantly lower cancer risk, the role of diet in cancer
prevention is difficult to study. For instance, the human diet is complex and
the food supply is ever changing (Kushi et al., 2012). Lifelong eating
patterns may be important but cannot be detected by relatively short-term,
randomized clinical trials (PDQ® Supportive and Palliative Care Editorial
Board, 2020). In addition, cancer takes years to develop, making
randomized controlled trials of dietary interventions to prevent cancer
impractical (Kushi et al., 2012). Although not all studies on the role of diet
as a cause of cancer reach the same conclusions, evidence that certain
dietary factors and patterns are associated with a lower risk of cancer is
consistent and serves as the foundation of the ACS and AICR nutrition and
lifestyle guidelines. tab 24.1 lists potential mechanisms by which nutrition-
related guidelines may help reduce the risk of cancer.
Although following nutrition and lifestyle recommendations has been
shown to lower cancer incidence and mortality, there is insufficient
evidence to recommend one particular eating pattern (e.g., DASH diet) to
reduce the risk of all cancers. It may be that the effectiveness of an eating
pattern on cancer risk depends on the type of cancer or on other risk factors,
such as family history, gender, age, other lifestyle factors, comorbidities, or
gut microbiota profiles (Steck & Murphy, 2020).
Think of Patrick. What lifestyle factors may have increased

his risk for cancer? Is it appropriate for him to adopt healthy
lifestyle behaviors while he is undergoing chemotherapy?
Table Potential Mechanisms by Which

Nutrition-Related Guidelines May
24.1 Help Reduce the Risk of Cancer
Recommendation Rationale
Maintain a Excess body fat can promote chronic inflammation,
healthy causing a favorable environment for cancer
weight growth; can cause excess estrogen production
which can increase the risk of breast and
endometrial cancer; and causes high levels of
insulin and other hormones that may stimulate
cancer cell growth.
Recommendation Rationale
Choose a healthy It is not known which components of plants may be
diet with an protective; therefore, eating a variety is important.
emphasis on
Supplements cannot duplicate the myriad of
plants naturally occurring substances in plants.
A plant-based eating pattern can also help manage
weight.
Limit calorie-
These foods can displace the intake of nutrient-
dense, dense, minimally processed foods.
nutrient-poor,
These foods can be high in calories, making weight
refined, and management more difficult.
processed
foods
Limit High meat intake can displace the intake of
consumption nutrient-dense foods and regular intake of
of red and processed meat can lead to weight gain.
processed Red and processed meat are associated with an
meat increased risk of colorectal cancer.
Limit Sugar-sweetened beverages are generally a source
consumption of empty calories that can make weight
of sugar- management difficult.
sweetened
drinks
Limit alcohol The metabolism of ethanol may damage DNA
consumption which can alter cell growth and function.
Alcohol is associated with an increased risk of
oral, esophageal, breast, and colorectal cancer
(in men) and may also increase the risk of liver
cancer and colorectal cancer in women.
Source: American Institute for Cancer Research. (n.d.). 10 cancer prevention recommendations.
Available at https://www.aicr.org/cancer-prevention/; National Cancer Institute. (2020). Cancer
prevention overview (PDQ)-Health professional version. https://www.cancer.gov/about-
cancer/causes-prevention/hp-prevention-overview-pdq
Nutrition Complications Related to Cancer
The effect of cancer on nutritional status and intake varies with baseline
nutrition status, disease site, stage of disease, and treatment approach
(PDQ® Supportive and Palliative Care Editorial Board, 2020). For a
number of reasons, cancer clients are among the most malnourished of all
client groups (Ryan et al., 2016), with a reported malnutrition prevalence
ranging from 25% to over 70% (Muscaritoli et al., 2017). Malnutrition in
cancer clients differs dramatically from malnutrition caused by simple
starvation in that the negative calorie balance and loss of skeletal muscle
are powered by a combination of inadequate food intake and alterations in
metabolism (Arends et al., 2017). However, there is not a universally
agreed-upon standard definition of malnutrition (PDQ® Supportive and
Palliative Care Editorial Board, 2020).
Local Tumor Effects

Local tumor effects occur when the tumor impinges on surrounding tissue,
impairing its ability to function. Nutrition complications vary with the site
and size of the tumor and are usually most severe with gastrointestinal (GI)
or head and neck tumors (tab 24.2).
Tumor-Induced Changes in Metabolism

Cancer metabolism has intrigued cancer researchers for almost a century
(Nelson, 2017).
• Tumor-induced alterations in metabolism can directly impair
nutritional status.
• Tumor-induced weight loss occurs frequently in clients with solid
tumors of the lung, pancreas, and upper GI tract.
• Although altered metabolism is universally accepted as one of the
hallmarks of cancer, many questions remain as to how
reprogrammed metabolism is related to cancer (Wu & Zhao, 2013).
Common Side Effects Based

Table on Tumor Site
24.2
Site Potential Effects
Brain/CNS Eating disabilities
Chewing and swallowing difficulties
Head and neck Dysphagia/odynophagia
Xerostomia
Taste alterations
Esophagus, Dysphagia, odynophagia
stomach Early satiety
Nausea/vomiting
Abdominal pain
Diarrhea/malabsorption
Anorexia/weight loss
Obstruction, which may necessitate enteral or
parenteral nutrition
Pancreas, liver, Early satiety
small intestine Nausea/vomiting
Abdominal pain
Diarrhea/malabsorption
Constipation/obstruction
Large intestine Diarrhea/ malabsorption
Constipation/obstruction, which may necessitate
enteral or parenteral nutrition
Source: PDQ® Supportive and Palliative Care Editorial Board. (2020). PDQ Nutrition in Cancer
Care. National Cancer Institute. https://www.cancer.gov/about-cancer/treatment/side-
effects/appetite-loss/nutrition-hp-pdq.
Inadequate Intake
Inadequate intake has been determined to be present if a client cannot eat
for more than a week or if the client consumes <60% of their estimated
calorie requirement for >1 to 2 weeks (Arends et al., 2017). The causes of
inadequate intake are complex and multifactorial.
• Anorexia is a major cause of inadequate intake. It may be present at
the time of diagnosis or may occur as a side effect of treatments or
the tumor.
• Other factors that may contribute to inadequate intake include
mouth ulcers, poor dentition, dry mouth, taste alterations, intestinal
obstruction, malabsorption, constipation, diarrhea, nausea, vomiting,
decreased GI motility, uncontrolled pain, depression, anxiety, and
side effects of medications (Arends et al., 2017).
• Inadequate intake can lead to weight loss, which has been correlated
with adverse outcomes, including increased incidence and severity
of treatment side effects and increased risk of infection, thereby
reducing the chance of survival (PDQ® Supportive and Palliative
Care Editorial Board, 2020).
Muscle Protein Depletion

Sarcopenia is the condition of severe muscle depletion. The loss of lean
body mass, with or without fat loss, is an independent risk factor for poorer
outcomes (PDQ® Supportive and Palliative Care Editorial Board, 2020). It
predicts risk of physical impairment, postoperative complications,
chemotherapy toxicity, and mortality (Arends et al., 2017).
• Sarcopenia is present in 20% to 70% of cancer clients depending on
the type of tumor (Ryan et al., 2016). However, a universal
definition of sarcopenia does not exist (PDQ® Supportive and
• Identifying muscle loss has become increasingly difficult as 40% to
60% of cancer clients are overweight or obese, even in the setting of
metastatic disease (Ryan et al., 2016). Sarcopenic obesity is an
independent risk factor for poor prognosis (PDQ® Supportive
and Palliative Care Editorial Board, 2020).
Impaired physical activity may also contribute to loss of muscle
• mass.
Lean Body Mass

the weight of the body minus the weight of fat.
Systemic Inflammation Syndrome

Systemic inflammation syndrome (SIS) is frequently activated in clients
with cancer; it is associated with the development of fatigue, impaired
physical activity, anorexia, and weight loss (Arends et al., 2017). SIS
impacts all relevant metabolic pathways, although the degree of impact
varies.
• Protein metabolism: Altered protein turnover, loss of fat and
muscle mass, and increase in acute phase proteins.
• Carbohydrate metabolism: Insulin resistance and impaired
glucose tolerance.
• Fat metabolism: Fat oxidation is maintained or increased,
especially in the presence of weight loss.
Interactions and Outcomes

Weight loss, impaired physical performance, and SIS in cancer clients are
all independently associated with an unfavorable prognosis (Arends et al.,
2017).
• Consequences include increased toxicity of anticancer treatments
leading to an interruption of treatment and reduced quality of life
(Arends et al., 2017).
• Interactions between weight loss, impaired physical performance,
and SIS lead to a continuous deterioration of the client’s well-being.
Cancer Cachexia
Cancer cachexia is an incompletely understood, multifactorial syndrome
characterized by unstoppable muscle wasting that cannot be fully reversed
by conventional nutrition support and leads to progressive impairment
(Fearon et al., 2011).
• Altered metabolism of carbohydrates, protein, and fat is evident.
• Weight loss can occur from poor intake and/or an increase in
metabolism (PDQ® Supportive and Palliative Care Editorial Board,
2020).
• Cachexia can increase toxicity related to treatment, aggravate
symptoms, worsen quality of life, and shorten survival (Zhou et al.,
2018).
Stages of cancer cachexia are as follows (Fearon et al., 2011):

• Precachexia, characterized by loss of appetite and altered glucose
intolerance that precede substantial weight loss.
• Cachexia, characterized by significant weight loss or sarcopenia in
the absence of simple starvation and defined as
• weight loss >5% in the past 6 months or
• body mass index (BMI) <20 and degree of weight loss >2% or
• Sarcopenia and any degree of weight loss >2%.
• Refractory cachexia is cachexia that usually associated with
advanced stage cancer or rapid progression of disease that is
unresponsive to treatment.
Nutrition Complications Related to Cancer

Treatments
Cancer treatments include surgery, chemotherapy, radiation, biotherapy,
hemopoietic cell transplantation, or a combination of therapies. Each
treatment modality can contribute to progressive nutritional deterioration
related to localized or systemic side effects that interfere with intake,
increase nutrient losses, or alter metabolism. Comorbidities may complicate
treatment and nutritional status. The success of treatment is influenced by
the client’s ability to tolerate therapy, which is affected by nutritional status.
Surgery
Surgery is often the primary treatment for cancer. People who are
malnourished prior to surgery are at higher risk of postoperative morbidity
and mortality.
• If time allows, nutritional deficiencies are corrected before surgery
and may require the use of oral nutrition supplements (ONS), enteral
or parenteral nutrition, and/or use of medications to stimulate
appetite.
• Postsurgical nutritional requirements increase for protein, calories,
vitamin C, B vitamins, and iron to replenish losses and promote
healing.
• Physiological or mechanical barriers to good nutrition can occur
depending on the type of surgery, with the greatest likelihood of
complications arising from GI surgeries.
• tab 24.3 outlines potential side effects and complications incurred
for various types of surgery.
Chemotherapy
Given alone or in combination, chemotherapy drugs damage the
reproductive ability of both malignant and normal cells, especially rapidly
dividing cells such as well-nourished cancer cells and normal cells of the GI
tract, respiratory system, bone marrow, skin, and gonadal tissue.
• The side effects of chemotherapy vary with the type of drug or
combination of drugs used, dose, rate of excretion, duration of
treatment, and individual tolerance.
• Chemotherapy side effects are systemic and, therefore, potentially
more numerous than the localized effects seen with surgery or
radiation.
• The most commonly experienced nutrition-related side effects are
anorexia, taste alterations, early satiety, nausea, vomiting,
mucositis/esophagitis, diarrhea, and constipation (PDQ® Supportive
Side effects increase the risk of malnutrition and weight loss, which
• may prolong recovery time between treatments. When subsequent
chemotherapy treatments are delayed, successful treatment outcome
is potentially threatened.
Table Potential Complications of

24.3 Surgery
Type Potential Complications

Head and neck Impaired ability to speak, chew, salivate, swallow,
resection smell, taste, and/or see
Enteral nutrition support dependency
Negative impact on nutritional status can be
profound
Esophagectomy or Early satiety
esophageal
Regurgitation
resection
Fistula formation
Stenosis
Vagotomy → decreased stomach motility,
decreased gastric acid production, diarrhea,
steatorrhea
Type Potential Complications
Gastric resection Dumping syndrome: crampy diarrhea that
develops quickly after eating, accompanied by
flushing, dizziness, weakness, pain, distention,
and vomiting
Hypoglycemia
Esophagitis
Decreased gastric motility
Fat malabsorption and diarrhea
Deficiencies in iron, calcium, and fat-soluble
vitamins
Vitamin B12 malabsorption related to lack of
intrinsic factor
Intestinal resection Malnutrition related to generalized malabsorption
Fluid and electrolyte imbalance
Diarrhea
Increased risk of renal oxalate stone formation
Metabolic acidosis
Massive bowel Steatorrhea
resection Malnutrition related to severe generalized
malabsorption
Metabolic acidosis
Dehydration
Ileostomy or Fluid and electrolyte imbalance
colostomy
Pancreatic Generalized malabsorption
resection Diabetes mellitus
effects/appetite-loss/nutrition-hp-pdq.
Radiation
Radiation causes cell death; particles of radioactive energy break chemical
bonds, disrupting reproductive ability. Although radiation injures all rapidly
dividing cells, it is most lethal for the poorly differentiated and rapidly
proliferating cells of cancer tissue. Side effects are localized. Recovery
from sublethal doses of radiation occurs in the interval between the first
dose and subsequent doses. Normal tissue appears to recover more quickly
from radiation damage than does cancerous tissue.
• The type and intensity of radiation side effects depend on the type of
radiation used, the site, the volume of tissue irradiated, the dose of
radiation, the duration of therapy, and individual tolerance.
• Clients most at risk for nutrition-related side effects are those who
have cancers of the head and neck, lower neck and mid chest,
abdomen and pelvis, and brain (tab 24.4).
• Side effects usually develop around the second or third week of
treatment and then diminish 2 or 3 weeks after radiation therapy is
completed. Some side effects may be chronic.
Biotherapy
Biotherapy is treatment to enhance the body’s immune system to boost the
body’s own response against cancer or to help repair normal cells damaged
as a side effect of treatment (PDQ® Supportive and Palliative Care
Editorial Board, 2020).
Table Potential Complications of

24.4 Radiation
Area Potential Complications

Area Potential Complications
Head and Altered or loss of taste (mouth blindness)
neck Xerostomia (dry mouth)
Thick salivary secretions
Difficulty swallowing and chewing
Loss of teeth
Mucositis
Stomatitis
Esophagitis
Chest Acute: esophagitis with dysphagia
Delayed: fibrosis, esophageal stricture, dysphagia
Nausea/vomiting
Edema
Anorexia
Abdomen Acute or chronic bowel damage can cause diarrhea,
and pelvis nausea, vomiting, enteritis, and malabsorption
Bowel constriction, obstruction, or fistula formation
Brain Anorexia
Nausea/vomiting
Dysphagia/odynophagia
• The side effects most likely to impact nutrition status are fatigue,
fever, nausea, vomiting, and diarrhea (PDQ® Supportive and
• Actual side effects depend on the type of biotherapy used, such as
growth factors, monoclonal antibodies, and vaccines.
Hemopoietic Cell Transplantation

