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Understanding
normal and
Clinical nutrition
eleventh e d i t i o n
Rolfes pinna
whitney
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203
Brief Contents
ChaPtER 1 An Overview of Nutrition 3
highlight 1 > Nutrition Information and Misinformation 30
ChaPtER 2 Planning a Healthy Diet 37
highlight 2 > Vegetarian Diets 64
ChaPtER 3 Digestion, Absorption, and Transport 71
highlight 3 > Common Digestive Problems 90
ChaPtER 4 The Carbohydrates: Sugars, Starches, and Fibers 99
highlight 4 > Carbs, kCalories, and Controversies 128
ChaPtER 5 The Lipids: Triglycerides, Phospholipids, and Sterols 133
highlight 5 > High-Fat Foods—Friend or Foe? 164
ChaPtER 6 Protein: Amino Acids 171
highlight 6 > Nutritional Genomics 194
ChaPtER 7 Energy Metabolism 201
highlight 7 > Alcohol in the Body 222
ChaPtER 8 Energy Balance and Body Composition 235
highlight 8 > Eating Disorders 256
ChaPtER 9 Weight Management: Overweight, Obesity, and Underweight 265
highlight 9 > The Latest and Greatest Weight-Loss Diet—Again 296
ChaPtER 10 The Water-Soluble Vitamins: B Vitamins and Vitamin C 301
highlight > 10 > Vitamin and Mineral Supplements 335
ChaPtER 11 The Fat-Soluble Vitamins: A, D, E, and K 343
highlight 11 > Antioxidant Nutrients in Disease Prevention 364
ChaPtER 12 Water and the Major Minerals 371
highlight 12 > Osteoporosis and Calcium 400
ChaPtER 13 The Trace Minerals 407
highlight 13 > Phytochemicals and Functional Foods 433
ChaPtER 14 Life Cycle Nutrition: Pregnancy and Lactation 441
highlight > 14 > Fetal Alcohol Syndrome 473
ChaPtER 15 Life Cycle Nutrition: Infancy, Childhood, and Adolescence 477
highlight 15 > Childhood Obesity and the Early Development of Chronic Diseases 516
ChaPtER 16 Life Cycle Nutrition: Adulthood and the Later Years 523
highlight 16 > Hunger and Community Nutrition 547
ChaPtER 17 Nutrition Care and Assessment 555
highlight 17 > Nutrition and Immunity 574
vii
Chapter 18 Nutrition Intervention 581
highlight 18 > Food Allergies 595
Chapter 19 Medications, Diet-Drug Interactions, and Herbal Products 599
highlight 19 > Complementary and Alternative Medicine 613
Chapter 20 Enteral Nutrition Support 619
highlight 20 > Inborn Errors of Metabolism 638
Chapter 21 Parenteral Nutrition Support 643
highlight 21 > Ethical Issues in Nutrition Care 659
Chapter 22 Metabolic and Respiratory Stress 663
highlight 22 > Multiple Organ Dysfunction Syndrome 681
Chapter 23 Upper Gastrointestinal Disorders 685
highlight 23 > Oral Health and Chronic Illness 704
Chapter 24 Lower Gastrointestinal Disorders 709
highlight 24 > Probiotics and Intestinal Health 735
Chapter 25 Liver Disease and Gallstones 739
highlight 25 > Anemia in Illness 757
Chapter 26 Diabetes Mellitus 763
highlight 26 > The Metabolic Syndrome 788
Chapter 27 Cardiovascular Diseases 793
highlight 27 > Coping with Feeding Disabilities 820
Chapter 28 Kidney Diseases 825
highlight 28 > Dialysis 847
Chapter 29 Cancer and HIV Infection 851
highlight 29 > Foodborne Illness 871
appendix a Cells, Hormones, and Nerves
appendix B Basic Chemistry Concepts
appendix C Biochemical Structures and Pathways
appendix d Measures of Protein Quality
appendix e Nutrition Assessment: Supplemental Information
appendix F Estimated Energy Needs
appendix G Choose Your Foods: Food Lists for Diabetes and Weight Management
appendix h Table of Food Composition
appendix i WHO Nutrition Recommendations
appendix J Healthy People 2020
appendix K Aids to Calculation
appendix L Enteral Formulas
Glossary GL-1
Index IN-1
inside Covers
Dietary Reference Intakes (DRI) A
Daily Values (DV) for Food Labels Y
Body Mass Index (BMI) Z
viii Brief Contents
Table of Contents
Preface xvii 2-2 Diet-Planning Guides 42
Acknowledgments xxiii USDA Food Patterns 42
Reviewers xxiv Food Lists 49
Putting the Plan into Action 50
ChaPtER 1 From Guidelines to Groceries 51
an overview of nutrition 3 2-3 Food Labels 56
1-1 Food Choices 4 The Ingredient List 56
Nutrition Facts Panel 56
1-2 The Nutrients 6
Claims on Labels 60
Nutrients in Foods and in the Body 6 Consumer Education 60
The Energy-Yielding Nutrients: Carbohydrate, Fat,
highlight 2 > Vegetarian Diets 64
and Protein 8
The Vitamins 11
The Minerals 11 ChaPtER 3
Water 12 digestion, absorption, and transport 71
1-3 The Science of Nutrition 12 3-1 Digestion 72
Conducting Research 12 Anatomy of the Digestive Tract 72
Analyzing Research Findings 16 The Muscular Action of Digestion 75
Publishing Research 17 The Secretions of Digestion 76
1-4 Dietary Reference Intakes 18 The Final Stage 77
Establishing Nutrient Recommendations 18 3-2 Absorption 78
Establishing Energy Recommendations 20 Anatomy of the Absorptive System 79
Using Nutrient Recommendations 21 A Closer Look at the Intestinal Cells 80
Comparing Nutrient Recommendations 21 3-3 The Circulatory Systems 82
1-5 Nutrition Assessment 22 The Vascular System 82
Nutrition Assessment of Individuals 22 The Lymphatic System 84
Nutrition Assessment of Populations 24 3-4 The Health and Regulation of the GI Tract 85
1-6 Diet and Health 26 Gastrointestinal Microbiome 85
Chronic Diseases 26 Gastrointestinal Hormones and Nerve Pathways 85
Risk Factors for Chronic Diseases 27 The System at Its Best 87
highlight 1 > Nutrition Information and Misinformation 30 highlight 3 > Common Digestive Problems 90
ChaPtER 2 ChaPtER 4
Planning a healthy diet 37 the Carbohydrates: Sugars, Starches,
2-1 Principles and Guidelines 38 and Fibers 99
Diet-Planning Principles 38 4-1 The Chemist’s View of Carbohydrates 100
Dietary Guidelines for Americans 40 Monosaccharides 100
Disaccharides 102
Polysaccharides 103
4-2 Digestion and Absorption of Carbohydrates 105
HSNphotography/Shutterstock.com
Carbohydrate Digestion 105

Carbohydrate Absorption 107
Lactose Intolerance 107
4-3 Glucose in the Body 108
A Preview of Carbohydrate Metabolism 109
The Constancy of Blood Glucose 110
ix
4-4 Health Effects and Recommended Intakes of Sugars 113 Roles of Proteins 179
Health Effects of Sugars 114 A Preview of Protein Metabolism 182
Recommended Intakes of Sugars 117 6-4 Protein in Foods 185
Alternative Sweeteners 118 Protein Quality 185
4-5 Health Effects and Recommended Intakes of Starch Complementary Proteins 185
and Fibers 120 6-5 Health Effects and Recommended Intakes of Protein 186
Health Effects of Starch and Fibers 121 Health Effects of Protein 186
Recommended Intakes of Starch and Fibers 123 Recommended Intakes of Protein 188
From Guidelines to Groceries 124 From Guidelines to Groceries 189
highlight 4 > Carbs, kCalories, and Controversies 128 Read Food Labels 190
Protein and Amino Acid Supplements 190
ChaPtER 5 highlight 6 > Nutritional Genomics 194
the Lipids: triglycerides, Phospholipids,
and Sterols 133 ChaPtER 7
5-1 The Chemist’s View of Fatty Acids and Triglycerides 134 Energy Metabolism 201
Fatty Acids 134 7-1 Chemical Reactions in the Body 202
Triglycerides 136
7-2 Breaking Down Nutrients for Energy 205
Characteristics of Solid Fats and Oils 136
Glucose 206
5-2 The Chemist’s View of Phospholipids and Sterols 140 Glycerol and Fatty Acids 208
Phospholipids 140 Amino Acids 210
Sterols 140 The Final Steps of Energy Metabolism 211
5-3 Digestion, Absorption, and Transport of Lipids 142 7-3 Feasting and Fasting 216
Lipid Digestion 142 Feasting—Excess Energy 217
Lipid Absorption 144 The Transition from Feasting to Fasting 218
Lipid Transport 144 Fasting—Inadequate Energy 218
5-4 Lipids in the Body 148 Low-Carbohydrate Diets 220
Roles of Triglycerides 148 highlight 7 > Alcohol in the Body 222
Essential Fatty Acids 148
A Preview of Lipid Metabolism 150 ChaPtER 8
5-5 Health Effects and Recommended Intakes of Saturated Fats, Energy Balance and Body Composition 235
Trans Fats, and Cholesterol 150
8-1 Energy Balance 236
Health Effects of Saturated Fats, Trans Fats,
and Cholesterol 151 8-2 Energy In: The kCalories Foods Provide 236
Recommended Intakes of Saturated Fat, Trans Fat, Food Composition 236
