Exam 1 LONG Study Guide
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Chapter 1
Nutrition: Science of food and its relationship to health
Health: State of complete well-being; Not merely absence of disease or infirmity
Anemia: Iron deficiency; Most prevalent nutritional deficiency
Disease Prevention
Primary prevention: Avert occurrence of disease
Secondary prevention: Monitoring techniques to discover diseases early
Tertiary prevention: Treatment after a disease has occurred
Nutrients
Classes:
Essential, Nonessential, Conditionally essential
Functions: Source of energy; Growth and maintenance of tissues; Regulation of body processes
Functional Foods
Physiologically active substances: Phytochemical, Animal, Microbial
Definition of functional foods
Categories of functional foods
Nutritional Genomics
Human genetic code: 23 pairs of chromosomes (Contain genes); Epigenetics
Nutrigenetics
Nutrigenomics
Body Composition
Physiologically active substances from plants are referred to as phytochemicals. Phytochemicals identified thus far number in the tens of thousands, including 8,000 polyphenols, which may stimulate the immune system, prevent cell damage, and reduce inflammation.
Health Promotion and Disease Prevention
Healthy People 2030: Nutrition and weight status; Physical activity
Dietary guidelines
MyPlate
Government surveys: What We Eat in America survey; State-specific trends
Unbalanced Nutrition
Malnutrition: Inadequate or unbalanced intake of food or nutrients; Caused by malfunction or disease
Food insecurity in the United States: Extent; Food costs and resources; Supplemental Nutrition Assistance Program (SNAP); Women, Infants, and Children (WIC) program; Pandemic impact
Nutritional Care
Nutritional status
Dietary status
Assessment: Nutritional; Anthropometric
Subjective data
Objective data: General appearance; Anthropometric data; Laboratory tests
Analysis/diagnosis: Physical standards (Body mass index (BMI); Waist circumference); Dietary intake (Analysis by food groups; Analysis of nutrients)
Planning/intervention: Motivational interviewing; Prioritization of problems; Use of Dietary Reference Intakes (DRIs)
Components of DRIs: Estimated average requirements (EARs); Recommended dietary allowances (RDAs); Adequate intakes (AIs); Acceptable macronutrient distribution range (AMDR); Tolerable upper intake levels (ULs)
Implementation: ChooseMyPlate; Healthy U.S. style food pattern
Evaluation and documentation: SOAP notes (Subjective data; Objective data; Analysis or diagnosis based
on S and O data; Plan of action or treatment)
Impact of Culture on Nutrition
Relation to longevity: Life expectancy; Mortality
Terminology: Ethnocentrism; Acculturation; Culturally competent care
Recommended dietary allowances (RDAs) refer to the intake that meets the needs of 97% to 98% of individuals in the defined group. RDA is intended for use as a goal for daily intake by individuals, not for assessing the adequacy of an individual’s nutrient intake.
Chapter 2
Carbohydrates
One of three energy nutrients (the others are fats and protein)
Provide 4 cal/g of energy
Manufactured by green plants in a process known as photosynthesis Photosynthesis: the process by which green plants and some other organisms use sunlight to synthesize foods from carbon dioxide and water. Photosynthesis in plants generally involves the green pigment chlorophyll and generates oxygen as a byproduct.
Two major groups: sugars and starches
All carbohydrates (CHO) are not equal in terms of health benefits from eating
*1 slice of bread = 15 grams of CHO*
Simple Carbohydrates
Made of just one or two sugar molecules
Two types: monosaccharides and disaccharides
Quickest source of energy, as they are rapidly digested
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Example: table sugar
Carbohydrate Composition
Includes monosaccharides and disaccharides
Mono = one; and di = two
C6H12O6 chemical formula
Note: the same ratio of hydrogen to oxygen as water (H2O)
Mono is one unit of C6H12O6 and di is two units of C6H12O6 minus one unit of H2O
Photosynthesis
Monosaccharides
Building blocks of all other CHO
Function: basic energy for cells 1. Glucose known as the blood sugar—the body converts all forms of sugar consumed to glucose 2. Fructose—found in honey; very sweet; the body converts to glucose after consumption
3. Galactose—comes mainly from the breakdown of milk
What is the range of normal fasting blood sugar per 100 milliliters of serum or plasma?
Normal fasting blood sugar (F B S) is 70 to 100 milligrams per 100 milliliters of serum or plasma.
Sugar Alcohols
Known by various names
Sugar replacers (Suplena®)
Polyols: A polyol is an alcohol containing multiple hydroxyl groups. In two different technological disciplines the term "polyol" has a special meaning: food science and polymer chemistry.
Nutritive sweeteners
Bulk sweeteners
The sugar alcohols commonly found in foods are sorbitol, mannitol, xylitol, isomaltose, and hydrogenated starch hydrolysates. Sugar alcohols come from plant products such as fruits and berries. The carbohydrate in these plant products is altered through a chemical process. Candies sweetened with
sorbitol cause diarrhea
Sugar alcohols don’t promote tooth decay, cooling effect on the tongue, slowly and incompletely absorbed from intestines into the blood, may have a laxative effect for some ppl if consumed in excess.
The amount of sugar that is in food product can be found on its label. The FDA has mandated that by 2020 manufacturers will have to use a new food label shown in Figure 2-2, which discloses the total amount of added sugar in a product. Sugar is present naturally in foods and added to foods., Sugar alcohol have various names such as sugar replacers, polyols, nutritive sweeteners, and bulk sweeteners. Lactitol, maltitol, isomaltose, sorbitol, xylitol, and mannitol are all sugar alcohols and currently are approved for use in the United States. Nonnutritive sweeteners are sugar substitutes that provide intense sweetness
Intense Sweeteners
Sugar substitutes such as artificial sweeteners
Saccharine
Do not add bulk or volume, only sweetness
150 to 500 times as sweet as sugar
Intense sweeteners are food additives that have a relative sweetness many times that of sugar which means they can be used in much smaller amounts. They are added to foods to replace the sweetness normally provided by sugars without contributing significantly to available energy. Sugar free soda for regular soda would be most effective substitution by trying to lose weight
Disaccharides
Function: energy, aids calcium and phosphorous absorption (lactose) 1. Sucrose = glucose + fructose (table sugar)
2. Lactose = glucose + galactose (milk sugar)
3. Maltose = glucose + glucose (produced mainly when other starches are broken down)—found in a few
sources naturally (malt); {sweeteners}
Complex Carbohydrates
Also called polysaccharides
Function: energy storage (starches), digestive aid (fiber)
1. Starch—major source of CHO in diet
2. Glycogen—“the animal starch”; animals, as well as humans, store; found in liver and muscle tissues
3. Dietary fiber
Chemically complex CHO are called Polysaccharides. Glycogen is crucial to the function of the human body. During intense physical activity, the body utilizes blood glucose for energy. Glycogen is built up and stored in muscle and the liver when blood glucose levels are high after infusion from the diet.
Example of complex CHO: Oatmeal, apples, lentils
Polysaccharides are complex CHO (starch, fiber, glycogen)
***Glycogen is the stored CHO energy source found in the liver and muscles. It is vital source of back up energy.
As complex CHO are ingested and broken down, they are easily absorbed in the intestine and into the bloodstream where they are stored in the liver and muscles for energy needs.
The body absorbs 80% to 95% of CHO. Absorption occurs mainly in the small intestine using pancreatic and intestinal enzymes.
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Dietary Fiber
Food and Nutrition Board recommends:
Men 50 years or younger: 38 grams per day
Women 50 years or younger: 25 grams per day
Men over 50: 30 grams per day
Women over 50: 21 grams per day
Average fiber intake in the United States only 15 grams per day (Adult: 21-38 grams)
Eating too much fiber not recommended
**Function: aid in eliminating intestinal waste**
Fiber is categorized as a carbohydrate, but it does not yield energy for the body, mostly from plants Fiber is important for proper bowel elimination. It adds bulk to the feces and stimulates peristalsis to ease elimination.
Studies show fiber helps to lower cholesterol and lessen the incidence of intestinal cancers.
Soluble Fiber
Dissolves in water
Oatmeal, oat bran, barley, apples, oranges, broccoli, and some dry beans Health benefits: may help lower cholesterol; may assist in lowering blood sugar levels; may promote satiety, and weight loss. Everyone needs both kinds of fiber in the diet
Dissolve in water and thicken to form gels.
Insoluble Fiber
Insoluble fiber does not dissolve in water
Wheat bran, corn bran, vegetables, nuts, fruit skins, and some dry beans contain soluble fiber
Health benefits: promotes regularity, may reduce risk of some forms of cancer, may reduce risk of diverticular disease
Examples of sources of insoluble fibers include the woody or structural parts of plants, such as fruit and vegetables skins, and outer coating (bran) of wheat kernels. Beans, rice and mixed green salad provide most fiber.
Review Question
Health benefits of insoluble fiber include all of the following except:
Promotes regularity
May assist in breakdown of starches
May reduce risk of some forms of cancer May reduce risk of diverticular disease
Carbohydrate Functions
Provides fuel/energy to the body
Spares body protein
Helps prevent ketosis
•Acetone
•Diabetic acidosis
Enhances learning and memory processes, provides fuel machine (CHO, fats, and proteins are human’s fuel); Spare body protein from being converted into glucose and allows protein to be used for growth and repair of body tissue; Help prevent ketosis If CHO is low, body will break down stored fat and internal protein to meet its fuel needs 50 grams of CHO/day enough to prevent ketosis; Enhance learning and memory processes Blood glucose concentration regulate neural and behavioral processes
Health and Carbohydrates
The kinds of CHO eaten are important to health
High intake of vegetables and fruits and low risk of chronic diseases
Regular consumption of whole grains has lower risk of certain cancers and heart disease
Sugary foods
Displace more nutritious foods
CHO provides energy for cellular work, and help to regulate protein and fat metabolism.
They are essential for normal cardiac and central nervous system (CNS) functioning. The body absorbs 80% to 95% of CHO. Absorption occurs mainly in the small intestine using pancreatic and intestinal enzymes.
Consumption Patterns Most of the world’s population subsists on CHO
Much research has shown that Americans and Canadians are eating too much of everything (except fiber), including CHO 2020–2025 Dietary Guidelines for Americans
Of particular concern is the excessive intake of sugar from sweetened carbonated beverages
Six servings of whole grains are recommended to increase fiber intake
Whole fruit and vegetable intakes are also lower than recommended levels
Carbohydrate Consumption and Dental Health
Genetic susceptibility
Other factors related to cavity formation: Length of time food is in the mouth; Food texture; Frequency of food intake; Acidity of food; Foods that help: aged cheeses and fibrous foods that stimulate saliva production; Interactions Necessary for Dental Cavity Formation
Several studies have shown relationship between CHO consumption and dental caries. Dental caries is the gradual decay of teeth. A dental cavity is the hole in a tooth caused by dental caries. Dental caries results from the interaction of 4 factors: a genetically susceptible tooth, bacteria, carbohydrate, and time. All 4 must occur simultaneously for a cavity to form. Fibrous foods include apples or celery. Sugars
eaten with a meal are less likely to cause decay than those eaten between meals.
Review Question
Factors related to cavity formation include all of the following except:
Food texture Frequency of food intake
Acidity of food
Fibrous foods
Main Ways to Maintain Oral Health
Reduce consumption and especially frequency of food and drink containing sugar
Consume sugar only as part of a meal
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Snacks and drinks should be sugar-free
Avoid frequent consumption of acidic drinks
Brush promptly after eating, chew gum sweetened with sugar alcohols, and choose fresh fruits for snacks
Carbohydrate Food Sources
Sugars (4 grams of CHO/teaspoon)
Honey, jam, jelly, sweetened carbonated beverages
Starches Cereals, grains, rice, pasta, potatoes, starchy vegetables, breads, beans
Sugars
Determining sugar consumption
Starches, Complex carbohydrates
Important sources of fiber and other nutrients: Whole grains, Oat products
Carbohydrates fall into two general groups: sugars and starches. All starches contain fiber; however, all starches do not provide equal amounts of fiber
Starches
Emphasis on whole grain
Make half of your grains whole
Enrichment
Starches: Complex carbohydrates; Important sources of fiber and other nutrients; Whole grains; Oat products
Exchanges Lists
To learn and teach others
Portion sizes
How much oatmeal would provide 15 grams of CHO? ¼ c of oatmeal would provide 15 grams of CHO. More than 3 grams of dietary fiber per serving. Food composition
How much fat is in orange juice? 1 cup of fruit juices count as 2 CHO.
How foods compare to each other within a given list: 1¼ cups strawberries = ⅓ cup grape juice
Exchange List Values
Starch/Bread Exchange List
Vegetable Exchange List
Fruit Exchange List
Milk Exchange List
Estimating the Fiber Content of Foods
Appendix B
Exchange List Values (Starch/Bread Exchange List)
One ADA exchange of starch contains approximately 15 grams of CHO
General rule: ½ cup of cereal, grain, or pasta or 1 oz of a bread product is = to one starch exchange
Exchange List Values (Vegetable Exchange List)
Raw and cooked vegetables are good sources of CHO
Vegetables contain between 2 and 3 grams of fiber per serving
One vegetable exchange contains approximately 5 grams of CHO
½ cup of cooked vegetable or one cup of raw vegetables equals one vegetable exchange
Vegetables adds vitamins and minerals to the diet
Exchange List Values (Fruit Exchange List)
Fruits are another source of CHO
One ADA exchange of fruit contains approximately 15 grams of CHO
Many fruits are excellent sources of fiber and contain vitamins and minerals
Example: ½ cup applesauce, unsweetened, ½ small banana,3/4 cup blueberries, ½ cup unsweetened 100% juice (orange, grapefruit, pineapple) The RDA for CHO is 130 grams of CHO a day more for pregnant and lactating women.
Strong evidence exists that a minimum of 130 grams of CHO per day is necessary for adequate brain and
body function.
When there is no or little CHO in the diet and the body uses protein or fat as a fuel source, the body in effect of cannibalizes itself for glucose. Muscle and organ mass is lost in the process.
Dietary Recommendations Food and Nutrition Board of the National Academy of Sciences
•Adults‒45% to 65% of calories from carbohydrates
Recommended dietary allowance
•Children and adults younger than 70 years‒130 grams per day
Focus on fruits (whole fruits are better than juices)— Eat 2 cups of fresh fruit per day
Vary your vegetables—Eat 2½ cups per day
Make half of your grains whole: whole-grain cereals, whole-grain breads, corn, whole-grain rice, and whole-grain pasta
Milk contains CHO—Eat or drink three servings a day from this group
FYI: Consume correct amount of CHO at every meal and snack!!!
http://www.health.gov/dietaryguidelines/Default.asp
Review Question
Dietary recommendations suggest making half of daily grain intake from:
Whole grains
Soluble fiber
Insoluble fiber
Unsaturated fats
Review Question To meet the body’s daily energy and nutritional needs, adults should get what percentage of their calories from carbohydrates?
A.5% to 15%
B.25% to 30%
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C.35% to 40%
D.45% to 65%
Following the Guidelines
Eat breakfast or take a couple of pieces of fruit to eat early in the day
Have whole-grain cereal and milk for breakfast with fruit
Snack on fresh fruits and vegetables
Mix vegetables with pasta Eat whole-grain breads
Vary fruit and vegetable intake
Have both a salad and cooked vegetable at most meals
Keystone: Carbohydrates are composed of sugars and starches.
The average American’s intake of sugars is considered excessive, whereas the intake of starches is considered low.
Many Americans would benefit from increasing their fiber intake through the consumption of more whole-grain starches, fruits, and vegetables.
Dietary carbohydrates promote tooth decay in susceptible individuals.
Strong evidence exists that a minimum of 130 grams of carbohydrates per day is necessary for adequate brain and body function.
