1. Discuss nutrition 1.

1 Definition/description of Terms: Nutrition Science that deals with: Undernutrition risk of infection medical care energy & or nutrients rural, traditional diets Optimal nutritional status risk of chronic & & infectious diseases diets nutritionally adequate but imprudent inactivity, alcohol smoking, stress adequate prudent disease Lack of inadequate in

- biological processes by which living organisms consume food & utilize the nutrients it contains for normal body structure & functions:
energy utilization growth, maintenance, development reproduction homeostasis adaptation response to environment - factors that influence food preferences: psychological social cultural economic technological

affluent modern

- proper balance diet to promote health, esp. in human beings

Food Any substances that is eaten or taken in & assimilated into the body Give nourishment to living organisms Nutritionally adequate diet satisfies 3 needs:

Obesity

- fuel (chemical energy) for all the cellular work of the body - organic raw materials for biosynthesis - essential nutrients (substances that animals cant make for itself from any raw material)
Nutritional status State of the body as a result of bodys food intake & use of energy Can identify nutritional needs of an individual or population based on

coronary heart disease diabetes hypertension stroke indicates nutrition transition rural, traditional diets Fat Sugar Fiber Low Low High Monotonous , little variety Mainly carbohydrat e staples affluent modern diets Western diets High High Low Diverse, Varied High in animal protein 1

- developed standards for the amount of nutrients we need plans to meet these needs

Module 20: The Old Man. BBS. Medicine-1. XU-JPRCM. 2005-2006.

Malnutrition Affects individuals at every stage of life (cycle) Have major impact on health & productivity of an individual or a population Impairment of health resulting from imbalance of nutrients thru:

needs, or those that limit iron bioavailability iron deficiency anemia risk of maternal & fetal mortality, premature delivery & low birth weight

- malabsorption - improper diet: poor diet or overeating too much or too little of one or more nutrients or energy

children: stunt growth & retard mental devt., resistance to infections, morbidity due to disease
child & adult: fatigue & productivity

older

Symptoms:

Iodine deficiency

- appear rapidly - take a lifetime to develop (chronic) - an important health concerns: - osteoporosis, cancer, heart disease (w/c is also due to other risk factors such as age, gender and genetics)
Two forms: overnutrition or undernutrition Overnutrition Excess intake of 1 nutrients & calories Food consumed in excess of energy needed is stored as body fat energy store & insulation obesity: risk of high BP, disease, diabetes, other chronic health problems Excess of specific nutrients (vitamins & mineral supplements) consumed

preventable

brain damage & mental retardation pregnancy: incidence of stillbirths, spontaneous abortion, developmental abnormalities such as cretism children: IQs & impaired school performance adults: associated w/ apathy & decision-making capabilities

goiter (12% of global popn) iodine: essential constituents of thyroid hormone

Vit B12 deficiency changes in the stomach that occur w/ age (risk for older adults) Vit. A deficiency - often accompanied by anemia rapid growth & devt. (infancy, early childhood, pregnancy, lactation) low intake/absorption of vitamin (A) & other nutrients (fat, protein & zinc) in relation to the need - inc Vit A need: frequent infections (such as those causing diarrhea) & illness (measles) blindness; depress immune function that risk of infection

adverse/toxic reaction in the body

Undernutrition
Deficient intake of 1 nutrients or energy Starvation: most severe form - deficiency of energy (calorie) weight loss, poor growth, inability to produce, & death (if severe enough) Symptoms often reflect body functioning that rely on the deficient nutrient Common forms: Iron deficiency rapid growth & need of iron common in children & adult chronic loss of iron due to blood loss (hook-worm infection, malaria, & other acute/chronic infections) diets w/ inadequate amounts of ironcontaining foods to meet individual
Module 20: The Old Man. BBS. Medicine-1. XU-JPRCM. 2005-2006.

Protein-energy malnutrition (PEM) - protein & energy deficiencies usually occur together

- protein deficiency can predominate in growing, developing, or healing individuals

Protein roles Synthesis of new tissue Immune func. Melanin synthesis Protein deficiency growth in height & weight

Morbidly obese Obese Overweight Normal Underweight

40 70 kg/m2 30 39.9 kg/m2 26 29.9 kg/m2 18.5 25.9 kg/m2

susceptibility to infection Skin flakes; Digestive tract cells die & cant be replaced impair absorption - refer to continuum of conditions ranging from Kwashiorkor - pure protein deficiency, to Marasmus energy deficiency (pls. refer to #2)

Desirable body weight Body wt. of a person in kg or lb that gives or would give a normal body mass index in relation to height2 of that person 1.2 Nutritional Status: Formula used Theres >1 way to compute for desirable/ideal wt: Thanhaussers method - in absence of Ht. & Wt. table - formula: Ht (cm) 100cm = wt. (kg) for western standard (- 10% wt for Filipinos) 1 in. = 2.54 cm eg, 157cm100cm=57kg57(10%) =51kg normalrange: 10 of Desired body wt > normal range: underweight < normal range: overweight Body Mass Index (BMI) anthropometric measure that uses height & wt. to estimate nutritional status in adults 1st used by Adolphe Quetelet in 1870 and was known as Quetelets Index (BMI), where:

8.5 18.4 kg/m2 Values of BMI in healthy individuals usually fall within the range 18.5 to 25.9 kg/m2 Both high and low BMI are associated with increased morbidity and mortality < normal BMI range: underweight; >: obesity BMI can also indicate body shape. Ex, many African populations are very tall and slim and hence have a very low BMI, whereas Inuit, who are short and stocky, have a high BMI Estimation frame size using elbow breath Elbow breath MEN Height in 1-inch heels 5 ft 2 in. 5 ft 3 in 5 ft 4 in. 5 ft 7 in 5 ft 8 in. 5 ft 11 in 6 ft 0 in. 6 ft 3 in 5 ft 4 in. & over 2 - 2 in. 2 - 2 in. 2 - 3 in. 2 - 3 in. 2 - 3 in. Elbow breath

WOMEN Heig ht
in 1-inch heels 4 ft 10in. 4 ft 11 in 5 ft 0 in. 5 ft 3 in 5 ft 4 in. 5 ft 7 in 5 ft 8 in. 5 ft 11 in

2 - 2 in. 2 - 2 in. 2 - 3 in. 2 - 3 in.

Nomogram in determining BMI

Module 20: The Old Man. BBS. Medicine-1. XU-JPRCM. 2005-2006.

6 ft & over

2 - 2 in.

- elbow breath: distance bet bony protrusions of elbow (right arm raised to horizontal, elbow flex to 900, w/ back of the hand facing the measurer) - medium frame: w/n range indicated - small frame: measurements < indicated - large frame: measurements > indicated - elbow 1.3 Compute your desirable body weight & comment on your nutritional status Examples: Computed DBW: 157cm100cm=57kg57(10%) =51kg Actual body wt.: 40 kg Comment: underweight Computed DBW: 157cm100cm=57kg57(10%) =51kg Actual body wt.: 60 kg Comment: Normal weight Computed DBW: 157cm100cm=57kg57(10%) =51kg Actual body wt.: 70 kg Comment: overweight Normal range: the DBW

Module 20: The Old Man. BBS. Medicine-1. XU-JPRCM. 2005-2006.

Differentiate the clinical features of the 2 types of undernutrition Marasmus often in children fed w/ diluted infant formula due to limited supply (children fed w/ cassava instead of protein-rich milk) less in breast-fed infants severe PEM (energy but also protein & other nutrients deficiency) protein:calorie is normal but total intake is not enough to prevent weight loss fat stores have been used to provide energy - generalized wasting: muscle & body fat - decreased body wt., & wrinkled face emaciated look, not so apathetic thin & dry hair Kwashiorkor common in children seen in hospitalized adults who have highprotein needs due to infection or trauma & a low-protein intake because they are unable to eat (intravenous 5% dextrose or clear diet) protein deficient: serum albumin & transferring severely diminished

fat stores retained, energy intake is adequate

no edema present - increased lipofuscin in most visceral organs (esp, heart & liver)

diarrhea frequently present pulse, BP & temperature low anemia growth failure impaired immune responses infections

apathetic & lethargic w/ severe anorexia skin depigmentation & thickening; dermatosis - flaky paint skin lesions on face & extremities are dry & hyperkeratotic - fine depigmented, reddish hair color that may fall out in patches from normal brown hair - linear depigmentation of hair generalized edema abdomen distended due to: flaccid abdominal muscle hepatomegaly (enlargement of liver due to fat accumulation because theres not enough protein to transport it) & / or ascites (because theres not enough protein to keep fluid in the blood) general atrophy of viscera or villous atrophy of the intestine may interfere nutrient absorption diarrhea is common anemia: usual feature but not generally life-threatening generalized growth failure (absent /mild)

2. Discuss the fat soluble vitamins as to: Fat soluble/lipid soluble vitamins are polar hydrophobic compounds that can only be absorbed efficiently when there is normal fat absorption. They are transported in the blood, like any other apolar lipid, in lipoproteins or attached to specific binding proteins. They have diverse functions, e.g., vitamin A, vision; vitamin D, calcium and phosphate metabolism; vitamin E,

antioxidant; vitamin K, blood clotting. As well as dietary inadequancy, conditions affecting the digestion and absorption o the lipid-soluble vitaminssuch as steatorrhea and disorders of the biliary systemcan lead to deficiency syndromes, including: night blindness and xerophthalmia (vitamin A); rickets in young children and osteomalacia in adults (vitamin D); neurologic disorders and anemia of the newborn (vitamin E); and hemorrhage of the newborn (vitamin K). Toxisity can result from excessive intake of vitamins A and D. Vitamin A and beta carotene (provitamin A), as well as vitamin E, are antioxidants and have possible roles in atherosclerosis and cancer prevention.