and Cholesterol 152 Food Intake 237
5-6 Health Effects and Recommended Intakes of 8-3 Energy Out: The kCalories the Body Expends 240
Monounsaturated and Polyunsaturated Fats 153 Components of Energy Expenditure 240
Health Effects of Monounsaturated and Estimating Energy Requirements 244
Polyunsaturated Fats 153 8-4 Body Weight and Body Composition 245
Recommended Intakes of Monounsaturated Defining Healthy Body Weight 246
and Polyunsaturated Fats 154 Body Fat and Its Distribution 248
From Guidelines to Groceries 154 8-5 Health Risks Associated with Body Weight and Body Fat 251
highlight 5 > High-Fat Foods—Friend or Foe? 164 Health Risks of Underweight 252
Health Risks of Overweight 252
ChaPtER 6 Fit and Fat versus Sedentary and Slim 253
Protein: amino acids 171 highlight 8 > Eating Disorders 256
6-1 The Chemist’s View of Proteins 172
Amino Acids 172
Proteins 173
Nejron Photo/Shutterstock.com
6-2 Digestion and Absorption of Proteins 175

Protein Digestion 175
Protein Absorption 175
6-3 Proteins in the Body 177
Protein Synthesis 177
x table of Contents
Nonvitamins 323
Interactions among the B Vitamins 323
10-3 Vitamin C 327
Blacknote/Shutterstock.com
Vitamin C Roles 327
Vitamin C Recommendations 329
Vitamin C Deficiency 329
Vitamin C Toxicity 330
Vitamin C Food Sources 330
highlight 10 > Vitamin and Mineral Supplements 335
ChaPtER 9
Weight Management: overweight, obesity, ChaPtER 11
and Underweight 265 the Fat-Soluble vitamins: a, d, E, and K 343
9-1 Overweight and Obesity 266 11-1 Vitamin A and Beta-Carotene 344
Fat Cell Development 266 Roles in the Body 344
Fat Cell Metabolism 267 Vitamin A Deficiency 346
Set-Point Theory 267 Vitamin A Toxicity 347
9-2 Causes of Overweight and Obesity 268 Vitamin A Recommendations 348
Genetics and Epigenetics 268 Vitamin A in Foods 349
Environment 270 11-2 Vitamin D 351
9-3 Problems of Overweight and Obesity 272 Roles in the Body 351
Health Risks 272 Vitamin D Deficiency 353
Perceptions and Prejudices 273 Vitamin D Toxicity 354
Dangerous Interventions 273 Vitamin D Recommendations and Sources 354
9-4 Aggressive Treatments for Obesity 274 11-3 Vitamin E 357
Drugs 275 Vitamin E as an Antioxidant 357
Surgery 275 Vitamin E Deficiency 357
9-5 Weight-Loss Strategies 276 Vitamin E Toxicity 357
Changes, Losses, and Goals 277 Vitamin E Recommendations 358
Eating Patterns 277 Vitamin E in Foods 358
Physical Activity 281 11-4 Vitamin K 358
Environmental Influences 284 Roles in the Body 358
Behavior and Attitude 285 Vitamin K Deficiency 359
Weight Maintenance 287 Vitamin K Toxicity 359
Prevention 288 Vitamin K Recommendations and Sources 360
Community Programs 289 highlight 11 > Antioxidant Nutrients in Disease Prevention 364
9-6 Underweight 289
Problems of Underweight 289 ChaPtER 12
Weight-Gain Strategies 290 Water and the Major Minerals 371
highlight 9 > The Latest and Greatest Weight-Loss
12-1 Water and the Body Fluids 372
Diet—Again 296
Water Balance and Recommended Intakes 372
Blood Volume and Blood Pressure 374
ChaPtER 10
Fluid and Electrolyte Balance 376
the Water-Soluble vitamins: B vitamins Fluid and Electrolyte Imbalance 379
and vitamin C 301 Acid-Base Balance 379
10-1 The Vitamins—An Overview 302 12-2 The Minerals—An Overview 381
10-2 The B Vitamins 304 12-3 The Major Minerals 382
Thiamin 305 Sodium 382
Riboflavin 308 Chloride 386
Niacin 309 Potassium 387
Biotin 312 Calcium 388
Pantothenic Acid 313 Phosphorus 394
Vitamin B6 313 Magnesium 395
Folate 315 Sulfate 397
Vitamin B12 320 highlight 12 > Osteoporosis and Calcium 400
Choline 322
table of Contents xi
CHAPTER 13 Infant Formula 483
The Trace Minerals 407 Special Needs of Preterm Infants 484
Introducing Cow’s Milk 484
13-1 The Trace Minerals—An Overview 408 Introducing Solid Foods 485
13-2 The Trace Minerals 410 Mealtimes with Toddlers 488
Iron 410 15-2 Nutrition during Childhood 488
Zinc 419 Energy and Nutrient Needs 488
Iodine 422 Hunger and Malnutrition in Children 491
Selenium 424 The Malnutrition-Lead Connection 492
Copper 425 Hyperactivity and “Hyper” Behavior 494
Manganese 426 Food Allergy and Intolerance 495
Fluoride 426 Childhood Obesity 496
Chromium 427 Mealtimes at Home 502
Molybdenum 428 Nutrition at School 504
13-3 Contaminant Minerals 429 15-3 Nutrition during Adolescence 507
Highlight 13 > Phytochemicals and Functional Foods 433 Growth and Development 507
Energy and Nutrient Needs 507
CHAPTER 14 Food Choices and Health Habits 509
Life Cycle Nutrition: Pregnancy and Lactation 441 Highlight 15 > Childhood Obesity and the Early Development
14-1 Nutrition prior to Pregnancy 442
of Chronic Diseases 516
14-2 Growth and Development during Pregnancy 443
CHAPTER 16
Placental Development 443
Fetal Growth and Development 443
Life Cycle Nutrition: Adulthood and the Later
Critical Periods 444 Years 523
14-3 Maternal Weight 448 16-1 Nutrition and Longevity 524
Weight prior to Conception 448 Observation of Older Adults 525
Weight Gain during Pregnancy 448 Manipulation of Diet 526
Exercise during Pregnancy 450 16-2 The Aging Process 528
14-4 Nutrition during Pregnancy 451 Physiological Changes 529
Energy and Nutrient Needs during Pregnancy 452 Other Changes 531
Vegetarian Diets during Pregnancy and Lactation 455 16-3 Energy and Nutrient Needs
Common Nutrition-Related Concerns of Pregnancy 455 of Older Adults 532
14-5 High-Risk Pregnancies 456 Water 532
The Infant’s Birthweight 457 Energy and Energy Nutrients 533
Malnutrition and Pregnancy 457 Vitamins and Minerals 533
Food Assistance Programs 458 Dietary Supplements 534
Maternal Health 458 16-4 Nutrition-Related Concerns
The Mother’s Age 460 of Older Adults 535
Practices Incompatible with Pregnancy 461 Vision 535
14-6 Nutrition during Lactation 464 Arthritis 536
Lactation: A Physiological Process 464 The Aging Brain 537
Breastfeeding: A Learned Behavior 465 Alcohol 539
Maternal Energy and Nutrient Needs during 16-5 Food Choices and Eating Habits of Older Adults 540
Lactation 465 Malnutrition 541
Maternal Health 467 Food Assistance Programs 541
Practices Incompatible with Lactation 468 Meals for Singles 542
Highlight 14 > Fetal Alcohol Syndrome 473 Highlight 16 > Hunger and Community Nutrition 547
CHAPTER 15
Life Cycle Nutrition: Infancy, Childhood,
Aydindurdu/ Dreamstime.com
and Adolescence 477

15-1 Nutrition during Infancy 478
Energy and Nutrient Needs 478
Breast Milk 480
xii Table of Contents
19-2 Diet-Drug Interactions 602
Drug Effects on Food Intake 604
Drug Effects on Nutrient Absorption 604
Dietary Effects on Drug Absorption 604
Drug Effects on Nutrient Metabolism 605
Dietary Effects on Drug Metabolism 606
Drug Effects on Nutrient Excretion 607
Rob Lewine/Getty Images

Dietary Effects on Drug Excretion 607
Diet-Drug Interactions and Toxicity 607
19-3 Herbal Supplements 608
Effectiveness and Safety of Herbal Products 609
Use of Herbal Products in Illness 611
ChaPtER 17 highlight 19 > Complementary and Alternative
nutrition Care and assessment 555 Medicine 613
17-1 Nutrition in Health Care 555

ChaPtER 20
Effects of Illness on Nutrition Status 556
Responsibility for Nutrition Care 556
Enteral nutrition Support 619
Nutrition Screening 557 20-1 Oral Supplements 620
The Nutrition Care Process 558 20-2 Tube Feedings in Medical Care 621
17-2 Nutrition Assessment 561 Candidates for Tube Feedings 621
Historical Information 561 Tube-Feeding Routes 621
Food Intake Data 562 20-3 Enteral Formulas 624
Anthropometric Data 565 Types of Enteral Formulas 624
Biochemical Data 569 Formula Characteristics 625
Physical Examination 571 Formula Selection 626
highlight 17 > Nutrition and Immunity 574 20-4 Administration of Tube Feedings 627
Safe Handling 627
ChaPtER 18 Initiating and Advancing a Tube Feeding 628
nutrition intervention 581 Meeting Water Needs 631
Medication Delivery during Tube Feedings 632
18-1 Implementing Nutrition Care 581
Tube-Feeding Complications 632
Approaches to Nutrition Care 582
