Nutrition for Health and Health Care

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Dietary Reference Intakes (DRI)
The Dietar y Reference Intakes (DRI) include two sets of The DRI also include the Tolerable Upper Intake Level
­nutrient intake goals for individuals—the Recommended (UL) that represents the estimated maximum daily amount
­Dietary ­A llowance (RDA) and Adequate Intake (AI). The RDA of a ­nutrient that appears safe for most healthy people to con-
ref lects the average daily amount of a nutrient considered sume on a regular basis. Turn the page for a listing of the UL
­adequate to meet the needs of most healthy people. If there for selected vitamins and minerals. Note that the absence of
is insufficient evidence to determine an RDA, an AI is set. a UL for a nutrient does not indicate that it is safe to consume
In a­ ddition, the Estimated Energy Requirement (EER) repre- in high doses, but only that research is too limited to set a UL.
sents the average dietary energy intake considered adequate Chapter 1 describes these DRI values in detail.
to maintain energy balance in healthy people.

Estimated Energy Requirements (EER), Recommended Dietary Allowances (RDA), and Adequate Intakes (AI) for Water,
Energy, and the Energy Nutrients

Linolenic Acidc
EERb (kcal/day)
Reference BMI

RDA (g/kg/day)
Height cm (in.)

Weight kg (lb)

Carbohydrate

Linoleic Acid

RDA (g/day) d
RDA (g/day)

Total Fiber
Reference

Reference

AI (g/day)

AI (g/day)

AI (g/day)

AI (g/day)
AI (L/day)

Total Fat

Protein

Protein
Water a

Energy
Age (yr)
Males
0–0.5 — 62 (24) 6 (13) 0.7e 570 60 — 31 4.4 0.5 9.1 1.52
0.5–1 — 71 (28) 9 (20) 0.8 f 743 95 — 30 4.6 0.5 11 1.20
1–3g — 86 (34) 12 (27) 1.3 1046 130 19 — 7 0.7 13 1.05
4–8 g 15.3 115 (45) 20 (44) 1.7 1742 130 25 — 10 0.9 19 0.95
9–13 17.2 144 (57) 36 (79) 2.4 2279 130 31 — 12 1.2 34 0.95
14–18 20.5 174 (68) 61 (134) 3.3 3152 130 38 — 16 1.6 52 0.85
19–30 22.5 177 (70) 70 (154) 3.7 3067h 130 38 — 17 1.6 56 0.80
31–50 22.5i 177 (70)i 70 (154)i 3.7 3067h 130 38 — 17 1.6 56 0.80
>50 22.5i 177 (70)i 70 (154)i 3.7 3067h 130 30 — 14 1.6 56 0.80
Females
0–0.5 — 62 (24) 6 (13) 0.7e 520 60 — 31 4.4 0.5 9.1 1.52
0.5–1 — 71 (28) 9 (20) 0.8 f 676 95 — 30 4.6 0.5 11 1.20
1–3g — 86 (34) 12 (27) 1.3 992 130 19 — 7 0.7 13 1.05
4–8 g 15.3 115 (45) 20 (44) 1.7 1642 130 25 — 10 0.9 19 0.95
9–13 17.4 144 (57) 37 (81) 2.1 2071 130 26 — 10 1.0 34 0.95
14–18 20.4 163 (64) 54 (119) 2.3 2368 130 26 — 11 1.1 46 0.85
19–30 21.5 163 (64) 57 (126) 2.7 2403j 130 25 — 12 1.1 46 0.80
31–50 21.5i 163 (64)i 57 (126)i 2.7 2403j 130 25 — 12 1.1 46 0.80
>50 21.5i 163 (64)i 57 (126)i 2.7 2403j 130 21 — 11 1.1 46 0.80
Pregnancy
1st trimester 3.0 +0 175 28 — 13 1.4 46 0.80
2nd trimester 3.0 +340 175 28 — 13 1.4 71 1.10
3rd trimester 3.0 +452 175 28 — 13 1.4 71 1.10
Lactation
1st 6 months 3.8 +330 210 29 — 13 1.3 71 1.30
2nd 6 months 3.8 +400 210 29 — 13 1.3 71 1.30
NOTE: BMI is calculated as the weight in kilograms divided height, and physical activity level. The values listed are based gFor energy, the age groups for young children are 1–2 years

by the square of the height in meters. For all nutrients, values on an “active” person at the reference height and weight and and 3–8 years.
for infants are AI. The glossary on the insert defines units of at the midpoint ages for each group until age 19. Chapter 8 hFor males, subtract 10 kcalories per day for each year of age

nutrient measure. Dashes (—) indicate that values have not
been determined.
aThe water AI includes drinking water, water in beverages, and
water in foods; in general, drinking water and other beverages
con­tribute about 70 to 80 percent, and foods, the remainder.
and Appendix F provide equations and tables to determine
estimated energy requirements.
cThe linolenic acid referred to in this table and text is the
omega-3 fatty acid known as alpha-linolenic acid.
d The values listed are based on reference body weights.
above 19.
iBecause weight need not change as adults age if activity is
main­tained, reference weights for adults 19 through 30 years
are applied to all adult age groups.
jFor females, subtract 7 kcalories per day for each year of age

Conver­sion factors: 1 L = 33.8 fluid oz; 1 L = 1.06 qt;
1 cup = 8 fluid oz.
bThe Estimated Energy Requirement (EER) represents the
aver­age dietary energy intake that will maintain energy
balance in a healthy person of a given gender, age, weight,
eAssumed to be from human milk. above 19.
fAssumed to be from human milk and complementary foods
and beverages. This includes approximately 0.6 L (~2½ cups) SOURCE: Adapted from the Dietary Reference Intakes
as total fluid including formula, juices, and drinking water. series, National Academies Press. National Academies of
Sciences.

A
Recommended Dietary Allowances (RDA) and Adequate Intakes (AI) for Vitamins

RDA (mg/day)a

RDA (μg/day) b

RDA (μg/day) c

RDA (μg/day) d
RDA (mg/day)

RDA (mg/day)

RDA (mg/day)
RDA (μg/day)
Pantothenic

AI (mg/day)

AI (mg/day)
Vitamin B12
AI (μg/day)

AI (μg/day)
Vitamin B 6
Riboflavin

Vitamin A

Vitamin D
Vitamin C

Vitamin K
Vitamin E
RDA (mg/

RDA (mg/
Thiamin

Choline
Niacin

Folate
Biotin

day)e
acid
day)
Age (yr)
Infants
0–0.5 0.2 0.3 2 5 1.7 0.1 65 0.4 125 40 400 10 4 2.0
0.5–1 0.3 0.4 4 6 1.8 0.3 80 0.5 150 50 500 10 5 2.5
Children
1–3 0.5 0.5 6 8 2 0.5 150 0.9 200 15 300 15 6 30
4–8 0.6 0.6 8 12 3 0.6 200 1.2 250 25 400 15 7 55
Males
9–13 0.9 0.9 12 20 4 1.0 300 1.8 375 45 600 15 11 60
14–18 1.2 1.3 16 25 5 1.3 400 2.4 550 75 900 15 15 75

From Whitney/Rolfes, Understanding Nutrition, 13E. © 2013 Cengage Learning.