Vitamin A

found preformed and in precursor or provitamin forms in our diet.

1. vitA. Dietary Sources Retinoids preformed vitamin A compounds which include retinal, retinol, and retinoic acid. Found only in foods of animal origin such as liver, fish, egg yolks, and dairy products Carotinoids- provitamin which comprises carotenes and other related compounds found in plants including carrots, cantaloupe, apricots, mangoes, and sweet potatoes Alpha, Beta, Gamma carotenes, and cryptoxanthin are most important provitamin carotenoids Alpha carotene- found in leafy green vegetables, carrots and squash Beta cryptoxanthin- found in corn, green peppers and lemons 2. vitA. Daily Requirements 900 microgram per day men 700 microgram per daywomen 3. vitA. Biochemical and Physiologic Role A. Visual pigments in the retina - retinal form of vitamin combines with the protein opsin to form the visual pigment rhodopsin which helps transform the energy from light into a nerve impulse, which allows us to see, to be sent to the brain. B. Regulation of Gene Expression and Cell Differentiation - regulated by all-trans-retinoic acid and 9-cis-retinoic acid - means that it can turn on or off the production of certain proteins that regulate functions within the cells and throughout the body. - In order to affect gene expression: Retinoic acid form of vitamin A enters specific target cell (inside nucleus) retinoic acid binds to protein receptors Retinoic acid-protein receptor complex then binds to regulatory regions of DNA Changes the amount of messenger RNA (mRNA) that is made by the gene

 Change in mRNA changes the amount of protein that is produced Turning on (or off) of the gene increases (or decreases) the production of proteins Affects various cellular functions (ex. Vitamin A turns on a gene that makes an enzyme in liver cells, which enable the liver to make glucose by gluconeogenesis) C. Maintenance of Epithelial Tissue - Includes skin, linings of the eyes, intestines, lungs, vagina, and bladder - If vitamin A is deficient, epithelial cell do not differentiate normally because vitamin A is not there to turn on or off the production of particular proteins Ex.: Epithelial tissue on many body surfaces contains cells that produce mucus for lubrication. When mucus-secreting cells die, new cells differentiate into mucus-secreting cells to replace them, but when vitamin A is deficient, the new cells do not differentiate properly and instead become cells that produce a protein called keratin which is a hard protein that makes up the hair and fingernails. D. Reproduction Growth and Immunity - In reproduction, vitamin A play a role during embryonic development by directing cells to form the shapes and patterns needed for a completely formed organism - In growth, vitamin A affects the activity of cells that break down bone - In immunity, vitamin A is needed for the differentiation that produces the different types of immune cells E. Beta Carotene (-carotene) - Beta carotene (carotenoids) can be converted to vitamin A in the intestinal mucosa and unconverted carotenoids also reach the blood and tissues where they may function as antioxidants, a role independent of any conversion to vitamin A - Beta carotene and other carotenoids are antioxidants that play a role in protecting cell membranes from damage by free radicals - Antioxidant properties of carotenoids have stimulated interest in their ability to protect against diseases in which oxidative process play a role, such as cancer, heart disease, and impaired vision due to muscular degeneration and cataracts. 4. vitA. Active Form A. Retinoids a. retinol b. retinaldehyde c. retinoic acid B. Carotenoids a. -carotenes b. -carotenes c. -carotenes d. cryptoxanthin In the retina, retinaldehyde functions as the prosthetic group of the light-sensitive opsin proteins, forming rhodopsin (in rods) and iodopsin (in cones) Any cones in the cells contain only one type of opsin and are sensitive to only one color In the pigment epithelium of the retina, all trans retinal is isomerized to 11-cis-retionol and oxidized to 11-cis retinaldehyde

This reacts with a lysine residue in opsin, forming the holoprotein rhodopsin Absorption of light by rhodopsin cause isomerization of the retinaldehyde from 11cis to altrans and a conformational change in opsin Result in the release of retinaldehyde from the protein and the initiation of a nerve impulse Formation of the initial excited form of rhodopsin, bathorhodopsin, occurs within Pico seconds of illumination Then a series of conformational change leading to the formation of metarhodopsin II, which initiates a guanine nucleotide amplification cascade and then a nerve impulse Final step is hydrolysis to release an all-trans-retinaldehyde and opsin. The key to initiation of the visual cycle is the availability of 11-cis-retinaldehyde hence vitamin A In deficiency both the tie taken to adapt to darkness and the ability to see in poor light is impaired.

5. vitA. Synthesis Carotenoid (Carotenes, Cryptoxanthin, and related compounds from plants) Provitamin A (from animals) Cleaved by enzyme carotene dioxygenase (Asymmetric cleavage) Retanaldehyde 8-, 10-, 12-apo-carotenals

Retinol

Retinoic acid

6. vitA. Manifestations of Deficiency: Earliest sign of deficiency is a loss of sensitivity to green light, followed by impairment of adaptation to dim light, then followed by night blindness. Prolonged deficiency leads to xerophthamia (keratinization of cornea and skin, and blindness). In differentiation of immune cells, mild deficiency leads to increased susceptibility to infectious disease. Furthermore, synthesis of retinol-binding protein in response to infection is reduced, decreasing the circulating vitamin and therefore, a further impaiment of immune responses. Vitamin A is toxic in excess Excessive intakes lead to accumulation beyond the capacity of binding proteins, so that unbound vitamin A causes tissue damage. Symptoms affect CNS ( headache, nausea, ataxa, anorexia, all associated with increased cerebrospinal fluid pressure), the liver (hepatomegaly with histologic changes and hyperlipidemia), calcium homeostasis (thickening of the long bones, hypercalcemia, calcification of soft tissues), and the skin (excessive dryness, desquamation, and alopecia).

Vitamin D

1. vitD. Dietary Sources egg yolk, liver, fish oils, salmon, fortified margarine and milk, sunlight 2. vitD. Daily Requirements 5-15 mg recommended intake for adult The recommended intake of vitamin D is based on the amount needed in the diet to maintain normal blood of 25-hydroxy vitamin D3 The AI for adult men and women is set at 5 microgram per day. The AI is expressed in microgram but the vitamin D content of foods and supplements may also be given as International Units ( IU ); one IU is equal to 0.025 microgram of vitamin D3 (40 IU=1 microgram of vitamin D.) The AI for vitamin D for adults is contained in about 2 cups of vitamin D-fortified milk 3. vitD. Biochemical and Physiological Role - Maintenance of calcium balance; enhances intestinal absorption of Ca2+ and mobilizes bone mineral. - The principal function of vitamin D is to maintain normal blood levels of calcium and phosphorus. When calcium blood levels drop too low, the parathyroid gland releases parathyroid hormone (PTH). PTH release stimulates enzymes in the kidney to convert 25-hydroxy vitaminD3 to active form of the vitamin 4. vitD. Active Form - Active vitamin D regulates calcium and phosphorus balance by altering gene expression in cells at the intestine and bone. At the intestine, Vitamin D increases the absorption of calcium and phosphorus. This occurs because vitamin D increases the expression of gene that code for intestinal calcium transport proteins - At the bone, vitamin D works in conjunction with the PTH to increase bone breakdown, releasing calcium and phosphorus into the blood. This occurs because vitamin D causes precursor cells in the bone to differentiate into cells that breakdown the kidneys - In addition to bone, intestine and kidney, receptors for active vitamin D have been found in the pancreas, parathyroid gland, cells of the immune system and reproductive organs. 5. vitD. Synthesis - Vitamin D is synthesized in the skin - 7- Dehydrocholesterol (an intermediate in the synthesis of cholesterol that accumulates in the skin), undergoes a nonenzymic reaction on exposure to ultraviolet light , yielding previtamin D - Undergoes a further reaction over a period of hours to form the vitamin itself, cholecalciferol, which is absorbed into the bloodstream. 6. vitD. Manifestations of Deficiency - In the vitamin D deficiency, rickets, the bones of children are undermineralizrd as as result of poor absorption of calcium. Similar problems occur in adolescent who are deficient during the growth spurt. - Osteomalacia in adults results from demineralization of bone in women who have little exposure to sunlight, often after several pregnancies. Although vitamin D is essential for prevention and treatment of osteomalacia in the elderly, there is little evidence that it is beneficial in treating osteoporosis

