risk of infection Lack of medical care

1. Discuss nutrition inadequate in energy

1.1 Definition/description of Terms: & or nutrients

Nutrition rural, traditional diets

Science that deals with:
- biological processes by which living organisms Optimal nutritional status
consume food & utilize the nutrients it contains for risk of chronic & adequate &
normal body structure & functions: infectious diseases prudent
energy utilization
growth, maintenance, development affluent modern diets
reproduction
homeostasis nutritionally adequate
adaptation but imprudent
response to environment
- factors that influence food preferences: inactivity, alcohol
psychological smoking, stress
social Obesity
cultural coronary heart disease
economic diabetes
technological hypertension
- proper balance diet to promote health, esp. in stroke
human beings indicates nutrition transition

Food rural, traditional affluent modern

Any substances that is eaten or taken in & assimilated into diets diets
the body Western diets
Give nourishment to living organisms Fat Low High
Nutritionally adequate diet satisfies 3 needs: Sugar Low High
- fuel (chemical energy) for all the cellular work of the Fiber High Low
body Monotonous, Diverse,
- organic raw materials for biosynthesis little variety Varied
- essential nutrients (substances that animals cant Mainly High in animal
carbohydrate protein
make for itself from any raw material)
staples

Malnutrition
Nutritional status
Affects individuals at every stage of life (cycle)
State of the body as a result of bodys food intake & use of
Have major impact on health & productivity of an
energy
individual or a population
Can identify nutritional needs of an individual or population
Impairment of health resulting from imbalance of
based on
nutrients thru:
- developed standards for the amount of nutrients we
- malabsorption
need plans to meet these needs
- improper diet: poor diet or overeating
too much or too little of one or more nutrients
or energy
Symptoms:
- appear rapidly
- take a lifetime to develop (chronic)
- an important health concerns:

Undernutrition disease
Module 20: The Old Man. BBS. Medicine-1. XU-JPRCM. 2005-2006.
1
 - osteoporosis, cancer, heart disease (w/c is also changes in the stomach that occur w/ age (risk
due to other risk factors such as age, gender for older adults)
and genetics)
Two forms: overnutrition or undernutrition Vit. A deficiency
- often accompanied by anemia
Overnutrition rapid growth & devt. (infancy, early childhood,
Excess intake of 1 nutrients & calories pregnancy, lactation)
Food consumed in excess of energy needed is stored as low intake/absorption of vitamin (A) & other
body fat nutrients (fat, protein & zinc) in relation to the
energy store & insulation
need
obesity: risk of high BP, disease, diabetes, other
- inc Vit A need: frequent infections (such as those
chronic health problems causing diarrhea) & illness (measles)
blindness; depress immune function that risk of
Excess of specific nutrients (vitamins & mineral
supplements) consumed infection
adverse/toxic reaction in the body
Protein-energy malnutrition (PEM)
Undernutrition - protein & energy deficiencies usually occur
Deficient intake of 1 nutrients or energy together
Starvation: most severe form - protein deficiency can predominate in
- deficiency of energy (calorie) weight loss, poor growth, growing, developing, or healing individuals
inability to produce, & death (if severe enough) Protein roles Protein deficiency
Symptoms often reflect body functioning that rely on the Synthesis of growth in height & weight
deficient nutrient new tissue
Common forms: Immune func. susceptibility to infection
Melanin Skin flakes; Digestive tract cells
Iron deficiency synthesis die & cant be replaced
rapid growth & need of iron common in children & impair absorption
adult - refer to continuum of conditions ranging from
chronic loss of iron due to blood loss (hook-worm Kwashiorkor - pure protein deficiency, to
infection, malaria, & other acute/chronic infections) Marasmus - energy deficiency (pls. refer to #2)
diets w/ inadequate amounts of iron-containing foods
to meet individual needs, or those that limit iron Desirable body weight
bioavailability Body wt. of a person in kg or lb that gives or would
iron deficiency anemia give a normal body mass index in relation to height2 of
risk of maternal & fetal mortality, premature delivery that person
& low birth weight
children: stunt growth & retard mental devt.,
resistance to infections, morbidity due to 1.2 Nutritional Status: Formula used
disease Theres >1 way to compute for desirable/ideal wt:
older child & adult: fatigue & productivity
Thanhaussers method
Iodine deficiency - in absence of Ht. & Wt. table
- formula:
goiter (12% of global popn) - iodine: essential
Ht (cm) 100cm = wt. (kg) for western standard (-
constituents of thyroid hormone 10% wt for Filipinos)
preventable brain damage & mental retardation
1 in. = 2.54 cm
pregnancy: incidence of stillbirths, spontaneous eg, 157cm100cm=57kg57(10%) =51kg
abortion, developmental abnormalities such as
normalrange: 10 of Desired body wt
cretism
> normal range: underweight
children: IQs & impaired school performance
< normal range: overweight
adults: associated w/ apathy & decision-making
capabilities Body Mass Index (BMI)
- anthropometric measure that uses height & wt.
Vit B12 deficiency to estimate nutritional status in adults