19–30 1.2 1.3 16 30 5 1.3 400 2.4 550 90 900 15 15 120
31–50 1.2 1.3 16 30 5 1.3 400 2.4 550 90 900 15 15 120
51–70 1.2 1.3 16 30 5 1.7 400 2.4 550 90 900 15 15 120
>70 1.2 1.3 16 30 5 1.7 400 2.4 550 90 900 20 15 120
Females
9–13 0.9 0.9 12 20 4 1.0 300 1.8 375 45 600 15 11 60
14–18 1.0 1.0 14 25 5 1.2 400 2.4 400 65 700 15 15 75
19–30 1.1 1.1 14 30 5 1.3 400 2.4 425 75 700 15 15 90
31–50 1.1 1.1 14 30 5 1.3 400 2.4 425 75 700 15 15 90
51–70 1.1 1.1 14 30 5 1.5 400 2.4 425 75 700 15 15 90
>70 1.1 1.1 14 30 5 1.5 400 2.4 425 75 700 20 15 90
Pregnancy
≤18 1.4 1.4 18 30 6 1.9 600 2.6 450 80 750 15 15 75
19–30 1.4 1.4 18 30 6 1.9 600 2.6 450 85 770 15 15 90
31–50 1.4 1.4 18 30 6 1.9 600 2.6 450 85 770 15 15 90
Lactation
≤18 1.4 1.6 17 35 7 2.0 500 2.8 550 115 1200 15 19 75
19–30 1.4 1.6 17 35 7 2.0 500 2.8 550 120 1300 15 19 90
31–50 1.4 1.6 17 35 7 2.0 500 2.8 550 120 1300 15 19 90
NOTE: For all nutrients, values for infants are AI. The glossary on the inside back cover b
Folate recommendations are expressed as dietary folate equivalents (DFE).
defines units of nutrient measure. c
Vitamin A recommendations are expressed as retinol activity equivalents (RAE).
a
Niacin recommendations are expressed as niacin equivalents (NE), except for d
Vitamin D recommendations are expressed as cholecalciferol and assume an absence of
recommendations for infants younger than 6 months, which are expressed as preformed adequate exposure to sunlight.
niacin. e
Vitamin E recommendations are expressed as α-tocopherol.

Recommended Dietary Allowances (RDA) and Adequate Intakes (AI) for Minerals
RDA (mg/day)

RDA (mg/day)

RDA (mg/day)

RDA (mg/day)

RDA (mg/day)

RDA (μg/day)

RDA (μg/day)

RDA (μg/day)

RDA (μg/day)
Molybdenum
Phosphorus

Manganese
Magnesium
AI (mg/day)

AI (mg/day)

AI (mg/day)

AI (mg/day)

AI (mg/day)

AI (μg/day)
Potassium

Chromium
Selenium
Chloride

Fluoride
Calcium
Sodium

Copper
Iodine
Zinc
Iron

Age (yr)
Infants
0–0.5 120 180 400 200 100 30 0.27 2 110 15 200 0.003 0.01 0.2 2
0.5–1 370 570 700 260 275 75 11 3 130 20 220 0.6 0.5 5.5 3
Children
1–3 1000 1500 3000 700 460 80 7 3 90 20 340 1.2 0.7 11 17
4–8 1200 1900 3800 1000 500 130 10 5 90 30 440 1.5 1.0 15 22
Males
9–13 1500 2300 4500 1300 1250 240 8 8 120 40 700 1.9 2 25 34
14–18 1500 2300 4700 1300 1250 410 11 11 150 55 890 2.2 3 35 43

From Whitney/Rolfes, Understanding Nutrition, 13E. © 2013 Cengage Learning.

19–30 1500 2300 4700 1000 700 400 8 11 150 55 900 2.3 4 35 45
31–50 1500 2300 4700 1000 700 420 8 11 150 55 900 2.3 4 35 45
51–70 1300 2000 4700 1000 700 420 8 11 150 55 900 2.3 4 30 45
>70 1200 1800 4700 1200 700 420 8 11 150 55 900 2.3 4 30 45
Females
9–13 1500 2300 4500 1300 1250 240 8 8 120 40 700 1.6 2 21 34
14–18 1500 2300 4700 1300 1250 360 15 9 150 55 890 1.6 3 24 43
19–30 1500 2300 4700 1000 700 310 18 8 150 55 900 1.8 3 25 45
31–50 1500 2300 4700 1000 700 320 18 8 150 55 900 1.8 3 25 45
51–70 1300 2000 4700 1200 700 320 8 8 150 55 900 1.8 3 20 45
>70 1200 1800 4700 1200 700 320 8 8 150 55 900 1.8 3 20 45
Pregnancy
≤18 1500 2300 4700 1300 1250 400 27 12 220 60 1000 2.0 3 29 50
19–30 1500 2300 4700 1000 700 350 27 11 220 60 1000 2.0 3 30 50
31–50 1500 2300 4700 1000 700 360 27 11 220 60 1000 2.0 3 30 50
Lactation
≤18 1500 2300 5100 1300 1250 360 10 13 290 70 1300 2.6 3 44 50
19–30 1500 2300 5100 1000 700 310 9 12 290 70 1300 2.6 3 45 50
31–50 1500 2300 5100 1000 700 320 9 12 290 70 1300 2.6 3 45 50
NOTE: For all nutrients, values for infants are AI. The glossary on the inside back cover defines units of nutrient measure.
Tolerable Upper Intake Levels (UL) for Vitamins

Vitamin B 6

Vitamin A

Vitamin D
Vitamin C

Vitamin E
(mg/day)c
(mg/day)a

(μg/day)a

(μg /day)b
(mg/day)

(mg/day)

(mg/day)

(μg /day)
Choline
Niacin

Folate
Age (yr)
Infants
0–0.5 — — — — — 600 25 —
0.5–1 — — — — — 600 38 —
Children

From Whitney/Rolfes, Understanding Nutrition, 13E. © 2013 Cengage Learning.

1–3 10 30 300 1000 400 600 63 200
4–8 15 40 400 1000 650 900 75 300
9–13 20 60 600 2000 1200 1700 100 600
Adolescents
14–18 30 80 800 3000 1800 2800 100 800
Adults
19–70 35 100 1000 3500 2000 3000 100 1000
>70 35 100 1000 3500 2000 3000 100 1000
Pregnancy
≤18 30 80 800 3000 1800 2800 100 800
19–50 35 100 1000 3500 2000 3000 100 1000
Lactation
≤18 30 80 800 3000 1800 2800 100 800
19–50 35 100 1000 3500 2000 3000 100 1000
a
The UL for niacin and folate apply to synthetic forms The UL for vitamin E applies to any form of supplemental
c

obtained from supplements, fortified foods, or a α-tocopherol, fortified foods, or a combination of the two.
combination of the two.
b
The UL for vitamin A applies to the preformed vitamin only.