Hemopoietic cell transplants are preceded by high-dose chemotherapy and
possibly total-body irradiation to suppress immune function and destroy
cancer cells.
• Treatments frequently result in nutrition-related side effects, such as
mucositis and significant diarrhea (PDQ® Supportive and Palliative
Care Editorial Board, 2020).
• Acute or chronic graft-versus-host disease may also occur, impairing
intake and the body’s ability to process adequate protein and
calories (PDQ® Supportive and Palliative Care Editorial Board,
2020).
• Parenteral or enteral nutrition support may be necessary for clients
who are malnourished and not expected to eat or absorb adequate
calories for >7 to 14 days (PDQ® Supportive and Palliative Care
• Neutropenia leaves the client susceptible to infection, so
precautionary measures must be taken to prevent foodborne illness
(Box 24.2): A neutropenic diet may be recommended, although
they have not been found to be superior to a regular diet in
neutropenic cancer clients (PDQ® Supportive and Palliative Care
Neutropenia
abnormally low number of neutrophils in the blood, which increases the risk of infection.
Neutropenic Diet
a diet intended to protect people with low neutrophil counts from bacteria and other organisms in
some food and drinks; eliminates fresh fruits, vegetables, raw nuts, yogurt, and other products
with live active cultures.
Nutrition Therapy during Cancer Treatment

The goals of nutrition therapy are to maintain or improve intake, maintain
skeletal muscle mass and physical performance, reduce the risk of
reductions or interruptions of scheduled anticancer treatments, and improve
quality of life (Arends et al., 2017). Goals are individualized according to
the client’s nutrition status, type and stage of disease, comorbid conditions,
and overall medical treatment plan (PDQ® Supportive and Palliative Care
Editorial Board, 2020). Early and regular nutrition screening is
recommended to identify nutritional problems at an early stage; however,
there is no agreement on which screening/assessment tools are most
accurate for assessing malnutrition in cancer clients (Muscaritoli et al.,
2017).
BOX Strategies to Reduce the Risk of

24.2 Foodborne Illness
Storage
• Refrigerate perishable and prepared foods immediately after purchase.
• Refrigerate leftovers immediately after eating; thoroughly reheat
before eating.
• Discard leftovers after 24 hours.
• Keep hot foods >140°F and cold foods <40°F.
• Use expiration dates on food packaging to discard foods that may be
unsafe to eat.
Food Preparation
• Wash hands before and after handling food and eating and after using
the restroom.
• Wash fruits and vegetables thoroughly in clean water.
• Avoid cross-contamination by using separate cutting boards and work
surfaces for raw meats and poultry; keep work surfaces clean.
Thawing
• Thaw food in the refrigerator, never at room temperature.
• If the microwave is used to thaw frozen meat, cook the meat
immediately after it is defrosted.
Cooking
• Cook all meat, fish, and poultry to the well-done stage.
Foods to Avoid
• Raw or undercooked meat and poultry
• Raw or undercooked fish, such as sushi, ceviche, or refrigerated
smoked fish
• Unpasteurized milk and fruit juices
• Soft cheeses made from unpasteurized milk such as feta, brie,
camembert, Queso fresco
• Foods that contain raw or undercooked eggs, such as homemade
Caesar salad dressing, raw cookie dough, and eggnog
• Raw sprouts (alfalfa, bean, and others), unwashed fresh vegetables,
and any moldy or damaged fruits and vegetables
• Hot dogs, deli meats, and luncheon meats that have not been reheated
• Unpasteurized, refrigerated pates or meat spreads
• Salad bars and buffets when eating out
Calories
Adequate calories are needed to maintain healthy weight and help maintain
lean body mass. Unfortunately, few studies have assessed total calorie
requirements of cancer clients (Arends et al., 2017).
• If indirect calorimetry is not available, calorie needs can be
estimated with the same general formula applied to healthy adults,
which is 25 to 30 cal/kg/day.
• Body weight and muscle mass are monitored to assess the adequacy
of calorie intake.
Protein
The optimal amount of protein for cancer clients has not been determined;
however, studies have shown that a high protein intake promotes muscle
protein anabolism in cancer clients (Arends et al., 2017).
• Recommendations state that protein intake should not be less than
1 g/kg/day and should be up to 1.5 g/kg/day if possible.
• In people with normal kidney function, protein intake up to and
above 2 g/kg/day is safe and may promote a positive protein balance
in clients with cancer.
Promoting an Oral Intake

The best way to maintain or increase calorie and protein intake is through
normal food (Arends et al., 2017).
• For clients who have difficulty consuming an adequate amount of
food, modifications to increase the calorie or protein density can
improve overall intake without increasing the volume of food
needed (Box 24.3).
• Interventions to mitigate side effects or complications of cancer or
its treatments can improve oral intake (Box 24.4).
BOX Ways to Increase the Protein and Calorie

24.3 Density of Foods
To Increase Protein and Calories

• Add skim milk powder to milk to make double-strength milk; chill
well before serving.
• Use double-strength milk on hot or cold cereals and in scrambled eggs,
soups, gravies, casseroles, milk shakes, and milk-based desserts.
• Substitute whole milk for water in recipes.
• Add grated cheese to soups, casseroles, vegetable dishes, rice, and
noodles.
• Use peanut butter as a spread on slices of apple, banana, pear, crackers,
or waffles; use as a filling for celery.
• Add finely chopped, hard-cooked eggs to sauces; add cream to soups
and casseroles.
• Choose desserts made with eggs or milk such as sponge cake, angel
food cake, custard, and puddings.
• Dip meat, poultry, and fish in eggs or milk and coat with bread or
cereal crumbs before baking, broiling, or pan frying.
• Use yogurt, especially Greek yogurt, as a topping for fruit, plain cakes,
or other desserts; use in gravies and dips.
To Increase Calories
• Mix cream cheese with butter and spread on hot bread and rolls.
• Whenever possible, add butter to hot foods: breads, pancakes, waffles,
soups, vegetables, potatoes, cooked cereal, rice, and pasta.
• Substitute mayonnaise for salad dressing in salads, eggs, casseroles,
and sandwiches.
• Add dried fruit, nuts, or granola to desserts and cereal.
• Use whipped cream on pies, fruit pudding, gelatin, ice cream, and
other desserts and in coffee, tea, and hot chocolate.
• Use marshmallows in hot chocolate, on fruits, and in desserts.
• Top-baked potatoes, vegetables, and fruits with sour cream.
• Snack frequently on nuts, dried fruit, candy, buttered popcorn, cheese,
granola, and ice cream.
• Use honey on toast, cereal, and fruit and in coffee and tea.
Recommendations for Managing Side

BOX
Effects or Complications That Affect
24.4 Nutrition
Anorexia
• Plan a daily menu in advance.
• Overeat during “good” days.
• Eat a high-protein, high-calorie, nutrient-dense breakfast if appetite is
best in the morning.
• Eat a small high-calorie meals every 2 hours.
• Seek help preparing meals.
• Add extra protein and calories to food.
• Eat high-protein foods first, such as meat, fish, poultry, eggs, legumes,
and yogurt.
• Limit liquids with meals to avoid early satiety and bloating at
mealtime.
• Use ONS (instant breakfast mixes, milk shakes, commercial
supplements) in place of meals when appetite deteriorates or the client
is too tired to eat.
• Make eating a pleasant experience by eating in a bright, cheerful
environment, playing soft music, and enjoying the company of friends
or family.
• Avoid strong food odors if they contribute to anorexia. Cook outdoors
on a grill, serve cold foods rather than hot foods, or use takeout meals
that do not need to be prepared at home. In the hospital, the tray cover
should be removed before the tray is placed in front of the client so
that food odors can dissipate.
• Try different foods.
• Perform frequent mouth care to reduce aftertastes.
• Be as active as possible to stimulate appetite.
Nausea
• Rinse mouth before and after eating.
• Eat 5 or 6 small meals daily instead of 3 large ones.
• Do not skip meals.
• Some people feel better by eating dry toast, crackers, or breadsticks
throughout the day.
• Slowly sip fluids throughout the day.
• Drink ginger ale or ginger tea.
• Eat foods served cold, such as chicken salad, instead of hot baked
chicken or deli roast beef instead of pot roast.
• Eat high-carbohydrate, low-fat, easy-to-digest foods such as toast,
crackers, pretzels, yogurt, sherbet, cooked cereal, soft or canned fruits,
watermelon, bananas, fruit juices, and angel food cake.
• Avoid fatty, greasy, fried, spicy, or foods with a strong odor.
• Sit up for 1 hour after eating.
• Keep track of and avoid foods that cause nausea.
• Avoid eating 1–2 hours before chemotherapy or radiotherapy.
• Take antiemetics as prescribed even when symptoms are absent.
Fatigue
• Eat a hearty breakfast because fatigue may worsen as the day
progresses.
• Engage in regular exercise if possible.
• Consume easy-to-eat foods that can be prepared with a minimal
amount of effort, such as frozen dinners, takeout foods, sandwiches,
instant breakfast mixes and liquid formulas, cheese and crackers,
peanut butter on crackers, yogurt, and pudding.
• If weight loss isn’t a problem, avoid overeating for energy. Excess
weight worsens fatigue.
• Enlist the help of friends and family to provide meals.
Taste Changes
• Eat cold or frozen foods.
• Use sugar-free lemon drops, gum, or mints to counter a metallic or
bitter taste in the mouth.
• Brush your teeth or rinse with a mouthwash before eating.
• Eat small frequent meals.
• Use plastic utensils if food has a metallic taste.
• Drink tart juice before eating, such as cranberry or orange juice, to
mask a metallic taste.
• Experiment with tart foods such as pickles, vinegar, or relishes to help
overcome metallic taste.
• Eat meat with something sweet, such as pork with applesauce or
turkey with cranberry sauce.
• Substitute poultry, eggs, cheese, and mild fish for beef and pork if they
have a “bad,” “rotten,” or “fecal” taste.
• Avoid foods that are offensive; stick to those that taste good.
• Try new foods, such as lemon yogurt in place of strawberry.
Sore Mouth (Stomatitis)

• Practice good oral hygiene (thorough cleaning with a soft-bristle
toothbrush or cotton swabs plus frequent mouth rinses with normal
saline and water or baking soda and water). Commercial mouthwashes
containing alcohol may irritate and burn the oral mucosa.
• Eat cold or room-temperature foods.
• Eat soft, nonirritating foods that are easy to chew and swallow, such as
bananas, applesauce, watermelon, canned fruit, cottage cheese, yogurt,
mashed potatoes, macaroni and cheese, puddings, milk shakes, ONS,
scrambled eggs, oatmeal, and other cooked cereals.
• Add gravy, broth, or sauces to increase the fluid content of foods, as
appropriate.
• Cook food until soft and tender.
• Cut food into small pieces or puree in a blender.
• Numb the mouth with frozen bananas, ice chips, ice cream, or
popsicles.
• Avoid spices, acidic foods, coarse foods, salty foods, alcohol, and
smoking that can aggravate an already irritated oral mucosa.
• Consume high-calorie, high-protein drinks in place of traditional
meals.
• Use a straw to drink liquids.
• Avoid wearing ill-fitting dentures.
• Glutamine swishes may reduce the duration and severity of mucositis.
Xerostomia (Dry Mouth)

• Use an alcohol-free mouth rinse before eating.
• Drink fluids with meals and all day long.
Eat moist foods softened with gravies or sauces. Casseroles and stews
• are easier to eat than baked or roasted meats.
• Avoid dry, coarse foods and very spicy or salty foods.
• Avoid foods that stick to the roof of the mouth such as peanut butter.
• Avoid sugary food and beverages that promote dental decay.
• Drink high-calorie, high-protein liquids between meals.
• Stimulate saliva production with citrus fruits if tolerated, such as
lemons, oranges, limes, and grapefruit.
• Consume frozen desserts, such as ice cream and frozen yogurt.
• Eating papaya may help break up “ropy” saliva.
• Use ice chips and sugar-free hard candies and gum between meals to
relieve dryness.
• Use a straw to drink liquids.
• Apply a moisturizer to the lips to help prevent drying.
• Brush after every meal and snack.
• Avoid tobacco and alcohol because they dry the mouth.
Diarrhea
• Replace fluid and electrolytes with broth, soups, sports drinks, and
canned fruit.
• Drink at least 1 cup of liquid after each loose bowel movement.
• Limit caffeine, hot or cold liquids, and high-fat foods because they
aggravate diarrhea.
• Avoid gassy foods and liquids such as dried peas and beans,
cruciferous vegetables, carbonated beverages, and chewing gum.
• Try foods high in pectin and other soluble fibers to slow transit time,
such as oatmeal, cooked carrots, bananas, peeled apples, and
applesauce.
• Avoid sugar-free candy or gum containing sorbitol because it can
contribute to osmotic diarrhea.
• Unless tolerance to lactose has been confirmed, limit or avoid milk.
Constipation
• Increase fiber gradually by eating more fruits, vegetables, and
legumes. Replace refined grains with whole-grain bread and cereals.
• Consume 2 tbsp wheat bran, which can be sprinkled on cooked or
ready-to-eat cereal, salad, applesauce, or yogurt. After 3 days, increase
by 1 tbsp daily until constipation is resolved. Bran intake should not
exceed 6 tbsp/day.
• Eat dried fruit, such as raisins, dates, or prunes.
• Eat high-fiber foods throughout the day.
• Drink 8–10 cups of fluid/day.
• Take walks and exercise regularly.
Table Drugs Commonly Used for

