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NCM 105-Nutrition and Diet Therapy

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MODULE ON NUTRITION AND DIET THERAPY

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ASST PROF. NARHUDA H. UNGA

COLLEGE OF HOME ECONOMICS

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II.Essential Nutrients and their Contribution to the Diet: Classification of Nutrients.
Lesson 03

Introduction:

What are Nutrients?

Nutrients are substances required by the body to perform its basic functions. Most nutrients
must be obtained from our diet, since the human body does not synthesize or produce them.
Nutrients have one or more of three basic functions: they provide energy, contribute to body
structure, and/or regulate chemical processes in the body. These basic functions allow us to detect
and respond to environmental surroundings, move, excrete wastes, respire (breathe), grow, and
reproduce.

There are six classes of nutrients required for the body to function and maintain overall
health. These are: carbohydrates, lipids/fats, proteins, water, vitamins, and minerals. Nutritious
foods provide nutrients for the body. Foods may also contain a variety of non-nutrients. Some non-
nutrients such as antioxidants (found in many plant foods) are beneficial to the body, whereas
others such as natural toxins (common in some plant foods) or additives (like certain dyes and
preservatives found in processed foods) are potentially harmful. Thus, all nutrient are needed by
all living organisms regardless of body form, needs, age, gender, races, etc.

Note: Consuming alcohol also contributes energy (calories) to the diet at 7 kilocalories/gram, so it
must be counted in daily energy consumption. However, alcohol is not considered a "nutrient"
because it does not contribute to essential body functions and actually contain substances that must
broken-down and excreted from the body to prevent toxic effects.

Objectives:
At the end of the lesson, the student can:
1.Discuss the Clinical manifestation, food sources of nutrients and explain their function.
2.Determine RENI, nutrient requirement, deficiency and toxicity of each nutrients.
3.Comprehend all the essential nutrients that contribute to the diet.
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Topic Outline:
Essential Nutrients and their Contribution to the Diet:
Classification of Nutrients:
Macronutrients and Micronutrients
1.Carbohydrates 4.Vitamins
2.Protein 5.Minerals
3.Fats 6.Water & Electrolytes

Try This!

Directions. Define the following and let’s see how do you understand the important terms in the
study of Nutrition and Diet therapy.
1.Nutrients
2.Organic Compounds
3.Inorganic Compounds
4.Carbohydrates
5.Protein
6.Fats
7.Vitamins
8.Minerals
9.Water
10.Electrolytes
11.Water Soluble Vitamins
12.Fat Soluble Vitamins
13.Macro-minerals
14.Micro-minerals
15.Toxicity

Think ahead!
1.Enumerate/list down/give food examples for each Nutrients listed below: (1-15)
Food CHO CHON FATS VITAMINS MINERALS WATER/
Sample ELECTROLYTES
No.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

Answer Key Sheet

Name:____________________________________ Score:________
Course/Year:_______________________________ Date:_________

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Read & Ponder!

Classification of Nutrients:
A.Macronutrients:
1.Carbohydrates
Carbohydrates are big group of organic compounds prominent in the plant kingdom which contain
the elements, carbon, hydrogen, and oxygen. It is synthesized through the process of photosynthesis.
Carbohydrates foods are starches and sugar which furnish the major source of energy and form the bulk
of diet.
CLASSIFICATION:
A. According to sugar unit:
1. Monosaccharide – simplest form of carbohydrate or one sugar unit.
a. Glucose – most important glucose in human metabolism, as physiologic sugar
 Also known as “dextrose”, or grape sugar, found free in nature, in fruits, honey, corn
syrup, sweet corn, and certain roots.
b. Fructose – sweetest of all sugars
 Known as fruit sugar or “levulose”
 Found in ripe fruits, and honey.
 Digestive end product of sucrose.
c. Galactose – digestive end product of milk sugar or lactose
 Not found free in nature
2. Disaccharide – made up of 2 simple sugar.
a. Sucrose – known as table sugar, cane sugar or beet sugar
 Yield glucose and fructose upon hydrolysis
 Sources from sugar cane, sugar beets, molasses, fruits and table sugar.
b. Maltose – “malt” or grain sugars
 Contains two glucose upon hydrolysis.
 Food sources as malted products, sprouted cereal
 Not found free in nature
c. Lactose – known as milk sugar
 Found in milk sugar and milk products
 Composed of glucose and galactose uponm hydrolysis
 Least sweet of all sugars and slowly digested.
3. Polysaccharide – made up of many units of monosaccharide
a. Starch – storage form of carbohydrates in plant such as grains, seeds, tubers, roots,
unripe fruits, vegetables and legumes.
b. Dextrin – intermediate product of starch hydrolysis like toasting of bread or browning of
cake crust.
c. Glycogen – storage form of carbohydrates in animals
 Known as animal starch which is stored in the liver and muscle.
 Found in liver, oyster and muscle meat.
d. Cellulose and Hemicellulose – indigestible polysaccharide.
 Adds bulk in the diet
 Stimulates peristalsis and aids min the elimination of waste material.
 Found in fruits, covering of nuts and legumes, stem, mature leaves.
e. Hemicellulose – same functionwith cellulose
 Foumnd in seaweeds or agar and slightly inm unripe fruits and vegetable in form of
pectin.
 Found in agar, pectin, woody fribers, leaves and stems
 Can be hydrolyzed by dilute acids.

B. According to Digestibility
a. Digestible Carbohydrates - sugars, starches, dextrin, and glycogen
b. Partially digestible carbohydrates – galactogens, mannosans, inulin and pentosans.
c. Indigestible carbohydrates – dietary fibers, cellulose, and hemicellulose.
FUNCTIONS:
A. Chief Source of Energy
 Body cells require a steady and constant supply of energy mainly as glucose and its
intermediate products. One gram carbohydrate yields 4 kilocalories
B. Cheap and main Energy Form
 Carbohydrate foods mainly as cereal grains, sugars, most fruits, and starchy vegetable
contribute at least half or 50% of total energy needs of people.
C. Protein Sparer
 Energy foods of the body are given first priority over body-building needs. To “save”
or “spare” protein for this unique function of the body-building, carbohydrates must
be adequate in the diet.
D. Sole Energy source for the Brain and Nerve Tissues
 The brain and nerve tissues utilize only glucose for energy. Lack of glucose or exygen
to release energy will result in an irreversible damage to the brain.
CLINICAL MANIFESTATION:
1. Inadequate Intake of Carbohydrates
A. PEM – Protein Energy Malnutrition
PCM – Protein-Calorie Malnutrition
Signs:
1. Loss of weight
2. Retarded growth
3. Low blood sugar level (<80-100mg/100ml)
2. Excess Intake of Carbohydrates
A. Fermentation causing gas formation
B. Dental carries
C. Obesity
D. Overweight
E. High Blood glucose level
SOURCES:
a. Sugar or empty calorie foods – brown sugar, refined sugar, candies, honey, carbonated
beverages.
b. Fruits – dried, fresh, sweetened, or canned.
c. Root
d. Root crops and other vegetables
e. Milk
RENI – 55-70% of the total kcals.
2. Proteins
- Comes from the Greek word “Protos” meaning “to tak the first place”.
- These are oraganic compounds containing carbon, hydrogen, oxygen, nitrogen, and little sulfur.
It describes the nitrogenous substances which is essential to the development, maintenance and
life of every cell of the body.
- Composed of amino acids as the building units linked together in peptide bond.

These Amino acids are nitrogen-containing compound which form building blocks of protein.
CLASSIFICATION
1. According to amino acid content of proteins:
a. Complete protein – are proteins contains all essential amino acids in amounts sufficient for
growth and maintenance of life.
 Animal proteins are complete proteins and have high biological value.
 E.g. eggs, milk, meat, fish, poultry, and milk products as casein in milk, and albumin
in egg whites
b. Partially complete protein – maintains life but cannot support growth
 E.g. gliadin in wheat, legumin in legumes
c. Incomplete – neither maintains life nor support growth; lacks one or more essential
nutrients.
 E.g. zein in corn, gelatin and most plant protein
2. According to classification of amino acids:
1. Essential or Indispensable Amino Acid – cannot be synthesized by the body; thus must be
provided in the diet.
9 essential Amino Acids (EAA):
1. Isoleucine 5. Tryptophan 9. Valine
2. Histidine (Infants) 6. Lysine
3. Threonine 7. Phenylalanine
4. Methionine 8. Leucine
2. Semi-essential or Semi-indispensable Amino Acids – those that can lowerthe requirement of
an essential amino acids but cannot replace them entirely.
1. Cystine 4. Glycine
2. Tyrosine 5. Serine
3. Arginine 6. Histidine
3. Non-essential or Dispenmsable Amino Acid - those that can lower the requirement of an
essential amino acid but cannot replace them entirely.
1. Glutamic acid 5. Proline 9. Hydroxyglycine
2. Hydroxyglumatic acid 6. Hydroxyproline
3. Aspartic acid 7. Norleucine
4. Alanine 8. Citrulline
FUNCTIONS:
1. Growth and Repair all Body Tissues.
2. Source of heat and energy
a. Body Building or Structural Role

Twenty percent (%) or one-fifth (1/5) of an adult body weight is protein, ½ in muscle,
1/5 in bones and cartilages, 1/10 in skin.
b. Essential for Growth
 All living cell in the body used protein plus the nine (9) available essential amino
acids and nitrogen to synthesize new protein.
c. Source of energy
 Protein supply 4 kcal per gram, although, it is more expensive source of energy. The
role nutrient supply amino acids for body building and repairing, protein should be
spared or saved for its more important function of building and repairing by adequate
fat and carbohydrates intake.
SOURCES:
1) Animal Sources – egg, milk, fish, poultry, lean meat, cheese, dairy products, and shellfish
2) Plant source – nuts, cereals and cereal products, vegetable and textured vegetable protein.

CLINICAL MANIFESTATION
1. General deficiency signs
a) Weight loss
b) General weakness
c) Reduced resistance to infection
d) Dry and scaly skin
e) Nutritional edema
f) Hypoproteinema
g) Pallor
2. PEM
a) Kwashiorkor – occurs after weaning when the diet is high in calories but low in ptotein.
b) Marasmus – carried by inadequate intake of both calories and protein.
TER = 100 – 200 KCAL/KDBW
Protein Reqt. = 4 – 6g P/KDBW

3.Fats
Lipids
 Is a broader term which includes fats, oils, and fat-like substance which are soluble
“fat solvents” like, chloroform, benzyl, etc.
Fats
 Is the most concentrated source of energy in foods which constitute the body’s chief
reserve of energy. Refers to the physical state of fats that is solid at room temperature.
Oil
 Refers to the physical state of fat that is liquid at room temperature.
Triglyceride
 The chemical name of fats and oils
Fatty Acids
 Major constituent of lipids which consist of chain series of carbon atoms.
CLASSIFICATION OF FATTY ACIDS
1. Saturated Fatty Acid – abundantly found in animal fat, liver oil, and in vegetable fat such as
coconut oil, peanut oil, coconut milk, palm oil and palm kernel. E.g. animal fat – palmitic and
stearic fatty acid
2. Unsaturated Fatty Acid – 2 types:
a) Mono-unsaturated fatty acids (MUFA)
e.g. oleic fatty acid – widely distributed in plants and animal such as olive oil, peanut oil and grape seed
oil, lard, beef, and lamb.
b) Poly –unsaturated fatty acids (PUFA)
e.g. 1. Linoleic acid – avocado, nuts, corn oil, safflower, cotton seed oil.
2. linolenic acid – soybean, linseed oil
3. arachidonic acid – peanut oil
The three types of PUFA are nutritionally important and considered as essential fatty acids (EFA)
FUNCTIONS:
1. Fuel or energy – highest energy giving foods, each gram of fat supplies 9 calories.
2. Body insulator – as an effective insulator that reduces losses of body heat and maintain body
temperature at a constant level.
3. Source of essential fatty acids
4. Carrier of fat-soluble vitamins
5. Satiety value
6. Palatability
7. Protector of nerve endings and delicate organs
RENI: 20 – 30 % of the TER/day
FOOD SOURCES
1) Animal Fats – refers to that found in foods like meat, fish, poultry, cheese, & whole milk
2) Vegetable Fats – includes margarine, seed and vegetable oils, nuts, and fruits.
3) Visible Fats – butter, salad dressing, cooking oil, lard, margarine, pork fat, tallow (fat of lamb or
beef) and suet (clear white, solid fat obtained from beef)
4) Invisible Fats – egg yolk, milk, olives, avocado, well-marbled lean meats.
CLINICAL MANIFESTATION
1) Excess Intake – (obesity and overweight)
2) Deficiency – caused retarded growth
- cause underweight
- reduced caloric supply in the body

B.Micronutrients:
4.Vitamins
- Are potent organic compounds of related chemical composition which occur in minute
quantities in foods and are needed in small amounts.
Functions:
1. For specific regulatory functions.
2. For the maintenance of life and normal growth.
Vitamin Related Substances:
 Pro-vitamin or vitamin precursor – a substances chemically related to the biologically
active form of vitamin but no vitamin activity until the body will convert it into an
active form.
e.g. carotene, intestinal wall, vitamin A
 Anti-vitamin or vitamin antagonist, pseudo-vitamins – substances that interfere with
the normal functioning of the vitamin either by competitive inhibition, by inactivation
or by chemical destruction.
e.g. Avidin (egg white) – Biotin

General Properties of Fat Soluble Vitamins

1) Soluble in fat
2) Intake in excess stored in the liver
3) Deficiencies slow to develop
4) Not needed everyday
5) Have precursor

FAT SOLUBLE VITAMINS

I. Vitamin A (Retinol)
Unit of Measurement: ug R.E.
Functions:
1) Maintenance of visual purple for vision in dim light.
2) For motion and maintenance for normal epithelial tissues which the body’s primary
barrier to infections.
3) Essential for normal growth, healthy skin and eyes.
Deficiency
1) Hyctalopia or “night blindness” – reduce vision in the dark especially after coming
from the bright light.
2) Hemeralopia or “glare blindness, day blindness” – defective vision in bright light.
3) Follicular Hyper-keratosis – skin becomes dry and scaly.
4) Lowered resistance to infections
5) Bitot’s spot – small triangular silvery spot on the conjunctiva.
6) Xeropthalmia – dry and lusteriess condition of the eyeball.
7) Keratomalacia – softening and necrosis of the cornea of the eye.
8) Faulty bone and tooth formation.
Toxicity – only happen when there is a large dose of vitamin A supplement e.g. Hyper-avitaminosis
RENI : Infants - 375 – 400ug Adults - 500 – 550ug
Children - 400ug Pregnant - 800ug
Adolescent -400 – 600ug Lactation - 900ug
Food sources
1) Dark green and leafy yellow vegetables, yellow fruits carrots, tomatoes, yellow
camote , corn, and ripe papaya
2) Fish liver oil, liver, egg yolk, milk, butter, and cheese.