Tolerable Upper Intake Levels (UL) for Minerals

Molybdenum
Phosphorus

Manganese
Magnesium

Vanadium
(mg/day)d

Selenium
(mg/day)

(mg/day)

(mg/day)

(mg/day)

(mg/day)

(mg/day)

(mg/day)

(mg/day)

(mg/day)

(mg/day)

(mg/day)
Chloride

Fluoride
Calcium

(μg/day)

(μg/day)

(μg/day)

(μg/day)
Sodium

Copper

Nickel
Iodine

Boron
Zinc
Iron

Age (yr)
Infants
0–0.5 — — 1000 — — 40 4 — 45 — — 0.7 — — — —
0.5–1 — — 1500 — — 40 5 — 60 — — 0.9 — — — —
Children
1–3 1500 2300 2500 3000 65 40 7 200 90 1000 2 1.3 300 3 0.2 —
4–8 1900 2900 2500 3000 110 40 12 300 150 3000 3 2.2 600 6 0.3 —
9–13 2200 3400 3000 4000 350 40 23 600 280 5000 6 10 1100 11 0.6 —
Adolescents
14–18 2300 3600 3000 4000 350 45 34 900 400 8000 9 10 1700 17 1.0 —
Adults
19–50 2300 3600 2500 4000 350 45 40 1100 400 10,000 11 10 2000 20 1.0 1.8
51–70 2300 3600 2000 4000 350 45 40 1100 400 10,000 11 10 2000 20 1.0 1.8
>70 2300 3600 2000 3000 350 45 40 1100 400 10,000 11 10 2000 20 1.0 1.8
Pregnancy
≤18 2300 3600 3000 3500 350 45 34 900 400 8000 9 10 1700 17 1.0 —
19–50 2300 3600 2500 3500 350 45 40 1100 400 10,000 11 10 2000 20 1.0 —
Lactation
≤18 2300 3600 3000 4000 350 45 34 900 400 8000 9 10 1700 17 1.0 —
19–50 2300 3600 2500 4000 350 45 40 1100 400 10,000 11 10 2000 20 1.0 —
d
The UL for magnesium applies to synthetic forms obtained from supplements or drugs SOURCE: Adapted with permission from the Dietary Reference Intakes for Calcium and
only. Vitamin D, © 2011 by the National Academies of Sciences, Courtesy of the National
NOTE: An upper Limit was not established for vitamins and minerals not listed and for Academies Press, Washington, D.C.
those age groups listed with a dash (—) because of a lack of data, not because these
nutrients are safe to consume at any level of intake. All nutrients can have adverse effects
when intakes are excessive.
 Nutrition for Health
seventh edition and Health Care

Linda Kelly DeBruyne

Kathryn Pinna

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 Nutrition for Health and Health Care,
Seventh Edition
Linda Kelly DeBruyne, Kathryn Pinna
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Linda Kelly DeBruyne

Kathryn Pinna

iii
 About the Authors
Linda Kelly DeBruyne, M.S., R.D., received her B.S. and M.S. degrees
in nutrition and food science at Florida State University. She is a founding member
of Nutrition and Health Associates, an information resource center in Tallahassee,
Florida, where her specialty areas are life cycle nutrition and fitness. Her other
publications include the textbooks Nutrition and Diet Therapy and Health: Making
Life Choices. She is a registered ­dietitian and maintains a professional membership in
the Academy of Nutrition and Dietetics.

Kathryn Pinna, Ph.D., R.D., received her M.S. and Ph.D. degrees in nutrition
from the University of California at Berkeley. She taught nutrition, food science, and
human biology courses in the San Francisco Bay Area for over 25 years and also
worked as an outpatient dietitian, Internet consultant, and freelance writer. Her other
publications include the textbooks Understanding Normal and Clinical Nutrition and
Nutrition and Diet Therapy. She is a registered dietitian and a member of the American
Society for Nutrition and the Academy of Nutrition and Dietetics.

v
 Brief Contents
Chapter 1 Chapter 13
Overview of Nutrition and Health 1 Nutrition Care and Assessment 379

Chapter 2 Chapter 14
Digestion and Absorption 39 Nutrition Intervention and Diet-Drug
Interactions 403
Chapter 3
Carbohydrates 67 Chapter 15
Enteral and Parenteral Nutrition Support 433
Chapter 4
Lipids 95 Chapter 16
Nutrition in Metabolic and Respiratory
Chapter 5
Stress 469
Protein 125
Chapter 17
Chapter 6
Nutrition and Upper Gastrointestinal
Energy Balance and Body Composition 147 Disorders 489
Chapter 7 Chapter 18
Weight Management 173 Nutrition and Lower Gastrointestinal
Disorders 513
Chapter 8
The Vitamins 199 Chapter 19
Nutrition and Liver Diseases 545
Chapter 9
Water and the Minerals 237 Chapter 20
Nutrition and Diabetes Mellitus 565
Chapter 10
Nutrition through the Life Span: Pregnancy and Chapter 21
Lactation 271 Nutrition and Cardiovascular Diseases 595
Chapter 11 Chapter 22
Nutrition through the Life Span: Infancy, Nutrition and Renal Diseases 625
Childhood, and Adolescence 303
Chapter 23
Chapter 12
Nutrition, Cancer, and HIV Infection 653
Nutrition through the Life Span: Later Adulthood 351
vii
viii
 Contents
Preface xvi
The Vascular System 50
Acknowledgments xx The Lymphatic System 51
Transport of Lipids: Lipoproteins 51
Chapter 1
Overview of Nutrition and Health 1 Gastrointestinal Hormones and Nerve Pathways 53
Gastrointestinal Microbes 53
The System at Its Best 54
Six Classes of Nutrients 6 Nutrition in Practice Food Safety 57
kCalories: A Measure of Energy 6

Chapter 3
Dietary Reference Intakes 8
Acceptable Macronutrient Distribution Ranges 10 Carbohydrates 67

National Health Goals 11 Monosaccharides 68

National Trends 11 Disaccharides 69
Polysaccharides 69

Dietary Ideals 13
Dietary Guidelines for Americans 14
Fitness Guidelines 16
The USDA Food Patterns 18 Sugars 74
MyPlate 23 Alternative Sweeteners: Sugar Alcohols 78
Alternative Sweeteners: Nonnutritive Sweeteners 79
The Ingredient List 24
Nutrition Facts Panel 25 Carbohydrates: Disease Prevention
Claims on Labels 27 and Recommendations 81
Nutrition in Practice Finding the Truth about Carbohydrates: Food Sources 84
Nutrition 34
Carbohydrates: Food Labels and Health Claims 86
Nutrition in Practice The Glycemic Index in Nutrition
Chapter 2 Practice 90
Digestion and Absorption 39
Chapter 4
The Digestive Organs 40 Lipids 95
The Involuntary Muscles and the Glands 42

Digestion in the Mouth 45

Digestion in the Stomach 46 Triglycerides 97
Digestion in the Small and Large Intestines 46 Fatty Acids 98
Phospholipids 101
Sterols 101
The Small Intestine 48
Absorption of Nutrients 49

ix
 Chapter 7
Fats and Heart Health 103
Recommendations 106 Weight Management 173

Finding the Fats in Foods 108 Genetics and Weight 174

Cutting Solid Fats and Choosing Unsaturated Environmental Stimuli 177
Fats 110
Nutrition in Practice Figuring Out Fats 117
Over-the-Counter Weight-Loss Products 180
Chapter 5 Other Gimmicks 180
Protein 125
Obesity Drugs 180
Surgery 181
The Structure of Proteins 126
Nonessential and Essential Amino Acids 127
A Healthful Eating Plan 182
Physical Activity 185
Behavior and Attitude 186
Protein Turnover 129 Weight Maintenance 188
Nitrogen Balance 129