24.5 Anorexia-Cachexia Syndrome
Drug Common Drugs

Category Used Effectiveness
Progesterone Megestrol acetate Improved weight gain
analogs Shown to improve appetite
Medroxyprogesterone for clients with advanced
cancer
Improved appetite and
stimulated weight gain
Corticosteroids Dexamethasone Similar efficacy to megestrol
Methylprednisolone acetate in improving appetite
Prednisolone Increased appetite but
negligible weight change
Short-term appetite
improvement but no weight
gain
Drug Common Drugs
Category Used Effectiveness
Cannabinoids Dronabinol Inconsistent evidence of
effectiveness; is inferior
to megestrol acetate for
appetite improvement
and weight gain
Antihistamines Cyproheptadine Increases appetite but may
not decrease weight loss in
adults
Anti- Melatonin Several systemic literature
inflammatory reviews have failed to show
agents Omega-3 fatty acids conclusive evidence of
(EPA) efficacy
No improvement in weight or
Pentoxifylline appetite vs. megestrol or
Thalidomide placebo
Poor compliance with high
doses but results suggest
improved lean body mass
Low doses had no effect on
weight gain or appetite
No effect on weight gain or
improvement in appetite
Shown to reduce weight loss
compared to placebo at
200 mg daily
effects/appetite-loss/nutrition-hp-pdq; Childs, D., & Jatoi, A. (2019). A hunger for hunger: A
review of palliative therapies for cancer-associated anorexia. Annals of Palliative Medicine, 8(1),
50–58. https://doi.org/10.21037/apm.2018.05.08
• ONS, which may be nutritionally complete, can be used to
supplement or replace oral meals and snacks.
• Most ONS provide between 230 to 360 calories and 10 to 20 g
protein per 8 oz serving.
• ONS may be the easiest and most consistent way to achieve a
high-calorie, high-protein intake.
• Appetite stimulants are helpful for a subgroup of cancer clients who
struggle with loss of appetite (tab 24.5) (Childs & Jatoi, 2019).
• Although they may improve appetite, they do not appear to
improve quality of life or survival.
Recall Patrick. He is experiencing anorexia, nausea,

vomiting, and mouth sores from chemotherapy and now
weighs 236 pounds. What percentage of his usual weight has
he lost? Is that significant? What strategies would you
suggest he try to maintain an adequate oral intake?
Nutrition Support
For both physiological and psychological reasons, an oral diet is preferred
whenever possible. When oral intake is inadequate or contraindicated,
enteral or parenteral nutrition can provide supplemental or complete
nutrition.
• Nutrition support is not used routinely but is indicated in clients who
are malnourished and are expected to not be able to consume
adequate oral nutrition for an extended period (PDQ® Supportive
• Enteral nutrition is preferred over parenteral nutrition whenever the
GI tract is functional.
• Parenteral nutrition support is an option when the GI tract is
nonfunctional, such as in the case of a complete bowel obstruction
or failure.
Additional considerations as put forth in the European Society for Clinical
Nutrition and Metabolism (ESPEN) guidelines on nutrition in cancer clients
are as follows (Arends et al., 2017):
• Cancer clients who are losing weight and have insulin resistance
may benefit from lowering the percentage of calories from
carbohydrate and increasing calories from fat. This change
decreases the glycemic load and increases calorie density.
• The use of a multivitamin and mineral that provides RDA levels of
nutrients is useful and safe. In general, single, high doses of
micronutrients should be avoided.
• The use of any diet that is not based on clinical evidence is not
recommended.
• Fad diets have the potential to cause micronutrient deficiencies
and exacerbate malnutrition.
• No diets have been proven to cure or prevent the recurrence of
cancer.
• Maintaining or increasing physical activity, including resistance
exercise, is recommended to support muscle mass, physical
function, and health-related quality of life.
Recall Patrick. His weight loss continues and he is having‐

difficulty staying hydrated due to mouth sores and vomiting.
Are there additional diet modifications you would
recommend that may enable him to consume adequate fluids
and calories? Is he a candidate for EN? What are the
potential risks and benefits?
Nutrition in Advanced Cancer

Refractory cachexia develops as a result of very advanced cancer or rapidly
progressive disease (PDQ® Supportive and Palliative Care Editorial Board,
2020). It is associated with active catabolism and weight loss that are not
responsive to nutrition therapy. At the end of life, clients often severely
restrict their intake of food and fluids as part of the normal dying process
(PDQ® Supportive and Palliative Care Editorial Board, 2020).
• The goals of nutrition intervention in clients with advanced cancer
are to promote the best possible quality of life and manage nutrition-
related symptoms that cause distress (Box 24.3) (PDQ® Supportive
• Eating is encouraged as a source of pleasure, not as an adjunct to
treatment, and the client’s preferences are the primary consideration.
• Studies on the last week of life do not support the use of artificial
nutrition, and studies on artificial hydration had mixed results
(PDQ® Supportive and Palliative Care Editorial Board, 2020).
Nutrition for Cancer Survivors

Cancer survivors are urged to follow nutrition and physical activity
recommendations for cancer prevention—namely, maintain a healthy
weight, be physically active, and eat a mostly plant-based diet (fig 24.1).
Several reviews indicate that obesity and metabolic syndrome might be
independent risk factors for recurrence and reduced survival in breast and
gastric cancer clients (Arends et al., 2017). Cancer survivors are at a
significantly higher risk of developing second primary cancers and other
chronic diseases such as coronary heart disease, diabetes, and osteoporosis
(Ng & Travis, 2008), emphasizing the importance of a healthy lifestyle.
Consider Patrick. He completed the recommended course

of chemotherapy and will be closely followed to ensure the
treatment was effective. He has high anxiety and fear that
the cancer will return and wants to do everything he can to
reduce the risk. What would you say to Patrick to help
manage his fear? What weight, intake, and exercise goals
would you recommend Patrick set?
HIV AND AIDS
HIV is a chronic infectious disease that attacks the immune system,

specifically CD4 cells. It is diagnosed with an enzyme-linked
immunosorbent assay test (ELISA) and confirmed with a Western blot test.
HIV progresses to AIDS when CD4 cell count is <200 cell/mL and/or an
AIDS-defining illness is diagnosed. Poor nutrition can impact the course of
HIV; untreated HIV can have significant effects on nutritional status (Box
24.5). The chronicity of HIV infection intensifies the challenge to nutrition.
When the HIV/AIDS pandemic began in the 1980s, people often died
from opportunistic infections within years or even months of diagnosis.
Since the introduction of potent antiretroviral therapy (ART) in the mid-
1990s, HIV has been transformed from a fatal illness to a manageable
chronic condition (Harris et al., 2018). Today, successfully treated HIV-
positive clients have a near-normal life expectancy (National Institutes of
Health, National Institute of Allergy and Infectious Diseases, 2019).
Antiretroviral Therapy (ART)

a combination of ART medications that are typically used to control and reduce viral load.
Nutrition-Related Complications
Although people living with HIV/AIDS (PLWH) are still at risk for
undernutrition and wasting, the use of ART has reduced many of the acute
malnutrition-related concerns associated with HIV (Tate et al., 2012). With
increased life expectancy, PLWH are facing the challenges of chronic
disease (Thuppal et al., 2017).
• Researchers have found that even when HIV is well controlled with
ART, immune cells undergo persistent activation that causes chronic
inflammation in organs and body systems (National Institutes of
Health, National Institute of Allergy and Infectious Diseases, 2019).
• Because inflammation is a key driver of many chronic diseases,
PLWH have higher risks of obesity, metabolic syndrome,
cardiovascular disease (CVD), and type 2 diabetes as they age.
• Public health concerns over nutrition and HIV have shifted from
acute malnutrition to providing optimal nutrition to improve quality
of life and overall health (Thuppal et al., 2017).
• Selected nutrition-related complications and comorbidities are
outlined in Box 24.6.
BOX Effect of HIV on Nutritional Status

24.5
• Inflammatory, hormonal, and immune responses to HIV can increase
metabolic rate and nutrient requirements, promote loss of lean body
tissue, cause anorexia, and alter nutrient storage and availability.
• Infections in the intestines can lead to diarrhea, malabsorption of
nutrients, blood loss, and damage to the intestinal lining.
• Opportunistic infections and cancers often result in weight loss.
• Severe infection increases the risk of malnutrition.
• ART medications have multiple adverse side effects that may affect
overall intake, metabolism, or nutrient utilization.
BOX Nutrition-Related Complications and

24.6 Comorbidities of HIV/AIDS
Undernutrition
Both malnutrition and HIV impair immune system functioning; when
malnutrition and HIV are combined, the effects on the immune system
are magnified (Willig et al., 2018).
• Death rates are higher in PLWH who have malnutrition, even those
receiving ART.
• HIV and ART may cause a dysregulation of metabolism that
negatively affects nutritional status and alters nutrient needs. Protein-
energy malnutrition, anemias, and micronutrient deficiencies are
common.
HIV-Associated Wasting
HIV-associated wasting was defined in 1987 as an AIDS-defining
condition (CDC, 1987). Before the advent of ART, the prevalence of
wasting was estimated to be as high as 37%. Some studies suggest the
current prevalence may be 20% to 34%, but the degree of wasting is less
severe (Myhre & Sifris, 2019).
• It is defined as an involuntary weight loss of >10% with either
diarrhea, or weakness and fever for ≥30 days with no other concurrent
illness or condition other than HIV infection that could explain the
findings (e.g., cancer, tuberculosis, etc.) (CDC, 1987).
• Losses of both fat and lean body mass occur.
• Causes may include HIV, opportunistic infections, or inflammatory
changes that increase calorie expenditure and protein breakdown.
• Although ART improves weight loss and malnutrition in PLWH, it
may not necessarily prevent the loss of muscle mass or replace it once
body weight is restored (Myhre & Sifris, 2019).

As with the general population in the United States, the prevalence of
overweight and obesity in PLWH has been rising.
• More than 60% of PLWH are overweight or obese (Hernandez et al.,
2017).
• Some people are obese at the time of HIV diagnosis, and others
experience significant weight gain after initiation of ART (Willig et al.,
2018).
Lipodystrophy
Lipodystrophy syndrome is characterized changes in body fat distribution
and metabolic disturbances.
• Peripheral fat wasting may occur with loss of subcutaneous fat in the
face, arms, legs, and buttocks.
• Abnormal fat accumulation may occur in the abdomen (visceral), back
of the neck, and breast (gynecomastia).
• Some clients have only fat gain, some have only fat loss, and some
have both.
• Metabolic disturbances of HIV lipodystrophy include impaired glucose
tolerance, insulin resistance, and hyperlipidemia, which increase the
risk of diabetes and atherosclerotic CVD.
• Factors associated with the development of lipodystrophy include
ART’s protease inhibitor, HIV clinical stage, age at the start of ART,
race, and exercise level (dos Santos et al., 2018).
• Body changes due to lipodystrophy may stigmatize clients, causing
low self-esteem, problems in social and sexual relations, anxiety, and
depression (Shenoy et al., 2014).
Chronic Disease
HIV infection is associated with CVD, hypertension, diabetes,
osteoporosis, frailty, and cognitive impairment (Willig et al., 2018).
• PLWH are 50% to 100% more likely to develop CVD than people
without HIV, in part due to the chronic inflammatory nature of HIV
(NIH, 2019).
• The age-adjusted and body mass index–adjusted rate of diabetes is
over 4 times greater in HIV-infected men compared to noninfected
men (Brown et al., 2005).
Nutrition Therapy for HIV/AIDS

Nutrition therapy has the potential to promote optimal nutritional status;
prevent foodborne illnesses; improve quality of life by managing symptoms
of HIV or side effects of medications that affect food intake; and manage or
reduce the risk of comorbidities. A well-nourished PLWH who has a
controlled viral load is more likely to withstand the effects of HIV
infection and delay disease progression (Willig et al., 2018). General
healthy eating recommendations are the same for PLWH as they are for
non-HIV individuals (Box 24.7)
Viral Load
the level of virus or viral markers measured in the blood.
• Because nutrition-related alterations can occur early in HIV

infection, nutrition intervention should begin soon after diagnosis
(Willig et al., 2018).
• There is not a one-size-fits-all diet for HIV/AIDS nor are there
unanimously agreed-upon recommendations for calories or nutrients
despite the universal goals of maintaining body weight and lean
body mass.
• Recommended intake ranges for macronutrients are the same
Dietary Reference Intakes (DRI) levels as those set for the general
public: 45% to 65% calories from carbohydrate, 10% to 35%
calories from protein, and 20% to 35% calories from fat (Willig
et al., 2018).
BOX General Healthy Eating

24.7 Recommendations for Clients with HIV
Overall
• Eat a calorie-appropriate, balanced eating pattern rich in a variety of
fruit, vegetables, and whole grains.
• Eat some carbohydrate, protein, and fat at each meal and snack.
• Drink adequate fluid.
• Practice food safety guidelines.
• Manage side effects or symptoms that affect nutrition, such as
anorexia, nausea, vomiting, and diarrhea.
Protein
• Choose lean sources such as skinless poultry, lean cuts of beef and
pork, fish and seafood, and legumes.
• Eat fish and seafood for healthy omega-3 fats.
Dairy
• Choose low-fat or nonfat milk or yogurt.
Fats
• Eat healthy fats in moderation, such as olive and canola oils, seeds,
nuts, nut butters, and avocados.
• Limit saturated and trans fats such as butter, margarine, and
shortenings and foods made with solid fats.
Added sugars
• Limit sugar-sweetened beverages and foods with added sugar such as
candy, cookies, cakes, and ice cream.
Calories
Calorie needs may be higher or lower than normal depending on the client’s
current weight and clinical status. Resting energy expenditure (REE) is
higher in PLWH than in HIV-negative people and is higher in clients with
lipodystrophy than in those with no lipodystrophy (Willig et al., 2018).
To maintain weight, calorie needs may be 10% higher in asymptomatic
PLWH and 20% to 30% higher during symptomatic HIV and AIDS (World
Health Organization, 2003).
• Calorie reduction for prevention of weight gain may be the primary
focus in clients who are overweight or obese (Willig et al., 2018).
Protein
No recent studies of protein need for PLWH have been conducted (Willig
et al., 2018)
• An individualized diet with the 10% to 35% of calories from protein
(the DRI) is recommended (Willig et al., 2018).
Micronutrients
Recent studies on micronutrients in well-controlled HIV infection are
lacking (Willig et al., 2018).
• Supplements of vitamin D and calcium may reduce the loss of bone
density that occurs with ART (Overton et al., 2015).
• Clients who do not consume adequate amounts of micronutrients
should be counseled on how to improve their intake of
micronutrients through better food choices.
• Micronutrient supplements should be used only in the case of
deficiencies (Willig et al., 2018).
Manage Symptoms
Clients with HIV/AIDS may experience problems with appetite and intake
similar to those of cancer clients. Diet modifications recommended for side
effects or complications of cancer are also appropriate for people infected
with HIV (see Box 24.4).
Nutrition for Comorbidities

The management of comorbidities and HIV has largely been extrapolated
from non-HIV–infected populations (Willig et al., 2018).
• It is not known if nutrition guidelines for hypertension and diabetes
in the general public also apply to PLWH (Willig et al., 2018).
• The following are among the modifiable risk factors associated with
reducing bone loss in PLWH: Maintain optimal weight; avoid
smoking, alcohol, and caffeine; and consume foods rich in calcium
and vitamin D (Overton et al., 2015).
• The primary interventions for clients with ART-related dyslipidemia
are nutrition and lifestyle (Calza et al., 2016).
• Recommendations include reducing the intake of saturated fat and
cholesterol and increasing the intake of vegetables and fiber.
• The general healthy eating guidelines outlined in Box 24.7 are
appropriate.
• Increasing physical activity and maintaining healthy body weight
usually produce a significant improvement in lipid profile (Calza
et al., 2016).
Food and Drug Interactions