II. Vitamin D: Ergocalciferol

Unit of Measurement : ug
Functions:
1. For strong bones and teeth
2. Helps body utilize calcium and phosphorus

Deficiency:
For infants and children – Rickets – a disease characterized by failure of bone to mineralize,
causing long bones to bow with bearing activities. Deformities occur in spine, thoracic and
pelvic areas.
For Adults – leads to impaired Ca and P absorption, leading to bone pain and osteomalacia.
Toxicity:
Over toxic reaction in humans, when RQA is chronically exceeded.
Skin Cancer – over exposure to sunlight.
RENI: 200 – 400 I.U.
Sources:
Fortified margarine, butter. Milk and cheese, liver and other glandular organs.

III. Vitamin E: Tocopherol

Unit of Measurement: ug
Functions:
1. Acts as anti-oxidant
2. Helps the formation and function of red blood cells, muscles and other tissues.
Deficiency:
Hemolysis – Destruction of Red Blood Cell
Toxicity:
No reported cases
RENI: 5 – 15 ug
Sources:
Vegetable oils, rice, nuts, and legumes like mongo
IV. Vitamin K - Phyloquinone (K1) green leaves
- Farnoquinone (K2) fish meal
- Menadione (K3) synthetic form
Obsolete names: anti-hemorrhagic factor
Unit of Measurement: microgram (ug)
Functions:
1) Prevents hemorrhage
2) Necessary for normal blood clotting
Deficiency:
1. Can cause a number of factors
2. Faulty intestine synthesis
3. Hepatic injury
4. Anti-coagulant therapy
Toxicity
Symptoms – vomiting, albuminuria and hemolytic anemia
RENI: 6 – 59 ug
Sources: Liver, dark green vegetables, wheat, vegetable oils.
GENERAL PROPERTIES OF WATER-SOLUBLE VITAMINS:
1) Soluble in water
2) Minimal storage of dietary excess
3) Needed or must be supplied every day in the diet
4) Deficiency symptoms often develop rapidly
5) Excreted by the way of urine.

I. ASCORBIC ACID : Vitamin C

Unit of Measurement: Milligram (mg)
Functions:
 Help keep bones, teeth, and blood vessels healthy.
 Important in the formation of collagen, a protein that provides structure to muscles,
bones, etc. (collagen is like a body cement representing 30% of all the protein in the
body).
Deficiency:
1) Scurvy: swollen spongy and bleeding gums
2) Poor wound healing
3) Reduced resistance to infection
RENI: 30 -105 mg
Sources:
 Fresh fruits like atis, guava, datiles, kasuy, strawberry, melon, kamatsili, papaya, and
green mangoes.
 Citrus fruits like kalamansi and suha
 Green leafy vegetables like lettuce and pechay.

II. THIAMINE: Vitamin B1

Unit of Measurement: Milligram (mg)
Functions:
1) Helps get energy from food by promoting proper metabolism of fatty acids and
carbohydrates rich foods like rice and sugar.
2) For correct functioning of the heart and nervous system.
Deficiency:
 Result in beri-beri, affecting nervous and cardiovascular systems.
 Symptoms are: anorexia and numbness of legs
 3 form of beri-beri:
1. Dry – inflammation of many nerves
2. Wet – heart disease
3. Infantile – seen in infant’s breastfeed by mothers suffering from beri-beri.
RENI: 7- 1.4 mg
Sources:
 Lean pork, liver and other glandular organs, egg yolk, rice, nuts and legumes like
mongo.

III. RIBOFLAVIN: Vitamin B2

Unit of Measurement: Milligram (mg)
Functions:
1) Promotes growth necessary for healthy skin.
2) Functions in the body’s use of carbohydrates.
3) Helps release energy to cells.
Deficiency:
1) Photophobia – abnormal sensitivity to light.
2) Angular Stomatitis – cracks in the angle of the mouth.
3) Cheilosis – redness, swelling and ulceration of the lips usually the center of the lower
lip.
4) Glossitis – swollen tongue or magenta tongue with purple-red in color.
5) Seborrheic dermatitis – skin is scaly, greasy eruptions especially on the skin
RENI: 0.3 -1.7 mg
Sources:
 Whole grain, legumes, leafy green vegetables, and seaweeds
 Cheese, milk, eggs, liver, other glandular organs and lean meats.

IV. NIACIN: Nicotinic Acid

Unit of Measurement: milligram NE
Functions:
1) Involved in energy producing reactions in cells
2) Aids the nervous system
Deficiency:
 Severe deficiency leads to pellagra characterized by 4D’s:
1) Dermatitis – the skin develops cracked, pigmented, scaly dermatitis, sensitive to solar
radiation.
2) Diarrhea – frequent passage of loose, watery, and unformed stools.
3) Dementia or Delirium –lesion appears in many parts of the CNS, resulting in mental
changes, confusion, and disorientation.
4) Death – if not remedied.
Toxicity:
 It increases gastro-intestinal motility and secretion of acid, causing epigastric pain and
reaction of peptic ulcer.
RENI: 1.5 – 18.0 mg NE
Sources:
 Liver and glandular organs, meats, egg yolk, milk, panutsa, rice, legumes, and nuts.

V. PYRIDOXINE: Vitamin B6
Unit of Measurement: Milligram (mg)
Functions:
1) Essential for proper utilization of proteins
2) Aids in the formation of red blood cells and correct functioning of the nervous system.
RENI: 0.1 – 2.0 mg
Sources:
 Vegetable oils, unpolished or red rice, lard, and nuts.

VI. PANTHOTENIC ACID

 Name from Greek word “Pantos” meaning everywhere. Due to its widespread
occurrence in food.
Unit of Measurement: Milligram (mg)
Function:
1) Required for metabolism of proteins, fats and carbohydrates and for the formation of
certain hormones.
2) Functions in the regeneration of tissue.
Deficiency:
 Absorbed, with natural diet, since this vitamin is widely distributed in foods.
Toxicity: None
RENI: 4.0 – 7.0 mg
Sources:
 Liver and glandular organs, meats, eggs, milk, cheese, legumes.

VII. COBALAMIN: Vitamin B12

Unit of Measurement: microgram (ug)
Functions:
1) Helps prevent certain forms of anemia
2) Assist in the information of red blood cells.
Deficiency:
 Pernicious anemia.
 Deficiencies occasionally seen in strict vegetarian.
Toxicity: None

RENI: 0.3 – 2.8 ug

Sources:
 lean meats, liver, kidney, marine water fishes, and shellfish
 Animal protein contains Vit. B12 while plant sources are practically nil.
Note: Nil – not in the list

VIII. PTYROGLUTAMIC ACID (PGA): FOLIC ACID/FOLACIN/FOLATE

Unit of Measurement: microgram (ug)
Functions:
1. Aids in the information of cells, especially red blood cells
2. Helps maintain functions of the intestinal tract.
3. Prevents certain forms of anemia
Deficiency:
 In man; not produce by inadequate diet, but occur secondary to disease.
 Symptoms includes: glossitis, gastro intestinal disturbance.
Toxicity:
Toxic in large doses, it may damage the kidney. In animals, they die of uremia.
RENI: 65.0 – 500 ug
Sources:
Green leafy vegetables, liver and other glandular organs, legumes, and cereals like rice.
IX. BIOTIN
Obsolete Name: Anti-egg white injury factor
Unit of Measurements: microgram (mcg)
Functions:
1. Involved in the formation of fatty acids and production of energy.
2. Essential to many chemical system in the body like maintenance of the thyroid and
adrenal glands, the nervous system and reproductive system.
Deficiency:
 Due to large intake of egg white in the diet
 Symptoms:
1. Dry scaly, dermatitis
2. Nausea feeling that leads to vomiting
3. Depression
4. Muscular or nervous disorder
Toxicity: None
RENI: 100.0 – 200.0 mg
Sources:
1) Plants – cereals, legumes, nuts, most fruits and vegetables
2) Animals – liver, egg yolk, fish and milk

5.Minerals
 Inorganic elements that remain as ash when food is burned. Make up about 4% of body
weight.
ESSENTIAL MINERALS:
1. Macro-minerals – major – minerals
 Those present in the body in large amounts.
1) Calcium - Ca
2) Phosphorus - P
3) Potassium -K
4) Sodium - Na
5) Magnesium - Mg
6) Sulfur -S
7) Chlorine - CI
2. Micro – minerals – trace elements
 Those present in the body in small intestine
1) Iron - Fe
2) Iodine - I
3) Cobalt - Co
4) Copper - Cu
5) Zinc - Zn
6) Manganese - Mn
7) Molybdenum - Mo
8) Selenium - Se
9) Chromium - Cr
10) Fluorine -F
1. CALCIUM
 Comprises 1.5% to 2% of body weight.
 99% of Ca found in bone, teeth, and hard tissues.
 1% in blood, extracellular fluid and cells of soft tissues
Unit of Measurement: gram/mg
Functions:
1. Build and maintain bones and teeth which involved 2 process carried on by 2 cells:
A. Osteoblast – continually form a new bone matrix, in which Ca phosphate is
deposited and bone crystal develop.
B. Osteoclast – balance the act by absorbing bone tissues.

2. Aids in the coagulation of the blood – in the blood clotting process, the ionized
calcium stimulates the release the thromplastin from blood platelets.
 One enzyme that accelerates the conversion of prothrombin to thrombin
protein in blood plasma needed for blood clotting.

3. Regulates muscle contraction and relaxation, thus is essential also for normal hearth
rhythm.
4. Required the normal transmission of nerve impulses.
5. Activates enzymes – important activators of certain enzymes such as ATPase
(adenosine triphosphate).
6. Promotes iron and vitamin B12 absorption.
Deficiency
1) Stunted growth and retardation, calcification of bones and teeth.
2) Rickets – characterized by enlarge joints, bowed legs, knocked-knees, beaded ribs.
3) Osteomalacia – reduction in the mineral content of the bone.
4) Osteoporosis – an absolute amount of bone in the skeleton has been diminished but
in which the remaining bone mass is of normal composition.
5) Tetany – reduction of circulating ionized Ca resulting in increase
excitability/irritability of nerve center.
Toxicity:
1) Hypercalcemia – elevated Ca in the blood
2) Renal Calcull – majority of kidney stones are composed of Ca
RENI:
1. Adult - 750 mg.
2. Pregnant/Nursing Mother - 750 – 800 mg.
3. Infant - 200 – 400 mg.
4. Children – 500 - 700 mg
5. Adolescent – 1000 mg.
Sources:
1) Plant – green leafy vegetables like mustasa, malunggay, petchay, saluyot, gabi
leaves
2) Animal – milk and milk products
Fish eaten with bones like dilis
Sardines and dried fishes
Shell fishes.
2. PHOSPORUS
 Comprises .8 to 1% of the total body weight
Unit of Measurement: milligram (mg)
Functions:
1) Mineralization of bones and teeth – about 80% of phosphorous in the form on
insoluble calcium phosphate crystals, which is constantly deposited and
reabsorbed in the dynamic process of bone formation. Phosphorous has been
called the “metabolic twin” of calcium
2) For growth and maintenance.
3) Maintains water and acid base balance – It is the principal anion within the cells.
Deficiency: Same as Calcium
Toxicity: hyperphosphatemia – excess accumulation of serum phosphate
RENI:
Infant - 90 – 275 mg
Children - 460 – 500 mg
Adolescent - 1,250 mg
Adult - 700 mg
Pregnant/ Lactating mothers - 700 mg
Sources: All sources rich in calcium and protein are good sources of phosphorous
3. POTASSIUM
 About 250 grams in adult body, concentrated inside the cells.
Unit of Measurement: milligram (mg)
Functions:
1) Regulates water and acid-base balance – the major cat ion of the fluid inside the
cells.
2) Maintains muscle contractility and nerve irritability – it works with Na and Ca to
regulate neuromuscular stimulation, transmission of electrochemical impulse and
contraction of muscle fibers.
Deficiency:
1) Hypokalemia – (low serum potassium) loss of potassium due to vomiting.
2) Muscle irritability, weakness and paralysis.
Toxicity:
 hyperkalemia – (elevated serum potassium) This result in weakening of heart action,
mental confusion, poor respiration, and numbness of extremities.
RENI:
 Infants – 90 – 275 mg
 Children - 460 – 500 mg
 Adolescent – 1,250 mg
 Adults - 700mg
 Pregnant/ Lactating mothers – 700mg
Sources:
 Richest sources are fruits and fruit juice, vegetables, legumes, nuts, cereals
and meats.
4. SODIUM
 Compresis 1.8 mg/kg total body weight
50% of Na - found in extra cellular fluid.
40% - skeleton
10% - inside the cell
Unit of Measurement: Milligram, gram
Functions:
1) Regulates osmotic pressure and water balance – ionized Na is the major cat ion of the
fluid outside the cell.
2) Regulates acid – base balance – It is a major component of the base partner of the
body’s main buffer. (regulates acid-base balance in the body)
Deficiency:
 Muscle cramps and distributed acid-base balance resulting from diarrhea, vomiting
and profuse sweating.
 Hyponatremia – low level of Na in the blood, due to very restriction of Na diets.
Toxicity:
 Not harmful since the body can excrete excess Na in the urine but a prolonged high
salt diet may aggravate a tendency toward high blood pressure, kidney disorder and
edema.
RENI: 2.8 – grams Na
Sources:
 Present in a wide variety of food particularly animals foods such as meat, fish,
poultry, milk, and eggs.