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

2
 - 1st used by Adolphe Quetelet in 1870 and was Computed DBW:
known as Quetelets Index 157cm100cm=57kg57(10%) =51kg
- (BMI), where: Actual body wt.: 40 kg
Comment: underweight

- Nomogram in determining BMI Computed DBW:

Morbidly obese 157cm100cm=57kg57(10%) =51kg
40 70 kg/m2 Actual body wt.: 60 kg
Obese 30 39.9 kg/m2 Comment: Normal weight
Overweight 26 29.9 kg/m2
Normal 18.5 25.9 kg/m2
Computed DBW:
Underweight 8.5 18.4 kg/m2 157cm100cm=57kg57(10%) =51kg
- Values of BMI in healthy individuals usually fall Actual body wt.: 70 kg
within the range 18.5 to 25.9 kg/m2 Comment: overweight
- Both high and low BMI are associated with
increased morbidity and mortality Normal range: the DBW
< 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

MEN Height Elbow breath
in 1-inch heels
5 ft 2 in. 5 ft 3 in 2 - 2 in.
5 ft 4 in. 5 ft 7 in 2 - 2 in.
5 ft 8 in. 5 ft 11 in 2 - 3 in.
6 ft 0 in. 6 ft 3 in 2 - 3 in.
5 ft 4 in. & over 2 - 3 in.
WOMEN Height Elbow breath
in 1-inch heels
4 ft 10in. 4 ft 11 in 2 - 2 in.
5 ft 0 in. 5 ft 3 in 2 - 2 in.
5 ft 4 in. 5 ft 7 in 2 - 3 in.
5 ft 8 in. 5 ft 11 in 2 - 3 in.
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:

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

3
Differentiate the clinical features of the 2 types of undernutrition

Marasmus Kwashiorkor
often in children fed w/ diluted infant formula due to common in children
limited supply (children fed w/ cassava instead of seen in hospitalized adults who have high-protein needs
protein-rich milk) due to infection or trauma & a low-protein intake
less in breast-fed infants because they are unable to eat (intravenous 5%
dextrose or clear diet)
severe PEM (energy but also protein & other nutrients protein deficient: serum albumin & transferring severely
deficiency) diminished
protein:calorie is normal but total intake is not enough
to prevent weight loss
fat stores have been used to provide energy fat stores retained, energy intake is adequate
- generalized wasting: muscle & body fat
- decreased body wt., & wrinkled face
emaciated look, not so apathetic apathetic & lethargic w/ severe anorexia
thin & dry hair 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
no edema present generalized edema
- increased lipofuscin in most visceral organs (esp, abdomen distended due to:
heart & liver) 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)
diarrhea frequently present general atrophy of viscera or villous atrophy of the intestine
pulse, BP & temperature low may interfere nutrient absorption
diarrhea is common
anemia anemia: usual feature but not generally life-threatening
growth failure generalized growth failure (absent /mild)
impaired immune responses infections

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 al-trans 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 D 3
(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 alpha-tocopherol 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 Whole wheat bread

Kiwi Apricots
Soy bean oil Beef liver
Carrots Sun Flower seeds
Lentils Almonds
Tomato Oat meal
Margarine