ART involves taking a combination of HIV drugs with the goal of reducing
viral load to an undetectable level. Although ART does not cure HIV, it
enables PLWH to live longer, healthier lives and reduces the risk of HIV
transmission (USDHHS, 2020). ART is recommended for all people
beginning at the time of HIV diagnosis. The actual drugs included in a
person’s treatment regimen vary with the individual’s needs. The
bioavailability of some medications depends on the medication being taken
with food (tab 24.6).
Table Single HIV/AIDS Medications

24.6 and Timing of Food Intake
Food Safety
Because clients infected with HIV have compromised immune systems,
steps should be taken to reduce the risk of foodborne illness. Food safety
strategies are listed in Box 24.2 (see Chapter 10 for more on foodborne
illness).
NURSING PROCESS Cancer
Karen is a 59-year-old former smoker who now calls herself a “health

nut.” She was recently diagnosed with lung cancer. She had surgery to
remove her right lung and is receiving chemotherapy for cancerous
“spots” on the left lung and stomach. She has lost 28 pounds and
complains of nausea, vomiting, and a bad taste in her mouth. Because
she has followed a healthy diet to prevent cancer for years, she is
reluctant to now change her eating habits and eat more protein, fat, and
calories. Right now, she is eating mostly fruit, sherbet, and skim milk.
Assessment
Medical– • Medical history such as diabetes, heart
Psychosocial disease, or hypertension.
History • Types of drugs the client is receiving
through chemotherapy; other prescribed
medications that affect nutrition.
• Physician’s goals and plan of treatment.
• Pattern of nausea and vomiting.
• Client’s understanding of increased
nutritional needs related to cancer and
cancer therapies.
• Willingness to change her attitudes toward
food and nutrition.
• Psychosocial and economic issues such as
financial status, employment, and outside
support system.
• Usual activity patterns.
Anthropometric • Height, current weight, usual weight.
Assessment • Rate of weight loss; percentage of usual
body weight lost.
• BMI.
Assessment
Biochemical and • Laboratory data: prealbumin, serum
Physical electrolytes, any abnormal values.
Assessment • General appearance/evidence of muscle
wasting.
Dietary Assessment • How many daily meals and snacks are you
eating?
• What is a typical day’s intake for you?
• When is your appetite the best?
• What do you do to alleviate nausea?
• How has your sense of taste changed?
What do you do to cope with the changes?
• Do you have any food allergies or
intolerances?
• Do you have any cultural, religious, or
ethnic food preferences?
• Do you use vitamins, minerals, or
nutrition supplements?
• Do you use liquid formulas, such as
instant breakfast mixes or commercial
products?
• How much liquid do you consume in a
day?
Analysis
Possible Nursing • Malnutrition risk related to nausea,
Analysis vomiting, and taste changes secondary to
cancer/cancer therapy as evidenced by 28-
pound weight loss.
Planning
Assessment
• Eat six times daily.
• Increase the protein and calorie density of
foods she eats.
• Drink at least 16 oz of a high-calorie,
high-protein ONS daily.
• Switch from skim milk to whole milk, as
tolerated.
• Verbalize interventions she will try to help
alleviate nausea and taste alterations.
• Verbalize the importance of consuming
adequate protein and calories and the role
of fat in providing calories.
• Maintain present weight until
chemotherapy is completed.
Nutrition Therapy Provide regular diet as ordered with high-
Client Teaching protein, high-calorie, in-between meal
supplements.
• An adequate nutritional status reduces the
side effects of treatment, may make cancer
cells more receptive to treatment, and may
improve quality of life; poor nutritional
status may potentiate chemotherapeutic
drug toxicity.
• A preventive eating style is no longer
appropriate; consuming adequate protein
and calories (even fat calories) is the
major priority.
Assessment
Instruct the client on eating plan essentials,
including the following:
• Protein sources the client may tolerate
despite nausea and taste changes such as
eggs, cheese, nuts, dried peas and beans,
yogurt, milk shakes, eggnogs, puddings,
ice cream, instant breakfast mixes, and
commercial supplements.
• How to increase the protein and calorie
density of foods eaten (see Box 24.4).
• To eat small, frequent “meals” to help
maximize intake but to avoid eating
12 hours before chemotherapy.
• To drink ample fluids 1–2 days before and
after chemotherapy to enhance excretion
of the drugs and to decrease the risk of
renal toxicity.
Instruct the client on interventions to
minimize nausea, as follows:
• Eating foods served cold or at room
temperature.
• Eating high-carbohydrate, low-fat foods
such as toast, crackers, yogurt, sherbet,
cooked cereal, soft or canned fruits,
watermelon, bananas, fruit juices, and
angel food cake.
• Avoiding fatty, greasy, fried, and strongly
seasoned foods.
Instruct the client on behavior to help
maximize intake, including the following:
• Viewing food as a medicine, rather than a
social pleasure, that must be “taken” even
Assessment
when the desire to eat is lacking.
• Keeping track of and avoiding foods that
cause nausea.
• Taking antiemetics as prescribed even
when symptoms are absent.
• Sucking on sugarless hard candy during
chemotherapy and using plastic utensils
and dishes to mitigate the “bad taste” in
her mouth.
• Avoiding anything that tastes unpleasant.
Evaluation
Monitor • Monitor food intake records.
• Monitor management of side effects;
suggest additional interventions as needed.
How Do You Respond?

Why do cancer prevention guidelines suggest red meat
intake be limited? According to the World Cancer
Research Fund/American Institute for Cancer Research
Continuous Update Project (2018), there is strong
evidence that the intake of red meat is a probable cause of
colorectal cancer and convincing evidence that processed
meat is a cause of colorectal cancer. The risk may be
related to substances that occur naturally in red meat (e.g.,
heme iron, fat content) and substances that are produced
when red meat is processed (e.g., nitrites that can become
carcinogenic compounds) or cooked (e.g., heterocyclic
amines formed at high heat). Other hypotheses are that
processed meats are high in fat, contributing to an excess
calorie intake and an increase in bile acids and that people
who have a high red meat intake tend to eat less plant-
based foods and thus miss out on their cancer-protective
substances. It is recommended that red meat consumption
be limited to no more than 3 portions per week, or about
12 to 18 ounces of cooked weight. Very little, if any,
processed meat should be eaten based on data that show
no level of intake can confidently be associated with a
lack of risk.
Doesn’t canola oil cause cancer? The rumor that canola
oil causes cancer stems from the fact that canola is
derived from rapeseed. Rapeseed is naturally high in
erucic acid, a fatty acid shown to be harmful to animals.
However, in the 1970s, traditional plant breeding methods
led to the creation of a low–erucic acid rapeseed, which is
used to make canola oil. Other objections about hexane
used to extract the oil and trans fats created during the
process of deodorizing the oil are not significant enough
to cause concern (Crosby, 2015). Canola oil is a safe and
healthy form of fat.
REVIEW CASE STUDY
Steve is a 39-year-old male who has been HIV positive for 6 years. His
waistline is expanding, and he blames that for his recent onset of heartburn.
Based on a physical examination and insulin resistance, his doctor
diagnosed lipodystrophy syndrome. Steve is 6 ft tall and weighs
190 pounds. His weight has been stable for the last several years, although
he feels “fatter.” He is on ART but is thinking of discontinuing the
medication if it is the cause of his change in shape. He is willing to exercise
but wants maximum benefit from minimum effort. He is also willing to
change his eating habits but relies heavily on eating out. A typical day’s
intake is shown on the right:
• Evaluate Steve’s current weight. Would you recommend weight loss?

• How does Steve’s weight affect heartburn and insulin resistance?
• How does his usual intake affect heartburn and insulin resistance?
• What are Steve’s nutrition-related problems? What nutrition therapy
recommendations would you make?
• What would you tell Steve about exercise?
• What criteria would you monitor to evaluate the effectiveness of nutrition
therapy?
Breakfast: A fast-food egg, bacon, and cheese sandwich on an English

muffin; hash browns; and large black coffee
Lunch: Double hamburger, french fries, and cola
Dinner: Grilled steak, baked potato with sour cream, and water
Snacks: Chips
STUDY QUESTIONS
1 The nurse knows their instructions about healthy eating to reduce the risk
of cancer have been understood when the client states,
a. “If I follow those healthy eating guidelines, I will not get cancer.”
b. “To reduce the risk of cancer, I have to eat a vegetarian diet.”
c. “There is not enough known about diet and cancer to make informed
choices about what to eat to reduce the risk of cancer.”
d. “A mostly plant-based diet may reduce the risk of cancer.”
2 The nurse knows their instructions on how to reduce the risk of
foodborne illness have been understood when the client states,
a. “It is okay to thaw food at room temperature as long as I cook it
immediately after it is defrosted.”
b. “Leftovers are not safe to eat.”
c. “Fruits and vegetables do not need to be washed if I peel them or eat
them after they are cooked.”
d. “Hot dogs, deli meats, and luncheon meats should be reheated before
being eaten.”
3 Which of the following strategies would the nurse suggest to help the
client increase the protein density of their diet?
a. Top-baked potatoes with sour cream.
b. Mix cream cheese with butter and spread on hot bread.
c. Substitute milk for water in recipes.
d. Add whipped cream to coffee.
4 Which of the following meals would be most appropriate for a client who
has nausea?
a. Cottage cheese and fresh fruit plate
b. Fried chicken and coleslaw
c. Hamburger and french fries
d. Spaghetti with marinara sauce and salad
5 The client asks what foods they can eat for protein because meat tastes
“rotten.” Which of the following would be the nurse’s best response?
a. Cheese omelet, cold chicken sandwich, and shrimp salad
b. Vegetable soup, pulled-pork sandwich, and chili
c. Pasta salad, beef taco salad, peanut butter, and jelly sandwich
d. Hot dogs, hamburgers, and vegetable pizza
6 A client asks if it is okay to drink nutrition supplements in place of eating
solid food because it seems to be the only thing they tolerate. Which of
the following is the nurse’s best response?
a. “Oral nutrition supplements are okay to use as a supplement in your
diet, but they do not provide enough nutrition to use them in place of a
meal.”
b. “Oral nutrition supplements are rich in nutrients and can be used in
place of meals if they are what you are able to tolerate best.”
c. “It is fine to rely on oral nutrition supplements but vary the brand to
ensure you are getting adequate nutrition.”
d. “Oral nutrition supplements generally are too high in calories and
protein to use in place of meals.”
7 Which statement indicates the client with HIV understands instruction
about healthy eating?
a. “Eating fat increases my chances of getting fat around my middle, so I
am trying to choose all nonfat or low-fat food.”
b. “Because I have HIV, it is too late for healthy eating to be beneficial.”
c. “Protein is the most important nutrient, so I am eating extra red meat at
every meal.”
d. “Unsaturated fats in olive oil, canola oil, nuts, and avocado are
healthiest. I am eating those in place of solid fats.”
8 When should nutrition therapy become part of the care plan for a client
with HIV?
a. Soon after diagnosis
b. When the client begins to lose weight
c. After the first acute episode of illness
d. When weight loss is >5% of initial weight

Clients with Cancer or HIV/AIDS
Cancer is a group name for different types of malignancies characterized by
the uncontrolled growth of cells. Thirty-nine to forty percent of Americans
will develop cancer in their lifetime
Nutrition in Cancer Prevention
• Potentially modifiable risk factors are estimated to be responsible for

more than 40% of incident cancers and almost 50% of all cancer deaths.
• The two largest modifiable risk factors are tobacco use and
overweight/obesity.
• Nutrition-related recommendations for cancer prevention include a plant-
based diet with limited consumption of fast foods, processed foods, red
and processed meat, sugar-sweetened beverages, and alcohol.
Nutrition Complications
Related to Cancer
Cancer clients are among the most malnourished of all client groups.
Malnutrition differs from starvation-related malnutrition in that inadequate
food intake is accompanied by an alteration in metabolism.
• Local tumor effects: Occur when the tumor impinges on surrounding
tissue and are most severe with GI and head and neck cancers.
• Tumor-induced changes in metabolism: Considered a hallmark of
cancer but exact mechanisms are not fully understood.
• Inadequate intake: The causes are complex and multifactorial and may
occur prior to diagnosis or be the result of cancer or cancer treatments.
• Muscle protein depletion: Loss of lean body mass is an independent
risk factor for poorer outcomes. Sarcopenia can be difficult to identify in
clients who are obese.
• Systemic inflammation Syndrome: Alters the metabolism of
carbohydrates, protein, and fat and is associated with fatigue, impaired
physical activity, anorexia, and weight loss.
• Interactions and Outcomes: Weight loss, impaired physical
functioning, and systemic inflammation in cancer clients are all
independently associated with unfavorable outcomes and interact to
diminish client well-being.
• Cancer cachexia: Multifactorial syndrome characterized by unstoppable
muscle wasting that cannot be fully reversed by conventional nutrition
support.
Nutrition Complications
Related to Cancer Treatments
Treatments can contribute to progressive nutritional deterioration due to
localized or systemic side effects. The success of treatment is influenced by
the client’s ability to tolerate therapy.
• Surgery: Healing from surgery increases the requirement for protein,
calories, vitamin C, B vitamins, and iron. GI surgeries have the greatest
likelihood of nutrition complications.
• Chemotherapy: Cancer cells and healthy cells of the GI tract,
respiratory system, bone marrow, skin, and gonadal tissue are most
vulnerable. Side effects are systemic; anorexia, taste changes, early
satiety, nausea, vomiting, mucositis, diarrhea, and constipation are most
common.
• Radiation: Side effects are localized; some may be chronic. Nutrition-
related side effects are most common from radiation to the head and
neck, lower neck and mid-chest, abdomen and pelvis, and brain.
• Biotherapy: Most common nutrition-related side effects are fatigue,
fever, nausea, vomiting, and diarrhea.
• Hemopoietic cell transplantation: Mucositis and significant diarrhea
are frequent side effects. Enteral or parenteral support may be indicated.
Nutrition Therapy during
Cancer Treatment
Goals of nutrition therapy are individualized according to the client’s
nutrition status, type and stage of disease, comorbid conditions, and
treatment plan.
• Calories: Can be estimated at 25 to 30 cal/kg/day and adjusted as
needed.
• Protein: Optimum intake is unknown; ≥1.0 to 2.0 g/kg/day may be
needed to promote positive protein balance.
• Promoting an oral intake: Ideally clients meet their need orally through
food. Calorie and protein density can be increased in food. ONS can be
used to supplement or replace meals as needed.
• Nutrition support: May be necessary if oral diet is inadequate or
contraindicated.
• Additional considerations: A low-carbohydrate diet may benefit cancer
clients with insulin resistance; a multivitamin and mineral supplement at
100% of the DRI is useful; fad diets are not recommended; and physical
activity is recommended.
Nutrition in Advanced Cancer

Refractory cachexia develops in clients with very advanced cancer or
rapidly progressive cancer. It is not responsive to nutrition therapy. Clients
often self-restrict food and fluid intake at the end of life. Nutrition-related
symptoms that cause distress should be managed.
Nutrition for Survivors of