When there is no or little carbohydrate in the diet and the body uses protein or fat as a fuel source, the body in effect cannibalizes itself for glucose. Muscle and organ mass is lost in the process.
The RDA for carbohydrates is 130 grams of carbohydrates a day. Pregnant and lactating women have a higher RDA for carbohydrates.
Chapter 3
The chemical group of fats is called lipids. Know your fats. Look for foods low in saturated and trans fats, and cholesterol, to help reduce the risk of
heart disease. Most of the fats you eat should be polyunsaturated and monounsaturated fats, such as those in fish, nuts, and vegetable oils. Three Functions of Fat in the Body. Fat is a backup source of energy to fuel your workout when carbohydrates are not available. Fat is an essential part of your diet. It provides energy, absorbs certain nutrients and maintains your core body temperature.
Primary function of fat is to provide energy. Within each food group, foods lowest in fat should be chosen often.
Elements. This diet is "rich in red meat, dairy products, processed and artificially sweetened foods, and salt, with minimal intake of fruits, vegetables, fish, legumes, and whole grains." The typical American diet is about 50% carbohydrate, 15% protein, and 35% fat. Fats contain more than twice the kilocalories of carbohydrates.
Fats (LIPIDS)
Comprise elements carbon, hydrogen, and oxygen The basic structural unit is one molecule of glycerol attached to one to three fatty acids
Provide 9 cal/g of energy Very-low-density lipoprotein (VLDL) carry triglycerides to the tissues
Low-density lipoprotein (LDL) carry cholesterol to the tissues (“bad/lazy cholesterol)
High-density lipoprotein (HDL) remove excess cholesterol from the tissues (“good/healthy cholesterol)
Chemical group of fats is called lipids, and they are available from many sources (dark meat, poultry skin, dairy foods, and added oils (margarine, butter, shortening, oils, and lards)
No more than 20% to 35% of total calories should come fat (10% or less from saturated fat sources)
Composition of Fats
Monoglycerides and diglycerides—one and two fatty acids attached to glycerol
Length of fatty acid chains
Long-, medium-, and short-chain fatty acids
Degree of saturation—fatty acids have different degrees of saturation
When a single fatty acid is joined to a glycerol molecule, the resulting fat is called a monoglyceride. When two fatty acids are joined to a glycerol molecule, the fat is called a diglyceride. The terms monoglycerides and diglycerides are commonly seen on food labels.
Glycerol is a backbone of fat molecule
Categories of fats Triglycerides Phospholipids
Cholesterol (Sterols)
Saturated fat: composed mostly of saturated fatty acids
Unsaturated fat: composed mostly of unsaturated fatty acids
Polyunsaturated fat (PUFA)
Trans-fatty acids: composed of partially hyrogenated fatty acids. Ex. Milk, meat. Increase LDL and trygs, and lower HDL.
Monosaturated fat: composed mostly of monounsaturated fatty acids
Polyunsaturated fat (PUFA): composed mostly of polyunsaturated fatty acids. Fat in corn, soybean, safflower, cottonseeds oils and in fish. Hydrogenation: process of adding hydrogen atoms to unsaturated vegetable oil, ex corn, soybean, and cottonseed
A balance intake of carbohydrate and fat is essential for optimal health. Excess fats in our diets are associated with cardiovascular disease, obesity, diabetes, and some types of cancer. Triglycerides Chemical name for fats
Primary form of fat in food
Combine with glycerol to supply energy to the body, allow fat-soluble vitamin transport, and forms adipose tissue that protects the body When three fatty acids are joined to a glycerol molecule, a triglyceride is formed. Most of the fat found in our diets and in the body is in the form of triglycerides. Excess triglycerides are stored in the specialized adipose cells that make up adipose tissue. An ester formed from glycerol and three fatty acid
groups. Triglycerides are the main constituents of natural fats and oils, and high concentrations in the blood indicate an elevated risk of stroke. The human body has a virtually unlimited capacity to store fat.
Phospholipids
Derived from triglycerides
Important to cell membrane structure
a lipid containing a phosphate group in its molecule, e.g., lecithin.
Cholesterol
Belongs to the chemical substance group called sterols
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Necessary for cell membrane stability and production of certain hormones and bile salts for digestion Found in brain and nerve tissue and blood
Precursor for production of steroid hormones Consume as little as possible and still consume a balanced diet
Food sources
•2020–2025 Dietary Guidelines for Americans
Not a true fat but belongs to a group called sterols
Component of many of the foods in our diet
Cholesterol is present only in animal foods. When animal products are ingested, one also ingests the cholesterol the animal made. The 2020–2025 Dietary Guidelines for Americans recommends a healthy eating pattern that limits the amount of saturated fat to fewer than 10% of total calories and therefore a
decreased level of cholesterol. Human body manufactures about 1000mg of cholesterol a day, mainly in the liver
The liver also filters out excess cholesterol and helps to eliminate it from the body If cholesterol is consumed in excess, it can build up in the tissues causing congestion and increasing the risk for cardiovascular disease
Cholesterol is fat substance that is present in animal food sources and produced by the human body. Many Americans would benefit from decreasing their intake of cholesterol, trans-fatty acids, and saturated fat. Functions of Cholesterol
Important functions of cholesterol
1. A component of bile salts that aid digestion
2. An essential component of all cell membrane
3. Found in brain and nerve tissue and in the blood
Cholesterol is necessary for the production of several hormones including: cortisone, adrenaline, estrogen, and testosterone
Saturated Fats
Solid at room temperature Animal or tropical oil origin
Become rancid slowly
Products made with this fat have a longer shelf life Raise “bad” cholesterol levels more than any other fat
All of the carbons are attached to hydrogen
Saturated fat are fat in meat, whole milk, egg yolk
Saturated fat: A fat that contains only saturated fatty acids, is solid at room temperature, and comes chiefly from animal food products. Some examples of saturated fat are butter, lard, meat fat, solid shortening, palm oil, and coconut oil. Saturated fat tends to raise the level of cholesterol in the blood.
Unsaturated Fats
Liquid at room temperature
Plant origins
Become rancid quickly
Have a double carbon bond (one or more hydrogens could add to the fatty acid chain)
A double bond on a fatty acid causes the chain to bend or change shape
Has a health benefit (Olive oil considered good fat)
Example: olive oil, canola oil, peanut oil, avocado, cashews, and almonds.
Unsaturated fats are fats or fatty acids that are liquid a room temperature. Unsaturated fats are derived from plants and some animals. They contain at least one double bond in their fatty acid chain. Conversely, a saturated fat has no double bonds meaning it is saturated with hydrogen atoms.
Trans Fatty Acids
Made from unsaturated fats by commercially adding hydrogen at double-bond sites
Causes an unnatural bend in the fatty acid chain
Has a health detriment
Food and Drug Administration (FDA) ban
Example: commercial baked goods and stick margarine
an unsaturated fatty acid of a type occurring in margarines and manufactured cooking oils as a result of the hydrogenation process, having a trans arrangement of the carbon atoms adjacent to its double bonds. Consumption of such acids is thought to increase the risk of atherosclerosis.
Essential Fatty Acids
Made from broken down fats, must be supplied by the diet
Example: omega-3 and omega-6 – used to support blood clotting, blood pressure, inflammatory responses, and many other metabolic processes
Essential fatty acids, or EFAs, are fatty acids that humans and other animals must ingest because the body requires them for good health but cannot synthesize them. The term "essential fatty acid" refers to fatty acids required for biological processes but does not include the fats that only act as fuel.
Linolic acid is an important essential and is found primarily in polyunsaturated vegetable oils AI, adequate intake.
AI for essential fatty acids
for adults 19–51 years
old*
Kind
Food sources
Men: 17 grams
Women: 12 grams
Omega-6 fatty acids
Linoleic acid
¢
Vegetable oils such as safflower, corn, soybean, cottonseed
¢
Poultry fat
¢
Nuts and seeds
Men: 1.6 grams
Women: 1.1 grams Omega-3 fatty acids
Linolenic acid
¢
Human milk
¢
Fatty fish
¢
Vegetable oils such as soybean, flax, canola
¢
Wheat germ
¢
Soybeans
*Refer to dietary reference intakes tables for other age groups.
Unsalted and raw or roasted without oil is the healthiest option for consumption.
Potential Drawbacks of Fish Oil Supplements
Prolong bleeding time
Doses more than 3g/day may suppress immune system function and may increase the risk of hemorrhagic stroke
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Most do not contain Vitamin A, those from shark and halibut liver oils contain high levels and they should not be used by pregnant women
Susceptible to rancidity and should be stored in the refrigerator
Salmon and trout are good sources of omega-3 fatty acids.
Functions of Fats
Two ways to discuss:
Fats in food
Fats in the body
Three Functions of Fat in the Body. Fat is a backup source of energy to fuel your workout when carbohydrates are not available. Fat is an essential part of your diet. It provides energy, absorbs certain nutrients and maintains your core body temperature
Fats in Food
Fuel source
Vehicle for fat-soluble vitamins
Satiety value
Sources of essential fatty acids: Arachidonic, Linolenic, Linoleic
Essential fatty acids, or EFAs, are fatty acids that humans and other animals must ingest because the body requires them for good health but cannot synthesize them. Those not essential are non-essential fatty acids
The body can synthesize most of the fats it needs from the diet. However, two essential fatty acids, linoleic and alpha-linolenic, cannot be synthesized in the body and must be obtained from food. These basic fats, found in plant foods, are used to build specialized fats called omega-3 and omega-6 fatty acids.
Fats in Food Imparts its own flavor Transfers heat to rapidly cook food
Absorbs flavors and aromas of ingredients to improve taste
Adds juiciness to meats
Adds texture or body to many foods
Imparts tenderness and moisture to baked goods
Fats in the Body
Fuel source
Fuel reserve
Organ protection
Lubrication
Insulation
Cell membrane structure
Supply fuel to most tissues
2. Function as an energy reserve
3. Insulate the body
4. Support and protect vital organs
5. Lubricate body tissues
6. Form an integral part of cell membranes
Major function of fat is to provide energy 1 g of fat (saturated or unsaturated) provides 9 calories of energy (9cal/ g)
Fats insulates and cushions internal organs
Body temp regulation
Facilitates the absorption of fat soluble vitamins (A,D, E, K)
Contribute flavor, satiety value, and palatability to the diet
Sources of essential fatty acids (linoleic, arachidonic, and linolenic)
Review Question
Fats function in the body in all of the following ways except:
Fuel source
Fuel reserve
Excretion
Lubrication
Fats in the American Diet
Many Americans eat too much dietary fat Some fat in the diet is necessary for optimal health
Some Americans attempt weight loss by the elimination of all fat from the diet
Review Question
Excessive fat intake is linked to which of the following diseases:
Type 1 diabetes
Crohn’s disease
Heart disease
Tay Sach’s disease
Fat Digestion Minimal digestion in mouth and stomach through the action of lingual and gastric lipases
Most fat digestion takes place in small intestine where bile, pancreatic lipase break down the fat into fatty acid and glycerol.
Absorption: 95 % of digested fat is absorbed in duodenum and jejunum. Most fatty acids end up stored in adipose tissue
Where do Fats belong in the Food Pyramid?
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Within each food group, the foods lowest in fat should be chosen first. Milk, meat and beans, oils provide a lot of fat. Turkey without skin low in fat Here are 10 high-fat foods that are actually incredibly healthy and nutritious.
Avocados. The avocado is different from most other fruits. ...
Cheese. Cheese is incredibly nutritious. ...
Dark Chocolate. ...
Whole Eggs. ...
Fatty Fish. ...
Nuts. ...
Chia Seeds. ...
Extra Virgin Olive Oil.
Fruits are fat free.
Grains: little fat
Fat Dietary Recommendations
Balance of both carbohydrates and fat Inadequate fat lacks satiety and palatability and may lack necessary levels of essential fatty acids/zinc/vitamins
Excessive fat is linked to heart disease/diabetes/
cancers/obesity
Adults should consume between 20% and 35% of kcal from fat
Children and infants should consume between 25% and 40% of kcal from fat
Trans fatty acids + cholesterol = no recommended amount
Linoleic acid range 17 grams for men and 12 grams for women
Alpha-linoleic acid = 1.6 grams for men/1.1 grams for women
Dietary Fat Intake and Health
Many experts advocate eating most of dietary fats as whole natural foods (e.g., olives, avocado, nuts)
Body fat—optimal body fat content
Men: 15% to 19%
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Women: 18% to 22%
Dietary Exchange List: Calculating Your Fat Intake
Milk Exchange List
Whole: 6 grams of fat/cup (1 cup = 1 exchange)
2% milk:
5 grams of fat/cup
Skim milk: ½ to 0 grams of fat/cup
Meat and Meat Substitute Exchange List
Very lean: 1 gram of fat per exchange
Lean: 3 grams of fat per exchange Medium: 5 gram of fat per exchange
High-fat: 8 grams of fat per exchange
Fat Exchange List
5 grams of fat per exchange
Strategies for Reducing and Modifying Fat Intake
Eat skinless white meat
Eat lean meat, limit red meat to one meal/week
Substitute low-fat on nonfat for regular varieties
Limit fat as flavoring
Reduce hydrogenated fat intake
Replace fatty foods with fruit and vegetables
Use “good” fats in moderation
Hydrogenated fats are unnatural fats that are detrimental to your health. Food fats naturally occur in three general types: Saturated (e.g., butter, lard, coconut oil) Monounsaturated (e.g., olive or canola oils) Make canola oil or olive oil your oil of choice
Butter vs. Margarine
Butter
Made from animal fat
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Contains cholesterol High levels of saturated fat (bad fat)
Margarine
Made from vegetable oils, so it contains no cholesterol Higher in "good" fats — polyunsaturated and monounsaturated — than butter is
These types of fats help reduce low-density lipoprotein (LDL), or "bad," cholesterol when substituted for saturated fat
Not created equal: some may contain more trans fats than butter
More solid = more trans fat
Margarine contains more trans-fat than butter. Butter contains cholesterol and margarine does not
Additional Sources of Fat
Some crackers
Cakes, pies, donuts, cookies
Coffees with whipped cream
Custards
Cream sauces
Gravies
Salty snack foods such as potato chips and microwave popcorn
Fried foods
Additional food sources of fat - Snack foods
Plant Stanols and Sterols
Derived from plants
Have been shown to reduce blood cholesterol levels
Examples: Benecol, Take Control, Smart Balance
One brand of orange juice now contains plant sterols
What foods contain plant sterols and stanols? Wheat germ, wheat bran, peanuts, vegetable oils (corn, sesame, canola and olive oil), almonds and Brussels sprouts contain plant stanols and sterols. Smaller amounts are found in other vegetables and some fruits. Minute maid contains stanols and sterols
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Found in membranes of plants
Resemble chemical structure of cholesterol
Reduce blood cholesterol levels
Dietary Recommendations Concerning Fat
Report on Dietary Reference Intakes for Macronutrients Remain current guidelines
Food and Nutrition Board of the Institute of Medicine
American Heart Association; National Heart, Lung, and Blood Association
The Dietary Guidelines for Americans 2020–2025; the American Heart Association; and the National Heart, Lung, and Blood Institute (NHLBI) recommend that most dietary fats come from sources of PUFAs and MUFAs. One way to obtain these fats is to incorporate nuts into the diet.
Nuts also provide other essential nutrients, such as linolenic acid, vitamins A and E, magnesium, dietary fiber, copper, and zinc. Many nuts are also high in phytonutrients.
The 2020–2025 Dietary Guidelines recommends an increase in consumption of nuts, seeds, and soy products. The best method of incorporating nuts into the diet is to practice good portion control. Based upon a 2,000-kilocalorie diet, the recommendation is for five 1-ounce equivalents each week. One ounce
of nuts contains about 170 kilocalories. Unsalted and raw or roasted without oil is the healthiest option for consumption.
