Care of the Patient's

Nutritional Needs 

1. A balanced diet should consist of the following:

a. fats
b. proteins
c. carbohydrates
d. water
e. vitamins
f. minerals
2. The 1990 recommendations by the United States Department of Agriculture (USDA) and Department of Health and Human Services (DHHS) for food choices that promote
the health of and prevent certain diseases in Americans include the following:
a. eat a variety of food
b. maintain a healthy body weight
c. eat a diet low in fat, saturated fat, and cholesterol
d. eat plenty of vegetables, fruits, and grain products
e. use sugars in moderation
f. use salt and sodium in moderation
g. if you drink alcohol, do so in moderation
3. Determining an estimate of the amount of energy provided in a food
a. measured in kilocalories
i. the amount of heat required to raise the temperature of 1000 grams of water 1 degree Celsius
b. calculation of the kilocalories in a food:
i. 1 gram carbohydrate = 4 kilocalories/gram
ii. 1 gram protein = 4 kilocalories/gram
iii. 1 gram fat = 9 kilocalories/gram
4. Determining an estimate of the ideal body weight (IBW) for an individual
a. calculation of the IBW for women:
i. for 5 feet, consider 100 pounds a reasonable weight
ii. for each inch over 5 feet, add 5 pounds
iii. for each inch under 5 feet, subtract 5 pounds
iv. add 10 pounds for a large-framed individual
v. subtract 10 pounds for a small-framed individual
b. calculation of IBW for men:
i. for 5 feet, consider 106 pounds a reasonable weight
ii. for each inch over 5 feet, add 6 pounds
iii. for each inch under 5 feet, subtract 6 pounds
iv. add 10 pounds for a large-framed individual
v. subtract 10 pounds for a small-framed individual
5. Determining an estimate of the daily energy needs for an individual
a. first, determine the individual’s basal metabolic rate (BMR)
i. the energy required to carry out involuntary activities of the body at rest and in a fasting state
ii. calculation of the BMR:
a. women: BMR = 0.9 kilocalories x weight (in kilograms) x 24 (hours in a day)
b. men: BMR = 1.0 kilocalories x weight (in kilograms) x 24 (hours in a day)
iii. factors that increase the BMR:
a. lean body tissue, childhood growth periods, exercise, sympathetic stimulation, shivering, fever (7% for every degree above 98.6 ), thyroid hormone,
pregnancy, stress, male sex hormone
iv. factors that decrease the BMR:
a. fat tissue, aging process, end-stage illness, dieting, starvation, sleep
b. second, determine the individual’s thermal effect of food (TEF)
i. the energy the body uses in the processes of digestion and absorption
ii. calculation of the TEF:
a. men and women: TEF = 10% of the total kilocalories in food consumed
c. third, calculate the individual’s physical activity energy cost (PAEC)
i. the energy the body uses in the processes of physical activity
ii. calculation of the PAEC:
a. for men and women who have a sedentary lifestyle:
iii. PAEC = 20% of the BMR
1. e.g., typing, writing, playing cards
1. for men and women who have a very lightly active lifestyle: PAEC = 30% of the BMR
1. e.g., walking on a level surface at 2 - 3 mph, making beds, painting
2. for men and women who have a moderately active lifestyle: PAEC = 40% of the BMR
1. e.g., walking on a level surface 3.5 - 4 mph, pulling weeds, golfing (no cart)
3. for men and women who have a heavily active lifestyle: PAEC = 50% of the BMR
1. e.g., shoveling snow, cross-country skiing, jogging 5 mph
d. fourth, calculate the individual’s total energy output (TEO)
i. the sum of the body’s three uses of energy: basal metabolic rate (BMR), thermal effect of food (TEF), and physical activity energy cost (PAEC)
ii. calculation of the TEO:
a. for men and women: TEO = BMR + TEF + PAEC
e. example of calculation of the TEO for a woman who has the following characteristics:
i. weighs 130 lbs (59 kilograms)
a. BMR = 0.9 x 59 x 24 = 1274 kilocalories
 ii. eats 1800 kilocalories a day
a. TEF = 1800 x 10% = 180 kilocalories
iii. maintains a regular exercise program
a. PAEC = BMR x 40% = 510 kilocalories
iv. TEO = 1274 + 180 + 510, or 1964 kilocalories