5. MAGNESIUM
 21 to 28 grams Magnesium in the body
60 – 70% - combined with Ca and P
30 – 40% - distributed in the soft tissue and body fluids
Unit of Measurement: Milligram (mg)
Functions:
1) Builds and maintains bone and teeth together with Ca and P
2) As part of the chlorophyll molecule which is important in photosynthetic reactions.
3) Needed for the production of ATP
Deficiency:
 Hypomagnesemic tetany – seen in infants suffering from kwashiorkor, alcoholics,
postoperative cases, and prolonged diarrhea.
Toxicity:
 Hypermagnesemia – (elevated serum magnesium) results to hypotension
RENI:
Infants - 26 – 54mg
Children - 65 – 100mg
Adolescent - 155 – 260mg
Adults - 205 – 235mg
Pregnant/ Lactating mothers – 205 – 250mg
Sources:
 Richest source are nuts, cocoa, soybean and whole grain cereal
6. SULFUR
 Comprise about .25% of body weight.
 Present in every cell in the body.
 Highest concentration is found in the hair, skin, and nails.
Unit of Measurement: Milligram (mg)
Functions:
 For structural function – principally as constituent of the following:
1) Amino acids, methionine, cysteine (reduced form) and cysteine (oxidized form).
2) Keratin – the protein of hair, nails, and skin.
3) Insulin – hormone which regulates carbohydrate metabolism.
4) Thiamine, panthothenic acid and bloth.
Deficiency/Toxicity:
 Hereditary defect in the re-absorption of amino acids cysteine causing excessive
secretion of these in the urine that lead production of cysteine kidney stones.
RENI: A diet adequate in protein will contain enough sulfur
Sources: All foods rich in protein provide sulfur.

7. CHLORINE
 About .15% of adult body weight.
Unit of Measurement: milligram (mg)
Functions:
1) Together with ionized Na, ionized CI’s major anion in the extra cellular fluid helps
maintain water balance and regulates osmotic pressure.
2) As component of HCL, it contributes to the necessary acidity needed in the stomach
for the breakdown of protein.
Deficiency:
 Alkalosis – results only when there is an excessive loss of chloride ions from the
gastric secretion during vomiting or diarrhea.
Toxicity: None
RENI: when Na intake is adequate, chloride will be adequately supplied
Sources:
 Table salt, meat, sea foods, milk and eggs.

MICRO – MINERALS
I. IRON
 Occurrence: about 0.004% or total of 3-5 grams of total body weight.
Distributed in the body in the following forms:
a) Transport – about .05 – 18 mg/ 100 ml is found in the plants.
b) Hemoglobin – about 60 – 75%.
c) Myoglobin – 5% as part of the muscle hemoglobin.
d) Storage Iron – 26% is stored in various organs (liver spleen, and bone marrow) as
ferritin.
e) Cellular Tissue Iron – 5% is distributed throughout the cell.
Functions:
1) Needed for hemoglobin formation.
 Hemoglobin in the RBC is the oxygen transport unit of the blood that conveys
oxygen to the cells for respiration and metabolism.
Deficiency:
 Is resulted to inadequate production of RBC causing anemia – a condition
characterized by reduction in size or number of RBC or the quantity of hemoglobin
or both, resulting in decreased capacity of the blood to carry oxygen.
According to cause anemia is classified as follows:
1. Nutritional Anemia
 Due to an inadequate supply of iron in the diet throughout the life cycle due
to poor quality of food sources.
2. Hemorrhagic Anemia
 Due to excessive blood loss such as surgery, wounds, injury.
Pregnancy, parasitism, and blood donation.
3. Pernicious Anemia
 Inadequate formation of RBC because of Vit. B12 deficiency caused by lack
of intrinsic factor.
4. Malabsorption Anemia
 Substance hinder iron absorption
5. Milk Anemia
 Feeding older infants solely milk which lacks iron.
Toxicity:
1. Hemochromatosis
 Abnormal deposits of hemosiderin in the liver and other tissues due to
abnormal absorption and storage of iron.
2. Hemosiderosis
 Accumulation of hemosiderin in the liver and other tissues.
RENI:
Infants - .38 – 10mg
Children - 8 – 11mg.
Adolescent - 13 -27mg.
Adults - 12 – 27mg
Pregnant/ Lactating women – 27 – 38mg.
Sources:
1) Plant – green leafy vegetables
2) Animal – liver and other meat organs

II. IODINE – mg./ug

 The body normally contains 20-30 mgs. Iodine concentrated in the thyroid gland
stored in the form of thyroglobulin
Functions:
1. Needed in the synthesis of throxine, the principle hormone of the thyroid gland. It
regulates the rate of oxygen consumption in the cells and involve in the growth of
tissues.
 Goitrogenic Substances – interfere with iodine utilization
 Goitrogens – are found in peanuts (especially in red skin), cabbage,
cauliflower, radish, peas, and cassava.
Deficiency:
1) Goiter – enlargement of the thyroid gland
2) Myedema – hypothyroidism in adult
3) Cretinism – seen in infants born to a mother who had inadequate intake of iodine
during pregnancy.
RENI:
Infants - 90mg
Children - 90 – 120mg
Adolescent – 120 – 150mg
Adult - 150mg
Pregnant/Lactating women – 200mg
Sources:
 Sea foods such as clams, sardines and other sea fishes are the richest sources.

III. COBALT – mg
 Comprise 4% of vitamin B12
Functions:
1) As component of Vitamin B12 essential for maturation of RBC
Deficiency:
 Is associated with B12 deficiency.
Toxicity:
 Polycythemia – over production of RBC
RENI: not known
Source:
 Widely distributed in nature

IV. COPPER - mg
 Adult body contained 75 – 150 mgs of copper.
Functions:
 Essential for the utilization of iron in the synthesis of hemoglobin.
Deficiency:
Hypocupremia – noted in children with iron deficiency anemia.
Toxicity:
 Resulted to Wilson’s disease, characterized by degenerative changes in brain tissue
together with cirrhosis of the liver.
RENI: .08 mg/KBW
Sources:
1. Plant – green leafy vegetables
2. Animal – liver (highest)

V. ZINC – mg
 Adult has about 2 gms of zinc.
Functions:
1. Essential for growth and gonad development in man.
Deficiency:
1. Impairs growth
2. hypogonadism
Toxicity:
 In poisoning, results in increased losses of iron and copper
RENI:
Infants - 1.4 4.2 mg
Children – 4.5 – 5.4mg
Adolescent – 6.0 – 5.4mg
Adult - 4.5 -6.4 mg
Pregnant/Lactating Women – 5.1 – 11mg
Sources:
 Widely distributed

VI. MANGANESE
 About 10-20 mg. is present in the adult body concentrated in the liver, bones,
kidneys, muscles and skin.
Function:
1. Plays a role in urea formation – part of the molecular structure of arginase, an
enzyme (arginine-an amino acid) essential for urea formation.
Deficiency: None
Toxicity:
 Can cause a reduction in Hb regeneration and results in decreased iron absorption in
liver, kidney, and spleen. Toxicity is found in miners as a result of prolonged
exposure to diet.
RENI:
Infant - .003 - .6mg
Children - 1.2 – 1.7mg
Adolescent - 1.6 -2.3mg
Adult - 1.8 – 2.3mg
Pregnant/Lactating women – 2.0 0 2.6 mg
Sources:
 Animal are poor sources
 Plant – nuts, legumes, whole grain cereals, tea, and dried fruits.

VII. MOLYBDENUM – mg
 Present in minute amount in the body
Functions:
1) An integral part of Xanthine Oxidase (involved in the formation of uric acid and
Aldehyde Oxidase ( as catalyst in the oxidation of aldehydes to corresponding
carboxylic acid).
Deficiency:
 Not observed in man
Toxicity:
 High Mo intake can induce copper deficiency
RENI: Not known
Sources:
 Widely distributed.
VIII. FLOURINE – mg
 Greatest concentration in bones and teeth
Functions:
 Prevents dental carries
Toxicity:
 Resulted in dental fluorosis or mottled enamel (with brownish and white patches
with or without of the enamel)
RENI:
Infant - .01 – 5mg
Children - 1.2 – 1.7 mg
Adolescent - 1.7 – 2.9mg
Adult - 2.5 – 3.0mg
Pregnant/Lactating women – 2.5mg
Sources:
 Found naturally in water supplies. In addition to water content, a normal diet may
contribute 1.5 mg. fluorine/ day for solid foods.

IX. CHROMIUM - mg
 About 20 pb in blood and higher in glandular organs.
Functions:
1) Catalyzes reactions involving energy release, particularly in the first steps of glucose
metabolism by facilitating transfer of glucose from plasma to cell.
Deficiency:
 Elevated blood glucose with excretion in urine
Toxicity:
 Toxic only when injected intravenously
RENI: Not known
Sources:
 FATS – highest concentration (corn oil)

X. SELENIUM – mg/ug
 Found in minute amount in the body, concentrated in the liver and other glandular
organs, blood, and muscles.
Functions:
 Antioxidant role related to Vitamin E

Deficiency:
 Not observed in man
Toxicity:
 Gastric and hepatic disorder results
RENI:
Infants - 6 -10mg
Children - 7 – 12mg
Adolescent - 21 – 36mg
Adult - 31mg
Pregnant/Lactating women - 35 – 40mg
Sources:
 Variable, depending on level in soil where plants are grown. (cereal and onion)

6.Water and Electrolytes.

Many authors classify water both as a food and a nutrient. It constitutes about 60 – 70%
of the body weight, a body that is deprived by at least 10% of water causes body illness. A loss of
20% water in the body causes death.
A body of a normal adult contains 45 liters of water. Two thirds (2/3) of which (30 liters)
is found inside or within the cells (intracellular fluids). One third (1/3) is found outside of the cells
(extra cellular fluids). Three liters of which is in the blood or intra vascular fluid and 12 liters in
the interstitial or intercellular fluid. Water is present in every tissue but its amount varies
considerably. The highest concentration is found in the metabolically active cells of the muscles
and viscera and lowest in the calcified tissue.

FUNCTIONS:
a. Water is nearly a universal solvent. In the blood, it carries simple sugars, amino acid, lipoproteins,
vitamins, and minerals for transportation to the different tissues for functioning and nourishment.
b. Water is used to excrete waste products from the lungs, skin, and kidneys.
c. Water is needed in all the chemical reactions; it serves a catalyst in many biological reactions
especially involving digestion and aids in absorption and circulation.
d. Water is a vital component of tissues, muscles, glycogen and etc. and is vital for growth.
e. Water acts as lubricant for the joints and the viscera in the abdominal cavity thus can protect a
sensitive tissue.
f. Water is also a regulator of body temperature through its ability to control heat.
Hard water can also be a source of trace minerals such as fluorine, calcium, magnesium, and copper. It
can also be a source of toxic elements such as lead, cadmium and other industrial wastes including
bacteria.

WATER BALANCE:
The amount of water taken must be equal to the amount of water output for a person to be in
metabolic equilibrium. Fluid intake is controlled by thirst and appetite and output by the endocrine
glands and temperature of the environment.

The body uses more water in the blood, saliva, intestinal, gastric, bile, and pancreatic juices than
the daily intake. However, enough water is available through more efficient conservation of water from
kidneys and intestines. The fluid intake is approximately equal to the urine output. This knowledge is
used in the fluid intake and output chart being used by the nursing staff in wards, which they fluid
useful as a practical procedure in the care of the patients with febrile or kidney disorder.
WATER INTAKE:
The amount of water needed by the body may be a direct intake of water coming from water
ingested such as water found in food and metabolic water, which is a result of the oxidation of
foodstuffs in the body. Water produced as an end- product of metabolism amounts to approximately 10
– 14 gram per 100 kcal.
For example:
100 g of fat, CHO, protein when oxidized will yield 107 ml, 55 ml and 41 ml of water respectively.
Varying amount of water present in foods:

 Meat and fish – 37 – 85%

 Fruits and vegetables – 60 – 69%
 Fatty foods – low or zero moisture content
 Brain foods – 2 – 12%
Water is immediately absorbed from the digestive tract into the blood and lymph.
WATER OUTPUT:
Water input is controlled by the hormone Vasopressin (anti – diuretic hormone or ADH) which
is secreted by the pituitary gland. Release of this hormone decreases water excretion by the kidney by
increasing the rate of water re-absorption from the tubules.