Transition to Table Foods 634
Documenting Nutrition Care 584
highlight 20 > Inborn Errors of Metabolism 638
18-2 Energy Intakes in Hospital Patients 585
Indirect Calorimetry 586
Predictive Equations 586
ChaPtER 21
18-3 Dietary Modifications 588
Parenteral nutrition Support 643
Modified Diets 588 21-1 Indications for Parenteral Nutrition 643
Alternative Feeding Routes 591 Peripheral Parenteral Nutrition 644
Nothing by Mouth (NPO) 592 Total Parenteral Nutrition 645
18-4 Foodservice 592 21-2 Parenteral Solutions 646
Menu Planning 592 Parenteral Nutrients 646
Food Selection 592 Solution Preparation 648
Food Safety 592 21-3 Administering Parenteral Nutrition 650
Improving Food Intake 593 Insertion and Care of Intravenous Catheters 650
highlight 18 > Food Allergies 595 Administration of Parenteral Solutions 651
Discontinuing Parenteral Nutrition 652
ChaPtER 19 Managing Metabolic Complications 653
Medications, diet-drug interactions, 21-4 Nutrition Support at Home 655
and herbal Products 599 Candidates for Home Nutrition Support 655
Planning Home Nutrition Care 655
19-1 Medications in Disease Treatment 599
Quality-of-Life Issues 656
Medication Administration 600
Risks from Medications 600
highlight 21 > Ethical Issues in Nutrition Care 659
Patients at High Risk of Adverse Effects 602
table of Contents xiii
ChaPtER 22 ChaPtER 25
Metabolic and Respiratory Stress 663 Liver disease and Gallstones 739
22-1 The Body’s Responses to Stress and Injury 664 25-1 Fatty Liver and Hepatitis 740
Hormonal Responses to Stress 664 Fatty Liver 740
The Inflammatory Response 665 Hepatitis 741
22-2 Nutrition Treatment of Acute Stress 666 25-2 Cirrhosis 742
Determining Nutritional Requirements 667 Consequences of Cirrhosis 743
Approaches to Nutrition Care in Acute Stress 670 Treatment of Cirrhosis 746
Patients with Burn Injuries 670 Nutrition Therapy for Cirrhosis 746
22-3 Respiratory Stress 672 25-3 Liver Transplantation 750
Chronic Obstructive Pulmonary Disease 673 25-4 Gallstone Disease 751
Respiratory Failure 676 Types of Gallstones 751
highlight 22 > Multiple Organ Dysfunction Syndrome 681 Consequences of Gallstones 752
Risk Factors for Cholesterol Gallstones 752
ChaPtER 23 Treatment of Gallstones 753
Upper Gastrointestinal disorders 685 highlight 25 > Anemia in Illness 757
23-1 Conditions Affecting the Esophagus 686
Dysphagia 686 ChaPtER 26
Gastroesophageal Reflux Disease 689 diabetes Mellitus 763
23-2 Conditions Affecting the Stomach 692 26-1 Overview of Diabetes Mellitus 763
Dyspepsia 692 Symptoms of Diabetes Mellitus 765
Nausea and Vomiting 693 Diagnosis of Diabetes Mellitus 765
Gastroparesis 693 Types of Diabetes Mellitus 765
Gastritis 694 Prevention of Type 2 Diabetes Mellitus 767
Peptic Ulcer Disease 694 Acute Complications of Diabetes Mellitus 767
23-3 Gastric Surgery 696 Chronic Complications of Diabetes Mellitus 769
Gastrectomy 696 26-2 Treatment of Diabetes Mellitus 771
Bariatric Surgery 699 Treatment Goals 771
highlight 23 > Oral Health and Chronic Illness 704 Evaluating Diabetes Treatment 772
Nutrition Therapy: Dietary Recommendations 773
ChaPtER 24 Nutrition Therapy: Meal-Planning Strategies 775
Insulin Therapy 778
Lower Gastrointestinal disorders 709
Antidiabetic Drugs 781
24-1 Common Intestinal Problems 709 Physical Activity and Diabetes Management 781
Constipation 710 Sick-Day Management 783
Intestinal Gas 712 26-3 Diabetes Management in Pregnancy 784
Diarrhea 712 Pregnancy in Type 1 or Type 2 Diabetes 784
24-2 Malabsorption 714 Gestational Diabetes 784
Fat Malabsorption 714 highlight 26 > The Metabolic Syndrome 788
Bacterial Overgrowth 715
24-3 Conditions Affecting the Pancreas 717
Pancreatitis 717
Cystic Fibrosis 719
24.4 Conditions Affecting the Small Intestine 721
Celiac Disease 721
Inflammatory Bowel Diseases 723
Dmitry Lobanov/Shutterstock.com
Short Bowel Syndrome 726

24.5 Conditions Affecting the Large Intestine 728
Irritable Bowel Syndrome 728
Diverticular Disease of the Colon 729
Colostomies and Ileostomies 730
highlight 24 > Probiotics and Intestinal Health 735
xiv table of Contents
CHAPTER 27 CHAPTER 29
Cardiovascular Diseases 793 Cancer and HIV Infection 851
27-1 Atherosclerosis 794 29-1 Cancer 851
Consequences of Atherosclerosis 794 How Cancer Develops 852
Development of Atherosclerosis 795 Nutrition and Cancer Risk 852
Causes of Atherosclerosis 796 Consequences of Cancer 854
27-2 Coronary Heart Disease (CHD) 797 Treatments for Cancer 856
Symptoms of Coronary Heart Disease 797 Nutrition Therapy for Cancer 858
Evaluating Risk for Coronary Heart Disease 797 29-2 HIV Infection 862
Lifestyle Management to Reduce CHD Risk 799 Prevention of HIV Infection 862
Vitamin Supplementation and CHD Risk 803 Consequences of HIV Infection 863
Lifestyle Changes for Hypertriglyceridemia 803 Treatments for HIV Infection 865
Drug Therapies for CHD Prevention 805 Nutrition Therapy for HIV Infection 866
Treatment of Heart Attack 805 Highlight 29 > Foodborne Illness 871
27-3 Stroke 807
Stroke Prevention 807
Stroke Management 807
APPEnDIx A
Cells, Hormones, and Nerves
27-4 Hypertension 808
Factors That Influence Blood Pressure 808 APPEnDIx B
Factors That Contribute to Hypertension 809 Basic Chemistry Concepts
Treatment of Hypertension 810 APPEnDIx C
27-5 Heart Failure 814 Biochemical Structures and Pathways
Consequences of Heart Failure 814
Medical Management of Heart Failure 815
APPEnDIx D
Measures of Protein Quality
Highlight 27 > Coping with Feeding Disabilities 820
APPEnDIx E
CHAPTER 28 Nutrition Assessment: Supplemental Information
Kidney Diseases 825 APPEnDIx F
28-1 Functions of the Kidneys 825 Estimated Energy Needs
28-2 The Nephrotic Syndrome 827 APPEnDIx G
Consequences of the Nephrotic Syndrome 827 Choose Your Foods: Food Lists for Diabetes and Weight
Treatment of the Nephrotic Syndrome 827 Management
28-3 Acute Kidney Injury 830 APPEnDIx H
Causes of Acute Kidney Injury 830 Table of Food Composition
Consequences of Acute Kidney Injury 830
Treatment of Acute Kidney Injury 831 APPEnDIx I
WHO Nutrition Recommendations
28-4 Chronic Kidney Disease 833
Consequences of Chronic Kidney Disease 833 APPEnDIx J
Treatment of Chronic Kidney Disease 834 Healthy People 2020
Kidney Transplants 838
APPEnDIx K
28-5 Kidney Stones 841 Aids to Calculation
Formation of Kidney Stones 841
Consequences of Kidney Stones 842 APPEnDIx L
Prevention and Treatment of Kidney Stones 842 Enteral Formulas
Highlight 28 > Dialysis 847 Glossary GL-1
Index IN-1
InsIDE CoVERs
AJPhoto/Science Source
Dietary Reference Intakes (DRI) A

Daily Values (DV) for Food Labels Y
Body Mass Index (BMI) Z
Table of Contents xv
>how to
t
Think Metric 9 Help Hospital Patients Improve Their Food Intakes 593
Calculate the Energy Available from Foods 10 Reduce the Risks of Adverse Effects from Medications 602
Determine Whether a Website Is Reliable 31 Prevent Diet-Drug Interactions 608
Compare Foods Based on Nutrient Density 39 Help Patients Improve Intakes with Oral Supplements 620
Calculate Personal Daily Values 59 Help Patients Cope with Tube Feedings 629
Reduce the Intake of Added Sugars 118 Plan a Tube-Feeding Schedule 630
Make Heart-Healthy Choices—by Food Group 157 Administer Medications to Patients Receiving Tube Feedings 632
Calculate a Personal Daily Value for Fat 160 Express the Osmolar Concentration of a Solution 645
Understand “% Daily Value” and “% kCalories from Fat” 161 Calculate the Macronutrient and Energy Content of a
Calculate Recommended Protein Intakes 189 Parenteral Solution 649
Estimate Energy Requirements 245 Estimate the Osmolarity of a Parenteral Solution 650
Determine BMI 249 Estimate Energy Needs Using Disease-Specific Stress Factors 668
Compare Foods Based on Energy Density 280 Improve Acceptance of Mechanically Altered Foods 689
Identify a Fad Diet or Weight-Loss Scam 299 Manage Gastroesophageal Reflux Disease 691
Evaluate Foods for Their Nutrient Contributions 306 Alter the Diet to Reduce Symptoms of Dumping Syndrome 698