6. Determining an estimate of the kilocalorie adjustment necessary for weight loss
a. calculation of the amount of kilocalories in 1 gram of pure fat and body fat:
i. 1 gram of pure fat = 9 kilocalories
ii. 1 gram of body fat = 7.7 kilocalories (some water in body fat cells)
b. calculation of the amount of kilocalories in 1 pound of pure fat and body fat:
i. 1 pound of pure fat = 454 grams x 9 kilocalories/gram = 4086 kilocalories
ii. 1 pound of body fat = 454 grams x 7.7 kilocalories/gram = 3496 kilocalories
c. calculation of the amount of kilocalorie adjustment necessary to loss one pound (3500 kilocalories) of body fat per week
i. 3,500 kilocalories 7 days (1 week) = 500 kilocalories/day
7. Carbohydrates
a. organic compounds composed of three elements:
i. carbon (C), hydrogen (H), oxygen (O)
b. significance of carbohydrates
i. provide an immediate and reserve source of energy at 4 kcal/gm
ii. spare protein from being used as a source of energy so that it can be used for other functions
iii. prevents ketosis as a result of inefficient fat metabolism for energy
c. percentage in the diet
i. composes 45% of the total kilocalories in the average American diet
ii. should compose 55% to 60% of the total kilocalories in the average American diet
d. classification of carbohydrates (monosaccharides and disaccharides)
i. simple sugars
a. monosaccharides
1. composed of a single sugar molecule
2. the three monosaccharides are:
a. glucose (dextrose), fructose, galactose
3. sources:
a. glucose
i. corn syrup
b. fructose
i. fruits, honey
c. galactose
i. milk
b. disaccharides
1. composed of two sugar molecules
2. the three disaccharides are:
a. maltose (glucose + glucose)
b. sucrose (glucose + fructose)
c. lactose (glucose + galactose)
3. sources:
a. maltose
i. sweetners in food products, intermediate and final starch digestion
b. sucrose
i. table sugar, sugar cane, sugar beets, molasses
c. lactose
i. milk
ii. complex sugars (polysaccharides; starch and fiber)
a. starch
1. long chain of hundreds of sugars derived from plants that are linked together by bonds that human digestive enzymes can break
2. sources:
a. grains and grain products, legumes, potatoes
b. fibers (cellulose, hemicellulose, gums, mucilages)
1. long chain of hundreds of sugars derived from plant cell walls that are linked together by bonds that human digestive enzymes cannot break
2. sources:
a. stems and leaves of vegetables, coverings of seeds and grains, algae, seaweed
e. carbohydrate metabolism
i. storage and conversion
a. carbohydrates are stored primarily in the liver and skeletal muscle as glycogen (a large polymer of glucose) through the process of glycogenesis
(formation of new glycogen) to remove excess glucose out of the bloodstream while maintaining a blood glucose level of 70 - 120 mg/dl
b. when the blood glucose level drops below 70 -120 mg/dl, glycogen stores in the liver and skeletal muscle are converted back to glucose through the
process of glycogenolysis (breakdown of glycogen into glucose)
c. if glycogen stores are depleted, proteins and fats are converted in the liver to glucose through the process of gluconeogenesis (creation of a new
glucose)
ii. energy production
a. each glucose molecule is broken down into two molecules of pyruvic acid (glycolysis)
b. pyruvic acid is then converted into two molecules of acetyl coenzyme A (acetyl - CoA)
c. each acetyl - CoA molecule is split in the citric acid cycle (Krebs cycle) and its energy is donated to energy storage compounds (adenosine
triphosphate - ATP)
f. carbohydrate digestion
i. simple sugars (monosaccharides)
a. require no digestion; quickly absorbed from the intestine and transported to the liver
ii. simple sugars (disaccharides)
a. require digestion; quickly absorbed from the intestine and transported to the liver only after being digested by a series of enzymes to simple sugars
 b. mouth
1. ptyalin
a. starch dextrins maltose
c. pancreas
1. pancreatic amylopsin
a. starch dextrins maltose
d. small intestine
1. sucrase
a. sucrose glucose + fructose
2. lactase
a. lactose glucose + galactose
3. maltase
a. maltose glucose + glucose
iii. complex sugars (polysaccharides)