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 warfarin-sensitive 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
O2
Glutamate residue Glutamate Carbanion
Vitamin K
epoxidose
Vitamin K hydroquinone Vitamin K
epoxide
disulfide

vitamin K quinone reductase

NADP+
quinone sulfhydryl Vitamin K
reductase quinone

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

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.
 Recommende
Deficiency Tolerable Upper
Vitamin Source: d Intake for Groups at risk Toxicity
manifestation intake level
adults
A Retinol Liver fish, 700 900 mmg Night blindness; Those living in Headache, 3000 mmg/day
carrot, Xerophthalmia poverty. vomiting, hair
peaches, (keratinization of Children and loss, liver
leafy cornea skin) pregnant women. damage, skin
greens, Those of low fat or changes, birth
fortified milk low protein defects
D Calciferol Egg yolk, 5 1 mmg Rickets poor Breast-fed infants, Calcium 50 mmg/day
liver, fish, mineralization of children and elderly deposits in
tuna, bone (especially with the soft
salmon, Osteomalacia dark skin and little tissue, growth
fortified (bone sun exposure, retardation,
margarine demineralization) people with kidney kidney
and milk disease damage
E Tcopherols, Vegetable 15 mmg Serious Those with poor fat Inhibition of 1000 mmg/day
Tocotrienols oil, leafy neurological absorption. vitamin K
greens, function Premature infants activity
nuts, (extremely rare)
peanuts
K Phylloquinone, Vegetable 90 120 mmg Impaired blood People with long- Brain damage ND (insufficient
Menaquinones oil, leafy clotting, tern antibiotics use, evidence to set
greens, hemorrhagic newborns an UL)
intestinal disease (especially
bacteria premature)
3. Identify descriptions of the water soluble vitamins to include:

Dietary Daily Metabolic/physio Active Form Synthesis Manifestations

Water-soluble
Sources Requirem logic role of deficiency
vitamins
ents
Whole
grain
and
Infants: dyspnea,
enriche
cyanosis,
d
diarrhea,
breads,
Central role in vomiting
cereals
energy-yielding Thiamin Adults: beriberi
, flours; Adult male:
metabolism and diphosphat (fatigue,
organ 1.5
metabolism of e peripheral
meats, mg/day
Vitamins B 1 CHO Thiamine (Thiamin neuritis),
pork, Adult
(thiamin) (decarboxylatio diphosphate diphospaht Wernicke-
other female:
n of pyruvate ase) Korsakoff
meats, 1.1
and alpha-keto syndrome/Wer
poultry, mg/day
acids), nervous Thiamin nickes
fish,
function encephalopat
legume
hy (apathy,
s, nuts,
ataxia, visual
milk,
probs.)
green
vegeta
bles
FMN formed
by ATP
dependent
Fulfills its role in phosphoryl
metabolism as ation of
the coenzymes riboflavin
Milk, Angular
Adult male: flavin whereas
organ stomatitis
1.7 mononucleotide FAD is
meats, Mononucleotide( (mouth
mg/day (FMN) and synthesize
Vitamin B 2 eggs, FMN) or Flavin lesions),
Adult flavin adenine d by a
(riboflavin) green Adenine dermatitis,
female: dinucleotide further
leafy dinucleotide photophobia,
1.3 (FAD); reaction
vegeta neurologic
mg/day oxidation, with ATP in
bles changes
reduction w/c the
enzymatic AMP
reactions moiety of
ATP is
transforme
d to FMN
Niacin Meat, Adult male: Oxidation- Nicotinamide Nicotinate is Pellagra
(nicotinic poultry, 19 reduction Adenine converted (dermatitis,
acid, fish, mg/day reaction, Dinucleotide to mucous
nicotinamide) whole Adult functional part (NAD+) and desamido- membrane
grain female: of NAD and Nicotinamide NAD+ by inflammation,
and 15 NADP Adenine reaction weight loss,
enriche mg/day Dinucloetide first w/ 5- disorientation)
d Phosphate phosphorib
breads, (NADP+) osyl 1-
flours, pyrophosp
cereals hate
, nuts, (PRPP)
legume and then
s by
 adenylylati
on w/ ATP.
The amido
group of
glutamine
then
contribute
to form the
coenzyme
NAD+. This
may be
phosphoryl
ated further
to form
NADP+
Most tissues
contain
enzyme
pyridoxal
Involved in amino kinase w/c
Meat, Infants: irritability,
acid is able to
poultry, seizures,
Adult male: metabolism; catalyze
fish, normocytic
2.0 enzyme the
Vitamin B 6 potatoe anemia,
mg/day systems phosphoryl
(pyridoxine, s, Pyridoxal vomiting,
Adult involving amino ation by
pyridoxal, sweet phosphate weakness
female: acid ATP of
pyridoxamine potatoe Adults: facial
1.6 transaminases, unphospho
) s, seborrhea
mg/day phosphorylases rylated
vegeta Stomatitis,
, forms of
bles glossitis
decarboxylases vitamin to
their
respective
phosphate
esters.
Pernicious
In animal
Anemia(when
foods
Myelin formation, lack of
only:
branched chain intrinsic
organ Methylcobalamin
keto acid Synthesized factor)=Megal
Vitamin B 12 meats, adenosylcobal
Adults: 2 metabolism, by oblastic
(cyanocobala muscle amin and
ug/day folate microorgan anemia with
min) meats, hydroxocobala
interconversion isms degeneration
poultry, min
s, DNA of the spinal
fish,
synthesis cord,
eggs,
neurologic
milk
abnormalities
Pantothenic Meat, 4-7 mg/day Acyl-group Normally not
acid (first poultry, (safe transfer seen alone
designated fish, and reactions (as --------- ---------- but with
as Vitamin whole allowable part of chemical
B 3) grain range) coenzyme A agonist:
cereals and Acyl carrier depression,
, protein) depressed
legume immune
s, system,
mushro muscle
oms, weakness
salmon
,
 smaller
amount
in fruits
and
vegeta
bles
Citrus
First, vague
fruits,
aches and
tomato
pains; if long-
es,
term, scurvy
melons
Connective tissue (hemorrhages
,
formation, into skin,
cabbag
catecholamine It is derived alimentary
e,
synthesis, from and urinary
Vitamin C broccol
cholesterol glucose by tract, anemia,
(Ascorbic i, 60 mg/day Ascorbic acid
metabolism, L- wound healing
Acid) strawb
anti-oxidant, gulonolacto delayed,swoll
erries,
absorption of ne oxidase en bleeding
fresh
certain minerals gums, loss of
potatoe
such as iron dental
s,
cement)
green
leafy
vegeta
bles
Folate
derivatives
on diet are
cleared by
specific
Organ intestinal
meats, enzymes to
deep- Adult male: monogluta
green 200 myl folate
vegeta ug/day Amino acid and for
bles; Adult nucleic acid absorption.
Folic Acid Tetrahydrofolate
muscle female: biosynthesis, Most of this Megaloblastic
(pteroylgluta (Ammonium
meats, 180 one carbon reduced to anemia
mic acid) folate)
poultry, ug/day transfer tetrahydrof
fish, Pregnancy: reactions olate in
eggs, 400 intestinak
whole ug/day cell by
grain folate
cereals reductase
w/c uses
NADPH as
donor of
reducing
equivalent
Biotin Organ 30-100 Coenzymes for Dermatitis can
(sometimes meats, ug/day CO2 progress to
called egg (safe carboxylation mental and
Vitamin H) yolks, and reactions in neurologic
nuts, allowable gluconeogenesi -------- ---------- changes,
legume range) s, lipogenesis, nausea,
s fatty acid anorexia,
synthesis and peripheral
for carboxyl vasoconstricti
group exchange on, impaired
 fat and
carbohydrate
metabolism
Energy
Muscle
metabolism and
Carnitine Meat --------- ---------- weakness,
Acyl-group
fatigue
transport

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, D-glucose, 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

COLOR Yellowish due to carotenes and Bluish due to Ca++ salt of casein
Vitamin A and emulsified fats
CHOLESTEROL AND Higher which gives it a laxative Lower
LECITHIN effect
PROTEIN Higher so that it coagulates on Lower, does not clot on boiling but
boiling forms a film
IMMUNE GLOBULIN Higher, serving as secondary Lower but it has higher albumin
means of neonatal immunization and casein content
(placental transmission is the first)
FAT higher Lower

4.3 Differentiate cows milk from human milk

Human Milk Cows Milk

1. greater albumin/ globulin fractions than casein Greater casein fraction than albumin/globilin
fractions
2. Forms lighter, easier to digerst milk cords due to Forms heavier, harder to digest milk curds due to
abundance of albumin abundance of casein
3. fatty acids are of long chained non volatile types Fatty acids are of shorter chained volatile types
4. Presence of IMMUNE ANTIBODIES passively NONE
transmitted
5. Less vitamins but the quality are those needed by More Vitamins
human infant
 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 heat-labile 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 Calories/lb.
Human ++++ + ++ ++++ + 316
Cow +++ +++ ++ +++ +++ 310
Goat ++ +++ +++ ++ +++ 318
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.