Food Label Terms
Food labeling regulations spell out what terms may be used to describe the level of fat in a food and how the labels can be used. These are the terms:
Fat-free on a food label means that the food contains no more than 0.5 grams of fat per serving. Synonyms for free include without, no, and zero. Nonfat is another synonym for fat-free. These terms legally can be used on a food label only if the product contains no amount of—or only trivial or “physiologically inconsequential” amounts of—fat, saturated fat, and cholesterol.
Low-fat is legally defined as a food that contains no more than 3 grams of fat in a serving.
Low saturated fat is legally defined as a food that contains no more than 1 gram of saturated fat per serving.
Low cholesterol is defined as a food that contains less than 20 milligrams of cholesterol per serving. Synonyms for low include little, few, and low source of.
In addition, serving sizes listed on food labels are standardized to make nutritional comparisons of similar products easier.
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Clicker Question Evidence suggests that clients with a higher intake of which fats may have a decreased risk of coronary heart disease?
A. Saturated fats
B. Total fat intake
C. Trans fat
D. Monounsaturated fat
Chapter 4: Protein
The unique function of protein in the human body is to: Serve as building materials for tissue repair
Amino acids are the building blocks of protein. (All proteins are composed of amino acids)
Protein Makes unique contributions to the body
Cannot be duplicated by carbohydrates or fats
Can be used as an auxiliary source of energy
If kilocaloric intake inadequate
Proteins
Contains carbon, oxygen, hydrogen and nitrogen. Sometimes sulfur and other elements Amino Acids: Essential and Nonessential Conditionally Essential Provides 4 cal/g (same as CHO)
Protein is the building blocks of life. Body needs protein to repair and maintain itself. Proteins are composed of 4 elements: carbon, hydrogen, oxygen, and nitrogen
These elements are arranged in building blocks called amino acids.
Next to water, protein is the next rich substance within the body. Think about the structure of the house, before you put the walls, you’ve got a basic flatform. So protein is that framework for almost every system in the body. So, without protein the body could not support life. That’s the big picture, now lets look at the smaller picture. Protein is the building block of the body. ..present in muscles, bones, marrow, nails, tissue, skin, teeth
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Composition of Proteins: Amino Acids
Polypeptide: Peptide bonds
Essential amino acids: Body unable to make in sufficient amounts-Needed for synthesis of body proteins
Conditionally (acquired) essential amino acids: Can become essential-Depending on biochemical needs of the body
Nonessential amino acids: Amino acids the body can build‒Typically derived from other amino acids
Recommended Dietary Allowance for Protein (cdc.gov)
Grams of protein needed each day
Children ages 1-3
13
Children ages 4-8
19
Children ages 9-13
34
Girls ages 14-18
46
Boys ages 14-18
52
Women ages 19-70+
46
Men ages 19-70+
56
Needed per day.
it's recommended that 10–35% of your daily calories come from protein.
The recommended dietary requirements of protein for adults is 10% of intake, or 46g/day for women and 56 g/day for men.
Functions of Protein in the Body
Provision of structure: Contractile proteins—in muscles; Fibrous proteins—in bone, hair, nails, skin
Maintenance and growth
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Regulation of body processes
Immunity
Circulation
Energy source
Contains digestive enzymes, to break larger molecules to smaller ones. Other body secretions: neurotransmitters, antibodies and hormones. Protein helps maintain normal blood ph. It helps transport substance throughout blood
Like CHO, protein provides 4 cal/g
Maintenance of Growth
Anabolism versus catabolism—Building versus breaking down of tissue
Nitrogen balance—Amount of nitrogen eaten is equal to the amount excreted
Positive nitrogen balance – person consuming more nitrogen than he/she excretes Negative nitrogen balance—insufficient protein intake so that the body is breaking down more tissue than it is building-Bedrest, malnutrition
Foods or artificial feedings containing protein are the body’s only external sources of nitrogen. Nitrogen is excreted in the urine, feces, sweat; nitrogen is also sometimes lost through bleeding or vomiting. Nitrogen balance occurs when the intake of nitrogen equals the amount excreted. A healthy adult at a stable body weight is usually in nitrogen equilibrium. Anabolism is the building up of tissues. Catabolism is the breaking down of tissues into simpler substances that the body can use or eliminate. Anabolism and catabolism are not always in balance, at times, one process may dominate the other. Catabolism is what happens when you digest food and the molecules break down in the body for use as energy. Positive nitrogen balance is when the body is building more tissue that it is breaking down, a normal state during periods of growth such as infancy, childhood, adolescence, and pregnancy. Negative nitrogen balance is when a person is consuming less nitrogen than he or she excretes. Situations marked by negative nitrogen balance include undernutrition, illness, and trauma, bedrest, malnutrition.
Anabolism/Catabolism of Protein
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Figure 4-1 in your book. Anabolism and catabolism of protein. The body obtains amino acids from dietary protein and the catabolism of body tissue, enzymes, and secretions. The body uses amino acids to build new tissue or for immediate or future energy use. Every meal or snacks does not have to contain every essential amino acid to permit anabolism. To maximize an adult’s health, all essential amino acids should be supplied in adequate amounts by diet daily or at least every 203 days.
Maintenance of Growth
Protein Energy Malnutrition/Protein Calorie Malnutrition (PEM/PCM)
Marasmus—Insufficient kilocalories and protein
Kwashiorkor—More kilocalories than in marasmus but insufficient protein (weanlings)
Protein Energy Malnutrition (PEM) Kwashiorkor
Occurs in child shortly after weaning from breast milk
Child receives more kilocalories but not enough protein to support growth Occurs in children between the ages of 1 to 4 years Marasmus
Occurs when the victim consumes too few kilocalories and insufficient protein
Person appears wasting away (severe weight loss)
Occurs in children < 2 years of age In U.S: d/t chronic disease, cancer, AIDS, Chronic pulmonary disease, homeless, eating disorders
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Regulation of Body Processes
Hormones—insulin, growth hormone
Enzymes—sucrase, lipase
Nucleoproteins that contain proteins—DNA, RNA
Hormones are chemicals secreted by various organs to regulate body processes. They are secreted directly into the bloodstream.
Enzymes act as catalysts, influencing the speed at which a chemical reaction takes place, but they do not
actually enter into the reaction.
Gluconeogenesis refers to the process in which the body uses protein for glucose production. Nucleoproteins are regulatory complexes that direct the maintenance and reproduction of the cell.
Other Functions
Immunity—antibodies
Circulation—albumin helps to maintain blood pressure by aiding in return of fluid from tissues back into bloodstream
Energy source—if carbohydrate (CHO) and fat intake inadequate
The main protein in blood is albumin. It helps maintain blood volume by drawing fluid back into the veins from body tissues. It plays a major role in maintaining blood pressure. Glucose is the most efficiently used source of energy, but fat and protein can be adapted as backup sources. When the body has insufficient glucose available for nervous system energy needs, the body will use body protein tissue to meet the energy needs of the brain and spinal cord.
Protein Catabolism for Energy
Body uses very little protein for energy
Inadequate calorie intake: proteins are sacrificed to provide amino acids Body protein loss of 30% causes impaired breathing
Adequate supply of energy from CHO and fat is needed to “spare protein” from being burned for calories
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 (calorie intake inadequate),
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dietary and body proteins are sacrificed to provide amino acids that can be burned for energy. Over time
loss of lean body tissue occurs. Loss of 30% of body protein causes impaired breathing r/t a decrease in muscle strength, altered immune system, altered organ function, and ultimately death. Insufficient protein affects immune system, loss muscle mass, and gain higher-body fat ratio.
Digestion and Metabolism of Protein Begins in the stomach, most occurs in small intestine.
Metabolism occurs in liver
Protein turnover is a continuous process Rates differ: For example: RBC replaced every 60-90 days, GI tract cells replaced every 2-3 days, and enzymes used in the digestion of food are constantly replenished
Nitrogen balance (Healthy Adults)
Positive balance: Increased synthesis during pregnancy, recovering from injury.
Negative balance: protein broken down faster than synthesis as in starvation, illness or injury
Nitrogen is a fundamental component of amino acids, which are the molecular building blocks of protein. Therefore, measuring nitrogen inputs and losses can be used to study protein metabolism. The fundamental rule when aiming to increase nitrogen balance is to eat sufficient complete proteins. Indeed, a caloric surplus of protein should be maintained at all times, to keep nitrogen balance positive. Nitrogen balance is a measure of nitrogen input minus nitrogen output. Nitrogen Balance = Nitrogen intake - Nitrogen loss. Sources of nitrogen intake include meat, dairy, eggs, nuts and legumes, and grains and cereals. Examples of nitrogen losses include urine, feces, sweat, hair, and skin. the difference between the amount of nitrogen taken into the body and the amount excreted
Positive nitrogen balance is associated with periods of growth, hypothyroidism, tissue repair, and pregnancy. This means that the intake of nitrogen into the body is greater than the loss of nitrogen from
the body, so there is an increase in the total body pool of protein.
Negative nitrogen balance is associated with burns, serious tissue injuries, fevers, hyperthyroidism, wasting diseases, and during periods of fasting. A negative nitrogen balance can be used as part of a clinical evaluation of malnutrition.[4]
The concept of nitrogen balance is that the difference between nitrogen intake and loss reflects gain or loss of total body protein. If more nitrogen (protein) is given to the patient than lost, the patient is considered to be anabolic or “in positive nitrogen balance”.
Albumin
Most prevalent protein of blood plasma
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Liver is responsible for filtering proteins **Low level associated with ↑ length of hospital stay, complications, morbidity, and mortality**
Ranges: 3.4 and 5.4 g/dL
Albumin lose: fluid can leak into tissues and cause swelling.
Decreased level = wound never heal The major protein in the blood, albumin, aids the return of fluid from the cells and tissues to the bloodstream to maintain blood volume and pressure. Liver is responsible for filtering proteins in the blood and breaking the proteins down into smaller molecules for use. f you do lose albumin in your body, the fluid can leak into your tissues and cause swelling.
Albumin is a transport protein that carries nutrients or elements to cells.
Albumin plays a significant role in metabolism. Albumin is a major blood protein. Albumin aids in water balance.
An albumin blood test checks your liver and kidney function. Albumin is protein in your blood plasma. Low albumin levels might be the result of kidney disease, liver disease, inflammation or infections. High albumin levels are usually the result of dehydration or severe diarrhea.
Classification of Food Protein: Complete Protein
Animal sources
Animal protein 90% to 99% digestible
Soybeans
One plant source of complete proteins
75% to 80% digestible
Classification of Food Proteins
Complete protein—Food that supplies all essential amino acids in sufficient quantity to maintain tissue and support growth
Incomplete protein—Food that lacks one or more of the essential amino acids
Complementary protein – food that when eaten together provide all the essential amino acids
Complete protein: animal sources
Incomplete protein: from plants: grains, nuts, legumes, vegetables, fruits
Complementary proteins are those food sources that when eaten together, provide all the essential amino acids
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Clients are instructed to estimate the size of a 3-ounce portion of boneless meat by comparing it to: a deck of cards Complete Proteins
Sources containing complete protein—meat, poultry, fish, eggs, milk, cheese
Exchange groups containing complete protein
Milk—8 grams (per cup)
Meat—7 grams (usually per ounce of meat)
One milk exchange provides 8 grams of protein.
Milk provides 8 grams of protein, which is greater than meat; meat supplies 7 grams of protein.
Review Question
The nurse is counseling the client on the importance of complete proteins in the diet, which include all of the following foods except:
Peanuts
Chicken
Milk
Cheese
Incomplete Proteins
Limiting amino acid—essential amino acid undersupplied in a food
Complementation—combining of incomplete proteins (grain and legume) so that all essential amino acids are supplied
Vegetable sources of protein—legumes (peas, beans, lentils, peanuts)
Leucine is an essential amino acid.
Phenylalanine is an essential amino acid.
Glycine is a nonessential amino acid.
Tryptophan is an essential amino acid. Exchanges containing incomplete protein
Starch/bread: 3 grams
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Vegetable: 2 grams
Complementary proteins: Beans and rice or tortillas.
Peanut butter sandwich. Macaroni and cheese. Tofu with rice (or any grain), Hummus with pita bread. Grilled cheese sandwich. Yogurt with nuts. Noodle stir-fry with peanut or sesame seed sauce.
Vegetarianism can be a healthy lifestyle with careful planning to replace nutrients in omitted foods
An amino acid is classified as essential if the body is unable to make it in sufficient amounts to meet metabolic needs. All essential amino acids must be available in the body simultaneously and in sufficient quantity for the synthesis of body proteins.
Protein Quality
Complete Protein
Provides all nine essential amino acids (adequate amt) needed by the body for protein synthesis
High quality proteins from animal sources
Soy protein (only plant source of complete protein)
Sources: meat, poultry, seafood, milk, yogurt, cheese, soybeans
Incomplete Protein
Provide all essential amino acids but one or more are in insufficient quantities to support protein
synthesis
Amino acids “limiting”
Lower quality protein
Complimentary (black beans and rice)
Sources: grains, vegetables, dried peas and beans, nuts, gelatin
Small amounts of a complete protein combined with any incomplete protein are complimentary
Conditions that Increase the Need for Protein When calorie intake is inadequate and so protein is being used for energy: Weight loss diets, starvation, protein energy malnutrition
When the body needs to heal itself: Hypermetabolic conditions, skin breakdown, multiple fx, hepatitis
To replace excessive protein losses: Peritoneal dialysis, protein-losing renal diseases, malabsorption syndromes
During periods of normal tissue growth: Pregnancy, lactation, infancy through adolescence
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Protein-calorie malnutrition is a type of nutrition resulting from inadequate food intake, often when the person is institutionalized and unable to self-feed.
Vegetarian Diets
Vegetarians have lower rate of obesity, type 2 diabetes cardiovascular disease, HTN, cancer, dementia Ovolactovegetarian—no meat, fish, or poultry
Lactovegetarian—no meat, fish, poultry, or eggs
Ovovegetarian—no meat, fish, poultry, or dairy
Strict vegetarian (vegan)—no animal products
Fruitarian—nothing but raw fruits, nuts, seeds, and berries
Pescatarian- does not eat meat, but does eat fish
There are many individual variations of these…
Concerns in the Vegetarian diet: Deficiency in Iron, Zinc, Calcium, Vit D, Omega 3 fatty Acids, Vitamin B12 (does not occur naturally in plants)
Tips for Following a Vegetarian Diet
Eat a variety of foods (including whole grains, veggies, fruits, dried peas and beans, nuts, seeds, if desired, dairy products and eggs)
Experiment with meat substitutes made from vegetables
Eat enough calories
Consume a rich source of vitamin C at every meal
Include two servings of fats that supply omega-3 fats
Don’t go overboard on high-fat cheese as a meat substitute
Experiment with ethnic cuisines
Supplement nutrients that are lacking from food
Dietary Allowances for Protein
Men: 56 grams
Women: 46 grams
Pregnancy and lactation: 71 grams
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Clicker Question
The dietary allowance for proteins during pregnancy and lactation is:
46 grams
56 grams
61 grams
71 grams
Dietary Reference Intakes
Adequate intake (AI): Less than 6 months
Recommended dietary intakes (RDAs): Older than 6 months
Acceptable macronutrient distribution range (AMDR)
Dietary Reference Intakes are provided in Appendix A. On the basis of body weight (grams per kilogram of body weight per day), infants synthesize more than twice the whole-body protein that adults do. Infants younger than 6 months of age are given an adequate intake based on the mean intake of healthy
full-term breastfed infants because protein deficiencies have not been reported in such infants. Individuals older than 6 months have assigned recommended dietary intakes (RDAs) (Clinical Calculation 4-2).
