Clinical Nutrition B Guide SY 2nd Sem 2022-2023 2

Far Eastern University
Nicanor Reyes Medical Foundation

Institute of Medicine
BIOCHEMISTRY AND NUTRITION
Clinical Nutrition B
Study Guide
2022 Edition
Agustin, Anne Julia H E
2
Clinical Nutrition B
Study Guide
CONTRIBUTORS:
Anna Belen Ignacio-Alensuela, MD

Mari-Ann Benigno-Bringas, MD
May Gabaldon, MD
Donn Jerome L. Sto. Domingo, MD
This material is downloaded for Anne Julia H. Agustin (20200015301)

at FEU Dr. Nicanor Reyes Medical Foundation.
For personal use only. No other uses without permission. All rights reserved. 3
TABLE OF CONTENTS
CHAPTER PAGE
1. Fundamentals of Nutrition 5
2. Diet Planning Using the Food Exchange List 22
3. Nutrition for Metabolic Syndrome 49
4. Nutrition for Adulthood 71
5. Nutrition in Pregnancy 103
6. Nutrition for Critically Ill 133

CHAPTER I
FUNDAMENTALS OF NUTRITION
Mari-Ann Benigno-Bringas, MD, MHM, FPAAB
Nutrition is the science of foods and the nutrients and other substances they
contain, and of their actions within the body (including ingestion, digestion,
absorption, transport, metabolism and excretion). A broader definition includes
the social, economic, cultural, and physiological implications of food and eating.
Foods are products derived from plants or animals that can be taken into the
body to yield energy and nutrients for the maintenance of life and the growth and
repair of tissues.
Diet refers to the foods and beverage a person eats and drinks.
Essential nutrients are nutrients a person must obtain from food because the
body cannot make them for itself in sufficient quantity to meet physiological
needs.
Diet Therapy is the science that deals with the use of foods to help in the
recovery from specific diseases.
Therapeutic diet is a normal diet that is quantitatively and/or qualitatively

modified to help in the recovery of a specific disease.
Nutritional therapy is a system of healing based on the belief that food, as

nature intended, provides the medicine we need to obtain and maintain a state of
health: Let food be your medicine and medicine be your food (Hippocrates).
Although some health problems require specific medication, many conditions can
be relieved effectively with nutritional therapy.
Nutritional therapy is beneficial even with no specific illness, for the maintenance
of optimum health. It is safe for babies and children as well as adults, because
the change of eating patterns that is prescribed has fewer side effects than
synthetic medicines.
Nutritional therapy is a holistic discipline; the key to good health is the all-
embracing fundamental principle in nutrition used since the time of the famous
Greek doctor and founder of western medicine, Hippocrates, to help people of all
ages to stay at their personal peak of energy and vitality. Today, new insights of
food scientists play a significant role in the practice of nutritional therapy as
preventative medicine. The judicious use of foods or their specific constituents
as therapeutic agents is revolutionizing the practice of medicine. The prevention
of nutritional diseases through the application of this knowledge is bringing
benefits to many.
THE DIET PRESCRIPTION
The diet prescription in nutrition serves the same purpose as the drug
prescription in medicine. It designates the type, amount, frequency, and route
and food ingestion just as the drug prescription identifies the drug name, dosage,
frequency and route of administration. The diet prescription contains the daily
caloric requirements based on the individual’s desirable body weight and normal
activity plus the amounts and forms of needed macronutrients and micronutrients
in the form of protein, fat and carbohydrate, minerals, vitamins and other
substances such as fiber and fluids.
DETERMINATION OF NUTRITIONAL STATUS:
1. Obesity - actual body weight is > 20% of IBW

2. Overweight - actual body weight is 10-20% of IBW
3. Normal - actual body weight is +/- 10% of IBW
4. Under nutrition/ underweight - based on Gomez Classification
a. first degree - weight is 75-89% of IBW
b. second degree - weight is 60-74% of IBW
c. third degree - weight is below 60% of IBW
ASSESSMENT OF NUTRITIONAL STATUS
COMPONENTS OF NUTRITIONAL ASSESSMENT:
BACKGROUND HISTORIES: Medical history

Medications history
Social history
Family history
Economic history
NUTRITION PARAMETER: Anthropometric measurement
Biochemical measurement
Clinical assessment
Diet history

BMI-ASSOCIATED DISEASE RISK
CLASSIFICATION BMI (kg/m2) RISK
Underweight <18.5 Increased
Normal 18.5-24.5 Normal
Overweight 25-29.9 Increased
Obese I 30.0-34.9 High
II 35.0-39.9 Very High
III >40 Extremely high
FOOD CHOICES
People decide what to eat, when to eat, and even whether to eat in highly
personal ways, often based on a behavioural or social motives rather than on
awareness of the nutrition’s importance to health. Food choices may depend on
the following factors:
• Personal preference
• Habit and values
• Ethnic Heritage or tradition
• Social interactions
• Availability, convenience and economy
• Positive and negative associations
• Emotional comfort
• Body weight and image
• Nutrition and health benefits
MAJOR NUTRIENTS
CARBOHYDRATES- major source of energy
Functions:
A. provide fuel for energy
B. protein sparer
C. allows normal fat metabolism
D. maintains functional integrity of the CNS
E. precursor of nucleic acid, connective tissue matrix, galactosides
F. facilitates excretion of chemical and bacterial toxins
G. aid in normal elimination of waste material
H. promote growth of coliform bacteria in GIT

Sources of Carbohydrates:
A. Starches - plain cooked rice, cereal grains, legumes, potatoes
B. Root crops - cassava, gabi, potatoes
C. Fruits - dried, fresh , sweetened, canned
D. Sugar or empty calories
RENI FOR Carbohydrates: 55-70% of TCR
FATS - provides high caloric diet with satiety value
Classification:
A. Simple lipids - neutral fats and waxes
B. Compound lipids - phospholipids, glycoplipids, lipoproteins
C. Derived lipids - fatty acids, glycerol, steroids
Dietary Fats:
A. Nature of Food Fats
1. Saturated fatty acids
2. Unsaturated fatty acids
Monounsaturated
Polyunsaturated
Visible fats
Hidden fats
B. Cholesterol - vital substance in human metabolism

- occurs naturally in all animal foods
- increasingly implicated in vascular diseases
Essential Fatty Acids:

A. Linoleic Acid
B. Alpha-linolenic Acid
C. Arachidonic Acid
Omega 3 Fatty Acids: Alpha-linolenic acid

Timnodonic acid (EPA)
Cervonic acid (DHA)
Properties of Omega 3 FA:

• Insoluble in water
• Soluble in solvents of low polarity
• Low melting point
• Liquid at room temperature
• Double bonds are oxidizable
• Saponifiable
• Have cis double bonds
Sources of EPA and DHA: Fish oils

The American Heart association recommends
consumption of two fatty fish meals per week
for a healthy heart.
Functions of Lipids:
A. provide energy
B. serve as shock absorber
C. protection for nerves
D. strengthens membrane structure
E. body insulator
F. protein sparer
G. carrier of vitamins
H. lubricant for GIT
Sources of Fats:
A. dietary lipids from animals (butter, lard, meat, eggs, milk)
B. dietary lipids from plants (vegetable oils)
RENI for Fats: 20-30% of TCR
PROTEIN - most abundant of the organic compounds in the body
Classification:
A. Indispensable Amino Acids
B. Dispensable Amino Acids
C. Conditionally Dispensable Amino Acids
Essential Amino Acids:

A. Essential for adults
Isoleucine Phenylalanine Lysine Methionine
Leucine Threonine Valine Tryptophan
B. Additional amino acids essential for infants

Arginine
Histidine

Functions of proteins:
A. maintenance of growth
B. regulation of body processes
C. source of heat and energy
D. contributes to numerous essential body secretions
E. maintains normal osmotic relations among body fluids
Sources of proteins:
A. Animal sources - meat, poultry, fish, milk, eggs, seafoods
B. Plant sources - wheat, corn, rice , beans, bread, cereals
RENI For Proteins: 10-15% of TCR
RECOMMENDED ENERGY AND NUTRIENT INTAKES (RENI)

Philippines, 2002 Edition
RENI Committee, Task Forces, and the FNRI-DOST Secretariat
Terminology
The revised edition of the dietary standards is changed from "Recommended