Nutrition in Practice Fad Diets 195

Protein Deficiency 132 Chapter 8

Malnutrition 133
Protein Excess 134 The Vitamins 199
Protein and Amino Acid Supplements 135
Protein Recommendations and Intakes 136
Vitamin A and Beta-Carotene 203
Protein Quality 137 Vitamin D 207
Protein Sparing 138 Vitamin E 211
Protein on Food Labels 138 Vitamin K 212
Nutrition in Practice Vegetarian Diets 141
The B Vitamins 214
Chapter 6 Thiamin 216
Riboflavin 216
Energy Balance and Body Composition 147 Niacin 217
Pantothenic Acid and Biotin 218
Feasting 148 Vitamin B6 218
The Economics of Fasting 149 Folate 219
Vitamin B12 220
Energy In 152 Non–B Vitamins 222
Energy Out 152 Vitamin C 222
Estimating Energy Requirements 155 Nutrition in Practice Phytochemicals and Functional
Foods 229
Defining Healthy Body Weight 156
Body Composition 159 Chapter 9
How Much Body Fat Is Too Much? 160 Water and the Minerals 237

Health Risks of Underweight 161 Water Balance 238

Health Risks of Overweight and Obesity 162 Fluid and Electrolyte Balance 240
Guidelines for Identifying Those at Risk from Acid–Base Balance 241
Obesity 163
Other Risks of Obesity 163
Sodium 243
Nutrition in Practice Eating Disorders 166 Chloride 244

x Contents
 Potassium 244
Calcium 245 Energy and Nutrient Needs 316
Phosphorus 249 Hunger and Malnutrition in Children 320
Magnesium 249 Lead Poisoning in Children 321
Sulfate 251 Food Allergy 322
Hyperactivity 324
Iron 251 Childhood Obesity 325
Zinc 256 Mealtimes at Home 330
Selenium 258 Nutrition at School 334
Iodine 259
Copper 260 Growth and Development during Adolescence 336
Manganese 260 Energy and Nutrient Needs 336
Fluoride 261 Food Choices and Health Habits 337
Chromium 261 Nutrition in Practice Childhood Obesity and
Other Trace Minerals 261 the Early Development of Chronic Diseases 345
Nutrition in Practice Vitamin and Mineral
Supplements 267 Chapter 12
Nutrition through the Life Span: Later
Chapter 10
Adulthood 351
Nutrition through the Life Span: Pregnancy
and Lactation 271 Slowing the Aging Process 353
Nutrition and Disease Prevention 355

Nutrition Prior to Pregnancy 272

Prepregnancy Weight 272 Cataracts and Macular Degeneration 356
Healthy Support Tissues 273 Arthritis 356
The Events of Pregnancy 274 The Aging Brain 357
Nutrient Needs during Pregnancy 276
Food Assistance Programs 281
Weight Gain 282 Energy and Energy Nutrients 360
Weight Loss after Pregnancy 283 Vitamins and Minerals 362
Physical Activity 284 Nutrient Supplements for Older Adults 363
Common Nutrition-Related Concerns of Pregnancy 285 The Effects of Drugs on Nutrients 364
Problems in Pregnancy 286
Practices to Avoid 288 Individual Preferences 365
Adolescent Pregnancy 291 Meal Setting 365
Depression 365
Nutrition during Lactation 292 Food Assistance Programs 365
Contraindications to Breastfeeding 294 Meals for Singles 366

Nutrition in Practice Encouraging Successful Nutrition in Practice Hunger and Community

Breastfeeding 300 Nutrition 373

Chapter 11 Chapter 13

Nutrition through the Life Span: Infancy,
Childhood, and Adolescence 303
Nutrient Needs during Infancy 304
Breast Milk 306
Infant Formula 309
The Transition to Cow’s Milk 311
Introducing First Foods 311
Looking Ahead 314
Mealtimes 315
Nutrition Care and Assessment 379
How Illness Affects Nutrition Status 380
Responsibility for Nutrition Care 381
Identifying Risk for Malnutrition 382
The Nutrition Care Process 383
Historical Information 385
Dietary Assessment 386
Anthropometric Data 389

Contents xi
 Biochemical Analyses 392 Chapter 16
Physical Examination 395 Nutrition in Metabolic and Respiratory Stress 469
Nutrition in Practice Nutritional Genomics 399
Hormonal Responses to Stress 471
Chapter 14 The Inflammatory Response 472
Nutrition Intervention and Diet-Drug
Interactions 403 Determining Nutritional Requirements 474
Approaches to Nutrition Care in Acute Stress 476

Care Planning 404

Approaches to Nutrition Care 406 Chronic Obstructive Pulmonary Disease 477
Respiratory Failure 480

Energy Intakes in Hospital Patients 408 Nutrition in Practice Multiple Organ Dysfunction
Modified Diets 409 Syndrome 486
Variations in the Diet Order 413
Chapter 17
Food Selection 414 Nutrition and Upper Gastrointestinal
Food Safety 414 Disorders 489
Improving Food Intake 414

Drug Effects on Food Intake 416 Dry Mouth 490

Drug Effects on Nutrient Absorption 416 Dysphagia 490
Dietary Effects on Drug Absorption 417 Gastroesophageal Reflux Disease 494
Drug Effects on Nutrient Metabolism 418
Dietary Effects on Drug Metabolism 419
Drug Effects on Nutrient Excretion 420 Dyspepsia 496
Dietary Effects on Drug Excretion 420 Nausea and Vomiting 497
Drug-Nutrient Interactions and Toxicity 420 Gastroparesis 497
Gastritis 498
Nutrition in Practice Complementary and Alternative Peptic Ulcer Disease 498
Therapies 424

Gastrectomy 500
Chapter 15 Bariatric Surgery 503
Enteral and Parenteral Nutrition Support 433 Nutrition in Practice Nutrition and Oral Health 509

Oral Supplements 434 Chapter 18

Candidates for Tube Feedings 435 Nutrition and Lower Gastrointestinal
Tube Feeding Routes 436
Enteral Formulas 438 Disorders 513
Administration of Tube Feedings 441
Medication Delivery during Tube Feedings 445 Constipation 514
Tube Feeding Complications 446 Intestinal Gas 516
Transition to Table Foods 446 Diarrhea 516

Candidates for Parenteral Nutrition 448 Fat Malabsorption 519

Venous Access 449 Bacterial Overgrowth 521
Parenteral Solutions 450 Lactose Intolerance 521
Administering Parenteral Nutrition 454
Managing Metabolic Complications 455 Pancreatitis 523
Cystic Fibrosis 524
Candidates for Home Nutrition Support 457
Planning Home Nutrition Care 457 Celiac Disease 526
Quality-of-Life Issues 458 Inflammatory Bowel Diseases 528
Nutrition in Practice Inborn Errors of Metabolism 463 Short Bowel Syndrome 531