Cancer
Cancer prevention guidelines—eat a plant-based diet, maintain healthy
weight, and be physically active—should be followed to potentially
decrease the risk of recurrence, second primary cancers, and other chronic
diseases.
HIV and AIDS
Poor nutrition impacts the course of HIV; HIV can have significant effects
on nutrition status. PLWH/AIDS now have a life expectancy near normal.
Nutrition-Related Complications. PLWH have higher risks of obesity,
metabolic syndrome, CVD, and type 2 diabetes as they age related to the
inflammatory nature of HIV. Focus has shifted from acute malnutrition to
managing chronic diseases.
Nutrition Therapy for HIV/AIDS. A PLWH who has a controlled viral
load is more likely to withstand the effects of HIV infection and delay
disease progression. General healthy eating recommendations for the
general public are appropriate for PLWH: Eat a plant-based diet that
provides a variety of fruit, vegetables, whole grains, and lean protein and
limit the intake of saturated fat, trans fat, and added sugar.
• Calories: PLWH may have a higher REE than noninfected people.
Calorie needs may be 10% higher in the absence of symptoms and 20%
to 30% higher during symptomatic HIV/AIDS. Prevention of weight
gain may be appropriate for PLWH who are overweight or obese.
• Protein: Exact requirements are unknown. Protein should provide 10%
to 35% of total calories (normal DRI).
• Micronutrients: Preferable source is food. Vitamin D and calcium
supplements may reduce loss of bone density with ART. Other
supplements should be used only in the case of documented deficiencies.
• Manage symptoms: Nutrition interventions may help relieve problems
with appetite and intake.
• Comorbidities: It is not known if nutrition guidelines for hypertension
and diabetes are the same for PLWH as they are for the general public.
Bone loss may be reduced with dietary and lifestyle interventions. A
heart-healthy eating pattern may improve dyslipidemia.
Food and Drug Interactions. The bioavailability of some drugs is
influenced by the presence of food.
Food Safety. Food safety is especially important for PLWH because
of their compromised immune system.
Figure sources: shutterstock.com/OKcamera and shutterstock.com/ESB Professional

book at
Websites
Websites related to cancer
American Cancer Society at www.cancer.org
American Institute for Cancer Research at www.aicr.org
National Cancer Institute at www.cancer.gov
National Center for Complementary and Alternative Medicine (NCCAM) at www.nccam.nih.gov
Oncology Nursing Society at www.ons.org
Websites related to HIV/AIDS
AIDSinfo (A Service of the U.S. Department of Health and Human Services) at
www.aidsinfo.nih.gov
Center for HIV Information from the University of California San Francisco School of Medicine at
www.hivinsite.org
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Appendix
Answers to Study Questions

Chapter 1
1. a
2. b
3. c
4. b
5. a
Chapter 2
1. a
2. c
3. c
4. a
5. c
6. a
7. a
8. b
Chapter 3
1. c
2. a
3. d
4. d
5. c
6. a
7. c
8. a
Chapter 4
1. b
2. d
3. b
4. b
5. a
6. c
7. d
8. a
Chapter 5
1. b
2. d
3. b
4. b
5. a
6. a
7. d
8. c
Chapter 6
1. b
2. c
3. c
4. c
5. d
6. b
7. c
8. a
Chapter 7
1. b
2. a
3. c
4. b
5. c
6. a
7. d
8. c
Chapter 8
1. c
2. b
3. c
4. b
5. c
6. b
7. a
8. b
Chapter 9
1. b
2. c
3. b
4. c
5. d
6. c
7. c
8. d
Chapter 10
1. c
2. d
3. c
4. a
5. a, c, d
6. c
7. a
8. a
Chapter 11
1. b
2. c
3. b, c, d
4. a, b, c, d
5. a, b, d
6. d
7. b
8. a
Chapter 12
1. b
2. a
3. d
4. c
5. b
6. a
7. a
8. c
Chapter 13
1. d
2. a
3. b
4. b
5. a, b, c
6. c
7. a
8. d
Chapter 14
1. d
2. c
3. a
4. b
5. b
6. a, b, c
7. a
8. d
Chapter 15
1. a
2. b
3. a
4. b
5. b, c, d
6. d
7. b
8. c
Chapter 16
1. c
2. b
3. c
4. a, c, d
5. b
6. a
7. a, b
8. a
Chapter 17
1. b
2. a, b, c
3. a
4. c
5. b
6. a
7. c
8. b
Chapter 18
1. b
2. c
3. d
4. c
5. c
6. c
7. d
8. b
Chapter 19
1. a
2. a
3. c
4. b
5. b
6. b
7. d
8. d
Chapter 20
1. b
2. a
3. b
4. b
5. b
6. a
7. a
8. d
Chapter 21
1. c
2. d
3. d
4. d
5. a
6. b
7. c
8. a, b, c
Chapter 22
1. b
2. c
3. a
4. a
5. a, b, c, d
6. d
7. c
8. b
Chapter 23
1. c
2. d
3. c
4. c
5. a
6. a
7. a, b, d
8. c
Chapter 24
1. d
2. d
3. c
4. a
5. a
6. b
7. d
8. a
Index
Note: Page numbers followed by b indicate a box; those followed by f, an