Water leaves the body through several channels:

 Skin – as sweat and insensible perspiration
 Lungs – as water vapor in the exhaled air
 Gastro – intestinal tract – as feces
 Kidneys – as urine
The urine is an important medium for the elimination of excess water. Water may also be lost
together with electrolytes through tears, stomach suction, breathing, vomiting, diarrhea, bleeding,
perspiration, drainage from burns, discharges from ulcer, skin diseases, and injured or burned areas.
Recommended Energy and Nutrient Intake (RENI):
Recommended for:
Adults – 1 ml / calorie
Infants – 1.5 ml / calorie
Approximately 1.5 – 2.5 liters or 6 – 10 glasses of water a day. Water intake is derived mostly
from beverages and prepared foods. During hot weather, fever, hemorrhage, excessive sweating,
vomiting, diarrhea, and high protein intake, the allowance for water is increased.
Increased fluid intake is recommended for:
1. Athletes
2. Pregnant mother
3. Lactating mothers

ABNORMALITIES OF WATER BALANCE:

a. Over dehydration or Water Intoxication
When large amount of water is lost in the body, it is usually caused by high environmental
temperatures, sodium is also lost. This phenomenon causes the brain to signal a need for water increase.
If the water intake is increase without the corresponding increase of sodium intake, then water
intoxication will occur.

Causes of Water Intoxication:

 Workers exposed to high environmental temperatures
 Travelers to tropical countries not accustomed to weather condition results to:
1. Muscle cramps
2. Weakness
3. Drop in blood pressure
This condition may be relieved by providing sodium in very small amount with the intake of fluids.
 Too much fluid is taken intravenously. If the intake of water exceeds the maximum rate
of urine flow, the cells and tissues become water-logged and diluted.
Conditions Result to:
1. Anorexia
2. Vomiting
3. If occurs in the brain, may lead to convulsion, coma and even death.

b. Dehydration. A serious condition of water loss about 10% of the total body water and fatal if the
loss is from 20-22%. Critical especially among the babies. Electrolytes are also lost with the
water. In this condition, the skin becomes loose and inelastic and the individual experiences
severe thirst and nausea. Work performance of the individual may seriously be affected.

ELECTROLYTE BALANCE:
When chemical compounds dissociate in solution these break up with separate particles called
ions. They are also known as electrolytes, because these changed particles can conduct electric current.
Examples of electrolytes: (do ionized)
1. Salts
2. Acids
3. Bases
Examples of non – electrolytes: (do not ionized)
1. Glucose
2. Alcohol
3. Urea
4. Protein
5. Other substance involved in metabolism
Each ion may either be positive (+) or negative ( - ).
Positive ions are cation which includes:
1. Sodium (Na+)
2. Potassium (K+)
3. Calcium (Ca++)
4. Magnesium (Mg++)
Negative ions are anions which include:
1. Chloride (CI -)
2. Bicarbonate (HCO3-)
3. Biphosphate (HPO4--)
4. Sulfate (SO4--)4
Ions of organic acids such as lactate, pyruvate, acetoacetate and many protein derivatives.

Important aspects of electrolytes in water balance:

1. Measurement of electrolytes in the body fluids
2. Electrolyte composition of body fluids
3. Electrolyte balance within fluid compartment.

Terms:
 Electrolytes concentration are measured in terms of milliequivalent (mEq.)
 Concentration refers to the number of particles per unit volume
 Extracellular fluid (ECF) is the fluid in the plasma, lymph, spinal fluid and secretions.
 Intracellular fluid (ICF) is the fluid contained within cell.
Electrolyte composition of the body fluids:
A. Major electrolyte found in the plasma and interstitial fluid:
1. Sodium (Na)
2. Chloride (CI)
B. Major electrolyte in the intracellular fluid:
1. Potassium (K)
2. Phosphate (P)
Sodium and potassium can control the amount of water that can be retained in any given compartment.
An alteration in the maintenance of osmotic equilibrium may result in dehydration or even
edema.
Electrolytes play an important role in regulating fluid and ph balance.
For therapeutic purposes, foods that will produce acid-ash, basic-ash, or neutral-ash are
necessary to produce acid or basic urine as needed by the body.
When mineral elements are released from foods after metabolism, these elements function to
maintain acid-base balance, and the organic acids are oxidized to form C02 and water.
TOXICITY
 Acidosis/ Alkalosis – a disturbance in the acid-base balance in the body
 Acidosis – the excessive accumulations of H ions.
 Alkalosis – great loss of hydrochloric acid (HCL).

__________________________________________________________________________________-
__________________________________________________________________
See if you can do this!

Directions: Summarize all the classification of Vitamins and Minerals according to the
Description of each column per rows.
Nutrients: Properties Function Sources RENI Deficiencies Remarks
Vitamins:
Fat Soluble
A
D
E
K
Water Soluble:
C
B1
B2
B3
B5
B6
B12
PGA
BIOTIN
Minerals:
Macro-minerals:
Ca
P
K
Na
Mg
S
CI
Micro –minerals:
Fe
I
Co
Cu
Zn
Mn
Mo
Se
Cr
F

2.Surveillance Food Intake. List down all your Food Intake for the whole week (7days)
following menu guide.
Menu Guide: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Remarks
Breakfast
AM Snacks
Lunch
PM Snacks
Dinner/Supper
BedTime snack
(if taken)

3.Classify according to these 6 basic nutrients of your food intake within a week
(7 days). Put “NONE” if no input in the nutrient intake.
Days: CHO CHON FAT VITAMIN MINERALS WATER/ Remarks
BEVERAGES
Meals/Food Meals/Foods Meals/Food Meals/Food Meals/Food Meals/Food
Intake Intake Intake Intake Intake Intake
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

4.Essay. Discuss briefly by answering the following questions below.

1.What do you think is the most important nutrients needed by the body? and why?.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________________.

2.How can an individual improve their food intake to maximize all the needed nutrients for the
day?.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________.

3.How do you find your food intake based on the food surveillance intake activity for the whole
week?
a.is it adequate or inadequate? Explain briefly for adequate? or;
b.how can you improve your food intake if inadequate?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________.

Godspeed…

______________________________________End_________________________________
Nutrition Tools, Standards and Guidelines Nutrient Recommendations
Lesson 04

Introduction:
The Department of Nutrition for Health and Development, in collaboration with FAO,
continually reviews new research and information from around the world on human nutrient
requirements and recommended nutrient intakes. This is a vast and never-ending task, given the
large number of essential human nutrients.

Many countries rely on WHO and FAO to establish and disseminate this information,
which they adopt as part of their national dietary allowances. Others use it as a base for their
standards. The establishment of human nutrient requirements is the common foundation for all
countries to develop food-based dietary guidelines for their populations.

Establishing requirements means that the public health and clinical significance of intake
levels – both normal, deficiency and excess – and associated disease patterns for each nutrient,
need to be continuously thoroughly reviewed for all age groups. Accordingly, every ten to fifteen
years, enough research is complete and new evidence accumulated to warrant WHO and FAO
undertaking a revision of at least the major nutrient requirements and recommended intakes.

Thus, this will be warrants to pattern, revise and adopt by the other nation for their
populations to achieve a recommended dietary intake and good health for all.

Objectives:
At the end of the lesson, the student can:
1.Determine the standards and guidelines on nutrients recommendations.
2.Discuss the tools in nutrition.
3.Recognize food and nutrition labelling.
_____________________________________________________________________________
Topic Outline:
Nutrition Tools, Standards and Guidelines Nutrient Recommendations:
A. Dietary Reference Intake (DRIs)
1.Estimated Average Requirements (EAR).
2.Recommended Dietary Allowance (RDA-RENI Revised).
3.Adequate Intake (Al).
4.Tolerable Upper Intake Levels (UL).
B.Dietary Guidelines and Food Guides
1.USDA Food Guide (My Pyramid)
2.Tools in the Study of Nutrition
3. Food and Nutrition Labelling
Try this! Look around you.
Directions: Cut out 10 Food Labels with Nutrition Facts.
1.Look for 10 Food labels with nutrition fact.
2.Cut out the nutrition labels and nutrition facts then glue/paste in an Answer key sheet provided.
3. Discuss as one or as a whole of your output.
a.What can you say or explain briefly about your output according to the Nutrition Tools,
Standards and Guidelines Nutrient Recommendations of the whole 10 cuts out nutrient label
products?.
b.Does the Nutrition label and nutrition facts are sufficient in their recommended nutrients labels
in the products. If Yes pls specify. If No why?.
3.Conclusion.
Answer Key Sheet
Name:___________________________________ Score:________
Course/Year:_______________________________ Date:_________

__________________________________________________________________________
Think ahead!
Directions: Search for the following tools of Nutrition. Draw and illustrate in a clear and clean
long bondpaper of the following:
1.Filipino Food Guide:
1.a.Food Pyramid for Adult.
1.b.Activity Guide(Physical activities).
1.c.Plate Model (Pinggang Pinoy).
1.d.Nutritional Guidelines for Filipinos (10 Kumainments-Sigla at Lakas ng Buhay).
2.Your Guide to Good Nutrition.
3. The United States Department of Agriculture (USDA) of Food Pyramid (My pyramid).
2.Make a Reflection paper about the following topics by consolidating as one thought.(50
words).
___________________________________________________________________________

Read & Ponder!

A. Dietary Reference Intake (DRIs):
1.Dietary Reference Intakes (DRIs) is a generic term for a set of nutrient reference values that
includes the Recommended Dietary Allowance (RDA), Adequate Intake (AI), Tolerable Upper
Intake Level (UL), and Estimated Average Requirement (EAR).
2.DRI is the general term for a set of reference values used to plan and assess nutrient intakes of
healthy people. These values, which vary by age and sex, include:
3.Recommended Dietary Allowance (RDA) (RENI-Revised): average daily level of intake
sufficient to meet the nutrient requirements of nearly all (97%-98%) healthy people.
4.Adequate Intake (AI): established when evidence is insufficient to develop an RDA and is set at
a level assumed to ensure nutritional adequacy.
5.Tolerable Upper Intake Level (UL): maximum daily intake unlikely to cause adverse health
effects. (see appendices)
B.Dietary Guidelines and Food Guides.
1.The United States Department of Agriculture (USDA) food pyramid, called MyPyramid to
distinguish it from earlier versions, contains recommendations on diet and exercise based on the
Dietary Guidelines for Americans 2005.

My Pyramid is intended to help Americans become more aware of what they eat and what their
nutrient requirements are. It is designed to help people learn how to eat a healthy diet, live an
active lifestyle, and maintain or gradually move in the direction of a healthy weight that will reduce
the risk of weight-related diseases. It is the most recent in a series of publications designed to
provide Americans with broad dietary recommendations that will promote health.

2.Basic Tools in the Study of Nutrition:

Your Guide To Good Nutrition ( YGGN) — the guide that classifies food according to body
building, energy- giving, and regulating functions. It is a daily food guide w/c suggests the use of
recommended amount and the number of servings in each group to provide the variety of
nutrients needed by the body.
Classification:
1. Body- Building Foods— foods rich in protein and minerals
- also supplies B vitamins and Iron
2. Energy — Giving Foods — foods rich in carbohydrates and fats
3. Regulating Foods — foods rich in vitamins, minerals, and cellulose.
2. Food Composition Table (FCT) — a table of food values computed at 100 grams edible portion.
A handbook that provides a rich source of information on the composition of foods commonly
consumed in the country.
Edible Portion (EP) — is the part of the food that is customarily eaten by the consumer
depending on his cultural/ food habits; Edible Portion is expressed as percent.
The percent edible portion is the proportion of edible matter in the food as collected or
purchased, expressed on the basis of weight.
3. Recommended Energy and Nutrition Intakes (RENI) — the revised edition of the dietary
standard (Recommended Dietary Allowance or RDA) to "emphasize that the standards are in
terms of nutrients, and not foods or diets.
RENI's are defined as levels of intakes of energy and nutrients which, on the basis of current
scientific knowledge, are considered adequate for the maintenance of health and well- being of
nearly all healthy persons in the population.
RENI's are equal to the average physiologic requirement (AR), corrected for incomplete
utilization or dietary nutrient bioavailability, plus two standard deviations (sd), or twice an
assumed coefficient variation (CV) to cover the needs of almost all individuals in the population.
Uses and Applications:
1. Goal for energy and nutrient intakes of groups and nutrient intakes of individuals.
The goal should be based on the individual's body weight since the recommended energy
intake is for a specified reference weight.
2. Reference standard for the assessment of the habitual energy and nutrient intakes
of the population or sub-groups. When used for this purpose, the percentage of individuals
with habitual intakes below the RNI (recommended nutrient intake) should be estimated.
As this percentages increase, so does the likelihood that the group is inadequately provided
for.
3. Reference standard for assessment of the adequacy of food supplies.
4. Tool for nutrition education and adequacy.
5. Basis for public health and food nutrition policies.
e.g. on food fortification, food importation, food and nutrition labeling supplementation
program. (Refer to Appendix — A - RENI TABLE)
4. Food Exchange List (FEL) — a grouping of common food that has practically the same
amount of proteins, carbohydrates, fats and calories.
 One food item can be exchanged with another provided that the specified serving
portion is followed.
Exchange refers to food in any one group that can be substituted or exchange.
 Serving portion indicates the amount of food that can be normally consumed by
one person at one time in one meal.
5. Food Pyramid Guide
 A simple and easy to follow daily eating guide. Food Pyramid Guide a new plan for
ensuring dietary adequacy that offers five (5) categories of foods to choose from. A simple
and easy-to-follow daily eating guide.
6. Nutritional Guidelines for Filipinos
 Primary recommendations to promote good health through proper nutrition. They
seek to foster an adequate and balanced diet as well as desirable food and nutrition
practices and healthy habits suitable for general populations.
 Serve as a handy reference for counseling and education services.
Guidelines:
1. Eat a variety of foods everyday.
2. Breast-feed infants from birth to 4-6 months, and then give appropriate foods
while continuing breast feeding.
3. Maintain children's normal growth through proper diet and monitor their growth
regularly.
4. Consume fish. Lean meat, poultry, and dried beans.
5. Eat more fruits, vegetables, and root crops.
6. Eat foods prepared with edible/cooking oil daily.
7. Consume milk, milk products, or other calcium-rich foods such as small fish and
dark green leafy vegetables everyday.
8. Use iodized salt, but avoid excessive intake of salty foods.
9. Eat clean and safe foods.
10.Exercise regularly, do not smoke, and avoid drinking alcoholic beverages.
10 Nutritional Guidelines for Filipinos: (Revised)
1. Eat a variety of foods every day to get the nutrients needed by the body.
2. Breastfeed infants exclusively from birth up to 6 months then give appropriate
complementary foods while continuing breastfeeding for 2 years and beyond for
optimum growth and development.
3. Eat more vegetables and fruits every day to get the essential vitamins,
minerals, and fiber for regulation of body processes.
4. Consume fish, lean meat, poultry, egg, dried beans, or nuts daily for
growth and report of body tissues,
5. Consume milk, milk products, and other calcium-rich foods - such as
small fish and shellfish - every day for healthy bones and teeth.
6. Consume safe foods and water to prevent diarrhea and other food and
water-borne diseases.
7. Use iodized salt to prevent Iodine Deficiency Disorders,
8. Limit intake of salty, fried, fatty, and sugar-rich foods to prevent
cardiovascular diseases.
9. Attain normal body weight through proper diet and moderate physical activity
to maintain good health and help prevent obesity,
10. Be physically active, make healthy food choices, manage stress, avoid
alcoholic beverages, and do not smoke to help prevent lifestyle-related non-
communicable diseases.