a. starch
1. require digestion; absorbed from the intestine and transported to the liver only after being digested by a series of enzymes in the same way as
disaccharides to simple sugars
b. fibers (cellulose, hemicellulose, gums, mucilages)
1. are never digested
8. Protein
a. organic substances composed of four elements:
i. carbon (C), hydrogen (H), oxygen (O), nitrogen (N)
b. significance of proteins
i. essential for tissue growth and repair
ii. component of the body framework and fluids
iii. help regulate fluid and acid-base balance
iv. form antibodies
v. provide a source of energy when carbohydrate intake is low at 4 kcal/gm
c. percentage in the diet
i. composes about 15% of the total kilocalories in the average American diet
ii. should compose about 15% of the total kilocalories in the average American diet
d. classification of proteins
i. essential or nonessential amino acids
a. essential amino acids
1. proteins that the body cannot manufacture and, therefore, must be supplied for the body as part of the diet
2. the nine essential amino acids are:
a. threonine, leucine, isoleucine, valine, lysine, methionine, phenylalanine, tryptophan, histidine
b. nonessential amino acids
1. proteins that the body can manufacture and, therefore, do not need to be supplied as part of the diet
2. the twelve nonessential amino acids are:
a. glycine, alanine, aspargine, aspartic acid, glutamic acid, glutamine, proline, hydroxylysine, hydroxyproline, cytine, tyrosine, and serine
ii. complete or incomplete amino acids
a. complete
1. contain all the essential amino acids and many nonessential ones
2. sources:
a. meats, poultry, fish, dairy products, eggs
b. incomplete
1. lack one or more of the essential amino acids
2. sources:
a. grains, legumes, vegetables
iii. complementary amino acids
a. two or more proteins whose amino acid assortments complement each other in such a way that the essential amino acids missing from each are
supplied by the other
b. a person should select from two or more of the following groupings to create complimentary amino acid combinations:
1. grains
a. e.g., oats, rice, whole grain breads, pasta
2. legumes
a. e.g., peanuts, soy products, pinto beans, black beans
3. seeds and nuts
a. e.g., cashews, nut butters, sesame seeds
4. vegetables
a. e.g., broccoli, cabbage, peppers, squash, spinach
e. protein metabolism
i. storage
a. as plasma proteins
1. e.g., albumin, globulin, fibrinogen
b. as body tissue
1. e.g., any body tissue or cell
ii. anabolism
a. synthesis of tissue proteins from amino acids
iii. catabolism
a. breakdown of the body’s tissue proteins to amino acids in the liver in the following way:
1. removing the nitrogen-containing amino part of the amino acid through the process of deamination and either:
a. converting it to ammonia to be excreted as urea in the urine
b. using it to make another compound, such as a nonessential amino acid
2. converting the remaining non-nitrogen containing part of the amino acid to either:
a. pyruvic acid, which can be converted to glucose
 b. acetyl Co A, which can enter the citric acid cycle (Krebs cycle)
iv. nitrogen balance
a. positive nitrogen balance
1. exists when the body takes in more nitrogen than it excretes
2. usually occurs during periods of rapid growth such as childhood and adolescence, pregnancy, and phases of physical exercise when muscle
mass increases
b. negative nitrogen balance
1. exists when the body takes in less nitrogen than it excretes
2. usually occurs during periods of convalescence from a protein-depleting illness or after fasting or inadequate intake of protein and calories
f. protein digestion
i. require digestion; absorbed from the intestine and transported to the liver only after being digested by a series of enzymes:
a. mouth
1. none
a. mechanical only
b. stomach
1. pepsin
a. protein polypeptides
c. pancreas
1. trypsin
a. protein, polypeptides polypeptides, dipeptides
2. chymotrypsin
a. protein, polypeptides polypepides, dipeptides
3. carboxypeptidase
a. polypeptides simpler peptides, dipepides, amino acids
d. small intestine
1. aminopeptidase