Dietary Allowances (RDA)" to Recommended Energy and Nutrient Intakes
(RENI) to emphasize that the standards are in terms of nutrients, and not foods
or diets. RENIs 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. For most nutrients, they 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
of variation (CV), to cover the needs of almost all individuals in the population. In
the case of nutrient for which data on AR are insufficient, the RNI is an "adequate
intake" (AI) which is based on the experimentally observed average intake of
healthy individuals. For energy, the recommended intake level is set at the
estimated average requirement of individuals in a group (no SD), since intakes
consistently above the individual’s r4equirement lead to overweight or obesity.
Uses and Applications:
The RENIs are meant to serve the following purposes and applications:
• Goals for energy and nutrient intakes of groups and nutrient intakes of
individuals. The goal for the energy intake of an individual should be

based on the individual’s body weight since the recommended energy
intake is for a specified reference weight.
• Reference standards for the assessment of the habitual energy and
nutrient intakes of the population or population sub-groups. When used for
this purpose, the percentage of individuals with habitual intakes below the
RENI should be estimated. As this percentage increases, so does the
likelihood that the group is inadequately provided for. The comparison of
intakes with RDA is a statement of risk of inadequacy that is, the chance
that the intake is adequate to meet the actual requirement. It is a
probability statement and is not a measure of severity of inadequacy.
• Goals for agricultural production. Targets should be set at levels higher
than the RENIs to allow for unequal distribution of the food supply.
• Reference standards for assessment of the adequacy of food supplies.
• Basis for public health and food and nutrition policies, e.g., on food
importation, food fortification, food and nutrition labelling, supplementation
programs
• Tool for nutrition education and advocacy.
ENERGY. The recommended energy requirement of an individual is the level of

energy intake from food that will balance energy expenditure when the individual
has a body size and composition, and level of physical activity, consistent with
long-term good health as well as allow for the maintenance of economically
necessary and socially desirable physical activity (FAO/WHO/UNU, 1985).
CALORIC ALLOWANCE. Calories are needed to keep the body warm and to
furnish energy for biological cell work, e.g. mechanical work of muscle
contraction, chemical work of synthesis and osmotic work as in active transport
mechanisms. It is quite possible to estimate roughly the calories required by a
person in health and disease. Appetite is a good checking device provided by
nature, and in most normally active persons it regulates the weight with
surprising accuracy. However, the appetite cannot be trusted nor depended
upon in diseases and in obesity.

The recommended energy intakes at varying level of physical activity are
presented in Table 1.
Body ENERGY
Population
Weight kcal/day (kcal/kg/day)
Group
(kg) Light Moderate Heavy
Male, y
19-29 59 2350 (40) 2490 (42) 2800 (47)
30-49 59 2290 (39) 2420 (41) 2730 (46)
50-64 59 2050 (35) 2170 (37) 2440 (41)
65+ 59 1780 (30) 1890 (32) 2120 (36)
Female, y
19-29 51 1740 (34) 1860 (36) 2100 (41)
30-49 51 1700 (33) 1810 (35) 2050 (40)
50-64 51 1520 (30) 1620 (32) 1830 (36)
65+ 51 1320 (26) 1410 (28) 1590 (31)
MODIFICATIONS OF A NORMAL DIET:
1. Change in caloric content

2. Change in protein content
3. Change in carbohydrate content
4. Change fat content
5. Change in consistency
6. Change in salt content
7. Change in number and frequency of meals
8. Omission of certain foods
INDICATIONS FOR INCREASING THE CALORIC CONTENT OF DIET
1. Growth 4. Marasmus/ Kwashiorkor

2. Pregnancy and Lactation 5. Hyperthyroidism
3. Convalescence 6. Fever/Infection

INCREASING THE CALORIC CONTENT OF A DIET:
The following are ways to increase the caloric content of the diet:
1. Serve jelly and jam along with bread and butter; butter toast when its hot
so more butter can be used.
2. Add sugar to fruit juice or milk; a teaspoon of sugar gives about 16
calories.
3. Serve gravy on meat and potatoes.
4. Serve mayonnaise, oil and salad dressings with sandwiches, salads and
vegetables.
5. Serve bacon, ham or sausage along with egg for breakfast
6. Add ice cream of whipped cream to desserts and milk beverages.
7. Serve cream soups instead of bouillon.
PROTEIN. A safe protein intake level for adults is defined as the lowest level of dietary
protein intake that will balance the losses of nitrogen from the body in persons
maintaining energy balance at modest levels of physical activity (FAO/WHO/UNU,
1985). The recommended intake levels for children are based on the safe level of
protein intakes estimated by the FAO/WHO/UNU (1985) for a reference protein (egg or
milk) adjusted for the protein quality of Filipino rice-based diets of 70% protein
digestibility corrected amino acid score (PDCAAS). These values are very close to
estimates obtained from direct studies on Filipinos consuming usual rice-based diets.
The bed ridden patient who requires more than 10 days hospitalization, patient losing
protein from burns, exudates, ascites, and renal disease, and the patient who is not
forming sufficient protein in hepatic disease will require and increase in protein. Severe
depletion of body protein can lead to prolonged convalescence , poor wound healing, an
increase in complications after surgery, anemia, and increased susceptibility to
infections.
CARBOHYDRATES. Carbohydrates may contribute 55-70% of TDE, 70% of which

should come from complex carbohydrates and not more than 10% should come from
simple sugars. Following IOM-FNB (2002) and FAO/WHO (2002) recommendations, a
daily intake of 20-25 g dietary fiber for adults is also suggested. Carbohydrates is the
major source of energy and if the amount of carbohydrates is insufficient to meet the
energy demand, the organism will utilize fat as the next fuel of priority which could lead
to ketoacidosis. It is also a protein sparer meaning less protein is utilized for energy if
adequate carbohydrate is present to supply the same.

FATS AND FATTY ACIDS. The recommended intake for Filipinos is 20-30% of TDE for
all age groups, except for infants which is 30-40% following the FAO/WHO
recommendation. The lower limit for adults is slightly higher than the minimum of 15%
set by the FAO/WHO (2002) to promote absorption of vitamin A which has been found to
be generally low in the average Filipino diet. The upper limit is the maximum intake level
recommended by most dietary guidelines as a preventive measure against the risk of
cardiovascular and other degenerative diseases.
Fat provides 9 calories for every gram oxidized, more than twice that provided by the
same amount of either carbohydrate or protein which gives only 4 calories. It is
therefore a very good source of energy without bulk. It is also a good protein sparer like
carbohydrates.
DESIRABLE CONTRIBUTION OF CARBOHYDRATES, FATS AND

PROTEIN
Carbohydrates 55-70%
Fats and fatty acids 30-40% for infants
20-30% for all others
Protein 10-15%
WATER AND ELECTROLYTES. The recommended water intake for adults under
average conditions of energy expenditure and environmental exposure is 2500 mL
based on a recommended intake of 1 mL per kcal of energy expenditure (NRC, 1989). It
may be increased to 3735 mL (1.5 mL/kcal) to cover variations in activity level, sweating,
and solute load. Thirst is normally a good indicator of the amount of extra water needed
to meet the daily requirement, except for older persons whose thirst mechanism may be
impaired. For infants, a recommended intake of 1.5 mL/kcal of energy expenditure,
which corresponds to the water-to-energy ratio in human milk, has been established as a
satisfactory level for the growing infant.
Minimum Daily Requirements for Electrolytes

POPULATION WEIGHT SODIUM mg CHLORIDE POTASSIUM
kg mg mg
Birth-5 mo 4.5 120 180 500
6 mo-11 mo 8.9 200 300 700
1 year 11.0 225 350 1000
2-5 years 18.0 300 500 1400
6-9 years 25.0 400 600 1600
10-18 years 50.0 500 750 2000
> 18 years 70.0 500 750 2000

Minimum Daily Requirements for Water
POPULATION GROUP MINIMUM DAILY REQUIREMENT
Infants
Birth -< 6 months 800 mL
6-< 12 months 1000 mL
Children (1-18 y) WT (KG)
10-20 1000 mL + 50 mL/ kg for each kg in
> 20 excess of 10
1500 mL + 20 mL/ kg for each kg in
excess of 20
Adults (> 18 y) 2500mL
Older persons ( > 65 y) 1500 mL
Pregnant women Additional 300 mL
Lactating women 1st 6 months Additional 750-1000 mL