xii Contents

Irritable Bowel Syndrome 534
Diverticular Disease of the Colon 535
Colostomies and Ileostomies 536
Nutrition in Practice Probiotics and Intestinal
Health 542
Chapter 19
Nutrition and Liver Diseases 545
Fatty Liver 546
Hepatitis 547
Consequences of Cirrhosis 549
Treatment of Cirrhosis 552
Nutrition Therapy for Cirrhosis 552
Nutrition in Practice Alcohol in Health and Disease 561
Chapter 20
Nutrition and Diabetes Mellitus 565
Symptoms of Diabetes Mellitus 566
Diagnosis of Diabetes Mellitus 567
Types of Diabetes Mellitus 567
Prevention of Type 2 Diabetes Mellitus 569
Acute Complications of Diabetes Mellitus 569
Chronic Complications of Diabetes Mellitus 571
Treatment Goals 573
Evaluating Diabetes Treatment 574
Nutrition Therapy: Dietary Recommendations 575
Nutrition Therapy: Meal-Planning Strategies 577
Insulin Therapy 580
Antidiabetic Drugs 583
Physical Activity and Diabetes Management 584
Sick-Day Management 585
Pregnancy in Type 1 or Type 2 Diabetes 586
Gestational Diabetes 586
Nutrition in Practice The Metabolic Syndrome 591
Chapter 21
Nutrition and Cardiovascular Diseases 595
Consequences of Atherosclerosis 597
Causes of Atherosclerosis 597
Symptoms of Coronary Heart Disease 599
Evaluating Risk for Coronary Heart Disease 599
Lifestyle Management to Reduce CHD Risk 600
Vitamin Supplementation and CHD Risk 603
Lifestyle Changes for Hypertriglyceridemia 605
Drug Therapies for CHD Prevention 605
Treatment of Heart Attack 607
Stroke Prevention 608
Stroke Management 608
Factors That Influence Blood Pressure 609
Factors That Contribute to Hypertension 609
Treatment of Hypertension 611
Consequences of Heart Failure 614
Medical Management of Heart Failure 615
Nutrition in Practice Helping People with Feeding
Disabilities 620
Chapter 22
Nutrition and Renal Diseases 625
Consequences of the Nephrotic Syndrome 627
Treatment of the Nephrotic Syndrome 627
Causes of Acute Kidney Injury 630
Consequences of Acute Kidney Injury 630
Treatment of Acute Kidney Injury 631
Consequences of Chronic Kidney Disease 633
Treatment of Chronic Kidney Disease 635
Kidney Transplants 640
Formation of Kidney Stones 642
Consequences of Kidney Stones 643
Prevention and Treatment of Kidney Stones 643
Nutrition in Practice Dialysis 648
Chapter 23
Nutrition, Cancer, and HIV Infection 653
How Cancer Develops 654
Nutrition and Cancer Risk 655
Consequences of Cancer 658
Treatments for Cancer 658
Nutrition Therapy for Cancer 661
Prevention of HIV Infection 665
Consequences of HIV Infection 666
Treatments for HIV Infection 668
Nutrition Therapy for HIV Infection 669
Nutrition in Practice Ethical Issues in Nutrition
Care 675
Contents xiii
Appendix A Aids to Calculation A-2 Chapter 19
a.1 Conversion Factors A-2 Man with Cirrhosis 556
a.2 Percentages A-2 Chapter 20
a.3 Weights and Measures A-3
Child with Type 1 Diabetes 585
Appendix B WHO: Nutrition Recommendations B-1
Woman with Type 2 Diabetes 587
Appendix C Choose Your Foods: Food Lists for
Chapter 21
Diabetes C-1
C.1 The Food Lists C-1 Patient with Cardiovascular Disease 614
C.2 Serving Sizes C-1 Chapter 22
C.3 The Foods on the Lists C-1 Woman with Acute Kidney Injury 632
C.4 Controlling Energy, Fat, and Sodium C-2 Man with Chronic Kidney Disease 640
C.5 Planning a Healthy Diet C-3
Chapter 23
Appendix D Physical Activity and Energy
Woman with Cancer 664
Requirements D-1
Man with HIV Infection 671
Appendix E Nutrition Assessment: Supplemental
Information E-1
E.1 Weight Gain during Pregnancy E-1 How To Features
E.2 Growth Charts E-1 Chapter 1
E.3 Measures of Body Fat and Lean Tissue E-2 Calculate the Energy a Food Provides 7
E.4 Nutritional Anemias E-8
Chapter 3
E.5 Cautions about Nutrition Assessment E-12
Reduce Intakes of Added Sugars 76
Appendix F Enteral Formulas F-1
Chapter 4
Glossary GL-1
Make Heart-Healthy Choices—by Food Group 110
Index I-1
Chapter 5
Calculate Recommended Protein Intakes 136
Case Studies
Chapter 6
Chapter 10
Estimate Energy Requirements 156
Woman in Her First Pregnancy 294
Chapter 7
Chapter 11
Apply Behavior Modification to Manage Body
Boy with Disruptive Behavior 324 Fatness 187
Chapter 12
Chapter 9
Elderly Man with a Poor Diet 366 Cut Salt Intake 243
Chapter 13 Add Calcium to Daily Meals 249
Nutrition Screening and Assessment 396 Add Iron to Daily Meals 257
Chapter 14 Chapter 11
Implementing Nutrition Care 407 Protect against Lead Toxicity 322
Chapter 15 Chapter 12
Injured Hiker Requiring Enteral Nutrition Support 448 Turn Convenience Foods into Nutritious Meals 368
Patient with Intestinal Disease Requiring Parenteral Stretch Food Dollars and Reduce Waste 375
Nutrition 456
Chapter 13
Chapter 16
Measure Length and Height 390
Patient with a Severe Burn 477 Measure Weight 390
Elderly Man with Emphysema 480 Estimate and Evaluate Changes in Body Weight 392
Chapter 17
Chapter 14
Woman with GERD 496 Estimate Appropriate Energy Intakes for Hospital
Nutrition Care after Gastric Surgery 503 Patients 408
Chapter 18 Help Hospital Patients Improve Their Food
Patient with Short Bowel Syndrome 533 Intakes 415
Young Adult with Irritable Bowel Syndrome 535 Prevent Diet-Drug Interactions 421

xiv Contents
Chapter 15 Chapter 18
Help Patients Improve Intakes with Oral Supplements 435 Follow a Fat-Restricted Diet 522
Help Patients Cope with Tube Feedings 442 Chapter 19
Plan a Tube Feeding Schedule 444 Help the Cirrhosis Patient Eat Enough Food 554
Administer Medications to Patients Receiving Tube Chapter 20
Feedings 446
Use Carbohydrate Counting in Clinical Practice 578
Express the Osmolar Concentration of a Solution 449
Chapter 21
Calculate the Macronutrient and Energy Content
of a Parenteral Solution 453 Implement a Heart-Healthy Diet 604
Reduce Sodium Intake 613
Chapter 16
Estimate Energy Needs Using Disease-Specific Stress Chapter 22
Factors 475 Help Patients Comply with a Renal Diet 640
Chapter 17 Chapter 23
Improve Acceptance of Mechanically Altered Foods 493 Increase kCalories and Protein in Meals 662
Manage Gastroesophageal Reflux Disease 496 Help Patients Handle Food-Related Problems 663
Alter the Diet to Reduce Symptoms of Dumping
Syndrome 502
Alter Dietary Habits to Achieve and Maintain Weight Loss
after Bariatric Surgery 505

Contents xv
 Preface
We are pleased to present this seventh edition
Nutrition for Health and Health Care
Chapter 1

Chapter 2

Chapter 3

Chapter 4

Chapter 5

Chapter 6

Changes for This Edition Chapter 7

xvi
Chapter 8
Chapter 16

Chapter 17
Chapter 9

acid regurgitation, heartburn, bloating, pernicious

anemia.

Chapter 18
Chapter 10

Chapter 11
Chapter 19

Chapter 20
Chapter 12

Chapter 13

Chapter 14

Chapter 21
Chapter 15

specialized nutrition support oral nutrition

support

Preface xvii
Chapter 22

protein-energy wasting.

hypocitraturia

Chapter 23

MindTap: Empower Your

Students

Features of this Text

Access Everything You Need

in One Place

Empower Students to Reach

their Potential

xviii Preface
Control Your Course—
and Your Content
Get a Dedicated Team, Whenever
You Need Them
Ancillaries
●●
A test bank is available through Cengage Learning
Testing Powered by Cognero, a flexible online system
that allows instructors to author, edit, and manage test
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instructor wants.
Instructor Companion Site
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Preface xix
 Acknowledgments

xx
 Overview of Nutrition
and Health
Chapter Sections and Learning Objectives (LOs)

1.1 Food Choices

LO 1.1 Describe the factors that influence personal food choices.