Estimate Niacin Equivalents 310 Alter Dietary Habits to Achieve and Maintain Weight Loss after
Estimate Dietary Folate Equivalents 317 Bariatric Surgery 701
Cut Salt (and Sodium) Intake 384 Follow a Fat-Restricted Diet 717
Estimate Your Calcium Intake 392 Help the Cirrhosis Patient Eat Enough Food 748
Estimate the Recommended Daily Intake for Iron 416 Use Carbohydrate Counting in Clinical Practice 776
Plot Measures on a Growth Chart 479 Treat High Blood Cholesterol to Reduce Atherosclerotic CVD Risk 799
Protect against Lead Toxicity 494 Implement a Heart-Healthy Diet 804
Stretch Food Dollars and Reduce Waste 550 Reduce Sodium Intake 813
Measure Length and Height 566 Help Patients Comply with a Renal Diet 839
Measure Weight 567 Increase kCalories and Protein in Meals 859
Estimate and Evaluate Changes in Body Weight 568 Help Patients Handle Food-Related Problems 860
Estimate Appropriate Energy Intakes for Hospital Patients 587 Prevent Foodborne Illnesses 875
CaSE
StUdY
Nutrition Screening and Assessment 572 Patient with Short Bowel Syndrome 728
Implementing Nutrition Care 594 Young Adult with Irritable Bowel Syndrome 729
Injured Hiker Requiring Enteral Nutrition Support 635 Man with Cirrhosis 749
Patient with Intestinal Disease Requiring Parenteral Child with Type 1 Diabetes 783
Nutrition 654 Woman with Type 2 Diabetes 785
Patient with a Severe Burn 672 Patient with Cardiovascular Disease 813
Elderly Man with Emphysema 676 Woman with Acute Kidney Injury 832
Woman with GERD 692 Man with Chronic Kidney Disease 840
Nutrition Care after Gastric Surgery 699 Woman with Cancer 862
Child with Cystic Fibrosis 720 Man with HIV Infection 868
xvi table of Contents
Preface
As we launch this eleventh edition of Understanding Normal through 13 describe the vitamins, the minerals, and water—
and Clinical Nutrition, nutrition research continues to un- their roles in the body, deficiency and toxicity symptoms, and
cover the many complex relationships between nutrition and sources. Chapters 14 through 16 complete the “normal” chap-
health. Our goals for this edition are to incorporate these ters by presenting the special nutrient needs of people through
current research findings into the core information neces- the life cycle—pregnancy and lactation; infancy, childhood,
sary for an introductory course in nutrition. As with previous adolescence; and adulthood and the later years.
editions, each chapter has been substantially updated and The remaining “clinical” chapters of the book focus on the
revised to include new topics as well as expand on existing nutrition care of individuals with health problems. Chapter
topics. The chapters include practical information and valu- 17 explains how illnesses and their treatments influence nu-
able resources to help readers apply nutrition knowledge and trient needs and describes the process of nutrition assessment.
skills to their daily lives and the clinical setting. Chapter 18 discusses how nutrition care is implemented and
A main objective in writing this book has always been to introduces the different types of therapeutic diets used in
share our enthusiasm about nutrition in a manner that mo- patient care. Chapter 19 explores the potential interactions
tivates students to study and learn. Moreover, we seek to pro- between nutrients and medications and examines the ben-
vide accurate information that is meaningful to the student or efits and risks associated with herbal products. Chapters 20
health professional. Students of nutrition often find the subject and 21 describe specialized methods for providing nutrients
to be both fascinating and overwhelming; there are so many to people who are unable to consume a regular diet. Chapter
details to learn—new terms, new chemical structures, and new 22 describes the inflammatory process and shows how meta-
biological concepts. Taken one step at a time, however, the sci- bolic and respiratory stress influence nutrient needs. Chap-
ence of nutrition may seem less daunting and the facts more ters 23 through 29 explore the pathology, medical treatment,
memorable. We hope that this book serves you well. and nutrition therapy for specific diseases, including gastro-
intestinal disorders, liver disease, diabetes mellitus, cardio-
vascular diseases, renal diseases, cancer, and HIV infection.
a Book tour of this Edition the highlights Every chapter is followed by a highlight
Understanding Normal and Clinical Nutrition presents updated, that provides readers with an in-depth look at a current, and of-
comprehensive coverage of the fundamentals of nutrition and ten controversial, topic that may relate to its companion chap-
nutrition therapy for an introductory nutrition course. The early ter. For example, Highlight 4 examines the scientific evidence
chapters introduce the nutrients and their work in the body as behind some of the current controversies surrounding carbohy-
well as recommendations about nutrition that are essential for drates and their role in weight gain and weight loss. New to this
maintaining health and preventing disease. The later chapters edition are Critical Thinking Questions designed to encourage
provide instruction in clinical nutrition—the pathophysiology readers to develop clear, rational, open-minded, and informed
and nutrition care for a wide range of medical conditions. thoughts based on the evidence presented in the highlight.
the Chapters Chapter 1 begins by exploring why we eat Special Features The art and layout in this edition have
the foods we do and continues with a brief overview of the nu-
been carefully designed to be inviting while enhancing stu-
trients, the science of nutrition, recommended nutrient intakes,
dent learning. For example, numbered steps have been added
and important relationships between diet and health. Chapter
to several figures to clarify sequences and processes. In addi-
2 describes the menu-planning principles and food guides used
tion, special features help readers identify key concepts and
to create diets that support good health and includes instruc-
apply nutrition knowledge. For example, when a new term
tions on how to read a food label. In Chapter 3, readers follow
is introduced, it is printed in bold type, and a definition is
the journey of digestion and absorption as the body breaks
provided. These definitions often include pronunciations and
down foods into absorbable nutrients. Chapters 4 through 6
derivations to facilitate understanding. The glossary at the
describe carbohydrates, fats, and proteins—their chemistry,
end of the text includes all defined terms.
roles in the body, and places in the diet. Chapter 7 shows how
the body derives energy from these three nutrients. Chapters definition (DEF-eh-NISH-en): the meaning of a word.
8 and 9 continue the story with a look at energy balance, the ● de = from
factors associated with overweight and underweight, and the ● finis = boundary
benefits and risks of weight loss and weight gain. Chapters 10

xvii
how to
LEaRninG GPS Many of the chapters include To” in Chapter 1 presents the
The opening page of each chapter provides a Learning GPS that “How To” features that guide steps in calculating energy in-
serves as an outline and directs readers to the main headings (and readers through problem-solv- take from the grams of carbohy-
subheadings) within the chapter. Each main heading is followed ing tasks. For example, a “How drate, fat, and protein in a food.
by a Learn It—a learning objective for the content covered in that
section. The Learn It also appears within the text at the start of
❯ tRY it Each “How To” feature ends with a “Try It” activ-
each main section as well as at the start of each Review It. After
ity that gives readers an opportunity to practice these new
reading and studying the chapter, students should be able to
lessons.
demonstrate competency in the Learn It objectives.