METABOLIC ROLES PLAYED BY VITAMINS AND THEIR DEFICIENCY
MANIFESTATIONS
VITAMINS COENZYME FUNCTION DEFICIENCY
FORM
Thiamine TPP Oxidative Beri-Beri
decarboxylation of
pyruvate to acetyl CoA
Riboflavin FAD, FMN Electron transport Cheilosis,
glossitis,
Stomatitis
Niacin NAD, NADP Electron transport Pellagra
Pyridoxine Pyridoxal PO4 Transamination Microcytic Anemia
Folic Acid FH4 Transport of 1-carbon Megaloblastic
moieties anemia
Biotin Biocytin Transfer of carboxyl
group
Cobalamin Coenzyme Promotes growth and Pernicious anemia
B12 Maturation of RBXC
Ascorbic Hydroxylation; collagen Scurvy
acid synthesis
Vitamin A 11 cis-retinal; Regeneration of Nyctalopia,
retinol rhodopsin for dim vision; xeropthalmia,
maintains integrity of keratomalacia
epithelial tissues;
phototransduction
Vitamin D cholecalciferol Bone remodelling; teeth Rickets
formation
Vitamin E tocopherols Antioxidant; inhibits
peroxidation of
membrane lipids;
neutralizes free radicals
Vitamin K menaquinone Promotes synthesis of Clotting disorders
prothrombin in the liver;
coagulation

HOUSE DIETS
All hospitals and institutions engaged in feeding the sick have specific,
basic routine diets for uniformity and convenience of service. These are called
“House diets” and are based on the foundation of an adequate diet which in turn,
is formulated from the Recommended Energy and Nutrient Intakes (RENI).
These recommendations however apply to normal, healthy individuals and are
not designed to meet the needs of acutely or chronically ill or injured
convalescent patients. Therefore, house diets should be carried a step further to
cover the increased metabolic demands created by illness or stress.
Full Diet or Regular Diet. This is a basic adequate diet of approximately 2,000-
2,500 Kcal and includes the four basic food groups, namely meat, milk, cereals,
breads, fruits and vegetables. Additional foods or more of the same foods such
as butter or fortified margarine, desserts, salad dressings, crackers and sugar
are added to increase calories and make a diet more palatable. There are no
particular food restrictions. However, food which may cause digestive
disturbances, such as cooked cabbage and fried pork are used with discretion.
Liquid Diet (Full liquid diet and Clear or restricted diet). The full liquid diet
contains food that are liquid at room temperature or could be liquified at room
temperature. Examples are milk beverages, ice cream, strained fruit juices,
chocolate, tea, coffee with cream and sugar, clear soups, strained cream soups,
strained cream vegetables soups. It is considered adequate for maintenance
requirements.
The clear or restricted liquid diet is ordered for post-operative patients to furnish
non-gas-forming fluid and nourishment. It is an adequate diet composed chiefly
of water and carbohydrates, therefore, it is used in a very short span of time. It is
served at frequent intervals to supply the tissues with fluid and to relieve thirst.
E.g. Tea, broth, carbonated beverages, strained fruit juices.

Indications: Acute infection, diarrhea, vomiting, fever, oral surgery.
Soft Diet. This is an adequate diet characterized by being moderately low in

cellulose and connective tissue. E.g. fruits and vegetables with low fiber content
and meat with little or no tough connective tissues. Thorough cooking, cutting,
mashing, pureeing, and removal of skin and seeds from fruits and vegetables
and of gristle and elastin of meats increase digestibility. Indications include poor
denture, oral lesions, after oral surgery, fever and mild infections, gastritis,

diarrhea, post-operative patients who cannot tolerate full diet, convalescence and
transition from liquid to full diet.
A soft diet can include many foods if they are mashed, pureed, combined with
sauce or gravy, or cooked in soups, stews, chili, or curries.
In some situations, there are additional restrictions. For example, patients who
need to avoid excessive reflux, such as those recovering from esophageal
surgery for achalasia, are also instructed to stay away from foods that can
aggravate reflux, which include ketchup and other tomato products, citrus fruits,
chocolate, mint, spicy foods, alcohol, and caffeine.
Many of the foods listed here can be adapted for a "full liquid" diet (not a "clear
liquid" diet) by processing in a blender with an appropriate thinning liquid, such
as a vegetable or meat broth, fruit or vegetable juice, or milk.
The soft diet is designed for the patient who cannot tolerate a general diet. The
soft diet is part of the post-surgical progression diet from clear liquid to full liquid,
then advancing to soft solids and finally regular foods. This diet incorporates
foods that are moderately low in fiber, have a soft texture and are moderately
seasons. The diet is individualized to meet the needs of the patient and varies
from smooth, creamy foods to foods that are slightly crispy. Fried foods and spicy
foods may be intolerable for the post surgical patient.
FOOD SELECTION GUIDELINES FOR SOFT DIET

FOOD RECOMMENDED NOT RECOMMENDED
CATEGORY
Beverages Milk and milk products, coffee, Alcoholic beverages.
tea, carbonated beverages,
cocoa, fruit juices, fruit drinks.
Desserts Cakes, cookies, pies, pudding, All sweets and desserts
custard, ice cream, sherbet, containing nuts, coconut, or
and gelatin made with allowed dried fruits, fried pastries
foods: fruit ice and frozen (doughnuts, fritters)
pops.
Fats Butter or fortified margarine; Highly seasoned salad
salad dressings; all fats and dressings.
oils.
Fruits All fruit juices; cooked or Other fresh and dried fruits;
canned fruit; Avocado, fruit Skins
banana, grapefruit and orange
Sections without membrane;
soft fruits Such as melon,
peaches.
Meats and meat All lean, tender meats, poultry, Strong-smelling or highly
substitutes fish and shellfish; crisp bacon; seasoned meats, cheeses, or
eggs; milk-flavored cheeses; fish; yogurt with nuts or dried
creamy peanut butter; tofu; fruit; fried eggs.
plain or flavored yogurt.
Potato and Potatoes (without skin); sweet Potato chips, fried potatoes.
substitutes potatoes (without skin)
enriched rice, barley,
spaghetti, macaroni, and other
pasta.
Soups Soups made with allowed Highly seasoned soups and
foods. soups made with gas-
producing vegetables.
Sweets Sugar, syrup, honey; jelly and Any with nuts or coconut.
seedless jam; hard candies;
plain chocolate candies;
molasses; marshmallows
Breads and White, refined wheat or light Coarse cereals(bran); whole-
Cereals rye breads, soft rolls and grain breads or crackers with
crackers; cooked or ready seeds; biscuits; breads or
to eat cereals. bread products with nuts or
dried fruits; corn chips, potato
chips; pretzels.
Vegetables All vegetable juices; cooked Raw and fried vegetables;
vegetables and lettuce as whole kernel corn; gas
tolerated; salads made producing vegetables
from allowed foods. (broccoli, Brussels sprouts,
cabbage, onions, leeks,
cauliflower, cucumber, gre en
pepper, rutabagas, turnips,
sauerkraut, dried beans and
peas).
Miscellaneous Iodized salt; flavorings; mildly Strongly flavored seasonings
flavoured gravies and sauces; and condiments (garlic, chili
pepper, herbs, spices, catsup, sauce, chili pepper,
mustard, and vinegar in horseradish); pickles;
moderation. popcorn, nuts and coconut.

REFERENCES
1. Food and Nutrition Research Institute, Department of Science and Technology (FNRI-DOST).
2002. Recommended Energy and Nutrient Intakes. Philippines, 2002 Edition.
2. Food and Nutrition Research Institute, Department of Science and Technology (FNRI-DOST).
2001. Philippine Nutrition Facts and Figures. Philippines.
3. Food and Agriculture Organization/World Health Organization (FAO/WHO). Human vitamin

and mineral requirements. Report of a joint FAO/WHO expert consultation. FAO/WHO. 2002
4. Institute of Medicine, Food and Nutrition Board (IOM_FNB). 1997. Dietary Reference Intakes
for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. National Academy of Sciences,
Washington, DC.
for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B 12, Pantothenic Acid, Biotin, and
Choline. National Academy of Sciences, Washington, DC.
for Vitamin C, Vitamin E, Selenium and Carotenoids. National Academy of Sciences, Washington,
DC.
for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese,
Molybdenum, Nickel, Silicon, Vanadium, and Zinc. National Academy of Sciences, Washington,
DC.
for Energy, Carbohydrates, Fiber, Fat, Fatty Acids (Macronutrients).National Academy of
Sciences, Washington, DC.
9. WHO. 1983. Measuring Changes in Nutritional Status, Guidelines for Assessing the Nutritional
Impact of Supplementary Feeding Programmes for Vulnerable Groups. World Health
Organizations, Geneva.
10. Henry, CJ. Basal metabolic rates in humans: Measurement and applications. Working draft
prepared for the FAO/ WHO/UNU Working Group on Energy and Protein in Human Nutrition.
June 27-July5, 2001. (With permission).
11. Food and Agriculture Organization/Word Health Organization/United Nations University