The RDAs for protein assume adequate intake of the other energy nutrients to avoid the use of protein for energy. The acceptable macronutrient distribution range (AMDR) of 10% to 35% of kilocalories offers
a broad goal for protein intake. See Appendix A
Wise Protein Choices
No tolerable upper intake level established
Concerns about high-protein diets: Risk of dehydration; Risk to bones from acidity; Leeching of minerals
Clicker Question Which of the following refers to the principle of a meal containing a combination of plant foods that provide all essential amino acids?
A. Limiting amino acid
B. Complementation
C. Nitrogen-fixing
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D. Ketosis
Chapter 6: Vitamins
Vitamins
Organic compounds made of carbon, hydrogen, oxygen and sometimes nitrogen or other elements.
Vita = essential for life needed in small amounts
Do not provide energy; are needed for metabolism of energy
Susceptible to destruction from heat, light, oxidation, acid and alkalis
Some are essential in the diet because the body cannot make them (exceptions vitamin A and D)
Enzymes cannot function without co enzymes and many co enzymes are vitamins ( All B vitamins work as coenzymes)
Vitamins are used as food additives Vitamins and minerals are considered micronutrient
Micronutrients, as opposed to macronutrients (protein, carbohydrates and fat), are comprised of vitamins and minerals which are required in small quantities to ensure normal metabolism, growth and physical well-being.
Hypervitaminosis: taking too much vitamins
A dose of 10 times the recommended dietary allowance (RDA) for a vitamin is called Megadose.
Sales in 2014 in US: 36.7 billion.
Vitamin Classifications
Fat soluble (A, D, E, and K)—more stable to environmental influences; absorbed with fat; stored in body
Water soluble (B vitamins and C)—less stable to environmental influences; only B12 stored for any length of time
Vitamins A, D, E, and K are fat soluble and require sufficient dietary fat intake and adequate fat digestion
for proper utilization. The water soluble vitamins, C and the B complex, are not stored in the body in appreciable amounts, requiring more frequent intake than fat-soluble ones
Vitamins Classifications Based on Solubility
Vitamins are organic and can be broken down
Fat-soluble vitamins – A, D, E, K (stored in the body and require dietary fat intake for absorption)
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Water-soluble vitamins – Vitamin C and the B’s thiamin, riboflavin, niacin, folate, B6, B12, biotin and pantothenic acid , (not stored in the body; needed on a daily basis; dissolved in water
Toxicity from A& D can be fatal
Fat soluble esp A&D stored in body tissue and tend to remain there
Fat- and Water-Soluble Vitamins
Fat soluble vitamins
Sources: the fat and oil of foods
Absorption: with fat encased in chylomicrons that enter the lymphatic system before circulation in the blood stream
Fat when consumed in excess of need: are absorbed in the liver and adipose tissue
Safety of consuming high intakes through supplements. Can be toxic with vit A and D
Frequency of intake: not daily usually as body retains them
Water soluble
Sources: watery portion of foods
Absorption: directly into the blood stream
Fat when consumed in excess of need: excreted in the urine usually
Safety of consuming high intakes through supplements: generally nontoxic can occur with vit B 6
large doses over long time
Frequency of intake: Must be consumed daily because there is no reserve in storage
Fats remain in the body.
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Vitamin C in fresh vegetables and fruit, especially citrus.
Vitamin A (Retinol)
Sources Retinol: Liver, milk butter cheese, cream egg yolk, ready to eat cereals, Beta-Carotene: Spinach, collard greens, kale , mango, broccoli, carrots, peaches, pumpkin, watermelon, cantaloupe, red pepper. Function : formation of visual purple which enables the eye to adapt to dim light, normal bone and teeth
development, formation and maintenance of mucosa, epithelium Deficiency: slow recovery of vision after flashes of bright light, bone shape changes, decreased saliva, dry scaly rough skin, increased susceptibility to infections
Toxicity: Headaches, vomiting, double vision, hair loss, bone abnormalities, liver damage, which may be reversible or fatal; can cause birth defects during pregnancy
Antioxidant. Egg yolk and fortified milk are good sources of preformed Vitamin A. Pregnant women should avoid excessive intake of preformed vitamin A from foods or supplements because of risk to the fetus. WHO recommends that in developing countries, clients with measles should receive supplemental vitamin A Deficiency of vitamin A results in xerophthalmia and night blindness.
Prevention and Treatment of Vitamin A Deficiency in Developing Countries
Prevention
Breastfeeding
Supplementation
Food fortification
Diet diversification
Treatment
High-dose vitamin A Active corneal disease is a medical emergency
Vitamin D
Vitamin D: sunshine vitamin
Sources: cod liver oil, oysters, mackerel, fish, egg yolks, fortified milk, ready-to-eat cereals, and margarine
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Function: Maintains calcium concentrations, promotes bone and teeth mineralization
Factors that impair vitamin D synthesis: Dense clouds, smog, sunscreen dark skin
Deficiency: Rickets (children) and Osteomalacia (adults)
Toxicity: calcification of soft tissue, hypercalcemia, renal stones, growth failure in children
Rickets and osteomalacia associated with vitamin D deficiency Sunlight is a good source of Vitamin D. Lack of sunlight can lead to a vitamin D deficiency
Vitamin D is added to milk because it normally does not contain vitamin D.
Kidney is the organs that provided the final step in the activation of vitamin D. the kidney converts the calcidiol to calcitriol, the active form of vitamin D Excessive vitamin D from supplements or multiple fortified foods maybe hazardous to children.
Vitamin D Functions
Increases intestinal absorption of calcium and phosphorus
Stimulates bone cells to build tissue
Signals kidney to return calcium to bloodstream, not excrete it in urine
Essential to proper bone metabolism. Recent findings suggest a role in the prevention and treatment of a wide range of chronic diseases, such as cancer, type 2 diabetes, and hypertension.
Vitamin D Toxicity
One of the most likely vitamins to cause toxicity if taken in excess
Pathology—calcium deposits in heart, kidneys, brain
S/sx: loss of appetite, n/v, polyuria, muscular weakness, and constipation Vitamin C, B12, thiamin, and niacin have specific diseases associated with deficiency: scurvy, pernicious anemia, beriberi, and pellagra. Hypervitaminosis D.
Vitamin E
Sources: vegetable oils, margarine, salad dressing nuts, seeds wheat germ, dark green vegetables whole grains
Function: acts as an antioxidant that protects vitamin A from being destroyed
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Deficiency: increased RBC hemolysis in infants, anemia, edema and skin lesions.
Toxicity: high doses enhance action of anticoagulant medications, ↓thyroid hormone level, ↑ in triglycerides
Involve in immune function
May increase risk of bleeding
Vitamin E lung cell membrane provides important barrier against air pollution. Too much Vitamin E caused narcolepsy, clinical application 6-3
Vitamin K
Sources: Bacterial synthesis, Brussels sprouts, Broccoli, cauliflower, Swiss chard, spinach, carrot, green beans, eggs
Function: necessary for blood clotting
Deficiency: Hemorrhage
Toxicity: none
Vitamin K has an impact on the effectiveness of the commonly prescribed Coumadin, which interferes with the synthesis of vitamin K. Vitamin K is an antidote for Coumadin overdose
Required for blood coagulation
Decreased level can raise the risk of uncontrolled bleeding
any of a group of vitamins found mainly in green leaves and essential for the blood-clotting process. They include phylloquinone (vitamin K1), menaquinone (vitamin K2), and menadione (vitamin K3). Vitamin K is present in green leafy vegetables and canola and soybean oils;
Vitamin K Functions
Blood clotting—Necessary for the liver to make prothrombin and other clotting factors
Bone metabolism—Facilitates synthesis of a calcium-binding protein (Osteocalcin)
Vitamin K is necessary for the liver to make factors II (prothrombin), VII, IX, and X. Four additional coagulation proteins are vitamin K dependent. These factors and proteins plus calcium are key links in the chain of events in producing blood clot. Bone metabolism: two vitamin K dependent proteins have been identified in bone and cartilage. Vitamin
K is converted to K2 within the femur, which increases osteocalcin production.
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Vitamin K Deficiency
Bleeding problems
Newborns
Long-term antibiotic therapy
Malabsorption syndromes
Possible impaired bone health
Individuals at risk for vitamin k deficiency include newborn infants as well as adults who avoid green leafy vegetables or undergoing long term antibiotic therapy. Clients with malabsorption syndromes are also at risk. Infants are at risk because of inadequate amounts of vitamin K cross the placenta and because the intestinal track of a newborn infant is sterile. For this reason the baby is not unable to produce vitamin k until the intestine is colonized with bacteria from the environment, usually within 24 hours when the baby can begin to synthesize vitamin K.
Review Question
Functions of vitamin K include:
Bone formation
Epithelial tissue growth
Red blood cell formation
Blood clotting
Water Soluble Vitamins: B Vitamins
Easily destroyed with cooking
All used in metabolism of energy Most B vitamins found in whole grains/legumes; B2 found mainly in milk, eggs, peanuts, organ meats; B3
requirement met, in part, by production from the amino acid tryptophan; B12 only found in animal products
Vitamin that dissolves in water are vitamin c, or ascorbic acid and the B vitamins (thiamin, riboflavin, niacin, vitamin b6, folate, and vitamin b 12 as well as pantothenic acid, biotin, and choline (not really a vitamin)
Vitamin C (Ascorbic Acid)
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First vitamin identified from experience of “limeys” (British sailors) – scurvy avoided by eating lemons (then called limes)
Scurvy = severe deficiency; bleeding gums/loose teeth = mild deficiency
Sources Found only in fruits and vegetables – leafy greens, citrus, melons, potato, green peppers, broccoli, kiwi, berries, and tomatoes
Acts as glue to hold body cells together
Promotes immunity and wound healing
Promotes bone growth and growth of all body tissues
Mega dose > 10 times RDA
Linus Pauling promoted mega dose of vitamin C as an antihistamine, reducing the symptoms of a cold, not a means to cure the common cold
To prevent rebound scurvy: reduce mega dose quantity incrementally Scurvy is the deficiency disease associated with vitamin C.
In the Winter of 1556, there was a scurvy epidemic that plague Europe. A sailor by the named Jacques Cartier, established explorer, noted that his sailors who had digested oranges, limes and berries did not get scurvy, those who had the disease recovered. Scurvy: a disease caused by a deficiency of vitamin C, characterized by swollen bleeding gums and the opening of previously healed wounds, which particularly affected poorly nourished sailors until the end of the 18th century.
Thiamin – Vitamin B1
Sources: whole grain and enriched breads and cereals, liver, nuts, wheat germ, pork, dried peas, and beans
Functions: CHO metabolism, assists function of the heart, muscles, and nervous system, promotes appetite and good function of the digestive tract Deficiency: polyneuritis, beriberi, fatigue, depression, poor appetite, edema, nervous instability, Wernicke-Korsakoff encephalopathy (found in persons with alcoholism), spastic muscle contractions
Toxicity: None known
All B vitamins help the body convert food (CHO) into fuel (glucose)
Individuals with alcoholism commonly develop a thiamin deficiency due to inadequate food intake, increase requirements, and decrease absorption. Thiamin given by injection is used to raise plasma levels sufficiently to cross the blood-brain barrier.
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Riboflavin (B2)
Function
Coenzyme in metabolism of protein and other vitamins
Required for growth and tissue healing Deficiency
Usually combined with other vitamin deficiencies
If alone: Ariboflavinosis; Typically, avoidance of milk products
DRIs for riboflavin
RDA: Men: 1.3 mg; Women: 1.1 mg
UL—not determinable
Sources of riboflavin—milk, meat (esp. liver), legumes, fortified cereals, green leafy vegetables Toxicity—unknown
Niacin – Vitamin B3
Sources: All protein foods, whole grains and enriched breads and cereals
Function: regulates energy metabolism; promotes good physical and mental health and helps maintain the health of the skin, tongue, and digestive system; aids in metabolism of fats, glucose, and alcohol.
Deficiency caused by poor dietary intake, alcohol abuse, and malabsorption
Pellagra: known as the 4 Ds: Diarrhea, Dermatitis (resembles sunburn and worsens with exposure to the sun), Dementia, Death
A crystalline acid that is a component of the vitamin B complex and is used to treat and prevent pellagra.
Also called nicotinic acid.
Corn as a staple food can lead to a niacin deficiency. Therefore, it would be important to assess for the adequacy of foods containing niacin.
The amino acid tryptophan serves as a provitamin for niacin. Pellagra is linked to overdependence on corn as a staple food
DRIs
Niacin equivalents (NE)—1 mg preformed niacin or 60 mg tryptophan
RDA—Men: 16 mg NE; women: 14 mg NE
UL—35 mg from supplements or fortified foods
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Toxicity of niacin—flushing; liver damage with long-term pharmaceutical doses to lower blood lipids
Vitamin B6 (Pyridoxine)
Sources: meats, fish, poultry, green leafy vegetables
Known as pyridoxine (plant sources) and pyridoxal and pyridoxamine (from animal products)
Need increased intake with high-protein diet, pregnancy, tuberculosis (result of Rx: ionized), and some contraceptives
Promotes conversion of tryptophan to niacin
Deficiency: dermatitis, cheilosis, glossitis, abnormal brain wave pattern, convulsions, and anemia Toxicity: depression from reduced production of serotonin from tryptophan
Excess intake > 100 mg related to irreversible nerve damage
Pyridoxine is the pharmaceutical preparation of Vitamin B 6. Vitamin B6 given with Isoniazid to prevent development of peripheral neuropathy
Folate “Foliage”
Sources: liver, spinach, asparagus, dried peas and beans seeds orange juice, breads and cereals Named for a chief source of folate: foliage or dark-green, leafy vegetables
Active form: folic acid, formed with vitamin C
Aids in metabolism of DNA, promotes chromosomal health, red blood cell formation
Helps prevent spina bifida if consumed in first few days of conception
Women of child-bearing years advised to include 400 mcg folate
Processed white-grain products are fortified with folate to lower the risk of infants born with spina bifida (a form of neural tube defect)
Deficiency of folate causes megaloblastic anemia
Deficiency can occur with use of antiepileptic Rx
Excess folate inhibits zinc
Folate also known as vitamin b9 and vitamin b13 were discovered during the search for the reason that eating liver cured megaloblastic anemia. Folic acid was discovered as a factor in yeast in 1931 and was later isolated from spinach leaves and named from the Italian for “foliage.”
RDAs
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400 mcg for adults
Women susceptible to pregnancy—400 mcg from fortified foods or supplements in addition to food folate
Pregnant women—600 mcg UL for synthetic folic acid obtained from supplements and/or fortified foods—1000 mcg
Vitamin B12 – Cobalamin
Important in synthesis of DNA, RNA, and myelin Sources only in animal-based foods
Deficiency causes irreversible nerve damage; pernicious anemia, other pathology—gastric resection, gastric atrophy, Crohn’s disease
B12 status should be monitored in vegetarians, if malabsorption is likely (especially of the ileum), and for the elder population because of diminished production of intrinsic factor
Vitamin B12 supplementation may not be adequate; IM B12 injections commonly provided for the elder population or persons with malabsorption, e.g., gastric bypass surgery
More than 3 million US cases per year
Vitamin B 12 is stored to a greater extent than the other B vitamins. Necessary for normal red blood cell formation. Intrinsic factor secreted by the gastric mucosal cells in the stomach.
Possible Signs and Symptoms B12 Deficiency: Depression; Mania and psychotic symptoms; Cognitive impairment/neurological symptoms; Circulatory symptoms include megaloblastic anemia: ** fatigue, pallor, SOB, tachycardia**; obsessive-compulsive disorder; Seizures with treatment of alcoholism
Neurological manifestations include these signs and symptoms that may be irreparable: numbness and tingling in the extremities, difficulty maintaining balance, confusion, and dementia.