Nutrition in Your Life/Nutrition CaSE

in the Clinical Setting StUdY
Chapters 1 through 16 open with a paragraph called Nutri- The clinical chapters include case studies that present prob-
tion in Your Life that introduces the chapter’s content in a lems and pose questions that allow readers to apply chapter
friendly and familiar way. This short paragraph closes with material to hypothetical situations. Readers who successfully
a preview of how readers might apply that content to their master these exercises will be better prepared to face real-
daily lives by inviting them to use the Nutrition Portfolio life challenges that arise in the clinical setting.
section at the end of those chapters. Similarly, Chapters 17
through 29 open with a Nutrition in the Clinical Setting
paragraph, which introduces real-life concerns associated
with diseases or their treatments. Nutrition Assessment Checklist
The clinical chapters close with Nutrition Assessment Check-
lists that help readers evaluate how various disorders impair
Nutrition Por tfolio/Clinical nutrition status. These sections highlight the medical, di-
etary, anthropometric, biochemical, and physical findings
Portfolio most relevant to patients with specific diseases.
At the end of Chapters 1 through 16, a Nutrition Portfolio

prompts readers to consider whether their personal choices are Diet-
meeting the dietary goals presented in the chapter. Chapters 17 Drug interactions
through 29 finish with a Clinical Portfolio section, which
enables readers to practice their clinical skills by addressing Most of the clinical chapters also include a section on Diet-
hypothetical clinical situations. Many of these assignments in- Drug Interactions that presents the nutrition-related concerns
clude instructions that use the Diet & Wellness Plus program. associated with the medications commonly used to treat the
Such tools help students assess their current choices and make disorders described in the chapter.
informed decisions about healthy options.
❯ REVIEW IT Each major section within a chapter concludes the appendixes The appendixes are valuable references
with a Review It paragraph that summarizes key concepts. Simi- for a number of purposes. Appendix A summarizes back-
larly, Review It tables cue readers to important summaries. ground information on the hormonal and nervous systems,
complementing Appendixes B and C on basic chemistry, the
Also featured in this edition are the 2015–2020 Dietary chemical structures of nutrients, and major metabolic path-
Guidelines for Americans, which are introduced in Chapter 2 ways. Appendix D describes measures of protein quality.
and presented throughout the text whenever their subjects Appendix E provides supplemental coverage of nutrition assess-
are discussed. Look for the following design. ment, and Appendix F presents the estimated energy require-
ments for men and women at various levels of physical activity.
Appendix G presents the 2014 Choose Your Foods: Food Lists for
> diE ta RY GUidEL inE S F oR a MERiC a nS 2 0 15 – 2 0 2 0
Diabetes and Weight Management. Appendix H is a 4000-item
These guidelines provide science-based advice to promote health and
food composition table. Appendix I presents nutrition recom-
to reduce the risk of chronic disease through diet and physical activity.
mendations from the World Health Organization (WHO).
xviii Preface
Appendix J presents the Healthy People 2020 nutrition- Chapter 3
related objectives. Appendix K features aids to calculations, ● Introduced microbiome and revised section on gastroin-
a short tutorial on converting metric measures and handling
testinal bacteria
basic math problems commonly found in the world of nu-
trition. Appendix L provides examples of commercial enteral
formulas commonly used in tube feedings or to supplement
Chapter 4
oral diets. ● Revised table showing nutrients in sugars and other
foods to include potassium and vitamin D
the inside Covers The inside covers put commonly ● Created tables to define glucose for normal and diabetes;
used information at your fingertips. The inside front covers to show the glycemic index of a few common foods; to
(pp. A–C) present the current nutrient recommendations, list the functions of sugars in foods; and to present ways
and the inside back covers feature the Daily Values used on to prevent dental caries
food labels and a glossary of nutrient measures (p. Y on the ● Included fructose metabolism in the highlight
left) as well as suggested weight ranges for various heights
(p. Z on the right). Chapter 5
● Created tables to define blood lipids for heart health; to
notable Changes in this Edition list fat choices among protein foods and among milk
products; to show omega-3 fatty acid quantities in a vari-
Because nutrition is an active science, staying current is para- ety of fish and seafood
mount. Just as nutrition research continuously adds to and ● Created new figure on how to read fish oil supplement
revises the accepted body of knowledge, this edition builds
labels
on the science of previous editions with the latest in nutrition
research. Much has changed in the world of nutrition and in
● Added definitions for resistin and adiponectin
our daily lives since the first edition. The number of foods has
increased dramatically—even as we spend less time than ever Chapter 6
in the kitchen preparing meals. The connections between ● Expanded discussion on the association between dietary
diet and disease have become more apparent—and consumer protein and body weight
interest in making smart health choices has followed. More
people are living longer and healthier lives. The science of Chapter 7
nutrition has grown rapidly, with new facts emerging daily. ● Created new figure illustrating labels on beer, wine, and
In this edition, as with all previous editions, every chapter liquor
has been revised to enhance learning by presenting current
information accurately and attractively. For all chapters and Chapter 8
highlights we have:
● Discussed “3500 kcalorie rule” and its limitations
● Reviewed and updated content
● Created new tables for estimating energy expended on
● Created several new figures and tables and revised others basal metabolism and on thermic effect of foods and for
to enhance learning percent body fat at various BMI
● Included 2015-2020 Dietary Guidelines for Americans ● Revised section on female athlete triad to include
new expanded term—Relative Energy Deficiency in
Chapter 1 Sports (RED-S)—and created new table of its adverse
● Created table to summarize ways to describe six classes consequences
of nutrients ● Added discussion of food addiction to section on binge
● Introduced registered dietitian nutritionist (RDN), another eating disorder
term to describe an RD
Chapter 9
Chapter 2 ● Added discussion of brite adipocytes to section on brown
● Revised section on Dietary Guidelines to reflect 2015– adipocyte tissue and uncoupling proteins
2020 recommendations
● Updated table on FDA-approved weight loss drugs
● Revised figure comparing nutrient density of two break-
● Revised figure on gastric surgery used to treat obesity
fasts to include potassium and vitamin D
● Deleted discussion and figure on unrealistic expectations
● Introduced proposed food labels and revised figure to il-
lustrate differences ● Created new table of national strategies to prevent
obesity
● Introduced front-of-package labeling and added figure to
illustrate ● Updated table on popular weight loss diets
Preface xix
Chapter 11 Chapter 20
● Added a paragraph on “golden rice,” a genetically modi- ● Refined the terms related to nutrition support: intro-
fied rice used in the worldwide fight against vitamin A duced the terms specialized nutrition support and oral
deficiency nutrition support
● Added details on vitamin D’s non-bone-related roles ● Shortened the section on oral supplements
● Rewrote the introduction to vitamin E ● Updated the feeding tube photo
● Rewrote the food sources of vitamin K paragraph to ● Modified the sections on initiating and advancing tube
include the terms phylloquinone (vitamin K 1) and feedings and meeting water needs
menaquinone (vitamin K2)
Chapter 21
Chapter 12 ● Added additional details in the table on patient moni-
● Revised calcium balance figure toring during parenteral nutrition
● Revised the section on discontinuing parenteral nutrition
Chapter 13 ● Revised the glossary definitions in the highlight on ethi-
● Created table of factors influencing iron absorption cal issues
Chapter 14 Chapter 22
● Created several new tables: benefits of WIC, risk factors ● Added glossary definitions for complement, indirect calo-
for gestational diabetes, signs and symptoms of pre- rimetry, and minute ventilation
eclampsia, complications from smoking during preg- ● Revised the sections on estimating energy needs during
nancy, tips to prevent listeriosis
acute stress, use of glutamine or arginine during acute
● Reorganized sections on fetal programming and fetal de- illness, and micronutrient needs in acute stress
velopment of chronic diseases ● Modified the How To feature for estimating energy needs
using stress factors
Chapter 15
● In the table on predictive equations used in ventilator-
● Created several new tables: protective factors in breast
dependent patients, updated the Ireton-Jones and Penn
milk, tips for picky eaters, examples of foods and non-
State equations, and used the Penn State equation in the
food items children can choke on, iron recommenda-
example
tions for adolescents
● Shortened the section on causes of chronic obstructive