(FAO/WHO/UNU). 1985. Energy and Protein Requirements. Joint FAO/WHO/UNU Expert
Consultation. WHO TRS No. 724. Geneva: FAO.
12. Intengan, CL. 1984. Long-term protein requirements of adult Filipinos consuming local diets.
In: Rand, WM, Uauy, R and Scrimshaw, NS (ed). Protein and Energy Requirement
Studies In Developing Countries: Results of International Research. UNU Food Nutr Bull
Supplement 10
13. Understanding Normal and Clinical Nutrition Seventh Edition. Sharon Rady Rolfes, Kathryn
Pinna, Ellie Whitney 2006 Thomson Wadsworth

CHAPTER 2
DIET PLANNING USING THE FOOD EXCHANGE LIST

Mari-Ann Benigno-Bringas, MD, DPAAB, MHM
DIET PLANNING PRINCIPLES
• Adequacy providing all the essential nutrients, fiber, and

energy in amounts sufficient to maintain health
• Balance providing foods in proportion to each other and in
proportion to the body’s needs
• Energy control management of food energy intake
• Nutrient Density a measure of nutrients a food provides relative to
the energy it provides. The more nutrients and the
fewer calories, the higher the nutrient density
• Moderation providing enough but not too much of a substance
• Variety eating a wide selection of foods within and among
the major food groups
IMPORTANT POINTS TO CONSIDER IN PLANNING

THERAPEUTIC DIETS:
(Source NDAP Manual 2010)
1. Provision of enough calories to maintain desirable body weight

2. Provision for enough protein to address loss of nitrogen during disease
process.
3. Provision for micronutrients to address deficiencies concomitant with
disease.
4. Diet should be a modification of the usual normal diet and must be
psychologically acceptable.
5. Diet must afford rest to the diseased organ.
6. Adjusted to the body’s ability to utilize nutrients.
ENERGY FROM FOODS
The amount of energy a food provides depends on how much

carbohydrate, fat, and protein it contains. When completely metabolized in the
body, a gram of carbohydrate yields about 4 kilocalories of energy; a gram of

protein also yields 4 kilocalories; and a gram of fat yields 9 kilocalories. Fat has
a greater energy density than either carbohydrate or protein. Figure 1 shows the
caloric values of energy nutrients.
Another substance that contributes energy is alcohol. Alcohol is not

considered a nutrient because it interferes with the growth, maintenance, and
repair of the body, but it does yield 7kcal of energy when metabolized in the
body.
Table 1. Kilocalorie Values of Energy Nutrients

Energy Nutrients Kcal (per gram)
Carbohydrates 4 kcal/g
Fat 9 kcal/g
Protein 4 kcal/g
Alcohol 7 kcal/g
HOW TO CALCULATE THE ENERGY AVAILABLE IN FOODS:
To calculate the energy available from a food, multiply the number of

grams of carbohydrate, protein, and fat by 4,4,9, respectively. Then add the
results together.
E.g. 1 slice of bread with 1 tablespoon of peanut butter on it contains

16 grams carbohydrate, 7 grams proteins, and 9 grams fat:
16 g carbohydrate x 4 kcal/g 64 kcal

7 g proteins x 4 kcal/g 28 kcal
9 g fat x 9 kcal/g 81 kcal
TOTAL 173 kcal
The percentage of kcal each of the energy nutrients contributes to the total. To
determine the percentage of kcal from fat, for example, divide 81 fat kcal by the
total 173 kcal.
81 fat kcal / 173 total kcal = 0.468 (rounded to 0.47)
Then multiply by 100 to get the percentage: 0.47 x 100 = 47%
ESTIMATING DAILY ENERGY EXPENDITURES:
TEE – Total Energy Expenditure

TER – Total Energy Requirement The amount of calories needed per day
TCR - Total Caloric Requirement

Three primary factors:
1. Basal metabolic rate Harris-Benedict Equation

BMR
2. Thermic effect of food Rough estimation: TEF = Total calories consumed/day x
0.1
Example: 2000 kcal diet. TEF = 2000 x 0.1 = 200 kcal/day.
TEF of protein >> carbohydrates >> fats.
3. Activities physical activity
Total Caloric Requirement = BMR x Activity Factor x Injury Factor (1.0)
Energy for Basal Metabolic Rate
HARRIS –BENEDICT EQUATION (BMR determination)l metabolic R)
Men = 66+ (13.7 x weight in kg) + ( 5 x height in cm ) - ( 6.8 x age in years )

Women = 655.1 + (9.6 x weight in kg) + (1.8 x height in cm) - (4.7 x age in years)
Harris JA, Benedict FG. A biometric study of human basal metabolism. Proc Natl Acad Sci USA 1918
SHORT METHOD:
Men: 1 kcal/kg/hour x 24 hours
Women: 0.9 kcal/kg/hour x 24 hours
The BMR obtained using the Harris-Benedict equation/Short method may be

used along with the activity level to calculate a rough estimate of the number of
calories needed per day (TEE/TER/TCR).
ACTIVITY FACTOR
LEVEL OF TYPE OF ACTIVITY ACTIVITY TEE
INTENSITY FACTOR (Kcal/Kg/Day)
Very light Seated and standing activities. Painting 1.3 (men) 31
trades, driving, laboratory work, typing, 1.3(women) 30
sewing, ironing, cooking, playing cards,
musical instrument
Light Intensive exercise for at least 20 minutes 1 to 1.6 (men) 38
3 times/ week. Bicycling, jogging, basketball, 1.5 (women) 35
swimming, skating, etc. If you do not
exercise regularly, but you maintain a busy
life style that requires you to walk frequently
for long periods, you meet the requirements
of this level
Moderate Walking 3.5-4mph. Intensive exercise for at 1.7 (men) 41
least 30 to 60 minutes 3 to 4 times per week. 1.6 (women) 37
Any of the activities listed above will qualify
Intensive exercise for at least 3-4x/week
Heavy Intensive exercise for 60 minutes or greater 2.1 (men) 50

5 to 7 days per week Labor-intensive 1.9 (women) 44
occupations include construction work (brick
laying, carpentry, general labor, etc.).
Farming, landscape worker or similar
occupations.
Exceptional Training in professional or world-class 2.4 (men) 58
athletic events 2.2 (women) 51
STRESS FACTORS/ INJURY FACTOR

Starvation 0.8-1.0
Normal/ Non-Stressed 1.0-1.3
S/P surgery without complications 1.25-1.35
Moderate Stress from chronic illness 1.35-1.5
Severe stress( acute illness, severe infection, trauma etc) 1.5
IDEAL BODY WEIGHT: Estimated IBW in (kg)
Males: IBW = 50 kg + 2.3 kg for each inch over 5 feet.

Females: IBW = 45.5 kg + 2.3 kg for each inch over 5 feet.
Eg. 5 feet 1 inch male = 50 + 2.3 kg = 52.3 kgs or 115 lbs
ADJUSTED BODY WEIGHT: Estimated ABW in (kg)
If the ABW is greater than 30% of the calculated IBW, calculate the adjusted
body weight (ABW):
ABW = IBW + 0.25 (actual weight - IBW)
STEPS IN CALCULATING DIETS:
DATA: A Filipino laborer, 36 years of age, 5 feet 1 inch tall (155 cm), actual
body weight is 120 lbs (55 kg) engaged in moderate physical activity.
RENI: Carbohydrates = 60%

Protein = 15 %
Fats = 25 %

DETERMINE ENERGY FOR BASAL METABOLIC RATE
A. Harris-Benedict Equation
Men’s BMR = 66+ (13.7 x W in kg ) + ( 5 x H in cm ) – (6.8 x age in years)
BMR = 66+ (13.7 x 55 kg) + (5 x 155 cm) – (6.8 x 36 y/o)
BMR = 66+ 753.5 + 755 – 244.8
BMR = 1329.7 or 1330 kcal
B. Short Method
Men: 1 kcal/kg/hour x 24 hours BMR = 55 x 24 = 1320 kcal
Total Caloric Requirement = BMR x Activity Factor x Injury Factor (1.0)
TCR = 1330 x 1.7 x 1 = 2261 kcal or 2300 kcal (round to nearest 50)
DETERMINE DISTRIBUTION OF CARBOHYDRATE, PROTEIN