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 with the Actual findings & FAO
Proposed Actual FAO Standard
Reference man 56 kg 53 kg 65 kg
Reference woman 49 kg 6 kg 55 kg
- 1 yrs old 9 kg 8 kg 9 kg
1 3 yrs old 12 kg 11 kg 12 kg
4 6 yrs old 17 kg 15.5 kg 18 kg
7 9 yrs old 25 kg 20.5 kg 27 kg
10 12 yrs old 33 kg 25 F 36 kg
28 M

Boys Proposed Actual FAO Standard

13 15 yrs old 44 kg 39 kg 49 kg
16 19 yrs old 48 kg 46 kg 54 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 Food- additional 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 ON PHYSIOLOGICAL
ACTIVITY AND SEX
Females Males
1. Sedentary habit 1800-2000 2500-2700
2. Moderate activity 2100-2200 2800-3000
3. Very active 2400-2600 3100-3200
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 group
(recommended servings)
I. Green, leafy and yellow vegetables; Alugbati, ampalaya leaves, kamote tops, kangkong,
1 or more servings/day malunggay, saluyot leaves, mustard, petsay, squash
(1 servings= cooked or 1 c raw) leaves, squash leaves, squash fruit, pepper leaves, carrot,
squash flowers
II. Vitamin C- Rich Foods Atis, kasuy, durian, guava, guyabano, kamatsili, mango,
1 or more servings/day melon, papaya, pomelo, mansanitas, siniguelas,
(1 servings= 1 med. fruit) strawberry, tomatoes
III. Other fruits and vegetables Abitsuelas, ampalaya, abocado, banana, chico, duhat,
2 or ore servings/day eggplant, mabolo, macopa, malunggay fruit, okra, patola,
( 1 serving= c cooked or 1 c raw) 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
A.) Whole milk, all kinds - Chicken
Pregnant & Nursing mothers = 2 cups - Liver
Children = 3-4 cups - Fishes [bolinao & other small fishes]
B.) Meat, Fish, Poultry - Pork
1 serving = 1 matchbox size [3serving/day] - Sausage
C.) Eggs: 2- 3 weeks - Shrimps
D.) Legumes: cup cooked - Tulya or clams
VI. Rice & other Energy Fods - Bread - Enriched rice
Rice = 3 servings/day - Corn - Pinipig ampaw
[1 serving = c. raw or c. cooked] - Kamote - Ube
Root crops - Kamoteng kahoy - Gabi - Sugars
[1 serving = 1 med size or 1 cup sliced] - Candied fruits - Bodbod - Palitaw

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
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.
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
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 high-calorie 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.
3 to 4 cups milk Breakfast
1 cup light cream
5 to 7 ounces meat, fish, poultry, or cheese Half grapefruit
1 egg Oatmeal
4 servings vegetables including: Fried egg
1 serving green or yellow vegetable Whole-wheat toast
2 servings white or sweet potato, corn, or beans Butter
1 serving other vegetable Milk
2 to 3 servings fruit, including one citrus fruit Coffee
1 serving whole-grain or enriched cereal
3 to 6 slices whole-grain or enriched bread Lunch
4 tablespoons or more butter or fortified margarine
high calorie foods to complete the caloric Chicken souffl
requirement; cereals such as macaroni, rice, Mushroom sauce
noodles, spaghetti, honey, molasses, syrups, Buttered green beans
hard candies, cakes, cookies, ice cream, Shredded carrot and raisin salad
puddings, sauces Whole-wheat roll and butter
Fresh peaches
Milk

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
high-carbohydrate 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:
A physician prescribes the amounts of carbohydrate,
protein, and fat that are to be used in measured diets.
Using the values for the exchange lists; the dietitian or
nurse calculates the number of exchanges to be
furnished by the diet.
Become familiar with the patients usual pattern of
meals, the food likes and dislikes, and so on. The
amount of money that can be spent, the preparation
facilities, and the cultural patterns must be
considered.
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.