a. polypeptides peptides, dipeptides, amino acids
2. dipeptidase
a. dipeptides amino acids
9. Lipids
a. organic compounds composed of three elements:
i. carbon (C), hydrogen (H), oxygen (O)
b. significance of lipids
i. provide structure
ii. insulate the body
iii. cushion the internal organs
iv. necessary for the absorption of fat-soluble vitamins
v. provide a source of energy when carbohydrate intake is low at 9 kcal/gram
c. percentage in the diet
i. composes 40% of the total kilocalories in the average American diet
ii. should compose 25% - 30% of the total kilocalories in the average American diet
d. classification of lipids
i. fatty acids (saturated fatty acids, unsaturated fatty acids, essential fatty acids)
a. saturated fatty acids
1. composed of a chain of carbon atoms and hydrogen atoms in which all carbon atoms are filled (saturated) with hydrogen
2. sources:
a. bacon, meat fat, lean red meat, poultry, seafood, egg yolk, dairy fat
b. unsaturated fatty acids
1. composed of a chain of carbon atoms and hydrogen atoms in which there is at least one double bond between two carbon atoms so all carbon
atoms are not filled (saturated) with hydrogen
2. the two types of unsaturated fatty acids are:
a. monounsaturated fatty acids, which have one double bond between two carbon atoms
b. polyunsaturated fatty acids, which have double bonds between two or more carbon atoms
3. sources:
a. olives, olive oil, vegetable oils
c. essential fatty acids
1. fatty acids that the body cannot manufacture and, therefore, must be supplied for the body as part of the diet
2. the two essential fatty acids are:
a. linoleic (Omega 6), linolenic (Omega 3)
3. sources
a. linoleic (Omega 6)
i. seeds of plants, oils harvested from seeds
b. linolenic (Omega 3)
i. fish oils
ii. glycerides
a. composed of one glycerol molecule and one, two, or three fatty acids
b. the three types of gylcerides are:
1. monoglycerides, which have one glycerol molecule and one fatty acid
2. diglycerides, which have one glycerol molecule and two fatty acids
3. triglycerides, which have one glycerol molecule and three fatty
a. 90% of all lipids are triglycerides
iii. phospholipids
a. composed of one glycerol molecule, two fatty acids, and choline or some other compound instead of a third fatty acid
b. sources:
1. lecithin
iv. sterols
a. composed of interconnected rings of carbon
 b. examples:
1. cholesterol, vitamin D, sex hormones
v. lipoproteins
a. composed of an interior of triglycerides and cholesterol (both water insoluble) surrounded by phospholipids and protein (water soluble) to provide a
means to transport water insoluble triglycerides and cholesterol in the bloodstream
b. classification of lipoproteins
1. very low-density lipoproteins (VLDL)
a. composed of 50% triglyceride; 20% phospholipid; 20% cholesterol; 10% protein
2. low-density lipoproteins (LDL)
a. composed of 10% triglyceride; 20% phospholipid; 50% cholesterol; 20% protein
b. larger, lighter, and more lipid filled
c. known as "bad" cholesterol because LDL’s transport cholesterol to all the body tissues
3. high-density lipoproteins (HDL)
a. composed of 10% triglyceride; 20% phospholipid; 20% cholesterol; 50% protein
b. smaller, denser, and packaged with more protein
c. known as "good" cholesterol because HDL’s transport cholesterol back to the liver to be broken down and excreted
e. lipid metabolism
i. trigylcerides are broken down to glycerol and fatty acids
a. glycerol is converted to pyruvic acid which can be converted to glucose
b. fatty acids are converted to acetyl Co A which can enter the citric acid cycle (Krebs cycle)
f. lipid digestion
i. require digestion; absorbed from the intestine and transported throughout the body only after being emulsified by gallbladder bile salts and digested by a
series of enzymes:
a. mouth
1. lingual lipase
a. some initial fat breakdown
b. stomach
1. none
a. mechanical separation of fats
c. pancreas
1. steapsin
a. triglycerides diglycerides
b. diglycerides monoglycerides
c. monoglycerides fatty acids and glycerol
d. small intestine
1. gallbladder bile salts
a. emulsifies fat
10. Micronutrients (vitamins and minerals)
a. vitamins