Vitamin E
A fat soluble substance with an anti-oxidant function First identified as a fat-soluble component of graits that was necessary for fertility in lab rats

Has chemical name for vitamin e, tocopherol, is from the Greek word tos (meaning child birth) and pheros (meaning to bring forth). Promoted as a cure for infertility, an anti-scar medication, a defense against air pollution, and a fountain of youth. 1. vitE. Dietary Sources Vitamin E can be found in vegetable oils, leafy green vegetables, nuts and peanuts 2. vitE. Daily Requirement The recommendation for vitamin e intake is based on the amount needed to maintain plasma concentrations of alpha-tocopherol that protects the red blood cells from breaking RDA for adult men and women is set at 15 mg/day of Alpha-tocopherol; the RADA does not change with advancing age. For infants, an adequate intake for vitamin e had been set based on the amount consumed by infants fed principally with human milk RDA for children and adolescent have been estimated for adult values Vitamin E is relatively non-toxic. The UL is 1000mg/day from supplemental sources. Supplement should not be taken by individuals taking blood-thinning medications because it reduces blood clotting and interferes with the action of Vitamin K. 3. vitE. Biochemical and Physiological Role Vitamin E functions as an antioxidant. It neutralizes reactive oxygen compounds before they damage unsaturated fatty acids in the cell membranes. By protecting the cell membranes, vitamin E is important in maintaining the integrity of the RBC, cells in the nervous tissue and cells of the immune system Vitamin E is a chain-breaking, free radical trapping anti-oxidant in cell membrane and plasma lipoproteins. It reacts with the lipid peroxide radicals formed by peroxidation of polysaturated fatty acids before they can establish chain reaction The tocopheroxyl radical is reduced back to tocopherol by the reaction with vitamin C from plasma. The resultant monodehydroascorbate free radical then undergoes enzymatic or non-enzymatic reaction to yield ascorbate or hydroascorbate, neither of which is a free radical. The stability of the tocopheroxyl free radical means that it can penetrate further into the cells and potentially propagate a chain reaction. Therefore vitamin E may also inhibit an enzyme that allows the build-up of atherosderotic plaque and increase the synthesis of an enzyme needed to produce eicesinoid that help lower BP and reduce blood clotting formation. 4. vitE. Active Forms Alpha tocopherol The form that can meet the vitamin e requirements in humans The other forms do not meet the vitamin E needs because they must be converted to alphatocopherol in humans and cannot be transported by the alpha-tocopherol transfer protein There are also differences between the natural and synthetic alpha-tocopherol found in dietary supplement and fortified foods. 5. vitE. Synthesis 6. vitE Manifestation of Deficiency Vitamin E deficiency results in resorption of fetuses and testicular atrophy. Although vitamin E deficiency is uncommon, supplements are promoted to grow hair; restore, maintain, and or increase sexual potency and fertility;

alleviates fatigue; maintain immune function; enhance athletic performance; reduces symptoms of PMS; slow aging; prevent heart disease and cancer and treat a host of other medical problems Vitamin E protects membranes, therefore a deficiency can cause membrane changes; RBC nerve tissue are particularly susceptible Newborn infants have low blood tocopherol level because there is little transfer of vitamin e from mother to fetus until the last week of pregnancy. In these infants, ruptured RBC may cause hemolytic anemia

Vitamin K
Discovered as a result of investigations into the cause of bleeding disorder (hemorrhagic or sweet clover disease) of cattle, and of chickens fed on a fat free diet. Vitamin K was name for KOAGULATION, the Danish word for COAGULATION, or blood clotting. 1. vitK. Dietary Sources The best sources of vitamin K are the leafy green vegetables such as spinach, broccoli, brussel sprouts, kale and turnip greens, and some plant oils. Some vitamin K are also secreted by bacteria in the human gastrointestinal tract. The following are some of the dietary sources of vitamin K: Mustard greens Kiwi Soy bean oil Carrots Lentils Tomato Margarine Whole wheat bread Apricots Beef liver Sun Flower seeds Almonds Oat meal

2. vitK. Daily Requirements Unlike other fat soluble vitamins, vitamin K is used rapidly by the body, so a constant supply is necessary. Adequate intake for men is 120 microgram per day, for women is 90 microgram per day. Adequate intake for infants is set based on the amount typically consumed in beast milk. 3. vitK. Biochemical and Physiologic Role Vitamin K is needed for the production of the blood clotting factors, this proteins are needed to produce fibrin, the proteins that forms the structure of a blood clot. Vitamin K is the co-enzyme for carboxylation of glutamate in the post synthetic modifications of calcium binding proteins. Vitamin K is the co-factor for the carboxylation of glutamate residues in the post synthetic modification of proteins to form the unusual amino acids carboxyglutamate (Gla), which chelates the calcium ion. Initially, vitamin K hydroquinone is oxidized to the epoxide, which activates glutamate residues in the protein substrate to a carbanion, that reacts non enzymatically with carbon dioxide to form -carboxyglutamate. Vitamin K epoxide is reduced to the quinone by a warfarin-sensitive reductase, and the quinone is reduced to the actual hydroquinone by either the same warfarinsensitive reductase or warfarin-insensitive quinone reductase. In the presence of warfarin, vitamin K epoxide can not be reduced accumulate and is excreted.

If enough vitamin K is provided in the diet, it can be reduced to the active hydroquinone by the warfarin-insensitive enzyme, and carboxylation can continue, with utilization of vitamin K and excretion of epoxide. A high dose of vitamin K is the antidote to overdose of warfarin. Prothrombin and several other proteins of the blood clotting system ( Factors VII,IX and X, and proteins C and S) each contains between 4 to 6 -carboxyglutamate residues which chelate calcium ion and so permit the binding of the blood clotting proteins to membranes.

Carboxyglutamate residue non-enzymatic O2 Glutamate residue Carbanion Vitamin K hydroquinone disulfide NADP+ quinone reductase NADPH Fig. 1 Role of vitamin K in biosynthesis of -carboxyglutamate Vitamin K is also important in the synthesis of bone calcium-binding proteins. Treatment of pregnant women with warfarin can lead to fetal bone abnormalities (fetal warfarin syndrome). Two proteins are present in bone that contains -carboxyglutamate, osteocalcin, and bone matrix Gla protein. Osteocalcin also contains hydroxyproline, so its synthesis is dependent on both vitamin K and C: its synthesis is induced by vitamin D. 4. vitK. Active Forms Phylloquinone The normal dietary source Found in the green vegetables Menaquinones The form of vitamin K found in supplements. Synthesize by the intestinal bacteria With differing lengths of side chain: Menadione Menadiol Menadiol diacetate *This three synthetic compounds can be metabolized to phylloquinone vitamin K quinone reductase sulfhydryl Vitamin K quinone Vitamin K epoxidose Vitamin K epoxide O2

Glutamate

5. vitK. Synthesis 6. vitK. Manifestations of Deficiency Abnormal blood coagulation is the major symptom of vitamin K deficiency. An abnormal precursor of prothormbin (pre-prothrombin) containing little or no carboxyglutamate, and incapable of chelating calcium ion, is released into the circulation. Inability to form blood clots due to vitamin K deficiency or drugs that interfere with vitamin K activity can caused death from excessive blood loss.

Vitamin A Retinol

Source: Liver fish, carrot, peaches, leafy greens, fortified milk

Recomme nded Intake for adults 700 900 mmg

Deficiency manifestati on Night blindness; Xerophthal mia (keratinizati on of cornea skin)

Groups at risk Those living in poverty. Children and pregnant women. Those of low fat or low protein Breast-fed infants, children and elderly (especially with dark skin and little sun exposure, people with kidney disease Those with poor fat absorption. Premature infants People with long-tern antibiotics use, newborns (especially premature)

Toxicity Headache , vomiting, hair loss, liver damage, skin changes, birth defects Calcium deposits in the soft tissue, growth retardatio n, kidney damage

Tolerable Upper intake level 3000 mmg/day

D Calciferol

Egg yolk, 5 1 mmg liver, fish, tuna, salmon, fortified margarin e and milk Vegetabl e oil, leafy greens, nuts, peanuts Vegetabl e oil, leafy greens, intestina l bacteria 15 mmg

Rickets poor mineralizati on of bone Osteomalaci a (bone demineraliza tion)

50 mmg/day

E Tcopherols , Tocotrieno ls K Phylloquin one, Menaquino nes

Serious neurological function (extremely rare) Impaired blood clotting, hemorrhagic disease

Inhibition of vitamin K activity

1000 mmg/day

90 120 mmg

Brain damage

ND (insufficient evidence to set an UL)

3. Identify descriptions of the water soluble vitamins to include: Watersoluble vitamins Dietar y Sourc es Whole grain and enric hed brea ds, cere als, flour s; orga n meat s, pork, other meat s, poult ry, fish, legu mes, nuts, milk, gree n vege table s Milk, orga n meat s, eggs, gree n leafy vege table s Daily Requir ements Metabolic/p hysiologic role Active Form Synthesi s Manifestat ions of deficiency

Vitamins B1 (thiamin)

Adult male: 1.5 mg/da y Adult femal e: 1.1 mg/da y

Central role in energyyielding metabolism and metabolism Thiamine of CHO diphospha (decarboxy te lation of pyruvate and alphaketo acids), nervous function

Thiamin diphosp hate (Thiamin diphosp ahtase) Thiamin

Infants: dyspnea, cyanosis, diarrhea, vomiting Adults: beriberi (fatigue, peripheral neuritis), WernickeKorsakoff syndrome /Wernicke s encephalo pathy (apathy, ataxia, visual probs.)