7. The Use of Computers

 Computers are considered as one of the important tools in nutrition education,
dietary analysis, diagnosis procedure and as therapeutic aids.
8. Nutrient Density
 Nutrient Density is a relative measure of nutrient in a food in proportion to its caloric
content.
 A food is considered nutritious when it contains more nutrients other than calories or
considered to have a high nutrient density
INQ or Index Nutrient Quantity = % RDA of Nutrient
%
Energy Requirement
 Food is considered nutritious if INQ of 1 or more for at least 4 nutrients for at
least 2 nutrients.
9. Labeling
 Nutritional labeling has been made mandatory for all processed foods. The ruling
requires that the label have the following format.
 Calories
 Protein
 Carbohydrates
 Fat
 Vitamin C
 Vitamin A
 Thiamine
 Riboflavin
 Niacin
 Calcium
 Iron
 Vitamin B16
 Vitamin B12
 Sodium
 The listing of other nutrients are optional

3.Food and Nutrition Labelling: How to read Food labels:

Consumers gather information about foods they purchase from a wide variety sources.
Family knowledge, education, the media and advertising all convey messages about food
characteristics; the information on those labels about the nutritional content and health benefits of
food is particularly important.
When such information is labelled on a food product it is referred to as a "nutrition label",
"nutrition claim" or "health claim".
Nutrition claims- refer to statements describing the presence, absence, or level of a nutrient.
Heath claims-refer to statements connecting a food, food components or a nutrient to a state of
desired health.
Nutrition facts- a statement or information of food labels indicating the nutrient(s) and the
quantity of the said nutrient found or added in the processed foods or food products.
Nutrition Labelling- a system of describing processed foods or food products on the basis of their
selected nutrient content. Printed in food labels as "Nutrition Facts."
Legal Basis:
The Bureau of Food and Drugs (BFAD) under the Department of Health (DOH) is the
government's major implementor of food labelling regulations as stated in:
 RA 3750-Food, Drugs and Cosmetics Act (amended by EO 175 in1987)
 RA 7394-The Consumer Act of the Philippines;
 BFAD Administrative Order No. 88-B s. 1984-Rules and Regulations Governing
the labelling of Prepackaged food Products.
 RA 8976-Philippine Food Fortification Act of 2000.

Philippine Food Labelling:

Per DOH administrative Order No. 88-B s. 1984 the basic requirements of labelling are the
following:
1. Brandname/Tradename
2. Product Name — the product name should state the true nature of the food
3. Net WeightNolume- the unit should be metric (kg, mg, ml).
4. Ingredients- all ingredients should be declared in decreasing order of proportion
5. Manufacturer/distributor- shall be declared with complete address; street address may be
omitted only if listed phone directory in the preceding year
6. Lot Identification Code/Manufacturing date or Expiry date.
Mislabeling as defined in the Consumer Act of the Philippines. Article 85 of Republic Act No.
7394 states: "A food shall also be deemed mislabelled if it's labelling or advertising is false or
misleading in any way." For example, the use of medical symbol or logos, such as the caduceus,
misleads the consumer by giving an impression that the product is a special dietary food for a
medical purpose and that it contains much needed nutrients to attain the expected effects, such as
convalescence requirement.
Fortified Foods:
RA 8976 — Philippine food fortification act of 2000, covers all imported or locally processed
foods productions for sale or distribution in the Philippines for voluntary food fortification under
the DOH Sangkap Pinoy Seal program, or mandatory food fortification of staple foods. The added
nutrients for fortification shall be in the form of nature identical nutrients.
DOH Administrative Order No. 4-A s. 1995 serve to regulate the use of nutritional claims or
micronutrients-fortified products and to assure that the claims are true and conform with the
standards. The fortification level shall be appropriately presented on the label indicating the
following information:
 Number of servings per container/package
 Serving size by weight or volume (by weight for solid food and volume for liquid food)
 Calories (kcal) per serving
 Nutrients added and their corresponding expressed as %RENI per serving.
For general requirements on nutritional claims that are below the fortification requirements,
the Codex Guidelines on Nutritional Labelling is adapted instead. In the absence of local
regulations, the regulations, the US FDA is adapted, particularly the New Labelling and Education
Act (NLEA) of 1990, or regulations of any other internally recognized Health Agency.
Examples of NLEA Nutrients Content Descriptors used are:
 Free: no amount of or "physiologically inconsequential"
 Fat-free: less than 0.5g/serving

Reading Food Labels:

Food labels are the primary means of communication between the producer or the manufacturer
and the purchases or consumer. Nutrition labelling is a description intended to inform the consumer
of nutritional properties. It consists of two components: nutrient declaration and supplementary
nutrition information:
 Nutrient declaration — standardized statement or listing of the nutrient content of food.
 Nutrition claim — representation which states or implies that a food has some particular
nutritional properties.

The "Nutritional Facts" food labels are intended to give you information about the specific
packaged food. Measurements of fat, cholesterol, sodium, potassium, carbohydrate, proteins,
vitamins and minerals are calculated for a typical portion. This information is intended to make it
easier for you to purchase foods that will fit in your meal plan.
Serving Size- is based on the amount of food people typically eat at a given meal. This may
not be the serving amount you normally eat. It is important to pay attention to the serving size,
including the number of servings in the package and compare it how much you actually eat. Do
not confuse portion size with serving size. The size of the serving on the food package influences
all nutrients amount listed on the top part of the label. For example if the package has 4 servings
and you eat the entire package, you quadruple the calories, fat, etc. that you have eaten.
Calories and Calories from Fat: The number of calories and grams of nutrients are
provided for the stated serving size. This is the part of the food label where you find the amount
of fat per serving.
Nutrients: This section lists the daily amount of each nutrient in the food package. These
daily values are the reference numbers that are set by the government and are based on current
nutrition recommendations.
• Some labels list daily values for both 2,000 and 2,500 calorie diets.
See if you can do this!

Directions: Identify and write the correct answer on the questions below.
_______________________1. This is intended to give information about the specific food
packaged.
_______________________2. A plan that ensure adequate dietary adequacy that is easy to follow.
_______________________3. Is designed to help people eat healthy and live active lifestyle that
reduce weight-related diseases.
_______________________4.It was revised and emphasize that the standards are in terms of
nutrients, and not foods or diets.
_______________________5.It suggests a daily recommended food guide to use an amount and
the number of servings in each group to provide the variety of nutrients needed by the body.
_______________________6. A general term for a set of reference values used to plan and assess
nutrient intakes of healthy people.
_______________________7. A handbook of a table of food values computed at 100 grams
edible portion.
_______________________8. A grouping of common food that has practically the same amount
of proteins, carbohydrates, fats and calories.
_______________________9. The Consumer Act of the Philippines.
_______________________10. A Food, Drugs and Cosmetics Act of the Philippines.

Godspeed…

___________________________________END___________________________________
Nutrition Care Process (ADIME Process)
Lesson 05
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Introduction:

The Nutrition Care Process is a systematic method to providing high-quality nutrition

care. It was published as part of the Nutrition Care Model. The process provides a framework for
the RDN/RND to customize care, taking into account the client's needs and values and using the
best evidence available to make decisions. Other disciplines in healthcare, including nurses,
physical therapists and occupational therapists have adopted care processes specific to their
discipline.

Nutrition Care process involved the ADIME Process Model, such as Assessment,
Diagnosis, Intervention, and Monitoring/Evaluation, is a process used to ensure high quality
nutrition care to patients and clients from nutrition professionals, such as Registered Dietitians
(RD) or Registered Dietitian Nutritionist (RDN). ADIME is used as a means of charting patient
progress and to encourage a universal language amongst nutrition professionals.
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Objectives:

At the end of the lesson, the student can:

1.Discuss the Nutrition Care Process.
2.Recognize the importance of NCP-ADIME Process of ADA Method.
3.Analyze and apply Assessment in Nutrition Care Process-ADIME Process.
4.Design and Plan Anthropometric Measurement of an individual on NCP.
5.Adopt Checklist for Documentation of Nutrition care process.
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Topic Outline:
A.Nutrition Care Process.
B.Nutrition Care Process (ADIME Process- ADA Model).
C.Nutrition Evaluation Approaches.
D.Nutrition Diagnostic Terminology.
E.Checklist for Documentation of Nutrition Care.
F.Nutritional Assessment Form.
Try this!
Directions: Answer all the necessary information needed in the column below. Use your own
profile such as your health, medication used/taken, personal, and diet history.
Type of History & Information: Remarks:
Significant Information
Health History:
a.Current health problem(s)
b.Past health problems
c.Family health history
d.Previous surgeries
Medication History:
a.Prescription Medications
b.Over-the-counter
medications
c.Herbal & Dietary
supplements
Personal History:
a.Age
b.Gender
c.Height
d.Weight
e.Cultural/ethnic identity
f.Occupation
g.Role in family
h.Educational, Motivational,
& Economic state
Diet History:
a.Food intake
b.Eating habits and patterns
c.Lifestyle patterns
2.What can you say or Discuss about your historical and nutrition assessment results. (Reaction
paper).

Answer Key Sheet

Name:___________________________________ Score:________
Course/Year:_______________________________ Date:_________
Think ahead!
Directions: Research on the process of the Nutrition Care using ADIME-ADA Model.
1.Draw in a clean and clear long bond paper the NCP ADIME-ADA Model.

2.Discuss briefly the concept.

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Read & Ponder!

Nutrition care process:

The nutritional care process is defined as the process of planning and meeting the
nutritional needs of a client.

Expected Outcomes of Nutritional Care:

• Improved nutrition status • Prevention/delay of complications
• Improved food and nutrient intake • Positive behavior change
• Improved knowledge • Risk factor reduction
• Ability to identify and access available resources • Improved self -management
• Improved laboratory values, weight, blood pressure • Improved quality of life
• Reduced clinic consultations and hospital admissions
“Historical Information and Nutrition Assessment”:
Type of History & Significant Information What It Identifies

Health History
• Current health problem(s)
Health factors that affect nutrient or nutrition
• Past health problems
education needs or place the client at risk for
• Family health history
poor nutrition status.
• Previous surgeries
• Potential health (problems)

Medication History
• Prescription Medications Medications, alternative therapies, and
• Over-the-counter medications illegal drug use that can affect nutrient
• Herbal & Dietary supplements needs or alter nutrition status.
• Illegal drugs

Personal History
• Age
• Gender Factors that affect nutrient needs, influence
• Cultural/ethnic identity food choices, or limit diet therapy options.
• Occupation
• Role in family
• Educational, Motivational, & Economic state

Diet History Nutrient intake and imbalances, reasons for

• Food intake potential nutrition problems & dietary
• Eating habits and patterns factors important to shaping a nutrition care
• Lifestyle patterns plan.

The Nutrition Care Process: ADIME (ADA Model).

The ADIME process consists of four steps:
1.Nutritional Assessment — needs critical thinking skills to do proper assessment
2. Nutrition Diagnosis — different from medical diagnosis; clustered into 3 domains
 nutrition diagnosis domains (intake, clinical & behavioral, environmental)
there are 62 nutrition diagnoses/problems clustered into the 3 domains but within each
domain are classes and in some
classes, subclasses
problems should be classified then the diagnosis components PES (problem, etiology,
signs & symptoms)
➢writing nutrition diagnostic statements and examples
- will use the ADA Standardized Language for the NCP
3. Nutrition Intervention — objectives are patient centered, achievable, stated in
behavioral terms, quantifiable terms that patient and counselor establish together.
 Four main classes are identified (Foods and/or Nutrition Provision, Nutrition
Education, Nutrition Counseling & Coordination of Care).
4. Nutrition Monitoring and Evaluation — steps include monitoring progress,
measuring outcomes and evaluating outcomes.