1.2 The Nutrients

LO 1.2 Identify which of the major classes of nutrients are organic and which
yield energy.

1.3 Nutrient Recommendations

LO 1.3 Describe the four categories of the Dietary Reference Intakes (DRI),
the Estimated Energy Requirement (EER), and the Acceptable Macronutrient
Distribution Ranges (AMDR).

1.4 National Nutrition Surveys

LO 1.4 Describe the ways in which the kinds of information collected by
researchers from nutrition surveys are used.

1.5 D
 ietary Guidelines, Fitness Guidelines,
and Food Guides
LO 1.5 Explain how each of the dietary ideals can be used to plan a healthy
diet, and how the Dietary Guidelines and USDA Food Patterns help make diet
planning easier.

1.6 Food Labels

LO 1.6 Compare the information on food labels to make selections that meet
specific dietary and health goals.

1.7 Nutrition in Practice: Finding the Truth about Nutrition

LO 1.7 Discuss how misinformation and reliable nutrition information can be
identified.

chapter

Rosenfeld/Flirt/Corbis
1
 Every day, several times a day, you make choices that will either
health

wellness

1.1 Food Choices

health: a range of states with physical,
nutrition
mental, emotional, spiritual, and social
components. At a minimum, health
means freedom from physical disease,
mental disturbances, emotional
distress, spiritual discontent, social
maladjustment, and other negative
states. At a maximum, health means
wellness.
wellness: maximum well-being; the cultural competence
top range of health states; the goal
of the person who strives toward
realizing his or her full potential Preference
physically, mentally, emotionally,
spiritually, and socially.
nutrition: the science of foods and the
nutrients and other substances they
contain, and of their ingestion, digestion,
absorption, transport, metabolism,
interaction, storage, and excretion. A
broader definition includes the study of bioactive food components phytochemicals
the environment and of human behavior
as it relates to these processes.
cultural competence: an awareness
and acceptance of one’s own and
others’ cultures, combined with the
skills needed to interact effectively
Habit
with people of diverse cultures.
bioactive food components:
compounds in foods (either nutrients
or phytochemicals) that alter client patient
physiological processes in the body.
client

2 CHAPTER 1 Overview of Nutrition and Health

 FIGURE 1-1 The Health Line phytochemicals (FIGH-toe-CHEM-ih-
cals): compounds in plants that confer
No matter how well you maintain your health today, you may still be able to improve tomorrow. color, taste, and other characteristics.
Likewise, a person who is well today can slip by failing to maintain health-promoting habits. Some phytochemicals are bioactive
food components in functional foods.
Nutrition in Practice 8 provides details.
Wellness— foodways: the eating habits and
optimal physical,
mental, emotional, culinary practices of a people, region,
spiritual, and social health
or historical period.

Superior
ethnic diets: foodways and cuisines
level of typical of national origins, races,
health
cultural heritages, or geographic
Good
level of locations.
health

Moderate
level of
health

Marginal
level of
health
Death Poor
from level of
disease health

Associations

Ethnic Heritage and Regional Cuisines

foodways

ethnic diets Photo 1-1

Values
Monkey Business Images/Shutterstock.com

ecolabels

halal Ethnic meals and family gatherings

nourish the spirit as well as the
body.

Food Choices 3
 TABLE 1-1 Selected Ethnic Cuisines and Food Choices
Protein
Grains Vegetables Fruit Foods Milk

Asian Millet, rice, Baby corn, bamboo Kumquats, Pork; duck and Soy milk
rice or wheat shoots, bok choy, loquats, lychee, other poultry;

Becky Luigart-Stayner/
noodles leafy greens (such as mandarin fish, octopus,

Encyclopedia/Corbis
amaranth), cabbages, oranges, sea urchin,
mung bean sprouts, melons, pears, squid, and
­scallions, seaweed, persimmon, other seafood;
snow peas, straw plums soybeans, tofu;
mushrooms, water eggs; cashews,
chestnuts, wild yam peanuts

Mediterranean Bulgur, cous- Artichokes, Berries, dates, Fish and other Feta, goat,
cous, focaccia, cucumbers, figs, grapes, seafood, mozzarella,
Italian bread, eggplant, fennel, lemons, ­melons, gyros, lamb, parmesan, provo-
pastas, pita grape leaves, leafy olives, oranges, pork, ­sausage, lone, and ricotta
Photodisc, Inc./
Getty Images

pocket bread, greens, leeks, pomegranates, chicken, fava cheeses; yogurt

polenta, rice onions, peppers, raisins beans, ­lentils, and yogurt
tomatoes almonds, walnuts beverages

Mexican Hominy, Bell peppers, ­cactus, Avocado, Beans, refried Cheese, flan
masa (corn cassava, chayote, bananas, guava, beans, beef, (baked caramel
Photodisc/Getty Images

flour dough), chili ­pepper, corn, lemons, limes, goat, pork, custard), milk in
tortillas (corn jicama, onions, mango, oranges, ­chorizo, chicken, beverages
Mitch Hrdlicka/

or flour), rice summer squash, papaya, plantain fish, eggs

tomatoes, winter
squash, yams

Social Interaction

Emotional State

Marketing

Availability, Convenience, and Economy

4 CHAPTER 1 Overview of Nutrition and Health

 Photo 1-2

wavebreakmedia/Shutterstock.com
Age

Nutrition is only one of the many factors

that influence people’s food choices.

Body Weight and Image

Medical Conditions

Health and Nutrition

whole foods: fresh foods such as

whole foods
vegetables, grains, legumes, meats,
and milk that are unprocessed or
minimally processed.
processed foods processed foods: foods that have been
intentionally changed by the addition
of substances, or a method of cooking,
preserving, milling, or such.
ultra-processed foods: foods that have
ultra-processed foods been made from substances that are
typically used in food preparation, but
not consumed as foods by themselves
(such as oils, fats, flours, refined
starches, and sugars) that undergo
further processing by adding a little,
if any, minimally processed foods, salt
and other preservatives, and additives
such as flavors and colors.

Food Choices 5
Another random document with
no related content on Scribd:
 *****

Päivällisen jälkeen loiottiin kalliolla ja luettiin Kiven Veljeksistä

parhaita paikkoja. Julistettiin tarinakilpailu, johon kaikki saisivat ottaa
osaa, ja yhdessä arvosteltaisiin tulokset.

Jallun tarina julistettiin voittaneeksi kilpailun ja tästä hyvästynyt

Jallu lupasi laittaa oikein suussa sulavan illallisen.

Illalla saivat Jaakko ja Mikko laskea pitkän siiman ja pohtia

uudelleen suunnitelmaansa kepposta.

— Mitäs, jos vene menisi niin kauaksi, etteivät sitä pojat tavoita ja
jäädään niin neuvoin kaikki saareen, sanoi Jaakko.

— No ei se mitään. Kylläpähän tulevat hakemaan, kun ei kotiin

kuulu ja ahvenia ongitaan muonaksi, sanoi Mikko.

— Niinpä sitten olkoon päätetty, julisti Jaakko. — Ennen uintia

jätetään venhe hyvin vähän kiinni kallion laitaan, ja toinen käy sitten
sopivassa tilaisuudessa irroittamassa sen ja antamassa sille
alkuvauhtia.