Other Essential Nutrients Biotin
Pantothenic acid (B5): coenzyme in fatty acid metabolism Biotin: coenzyme in the synthesis of fat, glycogen, and amino acids
Choline: essential for liver and brain function, lipid metabolism, and cellular membrane composition and
repair
Part of neurotransmitter acetylcholine and phospholipids
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Pantothenic acid — also known as vitamin B5 — is a water-soluble vitamin that is a precursor in the synthesis of coenzyme A.
Biotin: a vitamin of the B complex, found in egg yolk, liver, and yeast. It is involved in the synthesis of fatty acids and glucose.
Sources: eggs liver milk and dark green vegetables
Biotin deficiency can be aggravated by deficiency in pantothenic acid
Involved in fatty acid synthesis and metabolism
Both are synthesized by bacteria in the colon
Biotin deficiency can be caused by excess intake of raw egg white
Symptoms of biotin deficiency: loss of appetite, nausea and vomiting, hair loss, dermatitis, and hypercholesterolemia, certain types of anemia, depression, insomnia, and muscle pain
Pantothenic deficiency symptoms: burning foot syndrome, headache, fatigue, poor muscle coordination,
nausea, cramps
Choline discovered in 1862 , synthesized in 1866, but not recognized as essential for humans until 1998 because investigators thought the body manufactured sufficient amounts of the substance.
Vitamin Supplements Not intended as substitutes of healthy diet
No group promotes regular use of MVI (multivitamin); Without considering quality of a person’s diet; Should not exceed 100% of the RDA/Ais
Report to HCP along with med history Clicker Question An individual who has a vitamin C deficiency may develop:
A. Fat absorption problems
B. Scurvy
C. Beriberi
D. Night blindness
Chapter 7: Minerals
What are Minerals?
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Inorganic substances that help regulate body functions without providing energy
Becomes part of the body’s structure and enzymes
Major Minerals
Present in the body in amounts of 5 grams (1 teaspoonful) or more
The daily recommended intake is 100 mg or more
Trace Minerals
Are those present in small amounts with daily intakes less than the major minerals
However, even small amounts support essential function
Minerals
4% of body’s total weight Found all fluids and tissues
Trace minerals: Iron, iodine, zinc, selenium, copper, manganese, fluoride, chromium, molybdenum
Major: Calcium, Phosphorus, Magnesium, Sulfur, Sodium, Potassium, Chloride
Calcium, sodium, and potassium are major minerals essential to normal nerve and muscle function. Iron,
iodine, and zinc are trace minerals.
Function of Minerals
Provide structure
Fluid balance Acid-base balance
Nerve cell transmission & muscle contraction
Vitamin, enzyme, and hormone activity
Structure- calcium, phosphorus and magnesium provide structure to bones and teeth. Phos, k, iron and sulfur- soft tissue- sulfur is a constituent of skin, hair, and nails
Balance- sodium, k and chloride
Nerve cell- Na, k
Calcium stimulates muscle contractions
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Na, k, and magnesium stimulate muscle relaxation
Vit- cobalt is a component of Vit B12 Mag is a cofactor for hundreds of enzymes. Iodine is essential for
the production of thyroxine, chromium enhances the action of insulin
Not destroyed by light, air or acids. If burned are the ash that remains. Mineral are lost only when food is soaked in water
Major Electrolytes: Sodium, Chloride, Potassium
Sodium
Processed food, canned meat, vegetables, soups, restaurant and packaged
Normal: 135-145 mEq/L
Deficiency: chronic diarrhea, vomiting, renal disorders, nausea, dizzy, muscle cramps, apathy
Fluid and electrolyte balance; Acid base balance; Muscle irritability; Regulate cell membrane permeability; Nerve impulse transmission; Types of Salt
It helps maintain normal blood pressure, supports the work of your nerves and muscles, and regulates your body's fluid balance. A normal sodium level is between 135 and 145 milliequivalents per liter (mEq/L) of sodium. Hyponatremia occurs when the sodium in your blood falls below 135 mEq/L
Na+ is the mineral that has the most influence on extracellular fluid osmolality
1 tsp: 2,300 mg of sodium
Sea salt often has as much sodium as table salt according to Rachel Johnson RD at AHA.
Most of the sodium we consume is in the form of salt, and the vast majority of sodium we consume is in processed and restaurant foods. Too much sodium is bad for your health. It can increase your blood pressure and your risk for a heart attack and stroke.
The hormone that causes the kidney to conserve sodium and thus retain water is: aldosterone
Nearly all Americans eat too much salt (sodium). Most of the salt comes from eating processed foods (75%), or adding salt to food while cooking and using the salt shaker at meals (5% to 10%). On average, the more salt a person eats, the higher his or her blood pressure.
Normal sodium level: 135-145
Reduce sodium (salt); increase potassium. Research shows that eating less than 2,300 milligrams of sodium (about 1 tsp of salt) per day may reduce the risk of high blood pressure. Older adults tend to be salt-sensitive. If you are older adult or salt-sensitive, aim to eat no more than 1,500 milligrams of sodium
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each day—the equivalent of about 3/4 teaspoon. To meet the daily potassium recommendation of at least 4,700 milligrams, consume fruits and vegetables, and fat-free and low-fat milk products that are sources of potassium including: sweet potatoes, beet greens, white potatoes, white beans, plain yogurt, prune juice, and bananas. These counteract some of sodium’s effects on blood pressure. Iodine
Found in iodide form in the body
Average adult body contains 15–20 mg
70%–80% found in thyroid gland
Main function—synthesis of thyroid hormones
Intake from saltwater shellfish, fish, seaweed
Iodized salt, salt water fish, shellfish, seaweed Component of thyroid hormones regulate growth and metabolic rate
Deficiency: goiter, weight gain, lethargy- pregnancy can cause cretinism
Iodine is added to salt in the United States to prevent which deficiency, thyroid. Deficiency of iodine can result in goiter; Iodine plays a major role in the synthesis of the thyroid hormones and is added to salt to prevent thyroid
deficiency
Goiter refers to an enlargement of the thyroid gland due to a lack of sufficient iodine intake.
Fluoride
Major contribution to human health relates to its role in preventing dental caries
Contained in public U.S. drinking water
Overdose rare—large volumes of instant tea or secretive eating of toothpaste with fluoride
Deficiency of Fluoride, in dental caries
Potassium K
Canned tomato, sweet potato, soy nuts, pistachios, prunes, clams, molasses, yogurt, prune juice, cantaloupe, dried peas, beans, OJ, banana, peanuts, artichokes, fish, beef, lamb, avocados, apple juice, raisins, plantains, spinach, asparagus, kiwifruit, apricots
Balance, acid base, electrolytes, nerve, catalyst for many metabolic reactions, skeletal and cardiac muscle activity
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Deficiency: muscular weakness, paralysis, anorexia, confusion
Toxicity: muscle weakness, vomiting
Normal: 3.5-5 mEq/L
Important for maintaining normal heart electrical rhythm and for normal electrical signal in the nervous system.
mEQ, the unit of measures for electrolytes, is a term used to describe the number of particles of a substance in a solution rather than the total weight.
Functions: Helps to control fluid balance; Helps transmit impulses along nerves and muscle fibers
DRIs: AI—4.7 grams for adults; UL—not established
Deficiencies: Alkalosis, Potassium-wasting diuretics, related to diet only in severe protein-energy malnutrition, Losses due to diarrhea, vomiting, laxative abuse, Overhydration with plain water by perspiring athletes, Increased losses in urine, stool, or sweat
Clicker Question The nurse understands patients taking which medications are most at risk for potassium deficiencies?
A. Statins
B. Antacids
C. Diuretics
D. Analgesics
Chloride CL-
Same sources as sodium
Role in digestion and acid-base balance Fluid and electrolyte balance, acid base, component of hydrochloric acid in stomach
Deficiency: rare, secondary to diarrhea, vomiting: renal disorders, muscle cramps, anorexia, apathy
Toxicity: normally harmless- can have vomiting
Normal: 96-106 mEq/L
Helps keep up the amount of fluid inside and outside of your cells in balance.
Helps maintain proper blood volume, BP and pH of your body fluids.
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Major Minerals: Calcium, Phosphorus, Magnesium, Sulfur
Calcium 99% found in bones and teeth
1% in plasma- clotting, nerve, muscle contraction
Balance is achieved through Vit D and hormones
Foods ↑Ca+: salmon, sardines, clams, dark leafy greens, cheese, low fat milk and yogurt, Bok choy, fortified tofu, okra, broccoli, green beans, almonds, and fish canned with their bones.
Deficiency -children- impaired growth; Adult- Osteoporosis
Toxicity- constipation, renal stone formation, impaired absorption of iron
Normal: 8.5-10.2 mg/dL
Calcium is essential to the structure of bones and teeth and to nerve conduction, muscle contraction, and blood clotting. Milk, seafood with bones, and fortified orange juice are good sources of calcium.
Combines with phosphorus, magnesium and minerals
Cone reservoir- released when serum level is dropped need three servings of milk, yogurt, or cheese plus nondairy sources of calcium to ensure adequate intake
Mild is consisted nearly perfect source because it has Vit D. calcium fortified foods- fruit juice, tomato juice, read to eat breakfast
Low levels of ionized calcium in the blood indicates tetany. Chvostek’s sign, a tap over the facial nerve in front of the ear causes a twitch of the facial muscles on that side.
Calcium and Phosphorus combine to give bones and teeth their hardness.
alkalosis cause increased protein binding of ionized calcium, which results in tetany In alkalosis, because of the excessive alkalinity of body fluids, a greater # of calcium ions than usual are bound to serum proteins, effectively inactivating calcium and impairing nerve and muscle function.
Calcium and Bone Health
Bones play many roles in the body. They provide structure, protect organs, anchor muscles, and store calcium. Adequate calcium consumption and weight bearing physical activity build strong bones, optimizes bone mass, and may reduce the risk of osteoporosis later in life.
Associated with milk and cream tx for gastric ulcers in the past, milk, alkali syndrome now has been reported d/t ingesting calcium carbonate tablets to prevent osteoporosis.
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Calcium Intake. The recommended amounts of calcium for adults are as follows: For pre-menopausal women 25-50 years old and post-menopausal women on estrogen replacement therapy: 1,000-1,200 milligrams of calcium per day. 1,500 milligrams of calcium per day is recommended for pregnant or lactating women.
Calcium supplements may increased risk of developing dementia in senior women with cerebrovascular disease, finds a study published in neurology, the medical journal of the american academy of neurology.
Calcium Deficiencies
Osteoporosis—bone mineral density (BMD) >2.5 SD below mean for healthy young adults
Greatest risk—postmenopausal, fair-complexioned white women
Result—fractures: Spine, Hip, Forearm (sentinel event)
Tetany—MEDICAL EMERGENCY
Low ionized calcium in blood (hypocalcemia)
Diagnostic signs: Chvostek sign—tapping over facial nerve → twitch of the facial muscles; Trousseau sign
—B/P cuff pressure → spasms of the forearm and hand Calcium Toxicity
Hypercalcemia Caused by diseases, usually not diet
Can cause calcium deposits in soft tissues Milk-alkali syndrome Recent causes: excessive calcium carbonate ingestion to prevent osteoporosis
Phosphorus (P)
All animal products (meat, poultry, eggs, milk) dried peas, bran and whole grains, raisins, prunes, dates
Normal: 2.5-4.5 mg/dL
Bone and teeth, acid-base, energy metabolism, regulation of hormone
Deficiency: unknown
Toxicity: low blood calcium
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Normal Results. Serum phosphorus is measured in milligrams of phosphorus per deciliter of blood (mg/dL). A normal range (in adults) is generally 2.5 to 4.5 mg/dL. The normal range varies slightly depending on your age.
Calcitriol is the chief enhancer of absorption of phosphorus, which occur primarily in the duodenum and jejunum.
Magnesium Mg
Bone formation, nerve, smooth muscle relaxation, protein synthesis, CHO metabolism, enzyme activity
Deficiency: weakness, confusion, growth failure in children
Severe – convulsions, hallucinations, tetany
Toxicity- none from food
Supplemental Mg- diarrhea, nausea, cramping
Normal: 1.5-2.5mEq/dL
Important for maintenance of heart and nervous system
can cause deficiency-Diuretics: Lasix, Bumex, Edecrin, and hydrochlorothiazide Antibiotics: Gentamicin, and Amphotericin Anti-neoplastic medication: Cisplatin
Magnesium is the fourth most abundant mineral in the body and is essential to good health. Approximately 50% of total body magnesium is found in bone. The other half is found predominantly inside cells of body tissues and organs. Only 1% of magnesium is found in blood, but the body works very hard to keep blood levels of magnesium constant [1].
Green vegetables such as spinach are good sources of magnesium because the center of the chlorophyll molecule (which gives green vegetables their color) contains magnesium. Some legumes (beans and peas), nuts and seeds, and whole, unrefined grains are also good sources of magnesium [5]. Refined grains are generally low in magnesium [4-5]. When white flour is refined and processed, the magnesium-
rich germ and bran are removed. Bread made from whole grain wheat flour provides more magnesium than bread made from white refined flour. Tap water can be a source of magnesium, but the amount varies according to the water supply. Water that naturally contains more minerals is described as "hard". "Hard" water contains more magnesium than "soft" water.
Magnesium Deficiency and Toxicity
Deficiency
Malabsorption disorders—vomiting or diarrhea
Excessive alcohol use with poor nutrition
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Chronic diuretic use Diabetes
Toxicity: kidney disease
Sulfur S
All protein foods (meat, poultry, fish, eggs, milk, dried peas and beans, nuts)
Component of disulfide bridges in proteins, component of biotin, thiamin, and insulin
Function: give shape to the hair and skin
Deficiency- unknown
Toxicity- in animal, excessive intake of sulfur
Iron Fe
Essential in formation of hemoglobin
Primary storage form in body is ferritin
Selectively absorbed
The Western diet contains an estimated 5 to 7 milligrams of iron per 1000 kilocalories
Iron is essential component of hemoglobin that transports oxygen throughout the body. Red meat; cooked dark green, leafy vegetables; and fortified cereals are good sources of iron.
Beef liver, red meats, fish, poultry, clams, tofu, oysters, lentils, dried peas, beans, fortified cereals, bread, dried fruit
Oxygen transport via hgb and myoglobin
Deficiency: impaired function, decreased work capacity, apathy, lethargy, fatigue, itchy skin, pale nails beds and eye membranes, impaired wound healing, intolerance to cold temp
Toxicity: increased risk of infections, apathy, fatigue, lethargy, joint disease, hair loss, organ damage, enlarged liver, amenorrhea, impotence; Accidental poisoning- death
Iron deficient anemia- microcytic, hypochromic- iron stores depleted
Hgb is composed of heme, the non-protein portion that contains iron and globin, a simple protein
Lower than normal hemoglobin levels indicate anemia. The normal hemoglobin range is generally defined as 13.5 to 17.5 grams (g) of hemoglobin per deciliter (dL) of blood for men and 12.0 to 15.5 g/dL for women. The normal ranges for children vary depending on the child's age and sex. Most significant worldwide deficiency
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Groups at risk: infants, young children, adolescents, childbearing women; 30%–50% post bariatric patients Iron and Iron Deficiency Anemia
Iron is a mineral needed by our bodies. Iron is a part of all cells and does many things in our bodies. For example, iron (as part of the protein hemoglobin) carries oxygen from our lungs throughout our bodies. Having too little hemoglobin is called anemia. Although anemia has a number of causes, iron deficiency anemia is the most common type of anemia.
Increase intake has the potential to improve the health of millions of people In the US, iron is the most common cause of accidental pediatric poisoning deaths in children younger than the age of 6 years.
Surplus of iron is stored in the liver as hemosideria. When large amounts of hemosideria are deposited in the liver and spleen without tissue damage, a condition called hemosiderosis results. Iron absorption is increased in an acid environment. OJ provides such as environment.