Vitamin B2 (riboflavi n)

Adult male: 1.7 mg/da y Adult femal e: 1.3 mg/da y

Fulfills its Mononucleot role in ide(FMN) metabolism or Flavin as the Adenine coenzymes dinucleoti flavin de mononucle otide (FMN) and flavin adenine dinucleotid e (FAD); oxidation, reduction enzymatic reactions

FMN Angular formed stomatitis by ATP (mouth depend lesions), ent dermatitis phosph , orylatio photopho n of bia, riboflavi neurologic n changes whereas FAD is synthesi zed by a further reaction with ATP in w/c the AMP

Niacin (nicotinic acid, nicotina mide)

Meat, poult ry, fish, whol e grain and enric hed brea ds, flour s, cere als, nuts, legu mes

Adult male: 19 mg/da y Adult femal e: 15 mg/da y

Nicotinamid e Adenine Dinucleoti Oxidationde (NAD+) reduction and reaction, Nicotinami functional de part of NAD Adenine and NADP Dinucloeti de Phosphate (NADP+)

Vitamin B6 (pyridoxi ne, pyridoxal , pyridoxa mine)

Meat, poult ry, fish, potat oes, swee t potat oes, vege table

Adult male: 2.0 mg/da y Adult femal e: 1.6 mg/da y

Involved in Pyridoxal amino acid phosphate metabolism ; enzyme systems involving amino acid transamina ses, phosphoryl ases, decarboxyl

moiety of ATP is transfor med to FMN Nicotinate is convert ed to desami doNAD+ by reaction first w/ 5phosph oribosyl 1pyropho sphate (PRPP) and then by adenyly lation w/ ATP. The amido group of glutami ne then contribu te to form the coenzy me NAD+. This may be phosph orylated further to form NADP+ Most tissues contain enzyme pyridox al kinase w/c is able to catalyze the phosph

Pellagra (dermatiti s, mucous membran e inflammat ion, weight loss, disorienta tion)

Infants: irritability, seizures, normocyti c anemia, vomiting, weakness Adults: facial seborrhea Stomatitis, glossitis

ases

orylatio n by ATP of unphos phorylat ed forms of vitamin to their respecti ve phosph ate esters. Pernicious Anemia(w hen lack of intrinsic factor)=M egaloblast ic anemia with degenerat ion of the spinal cord, neurologic abnormali ties

In anim al foods only: Myelin orga formation, Methylcobal n branched amin meat Adults: chain keto adenosylc s, 2 acid obalamin musc ug/da metabolism and le y , folate hydroxoco meat interconver balamin s, sions, DNA poult synthesis ry, fish, eggs, milk Meat, poult ry, fish, whol e grain cere als, legu Acyl-group 4-7 mes, transfer mg/da mush reactions y (safe room (as part of and s, coenzyme allowa --------salm A and Acyl ble on, carrier range) small protein) er amo unt in fruits and vege table s

Vitamin B12 (cyanoco balamin)

Synthesiz ed by microor ganisms

Pantothe nic acid (first designat ed as Vitamin B3)

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Normally not seen alone but with chemical agonist: depressio n, depressed immune system, muscle weakness

Vitamin C (Ascorbic Acid)

Citrus fruits , toma toes, melo ns, cabb age, brocc oli, 60 straw mg/da berri y es, fresh potat oes, gree n leafy vege table s

Connective tissue formation, catecholam ine synthesis, cholesterol Ascorbic metabolism acid , antioxidant, absorption of certain minerals such as iron

It is derived from glucose by Lgulonol actone oxidase

First, vague aches and pains; if long-term, scurvy (hemorrha ges into skin, alimentar y and urinary tract, anemia, wound healing delayed,s wollen bleeding gums, loss of dental cement)

Folic Acid Organ Adult (pteroylgl meat male: utamic s, 200 acid) deep ug/da y gree Adult n femal vege e: 180 table ug/da s; y musc Pregnan le cy: meat 400 s, ug/da poult y ry, fish, eggs, whol e grain cere als

Amino acid and nucleic acid biosynthesi s, one carbon transfer reactions

Tetrahydrofo Folate Megaloblast late derivati ic anemia (Ammoniu veson m folate) diet are cleared by specific intestin al enzyme s to monogl utamyl folate for absorpti on. Most of this reduced to tetrahy drofolat e in intestin ak cell by folate reducta se w/c uses NADPH as donor of

reducin g equival ent Coenzymes for CO2 carboxylati on 30-100 reactions in ug/da gluconeoge y (safe nesis, and lipogenesis allowa , fatty acid ble -------synthesis range) and for carboxyl group exchange Energy metabolism and Acyl--------group transport Dermatitis can progress to mental and neurologic changes, nausea, anorexia, peripheral vasoconst riction, impaired fat and carbohydr ate metabolis m Muscle weakness, fatigue

Biotin (sometim es called Vitamin H)

Organ meat s, egg yolks , nuts, legu mes

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Carnitine

Meat

----------

4. Discuss milk 4.1. Describe human milk: to include its composition and importance. General composition of milk Milk is an oil in water type of emulsion stabilized by complex phospholipids and proteins adsorbed on the surface of fat globules. The proteins are in colloidal disperdion, while the lactose is in true solution containing minerals, especially calcium and phosphorus. Mixed with these are organic acids or their salts, vitamins, enzymes and some special components such as: Lactenins special constituent in milk possessing antibacterial properties against certain streptococci. Bifidus factors substances which aid in the growth of certain microorganisms found in the breast-fed babys intestines. This is an important factors to facilitate the growth of non-pathogenic microorganisms for the synthesis of vitamin K and other vitamins needed by the newborn. Some of these factors are: A growth factor composed of N- acetylglucosamine, oligosaccharides and polysaccharides. A tetrasaccharide composecd of N-acetylglucosamine, Dglucose, d-galctose and L-fucose. Gynolactose- secondary sugar component containing N2 Glucosamine and galactosamine.

Composition of Human milk I. Carbohydrates Lactose synthesized by the mammary gland from glucose of the blood, wherein one ,ole of glucose must form one form of galactose, which then combines with another mole of glucose to form lactose, in the following scheme, Outline Form Glucose-1-PO4 + uridine triphosphate (UTP) UDP glucose + Ppi UDP- glucose --- UDP galactose epimerase UDP galactose UDP galactose + Glucose-1-PO4 galactosyl transferase lactose 1- PO4 + UDP In the mammary gland Lactose 1 PO4 ------ Phosphate Lactose + H3PO4 Other milk sugars: L-fucosyl- lactose Gynolactose Allolactose II. Milk Proteins Are synthesized by the mammary gland from the essential and non- essential acids in the blood. Intermediary products from fatty acids, glucose and bicarbonates may also contribute to the carbon skeleton of the proteins. Proteins in the human milk includes: Casein is a phosphoprotein, insoluble at its I pH of 4.6 but is present as soluble calcium caseinate in milk whose pH is about 7.0 Non- Casein Proteins Lactalbumin B-lactoglobulins immunological properties IgA IgG IgM Amino acids III. Milk Lipids Human milk fat contains mostly long-obtained fatty acids, above 10-carbon atoms. They are in the form of very small globules. These milk fats are derived mostly from acetate. Some are derived from glucose like glycerols, others are derived from stearic and oleic acids from the blood. IV. Pregnanediol Not a constant constituent of milk but a hormone present in the serum of pregnant women, which may find its way into the infant through milk. It has an inhibitory effect on bilirubin conjugation and as a result may cause hyperbilirubinemia in very young infants who are fed by pregnant mothers. V. Ash or Mineral Salts Are present in the required quantity but iron may be deficient as the infant grows. o Thus, foods rich in iron must supplement the milk diet of infants. VI. Vitamins Milk is an excellent source of vitamin A, riboflavin and pantothenic acid. It is deficient in vitamin C and Vitanmin D and other members of the B complex