● Added information about fluoride and formula
pulmonary disease, and modified some sections on nu-
preparation
trition therapy for respiratory failure
● Added brief discussion about new AAP guidelines for re-
duced, low-fat, and fat-free milk for toddlers Chapter 23
● Added discussion of new school meal initiatives ● Added a discussion about gastroparesis
Modified some material in the sections on gastritis, gas-
Chapter 16
●
troesophageal reflux disease, and bariatric surgery; added

● Created new figure comparing healthy lens with cataract lens glossary definitions for bloating and bacterial overgrowth
In the section on bariatric surgery, added a figure show-
Chapter 17
●
ing the sleeve gastrectomy surgery

● Added a table showing the relationship between the rate
of involuntary weight loss and nutritional risk Chapter 24
● Updated the laboratory values in the table on routine ● Revised some of the material in the sections on constipa-
laboratory tests tion, intestinal gas, acute and chronic pancreatitis, cystic
● Added a paragraph about C-reactive protein in the sec- fibrosis, celiac disease, irritable bowel syndrome, and di-
tion on biochemical analyses verticular disease of the colon
● Revised the discussion on fluid retention ● Added calcium channel activators to the table of laxa-
tives and bulk-forming agents
Chapter 19 ● Revised the table of foods that increase intestinal gas
● Reorganized the beginning paragraphs of the highlight ● Introduced the concept of FODMAPs and added a defini-
on complementary and alternative medicine tion for bacterial translocation
xx Preface
Chapter 25 ● In the section on kidney stones, introduced hypocitratu-
ria as a risk factor and reformatted the table on food
● Shortened the paragraph on nutrition treatment for
sources of oxalates
hepatitis
● Modified some sections about cirrhosis complications, Chapter 29
including the table listing the clinical features of hepatic
● Updated the tables on factors that influence cancer risk
encephalopathy
● Revised the section on biological therapies for cancer to
● Revised the section on the medical treatment for cirrhosis
include more examples of cancer immunotherapy; in-
cluded new definitions for monoclonal antibodies and im-
Chapter 26 mune checkpoint inhibitors
● Updated statistics throughout the chapter
● Revised the section about food safety concerns for im-
● Added a margin table comparing glycated hemoglobin munosuppressed cancer patients
(HbA1c) and plasma glucose levels
● Expanded the section on the prevention of HIV infection
● In the section on diabetic neuropathy, distinguished be- to include a discussion about prophylactic medications
tween peripheral and autonomic neuropathy and added used in persons at risk of HIV exposure
glossary definitions for these two different forms of
● Updated the definition of AIDS-wasting syndrome to re-
neuropathy
flect current guidelines
● Revised various sections on nutrition therapy to reflect
the updated clinical guidelines
● Revised the discussion on exchange lists to reflect the Student and instructor Resources
food lists released in 2014 (Appendix G was also up-
dated to show the 2014 food lists) nutrition Mindtap for Understanding normal
● Added inhaled insulin and sodium-glucose cotrans- and Clinical nutrition
porter 2 (SGLT2) inhibitors to the tables listing the dif- MindTap is well beyond an eBook, a homework solution or
ferent types of insulin and antidiabetic drugs digital supplement, a resource center website, a course deliv-
ery platform, or a Learning Management System. More than
● Revised the discussion on insulin use in type 2 diabetes 70 percent of students surveyed said that it was unlike any-
● Updated several sections in the Nutrition in Practice on thing they have ever seen before. MindTap is a new personal
metabolic syndrome learning experience that combines all of your digital assets—
● Added a figure showing how metabolic syndrome varies readings, multimedia, activities, and assessments—into a
among ethnic groups and removed the figure showing singular learning path to improve student outcomes.
how it varies with age
diet & Wellness Plus
Chapter 27 Diet & Wellness Plus helps you gain a better understanding
● Revised various paragraphs in the sections on atheroscle- of how nutrition relates to your personal health goals. It en-
rosis, cardiovascular disease (CVD) risk assessment, CVD ables you to track your diet and activity, generate reports,
lifestyle management, hypertension, and heart failure and analyze the nutritional value of the food you eat! It in-
cludes over 55,000 foods in the database, custom food and
● Revised the How To feature about identifying and treat- recipe features, the latest Dietary References, as well as your
ing high blood cholesterol goal and actual percentages of essential nutrients, vitamins,
● Eliminated the box on assessing risk of heart disease and minerals. It also helps you to identify a problem behav-
● Updated the section on hypertension treatment ior and make a positive change. After completing a Wellness
● In the highlight on feeding disabilities, revised the sec- Profile questionnaire, Diet & Wellness Plus will rate the level
tion related to altered energy requirements of concern for eight different areas of wellness, helping you
determine the areas where you are most at risk. It then helps
Chapter 28 you put together a plan for positive change by helping you
select a goal to work toward, complete with a reward for all
● Modified the table on causes of acute kidney injury, and your hard work. Diet & Wellness Plus is also available as an
revised the discussion about the evaluation of acute kid- App that can accessed from the App dock in MindTap and
ney injury can be used throughout the course for students to track their
● Updated the section on the evaluation of chronic kidney diet, activity, and behavior change.
disease to reflect new clinical practice guidelines
● Clarified and updated some sections related to nutri- Global health Watch
tion therapy for chronic kidney disease to reflect current Updated with today’s current headlines, Global Health
recommendations Watch is your one-stop resource for classroom discussion
and research projects. This resource center provides access to
Preface xxi
thousands of trusted health sources, including academic
journals, magazines, newspapers, videos, podcasts, and more.
Closing Comments
It is updated daily to offer the most current news about topics We have taken great care to provide accurate information
related to your health course. and have included many references at the end of each chap-
ter and highlight. To keep the number of references man-
Cognero test Bank ageable over the decades, however, many statements that
Cengage Learning Testing Powered by Cognero is a flexible, appeared in previous editions with references now appear
online system that allows you to: without them. All statements reflect current nutrition knowl-
● Author, edit, and manage test bank content from mul- edge, and the authors will supply references upon request.
tiple Cengage Learning solutions In addition to supporting text statements, the end-of-chapter
references provide readers with resources for finding a good
● Create multiple test versions in an instant
overview or more details on the subject. Nutrition is a fas-
● Deliver tests from your learning management system cinating subject, and we hope our enthusiasm for it comes
(LMS), your classroom, or wherever you want through on every page.
instructor’s Companion Site Sharon Rady Rolfes

Everything you need for your course in one place! This col- Kathryn Pinna
lection of book-specific lecture and class tools is available Ellie Whitney
online via www.cengage.com/login. Access and download
PowerPoint presentations, images, the instructor’s manual,
videos, and more.
xxii Preface
Acknowledgments
To produce a book requires the coordinated effort of a team thoughtful suggestions and efficient analysis of reviews, Carol
of people—and, no doubt, each team member has another Samet for her management of this project, Tom Ziolkowski
team of support people as well. We salute, with a big round for his energetic efforts in marketing, Miriam Myers for her
of applause, everyone who has worked so diligently to en- dedication in developing online animations and study tools,
sure the quality of this book. and Christine Myaskovsky for her assistance in obtaining
We thank our partners and friends, Linda DeBruyne and permissions.
Fran Webb, for their valuable consultations and contribu- We also thank Gary Hespenheide for creatively designing
tions; working together over the past 30-plus years has been these pages, Mathangi Anantharaman at Lumina Datamatics
a most wonderful experience. We especially appreciate Linda’s Limited for selecting photographs that deliver nutrition messages
research assistance on several chapters. Special thanks to Da- attractively, Debbie Stone for copyediting, and MPS Limited for
vid Stone for his help in critiquing and proofreading various proofreading close to 1000 final text pages. We would also like
sections in the clinical chapters. Thanks also to Chelsea Mack- to extend our gratitude to Edward Dionne, our project manager,
enzie for her work on manuscript preparation and to Taylor and the talented team at MPS Limited for their assistance with
Newman for her assistance in creating informative tables and layout, production, and indexing. To the hundreds of others in-
descriptive figures. volved in production and sales, we tip our hats in appreciation.