Energy and Macronutrient Values of the Exchange List

Exchange Group Serving Size Energy (kcals) CHO Protein (g) Fat (g)
(g)
Carbohydrate
Group
Starch cup pasta, cereal, rice, 1 80 15 3 0-1
slice bread
Fruit 1 small apple, peach, or pear; 60 15 0 0
banana; cup canned fruit

Milk 1 cup milk or yogurt

Nonfat 90 12 8 0
Low Fat 110 12 8 3
Reduced Fat 120 12 8 5
Whole Serving sizes vary 150 12 8 8
Other Carb. cup cooked vegetables, 1 Varies 15 Varies Varies
Vegetables cup raw 25 5 2 0
Meat/Meat Substitute 1 oz. meat or cheese
Very lean
Lean 35 0 7 0-1
Medium Fat 55 0 7 3
High fat 75 0 7 5
100 0 7 8
Fat Group 1 tsb. butter, margarine, or oil; 45 0 0 5
1 tbsp. salad dressing

Sample Menu: (Food List)

Breakfast Toast 1 slice

Egg 1
Milk 1 cup Butter 1 teaspoon
Cantaloupe medium Cream, light 2 tablespoons
Whole flakes cup
Lunch Dinner

Milk 1 cup Asparagus tips

Radishes and celery sticks Baked acorn squash
Apple 1 small Pears, water packed 2 halves
Sandwich Potato, baked 1 small
Bread 2 slices Roll, dinner 1
Roast beef 2 oz. Roast pork, lean 3 oz
Mayonnaise 1 teaspoon 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 = 50% of 1500 cal . = 750 cal . = 188 grams

4 cal/gram 4 cal/gram

Protein = 15% of 1500 cal . = 225 cal . = 56 grams

4 cal/gram 4 cal/gram

Fats = 35% of 1500 cal . = 525 cal . = 48 grams

9 cal/gram 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) PRO (gram) FAT (gram) CALORIES

List I Vegetable Exchange
I-A 1 exchange NEGLIGIBLE
I-B 1 exchange 3 1 0 18
List II Fruit Exchange
1 exchange 10 0 0 40
List III Milk Exchange
1 exchange 12 8 10 170
List IV Rice Exchange
1 exchange 23 2 0 100
List V Meat Exchange
1 exchange 0 8 4 68
List VI Fat Exchange
1 exchange 0 0 5 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.

The 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.

It 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)

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 Cal
exchange
I. Vegetable A As desired - - - -
Vegetable B 1 3 1 - 16
II. Fruit 3 30 - - 120
III.Milk 1/2 6 4 5 85
Partial sum 39
Prescribed CHO ---------- 225
Partial sum CHO --------- 38
Difference ----------------136
186/23 = 8 rice exchange
IV. Rice 3 184 16 - 800
Partial sum 21
Prescribed PRO ----------- 65
Partial Sum PRO --------- 21
Difference ----------------- 44
41/3 = 6 meat exchange
V. Meat 6 - 43 24 408
Partial sum 28
Prescribe FAT ------------ 70
Partial sum FAT --------- 29
Difference ---------------- 41
41/5 = 8 exchange
VI. Fat 8 - - 40 360
Total 223 69 69 1789
Sugar 1 teaspoon with coffee ------------------------------------------------------- 20