4.2 Differentiate true milk from colostrums Colustrum True milk Yellowish due to Bluish due to Ca++ salt carotenes and Vitamin A of casein and emulsified fats CHOLESTEROL AND Higher which gives it a Lower LECITHIN laxative effect PROTEIN Higher so that it Lower, does not clot on coagulates on boiling boiling but forms a film IMMUNE GLOBULIN Higher, serving as Lower but it has higher secondary means of albumin and casein neonatal immunization content (placental transmission is the first) FAT higher Lower COLOR 4.3 Differentiate cows milk from human milk Human Milk 1. greater albumin/ globulin fractions than casein 2. Forms lighter, easier to digerst milk cords due to abundance of albumin 3. fatty acids are of long chained non volatile types 4. Presence of IMMUNE ANTIBODIES passively transmitted 5. Less vitamins but the quality are those needed by human infant Cows Milk Greater casein fraction than albumin/globilin fractions Forms heavier, harder to digest milk curds due to abundance of casein Fatty acids are of shorter chained volatile types NONE More Vitamins

4.4 Describe the different milk products 1. Skimmed milk fluid remaining after removing or pouring off the cream which rises after allowing milk to stand for sometime. very deficient in vitamin A 2. Butter produced by churning or agitating milk or cream, after previous souring by lactic acid/bacteria to permit the fat globules to coalesce more easily excellent source of vitamins A and D 3. Buttermilk the fluid left after milk has been churned in butter making. It differs from skimmed milk only on the loss of some casein due to the previous souring 4. Homogenized milk milk where the fat globules has been reduced in size by forcing the milk through very small apertures under pressure advantage: a. the reduced-in-size fat globules do not rise as cream when the milk is allowed to stand. b. the resulting greater surface area of the fats increases their digestion by lipases.

c. The increased fat surface will increase the amount of proteins that can be encased in it, making a less amount of protein available when clotting occurs, thus even much softer curd is formed. 5. Evaporated milk whole cows milk which has had about 60% of the water removed, homogenized and hermitically sealed in cans. 6. Condensed milk also reduced to about the same concentration as evaporated milk, but sugar (50%) is added as preservative disadvantage: o When reconstituted for infant feeding, the calorie content may be adequate but deficient in protein. 7. Dry milk may be prepared from whole milk, half-skimmed or skimmed milk. The nutritional value of dried milk is the same as the milk from which it was made with only loss of the heatlabile vitamins. ** The percentage of milk fat serves as an index of the nutritional value of the milk product thus, determining also its price. Commercially therefore, the fat of milk is its most valuable component, since it is marketed as cream and butter, or as a composition of cheese. 4.5 Discuss the factors modifying the general composition of milk 1. Species animals that grow faster has milk containing more protein for soft tissue building a. quantitative differences (comparative) between different species Species Water Proteins Fats Lactose Ash Human ++++ + ++ ++++ + Cow +++ +++ ++ +++ +++ Goat ++ +++ +++ ++ +++ Carabao + ++++ ++++ ++ ++++ b. qualitative differences between cows milk and goats milk i. goats milk gas higher proportion of lactalbumin than cows milk. ii. thiamine and riboflavin are higher in goats milk. iii. goats curd tension is lower, simulating human milk. iv. goats milk is lower in iron- resulting in anemia in countries where it is abundantly used. Calories /lb. 316 310 318 ---

2. Individual differences age the total volume of milk secreted depends on the demands of the infant, together with the secretory capacity of the mammary gland. Young mothers, as a rule secrete more milk than older ones not because they are primiparas, but because of youthful health and vigor. There are variations in the day to day secretions even in the same species or animal. Since milk is under hormonal control, pronounced effects upon lactation are observed in some endocrine dysfunction. 3. Period of lactation The first one or two weeks after delivery shows the normal composition of the colostrum, and even true milk shows a daily variation for at least eight weeks.

 The first colostrum shows an extremely high protein content, with a corresponding high content of essential amino acids. After the third week, the lactose and fats dominate the milk composition. 4. Diet High carbohydrate intake increases the volume and lactose. High fat increases the fat content, but diminishes the volume. High protein intake increases also the volume, and proteins. A poor nutritive condition influences not only the quantity, but also the quality of milk contents such as vitamins, etc. 5. Fraction of a single nursing At the beginning of a single nursing, the milk secreted is very rich in proteins, with low fat content. As secretion or nursing progresses, the protein gradually diminishes with a concomitant increase in fats, so that at about the end of the nursing period, the fats are much higher and proteins are lower than at the start. 4.6 Outline the synthesis of milk lactose Lactose synthesized by the mammary gland from glucose of the blood, wherein one mole of glucose must form one mole of galactose, which then combines with another mole of glucose to form lactose. Outline formation: a. glucose-1-PO4 + uridine triphosphate (UTP) UDP-glucose + PPi b. UDP-glucose ---UDP-galactose epimerase UDP galactose c. UDP galactose + glucose-1-PO4 ---galactosyl transferase lactose-1-PO4 + UDP d. In the mammary gland Lactose-1-PO4 ---phosphatase lactose + H3PO4 5. Discuss the recommended nutritional requirement 5.1 Define/ Describe the RDA Recommended Dietary Allowance represents a supposedly safe but arbitrary margin above the minimum requirement for a specified age, sex and body weight. This margin means that a great majority of a group will have a sufficient intake if they reached the safe allowance level. FAO & WHO publications cover the recommended requirements for calories, proteins, iron, calcium & most vitamins. Likewise, the food and Nutritional Council [FNRC have made various recommendations that are applicable to the Filipino men & women] In arriving at these recommendations, the general procedure that they have followed was to ascertain the minimum requirement for each nutrient [Minimum requirement means the level below which signs of deficiency symptoms occur or optimum health could not be possible.] To this, safety allowances were provided depending upon each particular nutrient sources, food availability, and food utilization were added. The allowances were estimated for people in normal health only, they do not provide for the increase needs for nutrients during some disease conditions. However these recommendations if followed should improved nutritional staus. The recommended allowances were intended to sere as basis for estimating national food needs, as goals in production, and as guide in planning or evaluating dietaries of groups of people. The recommendations may be used by individual if they fit within the context of the reference man & woman, otherwise, adjustment have to be made. The RDA formulated in 1960 used also the reference man & woman, as

those who are weighing 53 & 40 kg respectively in the 20-29 years old group. These weights were considered low when compared to the FAO standard. So, a

desirable weight was computed allowing an increment of 3 kg for both man & woman, making it 56 & 49 kg.

5.2 Compare the proposed body weight with the actual findings of FNRC & FAO standard Proposed Body Weight Compared Proposed Reference man 56 kg Reference 49 kg woman - 1 yrs old 9 kg 1 3 yrs old 12 kg 4 6 yrs old 17 kg 7 9 yrs old 25 kg 10 12 yrs old 33 kg with the Actual findings & FAO Actual FAO Standard 53 kg 65 kg 6 kg 55 kg 8 kg 11 kg 15.5 kg 20.5 kg 25 F 28 M 9 kg 12 kg 18 kg 27 kg 36 kg FAO Standard 49 kg 54 kg

Boys Proposed Actual 13 15 yrs old 44 kg 39 kg 16 19 yrs old 48 kg 46 kg Note: Body weight are for the mean age in each group 5.3 Describe the energy allowance Energy Allowances Energy is measured in terms of calorie. For allowances and intakes, the kilocalorie is used. A kilocalorie is defined as the amount of heat required to raise the temperature of 1000 grams of water through 1o C. Energy expenditures are of three kinds: a.) Basal Metabolism- energy expended to maintain metabolism during complete mental and physical rest. b.) Additional Energy Expenditure- mainly for muscular requirement, involved in performing physical work. c.) Specific Dynamic Action of Foodadditional energy expenditure mainly metabolic resulting from the consumption of food. This is about 10% of the BMR. Simple maintenance living usually needs about 33% more calories beyond the basal metabolism. Very active person, e.g. workers engaged in heavy industries, strenuous exercise, needs 2-3 times the basal requirements. While energy requirement is closely related to body weight or surface area of the body, it should be noted that chronically underfed person maybe 10% or more below their proper weight. Energy intake should therefore be ideally calculated according to the ideal body weight rather

than actual body weight. A stable body weight and energy intake, which just balances with energy expenditure does not necessarily mean that the diet is calorically adequate. This is important because calorie inadequacy may reduce physical activity either in adults or in children. Calorie intakes are usually regulated by appetite and food availability. In adults, the appetite is so finely adjusted to the bodily needs that a satisfied appetite and a constant body weight are normally achieved. This indicates perfect calorie balance. Period of hunger at certain times of the day or season of the year in an individual indicates calorie deficiency. Appetite, however, is not a reliable guide to the requirement for essential nutrition. This may be harmful in children who often have to go out without breakfast at certain seasons of the year. Nutrient intake may not be adequate in poor quality imbalance diet, which nevertheless do met the calorie requirement, thus prevent hunger and satisfy the appetite. CALORIE REQIUREMENT BASED PHYSIOLOGICAL ACTIVITY AND SEX ON

Females Males 1. Sedentary habit 1800-2000 2500-2700 2. Moderate activity 2100-2200 28003000 3. Very active 2400-2600 31003200

A decrease of 3% is suggested by FAO for each decade of 30-35 years and 40-49 years. For decades of 50-59 & 60-69 the decrement is increased to 7.5%. After 70 years, a further decrement of 10% is recommended.