Nutrition Care Process: ADIME (ADA Model)

STEP 1. NUTRITION ASSESSMENT:
"Nutrition Assessment" is the first step of the Nutrition Care Process. Its purpose is to
obtain adequate information in order to identify nutrition-related problems. It is initiated by
referral and/or screening of individuals or groups for nutritional risk factors.
Nutrition assessment is a systematic process of obtaining, verifying, and interpreting
data in order to make decisions about the nature and cause of nutrition-related problems.
The specific types of data gathered in the assessment will vary depending on the;
a) practice settings, b) individual/groups' present health status, c) how data are related to
outcomes to be measured, d) recommended practices such as ADA's Evidence Based
Guides for Practice and e) whether it is an initial assessment or a reassessment.
Nutrition assessment requires making comparisons between the information obtained and reliable
standards (ideal goals).
Nutrition assessment is an on-going, dynamic process that involves not only initial data collection,
but also continual reassessment and analysis of patient/client/group needs. Assessment provides
the foundation for the nutrition diagnosis at the next step of the Nutrition Care Process.
Data Sources/Tools for Assessment:
 Referral information and/or interdisciplinary records:
 Patient/client interview (across the lifespan)
 Community-based surveys and focus groups
 Statistical reports; administrative data
 Epidemiological studies
Types of Data Collected:
 Nutritional Adequacy (dietary history/detailed nutrient intake),
 Health Status (anthropometric and biochemical measurements, physical & clinical
conditions, physiological and disease status),
 Functional and Behavioral Status (social and cognitive function, psychological and
emotional factors, quality-of-life measures, change readiness).
Nutrition Assessment Components:
 Review dietary intake for factors that affect health conditions and nutrition risk,
 Evaluate health and disease condition for nutrition-related consequences,
 Evaluate psychosocial, functional, and behavioral factors related to food access, selection,
preparation, physical activity, and understanding of health condition,
 Evaluate patient/client/group's knowledge, readiness to learn, and potential for changing
behaviors,
 Identify standards by which data will be compared,
 Identify possible problem areas for making nutrition diagnoses.
Critical Thinking :
The following types of critical thinking skills are especially needed in the assessment step:
 Observing for nonverbal and verbal cues that can guide and prompt effective interviewing
methods;
 Determining appropriate data to collect;
Selecting assessment tools and procedures (matching the assessment method to the situation);
 Applying assessment tools in valid and reliable ways;
 Distinguishing relevant from irrelevant data;
 Distinguishing important from unimportant data;
 Validating the data;
 Organizing & categorizing the data in a meaningful framework that relates to nutrition problems;
and
 Determining when a problem requires consultation with or referral to another provider.
Documentation of Assessment:
Documentation is an on-going process that supports all of the steps in the Nutrition Care Process.
Quality documentation of the assessment step should be relevant, accurate, and timely. Inclusion of
the following information would further describe quality assessment documentation:
 Date and time of assessment;
 Pertinent data collected and comparison with standards;
 Patient/client/groups' perceptions, values, and motivation related to presenting problems;
 Changes in patient/client/group's level of understanding, food-related behaviors, and other clinical
outcomes for appropriate follow-up; and
 Reason for discharge/discontinuation if appropriate.
Determination for Continuation of Care:
If upon the completion of an initial or reassessment it is determined that the problem cannot be modified
by further nutrition care, discharge or discontinuation from this episode of nutrition care may be
appropriate.

STEP 2. NUTRITION DIAGNOSIS:

"Nutrition Diagnosis" is the second step of the Nutrition Care Process and is the identification and
labeling that describes an actual occurrence, risk of, or potential for developing a nutritional problem that
dietetics professionals are responsible for treating independently.
At the end of the assessment step, data are clustered, analyzed, and synthesized. This will reveal
a nutrition diagnostic category from which to formulate a specific nutrition diagnostic statement. Nutrition
diagnosis should not be confused with medical diagnosis, which can be defined as a disease or pathology
of specific organs or body systems that can be treated or prevented.
 A nutrition diagnosis changes as the patient/client/group's response changes.
 A medical diagnosis does not change as long as the disease or condition exists.
 A patient/client/group may have the medical diagnosis of "Type 2 diabetes mellitus"; however,
after performing a nutrition assessment, dietetics professionals may diagnose, for example,
"undesirable overweight status" or "excessive carbohydrate intake."
 Analyzing assessment data and naming the nutrition diagnosis(es) provide a link to setting realistic
and measurable expected outcomes, selecting appropriate interventions, and tracking progress in
attaining those expected outcomes.
Data Sources/Tools for Monitoring and Evaluation:
■ Patient/client/group records
■ Anthropometric measurements, laboratory tests, questionnaires, surveys
■ Patient/client/group (or guardian) interviews/surveys, pretests, and posttests
 Mail or telephone follow-up:

 ADA's Evidence Based Guides for Practice and other evidence-based

sources
Data collection forms, spreadsheets, and
computer programs

Types of Outcomes Collected:The outcome(s) to be measured should be directly related to the

nutrition diagnosis and the goals established in the intervention plan. Examples include, but
are not limited to:
 Direct nutrition outcomes (knowledge gained, behavior
change, food or nutrient intake changes, improved nutritional
status);
 Clinical and health status outcomes (laboratory values,
weight, blood pressure, risk factor profile changes, signs and
symptoms, clinical status, infections, complications);
 Patient/client-centered outcomes (quality of life, satisfaction,
self-efficacy, self-management, functional ability); and
 Health care utilization and cost outcomes (medication changes,
special procedures, planned/unplanned clinic visits, preventable
hospitalizations, length of hospitalization, prevent or delay nursing
home admission).
Data Sources/Tools for Diagnosis:
■ Organized and clustered assessment data.
■ List(s) of nutrition diagnostic categories and nutrition
diagnostic labels.
Currently the profession does not have a standardized list of nutrition diagnoses.
However ADA has appointed a Standardized Language Work Group to begin development of
standardized language for nutrition diagnoses and intervention. (June 2003).

Nutrition Diagnosis Components (3 distinct parts):

1. Problem (Diagnostic Label):
The nutrition diagnostic statement describes alterations in the patient/client/group's nutritional
status. A diagnostic label (qualifier) is an adjective that describes/qualifies the human response:
such as: Altered, impaired, ineffective, increased/decreased, risk of, acute or chronic.
2. Etiology (Cause/Contributing Risk Factors):
The related factors (etiologies) are those factors contributing to the existence of, or maintenance
of pathophysiological, psychosocial, situational, developmental, cultural, and/or environmental
problems.
Linked to the problem diagnostic label by words "related to" (RT)
■ It is important not only to state the problem, but to also identify the cause
of the problem.
•This helps determine whether or not nutritional intervention will improve the condition or
correct the problem.
•It will also identify who is responsible for addressing the problem. Nutrition problems are either
caused directly by inadequate intake (primary) or as a result of other medical,
genetic, or environmental factors (secondary).
•It is also possible that a nutrition problem can be the cause of another problem. For example,
excessive caloric intake may result in unintended weight gain. Understanding the cascade of
events helps to determine how to prioritize the interventions.
•It is desirable to target interventions at correcting the cause of the problem whenever possible;
however, in some cases treating the signs and symptoms (consequences) of the problem may also
be justified.
The ranking of nutrition diagnoses permits dietetics professionals to arrange the problems in
order of their importance and urgency for the patient/client/group.
3. Signs/Symptoms (Defining Characteristics):
The defining characteristics are a cluster of subjective and objective signs and symptoms
established for each nutrition diagnostic category. The defining characteristics, gathered during
the assessment phase, provide evidence that a nutrition-related problem exists and that the
problem identified belongs in the selected diagnostic category. They also quantify the problem
and describe its severity:
Linked to etiology by words "as evidenced by" (AEB);
The symptoms (subjective data) are changes that the patient/client/group feels and expresses
verbally to dietetics professionals; and
The signs (objective data) are observable changes in the patient/client/group's health status.
Nutrition Diagnostic Statement (PES):
Whenever possible, a nutrition diagnostic statement is written in a PES format that states the
Problem (P), the Etiology (E), and the Signs & Symptoms (S).
However, if the problem is either a risk (potential) or wellness problem, the nutrition diagnostic
statement may have only two elements, Problem (P), and the Etiology (E), since Signs &
Symptoms (S) will not yet be exhibited in the patient.
A well-written Nutrition Diagnostic Statement should be:
1.Clear and concise
2.Specific: patient/client/group-centered
3.Related to one client problem
4.Accurate: relate to one etiology
5.Based on reliable and accurate assessment data
Examples of Nutrition Diagnosis Statements (PES or PE):
Excessive caloric intake (problem) "related to" frequent consumption of large portions of high
fat meals (etiology) "as evidenced by" average daily intake of calories exceeding recommended
amount by 500 kcal and 12-pound weight gain during the past 18 months (signs),
Inappropriate infant feeding practice RT lack of knowledge AEB infant receiving bedtime juice
in a bottle,
Unintended weight loss RT inadequate provision of energy by enteral products AEB 6-pound
weight loss over past month,
Risk of weight gain RT a recent decrease in daily physical activity following sports injury.
Critical Thinking:
The following types of critical thinking skills are especially needed in the
diagnosis step:
 Finding patterns and relationships among the data and possible causes;
 Making inferences ("if this continues to occur, then this is likely to happen");
 Stating the problem clearly and singularly;
 Suspending judgment (be objective and factual);
 Making interdisciplinary connections;
 Ruling in/ruling out specific diagnoses; and
 Prioritizing the relative importance of problems for patient/client/group safety.
Documentation of Diagnosis:
Documentation is an on-going process that supports all of the steps in the Nutrition Care Process.
Quality documentation of the diagnosis step should be relevant, accurate, and timely.
A nutrition diagnosis is the impression of dietetics professionals at a given point in time.
Therefore, as more assessment data become available, the documentation of the diagnosis may
need to be revised and updated.
Inclusion of the following information would further describe quality documentation of this step:
 Date and time; and
 Written statement of nutrition diagnosis.
Determination for Continuation of Care:
Since the diagnosis step primarily involves naming and describing the problem, the determination
for continuation of care seldom occurs at this step. Determination of the continuation of care is
more appropriately made at an earlier or later point in the Nutrition Care Process.
Nutrition diagnosis is the critical link in the nutrition care process between assessment
and intervention. Interventions can then be clearly targeted to address either the etiology or signs
and symptoms of the specific nutrition diagnosis/problem identified. Using a standardized
terminology for identifying the nutrition diagnosis/problem will make one aspect of the critical
thinking that dietetics professionals do visible to other professionals as well as provide a clear
method of communicating among dietetics professionals. Implementation of a standard language
throughout the profession, with tools to assist practitioners, will make this bold initiative a
success. Ongoing input is critical as the standardized language is created to ensure a proper
foundation for its future implementation.

STEP 3.NUTRITION INTERVENTION:

Basic Definition &Purpose:
Is the third step of the Nutrition Care Process. An intervention is a specific set of activities
and associated materials used to address the problem.
Nutrition interventions are purposefully planned actions designed with the intent of changing
a nutrition-related behavior, risk factor, environmental condition, or aspect of health status for
an individual, target group, or the community at large.
This step involves a) selecting, b) planning, and c) implementing appropriate actions to meet
patient/client/groups' nutrition needs.
The selection of nutrition interventions is driven by the nutrition diagnosis and provides the
basis upon which outcomes are measured and evaluated.
Dietetics professionals may actually do the interventions or may include delegating or
coordinating the nutrition care that others provide. All interventions must be based on scientific
principles and rationale and, when available, grounded in a high level of quality research
(evidence-based interventions).
Dietetics professionals work collaboratively with the patient/client/group, family, or
caregiver to create a realistic plan that has a good probability of positively influencing the
diagnosis/problem.
This client-driven process is a key element in the success of this step, distinguishing it
from previous planning steps that may or may not have involved the patient/client/group to
this degree of participation.
Data Sources/Tools for■ Evidence-based nutrition guides for practice and protocols
Interventions ■ Current research literature
 Current consensus guidelines and recommendations from other

professional organizations
 Results of outcome management studies or Continuous Quality

Index projects.
 Current patient education materials at appropriate reading level and

language
 Behavior change theories (self-management training, motivational

interviewing, behavior modification, modeling)

Nutrition InterventionThis step includes two distinct interrelated processes:
Components Plan the nutrition intervention (formulate & determine a plan of action)
 Prioritize the nutrition diagnoses based on severity of problem;

safety; patient/client/group's need; likelihood that nutrition

intervention will impact problem and patient/client/groups'
perception of importance.
 Consult ADA's MNT Evidence-Based Guides for Practice and other

practice guides. These resources can assist dietetics professionals

in identifying science-based ideal goals and selecting appropriate
interventions for MNT. They list appropriate value(s) for control or
improvement of the disease or conditions as defined and supported
in the literature.
 Determine patient-focused expected outcomes for each nutrition
diagnosis. The expected outcomes are the desired change(s) to be
achieved over time as a result of nutrition intervention. They are
based on nutrition diagnosis; for example, increasing or decreasing
laboratory values, decreasing blood pressure, decreasing weight,
increasing use of stanols/sterols, or increasing fiber. Expected
outcomes should be written in observable and measurable terms that
are clear and concise. They should be patient/client/group-centered
and need to be tailored to what is reasonable to the patient's
circumstances and appropriate expectations for treatments and
outcomes.
 Confer with patient/client/group, other caregivers or policies and

program standards throughout planning step.