LIST I GROUP A LEAFY VEGETABLE

VEGETABLE EXCHANGE
 Leafy vegetable or vegetables high in water of\r fiber *kalabasa pula (red squash fruit)
contains negligible calories, CHO, PRO, FAT, if 1 *karot (carrot)
exchange measure is used. langka hilaw (jackfruit unripe)
Given as desired, if raw Okra
Paayap (cowpes)
Measure per exchange: Remolatsa
Leafy 1 exchange = 1 cup raw (25 grams) or cup Saguing puso (banana heart)
cooked (45 grams) Sinkamas (yam bean, turnip)
2 exchanges of I-A vegetables = 1 exchange of I-B Batong (yard long bean)
vegetables Taugi (mongo sprout)
Group A Vegetables: Note: you may substitute for this serving of vegetables 1
Alugbati (Malabar night shade leaves) cup cooked may be of any of the vegetables a group or a
Dabong (Bamboo shoots) combination of vegetables included
Gozo (seaweed)
Ispinaka (Spinach) Those marked with (*) are high in vitamin A value. At least
Katuray (Season Flower) one serving should be included in the diet each day.
Kamote Dahon (Camote leaves)
Kamunggay dahon (Horse raddish leaves) LIST II
Kapayas hilaw (green papaya) FRUIT EXCHANGE
Letsugas (lettuce)
Lato (seaweed) 1 Exchange = 10 grams Carbohydrates
Mustasa (mustard) 40 Calories
Pako (fern)
Petsay (Chinese cabbage) WEIGHT
FRUITS MEASURE
Pepino (cucumber) (gram)
Paliya dahon ug bunga (Bittermelon leaves and fruits) Atis (Sugar 50 1 small
Repolyo (cabbage) apple)
Sayote dahon ug bunga (Chayote leaves and fruits) Bayabas 35 1 medium
Sikwa (sponge gourd) (Guava)
Siguidilias (winged beans) Baungon 60 2 segments
Sili dahon (pepper leaves) (Pomelo)
Takway (Taro leaves) Dalanghita, 140 2 medium
Tamates (tomato) Okban (Native
Talinum Orange)
Tokog banog (Jute) Durian 30 1/3 of fruit
Talong (eggplant) Guyabano 70 1 halfmoon
Upo (bottle gourd) (Soursoup) slice
Istroberi 120 1 cup
Those marked with X are good sources of vitamin A and (Strawberry)
iron. At least one serving be included in the diet each day. Kaimito (Star 60 1 small
Apple)
GROUP B NON-LEAFY VEGETABLES Kamunsal (Aztec 70 10 pods
Kamunchill)
1 Exchange = 3 grams carbohydrates Kasuy Bunga 140 2 medium
1 gram protein (Cashew Fruit)
16 calories Lanzones 75 7-10 pcs.
(Lanson)
Measure: 1 exchange = cup raw (40 grams) or Letsiyas 65 5 pcs.
cup cooked (45 grams) (Laychees)
Lumboy (Black 50 20 pcs.
Group B Vegetables: Plum)
Mabolo 55 medium
Abitsuelas (snap green bean) Makopa 60 6 pcs.
Bataw (hyacnith bean) (Coracac apply)
Guisantes (sweet pod) Manga (Ripe 120 1 med. Slice
Kadios, lab-as (pigeon pea pod fruit) Mango)
Kamungay bunga (horse radish fruit) Mangostan 60 3 pcs. Med
 (Mangostene) WEIGHT
FOOD MEASURE
Mansanas 60 1 small (grams)
(Apple) *Carabaos milk (fresh) 240 1 cup
Mansanitas 75 cup Cows milk (fresh) 240 1 cup
(Chinese Date, Evaporated milk (to 120 1/2 cup
Indian Jujube) reconstitute
Milon (Spanish 50 1 small evaporated milk to whole
Melon) milk, dilute with 1/2 cup
Nangka 245 cup water)
(Jackfruit Ripe) **Powdered milk 30 1/4 cup or 4
Pakwan 30 1 small slice (Skimmed) tbsp (level)
(Watermelon) Powders (whole) 30 1/4 cup or 4
Papaya (Ripe 155 1 small slice (to reconstitute to whole tbsp
Papaya) milk add water enough
Peras (Pears) 90 1 pc. Medium to make 1 cup)
Pinya (Fresh 65 1 small slice NOTE: (*) omit 2 fat exchange from diet list contains