Yöksi rakensivat pojat kalliolle hongan pölkyistä nuotion, ja tyveniä

vesiä katsellen ja käen kukuntaa kuunnellen nukuttiin.

Aamupäivä meni pitkäsiimaa kokiessa, ja kun se antoi runsaan

saaliin, suoritettiin intiaanitanssi kalliolla kalastuksen kunniaksi.
Sopisi ylpeillä äideille ja siskoille hyvin onnistuneesta kalaretkestä.

Eilen toimittamatta jäänyt tervaaminen suoritettiin nyt hehkuvassa

auringon paahteessa, kun terva oli ensin padassa lämmitetty.
 — Hii, miten se kutittaa ihoa, sanoi Mikko.

— Kas, miten hyvin se menee nahkaan, ihaili Jaakko ja Jallu.

Olisipa nyt kelvannut näyttää ihoaan kotijoukoille.

— Nyt on parasta hiukan liotella ihoaan, koskapa sitä niin hirveästi

kuumottaa, sanoi Jallu. — Murjaanit järveen!

Jaakon ja Mikon sydän takoi kiivaammin, mutta koetettiin olla

huolettoman näköisiä kaikesta. Tuuli oli hyvä ja mantereeseen päin
lähtisi vene viilettämään, ja kun se oli toisella puolella saarta, kuin
poikien majapaikka, eivät Lassi ja Jallu tietäisi mitään, ennenkuin
venhe olisi jo kaukana.

Kevyt venhe jo viiletti kaukana, kun Lassi sen huomasi.

— Voi turkkilainen, kun venhe on karannut! huudahti hän, — Kuka

peikkolainen sen kytki niin huonosti.

— No voi sun saksan sakilainen! kivahti Jallukin, ja pojat hokivat

sitä samaa kuin toisetkin.

— Lähtään uimaan ja otetaan se kiinni, sanoi Jallu ja alkoi jo

vedellä voimakkain ottein selälle.

— Ei sitä tavoita enää minkäänlainen uimari, julisti Lassi. — Nyt

on vain otettava selvää, kuka venheen on kytkenyt niin huonosti, että
se pääsi karkaamaan. Ja sen minä sanon, että sen ilkimyksen korvat
kuumenevat.

Tutkittiin asiata ja tulos oli Lassille masentava. Hän oli viimeksi

käynyt veneellä viemässä rantarisuun lisää männynhavuja.
 — No koska minä olen joutunut syylliseksi, niin jokainen teistä saa
livauttaa minua korvalle, mutta tehkää se kepeällä kädellä, koskapa
teitä on niin kovin monta rankaisijaa.

— Täysi satsi Lassille, ei siinä auta puolustelu, huusi Jallu.

— Mikä mies se semmoinen on, joka pyrkii syntejään pakoon.

Korvat tänne!

— Ei muuta kuin pieni livaus vain, oli Mikon ja Jaakon

mielipiteenä. —
Onhan tässä otettava huomioon lieventävät asianhaarat.

Ja sen sijaan kuin Jallu antoi navakan tillikan Lassille, hipaisivat

toiset pojat Lassin korvalehteä hieman vain sormen päillään.

Lassilla oli kiivas luonto, jota hän ei osannut vielä kylliksi hillitä, ja
nyt se kuohahti siitä, että Jallu tahtoi kovempaa rangaistusta hänelle
kuin toiset.

— Sinä olet sakin jukuripää ja sinua on pehmitettävä, sanoi hän, ja

pian kieriskelivät pojat kalliolla ja kanervikossa ankarassa
sylirysyssä.

— Tämän piti nyt tulla meidän tähtemme, sanoi Jaakko.

— Ei se pahaa tee Jallulle pieni kuranssaus, sanoi Mikko. — Mitäs

ei tyytynyt toisten päätökseen.

Kun nujellus lakkasi, katseltiin mustelmia ja naarmuja, joita oli

saatu kanervikossa.

— Tunnustatko saaneesi hassausta ansiosta? kysyi Lassi Jallulta.

 — Kyl-lä. Samallahan sitä sait sinäkin, mutta sinun kauemmin
tervassa ollut pintasi kesti risujen raapaisuja paremmin kuin minun,
sanoi Jallu.

— Mutta mitäs tästä. Pääasia on se, että nyt olemme kuin hiiret
loukussa. Sinne meni vielä meidän riitatoverien vaatteet. Kuka
käskikin meidän niitä venheeseen riisumaan. Se oli noloa, se…

— Nyt on jo vene rannalla, sanoi Jaakko, joka oli sen kulkua

seurannut.

— Ja pysyy siellä. Saamme odottaa, kunnes tulevat sydän

kurkussa meitä katselemaan, arveli Mikko.

— Katsotaanpa, mitä meille jäi, sanoi Lassi.

— Pata jäi ja onget, kahvipannu ja sokerit meni veneen mukana,

ilmoitti
Jaakko, joka oli jo tehnyt tutkimuksen.

— Jäiköhän lierotuohinen edes?

— On jäänyt varmasti. Pistin sen kallion koloon, sanoi Jallu. —

Mitäs muuta kuin onkimaan ja ahvenia pataan.

— Tulikin pahuuksenmoinen nälkä siinä tappeluksessa, sanoi

Lassi.

— Eihän vain liene siinä nujakassa aapeluksemme, Seitsemät

Veljekset, hävinnyt? kysyi Jallu.

— Minä nostin kirjan puuhun, sanoi Jaakko.

 Päivä paistoi ja kallio poltteli jalkapohjia. Veneen menetys ei
surettanut liioin. Ainahan keinoja löytyi, kunhan vain aurinko paistoi
ja ruoka riitti. Ja sitä taas sai, kun vain heitti siiman kalliolta veteen.
Ahvenet hyppivät ihan maan ja veden rajassa.

*****

Jallu oli mennyt veljensä kanssa puita noutamaan nuotioon ja

Lassi kyykötti kallion reunalla odotellen ahventa onkeen. Jaakko oli
onkineen vähän matkan päässä. Hän nauroi.

— Mitä hörötät? kysyi Lassi.

— Sitä, kun sinulla ei ole vaatteita ja saat yöllä paahtaa itseäsi

kuin neekeri nuotiossa.

— Täälläpä ei ensi yötä ollakaan, sanoi Lassi.

— Mikäs auttaa?

— Sepähän nähdään.

Lassi oli löytänyt saaresta muutamia kuivia hirsiä, joista saisi

lautan, kun olisi millä se sitoa kokoon. Sitä hän nyt mietti siinä
seuratessaan kylläistä ahventa, joka repi syöttiä, mutta ei haukannut
sitä rohkeammin.

Olisipa vain köyttä, jolla solmiaisi puut yhteen ja sitten vielä purje.
Poikien paidoista ja housuista ei sitä taitaisi saada kokoon.

— Mustikoita, hei pojat! kuului toisten huuto metsästä.

Pojat jättivät onkensa ja juoksivat viidakkoon. Mustikat olivat

kesän ensimmäisiä heille ja halulla käytiin niihin käsiksi. Siinä
vierähtivät tunnit huomaamatta ja päivä alkoi olla illoillaan, kun pojat
palasivat kalliolle. Koetettiin onkia, mutta ahven ei syönyt enää.

— Oikeastaan me emme mitään päivällistä tarvitsekaan, kun

jokaisen maaru on mustikoita täysi, arveli Jallu.