Our heartfelt thanks to our editorial team for their efforts We are especially grateful to our friends and families for
in creating an outstanding nutrition textbook—Krista Mastroi- their continued encouragement and support. We also thank
anni for her leadership and support, Lauren Oliveira for her our many reviewers for their comments and contributions.
xxiii
Reviewers of Understanding
Normal & Clinical Nutrition
Becky Alejandre Sue Fredstrom Rebecca A. Kleinschmidt
American River College Minnesota State University, Mankato University of Alaska Southeast
Janet B. Anderson Trish Froehlich Vicki Kloosterhouse
Utah State University Palm Beach Community College Oakland Community College
Sandra D. Baker Stephen P. Gagnon Donna M. Kopas
University of Delaware Hillsborough Community College Pennsylvania State University
Angelina Boyce Leonard E. Gerber Susan M. Krueger
Hillsborough Community College University of Rhode Island University of Wisconsin, Eau Claire
Lynn S. Brann Jill Golden Barbara Lange
Syracuse University Orange Coast College College of Central Florida
Shalon Bull Barbara J. Goldman Melissa Langone
Palm Beach Community College Palm Beach State College Pasco-Hernando Community College
Dorothy A. Byrne Debra Goodwin Grace Lasker
University of Texas, San Antonio Jacksonville State University Lake Washington Institute of Technology
Angela Caldwell Kathleen Gould Darlene M. Levinson
Black River Technical College Towson University Oakland Community College, Orchard
John R. Capeheart Margaret Gunther Ridge
University of Houston, Downtown Palomar College Kimberly Lower
Leah Carter Charlene Hamilton Collin County Community College
Bakersfield College University of Delaware Mary Marian
James F. Collins Debra Head University of Arizona
University of Florida University of Central Arkansas Melissa B. McGuire
Cathy Cunningham D. J. Hennager Maple Woods Community College
Texas Tech University Kirkwood Community College Diane L. McKay
Diane Curis Catherine Hagen Howard Tufts University
Los Rios Community College District Texarkana College Anne Miller
De Anza College
Lisa K. Diewald Samantha Hutson
Montgomery County Community College Tennessee Technological University Anahita M. Mistry
Eastern Michigan University
Kelly K. Eichmann Jasminka Z. Ilich
Fresno City College Florida State University Lisa Morse
Arizona State University
Shannon Fenster Ernest B. Izevbigie
Bellevue College Jackson State University Mithia Mukutmoni
Sierra College
Shawn Flanagan Craig Kasper
Steven Nizielski
University of Iowa Hillsborough Community College
Grand Valley State University
Mary Flynn Shawnee Kelly
Carmen L. Nochera
Brown University Pennsylvania State University
Grand Valley State University
Betty J. Forbes Younghee Kim
Yvonne Ortega
West Virginia University Bowling Green State University
Santa Monica College
xxiv
Another random document with
no related content on Scribd:
Americans have known the French only superficially, and that, in
thinking and speaking of them, we have indulged in the careless and
inaccurate habit of generalization. We have subscribed to the
tradition of the superficiality and frivolity of the French people. We
have believed them lacking in seriousness and perseverance, a
strange misunderstanding of the race which has produced Richelieu
and Talleyrand and Robespierre, La Salle and Marquette and
Champlain. We thought them volatile and temperamental, these
countrymen of Bossuet and Montesquieu, of Pascal and Corneille.
We were wont to say quite patronizingly that French soldiers, though
they possessed verve and élan, were not stayers and “last-
ditchers”—this of the men of the Marne and Verdun! The trouble has
always been not with France, but with ourselves. The France that we
knew before this war gave us a broader vision was the France of
Rue de la Paix and the Champs Élysées, of Montmartre and the
Latin Quarter, of the Louvre and the Luxembourg, of Longchamps
and Auteuil, of Poiret and Paquin, of Giro’s and Voisin’s, of the Bon
Marché and the Galeries Lafayette, of the Opéra and the Comédie
Française, of the Riviera and Trouville and Aix-les-Bains. What have
we known of the sober, simple-hearted, industrious, frugal, plain-
living, deeply religious people who are the real France? France has
not been reborn. It is an affront to her to say it. She has but cast
aside the glittering garment which she wore for the gratification of
strangers in order to free her sword arm.
If you would understand the spirit which animates the French people,
read this letter which was written by a French cook to his wife the
day before he was killed in action. It is but a sample of thousands.
My dear Yvonne:—
Do not worry. I have good hope of seeing you again, as
well as our Raymond. I beg you to take care of yourself
and also of my son, for you know that I should never
forgive you if anything should happen to you or to him.
Now, if by chance anything should happen to me,—for,
after all, we are in war, and of course we are running
some risk,—I hope you will be courageous, and be sure
that if I die I put all my confidence in you, and I ask you to
live in order to bring up my son to be a man—a man of
spirit—and give him a good education as far as your
means will permit.
And above all you shall tell him when he is grown up that
his father died for him, or at least for a cause which should
serve him, as well as all the generations to come.
Now, my dear Yvonne, all this is but a precaution, and I
expect to be there to aid you in this task; but as I have
said, one never knows what may happen. In any case we
are leaving (for the front) all in good spirits and in the firm
belief that we shall conquer.
As to you, my dear Yvonne, know that I have always loved
you and that I will love you always no matter what
happens. As soon as you can, leave for Fontenay, for on
my return I should prefer to find you there; and once more
let me say that I count on you, and that you will be brave.
I will give you no more advice, for I believe that would be
superfluous.
Your little husband, who embraces you tenderly, as well as
dear Raymond—
Georges
America’s entrance into the war is the surest guarantee that the
world can have for a peaceful future. Our practically inexhaustible
military, financial, industrial, and agricultural resources give us all the
trump cards. We can double and, if necessary, redouble, every bid
that Germany makes. We must beware, however, of one pitfall: of
assuming that the war is going to be a short one. England,
notwithstanding the solemn warnings of Lord Kitchener, made that
mistake at the beginning of the war, and she has paid for it in blood
and tears. Though we are warned with all earnestness by the men
who are best qualified to know that peace is not in sight, and
probably will not be in sight for many, many months to come, one
nevertheless hears on every hand the confident assertion that
Germany is on her last legs, that the morale of her armies is
weakening, that her supply of men is almost exhausted, that her
people are starving, and that American troops will never get within
sound of the guns because the war will be over before they can be
made ready to send to France. There is no surer way to prolong the
war than to indulge in such talk as this. Why deceive ourselves? Let
us look the facts in the face. Germany is not starving, nor is there
any prospect of her being brought to that point for a long time to
come, if, indeed, at all. Her man-power, though greatly depleted, is
not giving out. Her morale apparently remains unimpaired; in short,
her military machine still seems impregnable. Remember, moreover,
that she is everywhere fighting on the enemy’s soil and that her own
frontiers remain intact. The extreme gravity of the situation was
recently made plain to the Canadian Parliament by the Premier, Sir
Robert Borden, in these words: “A great struggle still lies before us,
and I cannot put it before you more forcibly than by stating that at the
commencement of this spring’s campaign Germany put into the field
a million more men than she put into the field last spring. And that
million was provided by Germany alone and not by the whole of the
Central Powers.” There is, indeed, nothing to indicate at this time
that the German Government is prepared to negotiate peace save
on impossible terms. It has been a fallacy, and nearly a fatal one for
the Allies, this underestimating the power of Germany. She has, as
some one has truthfully said, made of war “a national industry.” She
is a professional, while the rest of us are, after all, but amateurs, and
she has repeatedly shown, moreover, that she has not the slightest
intention of adhering to the rules laid down by civilized nations for the
conduct of the game. She has spikes on her boots and brass
knuckles on her fingers, and she will not hesitate to gouge or kick or
strike below the belt. She is a ferocious, formidable, and desperate
adversary, possessed of immense staying power, and the only way
we can hope to crush her in reasonable time is by intelligent
coördination of effort, by the fullest and most painstaking
preparation, and by the exertion of every ounce of our strength.
Don’t let us be deceived by the made-in-Germany talk of an early
peace. In accepting it we are only playing the enemy’s game. In
every possible way Germany is throwing out the idea that the end of
the war is in sight. She is doing this because she knows that she has
reached the crest of her military strength. She is at “the peak of the
load.” She knows that every day she is weaker by so many men, and
that she no longer has any considerable reserves from which to
replace these losses. She is ready and anxious to quit—upon her
own terms. But she is prepared to fight a long, long time yet before
accepting the terms that we and our allies must insist upon in order
to safeguard the future peace of the world. The mere appearance of
American troops upon the battle-line is not going to end the war, as
so many of our people seem to think. Not until America begins
making war as though she was facing Germany alone will it be
possible to predict with any certainty when the end will come.
The truth of the matter is that the American people utterly fail to
realize the seriousness of our situation. In fact, the Government itself
did not realize its gravity until from the lips of the French and British
commissioners it learned the startling truth. Up to the moment of our
entrance into the war the Allied Governments, controlling all the
channels of information, had so successfully fostered the impression
that they had the Germans on the run, that all of our people, save a
handful who were in possession of the facts, looked to see the war
end in a sweeping victory for the Allies before the close of the
present year. The truth of the matter is that, had we remained aloof,
the war would in all probability have ended before this year was over,
but not in a victory for the Allies. The almost pathetic eagerness with
which the Allied Governments welcomed our proffered aid in money
and men is the best proof of how desperate was their plight. Here
are the facts: Germany’s submarine campaign is an almost
unqualified success. Unless we can successfully and immediately
combat this menace, England is in grave danger of being brought
within measurable distance of starvation. France is rapidly
approaching complete military and economic exhaustion. The drain
upon her vitality of nearly three years of war has left her faint and
gasping. Though she has inflicted huge losses upon the enemy, her
own losses have been enormous, and, with her much smaller
population, she is less able to stand them. It is not the slightest
exaggeration to say that France is in as crying need of American
assistance as were the American Colonies when Rochambeau and
his soldiery disembarked upon these shores. Should the Russian
Republic be betrayed into making a separate peace—and, at the
moment of writing, the Russian prospect is anything but cheering—
the Central Powers would have released for use upon the Western
Front not less than two million veterans. The war has become,
indeed, a race between ourselves and Germany. Can we build food-
ships faster than Germany can sink them? Can we raise enough
food to feed our allies as well as ourselves? Can we put more men
and guns upon the Western Front than Germany can? Upon the
answers to these questions depends the duration and decision of the
war.