AND FATS:
Percentage distribution: Carbohydrate 55-70% of the TER

Protein 10-15% of the TER
Fats 20-30% of the TER
For a normal diet, allot 60% of TER for CHO, 15% for protein and 25% for fat.
Carbohydrate 2300 x 0.60 1380 kcal  1400 kcal
Protein 2300 x 0.15 345 kcal  350 kcal
Fats 2300 x 0.25 575 kcal  600 kcal
Calculate the number of grams of CHO. CHON and Fat by dividing the
corresponding caloric distributions by the fuel values (4-4-9 rule).
Carbohydrate 1400/4 350 g
Protein 350/4 87.5 g  90 g
Fats 600/9 66.7 g  65 g
For simplicity and practicality of the diet prescription, ROUND OFF:

calories to the nearest 50
carbohydrates, proteins and fats to the nearest 5 grams values
Diet Rx kcal 2300 CHO 350 g (60%) CHON 90 g (15%) Fats65 g(25%)

EST. DAILY PROTEIN REQUIREMENTS (For Diseased patients)
Condition Estimated daily Protein
Requirement (g/kg)
Normal/ Non-stressed 0.8-1.0
Oncology/ stressed/ surgical 1-1.5
Severe stress/burns/multiple trauma 1.5 – 2.5 g/Kg 1.5-2.5
Bone marrow transplant 2 g/Kg* 2
Renal failure (no dialysis) 0.6 – 0.8 g/Kg 0.6-0.8
Renal failure (w dialysis) 1.2 – 1.5 g/Kg** 1.2-1.5
Hepatic encephalopathy 0.4 g/Kg
* unless in renal failure ** depends on BUN
DATA: A Filipino laborer, 36 years of age, 5 feet 1 inch tall (155 cm), actual
body weight is 120 lbs (55 kgs), MODERATE physical activity,.
TER = BMR x Activity factor = 1330 x 1.7 = 2261 or 2300 kcal
In computing for Macronutrient composition in disease states:

1. Compute for Protein requirement first.
1.0 g/kg x 55 = 55 grams 55 grams x4 = 220 kcal for proteins
2. Subtract the protein requirement from the TCR then compute for non-
protein requirements (CARBO AND FATS)
Energy from Non-protein= TER- Kcal from protein
Energy from Non-protein = 2300- 220 = 2080 kcal
If 70% from Carbohydrate and 30% from Fats:

2080 x .70 = 1456 kcal from CHO = 364 grams Carbohydrate
2080 x .30 = 642 kcal from Fats = 69 grams Fats
Diet RX: Kcal 2300 CHO 364 g(63%) CHON 55 g(10%) Fats 69 g (28%)

FOOD EXCHANGE LIST
LIST FOOD MEASURE CHO CHON Fat Energy
gram gram gram Kcal
IA Vegetable A cup, raw
½ cup, cooked
IB Vegetable B ½ cup, cooked 3 1 16
½ cup, raw
II Fruit Varies 10 40
III Milk Evaporated ½ cup 12 8 10 170
Whole 1 cup 12 8 10 170
Powdered 4 tbsp 12 8 10 170
Skim 4 tbsp 12 8 5 125
Very low fat 12 8 trace 80
IV Rice A varies 23 0 98
Rice B 23 2 100
Rice C 23 4 108
V Meat Low fat varies 8 1 50
Med fat varies 8 6 95
High fat varies 8 10 122
VI Fat 1 tsp 5 45
VII Sugar 1 tsp 5 20
Sample Calculations
Diet prescription: 350 g 90g 65g 2300 kcal

FOOD LIST Number of CHO CHON Fat Energy
exchanges gram gram gram Kcal
Vegetable A 1
Vegetable B 5 15 5 80
Fruit 3 30(10) 120(40)
Milk 2 24(12) 16 (8) 20 (10) 340 (170)
Sugar 5 25 (5) 100 (20)
Partial sum 94
[350 – 94] /23 = 11 exchanges rice
[prescribed CHO - partial sum CHO] / 23 exchanges = Rice exchanges
Rice 11 253 (23) 22 (2) 1100 (100)

Partial sum 43
[90 – 43] /8 = 6 exchanges meat
[prescribed CHON - partial sum CHON] / 8 exchanges = Meat exchanges
Meat 6 48 (8) 42 (7) 570 (95)
Partial sum 62
[65 – 62] /5 = 1 exchanges fat
[prescribed fat - partial sum fat] / 5 exchanges = Fat exchanges
1 5 (5) 45 (45)
TOTAL 347 91 67 2355

DIVIDING A DAY’S EXCHANGES BETWEEN MEALS AND SNACKS
Exchange group Number of Breakfast Lunch PM Dinner

exchanges Snack
Veg A 1 1
Veg B 5 2 3
Fruit 3 1 1 1
Milk 2 1 1
Sugar 5 1 2 1 1
Rice 11 3 3 2 3
Meat 6 2 2 2
Fat 1 1
TRANSLATING A DAY’S EXCHANGES INTO A DAY’S MEAL
BREAKFAST Fruit 1 1 slice papaya

Milk 1 1 glass fresh cow’s milk
Sugar 1 2 teaspoons jelly preserves
Rice 3 6 pieces Pan de Sal
Meat 2 2 slices of cheese/3 tbsps corned beef
LUNCH Veg A 1 ½ cup talong
Veg B 2 1 cup kalabasa
Fruit 1 1 medium slice mango
Sugar 2 4 pcs. Chocolate candy with milk
Rice 3 1 ½ cup rice
Meat 2 2 medium size chicken wings
Fat 1 1 cup coconut milk (for ginataang gulay)
PM SNACK Rice 2 2 pcs palitaw
Milk 1 1 glass powdered milk
Sugar 1 1 tsp sugar
DINNER VegB 3 1 cup boiled okra
Fruit 1 3 segments pomelo
Sugar 1 1 pc yema
Rice 3 1 ½ cup rice
Meat 2 1 pc pork pata

The Food Exchange List
The Food Exchange List is a tool used by medical care specialists and dieticians
in meal planning both for healthy patients and most specially for diet therapy.
The foods have been divided into six groups or lists called Exchanges.
The listed measures of each food constituting an exchange within each group
contain approximately the same amounts of energy, carbohydrate, protein and
fat. They also contain similar amounts of vitamins and minerals.
Food in any one group can therefore be substituted or exchanged with

other foods in the same group. Most foods are measured after they are
cooked.
NUTRIENT COMPOSITION OF FOOD EXCHANGES

gram gram gram Kcal
IA Vegetable A cup, raw
½ cup, cooked
IB Vegetable B ½ cup, cooked 3 1 16
½ cup, raw
II Fruit Varies 10 40
III Milk Evaporated ½ cup 12 8 10 170
Whole 1 cup 12 8 10 170
Powdered 4 tbsp 12 8 10 170
Skim 4 tbsp 12 8 5 125
Very low fat 12 8 trace 80
Rice B 23 2 100
Rice C 23 4 108
V Meat Low fat varies 8 1 50
Med fat varies 8 6 95
High fat varies 8 10 122
VI Fat 1 tsp 5 45
VII Sugar 1 tsp 5 20

LIST COMPOSITION
I. Vegetable Green leafy and non-leafy vegetables. Two exchanges of
vegetable A is equal to one exchange of vegetable B
II. Fruit Exchanges Fresh fruits, canned, dried, and fruit juices specified as
concentrated or diluted and sweetened or unsweetened
III. Milk Exchanges Varieties of milk appear in the milk exchanges. Milk is
classified into whole and non-fat types specified as
concentrated or diluted. The nutrient value of ½ glass
evaporated milk as whole milk is given as well as the
equivalent of other types of milk.
IV. Rice Exchanges Varieties of bread, bakery products, rice and corn
products are included in the list. Considering patients who
are on low fat diet, bakery products with high fat content
are to be restricted or should be considered in the fat
exchange.
V. Meat Exchanges 3 categories based on the amounts of fat: low, medium,
and high fat meat. The low fat meat exchange contains 8
g protein and 2 g fat per 30 grams. The medium fat meat
contains 8 g protein and 7 g fat. High fat meat contains 8
g protein and 10 g fat. Each category differs by almost 35
kcal.
VI. Fat Exchanges Classifies fats as saturated or polyunsaturated fatty acids
VII. Sugar Soft drinks, fruit concentrates and alcohols are included to
Exchanges provide additional information and to aid in the dietary
computation.