Iron Toxicity
Poisoning—most common cause of pediatric poisoning in United States
Hemochromatosis
Cooking in iron pots
Zinc Zn
Oysters, red meat, poultry, dried peas, beans, fortified cereals, yogurt, cashews, pecans, milk
Tissue growth, wound healing, sexual maturation and reproduction, Vit A transport taste perception
Deficiency: growth retardation, hair loss, diarrhea, delayed sexual maturation and impotence, eye and skin lesions, anorexia, delayed wound healing, taste abnormality, lethargy
Toxicity- anemia, elevated LDL, low HDL, diarrhea, vomiting, impaired Calcium absorption, fever, muscle pain, reproductive failure
Plays a role in sexual maturation. A deficiency of zinc can lead to delayed sexual maturation
Increase intake of zinc can interfere with iron and copper absorption.
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Zinc Deficiency
In children: Growth retardation, Skeletal abnormalities, Delayed sexual maturation In adults: Alopecia, Loss of taste sensation, Poor wound healing, Impaired immunity Zinc Toxicity
Swallowed coins that released zinc into the body Overuse of zinc-containing denture adhesive Selenium (Se); Copper (Cu)
Selenium:
Brazil nuts, tuna, beef, cod, turkey, egg, cottage cheese, rice, enriched and whole wheat bread
Antioxidant enzymes, immune system, thyroid gland activity
Def: enlarged heart, poor function, impaired thyroid
Toxicity: nausea, diarrhea, hair and nail changes nerve damage
Copper:
Organ meats, seafood, nuts, seeds, whole grain, cocoa, drinking water
Production of hgb – energy metabolism
Def: anemia, bone abnormality
Toxicity- vomiting, diarrhea, liver damage, Wilson disease
Deficiency of selenium causes cardiomyopathy. A deterioration of the heart due to selenium deficiency has occurred in residents of China’s Keshan province
Keshan disease, a cardiomyopathy frequently seen in China is r/t a deficiency or impaired metabolism of
selenium.
Menkes and Wilson diseases are inherited inabilities to metabolize copper producing deficiency and toxicity, respectively.
Manganese Mn; Fluoride Fl
Manganese:
Whole grains, oat, tea, pineapple, spinach, dried peas- beans
Metabolism of carbs, protein, fat, and bone formation
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Deficiency: rare
Toxicity: nervous system d/o
Fluoride: Fluoridated water, water naturally contain Fl, tea, seafood
Tooth enamel, resistance to dental decay, bone formation and integrity
Deficiency: dental decay, osteoporosis
Toxicity- fluorosis- mottling of teeth, nausea, chest pain, itching
Chromium Cr; Molybdenum Mo
Chromium:
Broccoli, grape juice, whole grains, red wine
Cofactor for insulin
Def: insulin resistance, impaired glucose tolerance
Toxicity: Occupational- damage skin and kidney
Molybdenum:
Milk, legumes, bread, grains
Works with riboflavin to incorporate iron into Hgb
Toxicity- occupational- gout like symptoms
Metallic taste sensation is characteristic of chromium toxicity.
Individuals receiving parenteral nutrition without chromium have shown these signs of deficiency:
Weight loss
Peripheral neuropathy
Impaired glucose utilization
High plasma levels of free fatty acids Cofactor for insulin: A cofactor is a non-protein chemical compound or metallic ion that is required for a protein's biological activity to happen. These proteins are commonly enzymes, and cofactors can be considered "helper molecules" that assist in biochemical transformations.
Mineral Supplementation
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Most beneficial healthy minerals can be supplemented by food intake
If supplementation is necessary with medication, make sure it meets daily requirements—not too much,
little
Make sure to tell health care providers what supplements you take
Excessive intake of nutrients can be as harmful as insufficient intake. For most healthy people, foods are the preferred source of minerals. Mineral supplements produced by a pharmaceutical manufacturer are the best choices.
Clicker Question Which of the following is a function of sulfur?
A. Participates in the synthesis of thyroid hormones
B. Assists in the formation of hemoglobin
C. Combines with toxins to neutralize them
D. Stimulates osteoblast production
Chapter 8: Water
Essential component of older adult’s nutrition plan
Important for maintenance of temperature
Easiest dietary means of fluid intake
Amount of water needed determined by: Age, gender, chronic disease, physical activity, heat exposure
Water in Human Nutrition
Largest single constituent of the human body
Need for water more urgent than other nutrients: Humans can only survive for 6 days without water
The body has autonomic monitoring and regulating mechanisms to achieve this homeostasis
It constitutes at least half of everyone’s body weight, so that the single most important measure of fluid balance is daily weight Babies comprise of 78% water Water is a colorless, transparent, odorless, tasteless liquid that forms the seas, lakes, rivers, and rain and
is the basis of the fluids of living organisms.
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Your body uses water in all its cells, organs, and tissues to help regulate its temperature and maintain other bodily functions. Because your body loses water through breathing, sweating, and digestion, it's important to rehydrate by drinking fluids and eating foods that contain water. Review Question
Which energy nutrients supplies the greatest amount of water produced by their metabolism?
A. CHO
B. Fat
C. Protein
D. Alcohol
Water
Single largest body substance
More than half body weight
Muscle tissue is 70% water
Fat tissue is 30% water
Bone tissue is 10% water Most essential of all nutrients
Adult body: 50%-60% water by weight
Proportion depends on body composition, age, bone density, body weight, and hormone status
Water requirement for adult is approx. 1mL/cal of intake
Requirement increased for patients who are immobile, have a fever, or have diarrhea
Children reach the adult proportion of body water to body weight at about 3 years of age
Premature infants – up to 80% of their body is water
Normal newborn – 75% of body is water
A woman’s body is approx. 50-54% water
A man’s body is approx. 60-65% of water
Used in every body process from digestion to absorption to elimination or secretion
Most foods contain water, and the body obtains a substantial amount needed directly from food
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Not stored in the body, what is lost during 24 hours must be replaced
General rule: the patient should take in an amount equal to the recorded fluid plus 500 mL
Water is absorbed back into the blood stream from the large intestine.
Fluid Compartments
Intracellular
Extracellular: Interstitial, Intravascular, Lymphatic, Transcellular Body fluids are contained in intracellular and extracellular compartments. These compartments are separated by semipermeable membranes, which allow some substances to pass through and prevent the passage of other substances. Water passes freely through the membranes. Intracellular: the fluid inside the cell or located or occurring within a cell or cells. In adults, intracellular water constitutes about 65% of body water. In infants, approximately 46% of the body water is intracellular. Extracellular: situated or taking place outside a cell or cells. 35% of the body’s water is extracellular, whereas in infants, the approximate proportion is 54%. Figure 8-2 illustrates these relationships. The difference is important because extracellular fluid is more easily and rapidly excreted than is intracellular
fluids. Extracellular fluid includes interstitial, intravascular, lymph, and transcellular fluids. interstitial: between the cells. Assist in transporting substances between the cells and the blood and lymph vessels. Intravascular: situated or occurring within a vessel or vessels of an animal or plant, especially within a blood vessel or blood vascular system. Examples: arteries, arterioles, capillaries, venules, and veins.
Lymphatic: of or relating to lymph or its secretion. Via the lymphatic vessels assists in returning the fluid part of the blood to the heart.
"Lymphatic vessels"
Transcellular transport involves the transportation of solutes by a cell through a cell. One classic example is the movement of glucose from the intestinal lumen to extracellular fluid by epithelial cells. Examples: CSF, pericardial, pleural, synovial, intraocular, and GI secretions.
Functions of Water
Gives shape and form to cells
Maintains blood volume and blood pressure
Helps form the structure of large molecules
Serves as a lubricant and a solvent
Helps regulate body temperature
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Transport nutrients to and waste away from cells
Is a medium form and participant in chemical reactions
Water is not a source for energy
Absorption
Small amount in the bloodstream
Larger amounts from the intestines
Retained in certain disease processes (edema) of interstitial fluid: Venous or lymphatic blockage, Heart failure, Severe protein deficiency, Sodium retention, Some Kidney diseases
Dietary Reference Intakes
80% from fluid intake
20% from food intake
Increase consumption when physically active
Infants receive adequate amounts via breast milk Watch older adults because thirst mechanism may be altered
Physiology of Body Fluids: Effect of Electrolytes on Water Balance
Important body electrolytes
Osmotic pressure: Transport mechanisms (Sodium pumps; Potassium pumps), Determination of osmotic
pressure, Osmolality and nutrition (Osmolarity: milliosmoles per liter; Osmolality: milliosmoles per kilogram), Serum electrolytes
Each fluid compartment has an electrolyte composition that serves its needs and has automatic mechanisms designed to keep it electrically neutral, or balanced. Osmosis is the movement of water (or another solvent) across a semipermeable membrane from an area with fewer particles to one with more particles. Osmosis is a passive process. Sodium pumps move sodium ions out of cells (and water follows). Potassium pumps move potassium ions into cell. In this manner, the body maintains electrolyte concentrations of the intracellular and extracellular fluid compartments. Active transport requires energy to operate. When two solutions on either side of a semipermeable membrane have different concentrations, pressure develops. This pressure, which is exerted on the semipermeable membrane is called osmotic pressure. Osmotic pressure causes a solvent such as water to cross the membrane, but the solutes (particles) that are outside the membrane cannot go through.
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The measure of the osmotic pressure exerted by the number of particles per volume of liquid is referred to as its osmolarity. The unit of measure for osmotic activity is the milliosmole. Clinically, osmolarity is usually reported in milliosmoles per liter. Osmolality, in contrast, is the measure of the osmotic pressure
exerted by the number of particles per weight of solvent, usually reported in milliosmoles per kilogram. The normal value of osmolality of human blood serum is about 275 to 290 milliosmoles per kilogram. The primary determinant of osmolality in the extracellular fluid is sodium. Fluids are designated isotonic if they approximate the osmolality of blood plasma. Two commonly administered isotonic intravenous fluids are 5% glucose in water and 0.9% sodium chloride. Fluids exerting less osmotic pressure than plasma are labeled hypotonic. Those exerting greater osmotic pressure than plasma are called hypertonic (ginger ale with 510 milliosmoles, 7 Up, with 640. Serum electrolytes (major electrolytes – Sodium (extracellular), K (intracellular), calcium (extracellular), Mg (intracellular), Cl (extracellular), Bicarbonate (HCO3) {extracellular}, Phosphate (HPO4) {Intracellular}
Physiology of Body Fluids: Effect of Plasma Proteins on Water Balance
Blood pressure: Systolic pressure, Diastolic pressure
Hydrostatic pressure: Capillaries (Plasma proteins, Colloidal osmotic pressure (COP))
Adequate blood pressure is necessary for this transport system to function. Bp is the force exerted against the walls of the arteries by the beating heart. One of the factors necessary to maintain blood pressure is a sufficient volume of blood in the arteries and veins. Water and nutrients in the blood are pushed out through the thin walls of capillaries into the interstitial fluid by hydrostatic pressure (BP) supplied by the heart. From the interstitial compartment, the water and nutrients cross cell membranes to bathe and nourish the cell. Plasma proteins, including albumin, remain in the capillaries because they are too large to squeeze through the capillary wall. Inside the capillaries, the remaining plasma proteins exert colloidal osmotic pressure (COP). Low serum protein is the cause of water imbalance in the body, resulting in an accumulation of water in the interstitial spaces. This edema develops because there are not enough plasma proteins in the capillaries to hold the water within the circulatory system.
Physiology of Body Fluids: Regulation of Water Intake and Excretion
Thirst mechanism
Antidiuretic hormone: Secreted from pituitary gland, also called vasopressin
Aldosterone: Hormone secreted by adrenal glands
Thirst is the desire for fluids, especially water. Thirst normally occurs when 10% of the intravascular volume is lost or when cellular volume is reduced by 1% to 2%. When blood contains too little water, its osmotic pressure increases. Special sensors in the hypothalamus monitor the osmotic pressure as the blood circulates in the brain. When the hypothalamus detects an increase in osmotic pressure, the gland
triggers a desire to drink.
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Excretion—two hormones: Aldosterone—causes body retain sodium; Antidiuretic hormone—causes body retain/reabsorb water
If thirst is not alleviated, the hypothalamus increases production of antidiuretic hormone (ADH), which is
then secreted from the posterior pituitary gland. ADH, also named vasopressin, causes the kidneys to return more water to the bloodstream rather than spill it into the urine. A rise in osmolality by 2% to 3% stimulates enough ADH to maximally concentrate the urine. The opposite is also true: a decline in osmolality by 2% to 3% produces maximally dilute urine. ADH also constricts arteries to increase blood pressure. A similar situation occurs by putting a finger over the end of a garden hose, narrowing its diameter, thereby increasing pressure of the flowing water. The release of aldosterone, a hormone secreted by the adrenal glands, is another water-balancing mechanism in the body. Aldosterone causes sodium ions to be returned to the bloodstream by the kidneys rather than to be spilled into urine. Sodium, the most influential extracellular ion, pulls water along with it. Water Imbalances
Diabetes insipidus Syndrome of inappropriate antidiuresis hormone (SIAD) Diabetes insipidus: a rare form of diabetes caused by a deficiency of the pituitary hormone vasopressin, which regulates kidney function. Diabetes insipidus (DI) is defined as the passage of large volumes (>3 L/24 hr) of dilute urine (< 300 mOsm/kg). It has the following 2 major forms: Central (neurogenic, pituitary, or neurohypophysis) DI, characterized by decreased secretion of antidiuretic hormone (ADH; also referred to as arginine vasopressin [AVP])
Diabetes Insipidus
A disorder of salt and water metabolism marked by intense thirst and heavy urination.
A rare form of diabetes caused by a deficiency of the pituitary hormone vasopressin, which regulates kidney function.
Diabetes insipidus and DM are not related.
Diabetes insipidus (die-uh-BEE-teze in-SIP-uh-dus) is an uncommon disorder that causes an imbalance of
water in the body. This imbalance leads to intense thirst even after drinking fluids (polydipsia), and excretion of large amounts of urine (polyuria).
While the names diabetes insipidus and diabetes mellitus sound similar, they're not related. Diabetes mellitus — which can occur as type 1 or type 2 — is the more common form of diabetes.
There's no cure for diabetes insipidus, but treatments are available to relieve your thirst and normalize your urine output.
The most common signs and symptoms of diabetes insipidus are: Extreme thirst, Excretion of an excessive amount of diluted urine
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Pituitary hormone: Anterior pituitary: The front portion of the pituitary, a small gland in the head called the master gland. Hormones secreted by the anterior pituitary influence growth, sexual development, skin pigmentation, thyroid function, and adrenocortical function.
Vasopressin: a pituitary hormone that acts to promote the retention of water by the kidneys and increase blood pressure.
Causes: Diabetes insipidus occurs when your body can't regulate how it handles fluids. Normally, your kidneys remove excess body fluids from your bloodstream. This fluid waste is temporarily stored in your bladder as urine, before you urinate.
Depending on the severity of the condition, urine output can be as much as 16 quarts (about 15 liters) a day if you're drinking a lot of fluids. Normally, a healthy adult will urinate an average of less than 3 quarts (about 3 liters) a day.
SIAD Causes
Central nervous system disorders (infections, hemorrhage, multiple sclerosis)
Lung disease (pneumonia, tuberculosis, cystic fibrosis)
Some tumors (oat cell of lung, carcinoma of pancreas, lymphoma, leukemia)
Certain drugs (selective serotonin reuptake inhibitors or SSKIs [saturated solution of potassium iodides], chemotherapeutic agents, antidepressants) Surgery-induced severe nausea, pain Physiology of Body Fluids: Acid–base balance
Difference between acids and bases
Buffers
Extracellular fluid: Respiratory system, Renal system
Intracellular fluid
The body is well equipped to digest and metabolize acidic and basic foods without jeopardizing its acid-
base balance, assuming normal amounts are ingested. The use of substances such as baking soda to treat an upset stomach should be discouraged, because the baking soda can be absorbed into the blood,
thereby affecting the whole body. Buffers are substances that can neutralize both acids and bases. Proteins (hemoglobin) and the bicarbonate carbonic acid system are the most important buffers in the extracellular fluid. Phosphate and proteins are two important buffers in the intracellular fluid.