If we are to win this war it will be necessary for us to practise self-
denials, to endure hardships, perhaps to know sorrows of which we
have never dreamed. We must hold back nothing. Our sheltered,
ordered, comfortable lives will be turned topsy-turvy. There will be no
man, woman, or child between the oceans which this war will not in
some way affect. It will impose burdens alike on the rich and the
poor, on the old no less than on the young, on women as well as on
men. It will entail innumerable sacrifices, many of which will be hard
and some of which will seem unjust, yet we must accept them
cheerfully.
If millions of our young men are prepared to give up their lives for
their country, is it too much to ask the rest of us to give up for a time
our comforts and our pleasures?
The civilian must do his duty no less than the man in khaki. And
“duty,” at this time, has many meanings. It is a duty to pay taxes.
These will, without doubt, be increased again and again and yet
again before this war is over, and in many cases they will be directly
felt. The man who dodges taxes when his country is at war is more
deserving of contempt than the soldier who shows the white feather
on the firing-line, for whereas the one fears for his life the other fears
only for his pocketbook. It is a duty to raise foodstuffs and to give
every possible encouragement to others to do so. The householder
who refuses to plough his yard and plant it to vegetables because it
would spoil the looks of his place is as much a slacker as the man
who attempts to evade his military obligations. It is a duty to refrain
from every form of extravagance. By this I do not mean to imply that
people should suddenly stop buying, but only that they should stop
buying things that they do not need or that they can get along
without. For how, pray, are we to place some seven billion dollars of
purchasing power at the disposal of the Government unless we
curtail our individual expenditures? And it is the duty of our
merchants and business men to promptly cease their gloomy
prophecies that an era of national economy will bring on a paralysis
of trade and industry. As a matter of fact, it will do nothing of the sort.
There is far more danger of there being a lack of workers than there
is of there being a lack of work. Already there is more work in sight
than can possibly be done. The shipyards, the steel-mills, the
clothing-factories, the munitions plants, the mines, the farms, the
railways are all clamoring for it, and they will clamor for labor still
more insistently when a million or so men have been taken out of
industry for the army. It is a duty to keep cool, to think sanely, to
avoid hysteria. It is a duty to refrain from giving circulation to
sensational rumors. It is a duty to refrain from nagging the
Government, for the Government is, you may be sure, doing the best
it can. And finally, it is a duty to buy your country’s bonds. Buy all you
can. Take that ten or hundred or thousand dollars that you have
been saving for some cherished personal purpose and invest it in the
Liberty Loan. That is the most practical way I know of showing that
your patriotism is not confined to words.
There is another form of sacrifice which the American people will
inevitably be called upon to make, and that is to accept without
complaint the heavy restrictions which the Government will find it
necessary to put on their private activities. The Government must
have the first call on coal, iron, steel, timber, chemicals, on supplies
of every kind, and particularly on transportation and labor. The
sooner the public gets over the idea that we must have “business as
usual,” the better. The country must immediately awake to the fact
that we cannot carry on a war like this with one hand and continue to
do all the business we did before with the other. We can no more
expect to change from peace conditions to war conditions without
business inconvenience and loss than we can expect to send an
army into battle without having killed and wounded. We must,
therefore, adjust our business and personal affairs so as to support
the army with the greatest possible efficiency, and we must do it with
the least possible delay. The woman who orders a gown which she
does not need is not helping labor to find employment, as she likes
to think; she is preventing a soldier from having a uniform—for how
is labor to be had for making uniforms unless it is released from
making other clothes? Our soldiers must have blankets—but how
are those blankets to be had unless the looms are released from
something else? How is steel to be had for food-ships and field-guns
and destroyers unless there is a prompt curtailment of its use for
other purposes? If one of your pet trains is suddenly discontinued,
don’t grumble, but just stop to remember that the Government needs
that train and its crew for the purpose of moving troops and
munitions. If your favorite restaurant curtails its menu, bear in mind
that it has been done by order of the Government, which recognizes
the imperative necessity for food control. It is a stupendous task that
we have undertaken, and it will require every particle of grit and
staying power that we possess to see it through.
I would that every man and woman in these United States might
show the spirit which led the third-year cadets at West Point, who
were this summer entitled by law and custom to the one furlough a
cadet has in four years, to unite in waiving their right to these two
months to which they had looked forward so long and so eagerly and
for the spending of which they had made so many plans, and to offer
their services to the Secretary of War in any work for which he thinks
them fitted. In writing to his parents to explain why he would probably
not be home on the long-talked-of furlough, one of these cadets said:
—
“You know, as cadets, we haven’t anything but these two months to
give, so we thought if we offered all we had it would maybe be worth
while, even if it wasn’t much.”
How about it, my friend? Have you offered your country all you have
to give?
There are doubtless those who sometimes ask themselves, though
they may deem it the part of wisdom not to ask others, “Even if the
Germans were to win this war, what difference would it make
anyway?” Well, just for the sake of argument, suppose that our
European allies had been forced to sign a separate peace and that
Germany, thus left free to give us her undivided attention, had
landed an army on these shores (which she could do with
comparatively little trouble, the military experts agree) and held a
portion of our Eastern seaboard. And suppose that one evening a
column of men in gray came tramping into the little town where you
live—Quincy or Tarrytown or Plainfield or New Rochelle, which it
doesn’t matter. And suppose that the first thing they did after
establishing themselves in your town was to arrest the mayor and a
score or so of the leading citizens—some of your closest friends,
members of your own family, perhaps, among them—and lock them
up in the jail or the town hall. And suppose that the next morning,
when you start down town, your eye is caught by a notice tacked to a
tree. The notice, which is headed by the Prussian eagle, reads
something like this:—
PROCLAMATION
In future the inhabitants of places situated near railways
and telegraph lines which have been destroyed will be
punished without mercy (whether they are guilty of this
destruction or not). For this purpose hostages have been
taken in all places in the vicinity of railways in danger of
similar attacks; and at the first attempt to destroy any
railway, telegraph, or telephone line, they will be shot
immediately.
The Governor
And supposing, still for the sake of argument, that that same evening
some one, ignorant of the German threat or wishful to hamper the
invaders at any cost, succeeds in destroying a bridge or cutting a
telegraph line. And that, early the next morning, you are awakened
by a sudden crash, as though many rifles were fired in unison. And
that, hurriedly dressing, you hasten down town to learn what has
happened. And that, turning into the main street, you see a row of
bodies—the bodies of men some of whom you had known all your
life, men with whom you had gone to college, men who were fellow
lodge-members, men with whom you had played bridge at the club,
the body of your father or your son or your brother perhaps among
them—sprawled on the asphalt in grotesque and horrid attitudes
amid a slowly widening lake of crimson. Suppose that this dreadful
thing happened, not in some European town of which you had but
vaguely heard, but in your own town—in Newburyport or Yonkers or
Princeton, which it doesn’t matter. Then would you ask “Even if the
Germans were to win this war, what difference would it make
anyway?” The proclamation just quoted is not imaginary. It was
signed by Field Marshal von der Goltz when German governor of
Belgium and was posted on the walls of Brussels in October, 1914. I
saw it there myself. It is to destroy the monstrous system which
permits and approves the execution of people “whether they are
guilty or not” that we have gone to war. For if we don’t destroy it, it
will most certainly destroy us. The trouble is that we stubbornly shut
our eyes to the gravity of the situation which confronts us; we have
not aroused ourselves to the colossal magnitude of our task.
Sacrifices and sorrows without number await us. Before this
business is over with, we must expect to be deprived of many of our
comforts and most of our pleasures. We must be prepared to accept
without grumbling the imposition of very burdensome taxes. We
must be prepared to make countless personal sacrifices, to submit to
innumerable annoying restrictions. We must expect months of
discouragement and heart-breaking anxiety and gloom. We must
gird ourselves for those dark days when the lists of the wounded and
the dead begin to come in. For such will be the price of victory.
The surest way to bring about an early peace is to convince
Germany, beyond the possibility of misunderstanding, that we stand
behind the Government to the last cent in our purses and the last
breath in our bodies; that in our vocabulary there is no such word as
“quit”; that, no matter how appalling the price that may be exacted
from us, we shall not relax our efforts by one iota until the world has
been “made free for Democracy” forever.
THE END
The Riverside Press
CAMBRIDGE . MASSACHUSETTS
U.S.A
TRANSCRIBER’S NOTES:
Obvious typographical errors have been corrected.
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