illustration; and those followed by t, a table.
A
Absorption
fat, 88
proteins, 63
Academy of Nutrition and Dietetics and the American Society of Parenteral and Enteral Nutrition (ASPEN), 315, 349, 350
Acceptable Daily Intake (ADI), nonnutritive sweeteners, 54
Acceptable Macronutrient Distribution Ranges (AMDRs), 6
carbohydrate intake, 45, 46t, 47f
fat, 91–92, 91f
protein, 68–69
Acculturation, dietary, 216–217, 216b
Acesulfame K, 55t
Acid–base balance, 62b
Acute diabetes, 475, 476b
Acute disease or injury-related malnutrition, 315f
Acute kidney injury (AKI), 518–519
Acute lung injury (ALI), 400
Acute pancreatitis, 450
Acute-phase response, 392
Acute respiratory distress syndrome (ARDS), 400
calories and protein, 401
enteral nutrition, 400–401
Added sugars, 40, 466b
limitation of, 49–56, 52b
source of carbohydrates, 40
sources of, 51f
Adequate Intake (AI), 5
fats, 91
Ad lib approach, 364
Adolescent pregnancy, 250–251
Advanced carbohydrate counting, 470–471
Advantame, 55t
African Americans
diet quality, 219–220
food and culture, 219b
nutrition-related health issues, 220
soul foods, 219
tradition, 489b
traditional diets, 219–220
Aging. See also Older adults
changes with, 290–291, 291t
healthy, 295–298
Ahimsa, 225
Alcohol, 466b
modifiable risk factor for chronic disease, 12b
use during pregnancy, 242
Allergens, 176, 177b
Alpha-Linolenic acid (n-3 from plants), 84–85
Altered bowel elimination
constipation, 427, 428–429b, 429
diarrhea, 429–430, 430b
Alzheimer disease, 303–304
American adults, 487–488, 487t
American Association for the Advancement of Science (AAAS), 199
American Cancer Society (ACS), 531
nutrition and PA recommendations, 30t
American College of Cardiology, nutrition and PA recommendations, 30t
American College of Lifestyle Medicine, 12–13
American Council on Science and Health (ACSH), 199
American cuisine, 208–212, 209t
eating healthy while eating out, 210–211b
fast-food and ethnic restaurants, 211–212b
food away from home, 209–212b
American Heart Association, 487
American Institute for Cancer Research (AICR), 530–531
nutrition and PA recommendations, 30t
American Medical Association, 199
Amino acids, in protein, 61, 61b, 61f
Anabolism, fat, 89
Anorexia, 408–409, 538b
Anorexia-cachexia syndrome, 540t
Anorexia nervosa (AN), 379, 380t, 381–382, 383b
Antibiotic-acquired diarrhea, 430b
Antibiotics, in the food supply, 201–202, 201f
Antioxidants, 101
Antiretroviral therapy (ART), 542, 545
Asian Americans, 221–222
diet quality, 221
nutrition-related health issues, 222
Aspartame, 55t
Aspiration, 345
Atherogenic lipoproteins, 496
Atherosclerotic cardiovascular disease (ASCVD), 463, 465
Authorized health claims. See Unqualified health claims
B
Babies, healthy eating for. See Pregnancy
Bariatric surgery, 370–371
candidates for, 371b
laparoscopic adjustable gastric banding, 372–373, 373f
nutrition for, 376t, 377
nutrition therapy for, 373–375
Roux-en Y Gastric Bypass, 371, 372f
Sleeve Gastrectomy, 371, 372f
success of, 375–376
Basal energy expenditure (BEE), 157, 157b
Basal insulin, 470
Basal metabolic rate (BMR), 157, 158t
Basal metabolism, 157
Basic carbohydrate counting, 469, 470b
Behavior change, 472–473, 473f
Behavioral interventions, 366, 367b
Bezoar, 419
Binge-eating disorder (BED), 383–384, 385b
Bioinformatics, 13
Biomarkers, 14
Biotherapy, 535–536
Body dysmorphic disorder, 379
Body fat distribution, 161–163
waist circumference, 161–163
waist-to-height ratio, 163
Body mass index (BMI), 160–161, 162t, 321, 358, 361t
body fat distribution, 161–163
childhood and adolescent weight status, 272t
early childhoods (1–5 years), 269, 270–271f
pear shape versus apple shape, 162f
pregnancy, 232, 235t
recommended amount of weight gain, 234–235, 235t
recommended pattern of weight gain, 235t, 236
Body weight. See also Weight
evaluating status, 160–163, 161t
pregnancy, 232
Bolus feedings, enteral nutrition, 342
Bolus insulin, 470
Breast cancer, nutrition and, 11t
Breastfeeding
benefits, 251b
calories, 253
contraindications, 252b
factors that affect the duration of exclusive, 252b
promotion of, 251–252
teaching points, 265b
Breast milk, 264, 264b
Buddhism, food habits, 225–226
Bulimia nervosa (BN), 379, 380t, 382–383, 384b
Burns, 398–399
enteral nutrition, 399
nutrient, 399–400
nutrition after discharge, 400
oral nutrition, 399
C
Caffeine, use during pregnancy, 242, 243t
Calcium, 136, 147, 514
older adults, 294
Calcium and vitamin D, during pregnancy, 241
Calorie-reduced eating plan, 363–366
Calories, 395–396, 397b, 399b, 401, 514, 537, 538b, 544
adolescents, 277
in breastfeeding, 253
consuming appropriate, 164–165
counting, 154–155
definition, 153
early childhoods (1–5 years), 272–273, 273t, 274t
eating patterns and, 238
estimated needs per day, 159–160t
estimating, 155–156, 157b, 159–160
in food choices, 23f
food lists, 156t
health eating patterns, 21t
healthier alternatives, 166b
middle childhood, 277
older adults, 292, 292f
in PN solutions, 349
pregnancy and, 236–238, 239f
sources of intake, 155f
Campylobacter, 195
Canada’s food guide, 31f
Cancer, 529, 546–547
case study, 548
learning objectives, 529
metabolism, 532
nursing process, 546–547
nutrition
advanced cancer, 541
for cancer survivors, 541
in prevention, 530–531, 530f
nutrition complications, 532
cancer cachexia, 533–534
inadequate intake, 533
interactions and outcomes, 533
metabolism, 532
muscle protein depletion, 533
systemic inflammation syndrome, 533
tumor effects, 532, 532t
nutrition complications to treatments, 534
biotherapy, 535–536
chemotherapy, 534
hemopoietic cell transplantation, 536
radiation, 535, 536t
surgery, 534, 535t
nutrition therapy, 536
calories, 537
ESPEN guidelines, 541
nutrition support, 540
oral intake, 537, 538–539b, 540
protein, 537
risk factor, 530b, 531t
study questions, 549
summary, 550–551
Cancer cachexia, 533–534
Cannabidiol, 184–185
Carbohydrate-containing compounds, using glucose to make, 46
Carbohydrates (CHO), 466b
Acceptable Macronutrient Distribution Range, 47f
case study for, 56–57
classifications, 36–40, 37f
complex, 36, 37f
simple sugars, 36–38, 37f
counting, 467–471, 468b, 469b, 469f, 470b
Dietary Reference Intakes, 46–47
digestion and absorption, 42–43, 43f
functions of, 45–46
glycemic response, 44–45
health promotion, 47–56
metabolism, 43–45, 533
sources of, 40, 41–42t, 468b
study questions, 57
summary, 58
whole grains, 47–49, 48b
Cardiovascular disease (CVD), 497. See also specific disease or disorder
case study, 500
healthy eating pattern, 497
heart failure, 498
nutrition and, 11t
summary, 502
Cardiovascular health, 487
American adults, 487–488, 487t
case study, 500
heart-healthy eating patterns, 488, 489–490t, 489b
dietary approaches, 489, 491
Mediterranean-Style Eating Pattern, 491–492, 491f
nutrition for, 492
hypercholesterolemia, 493, 495–496
hypertension, 493, 494–495b
metabolic syndrome, 496, 497t
overweight and obesity, 492
summary, 502
Cariogenic bacteria, 143
Carotenoids, 103
Catabolism
fat, 88–89
protein, 64
Causes of death, 10b
CDC. See Centers for Disease Control and Prevention (CDC)
Celiac disease, 437–440b, 440
Centers for Disease Control and Prevention (CDC)
foodborne illness, 195–197
Central obesity, 161, 361
Central parenteral nutrition, 349
Chelated minerals, 148
Chemical substances, vitamins, 100
Chemotherapy, 534
Children and adolescents
calorie needs, 276–277
case study, 286
diet quality, 278
healthy snacks, 278b
nursing process for well child, 279–280
nutrient needs, 277
nutrients, 279b
nutrition, 276–280
overweight and obesity, 281–285
physical activity guidelines for, 277b
promoting healthy habits, 277–278
study questions, 286–287
summary, 287–288
Chinese American tradition, 489b
Chloride, 136
Chlorine, 148
Cholecystitis, 451
Cholelithiasis, 451
Cholesterol, 86–87. See also specific type
Choline, 113
Choose Your Foods: Food Lists for Diabetes, 471
Christianity, food habits, 223–224
Chromium, 144
Chronic disease, 10–11, 543b
modifiable risk factors, 12b
Chronic disease–related malnutrition, 315f
Chronic Disease Risk Reduction (CDRR) intake, 3, 5
Chronic kidney disease (CKD), 505, 508, 521–522
complications of, 509b
dietary adherence to, 517b
disease progression, 508–509
eating tips for, 511b
food choice, 516b
nutrition therapy, 510, 510t
dietary concerns, 514–515
during dialysis, 517
mediterranean style, 512, 512b
phosphorus, 513
potassium, 514
protein, 513
sodium, 513
renal meal plan, 515–516
risk factors, 508
transplantation, 518, 519t
Chronic pancreatitis (CP), 450–451
Chylomicrons, 88
Cirrhosis, 447, 448–450
Cis fats, 87
Clostridium perfringens, 196t
Coconut oil, 95
Coenzymes, 100–101
Colorectal cancer, nutrition and, 11t
Colostomy, 446
Commensal microbiome, 450
Commercial weight-loss diets, 368
Comorbidities, 544–545
Complementary proteins, 67b
Complex carbohydrates, 38–40
fiber, 38–40, 39b, 39t
glycogen, 38
polysaccharides, 38
starch, 38
Comprehensive lifestyle programs, 367–368
Consistency modification, 411
Constipation, 427, 428–429b, 429, 539b
Consumer issues
case study, 205
information and misinformation, 189–190
regarding health, 199–200
summary, 206
Continuous drip method, enteral nutrition, 342
Convenience foods, 209
Copper, 143
Core foods, 213
Crohn’s disease (CD), 434
ulcerative colitis versus, 434t
Cultural considerations, 489b
Culture. See also Religion; specific culture
case study, 226
cross-cultural nutrition counseling, 217b
determines what is edible, 212
dietary acculturation, 216–217, 216b
food and, 219b
health statistics by cultural group, 218t
how food is prepared, 214
subgroups, 212
traditional diets, 218–222
summary, 227–228
symbolic use of food, 214
values, 214, 215t
when and how food is eaten, 214
Cyclical PN infusions, 351
Cyclic feedings, enteral nutrition, 342
Cytokines, 392–393
D
Daily Values (DVs), 175
Databases, nutrition, 13
Denatured proteins, 62b
Dextrose monohydrate, in PN solutions, 350
Diabetes mellitus, 461–462
acute, 475, 476b
case study, 481
children and adolescents, 477–478
diagnostic criteria for, 462t
food choice, 516b
gestational, 247–248
in hospital, 476–477
insulin and effects, 462t
in later life, 478
long-term, 463–464
medications, 473–474
nutrition for, 11t
prediabetes, 463, 464b
sick-day management, 476–477
summary, 482–484
type 1 (See Type 1 diabetes)
type 2, 15, 462–463
Diabetes self-management education and support (DSMES), 464
Diabetic ketoacidosis (DKA), 475
Dialysate, 517
Dialysis, nutrition therapy during, 517
Diarrhea, 429–430, 430b, 539b
Diets, 364–366, 365t. See also specific type
carbohydrate, 469b
gluten-free, 439–440b
high-fiber, 428–429b
hypertension, 507
low-fat, 452–453b
low-fermentable Oligo-, Di-, and Monosaccharides, and Polyols, 444–445b
low-fiber, 436b
low-lactose, 433b
neutropenic, 536
postsurgical diet progression, 375b
Dietary acculturation, 216–217, 216b
Dietary approaches, 489, 491
to hypertension diet, 507
Dietary Approaches to Stop Hypertension (DASH) diet, 7, 233, 364, 488–490t, 491, 507, 518, 520
Dietary fiber, 40
Dietary Guidelines for Americans 2020–2025 (DGA)
added sugars, 50
carbohydrates, 47
diet quality, 7–8
dietary patterns, 6–7
fats, 92
healthy beverages, 144
for healthy eating, 19, 19–20b
older adults, 295–297
protein, 71
sodium, 145
summary of objectives, 9–10b
vegetarian, 72
vitamins, 114
Dietary patterns, 6–7
Dietary Reference Intakes (DRIs), 3–6
fiber, 47
during pregnancy, 239–240
from protein, 71–74
representation of, 3f
total carbohydrate, 46
Dietary supplements, 180–185, 181f
case study, 186
good manufacturing practices, 182
older adults, 181b
popularity, 181–182
precautions for users, 184b
regulations, 182
new dietary ingredient, 183
summary, 187
Diet quality, U.S., 8, 164–165, 219–220
during middle childhood and adolescence, 278
Digestion
carbohydrates, 42–43, 43f
fat, 87–88, 88f
proteins, 63, 63f
Disaccharides, 37–38
Disease-specific formulas, enteral feeding, 339, 339t
Disorders. See specific disorders
Diverticular disease (DD), 443, 445–446
Diverticulitis, 443
Diverticulosis, 428b
Dumping syndrome, 371, 419
nutrition Therapy for, 420, 420b
Dysbiosis, 514
Dysphagia, 410, 410f
esophageal, 411
fluid intake, 414
nutrition therapy for, 411–412, 412f, 413t, 414f, 415f
oropharyngeal, 410
promoting intake, 412–413, 416b, 416f
signs and symptoms, 411
texture and consistency modification, 411
E
Early childhoods (1–5 years)
body mass index, 269
calories and nutrients, 272–273, 273t
feeding guidelines, 273–276, 274t
fluid, 274–275
food, 275
nutrition for, 269–276
promoting healthy habits, 276
Eating. See also Healthy Eating Guidelines
Eating behaviors, 383b
short bowel syndrome, 442b
Eating disorders, 379, 379b, 381
anorexia, 408–409
anorexia nervosa, 379, 380t, 381–382, 383b
binge eating, 383–384, 385b
bulimia nervosa, 379, 380t, 382–383, 384b
EDNOS, 385
nausea and vomiting, 409
Eating disorders not otherwise specified (EDNOS), 385
Eating goals, 384b
Eating patterns, 467, 506–507
calories and, 238
Dietary Approaches to Stop Hypertension (DASH) diet, 233
older adults, 301, 301b
in pregnancy, 232–233, 236–238
of pregnant and lactating women, 239
U.S.-Style, 274t
Edema, 62b
Edible, 212
Electrolyte balance, fluid and, 129–130
Electrolytes attract water, 130
Electronically delivered weight-loss programs, 368
Emulsifiers, definition, 86
End jejunostomy, 441b
End-stage renal disease (ESRD), 509
Energy balance, 154f
case study, 170
in health promotion, 164–169
intake, 154–156
negative, 154f
positive, 153f
summary, 171
Energy expenditure, 157–158, 157b
physical activity, 157–158
thermic food effect, 158
Enrich, definition, 101
Enriched flour, 49
Enteral nutrition (EN), 335–347, 399, 400–401, 435
aspiration, 345
barriers to, 344b
bolus feedings, 342
case study, 353
continuous drip method, 342
cyclic feedings, 342
delivery methods, 341–343
estimating nutritional needs, 336–337, 337b
feeding route, 340–341, 341t
formula characteristics, 340, 340b
formula selection, 337–339
initiating and advancing the feeding, 342–343
summary, 354–355
transition to an oral diet, 346
tube-feeding intolerance, 344–345, 345b
water flushes, 344
Enzymes, 100
Escherichia coli, 195f
Esophageal dysphagia, 411
Esophagus disorders. See Dysphagia; Gastroesophageal reflux disease (GERD)
Essential fatty acids, definition, 84
Essential nutrient, 104
Estimated Average Requirement (EAR), 5
Estimated Energy Requirements (EERs), 6
Estimated glomerular filtration rate (eGFR), 508
Ethnic restaurants, best choices, 211–212b
Exercise, 474
Extraintestinal presentation, 438b
F
Facts Up Front, food labeling, 180, 180f
Fair Packaging and Labeling Act, 174
Fast-food restaurants, best choices, 211–212b
Fatigue, 538–539b
Fat anabolism, 89
Fat catabolism, 88–89
Fat metabolism, 533
Fats, 466b, 515
absorption, 88
body’s handling of, 87–89
case study, 96
cis (See Cis fats)
dietary reference intakes, 91–92, 91b, 91f
digestion, 87–88, 88f
functions in the body, 87
healthy eating patterns, 92–95
saturated (See Saturated fats)
sources of, 89, 90t
study questions, 96
summary, 97–98
trans (See Trans fats)
using glucose to make, 46
Fat-soluble vitamins, 101–108
Fatty acids
chain length, 82
configurations, 82f
definition, 82
essential, 84
monounsaturated, 84
polyunsaturated, 84
profile, 86f
saturated, 84
trans, 85
types of, their functions, sources and impact on health, 83t
unsaturated, 84
Fatty liver disease, 447–448
FDA. See U.S. Food and Drug Administration
Feeding guidelines, early childhoods (1–5 years), 273–276, 274t
Fermentable Oligo-, Di-, and Monosaccharides, and Polyols (FODMAP), 443
Fetal alcohol syndrome, 242
Fiber, 38–40, 39b, 39t, 466b, 514–515
adequate intake (AI), 47
classifications
insoluble, 40
soluble, 40
content in fiber-rich foods, 39t
Dietary Reference Intakes, 47
older adults, 293
potential health benefits of, 39b
“15–15 Rule,” 476b
Fish oils, 84
Fixed acid, 509
Flaxseed, 95
Fluid
early childhoods (1–5 years), 274–275
and electrolyte balance, 129–130
imbalances, treatment of, 129t
requirements, 128, 128b
Fluid intake
excessive, 128
inadequate, 128
Fluids, infant, 268
Fluoride, 143–144
Folate, 111–112, 114, 233
Folic acid, 233, 240
Food, 6–8
access, 203–204
antibiotics in, 201–202, 201f
choking hazards in infants, 269b
convenience, 209
core, 213
cultural and religious influences, 208–230
deserts, 203–204
early childhoods (1–5 years), 275
fats, 85
FDA-allowed claims, 177–179
functional, 191–192, 191t
infants, 268, 269b
insecurity, 203
lists for diabetes, 471–472
nutrient-dense, 22
nutrient needs through, 22–23
organic, 192
peripheral, 213
processing on Sodium, 494b
religion and, 223–226, 223t
role of, in health and disease, 214–215
safety, 546
secondary, 213
selection and decision making, 213f
soul, 219
variety of, 24
vehicles of transmission, 195–197
Food allergies, infants, 269
Food and culture
African American, 219b
Chinese American, 222b
Mexican American, 221b
Food and drug interactions, 545, 545t
Food biotechnology, 198–200
benefits of, 198–199b
labeling regulations, 200
U.S. FDA regulates GE, 199
Foodborne illness, 195–197, 537b
food vehicles of transmission, 195–197
outbreak, 195
on 2017 outbreaks, 197b
pathogens, 195f
during pregnancy, 243–244, 244t
prevention of, 197
risk of, 197b
symptoms, 197
Food irradiation, 189, 202, 203b
Food label, 174–180
additional declarations, 176–177
allergens, 176
exemptions, 176
FDA-allowed claims, 177–179
front-of-package labeling, 180, 180f
gluten-free, 176
industry-originated, 180, 180f
ingredient list, 174–175
nutrition facts, 175–176, 175f
organic, 193
refreshed design, 176
serving sizes, 175–176
supplement labels with, 182
Foodway, 212
Formula
categories, 265
feeding, 266, 266b
teaching points, 266b
Fortify, definition, 103
Frailty, older adults, 302–303, 303f
Frazier Free Water Protocol, The, 414
Free radicals, 101
Free radicals, definition, 101
Fructose, 37
Functional fiber, 40
Functional foods, 189, 191–192, 191t
G
Galactose, 37
Gallbladder disease, 451–452, 452–453b
Gallstones. See Cholelithiasis
Gastrectomy, 419–420
Gastric residual volume, 343
Gastroesophageal reflux disease (GERD), 416–417, 417b
Gastrointestinal disorders
accessory organs, 447–454
gallbladder disease, 451–452, 452–453b
liver disease, 447–450
pancreatitis, 450–451
lower
altered bowel elimination, 427–430
case study, 455
celiac disease, 437–440b, 440
characteristics of, 431b
diarrhea, 429–430, 430b
inflammatory bowel disease, 434–435, 434t, 436b
lactose, 431–433, 433b
large intestine, 443, 445–446, 444–445b
malabsorption disorders, 431–433
nutrition therapy for, 432t
nutrition-focused assessment, 427b
short bowel syndrome, 441–442, 441b, 442b
summary, 456–458
upper
case study, 422
dysphagia, 410, 410f
gastroesophageal reflux disease, 416–417, 417b, 421–422
nutrition for clients, 407–425
role of, 408t
stomach disorders, 418–420
summary, 424
Gastroparesis, 418–419
Generally Recognized as Safe (GRAS), 85
Genetically modified organisms (GMOs). See Food biotechnology
Genetic engineering (GE)
environmental concern, 200
public concerns regarding health, 199–200
research on safety, 200
use of, 199
U.S. FDA regulates, 199
Genomics, 14
Gestational hypertension, 248
Gestational weight gain (GWG), 246–247
Globular proteins, 62b
Glomerular filtration rate (GFR), 506
Glucose (dextrose), 37
for energy, 45
to make fat, 45
using to make other compounds, 46
Gluten, 437
Gluten-free diet, 176, 439–440b
Glycemic index (GI), 44, 44t
Glycemic load (GL), 44, 44t
Glycemic response, carbohydrates and, 44–45
Glycerol, 82
Glycogen, 38
Goitrogens, 143
Grains
refined, 49
whole, 47–49, 48b
in bread, 50f
intake, tips for increasing, 50b
H
Halal, Islamic dietary laws, 225
Haram, Islamic dietary laws, 225
Health
future of, 13–14
role of food in, 214–215
WHO definition, 9
Health claims
in food labeling, 178–179
qualified, 178, 179b
unqualified, 178, 178b
Health statistics by cultural group, 218t
Healthy and detrimental eating patterns, dietary patterns, 6–7
Healthy beverages, 144
Healthy eating guidelines, 31f. See also Eating; MyPlate
case study, 32
dietary patterns, 6–7
guidelines and graphics in other countries, 29
recommendations from health agencies, 29
summary, 33–34
Healthy Eating Index-2015 (HEI-2015), 7
components of, 8t
Healthy eating pattern, 497
fats, 92–95
minerals, 147, 148t
Healthy Mediterranean-Style Eating Pattern, older adults, 296–297
Healthy People 2030, 9–10
summary of nutrition and weight status objectives, 9–10b
Americans improving their, 29
calorie levels for, 21t
Healthy Mediterranean-Style Eating Pattern, 20–21
Healthy Vegetarian Eating Pattern, 22
underlying concepts, 22–24
U.S.-Style, 20
Heart failure (HF)
nutrition therapy for, 498
Heart-healthy eating patterns, 488, 489–490t, 489b
dietary approaches, 489, 491
Mediterranean-Style Eating Pattern, 491–492, 491f
Helicobacter pylori, 418
Hemopoietic cell transplantation, 536
Hepatic encephalopathy, 448
Hepatitis, 448
Herbal supplements, 182–184, 182b
Cannabidiol, 184–185
regulations
safety and effectiveness, 183
self-prescription, 184
standardization, 183
warning labels, 183
High-fiber diet, 428–429b
High-Fructose Corn Syrup (HFCS), 52
High output stomas, 446
Hinduism, food habits, 225
Hispanic/Latino Americans, 220
diet quality, 220
nutrition-related health problems, 220
HIV/AIDS, 542, 542b
food and drug interactions, 545, 545t
food safety, 546
nutrition-related complications, 542, 543b
nutrition therapy, 543
calories, 544
comorbidities, 544–545
manage symptoms, 544
micronutrients, 544
protein, 544
HIV-associated wasting, 543b
Homocysteine, 110
Hormonal response, 392
Hospital patients
case study, 331
dietitian activities, 319b
feeding, 326–330
malnutrition, 314–318
modified consistency diets, 326–328, 327t
nursing analysis, 324
nursing assessment, 321–324
body mass index (BMI), 321
dietary intake, 323
laboratory data, 323–324
medical–psychosocial history, 321
physical findings, 323, 323b
psychosocial factors, 322b
weight loss, 322
nutrition approach, 316f
nutrition assessment, 318–319
nutrition care process, 318f
nutrition in nursing process, 321–325