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Extracellular fluid: the lungs help maintain pH by varying amount of carbon dioxide exhaled. Retained carbon dioxide makes the body fluids more acidic because it reacts to form carbonic acid, a source of hydrogen ions. Too much carbonic acid, or too much of any acid results in acidosis, a condition that causes the lungs to automatically increase the rate and depth of breathing, eliminating more carbon dioxide and water. Renal system: metabolic acids, usually derived from the diet, as well as excess carbonic acid, must be eliminated in urine. Intracellular fluid: the normal pH of the intracellular fluid is 6.8 to 7.0, slightly acid to neutral. Within the intracellular fluid, organic phosphates and proteins are the most important buffers.
Clicker Question
It is especially important to monitor the elderly for fluid balance because of:
A. Potential for changes in body temperature
B. Changes in skin turgor
C. Potential for alterations in thirst mechanism
D. Cognitive changes
Water Balance and Imbalances: Sources of Water
Most of water consumed in other beverages: Milk
Nutrients in water: Hard water, Water conditioners
Product of metabolism
Bottled water
Plain water from the tap and bottled water are obvious sources, but much of our water is consumed in other beverages. Skim milk is 91% water, and whole milk is 88% water. Hard water has calcium, magnesium, and often iron. Water conditioners used to soften water replace those minerals with sodium or potassium. We obtain about four cups of water per day in foods. Water is also a product of metabolism, which yields about 1 cup of water per day in the average person. Each energy nutrient produces a different amount of metabolic water. 1 gram of CHO produce 0.60 gram of water; 1 gram of fat = 1.07 grams of water, 1 g protein = 0.41 gram of water and 1 ounce of pure alcohol requires 8 ounces of water for its metabolism. Bottled water is not automatically safer than tap water in the US. It is estimated that 25% of all bottled water is tape water.
How Water is Lost
Sensible water losses: Skin: perspiration; Kidneys: urine; Intestinal tract: feces
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Insensible water losses: Lungs: deep perspiration or a dry climate increase the amount of water lost; Skin: evaporation A person produces approximately one quart of sweat per day.
Sensible water losses: Perspiration (skin); Urine (kidney); Gastrointestinal secretions (feces) (Above the pylorus (vomiting or stomach suctioning); Below the pylorus (diarrhea and intestinal suctioning))
Insensible water losses: Lungs and skin
Water Balance
Regulated within plus or minus 0.02%
Humans’ average loss is 1750-3000ml/day
Intake varies 2.2 L-3.7 L
Insensible loss: lungs, skin (800-1000mL/d) Sensible losses: Urine & feces
What is the minimum daily total fluid output? 400-600 mL/day is the amount of urine usually required to excrete metabolic waste. 500 ml of urine daily to rid itself of metabolic wastes, the minimum daily total fluid output is approximately 1500mL. To maintain water balance, intake should approximate output
Intake = Output
Average person produces approximately one quart of sweat per day
Obligatory excretion is the amount of urine necessary to carry waste products
Water Balance and Imbalances: Assessment
Weight: Daily weight (Most important indicator of fluid status), Acute weight loss, Infant fluid balance, Weight changes (Metabolic events, Fluid shifts)
One liter is 1 kilogram or 2.2 pounds
Mild volume deficit, 2% to 5% loss
Moderate volume deficit, 5% to 10% loss
Severe volume deficit, greater than 10% loss.
Best time is early in the morning before breakfast. Intake and output: Approximately equal, Measuring (Intake, Output)
Water imbalances
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Insufficient fluid volume: Hypotonic fluids (Plain water not advised), Children with diarrhea
Excessive fluid volume: Overhydration, Osmotic diuretic drugs
Treating insufficient fluid volume with appropriate fluids is essential, as is correcting the cause. Hypotonic fluids are given to replace fluid volume and correct electrolyte imbalances orally if possible but by nasogastric tube or IV if necessary. Ex of hypotonic is Pedialyte for children with diarrhea. Plain water not advised for treating insufficient fluid volume because it is likely to inhibit thirst and to increase
urine output. Mannitol is an osmotic diuretic drug in the extracellular space. By increasing the osmotic pressure there, these drugs pull excess fluid from the cells to be excreted by the kidney.
“Third” Space Losses
Large amounts of fluid can accumulate in several places in the body outside the circulatory system Third-space losses involve internal bleeding, collection of fluid in the chest cavity, or abdomen (ascites) An alert nurse can spot an early clue to third-space losses: decreasing urine output despite seemingly adequate fluid intake
Ascites - Abdominal swelling caused by accumulation of fluid, most often related to liver disease.
Water Intake
It is essential body cannot produce as much as it needs.
Intake needs and recommendations? How do you evaluate your client’s hydration needs?
What factors cause increase loss?
Alteration in Intake:
What are the signs and symptoms of dehydration?
Problems with over consumption of water, Hyponatremia
Symptoms include lung congestion, muscle weakness, lethargy, confusion leading to seizures
Ascites: accumulation of fluid in abdominal cavity.
Impaired mental functioning, impaired motor control increased body temperature, increased heart rate,
Ascites tx: abdominal tap/paracentesis. Abdominal tap, or paracentesis, is a procedure to remove excess
fluid from the abdominal cavity, which is the area between the abdominal wall and the spine. Excess fluid in the abdomen is called “ascites.” Normally, there should be no ascites within the abdominal cavity.
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Dehydration: decreased urine output, increase pulse, decreased BP, cool, clammy skin, insufficient fluid volume taking longer than 3-5 seconds
Edema is the accumulation of excessive fluid in the interstitial (fluid between the cells) space
The Body’s Sources of Water
Beverages
Foods
Water from the metabolism of the energy nutrients
Waterborne Diseases Caused by pathogenic microorganisms that most commonly are transmitted in contaminated fresh water
Infection commonly results during bathing, washing, drinking, in the preparation of food, or the consumption of food thus infected.
Top 10 Causes - Outbreaks in Public Water Systems: Giardia, Legionella, Norovirus, Shigella, Campylobacter, Copper, Salmonella, Hepatitis A, Cryptosporidium, E. coli, excess fluoride (tie)
Chapter 9: Digestion, Absorption, Metabolism, and Excretion
Digestion
The first step in preparing food for use
Alimentary canal: Oral cavity, pharynx, esophagus, stomach, small intestine, large intestine; Sphincters separate segments; Mucosa lines and secretes mucus
Accessory organs: Liver, Gallbladder, Pancreas
Digestive Action
Mechanical digestion: Chewing, swallowing, peristalsis, emulsification
Chemical digestion: Chemicals, Secretions, End products
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The Food Pathway
Oral cavity: Digestive action - Salivary amylase
Pharynx: No digestive action
Esophagus: No digestive action
The Food Pathway: Stomach
Structure
Gastric juice
Digestive action: Chyme, Gastric emptying (Gastroparesis, Ileus)
The Food Pathway: Small Intestine
Structure
Digestion of carbohydrates: Enzymes (Maltase, Sucrase, Lactase), Lactose in miscellaneous products
Digestion of carbohydrates: The action of pancreatic and intestinal enzymes completes carbohydrate digestion. Pancreatic amylase breaks down any remaining starch into maltose. And the action of three enzymes (maltase, sucrose, and lactase) located in the walls of the small intestine reduces the disaccharides maltose, sucrose, and lactose to monosaccharides. Each of these enzymes is specific for a given disaccharide:
Maltase breaks down maltose to glucose and glucose.
Sucrase breaks down sucrose to glucose and fructose.
Lactase breaks down lactose to glucose and galactose.
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Digestion of fats: Emulsification
Digestion of protein: Pancreatic enzymes (Trypsin, Chymotrypsin), Intestinal wall enzymes (Peptidases)
Digestion of fats: Fats are emulsified by bile salts in the small intestine before they are digested further. Emulsification is the physical breaking up of fats into tiny droplets. In this way, more surface area of the fat is exposed to the chemical action of the enzyme pancreatic lipase. Pancreatic lipase completes the digestion of fats by reducing triglycerides to diglycerides and monoglycerides, fatty acids, and glycerol.
Digestion of protein: Although hundreds of enzymes are involved in protein digestion, this text reviews only a few of the major ones. The shorter polypeptides, resulting from the stomach’s digestive action, are broken down further by pancreatic and intestinal enzymes. Two of the major pancreatic enzymes are trypsin and chymotrypsin, which have inactive precursors that are activated by other enzymes.
The intestinal wall also secretes a group of enzymes known as peptidases, which act on the smaller molecules produced by the pancreatic enzymes, reducing them to single amino acids and small peptides,
the final products of protein digestion.
Clicker Question A semifluid mass of partially digested material is called:
Trypsin
Salivary amylase
Lacteal
Chyme
Absorption
End products of digestion: Move to blood or lymphatic system, Consist of (Monosaccharides, Fatty acids and glycerol, small peptides and amino acids) Site of occurrence: Small intestine
The end products of digestion move from the gastrointestinal tract into the blood or lymphatic system in
a process called absorption. The lymphatic system transports lymph from the tissues to the bloodstream, which is technically part of the circulatory or cardiovascular system. All fluid in the lymphatic system enters the blood after it collects in the thoracic duct, which opens into the subclavian vein. Lymph enters the bloodstream through the subclavian vein. Only after nutrients have been absorbed into either the blood or lymphatic system can the body’s cells use them.
The end products of digestion include monosaccharides from carbohydrate digestion, fatty acids and glycerol (and often monoglycerides) from fats, and small peptides and amino acids from protein digestion. Absorption occurs primarily in the small intestine.
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Absorption: Small Intestine
Inner surface: Mucosal fold, Villi (Blood capillaries, Lacteal), Microvilli
Water-soluble nutrients: Hepatic portal circulation
The inner surface of the small intestine has mucosal folds, villi, and microvilli to increase the surface area for maximum absorption (Fig. 9-2). The mucosal folds are similar to pleats in fabric. On each fold (pleat) are millions of finger-like projections, called villi. Each villus has hundreds of microscopic, hair-like
projections (resembling bristles on a brush), called microvilli, on its surface. The large surface area resulting from this arrangement fosters the movement of nutrients into the blood or lymphatic system. The structure of the mucosa serves as a unit that accomplishes the absorption of nutrients.
These water-soluble nutrients, including short- and medium-chain fatty acids, eventually enter into hepatic portal circulation (via the portal vein) and travel to the liver. Hepatic portal circulation is a subdivision of the vascular system by which blood from the digestive organs and spleen circulates through the liver before returning to the heart. In the liver, the nutrients are modified according to the body’s needs
Fat-soluble nutrients: Combined with bile salts, Absorption
Starvation, stress, bowel rest: Decreases in size or wastes away
Metabolic Modifications in the Liver
Energy Nutrient
Modification
Carbohydrates
Fructose and galactose changed to glucose, excess glucose converted to glycogen
Lipids
Lipoproteins formed, cholesterol synthesized, triglycerides broken down and built
Amino acids
Nonessential amino acids manufactured, excess amino acids deaminated and then changed to carbohydrates or fats, ammonia removed from the blood, plasma proteins made
Other
Alcohol, drugs, and poisons detoxified
Absorption
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Large intestine (colon): Extends from ileum to anus, Absorbs water, minerals, and vitamins
Elimination: Composition of solids in feces
Indigestible carbohydrates: Intestinal gas
The large intestine, also called the colon, extends from the ileum (last part of the small intestine) to the anus. When chyme leaves the small intestine, it enters the first portion of the large intestine, the cecum.
It then travels slowly through the remaining parts of the large intestine: the ascending colon, the transverse colon, the descending colon, th sigmoid colon, the rectum, and the anal canal.
The appendix is attached to the cecum. It has been thought that the appendix has no known function. However, some scientists believe it plays a role in gut health. The appendix contains a layer of biofilms (a
thin layer of microbes, mucus, and immune system molecules). If disease wipes out the gut bacteria, it is
theorized that the appendix biofilm bacteria emerge to recolonize the gut (Bennington-Castro, 2018).
Water is the main substance absorbed by the large intestine. However, the absorption of some minerals and vitamins also occurs in the colon. Up to 80% of the water is extracted in the cecum and the ascending colon and returned to the bloodstream. Vitamins synthesized by intestinal bacteria, including vitamin K and some of the B complexes, are absorbed from the colon. After absorption and digestion have taken place, the remaining waste products are eliminated in the feces through the rectum
Elimination: Absorption of water into the bloodstream slowly reduces the water content of the material left inside the large intestine, and the waste product (feces) has a solid consistency. Mucus, the only secretion of the large intestine, provides Factors interfering with absorption: Malabsorption, Gut failure, Steatorrhea
Food allergies: Medical definition (Immunologically mediated abnormal reactions to foods that are life-
threatening)
Factors Interfering With Absorption
Malabsorption is the inadequate movement of digested food from the small intestine into the blood or lymphatic system. Malabsorption can cause malnutrition. Table 9-5 lists factors that interfere with the absorption of nutrients. Note in the table that many diseases, medications, and some medical treatments have a negative impact on the absorption of nutrients. Clinical Application 9-2 discusses surgical removal of all or part of the alimentary canal and the effect on absorption. Clinical Application 9-
3 discusses inadequate absorption.
The cells lining the inside layer of the small intestine have a very short life. The smallest structures are replaced every 2 to 3 days. Although this rapid cell turnover helps to promote healing after injury, it also allows vulnerability to any nutritional deficiency or process that might interfere with cell reproduction. Genomic Gem 9-1 describes celiac disease, in which ingestion of gluten causes an autoimmune response
that damages the lining of the small intestine.
Gut failure describes a situation in which the small intestine fails to absorb nutrients properly. Symptoms of gut failure include:
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Metabolism
Metabolism: All chemical and physical processes in an organism
Catabolic reactions: Breakdown of nutrients for energy, Storage of excess nutrients
Anabolic reactions: Growth and repair of tissue, Energy Production in the Cells
Metabolism is the sum of all chemical and physical processes continuously going on in living organisms, comprising of both anabolism and catabolism. Liver plays a major role in metabolism. Catabolic reactions: results in the release of energy. It is the breaking down of tissues into simpler substances that the body can reuse or eliminate. Many steps are involved in the catabolic process responsible for the release of this energy. These steps require one or more of the following agents: enzymes, coenzymes, or hormones. Some vitamins and minerals act as coenzymes. Oxygen is also necessary for the full release of any potential energy. The addition of oxygen to the reaction is called oxidation. During the many steps that occur, energy is released little by little and stored as ATP.
The breakdown process includes the formation of intermediate chemical compounds such as pyruvate (pyruvic acid) and acetyl CoA. Acetyl CoA can be broken down further by entering a series of chemical reactions known as the Krebs cycle or the tricarboxylic acid (TCA) cycle. Waste
Materials of no use to cell
Types: Solid; Nonsolid (Gaseous, Liquid)
Materials of no use to the cells become waste that is eliminated through excretion. Solid waste and some liquid is disposed of in the feces. The digestive system needs assistance from other body systems in the disposal of nonsolid waste. The lungs dispose of gaseous waste. Most liquid waste is sent first to
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the kidneys and then to the bladder to be eliminated in the urine. Some liquid waste is disposed of by the skin through perspiration.
Carbon dioxide (CO2) is a gas that is eliminated through the lungs each time one exhales. The amount of carbon dioxide exhaled depends on the type of fuel (lipid, protein, or carbohydrate) or the source of fuel
that the body is currently burning for energy. For example, more CO2 is produced when carbohydrates are utilized than when protein or fat are used.