 Define intervention plan (for example write a nutrition

prescription, provide an education plan or community program,

create policies that influence nutrition programs and standards).
 Select specific intervention strategies that are focused on the

etiology of the problem and that are known to be effective based

on best current knowledge and evidence.
 Define time and frequency of care including intensity, duration,
and follow-up.
 Identify resources and/or referrals needed.

2. implement the nutrition intervention (care is delivered and actions are

carried out)
 Implementation is the action phase of the nutrition care process.

During implementation, dietetics professionals:

Communicate the plan of nutrition care;
- Carry out the plan of nutrition care; and
- Continue data collection and modify the plan of care as needed.
 Other characteristics that define quality implementation include:

- Individualize the interventions to the setting and client;

- Collaborate with other colleagues and health care professionals;
- Follow up and verify that implementation is occurring and needs
are being met; and
- Revise strategies as changes in condition/response occurs.

Critical Thinking Critical thinking is required to determine which intervention

strategies are implemented based on
analysis of the assessment data and nutrition diagnosis. The
following types of critical thinking skills are especially needed in the
intervention step:
1. Setting goals and prioritizing;
 Transferring knowledge from one situation to another;

 Defining the nutrition prescription or basic plan;

 Making interdisciplinary connections;

 Initiating behavioral and other interventions;

 Matching intervention strategies with client needs, diagnoses, and

values;
 Choosing from among alternatives to determine a course of action;

and
 Specifying the time and frequency of care.

Documentation: Documentation is an on-going process that supports all of the steps in the
Nutrition Care Process.
Nutrition Interventions Quality documentation of nutrition interventions should be relevant,
accurate, and timely. It should
also support further intervention or discharge from care. Changes in
patient/client/group's level of understanding and food-related behaviors
must be documented along with changes in clinical or functional
outcomes to assure appropriate care/case management in the future.
Inclusion of the following information would further describe quality
documentation of this step:
 Date and time;
Determination for Continuation of Care:
 Specific treatment goals and expected outcomes;
 Recommended interventions, individualized for patient;
 Any adjustments of plan and justifications;
 Patient receptivity;
 Referrals made and resources used;
 Any other information relevant to providing care and monitoring progress over
time;
 Plans for follow-up and frequency of care; and
 Rationale for discharge if appropriate. If the patient/client/group has met
intervention goals or is not at this time able/ready to make needed changes, the
dietetics professional may include discharging the client from this episode of
care as part of the planned intervention.

STEP 4. NUTRITION MONITORING AND EVALUATION:

Monitoring specifically refers to the review and measurement of the patient/client/group's status
at a scheduled (preplanned) follow-up point with regard to the nutrition diagnosis, intervention
plans/goals, and outcomes, whereas;
Evaluation is the systematic comparison of current findings with previous status, intervention
goals, or a reference standard. Monitoring and evaluation use selected outcome indicators
(markers) that are relevant to the patient/client/group's defined needs, nutrition diagnosis,
nutrition goals, and disease state. Recommended times for follow-up, along with relevant
outcomes to be monitored, can be found in ADA's Evidence Based Guides for Practice and other
evidence-based sources.
The purpose of monitoring and evaluation is to determine the degree to which progress is
being made and goals or desired outcomes of nutrition care are being met. It is more than
just "watching" what is happening, it requires an active commitment to measuring and
recording the appropriate outcome indicators (markers) relevant to the nutrition diagnosis
and intervention strategies. Data from this step are used to create an outcomes management
system. Refer to Outcomes Management System in text.
Progress should be monitored, measured, and evaluated on a planned schedule until
discharge. Short inpatient stays and lack of return for ambulatory visits do not preclude
monitoring, measuring, and evaluation. Innovative methods can be used to contact
patients/clients to monitor progress and outcomes. Patient confidential self-report via
mailings and telephone follow-up are some possibilities. Patients being followed in disease
management programs can also be monitored for changes in nutritional status. Alterations
in outcome indicators:
such as hemoglobin Al C or weight are examples that trigger reactivation of the
nutrition care process.
Data Sources/Tools for Monitoring and Evaluation:
■ Patient/client/group records
■ Anthropometric measurements, laboratory tests, questionnaires, surveys
■ Patient/client/group (or guardian) interviews/surveys, pretests, and posttests
 Mail or telephone follow-up:

 ADA's Evidence Based Guides for Practice and other evidence-based

sources
 Data collection forms, spreadsheets, and
computer programs

Types of Outcomes Collected:The outcome(s) to be measured should be directly related to the

nutrition diagnosis and the goals established in the intervention plan. Examples include, but
are not limited to:
 Direct nutrition outcomes (knowledge gained, behavior

change, food or nutrient intake changes, improved nutritional

status);
 Clinical and health status outcomes (laboratory values, weight,
blood pressure, risk factor profile changes, signs and symptoms,
clinical status, infections, complications);
 Patient/client-centered outcomes (quality of life, satisfaction, self-
efficacy, self-management, functional ability); and
 Health care utilization and cost outcomes (medication changes,
special procedures, planned/unplanned clinic visits, preventable
hospitalizations, length of hospitalization, prevent or delay nursing
home admission).

Nutrition Monitoring and Evaluation Components:

1. Monitor progress:
This step includes three distinct and interrelated processes:
■ Check patient/client/group understanding and compliance with
plan;
 Determine if the intervention is being implemented as prescribed;

 Provide evidence that the plan/intervention strategy is or is not

changing patient/client/group behavior or status;

 Identify other positive or negative outcomes;

 Gather information indicating reasons for lack of progress; and

 Support conclusions with evidence.

2. Measure outcomes:
 Select outcome indicators that are relevant to the nutrition

diagnosis or signs or symptoms, nutrition goals, medical

diagnosis, and outcomes and quality management goals.
 Use standardized indicators to:

- increase the validity and reliability of measurements of change; and

Facilitate electronic charting, coding, and outcomes measurement.
3. Evaluate outcomes:
 Compare current findings with previous status, intervention

goals, and/or reference standards.

Critical Thinking:
The following types of critical thinking skills are especially needed in the
monitoring and evaluation step:
 Selecting appropriate indicators/measures;

 Using appropriate reference standard for comparison;

 Defining where pafient/client/group is now in terms of expected

outcomes;
 Explaining variance from expected outcomes;

 Determining factors that help or hinder progress; and

Deciding between discharge or continuation of
nutrition care.
Documentation of Monitoring and Evaluation:
Documentation is an on-going process that supports all of the steps in the Nutrition
Care Process and is an integral part of monitoring and evaluation activities. Quality
documentation of the monitoring and evaluation step should be relevant, accurate, and
timely. It includes a statement of where the patient is now in terms of expected outcomes.
Standardized documentation enables pooling of data for outcomes measurement and quality
improvement purposes. Quality documentation should also include:
 Date and time;

 Specific indicators measured and results;

 Progress toward goals (incremental small change can be significant

therefore use of a Likert type scale may be more descriptive than a

"mer or "not met" goal evaluation tool);
 Factors facilitating or hampering progress;

 Other positive or negative outcomes; and

 Future plans for nutrition care, monitoring, and follow

up or discharge.
Determination for Continuation of Care:
Based on the findings, the dietetics professional makes a decision to
actively continue care or discharge the patient/client/group from nutrition care (when
necessary and appropriate nutrition care is completed or no further change is expected at this
time). If nutrition care is to be continued, the nutrition care process cycles back as necessary
to assessment, diagnosis, and/or intervention for additional assessment, refinement of the
diagnosis and adjustment and/or reinforcement of the plan. If care does not continue, the
patient may still be monitored for a change in status and reentry to nutrition care at a later date.

The NCP is designed to improve the consistency and quality of

individualized patient/client care and the predictability of patient/client outcomes. It aims to
standardize the process for providing care.
The nutrition diagnosis is the new component of the NCP. The use of standardized nutrition
diagnosis language will consistently describe nutrition problems so they are clear within all
and outside the ND profession and will enhance communication and documentation of
nutrition care. Thus, naming the nutrition diagnosis(es), identifying the etiology, and signs &
symptoms to establish priority in planning the nutrition intervention is very important. Ideally,
a nutrition diagnosis (e.g., excessive CHO intake) will be resolved with nutrition intervention.
Medical diagnosis is a disease or pathology of specific organs or body systems (e. g., Diabetes
mellitus) and does not change as long as the condition exists.

Sample Nutrition Diagnostic Statement:

Metabolic Syndrome:
 PES: Inappropriate intake of types of CHO r/t knowledge deficit as evidenced by triglycerides of 300 mg/dL
 and HDL of 25 mgldL.
 Assessment Data: Food intake records; refined CHO and soft drink intake; dietary fiber. Physical activity
history.
 Intervention: Education about desirable CHO and fiber and benefits of regular exercise.
 Monitoring & Evaluation: Labs in 3-6 mos; reports of physical activity; dietary records.

Sample Nutrition Diagnostic Statement:

Diarrhea:
 PES: Altered GI fxn rit excessive intake of poorly absorbed CHOs AEB frequent intake of apple juice
and sorbitol-containing dietetic products with cramping and loose stools.
 Assessment Data: Food diary, bowel patterns.
 Intervention: Educate about impact of poorly absorbed CHO on bowel function.

 Monitoring & Evaluation: Reports of less abdominal cramping and loose stools.

Sample Nutrition Diagnostic Statement

Constipation:
 PES: Altered GI fxn r/t very low fluid intake and use of
constipating medications AEB pt complaints of hard, dry, infrequent stools.
 Assessment Data (sources of info): Fluid intake records (I & 0),
medication hx and recent changes, stool patterns and frequency.
 Intervention: Counseling about fluid sources & ways to incorporate more fluids into meals &
nourishments, discussion of fluid tracking with staff/family as well as pt, discuss need for stool softener
with M.D. or nursing staff.
 Monitoring & Evaluation: Fluid intake records, stool patterns and frequency records, review of
medication changes or addition of stool softener.
Sample Nutrition Diagnostic Statement
Type 2 Diabetes Mellitus:
 PES: Self-monitoring knowledge deficit r/t lack of under-standing how to record F&B intake AEB
incomplete food records at last two clinic visits and lab of HBA1c=8.5 mg/dL.
 Assessment Data (sources of info): Blood glucose sell-monitoring records, food diary worksheets
and meal records, blood glucose levels (fasting, 2-hr pp and /or HbAlc levels).
 Intervention: Teaching pt & family members about use of simple blood glucose self-monitoring records
(recording of timing, amount, blood glucose levels) and meal records.
 Monitoring & Evaluation: HbAlc levels (goal <7 mg/dL); other glucose labs, food diary and
records; discussion about complications of using the records.
Nutrition Evaluation Approaches:
Assessment by Anthropometry:
Nutritional anthropometry is the measurement of variations in body size, physical
dimensions, and gross composition of the human body at different age levels and degrees
of nutrition. Anthropometric data are most useful when they reflect accurate
measurements and are recorded over a period of time.
Well-recognized and valuable measurement parameters are height, weight, and body
circumferences. Measurements are compared to population standards specific for gender
to evaluate how the body composition compares to norms.
Sample Nutrition Diagnostic Statement:
Infertility:
 PES: Imbalance of nutrients r/t low micronutrient intake (Vit A & C, Mg, & K) AEB consistent omission of
fruits and vegetables in dietary intake records and poor nutritional lab values.
 Assessment Data: Dietary recall, nutrient analysis for vitamins & minerals, laboratory analyses.

 Intervention: Counseling & education about a healthy diet for promoting optimal reproductive health.
 Monitoring & Evaluation: Dietary intake records, increased intake of F&V, improved nutritional lab
rpts.
Weight:
Body weight is a sensitive marker of current nutritional status. In children, it is a
good indicator of satisfactory diet andrecent food intake. Weight provides a crude
evaluation of overall fat and muscle stores. Actual weight reflects a measurement
obtained at the time of examination. Note that actual weight may be influenced by
changes in the person's fluid status .
Obtaining Correct Weight Measurement :
 Use a beam balance (adult or pediatric scale) or a metabolic scale (for bedridden
person); spring-operated scales such as bathroom scale are less reliable.
 Weighing should not be done after a full meal or with full bladder. Weight sho uld
be taken at the same time of the day preferably before breakfast. Minimum clothing
is ideal with no footwear and heavy accessories.
 Allow the subject to stand still in the middle of the scale without touching any
else. For uncooperative children, the m other should carry the child and they are
weighed together; then the mother's weight (alone) is taken. Subtract the mother's
weight from the initial weight (mother and child weight) to determine the child's
weight.
 Weight is read to the nearest 10 grams fo r infants or 100 grams for children and
older.
Classifying Weight Status using Reference Standards :
Weight status of children can he classified by using reference tables. In the past,
weight status is compared to growth standards developed by the Food and Nutrition
Research Institute of the Department of Science and Technology and the Philippine
Pediatric Society (FNRI-PPS, 1992). Recently, the use of the International Reference
Standards (IRS) Growth Tables and Charts (FNRI, 2003) is recommended (Table 2.1 to
2.6). Weight-for-age compares the child to reference data for weight attained at any
given age.