i. organic compounds that are noncaloric, essential nutrients necessary in very small amounts for specific metabolic control and disease prevention that
cannot be manufactured by the body
ii. classification of vitamins
a. water-soluble vitamins
1. vitamins the body cannot store and, therefore, must be supplied daily in the diet
2. the nine water-soluble vitamins are:
a. C (ascorbic acid), thiamin (B 1), riboflavin (B 2), niacin (B 3), pyridoxine (B 6), folic acid (B 9), cobalamin (B 12 ), pantothenic acid, biotin
3. sources:
a. C (ascorbic acid)
i. citrus fruits, green peppers, tomatoes, white potatoes, cabbage, broccoli, chard, kale, turnip greens, asparagus, berries, melons,
pineapples, guavas
b. thiamin (B 1)
i. pork, beef, liver, whole or enriched grains, legumes
c. riboflavin (B 2)
i. milk, meats, enriched cereals, green vegetables
d. niacin (B 3)
i. meats, peanuts, legumes, enriched grains
e. pyridoxine (B 6)
i. grains, seeds, liver and kidney, meats, milk, eggs, vegetables
f. pantothenic acid
i. meats, cereals, legumes, milk, vegetables, fruits
g. biotin
i. liver, egg yolk, soy flour, tomatoes, yeast
b. fat-soluble vitamins
1. vitamins the body can store to a certain extent and, therefore, do not need to be supplied daily in the diet
2. the four fat-soluble vitamins are:
a. A (retinol), D (cholecalciferol), E (tocopherol), K
3. sources:
a. A (retinol)
i. fish liver oils, liver, egg yolk, butter, cream
b. D (cholecalciferol)
i. yeast, fish liver oils, enriched milk
c. E (tocopherol)
i. vegetable oils
d. K
i. green leafy vegetables
b. minerals
 i. inorganic elements, widely distributed in nature, required by the human body in different amounts to do numerous metabolic tasks
ii. classification of minerals
a. macrominerals
1. minerals required by the body in amounts more than 100 milligrams a day
2. the seven macrominerals are:
a. calcium, phosphorus, sodium, potassium, magnesium, chloride, sulfur
3. sources:
a. calcium
i. milk, cheese, whole grains, egg yolk, legumes, nuts, green leafy vegetables
b. phosphorus
i. milk, cheese, meat, egg yolk, whole grains, legumes, nuts
c. sodium
i. table salt, milk, meat, egg, baking soda, baking powder, carrots, beets, spinach, celery
d. potassium
i. fruits, vegetables, meats, whole grains, legumes
e. magnesium
i. whole grains, nuts, legumes, green vegetables
f. chloride
i. table salt
g. sulfur
i. meat, egg, cheese, milk, nuts, legumes
b. microminerals
1. minerals required by the body in amounts less than 100 milligrams a day
2. the ten microminerals are:
a. iron, iodine, zinc, copper, manganese, chromium, cobalt, selenium, molybdenum, fluorine
3. sources:
a. iron
i. liver, meats, egg yolk, whole grains, enriched bread and cereal, dark green vegetables, legumes, nuts
b. iodine
i. iodized salt, seafood
c. zinc
i. meat, seafood, eggs, milk, whole grains, legumes
d. copper
i. liver, seafood, whole grains, legumes, nuts
e. manganese
i. cereals, whole grain, soybeans, legumes, nuts, tea, vegetables, fruits
f. chromium
i. whole grains, cereal products
g. cobalt
i. preformed vitamin B12
h. selenium
i. seafoods, kidney, liver, meats, whole grains
i. molybdenum
i. organ meats, milk, whole grains, leafy vegetables, legumes
j. fluourine
i. fluoridated water
11. Food guide pyramid
a. bread, cereal, rice, pasta
i. 6-11 servings a day
b. vegetable group
i. 3 to 5 servings a day
a. 1 or 2 of them should be good sources of vitamin C
b. 1 of them should be a good source of vitamin A every other day
c. fruit group
i. 2 to 4 servings a day
a. 1 to 2 of them should be good sources of vitamin C
b. 1 of them should be a good source of vitamin A every other day
d. meat, poultry, fish, bacon, eggs, nuts
i. 2 to 3 servings a day
e. milk, yogurt, cheese
i. children less than 9: 2 to 3 servings a day
ii. children 9 to 12: 3 or more servings a day
iii. teenager: 4 or more servings a day
iv. adult: 2 or more servings a day
v. pregnant: 3 or more servings a day
vi. lactating: 4 or more servings a day
f. fat, oils, sweets
i. use sparingly
12. Factors influencing diet
a. ethnicity and culture
b. age
c. religion
d. economic status
e. peer groups