— Mutta kotiin paluuta meidän olisi pohdittava ankarasti, sanoi

Lassi.
— Minulla olisi hyvä keino, mutta siinä on yksi niksi.

— Mikä, sanohan?

— Ei ole köyttä. Saaren rannalla on ainakin kahdeksan vankkaa

hirttä, ja niistä me voisimme laittaa lautan, kun olisi vain nuoraa.

— Sitä me saamme Koivunvesoista vaikka kuinka… voimme niillä

kyllä sitoa lautan kokoon, sanoi Mikko ja kimpaisi metsään vitsaksia
noutamaan.

— No nyt ei siis puutu muuta kuin kiireesti lautan tekoon, sanoi

Lassi. — Sattui vielä niin mainiosti, että puut ovat mantereen
puoleisella rannalla. Ei muuta kuin heti purjetta laskemaan.

Puut olivat raskaita ja vaivoin saatiin ne vieritetyksi veteen. Kun

lautta oli valmis, aleni jo aurinkokin kaukaisen rannan taakse ja tuuli
laimeni.

— Näyttää siltä, että yöksi tulee aivan tyyni, mutta voimmehan

soutaa lauttaa maihin, sanoi Jallu.

— Tahi odottaa aamua, jolloin tuuli kantaa meitä soutamattakin,

arveli
Lassi.
 — Millä me soudamme, kun ei ole airoja. Ja sitäpaitsi me
palellumme lautalle, kun ei ole vaatteita, sanoi Jallu. Parasta, kun
viritämme nuotion ja odotamme aamua.

— Mutta minulla on niin turkkilaisen nälkä, eikä ole enää

leipääkään, sanoi Lassi. — Kyllä me lämmintä saamme, kun
melomme oikein vahvasti seipäillä.

Mikko oli taas kähminyt verkkomökille ja toi nyt sieltä vanhan

sarkapalton, joka kai oli Lassin ja Jaakon isältä joskus sinne jäänyt
kalamatkoilla oltaessa. Toinenkin, vielä kuluneempi vanha takki löytyi
ja Mikko palasi meluten saaliineen.

— Nyt ei ole enää muusta puutetta kuin tuulesta, riemuittiin.

Sitä odotellen tehtiin nuotio ja jokainen sai nyt koettaa parastaan

tärinäin kertomisessa, että aika paremmin kuluisi.

Lassi oli huomannut eteläisellä ilmanrannalla pilven kasvavan ja

piti sitä silmällä. Kohta alkoikin haapa kalliolla hiljaa humista ja
veden pintaan syntyi tummia juovia. Pilvikin etelän taivaalla kasvoi
kasvamistaan ja siellä välähti joskus salama.

— Tuliko lautta hyvin kiinni? kysyi Lassi pojilta.

— Tuli varmasti.

Pian alkoivat laineet lipattaa kallion laitaan ja pojat tunsivat

selvästi tuulen kiihtyvän.

Nyt lautta irti ja mars matkalle! komensi Lassi. — Tulee pian sade
ja silloin ei ole täällä kovinkaan hauskat olot.
 Lautta kannatti hyvin. Melottiin tuulen avuksi sauvoimilla, ja lautta
eteni rannasta paremmin kuin olisi osattu odottaakaan.

— Tämäpä on suurenmoista! kehasivat pojat. Sarkaviitasta

laitettiin vielä purje, ja se lisäsi vauhtia. Jallu sai väliin lainata Lassille
takkiressuaan ja onneksi oli tuulikin lämmintä ja se kiihtyi joka hetki.
Laineet keinuttelivat jo lauttaa, niin että oli varottava siltä syvyyteen
suistumasta.

Ukkonenkin jyrähteli jo ja salamat valaisivat tummentuvaa

taivasta. Vakavina katselivat pojat mantereen rantaa ja vuoroin
taakseen, jossa taivas yhä synkkeni. Ulappa kuohui jo
valkopäälaineissa ja poikien täytyi laskeutua polvilleen lautalle
pysyäkseen sillä. Sitäpaitsi täytyi Lassin ja Jallun meloa voimiensa
takaa estääkseen kylmää, joka tahtoi väkisinkin puistatella ruumista.

Jyrisi yhä ankarammin, ja Mikko alkoi vetistellä, mutta ei sanonut

mitään. Häntä vaivasi se, että oli näin aiheuttanut Jaakon kanssa
heille kaikille yhteisen kärsimyksen. Olisi jo pitänyt tunnustaa, mutta
Mikko pelkäsi, että hänet heitettäisiin Jaakon kanssa uimaan.

Jaakko oli kovin kalpea. Hän ei miettinyt muuta, kuin että rannalle
päästyä on heti tunnustettava asia pojille, vaikkakin he kuinkakin
peittoaisivat. Ei mitenkään voisi jättää tunnustamatta. Ja nyt kun sen
tekisi, olisi kuranssauskin ehkä lievempi, kun pojat olivat väsyneitä.

Ranta oli enää vain noin puolen kilometrin päässä, kun jyrähti
entisiä ankarammin ja sadepilvi puhkesi. Vettä tuli, niin että romisi.

Pojat luulivat nyt jo voivansa loppumatkan uidakin hätätilassa ja se

antoi jälleen varmuuden tunnetta.
 — Jopa nyt aivan kaatamalla sataa, sanoi Jallu ja vilu tärisytti
pojan leukoja.

— Antaa tulla vain!

— No kyllä minun puolesta vaikka seipäitä. Siinä tämä poika

kestää, missä toinenkin, kehaisi Jallu.

Lautta alkoi kolista rantakivillä ja odottamatta sen kokonaan

rannalle ajautumista pojat kahlasivat maalle. Ei siitä ollutkaan pitkä
matka veneelle, joka oli heiltä karannut. Se vedettiin kiireesti maalle
ja sitten hurjaa juoksua kotiin. Vaahtopäälaineissa ei viitsitty enää
lähteä venhettä, soutamaan.

Vasta puolitiessä kotimatkaa huomasivat pojat, että heidän

vaatteensa olivat unohtuneet venheeseen.

— Jääkööt!

Peräkkäin paineltiin rantaa pitkin ja pellon poikki oikaistiin suoraan

saunaan.

Se oli illalla lämminnyt ja kiuas pohisi vielä, kun sitä vesitti.

— Hei pojat! Nyt otetaan oikein mustalaisen löylyt sen retken

kunniaksi!

Jaakko ja Mikko tekivät tunnustusta. Kovin heitä vapisutti.

— Sitä jo ajattelinkin, sanoi Lassi. — Kylläpä siitä vielä nahkanne

kuumenee.

— Mutta rankaisu pitää toimittaa ihmisiksi, tokaisi Mikko. — Mitäs

kiusasitte minua saaressa.
 Lassi mietti, että vähällä taitavat pojat siitä päästä, kun kerran
hyvin oli seikkailusta selvitty. Ja olihan ollut oikeastaan hauskakin se
lauttakyyti. Seikkailua!

Saunan ovi avattiin ja äidin pää pisti oviaukosta esiin.

— Ovatpahan toki vielä hengissä, sanoi hän. — Minä olen jo ollut

niin levoton teidän tähtenne. Tulkaa sitten lapsikullat syömään, kun
joudutte.

Lassin olisi tehnyt mieli selvittää matkansa seikkailu äidille, mutta

se jäi seuraavaan päivään. Nyt nautittiin löylystä, joka teki kovin
hyvää tervaiselle iholle.
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