5.4 Describe the 6 basic food groups FOOD GROUPS Examples of foods belonging to each (recommended servings) group I. Green, leafy and yellow vegetables; Alugbati, ampalaya leaves, kamote tops, 1 or more servings/day kangkong, malunggay, saluyot leaves, (1 servings= cooked or 1 c raw) mustard, petsay, squash leaves, squash leaves, squash fruit, pepper leaves, carrot, squash flowers II. Vitamin C- Rich Foods 1 or more servings/day (1 servings= 1 med. fruit) Atis, kasuy, durian, guava, guyabano, kamatsili, mango, melon, papaya, pomelo, mansanitas, siniguelas, strawberry, tomatoes III. Other fruits and vegetables Abitsuelas, ampalaya, abocado, banana, 2 or ore servings/day chico, duhat, eggplant, mabolo, macopa, ( 1 serving= c cooked or 1 c raw) malunggay fruit, okra, patola, pineapple, langka or jackfruit, kaimito, kadyos, labanos, santol, sigarilyas, sitao, sili fruit, watermelon. IV. Fat Rich Foods - Butter - Enriched margarine 3 tbsp. daily - Coconut - Lard - Coconut milk - Cooking oil - Coconut oil V. Protein-Rich Foods Beef - Legumes & Nuts Chicken A.) Whole milk, all kinds Pregnant & Nursing mothers = 2 Liver Fishes [bolinao & other small fishes] cups Pork Children = 3-4 cups Sausage B.) Meat, Fish, Poultry Shrimps 1 serving = 1 matchbox size Tulya or clams [3serving/day] C.) Eggs: 2- 3 weeks D.) Legumes: cup cooked VI. Rice & other Energy Fods - Bread - Enriched rice Rice = 3 servings/day - Corn - Pinipig ampaw [1 serving = c. raw or c. - Kamote - Ube cooked] - Kamoteng kahoy - Gabi - Sugars Root crops - Candied fruits - Bodbod - Palitaw [1 serving = 1 med size or 1 cup sliced] 5.5 State the RDA of food by using the Food Composition Table 6. Make a dietary prescription and orresponding dietary plan Underweight diet prescription and dietary plan Underweight Causes

Minerals and vitamins: if the quality of the diet resulting in weight loss was poor, considerable body deficits of minerals and vitamins may likewise have occurred. Usually the highcalorie diet will provide liberal levels of all these nutrients. When supplements are prescribed, it is important that the patient understand that they are in no way a substitute for the calories and protein provided by food. Planning the daily diet Patient cannot always adjust immediately to a higher caloric intake. It is better to begin with the patients present intake and to improve the diet both quantitatively and qualitatively day by day until the desired caloric level is reached The caloric intake may be increased by using the additional amounts of foods from the Four Food Groups, thus increasing the intake of protein, minerals, and vitamins Some patients make better progress if given small frequent feedings; but for many patients midmorning and midafternoon feedings have been found to interfere with the appetite for the following meal. The following list of foods illustrates one way in which the Four Food Groups may be adapted to a high calorie level. List of Food Sample Menu 3 to 4 cups milk Breakfast 1 cup light cream 5 to 7 ounces meat, fish, poultry, or Half grapefruit cheese Oatmeal 1 egg Fried egg 4 servings vegetables including: Whole-wheat toast 1 serving green or yellow vegetable Butter 2 servings white or sweet potato, Milk corn, or beans Coffee 1 serving other vegetable 2 to 3 servings fruit, including one Lunch citrus fruit 1 serving whole-grain or enriched Chicken souffl cereal Mushroom sauce 3 to 6 slices whole-grain or enriched Buttered green beans bread Shredded carrot and raisin salad 4 tablespoons or more butter or Whole-wheat roll and butter fortified margarine Fresh peaches high calorie foods to complete the Milk caloric requirement; cereals such Results when the energy intake does not fully meet the energy requirements. Occurs in people who are very active, tense, and nervous, and who obtain too little rest. Sometimes irregular habits of eating and poor selection of foods are responsible for an inadequate caloric intake. Some patients with mental illness reject food to such extent that severe weight loss results; this condition is referred to as anorexia nervosa. Modifications of the diet before weight gain can be effected, the direct cause for the inadequate caloric intake must be sought. Energy: approximately 500 kcal in excess of the daily needs will result in a weekly gain of about 0.5 kg. For moderately active individuals diets containing 3000 to 3500 kcal will bring about effective weight gain. Somewhat higher levels are required when fever is high, or gastrointestinal disturbances are interfering with absorption, or metabolism is greatly increased. Protein: A daily intake of 100 g protein or more is usually desirable since body protein as well as body fat must be replaced.

as macaroni, rice, noodles, spaghetti, honey, molasses, syrups, hard candies, cakes, cookies, ice cream, puddings, sauces

Dinner Boiled trout Creamed potato Buttered spinach Rye bread with butter Lemon-flake ice cream Brownies Milk Tea with lemon

7. Discuss the food exchange list 7.1 Describe the food exchange list Exchange List Is a food group system that is useful in planning diets to meet specific energy and macronutrient goals. First developed in 1950 by the American Dietetic Association and the American Diabetes Association as a meal-planning tool for individuals with diabetes. Since then, its use has been expanded to planning weight-loss diets and weight loss in general. The latest revision of the Exchange List divides foods into three main groups based on their macronutrient content: o The carbohydrate group includes exchange lists for foods that are sources of carbohydrates: starches, fruits, milk, and vegetables. It also defines a list of other highcarbohydrate foods and indicates how fit these foods into a diet based on exchanges. o The meat and meat-substitute group - includes an exchange list with four subgroups: very lean, lean, medium-fat, and high-fat meat. o Fat group includes an exchange list with subgroups of

monosaturated, polyunsaturated, and saturated fats. o (See also the correlate from Dr. Salubre below) The serving sizes for foods within each exchange list are different from those in the Food Guide Pyramid. The exchanges are set so that each food within a list contains approximately the same amount of energy carbohydrate, protein, and fat. The food groupings of the exchange list differ from the food guide pyramid groups because the lists are designed to meet energy and macronutrient criteria, whereas the pyramid groups are designed to be good sources of certain nutrients regardless of their energy content. Example: a potato is included in the starch exchange list because it contains about the same amount of energy, carbohydrate, protein, and fat as breads and grains, but in the food guide pyramid a potato is in the vegetable group because it is a good source of vitamins, minerals, and fiber.

7.2 Describe the components of the meal exchange list 7.2.1 calorie, fat, protein, and CHO content in each of the list 7.2.2 food included in each of the list Method for dietary calculations: Become familiar with the patients A physician prescribes the amounts of usual pattern of meals, the food carbohydrate, protein, and fat that likes and dislikes, and so on. The are to be used in measured diets. amount of money that can be Using the values for the exchange spent, the preparation facilities, lists; the dietitian or nurse calculates and the cultural patterns must be the number of exchanges to be considered. furnished by the diet.

Include basic food to ensure adequate levels of minerals and vitamins: ex. 2 cups milk; 5 oz. Meat; 2 servings vegetables; two servings fruit; breads and cereals. List the carbohydrate, protein, and fat values for the milk, vegetables, and fruit. Subtract the carbohydrate value of these foods from the carbohydrate level prescribed. Divide the difference by 15 to determine the number of bread exchanges. Subtract from the protein prescribed. Divide the difference by 7 to determine the number of meat exchanges.

Total the fat values for milk and meat and subtract from the total fat prescribed. Divide the difference by 5 to determine the number of fat exchanges. Check the calculations to be certain that they are correct. It is not a good idea to split the fruit, bread, and meat exchanges into half. The calculations for carbohydrate should be within 7 gm of the prescribed level, and those for protein within 3 gm of the prescribed level. Divide the total exchanges for the day into meal patterns according to the physicians diet order and the patients preference.
CHO (g) 15 15 Protein (g) Fat (g)

Energy and Macronutrient Values of the Exchange List

Exchange Group Carbohydrate Group Starch Fruit Milk Nonfat Low Fat Reduced Fat Whole Other Carb. Vegetables Meat/Meat Substitute Very lean Lean Medium Fat High fat Fat Group Serving Size Energy (kcals)

cup pasta, cereal, rice, 1 slice bread 1 small apple, peach, or pear; banana; cup canned fruit 1 cup milk or yogurt

80 60

3 0

0-1 0

Serving sizes vary cup cooked vegetables, 1 cup raw 1 oz. meat or cheese

90 110 120 150 Varies 25

12 12 12 12 15 5

8 8 8 8 Varies 2

0 3 5 8 Varies 0

1 tsb. butter, margarine, or oil; 1 tbsp. salad dressing

35 55 75 100 45

0 0 0 0 0

7 7 7 7 0

0-1 3 5 8 5

Sample Menu: (Food List) Breakfast Milk 1 cup Cantaloupe medium Whole flakes cup Toast 1 slice Egg 1 Butter 1 teaspoon Cream, light 2 tablespoons Lunch Milk 1 cup Radishes and celery sticks Apple 1 small Sandwich