f. personal preference and uniqueness
g. life-style
h. beliefs about health effects of food
 i. alcohol abuse
j. advertising
k. psychologic factors
l. health status
m. therapy
n. medications
13. Methods to stimulate the appetite
a. relieve illness symptoms that depress the appetite, e.g.:
i. analgesic for pain; antipyretic for fever
b. provide familiar food the client likes
c. select small portions
d. avoid unpleasant, uncomfortable treatments immediately before or after meals
e. provide tidy, clean, pleasant, odor-free environment around meals
f. encourage/provide oral hygiene before meals
g. reduce psychological stress around meals
14. Diagnostic studies
a. blood tests
i. hemoglobin and hematocrit
a. collection of a specimen of blood to measure the amount of hemoglobin and hematocrit in the blood to ascertain state of hydration and protein and
iron deficiencies
ii. serum albumin
a. collection of a specimen of blood to measure the amount of serum albumin in the blood to ascertain state of hydration and protein and iron
deficiencies
iii. transferrin
a. collection of a specimen of blood to measure the amount of transferrin in the blood to ascertain protein and iron deficiencies
iv. total iron-binding capacity (TIBC)
a. a collection of specimen of blood to measure the iron-binding capacity of a red blood cell and ascertain iron deficiencies
v. total lymphocyte count
a. collection of a specimen of blood to measure the amount of lymphocytes in the blood to ascertain immune function and presence of infection
vi. blood urea nitrogen
a. collection of a specimen of blood to measure the amount of urea nitrogen in the blood to ascertain protein status
vii. mean corpuscular volume (MCV)
a. collection of a specimen of blood to measure the average size of a RBC to ascertain the presence and type of anemia
viii. mean corpuscular hemoglobin (MCH)
a. collection of a specimen of blood to measure the average weight of hemoglobin in a RBC to ascertain the presence and type of anemia
ix. mean corpuscular hemoglobin concentration (MCHC)
a. collection of a specimen of blood to measure the average concentration of hemoglobin in a RBC to ascertain the presence and type of anemia
b. urine tests
i. urine urea nitrogen
a. collection of a 24-hour composite specimen of urine to measure the amount of urea nitrogen to ascertain protein balance
ii. urinary creatinine
a. collection of a 24-hour composite specimen of urine to measure the amount of creatinine to ascertain protein balance
c. anthropometric measurements
i. height
ii. weight
iii. triceps skin-fold (TSF)
a. measurement of the skin-fold in the midpoint of the back of the upper arm with calipers to determine the amount of leanness and fatness
iv. subscapular skinfold (SSF)
a. measurement of the skin-fold of the skin just below the scapula with calipers to determine the amount of leanness and fatness
v. mid-upper arm circumference (MAC)
a. measurement of the midpoint of the upper arm, halfway between the acromion process and the olecranon process, with a tape measure to determine
skeletal muscle mass
15. Alternative feeding methods
a. enteral
i. nasogastric
a. instillation of specially prepared nutrients through a tube that is inserted through one of the nostrils, down the nasopharynx, and into the stomach
ii. gastrostomy
a. instillation of specially prepared nutrients through a tube that is surgically placed through the abdominal wall into the stomach
iii. percutaneous endoscopic gastrostomy (PEG) tube
a. instillation of specially prepared nutrients through a tube that is placed through the abdominal wall into the stomach under the guidance of an
endoscope
iv. jejunostomy
a. instillation of specially prepared nutrients through a tube that is surgically placed through the abdominal wall into the jejunum
b. parenteral
i. peripheral parenteral nutrition (PPN)
a. instillation of specially prepared nutrients through a tube that is inserted into a peripheral vein
ii. total parenteral nutrtion (TPN)
a. instillation of specially prepared nutrients through a tube that is inserted into a large central vein (usually subclavian)

end