nutrition interventions, 324–325, 325b
nutrition-related client outcomes, 324
nutrition-related monitoring, 325
nutrition screening, 317–318, 317f
protocol, 317
tools, 317
nutrition therapy, 318–319
oral diets, 326–328
oral nutrition supplements, 330t
regular diet, 326
summary, 332–333
therapeutic diets, 328–329t
Hydrogenation, 87
Hydrolyzed formulas, enteral feeding, 338–339, 339t
Hypercatabolism, 392
Hypercholesterolemia, 493, 495–496
Hyperinsulinemia, 463
Hyperlipidemia, 507
Hypermetabolism, 393
Hyperosmolar hyperglycemic state (HHS), 475
Hypertension, 493, 494–495b
diet, 507
gestational, 248
Hypoalbuminemia, 507
Hypoglycemia, 475, 476b
I
Ideal body weight, 160
Ideal cardiovascular health, 487
Ileostomy, 446
Impaired fasting glucose, 463
Impaired glucose tolerance, 463
Inadequate intake, 533
Indirect calorimetry (IC), 395
Industry-originated labeling, 180
front-of-package labeling, 180, 180f
Inedible, 212
Infants
average growth in the first year, 263b
choking hazards, 269b
complementary foods, 267–269
feeding guidelines, 268–269
feeding in their first year, 267t
feedings, 265–266
fluids, 268
food allergies, 269
introducing solids, 267–268
nutrient needs, 267
breast milk, 264
formula, 264–265
Inflammatory bowel disease (IBD), 434–435, 434t, 436b. See also Crohn disease; Ulcerative colitis
Inflammatory response, 392–393
Ingredient list, 174–175
Inorganic elements, 125
Insensible water losses, 126
Insoluble fibers, 40
Insulin resistance, 462
Insulin-to-carbohydrate ratio (ICR), 470
Intermittent feedings, enteral nutrition, 341–343
International Dysphagia Diet Standardization Initiative (IDDSI), 411–412
Interstitial compartments, 62b
Intestinal presentation, 438b
Intracellular compartments, 62b
Intractable vomiting, 409
Intravascular compartments, 62b
Iodine, 142–143
during pregnancy, 241
Iron, 139–142
older adults, 294
Iron deficiency anemia, 141
Irritable bowel syndrome (IBS), 443, 444–445b
Islam, food habits, 225
IU (International units), 105
J
Jejunocolic anastomosis, 441b
Jejunoileal anastomosis, 441b
Jewish tradition, 489b
Judaism, food habits, 224
K
Ketoacidosis, 462
Ketone body, 45
Ketosis, prevention of, 45
Kidney, 505. See also Chronic kidney disease (CKD); Nephrotic syndrome
case study, 523
functions, 506b
health, 506–507
summary, 525–526
transplantation, 518, 519t
Kidney stones, 520
Kosher, 223, 224b
Kwashiorkor, 69, 70t
L
Lactase nonpersistence (LNP), 431
Lactase persistence, 431
Lactation
fluid intake, 253
nutrition needs, 253–254
postpartum weight retention, 254
promotion of breastfeeding, 251–252
vitamins and minerals supplements, 253–254
Lactose, 37–38, 430
intolerance, 431
malabsorption, 431–433, 433b
Laparoscopic adjustable gastric banding (LAGB), 372–373, 373f
Large intestine
diverticular disease, 443, 445–446
ileostomies and colostomies, 446
irritable bowel syndrome, 443, 444–445b
Lean body mass, 533
Life’s Simple 7, 488
Lifestyle/behavioral therapy, 363, 363b
Lifestyle management, 464
behavior change, 472–473, 473f
diabetes medications, 473–474
diabetes self-management education and support, 464
meal-planning approach, 467, 468t
carbohydrate counting, 467–471, 468b, 469b, 469f, 470b
food lists for diabetes, 471–472
plate method, 471, 471f
portion sizes, 472
medical nutrition therapy, 464–465
eating patterns, 467
nutrients and dietary recommendations, 465, 466–467b
weight management, 465
physical activity, 474, 474b
Light or partial hydrogenation, 85
Linoleic acid (n-6), 84
Lipids
definition, 82
triglycerides, 82–86, 82f
Lipodystrophy, 543b
Listeria monocytogenes, 195, 196t, 244
Liver disease, 447
cirrhosis, 448–450
fatty liver disease, 447–448
hepatitis, 448
Long-term care, older adults, 301
Long-term diabetes, 463–464
Longer-duration programs, 368
Low birth weight (LBW) infant, 250
Low-density lipoprotein (LDL) cholesterol, 85
Lower gastrointestinal (GI) tract, 426, 427f
diarrhea, 429–430, 430b
gallbladder disease, 451–452, 452b–453b
large intestine
diverticular disease, 443, 445–446
ileostomies and colostomies, 446
irritable bowel syndrome, 443, 444–445b
liver disease, 447
cirrhosis, 448–450
fatty liver disease, 447–448
hepatitis, 448
malabsorption, 431
lactose, 431–433, 433b
pancreatitis, 450
acute, 450
chronic, 450–451
Low-fat diet, 452–453b
Low–fermentable Oligo-, Di-, and Monosaccharides, and Polyols diet, 444–445b
Low-fiber diet, 436b
Low-lactose diet, 433b
Luo han guo, 55t
M
Macronutrients, 69
Magnesium, 138
Major electrolytes, 132–136, 133t
chloride, 136
potassium, 135–136
sodium, 133–135, 134b, 135f
Major minerals
calcium, 136
magnesium, 138
phosphorus, 137–138
sulfur, 138
summary of, 137t
Malabsorption, 431
lactose, 431–433, 433b
Malnutrition, 393
diagnosis of, 315–316
etiology-based definitions, 315f
interpretation of weight loss, 322t
older adults, 298–301, 299b
physical findings, 323b
screening tool, 317f
Maltose, 38
Manganese, 143
Marasmus, 69, 70t
Maternal health, 245–250, 245t
diabetes mellitus, 247–248
excessive gestational weight gain, 246–247
phenylketonuria, 249, 250b
pica, 247
Meal-planning approach, 383b, 384b, 467, 468t
carbohydrate counting, 467–471, 468b, 469b, 469f, 470b
food lists for diabetes, 471–472
plate method, 471, 471f
portion sizes, 472
Meal replacement approach, 366
Medical foods, 249
Medical nutrition therapy, 464–465
eating patterns, 467
nutrients and dietary recommendations, 465, 466–467b
weight management, 465
Medications
enteral feeding, 346
vitamins as, 101
Mediterranean-style diet, 364, 489–490t, 512, 512b
Mediterranean-Style Eating Pattern, 7, 490t, 491–492, 491f, 507, 518
Megadose, definition, 101
Mercury, toxicity during pregnancy, 242
Metabolic pool, 64
Metabolic stress
Metabolic syndrome (MetS), 359, 463, 496, 497t
Metabolic water, 127
Metabolism
carbohydrates, 43–45
protein, 64–65
Methionine, 110
Mexican American tradition, 489b
Micelles, 88
Microcephaly, 249
Micronutrients, 100, 397, 400, 544
and herbal supplements, 466b
supplements, 515
Milk anemia, 274
Minerals
balance, 131
case study, 149
classifications, 130
general functions, 130, 131t
healthy eating patterns, 147, 148t
interactions, 131–132
in lactation, 253–254
major (See Major minerals)
shortfall, 146–147, 146f
sources of, 132, 132t
summary, 150–151
supplements, 132
supplements, older adults, 294–295
toxicities, 131
trace (See Trace minerals)
Modified consistency diet, hospital patients, 326–328, 327t
Molybdenum, 144
Monoglyceride, 87
Monosaccharides, 37
Monounsaturated fatty acids (MUFA), 84
Muscle building, 74–77
Muscle protein depletion, 533
MyPlate
dairy, 28
food groups, 26t, 27t
fruit, 25
grains, 27
graphic, 275f
Kitchen, 28
protein foods, 27
Spanish, 29f
vegetables, 25
N
National Academy of Sciences, 199
National Weight Control Registry (NWCR), 368
Native American/Alaska Native traditions, 489b
Nausea, 409, 538b
Neotame, 55t
Nephrotic syndrome, 507–508
Neural tube defect, 233
Neutropenia, 536
Neutropenic diet, 536
New dietary ingredient, 183
Niacin, 110
Niacin equivalents (NEs), 110
Nitrogen balance, 65, 65b
Nitrogenous wastes, 506
Nonalcoholic fatty liver disease (NAFLD), 447
Nonalcoholic steatohepatitis (NASH), 447
Nonceliac gluten sensitivity (NCGS), 438, 438b, 440
Non-fermentable fiber, 40
Nonnutritive sweeteners, 467b
ADI, 54
use during pregnancy, 242
Nonnutritive sweeteners (NNS), 53, 54, 55–56t. See also Sweeteners
Nonsteroidal antiinflammatory drugs (NSAIDs), 418
Norovirus, 195f, 195t
Nursing
analysis, 324
assessment, 321–324
nutrition in, 321–325
Nursing process
cancer, 546–547
chronic kidney disease, 521–522
Crohn’s disease, 453–454
enteral nutrition support, 346–347
gastroesophageal reflux disease, 421–422
heart failure, 498–499
malnutrition, 320–321
metabolic stress, 401–402
obesity, 377–379
for pregnancy, 255–256
type 2 diabetes, 478–480
well child, 279–280
Nutrient, 2, 399–400
children and adolescents, 277
density, 7
and dietary recommendations, 465, 466–467b
kidney transplantation, 519t
needs of infants, 267
standards for age 1 year and older, 4t
Nutrient content claims, in food labeling, 177, 177b
Nutrient-dense foods and beverages, 22
Nutrigenomics, 13, 14
Nutrition, 393, 394, 510. Children and adolescents; Early childhoods (1–5 years); Infants
assessment, 318–319
calories, 395–396
care process, 318f
case study, 15
cross-cultural counseling, 217b
during recovery, 397, 398t
enteral (See Enteral nutrition)
facts, 11t
formula, 395
future of, 13–14
goals, 393–394
guidelines, 394b
interventions, 324–325, 325b
kidney health, 506–507
for lactation, 251–256
micronutrients, 397
needs during lactation, 253–254
needs of older adults, 292–295
in nursing process, 321–325
pregnancy and, 232–234
protein, 396
recommendations, 30t
recovery, 397, 398t
-related client outcomes, 324
-related monitoring, 325
research, 13b
screening, 299–301, 317–318
study questions, 15
summary, 16
support, 391, 393–398, 394b
therapy during dialysis, 517
therapy for active inflammatory bowel disease, 435, 436b
therapy for acute kidney injury, 519
therapy for acute pancreatitis, 450
therapy for anorexia nervosa, 381–382
therapy for bariatric surgery, 373–375, 374b, 376t, 377
therapy for bulimia nervosa, 382–383
therapy for celiac disease, 437–440b
therapy for chronic pancreatitis, 451
therapy for cirrhosis, 449
therapy for clients at nutritional risk, 318–319
therapy for constipation, 427, 428–429b, 429
therapy for diabetes, 466–467b
therapy for diarrhea, 429–430
therapy for dietary concerns, 514–515
therapy for diverticular disease, 445–446
therapy for dumping syndrome, 420
therapy for dysphagia, 411–412, 412f, 413t, 414f, 415f
therapy for frailty, 303
therapy for gallbladder, 451–453b
therapy for gastroesophageal reflux disease, 417, 417b
therapy for gastroparesis, 418–419
therapy for heart failure, 498
therapy for hepatitis, 448
therapy for ileostomies and colostomies, 446
therapy for irritable bowel syndrome, 443, 444–445b
therapy for kidney stones, 520
therapy for lactose malabsorption, 433, 433b
therapy for liver transplantation, 449–450
therapy for malabsorption, 432t
therapy for mediterranean style, 512
therapy for nephrotic syndrome, 508
therapy for nonalcoholic fatty liver disease, 448
therapy for peptic ulcer disease, 418
therapy for phosphorus, 513
therapy for potassium, 514
therapy for protein, 513
therapy for short bowel syndrome, 442b
therapy for sodium, 513
therapy for type 1 diabetes, 477
therapy remission of inflammatory bowel disease, 435
Nutrition facts, food labeling, 175–176, 175f
Nutrition screening for malnutrition, 299–301
Nutritional value, 192–193
O
Obesity, 358, 377–379, 492, 543b. See also Overweight; Weight loss
case study, 385
causative factors, 357t
lifestyle modification, 283b
overweight and, 281
parent’s role, 284–285
prevention strategies, 282–283, 283b
risks, 281
screening, 282
treatment strategies, 283–284, 284b
classification, 358t
complications, 359–361, 360b, 361t
definition, 357
management of, 361–362
measures of, 357–358
modifiable risk factor for chronic disease, 12b
overweight and, 11t
prevalence, 358–359, 360f
readiness to lose weight, 361
summary, 387–388
treatment goals, 362
trends in, 359f
U.S. Food and Drug Administration, 369t
Oils, strategies for increase, 94b
Older adults. See also Aging
aging changes, 290–291, 291t, 295–298
case study, 307
community-dwelling, additional considerations, 300–301
dietary supplements, 181b
healthy eating, 295–298
Healthy Mediterranean-Style Eating Pattern, 296–297
interventions to improve intake and weight, 300
long-term care residents, additional considerations, 301
MIND diet, 297
nutritional needs, 290–311
calcium, 294
calories, 292, 292f
fiber, 293
iron, 294
protein, 292–293
vitamin, 294
vitamin and mineral supplements, 294–295
vitamin B12, 294
nutrition-related concerns, 298–304
Alzheimer disease, 303–304
frailty, 302–303, 303f
malnutrition, 298–301, 299b
obesity, 302
risk factors, 299b
sarcopenia, 302
nutrition screening, 299–301
liberal eating patterns, 301, 301b
physical activity, 167b, 298, 298b
sarcopenia, 293
summary, 308–309
Omega-3 (n-3) fatty acids
definition, 84
Omega-6 fatty acids (n-6), definition, 84
Oral diets
hospital patients, 326–328
transition from EN, 346
Oral intake, 537, 538–539b, 540
Oral nutrition, 399
Oral nutrition supplements, hospital patients, 328–330, 330t
Organically grown food, 192
impact on health, 193
nutritional value, 192–193
Organic food, 192
Organic products, USDA criteria for labeling, 194t
Oropharyngeal dysphagia, 410
Osmotic diarrhea, 430b
Osteomalacia, 106
Ostomy routes, 341
Overweight, 358, 492, 543b. See also Obesity; Weight loss
classification, 358t
complications, 360, 360b
management of, 361–362
trends in, 359f
Oxalate, 520
Oxidation, 100
P
Pancreatitis, 450
acute, 450
chronic, 450–451
Pantothenic acid, 113
Parenteral nutrition (PN), 348–352
access sites, 348–349
disadvantages and contraindications of, 348
indications for, 348
initiation and administration, 351
nursing management, 351b
potential metabolic complications, 348b
refeeding syndrome, 352
solutions, 349–351
transitioning from, 352
Pathobiome, 450
Pediatrics. See Children and adolescents; Early childhoods (1–5 years)
Peptic ulcer disease (PUD), 418
Percent daily value (%DV), 175
Percentage of weight loss, 322
Peripheral foods, 213
Peripheral parenteral nutrition (PPN), 348–349
Pesticides, 193, 194t
Phenylketonuria (PKU), 245, 249, 250b
Phospholipids, definition, 86
Phosphorus, 137–138, 513
Phylloquinone, 107
Physical activity (PA), 157–158, 165–167, 366, 474, 474b
guidelines for children and adolescents, 277b
health benefits, 167b
older adults, 167b, 298, 298b
during pregnancy, 244–245, 245b
recommendations, 30t
tips for increasing, 168b
Physical inactivity, modifiable risk factor for chronic disease, 12b
Phytonutrients, 2, 48, 116–117, 117b
Pica, 247
Plate method, 471, 471f
Polydipsia, 462
Polyols, 53–54, 53t
Polyphagia, 462
Polysaccharides, 38
Polyunsaturated fatty acids (PUFA), 84
Polyuria, 462
Portion control, 23–24
distortion, 165t
portion size, 24, 165t
serving size, 24
strategies to, 164b
Portion size, 24, 472
Postsurgical diet progression, 375b
Potassium, 135–136, 146–147, 514
Potential form, 438b
Prebiotics, 429
Prediabetes, 463, 464b
PREDIMED, 492
Preeclampsia, 249
Preformed vitamin A, 104
Pregnancy
adolescent, 250–251
alcohol use, 242
caffeine and, 242, 243t
calcium and vitamin D, 241
case study, 257
common complaints, 245t
excessive weight gain, 246–247
folate, 233
folic acid, 233, 240
foodborne illness, 243–244, 244t
healthy eating patterns, 232–233
healthy weight, 232
hypertension and preeclampsia, 248–249
increased calorie needs, 236–238
iodine, 241
iron, 241
medical foods, 249
mercury, 242
neural tube defect, 233
nonnutritive sweeteners, 242
nutrition, 232–234
physical activity, 244–245, 245b
prenatal supplements, 241
seafood, 242
summary, 258–259
vitamins and minerals requirements, 239–241, 241f
weight gain in normal, 235b
weight gain in obese women, 235, 237f
Preoperative nutrition, 373–374
Probiotics, 429
Progression, 508–509
PROT-AGE Study group
protein, 68t
recommendations, 293
Protein, 396, 397b, 399b, 400, 401, 466b, 513, 537, 538b, 544
AMDR, 68–69
case study, 78
catabolism for energy, 64
complementary, 67b
composition, amino acids, 61, 61b, 61f
composition and structure, 60–62
deficiency, 69–70
denatured, 62b
digestibility, 63
digestion and absorption, 63, 63f
excess, 70–71
food group, 71
functions of, 62, 62b
intake of protein food, 71–72
lean animal and plant protein choices, 71b
metabolism, 64–65
for muscle building, 74–77
RDA, 67–68, 68t
seafood, 71–72, 73f
sources of, 65–67, 66t, 67b
study questions, 78
summary, 79
synthesis, 64
turnover, 64
used for energy, 68b
vegan eating patterns, 76t
Protein–energy malnutrition (PEM)
signs and symptoms of, 69–70
treatment, 70
Protein energy wasting (PEW), 509, 519
Protein metabolism, 533
Protein sparing, 45
Proteinuria, 507
Proton pump inhibitors (PPIs), 417
Provitamins, 100
Q
Qualified health claims, 178, 179b
R
Radiation, 535, 536t
Radura, food irradiation, 202f
Rancidity, risk of, 85
Recommended Dietary Allowances (RDAs), 4
carbohydrates, 46
fats, 91
health impairments and, 67
protein, 67–68, 68t
Refeeding syndrome, 382, 396b
in PN, 352
Refined grains, 47
Refractory Crohn’s disease, 438b
Religion. See also Culture
food and, 223–226, 223t
Renal meal plan, 515–516
Resting energy expenditure (REE), 157
Resting metabolic rate (RMR), 157
Riboflavin, 110
Rickets, 106
Roux-en Y Gastric Bypass (RYGB), 371, 372f
S
Saccharin, 55t
Salmonella, 195f, 195t
Salt. See Sodium
Sarcopenia, 293, 533
Saturated fats, 92, 488
top sources and average intake of, 93f
Saturated fatty acids, definition, 84
Seafood, 72
recommended fish choices based on mercury content, 73f
Secondary foods, 213
Secretory diarrhea, 430b
Selenium, 143
Sensible water losses, 126
Sepsis, 393
Serving sizes, 24, 175–176
estimation of recommended, 24b
Shiga-toxin-producing Escherichia coli (STEC), 195f, 196t
Short bowel syndrome (SBS), 431, 441–442, 441b, 442b
Sick-day management, 476–477
Simple sugars
disaccharides, 37–38
monosaccharides, 37
Sitting time, reducing, 168–169, 169f
Sleeve Gastrectomy (SG), 371, 372f
Smoking, modifiable risk factor for chronic disease, 12b
Sodium, 133–135, 134b, 135f, 466b, 513
additives, 134b
food sources, 135f
intake, 494–495b
lowering of intake, 145, 145b
Solid fats, strategies for reduction, 94b
Solubility, vitamin classifications based on, 101–114
Soluble fibers, 40
Sore mouth (stomatitis), 539b
Standard formulas, enteral feeding, 338, 338t
Standardization, dietary supplements, 183
Steatohepatitis, 447
Steatorrhea, 431
Stevia, 55t
Stomach disorders
gastrectomy, 419–420
gastroparesis, 418–419
peptic ulcer disease, 418
Stress response, 391–392
case study, 403
complications of, 393
hormones, 392
inflammation, 392–393
phases, 392b
study question, 403–404
summary, 404–405
Structure/function claims, in food labeling, 179, 179b
Subclinical form, 438b
Sucralose, 56t
Sucrose, 37
Sugar alternatives, 53–54
Sugars
added, 40
simple, 36–38, 37f
Sulfur, 138
Systemic inflammation syndrome (SIS), 533
T
Taste changes, 539b
Teratogen, 242
Texture modification, 411
Therapeutic diets, hospital patients, 328–329t
Thermic effect of food, 158
Thiamin, 109–110
Thirst, 518b
Tolerable upper intake level (UL), 5, 91b
Total fiber, 40
Toxoplasma gondii, 244
Trace minerals, 139–144
chromium, 144
copper, 143
fluoride, 143–144
iodine, 142–143
iron, 139–142
manganese, 143
molybdenum, 144
selenium, 143
summary, 140–141t
zinc, 142
Trans fat, 87, 488
Trans fatty acids, 85
Transnasal routes, 341
Transport molecules, 62b
Triglycerides, 82–86, 82f
definition, 82
Tube feeding. See also Enteral nutrition (EN)
medications during, 346
Tumor effects, 532, 532t
Type 1 diabetes, 462, 477
Type 2 diabetes, 462–463
in youth, 478
U
Ulcerative colitis, 434, 434t
Undernutrition, 543b
Unqualified health claims, 178, 178b
Unsaturated fat, 488
Unsaturated fatty acids, definition, 84
Upper gastrointestinal disorders. See also Eating disorders
dysphagia, 410, 410f
esophageal, 411
fluid intake, 414
nutrition therapy for, 411–412, 412f, 413t, 414f, 415f
oropharyngeal, 410
promoting intake, 412–413, 416b, 416f
signs and symptoms, 411
texture and consistency modification, 411
gastroesophageal reflux disease, 416–417, 417b, 421–422
role of, 408t
stomach disorders
gastrectomy, 419–420
gastroparesis, 418–419
peptic ulcer disease, 418
U.S. Department of Agriculture (USDA)
organic product labeling, 194t
National Household Food Acquisition and Purchase Survey, 204
pesticide contamination, 193, 194t
U.S. Department of Health and Human Services (USDHHS), Healthy People 2020, 9
U.S. Food and Drug Administration (FDA), 369t
claims allowed by, 177–179
good manufacturing practices, 182
health claims, 178–179
nutrient content claims, 177, 177b
Nutrition Facts, 175–176, 175f
pesticide contamination, 193, 194t
regulates genetically engineered food, 199
structure/function claims, 179, 179b
U.S. Pharmacopeia (USP), 120
U.S. Preventative Services Task Force, 118
U.S.-Style Eating Pattern, for toddlers ages 12 to 23 months, 274t
V
Vegan eating patterns, 76t
Vegetarian diets, 72–74
nutrients of concern, 74
protein content, 75b
tips for following, 75b
type of, 73b
vegan eating patterns, 76t
Very-low-calorie diets (VLCDs), 366
Viral load, 543
Viscosity, 411
Viscous fiber, 40
Vitamin B12, older adults, 294
Vitamins
A, 103–104
antioxidants, 101
B6, 110–111
B12, 112–113
C, 114
case study, 120
choline, 113
coenzymes, 100–101
D, 104–106
E, 106–107
essentiality of, 100
folate, 111–112
food additives, 101
K, 107–108
in lactation, 253–254
as medications, 101
multiple forms, 100
niacin, 110
pantothenic acid, 113
phytonutrients, 116–117, 117b
requirements in pregnancy, 239–241, 241f
riboflavin, 110
shortfall, 114–115, 115f, 116b
solubility classifications, 101–114
fat-soluble, 101–108
water-soluble, 102t, 108–109t, 108–113
summary, 121–123
supplements, 117–120, 119t
during lactation, 253–254
older adults, 294
thiamin, 109–110
understanding of, 100–101
chemicals, 100
susceptibility to destruction, 100
Vomiting, 409
W
Waist circumference, 161–163, 358
Waist-to-height ratio, 163
Water
adequate intake, 127
balance, 126, 126f
enteral formulas, 344
output, 126
Weight gain
in normal pregnancy, 235b, 236f
in obese women, 235, 237f
underweight pregnancy and, 238f
Weight loss
bariatric surgery, 370–371
candidates for, 371b
laparoscopic adjustable gastric banding, 372–373, 373f
nutrition for, 376t, 377
nutrition therapy for, 373–375, 374b
Roux-en Y Gastric Bypass, 371, 372f
Sleeve Gastrectomy, 371, 372f
success of, 375–376
behavioral interventions, 366, 367b
calorie-reduced eating plan, 363–366
comprehensive lifestyle programs, 367–368
devices, 370
diet for, 364–366, 365t
lifestyle/behavioral therapy, 363, 363b
maintenance, 368, 368b
medications, 369
physical activity, 366
supplements, 370b
Weight management, 465
Whole grains, 47–49, 48b, 48f
X
Xerostomia (dry mouth), 539b
Z
Zinc, 142