Prior to comparison, the correct age in months (nearest age) o f c h i l d r e n and

adolescents must be determined using this method:

Year - Month Day Sample Data

Date of weighing 2005 06 15 (June 15, 2005)
(Less) Birth date 2001 02 10 (February 10,
4 4 05 2001)

Convert age in months by multiplying by 12.

Add the age in months to the product. Disregard the number of days.
Answer:
Nearest age in
months = 52
months % standard weight = ABW X 100 (4
years x DBW 12
mo/yr = 48 ±
4 mon)
Classifying Weight Status Based on Percentage Standard Weight;
An alternative way of determining the level of weight status is through
calculating the percentage, standard weight by comparing expected weight and the
actual body weight.
Expected weight is the same as the standard weight or d e s i r a b l e b o d y
w e i g h t . Methods of computing the desirable body weight are discussed in detail in
Chapter 6. Table 2.7 is a point of reference in identifying the presence of malnutrition
in children. For teens and adults, use Table 2.8 as guidelines in categorizing weight
status of individual.

Classifying Weight Status Based on Body Mass Index:

The body mass index, also called the Quetelet index, is fradilionally used to
estimate degree of obesity (that is, the amount of total body fat) of i ndi vi dual s .
Toda y, dat a on body mass index can be very useful in deter mining how much risk
people have of developing certain health problems because of t hei r wei ght . Thus , i t
provi des an important indication of a person's overall health
BMI = W
B M I i s c o m p u t e d u s i n g t h e equation given H2
in
the inbox and interpreted using standard weight
w h e r e : W = weight in kilos
status categories.
H = height in meter
Sample Calculation using Body Mass Index
Subject — Gerardo, 5 feet and 9 inches tall (68 inches), weighing 145 pounds
1.Convert weight into kilos by dividing his weight in pounds by 2.2 pounds per kilo:
145 pounds/2.2 pounds per kilo = 65.91 kilos
2. Convert height into meters by multiplying his height in 'inches by 0.0254 meter
per inch:
68 inches X 0.0254 meter/inch = 1.73 meters

3. Find the square of his height:

1.73 meters X 1.73 meters = 2.99 m2
4 Apply the BMi equation. Divide his weight in kg by his height in m2: 65.91
kg/2.99 m2 = 22.04 kg/ m2 (normal BMI).
Interpreting Computed BMI values:
The BMI ranges are based on the relationship between body weight and disease and death.
Overweight and obese persons are at increased risk for health conditions, including Type 2
diabetes, heart disease, hypertension, dyslipidemia (for instance, high levels of triglycerides or
high levels of LDL-cholesterol), stroke, gallbladder disease, osteoarthritis, sleep apnea and
respiratory problems, and some cancers (endometrial, breast, colon). A very low BM! (below 18.5)
is likewise associated with treater risk of health problems and death. Filipinos and other Asians
may follow the Asia Pacific Guidelines. According to the WHO expert consultation (Lancet,
2004). Asians general!), have a higher percentage of body fat than white people of the same age,
sex and BMI. in addition, the proportion of Asian people with risk factors for type 2 diabetes and
cardiovascular disease is substantial even below the existing WHO BMI cut-off points of 25
kg/m2.

Height:
Height suggests linear dimension comprising of legs, pelvis, spine, and skull. It is used as
an indication of past or chronic nutritional status (stunting, i.e., if the child's height or length falls
below the reference values, the child is stunted).

Obtaining Correct Height Measurement

 Use infantometer (for children below 1 year), a stadiometer or non-stretchable tape
measure (for older children and adults).
 For infants: Knees are extended by a firm pressure applied and bare feet are flexed at the
right angles to the lower legs. Head is positioned firmly against the fixed headboard or in
line with "0" point of measuring device.
 In children/adults: Subject should wear no shoes and properly positioned ; feet parallel,
heels, buttocks, shoulder blades and back of the head touching the scale, and head is held
comfortably erect). The client's line of sight should be horizontal. Arms are hanging at
the sides.
 CI Use a thin and stiff headpiece; gently lower the headpiece crushing the hair and
making contact with the top of the head. Headpiece is at a right angle to the wall.

To interpret, it is recommended to use the IRS (FNRI, 2003) to categorize height status of
children, which appear in Table 2.16 to 2.21. Height of elderly and person who is bedfast or
chair bound, or with spinal curvature may be measured using a knee-height caliper.

Knee Height
Knee height is used to estimate stature of patients whose standing height cannot be taken
accurately. It is indicated in an elderly, person with large fat deposit at the back, person unable to
stand alone, or individuals who have curvature of the spine.

Obtaining Correct Knee-height Measurement

 Use a broad-blade caliper to get knee-height measurement. the subject lies on the back
with the knee bent to a 90-degree angle.
 Press the sliding blade of the caliper against the thigh about 2 inches behind the kneecap
and hold the caliper shaft in line with the shaft of the tibia. Two readings should agree
within 0.5 cm.
 Formula for estimating full height using knee height measurement data.
Men: Height (cm) = 64.19 — (0.04 x age in years) + (2.02 x knee height in cm) Women:
Height (cm) = 84.88 — (0.24 x age in years) + (1.83 x knee height in cm)

Waist-to-hip Ratio
Waist-to-hip ratio (WHR) is a valuable indicator of body fat distribution and adiposity. It
allows differentiating between the / profile of adipose tissue in overweight patients of the "apple"
type, the "pear" shape, and the intermediate type. It is also a valuable guide in evaluating health
risk (heart disease, diabetes, etc.). Alternatively, it is called abdominal/gluteal ratio or abdominal
girth measurement.

Obtaining Correct Measurement

Use non-stretchable tape measure (in centimeter). Subject should stand erectly,
abdominal muscles relaxed, arms at the sides, and feet together. The measurer faces the subject
and places the tape measure. Measure waist at the most narrow area below the rib case above the
umbilicus. Measure hip circumference at the widest point around the hips or buttocks with the
subject standing. Read measurement to the nearest 0,1.

Formula for Assessing Body Fat Distribution by WHR

The ratio of waist and hip circumference is calculated using this formula:
WHR = Waist circumference (cm)
Hip circumference (cm)
 A ratio of 1.0 or greater in men or 0.8 or greater in women is indicative of
android obesity ("apple" shape) and an increased risk for obesity -related
diseases. This also appears to be true in children.
 Gynoid, "pear-shaped" people, store more fat in the buttocks, thighs, and hips.
Android, "apple-shaped" people, carry their extra fat around the .
abdomen/upper body. Calculating the ratio of waist to hip is very useful in
determining the metabolic and vascular risk of individuals.
 The waist-to-hip ratio may partially explain the difference in high blood pressure
between men and women. Men are more likely to be "apples" and women to be
"pears," Men have higher rates of hypertension and more complications.
Waist Circumference:
Waist circumference serves as a marker of abdominal fatness. Waist
circumference alone has been considered a valid indicator for both men and women.

Interpretation of Waist Circumference Data:

Women with a waist circumference greater than 35 inches and men with
waist circumference greater than 40 inches have high risk of central obesity-related
health problems.
Body Frame Size:
Determination of body frame allows the weight to be adjusted for height to
refl ect a more suit able desirable wei ght range. Bod y build (muscularity, bone
thickness, and body proportions) affect body weight. Body frame size may be
obtained through one of the methods described here.

Method 1: Based on the Ratio of Height to Wrist Circumference (Grant, 1985)

Obtaining Measurements
 To obtain wrist circumference, the subject's right hand is extended.
 Measure wrist circumference at the joint just distal to the styloid process (bony
protrusion).
 Calculate the ratio of height to wrist circumference with this equation:

Method 2 - Body frame according to wrist size

To determine frame size, wrap the fingers of one hand around the opposite wrist:
• If the thumb and middle finger overlap by 1 cm, the frame size is small.
• If the thumb and middle finger touch, the body frame is medium.
• If the thumb and middle finger cannot reach by 1 cm, body frame is large.

Mid-Upper Arm Circumference (MUAE)

MUAC is used to evaluate fat stores. MUAC measures the size of the arm and all of its
components: muscle mass, subcutaneous fat, and bone. It provides an estimate of the arm soft
tissue or "wasting."
Technique in Measurement:
• Use either non-stretchable tape, an insertion tape, or Shakir tape (3-Colored).
• Have the subject sit with the left arm (if right-handed and vice-versa) hanging freely at
the side.
• Mark the midpoint between the acromion and olecranon.
• Place the tape gently but firmly around the mid-upper arm.
• Measure three times; readings are taken to the nearest centimeters. Average the results of
three (3) measurements.

Interpretation of MUAC Measurements:

For children, use reference table such as the FNRI-PPS Anthropometric Tables and
Charts for Filipino Children (1992) or refer to User's Manual, IRS by the FNRI (2003). Table
2.23 is an alternative reference.

Assessment by Clinical Method:

Clinical assessment of nutritional status deals basically with the examination of changes
that can be seen or felt in superficial tissues such as the skin, hair, and eyes. This method is
usually coupled with medical history taking to identify nutrition-related deficiencies or risks.
Table 2.25 provides a quick reference for recognizing nutrient deficiencies or excess.

Syndromes of Malnutrition:
Malnutrition may result from protein-energy-malnutrition (PEM), micronutrient
deficiency disorders, or chronic diet-related diseases. Protein-energy malnutrition is the most
common form of malnutrition in the world today. It often strikes early in childhood; many adults
are also affected. In children, PEM is characterized by low birth weight (2.5 kg or less), poor
growth (too short, too thin) and high levels of mortality, especially between 12 to 24 months. A
deficiency, of protein and food energy, PEM takes in three different forms, with some cases
exhibiting a combination of two. Table 2.26 illustrates the distinctive features of the three.
A lack of essential vitamins and minerals lead to micronutrient deficiency diseases. On
the other hand, diets high in calories and animal fat but low in fiber, combined with unhealthy
habits and lifestyle, can contribute to a wide range of chronic diseases.

Physical Signs of Dehydration:

Dehydration is the loss of water from the body that occurs when water output exceeds
water input. The symptoms progress rapidly from thirst, to weakness, to exhaustion and delirium
and end in death if not corrected. Other signs are:
• sunken eyes
• hollow cheekbones
• dry mucous membranes
• loss of skin turgor (elasticity)
• weak cry
• depression of the anterior fontanel
• deep, gasping respirations
• weak, rapid pulse
• thirst
• reduced urinary output
• weight loss

Biochemical Assessment of Nutritional Status:

Knowledge of the body's blood chemistry allows a person to begin a health program long
before these concerns reach the clinical or disease state. In medical nutrition therapy,
biochemical evaluation provides information on protein balance, vitamin and mineral status,
fluid status, body composition, organ function, and metabolic status. It also helps determine if
diet intervention is appropriate or if a person is complying with a special diet.
• A variety of tissue samples can be used such as the serum, plasma, urine, feces,
saliva, and other tissues taken through biopsy.
• Results of tests are generally compared to reference values that may be specific
for age and gender.
• Routine and nutrition-related biochemical tests are given in the following
presentation. Reference standards may vary and no single lab test is diagnostic
because many factors influence test results.
•1-he low blood concentration of a nutrient may reflect a primary deficiency of
that nutrient, but may also be secondary to the lack of one or several other
nutrients or to a factor unrelated to nutrition (disease conditions, physiologic state,
or treatment and medications).
• The succeeding data in Tables 2.28 to 2.30 illustrate the various parameters
valuable in assessing nutritional risks and diet-related problems.

Assessment by Dietary Methods:

Dietary evaluation provides a means of generating information on individual's food
habits, food, likes and dislikes, usual food pattern, and type of meals normally eaten over a
relatively long period of time. These data may reflect risk for nutritional deficiency or excess.
Knowledge of dietary intakes is crucial for planning programs for education and intervention.
Diet history, food recall, food frequency checklist, and food diary are some of the examples.
• Diet history — a comprehensive record of eating-related behaviors and food intake.
• 24-hour recall — a record of foods consumed by person in the last 24 hours (see inbox). o
Food frequency — a record of how often the different foods are eaten. The types (and
sometimes the amount) of foods a person routinely consumed in a week or a month can
also be included.
• Calorie court — a determination of a client's food intake. from a direct observation of
how much the person eats.
• Foad record/Food diary — a record of food intake; the client takes down all the foods
eaten over a period of time and this may include records of behaviors and symptoms,
physical activity, and medications.
• MEDFICTS questionnaire — is a rapid dietary fat screening instrument designed for
assessing the major contribution of total dietary fat, including meat, eggs, dairy, fried
foods, fat in baked goods, convenience foods, fat added at the table, and snacks (Peal, et
al., 2007). MEDFICTS has been used to evaluate self-reported dietary change in response
to nutrition education programs (e.g., NCEP Step 1 and Step 2 diets) with coronary heart
rehabilitation patients. It can also be used as an initial dietary fat screener for dietary
assessment, patient education, and behavior modification. This tool produces a score that
corresponds to percent energy from total dietary fat consumption.

Note: See Appendices for formula, computations and Forms.

___________________________________________________________________________

See if you can do this!

Nutrition Care Process.

Direction: Interview at least 1 (One) Client either from your family, friends, love ones, etc.,
with specific illness or disease/s and fill up the Nutrition Assessment Forms for NPC.
1.Apply Nutrition Care Process following the checklist and Nutritional Assessment Forms
*See appendices for the Forms. If no input/data; indicate “NONE/N/A”.
2.Conclusion and Recommendation.
*You may use the previous or past data in terms of Laboratory results.
Answer Key Sheet
Name:______________________________________ Score:________
Course/Year:_______________________________ Date:_________

Godspeed…
___________________________________END___________________________________