Food Exchange List
LIST 1 - VEGETABLE EXCHANGES

gram gram gram Kcal kjoule
IA Vegetable cup, raw (25 g)
A ½ cup, cooked (45 g)
IB Vegetable ½ cup, cooked (45 3 1 16 67

B g)
½ cup, raw (40g)
Group A Vegetables (Group A contains negligible carbohydrates, protein and energy

if only one exchange or less is used.)
Alagaw, dahon (fragrant premona leaves) Letsugas (lettuce)
Alugbati, dahon (Malabar night shade Malunggay, dahoh (horseradish leaves)
leaves) Mustasa (Mustard)
Ampalaya, dahon at bunga (bittermelon) Pako (fern)
Bawang, dahon ( garlic) Papaya, hilaw
Kalabasa, bulaklak at dahon (squash Patola (sponge gourd)
Kamatis (tomatoes) Pepino (cucumber)
Kamote, dahon (sweet potato leaves) Petsay (Chinese cabbage)
Kamoteng kahoy, dahon (cassava leaves) Repolyo (cabbage)
Kangkong (swamp cabbage) Saluyot (jute)
Katuray, bulaklak at dahon (sesban flowers Sili, dahon at bunga (pepper)
and leaves) Sitaw, dahon (yard-long bean)
Cauliflower Sayote,dahon/bunga (chayote)
Himbabao Talinum (Phil spinach)
Ispinaka (New Zealand spinach) Talong (eggplant)
Labanos (radish) Unsoy (Coriander)
Kintsay (celery) Upo (bottle gourd)
Gabi, dahon
Labong (bamboo shoots)
Group B Vegetables
Abitswelas, bunga (snap green beans pod) Okra
Bataw (hyacinth bean) Paayap (cowpea)
Remolatsa (beets)
Kabuti (mushroom) Rimas (breadfruit)
Kadyos, sariwa (pigeon pea pod) Saging, puso (banana heart)
Kalabasa, bunga (squash fruit) Sibuyas (onion)
Singkamas, bunga (Yam bean)
Kamansi, bunga Sitaw, bunga (stringbeans, rod)
Karot (carrot) Sitsaro (sweet pea)
Gamet (seaweed) Togue (mung bean srpout)
Langka, hilaw (jackfruit, unripe)
Malunggay, bunga (horseradish, fruit)
Niyog, ubod (coconut shoot)

Vegetable Products: wt (gram)/edible portion Measure
Kamatis, katas, nakalata 60 ½ cup undiluted
(tomato juice, canned)
Kamatis, ketsup (tomato catsup) 10 2 teaspoons
Tomato chili sauce 10 2 teaspoons
Grean peas canned 15 1 tablespoon
Mustard leaves, pickled 130 1 cup
Mustard leaves, salted 100 10 leaves
Papaya, atsara (pickled) 10 1 tablespoon
LIST 2 – FRUIT EXCHANGES: 1 exchange = 10 g carbohydrates =40

kcal
Fruits may be used fresh, dried, canned, frozen or cooked.
FOOD wt (gram)/EP Measure
Fresh:A. High Vitamin C
Anonas 30 ½ small – 5 cm diameter
Atis (sugar apple) 40 ½ small - 5x4 cm
Bayabas (guava) 50 2 medium - 4 cm diameter
Kamatsili 50 7 pods
Kasuy (cashew) 70 1 large - 7 x 6 ½ cm
Dalanghita (ladu) 135 2 medium - 6 cm diameter
Datiles (Jamaica cherry) 45 2/3 cup
Guyabano (soursop) 60 ½ of 8 x 6 x 2 cm
Strawberry 140 1 cup
Mango, green 65 1 medium slice - 11 x 7 cm
Mango, ripe 60 1 medium slice - 11 x 6 cm
Papaya, hinog 85 1 slice - 10 x 6 x 2 cm
Suha
Suha (Pomelo) 90 3 segments - 8 x 4 x3 cm
Tiessa 25 1.4 medium - 10 cm long
B. Other Fresh Fruits
Balimbing (carambola) 130 1 ½ large - 9 x 5 cm
Kaimito ( star apple) 60 ½ medium - 6 cm diameter
Kamyas (balimbi) 220 15 medium - 6 x 2 cm
Duhat (balck plum) 60 24 small pieces
Duryan 30 1/8 of 22 x 15 cm
Langka (Jackfruit, ripe) 40 2 segments - 8 cm
Lansones 70 7 medium – 4 x 2 cm
Lychees 50 4 pcs
Mabolo 50 ½ small - 6 cm diameter
Makopa 130 6 small - 4 cm diameter
Mango, medium, ripe 60 1 medium slice - 11 x 6 cm
Mango, Indian 80 1 small
Mangga, paho 60 8 small
Mangosteen 55 3 medium - 6 cm diameter
Mansanas (apple) 65 1 small - 6 cm diameter
Marang 35 ½ medium 12 x 10 cm
Melon 175 1 slice - 23 x 6 cm

Pakwan (watermelon) 140 1 slice - 11 x 6 cm
Peras ( pears) 80 1 medium - 6 cm diameter
Pinya (pineapple) 75 1 slice - 10 x 6 x 2 cm
Rambutan 50 3 pcs
Saging, Banana, bungulan 40 ½ of 1 medium - 15 x 4 cm
Saging, Banana, lakatan 35 1 small - 10 x 3 cm
Saging latundan 40 1 small - 10 x 4 cm
Saging, saba 40 1 small - 10 x 4 cm
Sampaloc, hinog (tamarind) 15 2 medium 7 segments
Santol 70 1 medium 7 cm diameter
Siniguwelas ( Spanish plum) 50 5 small - 4 cm diameter
Tsiko (sapodilla) 40 1 small - 4 cm diameter
Ubas (grapes) 50 12 pcs.
Canned, drained:
Apple sauce 45 3 tablespoons
Fruit cocktail 55 ¼ cup
Fruit cocktail, tropical 40 3 tablespoons
Peaches 65 1 medium
Pineapple, crushed 60 3 tablespoons
Pineapple, sliced 35 1 slice - 7 cm diameter
Dried
Banana chips, salted 20 4 pcs - 6 c 3 ½ cm
Champoy 10 2 pcs - 2 cm diamter
Dates 15 3 pcs
Likyam (preserved fruit) 15 2 pcs
Mangga, chips 10 2 pcs - 2 x 8 cm
Pasas (raisins seedless) 15 2 tablespoons
Prunes 15 3 pcs
Fresh Juices
Kalamansi 120 ½ cup, undiluted
Dayap (lime) 160 ¾ cup
Canned
Apple juice, sweetened 60 ¼ cup
Mango juice, sweetened 5 6 tablespoons
Orange juice, unsweetened 100 7 tablespoons
Pineapple juice, unsweetened 60 ¼ cup
Pineapple-grapefruit, sweetened 75 5 tablespoons
Pineapple-orange, sweetened 85 6 tablespoons
Pine-pomelo, sweetened 75 5 tablespoons
Prune juice, unsweetened 60 ¼ cup
Others
Buko, meat (young coconut) 100 ½ cup
Buko water 180 1 cup
Sherbet 40 3 tablespoons

LIST 3 - MILK EXCHANGES:
LIST MEASURE CHO CHON Fat Energy
FOOD gram gram gram Kcal/ kjoule
III Milk Whole milk 1 cup 12 8 10 170 711
Powdered 4 tbsp 12 8 10 170 711
Low fat/Skim 4 tbsp 12 8 5 125 522
Very low fat 12 8 trace 80 344

Whole Milk
Milk, evaporated, undiluted 120 ½ glass
Milk, evaporated, filled undiluted 140 ½ glass
Milk, evaporated, recombined, 155 ½ glass
Undiluted
Milk, fresh carabao’s 240 1 glass
Milk, fresh cow’s 240 1 glass
Milk, powdered 30 4 level teaspoons
Non-fat milk
Buttermilk 195 ¾ glass
Powdered 30 4 level tablespoons
Yoghurt 125 ½ cup
LIST 4 - RICE EXCHANGES:

1 exchange = ½ cup rice or 1 rice equivalent
gram gram gram Kcal
Rice B 23 2 100
Rice C 23 4 108
Rice and Rice products
1. Rice, cooked 80 ½ cup, packed
2. Lugaw (rice gruel) 180 1 cup
3. Rice products
Ampaw, bigas 25 1 pc - 8x5x4 cm
Ampaw, pinipig 25 1 pc. - 15x6 cm
Bibingka, galapong 45 1 slice -¼ of 15 cm diameter
Bibingka, malagkit 40 ½ slice – 6x5x3 cm
Biko 40 ¾ of a slice 10x5x1 cm
Butse,Kamote 45 1 pc. - 7x1 cm
Butse, monggo 50 1 pc - 7x1 cm
Kalamay, malagkit at latik 50 1 pc - 4x6x2 cm
Kalamay, ube 55 1 pc - 4x6x2 cm
Karyoka 40 3 pc. - 4 cm diameter
Kutsinta 60 3 pc. - 4 cm diameter
Espasol 35 3 pc. - 4 cm diameter

Palitaw 55 1 pc - 12x7x1 cm
Puto bumbong 40 2 pcs - 11x2x1 cm
Puto, pula 45 3 pcs - 4x3 cm
Puto, puti 45 1/3 of a slice 9x8 cm
Puto seko, bilog 25 6 pcs – 4x5 cm
Puto seko, haba 25 5 pcs - 5 cm long
Sapin-sapin 75 1 slice - 5x3x4 cm
Suman sa ibos 60 ½ of 13x3 cm
Suman sa lihiya 55 1 pc - 9x3 cm
Suman marweko 50 2 pc - 9x3x2 cm
Tamales 100 2 pcs - 7x6 cm
Tikoy 40 1 slice - ¼ of 12 cm
Tupig 35 ½ pc - 14x3x1 cm
Rice equivalents:
1. Bread
Pan amerikano 40 2 pcs - 9x8x1 cm
Pan be bonete 40 1 pc- 6 cm diam base X7 cm
thick
Pan de coco 40 1 pc - 7x6 cm
Pan de leche 40 1 pc - 3x8x8 cm
Pan de limon 40 1 pc - 6x5x4 cm
Pan de monay 40 ¾ pc - 10x9x4 cm
Pan de sal 40 2 pcs - 7x4 cm
Rolls 40 ¾ pc - 11x4x3 Cm
1. Bakery Products
a. Cakes
Cake, chocolate 40 1 slice - 3x2x2 cm
Cake, fruit 45 1 slice - 4x2x2 cm
Cake, hot 55 1 pc - 10 cm diameter
Cake, sponge 40 1 slice - 5x5x5 cm
Cinnamon rolls 40 1 pc - 9x6 cm
Mamon, tostado 30 2 pcs - 6x3 cm
Piyanono 35 1 slice - 5x4 cm
b. Biscuits
Apa (wafer) 35 7 pcs - 5 cm square
Apas (Lucena biscuits) 25 6 pcs - 1 ½ x 12 cm
Biskotso 30 2 pcs - 8x7x1 ½ cm
Biskwuit, gem 30 15 pcs
Biskwuit, jacobina 30 3 pcs
Bitso-bitso 40 ¾ pc - 13x5 cm
Kababayan 35 1 pc - 6x2 cm
Kamatsili, tinapay 35 6 pc - 6x2 cm
Krakers, maalat 30 8 pcs - 5x4x1/2 cm
Galyetas, patatas 30 8 pcs - 5x4x1/2 cm
Gurgurya 35 23 pcs - 4x1 cm
Ogoy-ogoy 30 6 pcs - 5x3x1 cm
Pilipit 30 1 pc - 10-3cm
Pretzels 30 10 pcs

b. Cookies
Brohas (lady finger) 30 5 pcs - 9x4 cm
Cookies, assorted 30 8 pcs - 4 1/2x ½ cm
Cookies, butter 35 7 pcs - 6x2 cm
Cookies with nuts 35 ½ pc - 9x3 cm
Doughnuts 45 ½ pc - 9x3 cm
Ensaymada 35 ½ pc - 11x8 cm
Masapudrida 25 1 pc - 7x1 cm
Pasensiya 25 6 pcs -3 cm diameter
b. Bakery Products with Fillings
Cream puff 45 2 pcs - 6 cm diameter
Empanada 55 1 pc - 7x11x2 cm
Hopia, baboy 35 1 pc - 5x3x2 cm
Hopia hapon 35 1 pc - 5 cm diameter
Hopia, munggo 35 1 pc - 5 cm diameter
Corn and Corn Products
Binatog 90 ½ cup
Chiz curls 25 1 ¼ cup
Corn flakes 25 1 cup
Mais, nilaga 65 1- 12x4 cm
Mais, dilaw, nakalata 145 1 cup
Maha, mais 85 1 slice -5x4x2 cm
Popcorn, maalat 35 2 cups
Popcorn, matamis 30 2 cups
Noodles, cooked
Bihon, canton, macaroni, mami 100 1 cup
Miswa, sotanghon, spaghetti
Rootcrops and products
Kamote (sweet potato) 80 1 pc - 8 ½ x 5 cm
Kamote (kahoy) cassava 85 1 pc - 9x5 ½ cm
Gabi (taro) 85 1 pc - 9x5 ½ cm
Patatas 165 1 ½ pc
Suman - kamoteng kahoy 45 ½ pc - 15x3x2 cm
Tugi 135 2 pcs - 11x3 cm
Ubi (yam) 130 1 ¼ cups subbed
Others
Cornstarch 5 1 tsp
Flour, all purpose 30 3 tbsp
Ice cream, 12 % fat 120 ½ cup
Oatmeal, raw 30 3 tbsp

LIST 5 - MEAT EXCHANGES:
LIST MEASURE CHO CHON Fat Energy
FOOD gram gram gram Kcal kjoule
V Low fat varies 8 2 50 209
Meat Med fat varies 8 7 95 398
High fat varies 8 10 122 510
LOW FAT MEAT EXCHANGES
Pork Internal organs:
Atay(liver) 35 1 slice - 4 ½ x 3x1 cm
Bahay guya(uterus), small 40 ¾ cup
Intestines, dugo, lapay (spleen)
Puso (heart) 40 ¾ cup
Beef
Bias (shank), Laman(lean meat) 35 1 pc - 3 cm cube
Paypay (chuck), pierna corta at
Pierna larga (round),
solomilyo (tenderloin),
tagiliran gitna (porterhouse steak),
tagiliran hulihan (sirloin steak),
tagiliran unahan (centerloin)
Beef internl organs:
Atay (liver), uterus, small intestines, 40 ¾ cup
Dugo, spleen, librilyo (omassum)
Heart
Carabao
Bias(shank), Hita(round), 35 1 pc - 3 cm cube
Laman bahagyang taba(meat, thin
fat),
Laman katamtaming taba (meat,
medium fat),
laman, walang taba (lean meat)
Paypay (shoulder), pierna corta at
pierna larga
Paypay (shoulder), pierna corta at
pierna larga round), tapadera
(rump)
Internal organs: 40 ¾ cup
Atay, baga,dugo, lapay,
librilyo,Puso
Chicken
Hita (leg), Laman (meat), Paa (feet) 20 ½ small leg or 4 pc feet Or 3 cm
Pitso (breast meat) cube meat or ½ breast
Internal organs: 30 1 ½ pc liver or 2 pcs gizzard,
Atay, balunbalunan (gizzard) Dugo Or ½ cup blood
Fish
Large variety 35 1 slice - 7x3x2 cm
Medium variety 30 1 pc
Small variety 35 2-3 pcs

Other Seafooods
Alamang 30 1 ¼ tbsp
Alimango, aligue (crab fat) 15 1 tbsp
Alimango, laman (crab meat) 45 ½ cup flaked or medium
Kuhol (snail) 50 ½ cup shelled
Hipong puti 70 ½ cup
Halaan (clam) 75 1/3 cup shelled or 3 cups With
shell
Hipon, swahe 45 9 pcs
Hipon, tagunton 25 1 ¼ tbsp
Paros (rayed shell) 60 1 cup shelled or 2 cups
With shell
Pugita(octopus) 30 ½ cup
Pusit (squid) 45 2 ¼ medium pcs
Sugpo (tiger prawn) 25 1 medium
Susong pilipit ( fresh water snail) 65 1/3 cup shelled or 2 cups with
shell
Tahong (saltwater mussel) 260 1 ½ cups
Talaba (oyster) 105 2/3 cup
Talangka (small crabs) 30 75 pcs
Tulya (clam) 90 1/3 cup shelled or 7 cups with
shell
Beans and Nuts
Abitswelas (snap beans) 100 2/3 cup
Kadyos (pigeon pea sead) 55 2/3 cup
Kastanyas (roasted chestnut) 160 45 pcs large or 77 pcs. Small
Garbansos (chick pea seed) 65 ½ cup
Munggo (mung bean) 55 ½ cup
Paayap (cow pea seed) 40 ½ cup
Patani (lima beans) 75 ½ cup
Cheese
Cottage Cheese 60 1/3 cup
Processed foods:
A. Bean Products
Chili con carne 100 1 cup
Ve- G-franks 60 2 pcs.
Ve- G-Meat 50 1 ½ slices
Ve- G-sausage 50 4 pcs.
B. Meat products
Tocino 45 ¾ pc. - 3cm cube
C. Fish Products
Daing small 20 3 pcs
Medium 20 1 pc. 22x11 cm
Large 20 ¼ pc 30x40 cm
Fishball 95 6 pcs – 3 ½ cm diameter
Tinapa, bangus 30 ¼ pc - 29x8 cm
Tinapa, galunggong 30 3 pcs - 13 ½ x 3 ½ cm
Tinapa, tamban 30 1 ½ pcs - 16x8 cm
Tuyo small 20 3 small