Nutrition Essentials For Nursing Practice 9th Edition - Susan Dudek

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Nutrition Essentials For Nursing Practice 9th Edition - Susan Dudek

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Nutrition Essentials

for Nursing Practice

SUSAN G. DUDEK, RD, CDN, BS

Copyright © 2022 Wolters Kluwer.

Library of Congress Cataloging-in-Publication Data

Names: Dudek, Susan G., author.

Claire Creamer, PhD, APRN-CPNP-PC

NEW TO THIS EDITION

ORGANIZATION OF THE TEXT

Lippincott® CoursePoint is an integrated, digital curriculum solution for

Resources for Instructors

Resources for Students

Susan G. Dudek, RD, CDN, BS

2 Guidelines for Healthy Eating

7 Water and Minerals

10 Consumer Interests and Concerns

11 Cultural and Religious Influences on Food and

13 Nutrition for Infants, Children, and Adolescents

14 Nutrition for Older Adults

UNIT Nutrition in Clinical Practice

15 Hospital Nutrition: Identifying Nutrition Risk and

16 Enteral and Parenteral Nutrition

17 Nutrition for Obesity and Eating Disorders

18 Nutrition for Clients with Critical Illness

20 Nutrition for Clients with Disorders of the Lower

21 Nutrition for Clients with Diabetes Mellitus

22 Nutrition for Clients with Cardiovascular Disorders

23 Nutrition for Clients with Kidney Disorders

24 Nutrition for Clients with Cancer or HIV/AIDS

Upon completion of this chapter, you will be able to:

Food is a complex mix of essential and nonessential components in various ratios

This chapter begins with nutrient recommendations. The relationship between

DIETARY REFERENCE INTAKES

Figure 1.1 ▲ Representation of Dietary Reference Intake along a continuum

Table Standards Applied to Each

In 2019, the National Academies of Sciences, Engineering, and Medicine Food

Recommended Dietary Allowances

• RDAs exceed the requirements of almost all members of the group;

Estimated Average Requirement

• AI is a recommended average daily intake level that is expected to meet or

Tolerable Upper Intake Level

• It is not intended to be a recommended level of intake: There is no benefit

Chronic Disease Risk Reduction Intake

Acceptable Macronutrient Distribution Ranges

Percentage Total Calories Consum

Estimated Energy Requirements

• Exceeding EERs may produce weight gain.

FROM NUTRIENTS TO FOOD

Focus on Total Diet

Overall Diet Quality

Diet Quality in the United States

Table Components of the

Standard for Minimum Standard for Maximum

Think of Tyrone His typical intake while traveling is: two

NUTRITION AND HEALTH

Healthy People 2030

Healthy People 2030 Summary of Core

Nutrition and Healthy Eating Objectives—General

Heart Disease and Stroke

Overweight and Obesity

Overweight and Obesity Objectives

Nutrition and Healthy Eatinga

Pregnancy and Childbirth

Overweight and Obesity topics.

BOX Ten Leading Causes of Death in the

• Today, 60% of American adults have one or more diet-related chronic

Table Facts about Nutrition-

• Children and adolescents also have chronic diseases, such as type 2

BOX Modifiable Risk Factors for Chronic Disease

Consider Tyrone. From what we know about Tyrone, what

Remember Tyrone. Tyrone considers himself more interested in

BOX Some Questions Driving Nutrition Research

• How do an individual’s genes determine how the body handles specific

• Technology will enable researchers to expand and update nutrition

• Mapping the sequence of the human genome allows researchers to

• individualized dietary advice and customized dietary guidelines based