Bread 2 slices Roast beef 2 oz. Mayonnaise 1 teaspoon Dinner Asparagus tips

Baked acorn squash Pears, water packed 2 halves Potato, baked 1 small Roll, dinner 1 Roast pork, lean 3 oz Butter on potato 1 teaspoon

Reference: Smolin and Grosvenor. Nutrition: Science and Applications, 4th ed. 2003. pp. 43-44, 100, 136. CORRELATE FROM DR. NENA SALUBRE MODIFICATION IN CALORIE CONTENTS I. CALCULATION OF DIETARY PRESCRIPTION A. Calorie allowance the proper calorie allowance for the adult s that which over an extended period of time will maintain his weight or near his ideal body weight for his height and sex. All computations for dietary purposes should be based on the desirable or ideal body weight and not on the actual weight, since the objective of proper nutrition is to maintain the desirable weight. There is more than one way of getting the desirable or ideal weight. In the absence of Height and Weight Table, the Thanhaussers method can be used, which is simple enough and comes out with a figure, which falls within the range of the standard height and weight table for age and sex. THANHAUSSERS TABLE Ht. (cm) 100 = wt. (kg) for western standard, deduct 10% for Filipinos Example: Height is 52 (62 in.) = convert this to cm by multiplying 2.54 = 157 cm 157 cm 100 = 57 kg (western standard) 5.7 (10%) = 51 kg DBW for Filipinos *DBW desirable body weight COMPUTING FOR CALORIE ALLOWANCE: Step I Calculate the basal calorie used for 24 hours based on DBW *BMR = 1 cal/kg.DBW/ hour Step II Calculate energy needs for Physical Activity (PA) Short method is to allow: a. Bed rest (Hospitalized patients) ----------------------------------- 10% of basal needs b. Sedentary ------------------------------------------------------------- 30% of basal needs c. Light work ------------------------------------------------------------- 50% of basal needs d. Moderately active -----------------------------------------------75% of basal needs e. Very active ------------------------------------------------------------- 100% of basal needs Step III Compute for Specific Dynamic Action (SDA) of food *10% of the sum of BMR and PA

Then take the summary of total energy requirement by adding the BMR, PA and SDA. Round it off to the nearest hundred. Sample computation using above formula in a hospitalized patient: Step I BMR = 1 cal/kg. x 51 kg x 24 hours = 1224 cals. Step II PA = bed rest (allow 10% of basal needs) = 10% of 1224 = 122 cals.

Step III. SPA

= 10% of of BMR + PA = 10% (1224 + 122) = 10% (1346) = 135 cal. Therefore, the TER = 1224 + 122+ 135 = 1481 or 1500 cal/day B. Protein-Carbohydrates and Fats may be divided as follows: a. Protein grams = 15% of TER (cal) . 4 cal/gram b. Carbohydrates = 50% of TER (cal) . 4 cal/gram c. Fats = 35% of TER (cal) . 9 cal/gram or a. Protein = 1-1.5 grams per kg IBW b. Carbohydrates = 40-50% of the nonprotein calorie c. Fats = remaining calorie Sample computation: Carbohydrate Protein Fats = 50% of 1500 cal . = 750 cal . 4 cal/gram 4 cal/gram = 225 cal . 4 cal/gram = 188 grams

= 15% of 1500 cal . 4 cal/gram = 35% of 1500 cal . 9 cal/gram

= 56 grams = 48 grams

= 525 cal . 9 cal/gram

C. Dietary prescriptions for carbohydrates, protein and fats are expressed in grams. The conversion factor from calorie to gram is 4, 4, and 9 respectively. D. In uniting the dietary prescriptions calorie are rounded up to the nearest 100, carbohydrate, protein and fats are rounded up to the nearest five (5). Dietary prescription: TER calorie = carbohydrates-proteins-fats Example: 1500 cal = 190 grams 55 grams 50 grams II. Meal Exchange List Divided as a practical guide for planning diets without accurately weighing the foods. Instead, the foods are given in household measurements for example, it is easier

to remember and prepare 1 exchange of bread and 1 exchange of meat = 1 matchbox size instead of weighing an oz. or 30 grams of meat There are six food exchanges. Each list is composed of foodstuffs with their corresponding household measurements. The measurements vary such that each food within the exchange list gives definite amounts of carbohydrates, proteins, fats and calories. The six exchange list are as follows:

CHO (gram) List I Vegetable Exchange I-A 1 exchange I-B 1 exchange List II Fruit Exchange 1 exchange List III Milk Exchange 1 exchange List IV Rice Exchange 1 exchange List V Meat Exchange 1 exchange List VI Fat Exchange 1 exchange

PRO (gram)

FAT (gram)

CALORIES

NEGLIGIBLE 3 10 12 23 0 0 1 0 8 2 8 0 0 0 10 0 4 5 18 40 170 100 68 45

If one examines each exchange list it will be noted that foods of similar composition are group together to yield the same amount of CHO, Pro, Fat and Calories, as long as one observe the given measurement for each food item. Examples: See list II 1 small apple will give the same CHO, Pro, Fat and Calories as 1/3 medium sized mabolo or 2 medium sized narangita. See list IV 1/2 cup, cooked, well-packed rice can be exchange for 2 slices of bread or 2 pieces of small pandesal or 1 cup oatmeal.
This

is the origin of the word exchange, i.e within a list, 1 foodstuff may be exchange or substituted for another by carefully observing the measurements for each food. use of the exchange list system is not limited to calculating diabetic diets. The doctor and dietician also finds it useful for estimating the CHO, Pro, Fat and Calories (or any of these) for a given diet or menu. should be emphasized that these food values are closed approximation of actual chemical analysis. For calculating average daily intake, the exchange list system is satisfactory (accurate enough and very practical)

The

It

III. CALCULATIONS OF EXCHANGES The method used in planning calculated diet is based on the idea of food exchange list. The common foods allowed are divided into six groups according to their composition. In each of these groups are listed the kinds and amounts of food that have approximately the same nutritional value in carbohydrate, fat and protein. Nutritive adequacy of the diet is assured by including the 6 Basic Food Groups and tries to meet all the dietary allowance. Food may not necessarily weigh but portions are controlled by measurement. Steps in Planning the Dietary Pattern 1. Compute for the amount of milk, vegetables and fruits included in the diet Give milk only if desired. Usually, only one exchange of the B vegetable is given.

 The vegetable A group may be given as desired within certain limits. Unless the carbohydrate is severely restricted, give at least three exchanges of fruits. 2. Sub-total the carbohydrate coming from milk, B vegetable and fruits. Take the difference from the total described carbohydrate. Divide the remaining carbohydrate by 23 to get the number of rice exchange to give. The number of rice exchange must be computed to nearest half of an exchange to avoid awkward and impractical measurements. 3. Sub-total the protein coming from milk, B vegetable and rice exchanges. Take the difference from the total prescribed protein and divide the remainder by 6 to get the number of meat exchanges. The number of meat exchange must be computed to a whole number that will give the nearest prescription for protein. 4. Sub-total the fat coming from milk and meat. Subtract from the total prescribed fat and divide the number of exchanges of fat. 5. Sum up all carbohydrate, protein, fats and calories to check whether the prescribed levels are met. A margin of error of 5 grams above or below the prescribed levels of CHO, PRO and FAT is allowed so that odd fractions are avoided. 6. Allow sugar to compensate for CHO deficiency. (No allowance in diabetic diet) 1 teaspoon refined sugar is equivalent to 5 grams CHO = 20 calories o 3 tsp. = 1 tbsp. o 1 tbsp. = 15 grams CHO or 60 calories Sample Calculations Dietary prescription: 1600 cal -----225 65 70 (CHO-Pro-fat) Food list No. of CHO gm Pro gm FAT gm exchang e I. Vegetable A As desired Vegetable B 1 3 1 II. Fruit 3 30 III.Milk 1/2 6 4 5 Partial sum 39 Prescribed CHO ---------- 225 Partial sum CHO --------- 38 Difference ----------------136 186/23 = 8 rice exchange IV. Rice 3 184 16 Partial sum 21 Prescribed PRO ----------- 65 Partial Sum PRO --------- 21 Difference ----------------- 44 41/3 = 6 meat exchange V. Meat 6 43 24 Partial sum 28 Prescribe FAT ------------ 70 Partial sum FAT --------- 29 Difference ---------------- 41 41/5 = 8 exchange VI. Fat 8 40 Cal 16 120 85

800

408

360

Total 223 69 69 1789 Sugar 1 teaspoon with coffee ------------------------------------------------------- 20

LIST I VEGETABLE EXCHANGE GROUP A LEAFY VEGETABLE Leafy vegetable or vegetables high in water of\r fiber contains negligible calories, CHO, PRO, FAT, if 1 exchange measure is used. Given as desired, if raw