The skin removes some of the liquid waste in the form of perspiration or water, and some is excreted in the feces. The kidneys eliminate most of the excess water, sodium, hydrogen, and urea. Urea is synthesized in the liver from the nitrogen resulting from the breakdown of amino acids. Some water is also removed from the body each time one exhales.
Clicker Question
Which of the following systems assists the digestive system in the elimination of nonsolid waste?
Lymphatic system
Respiratory system
Endocrine system
Circulatory system
Chapter 17: Diet in Diabetes Mellitus and Hypoglycemia
National Diabetes Statistics Report
Key findings include:
37.3 million Americans—about 1 in 10—have diabetes.
About 1 in 5 people with diabetes don’t know they have it.
96 million American adults—more than 1 in 3—have prediabetes.
More than 8 in 10 adults with prediabetes don’t know they have it.
In 2019, about 1.4 million new cases of diabetes were diagnosed.
For people aged 10 to 19 years, new cases of type 2 diabetes increased for all racial and ethnic minority groups, especially Black teens.
For adults with diagnosed diabetes: 69% had high blood pressure, and 44% had high cholesterol. 39% had chronic kidney disease, and 12% reported having vision impairment or blindness.
Diabetes was highest among Black and Hispanic/Latino adults, in both men and women.
Nutrition is integral to the management of diabetes
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Nationally, diabetes is the seventh leading cause of death
Definition and Diagnosis of Diabetes
Diabetes: Group of disorders with persistent hyperglycemia
Diagnosis: Glycosylated hemoglobin (A1C), Blood glucose levels
Definition of Diabetes
Defined by laboratory analysis
Fasting glucose (blood sugar) levels of at least 126 mg/dL
Prediabetes or impaired fasting glucose : 100-126 mg/dL or greater Causal or random blood glucose (RBG) greater than 200 mg/dL plus classic symptoms (increased urination, increased thirst, weight loss) is another method for diagnosing DM in adults and children
Causal or random blood glucose: 140 to 199 mg/dL is diagnostic of prediabetes
126mg/dL are required for a diagnosis of diabetes in nonpregnant adults
Fasting is defined as no kilocalorie intake for at least 8 hours
A fasting blood glucose level 100 to 126 or greater is diagnosed as prediabetes or impaired fasting glucose
Laboratory Tests for Diabetes
Fasting blood sugar
Glucose Tolerance Test (GTT)
Urine Tests
Urine Acetone
Glycosylated Hemoglobin (A1C)
Fasting blood sugar: Medical Definition of Fasting blood glucose. ... The normal range for blood glucose is 70 to 100 mg/dl. Levels between 100 and 126 mg/dl are referred to as impaired fasting glucose or pre-diabetes. Diabetes is typically diagnosed when fasting blood glucose levels are 126 mg/dl or higher.
GTT: a test of the body's ability to metabolize glucose that involves the administration of a measured dose of glucose to the fasting stomach and the determination of glucose levels in the blood and urine at measured intervals thereafter and that is used especially to detect diabetes mellitus.
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Urine tests: to evaluate severe hyperglycemia (severe high blood sugar) by looking for ketones in the urine. Ketones are a metabolic product produced when fat is metabolized. Urine acetone: Acetone is also one of the ketone bodies that is formed when the body uses fat instead of glucose (sugar) for energy. The formation of acetone is usually a sign that cells lack insulin or cannot effectively use the insulin that is available, as occurs in diabetes. Acetone is excreted from the body in the urine.
A1C: a test that measures the level of hemoglobin A1c in the blood as a means of determining the average blood sugar concentrations for the preceding two to three months — called also A1c, glycated hemoglobin, glycohemoglobin, glycosylated hemoglobin, HA1c, HbA1c.
Type 1 Diabetes
Formerly known as IDDM
Characterized by the absence of insulin
Occurs from autoimmune response that damages or destroys pancreatic beta cells, leaving them unable to produce insulin
Cannot survive without daily doses of insulin because the pancreas does not produce sufficient insulin for glucose uptake
Prone to two conditions: Ketoacidosis: hyperglycemia and excessive ketones; Hypoglycemia: low blood glucose level
Risk factors of Type 1 Diabetes
No known way to prevent Type 1 diabetes
Risk factors: Autoimmune, Genetic, Environmental Classic symptoms: Polyuria, Polydipsia, Polyphagia
First sign of disease is ketoacidosis
Accounts for 5% to 10% of all diagnosed diabetes cases
Type 1 diabetes, once known as juvenile diabetes or insulin-dependent diabetes, is a chronic condition in which the pancreas produces little or no insulin, a hormone needed to allow sugar (glucose) to enter cells to produce energy.
Type 2 Diabetes
Occurs after age of 45 and often asymptomatic
Slowly progressive and begins as a problem of insulin resistance
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Cells do not respond to insulin as they should
Pancreas compensate by secreting higher than normal levels of insulin
Insulin is preferred med
During this period of impaired glucose tolerance, glucose levels are relatively normal but insulin levels are high
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 sensitivity and insulin secretion deteriorate and frank type 2 diabetes occurs
Diabetes mellitus type 2 (also known as type 2 diabetes) is a long-term metabolic disorder that is characterized by high blood sugar, insulin resistance, and relative lack of insulin. Common symptoms include increased thirst, frequent urination, and unexplained weight loss.
Prevalence of Type 2 DM
Markedly increased among: Native Americans, Native Hawaiians, African Americans, Hispanic Americans, Islanders
Diabetes can occur as a result of a variety of disorders: Pancreatitis, Cystic Fibrosis, Surgical removal of pancreas, Cushing’s disease, Use of glucocorticoids (prednisone) or other hormones or drugs
Prediabetes
Impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) refer to a metabolic state intermediate between normal with glucose homeostasis and diabetes
Meet the criteria for IGT or IFG: if fasting glucose level of greater than 100 mg/dL but less than 126 mg/dL on more than two occasions
Gestational Diabetes
Hyperglycemia during pregnancy between 24 and 28 weeks of gestation
Risk factors include: History of gestational diabetes, Obesity, Member of certain ethnic population (Native Americans, Hispanic, Mexican, Black, Asian), Hx of giving birth to infant weighing > 9 pounds
Other/Secondary Diabetes
Other conditions: Genetic defects, Surgery, Medications, Infections, Pancreatic disease, other illnesses
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Secondary diabetes caused by: Pancreatitis, Cystic fibrosis, Down syndrome, Surgical removal of pancreas, Cushing disease, Maturity-onset diabetes of the young (MODY), Pharmacological doses of glucocorticoids or other hormones or drugs
Causes of Diabetes
Include genetic factors, lifestyle, and viral infections
Classic triad of signs and symptoms (Commonly seen in Type1)
*Polyuria: increased urination
*Polydipsia: increased thirst
*Polyphagia: increased appetite and weight loss
Other signs and symptoms: Blurred vision, bladder infection, fatigue, infection, vaginitis, poor wound healing, impotence in men, kidney disorders
Acute Clinical Situations: DKA
Diabetes ketoacidosis (DKA): experience profound insulin deficiency
Treatment: supplemental insulin, F&E replacement, and medical monitoring
Three main precipitating factors: decreased or missed dose of insulin; an illness or infection; uncontrolled disease in a previously undiagnosed person
Diabetic ketoacidosis (DKA) is a life-threatening problem that affects people with diabetes. It occurs when the body cannot use sugar (glucose) as a fuel source because there is no insulin or not enough insulin. Fat is used for fuel instead. DKA from poorly controlled diabetes
Acute Clinical Situations: HHNS
Hyperglycemic Hyperosmolar Nonketotic Syndrome
Usually seen in people with undiagnosed type 2 Diabetes
Similar to DKA but insulin deficiency is not as severe
Four Signs of HHNS: Blood glucose level > 600mg/dL; Absence of or slight ketosis; Plasma hyperosmolality; Profound dehydration
Hyperosmolar hyperglycemic state (HHS) is a complication of diabetes mellitus (predominantly type 2) in
which high blood sugars cause severe dehydration, increases in osmolarity (relative concentration of solute) and a high risk of complications, coma and death. It is diagnosed with blood tests.
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Hypoglycemia
Both type 1 and type 2 can develop hypoglycemia
May be caused by: too much insulin (accidental or deliberate), too little food intake, a delayed meal, excessive exercise, alcohol (especially in the fasting state), and medications such as oral hypoglycemic agents
Symptoms: confusion, tremors, headache, double vision, rapid heartbeat, sweating, hunger, seizure, and
coma
Hypoglycemia in Diabetes Mellitus
The immediate goal for a glucose level of less than 60mg/dL is to increase blood glucose to within a normal level as rapidly as possible
If the blood glucose level is less than 60 mg/dL, 15 grams of CHO should be consumed
15 grams of CHO are equal to: 2 to 3 glucose tablets, 6 to 10 Lifesavers candies, 4 to 6 ounces of fruit juice
Medication and Hospitalization for Diabetes
Types of medications
Insulin: Administration
Oral hypoglycemic agents: Function, Contraindications
Management of hospitalized clients: Treatment
Functions of Insulin
Only hormone that lowers blood glucose
Insulin stimulates the storage of glucose as glycogen
Influences the metabolism of protein and fat, and stimulates entry of amino acids into cells and enhances protein formation
Enhances fat storage in adipose tissue and indirectly inhibits the breakdown of fat for energy
Almost all insulins in United States are human. Insulin is necessary for glucose to gain entry into a cell. Insulin: a hormone produced in the pancreas by the islets of Langerhans that regulates the amount of glucose in the blood. The lack of insulin causes a form of diabetes.
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Long-Term Complications of Diabetes
The seventh leading cause of death in the United States
The leading cause of kidney failure, nontraumatic lower-limb amputations, and new cases of blindness among adults in the United States.
A major cause of heart disease and stroke
Chronic Complications
Involving the eyes, kidneys, and nervous system
Diabetic retinopathy: d/o involves the retina
Diabetic neuropathy: lack of sensation in extremities
Gastroparesis: paralysis of the stomach with delayed gastric emptying)
Diabetic nephropathy: kidney disease
Tragically: Some clients do NOT take the threat of chronic complications seriously until much damage has occurred.
Goals of Diabetes Management
****Keep blood glucose levels as near normal as possible*****
Attain and maintain control of blood lipid levels and blood pressure
Prevent or delay the development of complications
Meet the individual’s cultural and personal needs
Maintain the pleasure of eating by not limiting any foods unless indicated by scientific evidence
Nutrition Recommendations for Managing Diabetes
Nutrition therapy regardless of weight status, medications, blood glucose levels, and presence or absence of symptoms
Loss weight if overweight
Eat less saturated fat and cholesterol
Eat more fiber and less sodium
Medical Nutritional Management of Diabetes
Nutritional goals
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Areas where clients need assistance
Goal priority
Meal frequency
Client readiness to change
Five stages: Pre-contemplation, Contemplation, Preparation, Action, Maintenance Goal is to educate the client so they can make changes
Insulin: consistency Meal: q 4-5 hours but individualized based on the client’s lifestyle and/or medical condition.
Meal-planning approaches
Energy nutrient distribution
Macronutrient distribution: Carbohydrate, Protein, Fat
Carbohydrate counting
To achieve optimal glucose control Carbohydrate counting more precise
Mediterranean diet: Composition
Glycemic index (G I) and glycemic load (G L): Glycemic load calculation, Special considerations, Benefits of low G I and G L diet
Mediterranean diet based on the way people who live in Italy, Spain, and other countries consist of plant-based meals with small amounts of meat and chicken when they are used. Whole grains, fresh fruits and vegetables, nuts, and legumes. Fish and seafood, limited in red meat, olive oil as the main source of fat
Low Glycemic index and glycemic load, the more process the food the higher its GI/GL
ADA Recommendations for People with Diabetes
Limit saturated fat intake < 7% of total calories and minimize their intake of trans fat
Cholesterol intake <200 mg/day
2 servings of fatty fish are recommended per week Recommendations consistent with the AHA’s dietary recommendations for people at high risk of heart disease
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Preventive Care for People with Diabetes
1. Flu shot every year
2. Aspirin 81 mg per day
3. Pneumovax vaccine age 60 (or earlier if in high-risk category)
4. Ophthalmologist: yearly dilated eye exam
5. Podiatrist: once to twice a year especially with older diabetics
6. BP: 130/80 mm Hg
Exchange Lists for Diabetes
Based on their micronutrients content
A meal plan that shows the client how many exchanges from each list he/she should have
Any item on the list can be exchanged for any other Exchange lists are complex and very structured
Carbohydrate Counting
Focuses mainly on the carbohydrate content of foods
Protein and fat are not tightly controlled
Client selects foods for each meal based on how may grams of carbohydrate choices their meal plan allows
Provides more flexibility than the exchange system and is easier to use
Management of Type 1 Diabetes
Must take exogenous insulin
Intensive insulin therapy allows clients to determine their premeal insulin dosage based on their glucose
level and the amount of carbohydrate they anticipate eating
Health professionals who treat people with diabetes often apply these terms to insulin: Endogenous insulin refers to the insulin the pancreas makes, and exogenous insulin refers to the insulin people inject or infuse via an insulin pump.
Management of Type 2 Diabetes
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Have the potential to achieve glycemic control through diet and exercise
Disease progression causes most people to need oral medications and/or insulin
Oral medications vary in their action, side effects, and food concerns
Children and Adolescents with Diabetes
Have a greater variation in their daily calorie needs than adults because of their nutritional needs for growth and their more erratic activity and eating patterns
Managing diabetes is more challenging in young people
Diabetes During Pregnancy
Cause problems in the fetus and complications at delivery
Frequent glucose monitoring and three meals and two to three snacks daily are recommended
Older People with Diabetes
May need to be treated conservatively than younger people
More susceptible to severe hypoglycemia
Greater nutritional risk
May have physical or sensory impairments than complicate self-management
Labs Goal of treatment: HgbA1c of 6% or less
Newly diagnosed diabetics: check HgA1c every 3 months until blood glucose is controlled
Lipid profile at least once a year (or more if elevated)
Urinalysis once a year. If urinalysis is normal: Check urine for microalbuminuria, If positive, order 24-
hour urine for protein and creatinine
Other: electrolytes (potassium, magnesium, sodium), liver function panel, TSH
In diabetes, microalbuminuria is an early sign of diabetic kidney disease. 2. Specifically, the excretion of greater than 30 mg and less than 300 mg a day of albumin in the urine. The normal urinary albumin is less than 30 mg per 24 hours and 300 mg or more of urinary albumin per day is considered gross albuminuria.
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During Illness
Maintain normal med schedule and monitor glucose levels
Keep taking insulin or oral meds as ordered unless FBG lower than normal
Eat small amounts of food every 3 to 4 hours to keep FBG as normal as possible
Check urine for ketones. If levels moderate to high – call HCP
Drink fluids. If dehydrated call HCP Call HCP if: blood glucose >250 mg/dL, urine ketones moderate to high, feel sleepier than normal or cannot think clearly, unable to keep fluids down, diarrhea > 6 hours
Exercise
Increases glucose utilization and promotes weight loss
Some patients may reduce usual dose of medication or eat snacks before activity and afterward
There is a higher risk of hypoglycemic episodes if patient does not compensate for ↑ glucose utilization from exercising
For example: if patient exercises in the afternoon, high risk of hypoglycemia at night/bedtime if doesn’t compensate by eating snacks or lowering insulin dose
Older diabetics: stress EKG. Rule out preexisting CHD before starting exercise regimen
Simple carbohydrates (candy, juices) before or during exercise
Complex carbohydrates (granola bars) after exercise (avoid post exercise hypoglycemia)
Teaching Self-Care
People ultimately treat themselves: Education key to avoiding complications, Follow-up care critical
Hypoglycemia not related to diabetes: Reactive, Fasting
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