Pineapple) about 20 grams fat per cup.
Saging (Lacatan, 75 1 small piece (**) add 2 more fat exchanges to diet if
Tundan, bungan, skimmed.
cardaba
(banana) LIST IV
Sambag 40 22 pcs. RICE EXCHANGES
(Tamarind)
1 Exchange = 23 grams CHO
Sineguelas 20 5 pcs. 2 grams PRO
(Spanish Plum) Medium 100 Calories
Tambis (Macopa) 50 5-6 pcs. Med
Tiesa (Carristal 120 1 small COOKED E.P.
Tiesa) Weight MEASURE
Ubas (Grape) 30 12 pcs. (grams)
I. Rice Cooked 75 1/2 cup
CANNED FRUITS WEIGHT MEASURE II. Rice Equivalents
(gram) Bread
Orange 120 grams Cup Pan 30 2 slices
Pineapple 120 grams Cup American
(Unsweetened) Pan de 30 1 piece
bonete
Pan de limon 55 1 piece
OTHERS WEIGHT MEASURE Pan de sal 88 2 pieces
(gram) Rolls 88 1 piece
Butong (young 120 grams Cup Corn 100 3/4
coconut) Corn; Boiled 50 1 piece
Buting tubig 240 gram 1 Cup Maha, Mais 43 1sliced 4x4
(Buko Juice 1/2 1/2 mm
Lemonsito Juice 120 grams Cup Root Crops:
Gabi (Taro) 95 1 pc.(10 x 6cm)
Note: Kamote 100 1pc. (101 / 2 x
Those with ( * ) are rich source of Vitamin C. Include (Sweet 6cm)
at least 1 exhange daily in the diet Potato)
Kamoteng 75 1pc. (5.5 x
LIST III Kahoy 4.5cm)
MILK (Cassava)
Patatas 100 1pc. (7 x 6 cm)
1 Exchange = 12 grams CHO (Potato)
8 grams PRO Suman 50 1pc. (7.5 x 3 x 2
10 grams FAT (Kamoteng cm)
170 Calories Kahoy)
Ubi 100 1cup cube
 Noodles Other internal 40 cup
Bihon, Miki 100 1 cup organs
Macaroni, 100 1 cup PROCESSED MEAT
Spaghetti Corned beef 30 3 tbsp.
Sotanghon 100 1 cup Frankfurter 45 1 piece
Other Cereals Ham 30 1 slice
Dry (flakes 25 1 cup Vienna Sausage 30 3 pieces
and Puff EGGS
Variety) Balut 60 1 piece
Lugao 130 1 cup Chicken egg 50 1 piece
Oatmeal 175 1 cup Penoy (infertile) 55 1 piece
Bakery Salted duck's egg 55 1 piece
Products CHEESE
Biscocho 30 2 pieces Cottage 60 cup
*Cookies, 33 5 pieces Imported 30 1 slice
Araro Native 30 1 piece
*Cookies 20 5 pieces BEANS
Assorted Abitsuelas (snap 150 cup cooked
Mamon 30 2 pieces beans)
Saltines 30 10 pieces Garbanzos (chick 70 cup cooked
Soda 30 8 pieces peas)
*Sponge 40 1 Munggo (mongo 150 1 cup
cake bean)
Tokwa(gourling 70 1 piece
(*) decrease rice allowance by 1 exchange for these items cheese)
NUTS
LIST V Kasuy, roasted 20 cup
MEAT EXCHANGES (cashew)
Peanuts, boiled 65 1 cup with shell
1 Exchange = 3 grams Protein Peanuts, roasted 30 2 tbsp.
4 grams Fat
66 Calories

FOOD COOKED EP MEASURE

FISH
Large-(bangus, 30 1 slice match
mamsa, etc. box
Medium-(danggit, 30 1 piece (15 cm)
kitong,etc)
Small- (caraballas, 30 2 pieces
lagao, etc.) LIST VI
very small (bolinao) 30 cup FATS
Flaked 30 2 tbsp. Heaping
1 Exchange = 5 grams
(salmon,tuna) 45 calories
OTHER SEAFOODS
Hipon(small 45 cup FOOD COOKED E.P. MEASURE
shrimps) Avocado 70 1 medium
Alimango,lambay 50 1 medium Bacon 8 1 strip
(crabs) Butong Pakwan 10 cup
Pasayan (shrimps) 50 2 medium (dried seeds)
Nokos (squid) 40 2 pieces Butter or 5 1 tbsp.
Sisi (oyster) 90 cup margarine
Kinhason (clams) 50 cup Coconut milk 5 1 tbsp.
MEAT French dressing 5 1 tbsp.
Chicken 50 1 breast/small Mayonnaise 15 1 tbsp.
leg Sitsaron 10 1 piece
Lean pork or beef 30 1 slice matchbox Shortening, 5 1 tsp.
cooking oil
Coconut grated 5 1 tbsp.

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

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