Talong (eggplant) Upo (bottle gourd) Those marked with X are good sources of vitamin A and iron. At least one serving be included in the diet each day. GROUP B NON-LEAFY VEGETABLES 1 Exchange = 3 grams carbohydrates 1 gram protein 16 calories Measure: 1 exchange = cup raw (40 grams) or cup cooked (45 grams) Group B Vegetables: Abitsuelas (snap green bean) Bataw (hyacnith bean) Guisantes (sweet pod) Kadios, lab-as (pigeon pea pod fruit) Kamungay bunga (horse radish fruit) *kalabasa pula (red squash fruit) *karot (carrot) langka hilaw (jackfruit unripe) Okra Paayap (cowpes) Remolatsa Saguing puso (banana heart) Sinkamas (yam bean, turnip) Batong (yard long bean) Taugi (mongo sprout)

Measure per exchange: Leafy 1 exchange = 1 cup raw (25 grams) or cup cooked (45 grams) 2 exchanges of I-A vegetables = 1 exchange of I-B vegetables Group A Vegetables: Alugbati (Malabar night shade leaves) Dabong (Bamboo shoots) Gozo (seaweed) Ispinaka (Spinach) Katuray (Season Flower) Kamote Dahon (Camote leaves) Kamunggay dahon (Horse raddish leaves) Kapayas hilaw (green papaya) Letsugas (lettuce) Lato (seaweed) Mustasa (mustard) Pako (fern) Petsay (Chinese cabbage) Pepino (cucumber) Paliya dahon ug bunga (Bittermelon leaves and fruits) Repolyo (cabbage) Sayote dahon ug bunga (Chayote leaves and fruits) Sikwa (sponge gourd) Siguidilias (winged beans) Sili dahon (pepper leaves) Takway (Taro leaves) Tamates (tomato) Talinum Tokog banog (Jute)

Note: you may substitute for this serving of vegetables 1 cup cooked may be of any of the vegetables a group or a combination of vegetables included

Those marked with (*) are high in vitamin A value. At least one serving should be included in the diet each day. LIST II FRUIT EXCHANGE 1 Exchange = 10 grams Carbohydrates 40 Calories FRUITS Atis (Sugar apple) Bayabas (Guava) Baungon (Pomelo) Dalanghita, Okban (Native Orange) Durian Guyabano (Soursoup) Istroberi (Strawberry ) Kaimito (Star Apple) Kamunsal (Aztec Kamunchill) Kasuy Bunga (Cashew Fruit) Lanzones (Lanson) Letsiyas (Laychees) Lumboy (Black Plum) Mabolo Makopa (Coracac apply) Manga (Ripe Mango) Mangostan (Mangosten e) Mansanas (Apple) Mansanitas WEIGHT (gram) 50 35 60 140 MEASUR E 1 small 1 medium 2 segments 2 medium

(Chinese Date, Indian Jujube) Milon (Spanish Melon) Nangka (Jackfruit Ripe) Pakwan (Watermel on) Papaya (Ripe Papaya) Peras (Pears) Pinya (Fresh Pineapple) Saging (Lacatan, Tundan, bungan, cardaba (banana) Sambag (Tamarind) Sineguelas (Spanish Plum) Tambis (Macopa) Tiesa (Carristal Tiesa) Ubas (Grape) CANNED FRUITS Orange

50 245 30 155 90 65 75

1 small cup 1 small slice 1 small slice 1 pc. Medium 1 small slice 1 small piece

30 70 120 60 70 140

1/3 of fruit 1 halfmoon slice 1 cup 1 small 10 pods 2 medium

40 20 50 120 30 WEIGHT (gram) 120 grams 120 grams

22 pcs. 5 pcs. Medium 5-6 pcs. Med 1 small 12 pcs. MEASUR E Cup Cup

75 65 50 55 60 120 60 60 75

7-10 pcs. 5 pcs. 20 pcs. medium 6 pcs. 1 med. Slice 3 pcs. Med 1 small cup

Pineapple (Unsweeten ed) OTHERS Butong (young coconut) Buting tubig (Buko Juice Lemonsito Juice

WEIGHT (gram) 120 grams 240 gram 120 grams

MEASURE Cup 1 Cup Cup

Note: Those with ( * ) are rich source of Vitamin C. Include at least 1 exhange daily in the diet LIST III MILK 1 Exchange = 12 grams CHO 8 grams PRO 10 grams FAT 170 Calories WEIGH T (grams ) 240 240 120

bonete Pan de limon Pan de sal Rolls Corn Corn; Boiled Maha, Mais Root Crops: Gabi (Taro) Kamote (Sweet Potato) Kamoten g Kahoy (Cassava) Patatas (Potato) Suman (Kamoten g Kahoy) Ubi Noodles Bihon, Miki Macaroni, Spaghetti Sotangho n Other Cereals Dry (flakes and Puff Variety) Lugao Oatmeal Bakery Products Biscocho *Cookies, Araro *Cookies Assorted Mamon Saltines Soda *Sponge cake

55 88 88 100 50 43

1 piece 2 pieces 1 piece 3/4 1 piece 1sliced 4x4 1/2 1/2 mm 1 pc.(10 x 6cm) 1pc. (101 / 2 x 6cm) 1pc. (5.5 x 4.5cm) 1pc. (7 x 6 cm) 1pc. (7.5 x 3 x 2 cm) 1cup cube 1 cup 1 cup 1 cup

95 100 75 100 50 100 100 100 100

FOOD *Carabaos milk (fresh) Cows milk (fresh) Evaporated milk (to reconstitute evaporated milk to whole milk, dilute with 1/2 cup water) **Powdered milk (Skimmed)

MEASURE 1 cup 1 cup 1/2 cup

30

Powders (whole) 30 (to reconstitute to whole milk add water enough to make 1 cup) NOTE: (*) omit 2 fat exchange from diet list contains about 20 grams fat per cup. (**) add 2 more fat exchanges to diet if skimmed. LIST IV RICE EXCHANGES 1 Exchange = 23 grams CHO 2 grams PRO 100 Calories COOKED E.P. Weight (grams) 75

1/4 cup or 4 tbsp (level) 1/4 cup or 4 tbsp

25

1 cup

130 175 30 33 20 30 30 30 40

1 cup 1 cup 2 pieces 5 pieces 5 pieces 2 pieces 10 pieces 8 pieces 1

MEASURE 1/2 cup

I. Rice Cooked II. Rice Equivalents Bread Pan American Pan de

30 30

2 slices 1 piece

(*) decrease rice allowance by 1 exchange for these items LIST V MEAT EXCHANGES 1 Exchange = 3 grams Protein 4 grams Fat 66 Calories FOOD FISH Large-(bangus, mamsa, etc. Medium(danggit, kitong,etc) Small(caraballas, lagao, etc.) very small (bolinao) Flaked (salmon,tuna) OTHER SEAFOODS Hipon(small shrimps) Alimango,lamb ay (crabs) Pasayan (shrimps) Nokos (squid) Sisi (oyster) Kinhason (clams) MEAT Chicken Lean pork or beef Other internal organs PROCESSED MEAT Corned beef Frankfurter Ham Vienna Sausage EGGS Balut Chicken egg Penoy (infertile) COOKED EP 30 30 30 30 30 MEASURE 1 slice match box 1 piece (15 cm) 2 pieces cup 2 tbsp. Heaping cup 1 medium 2 medium 2 pieces cup cup 1 breast/small leg 1 slice matchbox cup 3 1 1 3 tbsp. piece slice pieces

Salted duck's egg CHEESE Cottage Imported Native BEANS Abitsuelas (snap beans) Garbanzos (chick peas) Munggo (mongo bean) Tokwa(gourlin g cheese) NUTS Kasuy, roasted (cashew) Peanuts, boiled Peanuts, roasted

55 60 30 30 150 70 150 70 20 65 30

1 piece cup 1 slice 1 piece cup cooked cup cooked 1 cup 1 piece cup 1 cup with shell 2 tbsp.

45 50 50 40 90 50 50 30 40 30 45 30 30 60 50 55

LIST VI FATS 1 Exchange = 5 grams 45 calories FOOD Avocado Bacon Butong Pakwan (dried seeds) Butter or margarine Coconut milk French dressing Mayonnaise Sitsaron Shortening, cooking oil Coconut grated COOKED E.P. 70 8 10 5 5 5 15 10 5 5 MEASURE 1 medium 1 strip cup 1 tbsp. 1 tbsp. 1 tbsp. 1 tbsp. 1 piece 1 tsp. 1 tbsp.

1 piece 1 piece 1 piece

FOODS ALLOWED AS DESIRED Contains negligible carbohydrates, protein, fats and calories

Buillon (fat free) Coffee(unsweetened) Flavor extract Garlic Gelatin Kalamansi Patis Toyo Vetsin Herbs Spices (in amounts needed to season) Lemon Mustard Pickle, dill or sour (unsweetened) Saccharine or cyclamate (sweeteners) Tea (unsweetened) Vegetable A on the list up to one exchange Vinegar

Group 2 [d genius powerful pirates]. | Algar | Araneta | Datu | Dela Rama | Gadian | Lungay | Maulod | Namoc | Naval | Ramonal | Tancongco | Uriarte |.