Tuyo alamang 15 1/3 cup
Tuyo, pusit 15 ¾ pc - 20x6 cm
MEDIUM – FAT MEAT EXCHANGES:

1. Pork
Pata (leg) 35 1 pc - 3 cm cube
Internal organs: Sitsaron laman 40 ¾ cup
loob
2. Beef
Kabilugan (flank), punta y 35 1 pc - 3 cm cube
Pecho (brisket), tadyang (plate)
Internal organs: goto utak 40 ¾ cup
3. Carabao
Internal organ: Bitukang maliit 40 ¾ cup
4. Chicken
Pakpak (wings) 25 1 medium or 2 small
Ulo (head) 35 2 heads
5. Fish
Karpa 35 1 slice - 16x7x2 cm
6. Other seafoods
Alimasag, aligue (crab fat) 35 2 tbsps
7. Eggs
Century egg 65 1 egg
Maalat (salted duck’s egg) 60 1 egg
Manok (hen or chicken egg) 60 1 egg
Pugo (quail egg) 70 9 eggs
8. Beans and Nuts
Utaw ( soy beans) 40 ½ cup
9. Cheese
Imported 35 1 slice - 2 ¾ cups
Spread 55 4 tbsps
10. Processed Foods
A. Bean products
Taho 275 2 ¾ cups
Tofu 100 ½ cup
Tokwa 60 1pc - 6x6x2 cm
B. Fish products
Kikiam 190 1 ¾ pcs - 17x4 cm
Salmon, canned 40 1/3 cup, flaked
Sardines, canned in oil 40 2/3 pc - 10x4 ½ cm
Sardines, canned in tomato sauce 45 ¾ pc - 10x4 ½ cm
Tuna, canned 30 ¼ cup, flaked
Tuna, sardines 50 1 ½ pcs - 6 ½ x3 ½ x 3 cm

C. Meat Products
Corned beef 40 3 tbsps
Ham sausage 55 2 ¾ pcs - 9 ½ cmr x 3 cm
Luncheon meat 55 1 2/3 slices - 9x5x1 cm
Meat loaf 70 1 ¾ slics - 9x5x1 ¼ cm
Murkon 60 1 ¾ slices - 5 ½ x 1 ¾ cm
Potted meat 75 5 tbsps
HIGH – FAT MEAT EXCHANGES:

1. Pork
Lomo (tenderloin), paypay laman 35 1 pc - 3 cm cube
(shoulder steak), pig (ham)
Internal organs: Dila (tongue), utak 40 ¾ cup
(brain)
2. Beef
Internal organs: Dila (tongue), 40 ¾ cup
Mansinilya (reticulum)
3. Carabao
Internal organ: utak 40 ¾ cup
4. Eggs
Balut (duck’s eggs fertilized) 65 1 egg
Pato (duck egg) 70 1 egg
Penoy (unfertilized duck’s egg) 60 1 egg
5. Beans and Nuts
Mani, cracker 35 5 ¼ tbsps or 1/3 cup
Mani, boiled 60 ½ cup
Mani, roasted 25 1/3 cup
6. Cheese
Filled 40 1 1/3 slices - 2 ½ cm cube
Native 60 2 slices - 4x4x1 cm
Pimiento 40 1 1/3 slices - 2 ½ cm cube
7. Processed foods
A. Fish Products
Tuna spread, canned 30 2 tbsp
B. Meat Products
Chicken spread 70 5 tbsp
Embutido 60 2 ½ slices - 5 x 1 ½ cm
Frankfurters 60 1 1/3 pcs - 12 x 1 1/3 cm
Hamburger 50 2 ½ pcs - 4 ½ x 1 cm
Hotdog 70 1 ¼ pcs - 10 ½ x 4 cm
Liverspread 65 4 ½ tbsps
Longanisa, soriso 25 ½ pc - 9 ½ cm
Spam 55 2 ¾ slices - 9x5x ¾ cm
Salami 50 1 ¾ slices - 10x ½ cm
Tapa 50 1 ¾ pcs - 18x12x8 cm
Vienna sausage 70 4 pcs- 5x 1 ½

VERY HIGH – FAT MEAT EXCHANGES:
This list shows the kinds and amounts of very high fat meat and other protein-rich foods, with
their corresponding fat values. The protein content for each category is 8 grams. When using
these food items the appropriate fat allowance should be adjusted.
FOOD wt (gram)/EP FAT Measure
(GRAM)
1. Pork
Buntot (tail) 25 3.0 cm cube
Kasim (picnic) 20
Liempo sa hulihan (loin fat) 35
Likod (back fat) 35 35
Paypay (shoulder) 35
Tadyang (spareribs) 35
Tagiliran, laman (centerloin) 35
2. Beans and Nuts
Kasuy, binusa (cashew, 40 20 1/3 cup
roasted)
3. Processed Foods
A. Meat Products
Longanisa, bilbao 40 20 1 2/3 pcs - 6x2 ½ cm
Longanisa, makaw 60 45 2 ½ pcs - 12 X 2 cm
Longanisa, native 75 45 3 pcs - 6 ½ x 2 ½ cm
LIST 6- FAT MEAT EXCHANGES: 1 exchange = 5 grams = 45

kcal
SATURATED FATS
Bacon 50 1 strip
Butter 5 1 tsp
Coconut grated 20 2 tbsps
Coconut, milk 15 1 tbsp
Cream cheese 15 1 tbsp
Kropek 20 4 pcs - 7 ½ x 11 ½ cm
Latik 10 2 tsp
Margarine 5 1 tsp
Mayonnaise 5 1 tsp
Salad dressing, mayonnaise 10 2 tsp
Sandwich spread 15 1 tbsp
Shortening (lard, coconut oil) 5 1 tsp
Sitsaron 10 1 pc - 6x8 cm
Whipping cream, heavy 15 1 tbsp
Whipping cream, light 15 1 tbsp
POLYUNSATURATED FATS
Oil 5 1 teaspoon
(corn, marine, soybean, rapeseed-
canola, rice sunflower, safflower,
sesame)

MONOUNSATURATED FATS
Avocado(red and green) 75 ½ medium - 12 x 7 cm Or
¼ large - 15 x 4/5 x 8 3/10 cm
Butong pakwan 10 1 tbsp E.P. or ½ cup A.P.
Peanut butter 10 2 tsp
Pili nut 5 5 pcs
Salad dressing, French 15 1 tbsps
Salad dressing, French 5 1 tsp
LIST 7 - SUGAR EXCHANGES: 1 serving = 5g CHO = 20 kcal

Banana crackers 10 1/8 cup
Banana chips 5 1 pc - 6 x 3 ½ cm
Bukayo 5 1 pc - 3 ½ x 1 cm
Caramel 5 1 pc - 2x2 cm
Champoy 5 1 pc - 2 cm diameter
Chewing gum, bubble gum 5 1 pc
Chocolate candy with milk 10 2 pcs - round
Chocolate, orange crunch 10 ½ pc
Condensed milk 10 1 tsp
Honey 5 1 tsp
Ice drop 25 ¼ pc
Jams, jellies and preserve 10 2 tsp
Kundol, matamis 5 ¼ pc - 7x5 cm
Mani, matamis 10 1 pc
Marshmallow 5 1 pc
Matamis na bao 5 1 pc
Nata de coco 15 2 tbsp
Nata de pinya 10 2 tbsp or 1/8 cup
Pakaskas 5 ½ tbsp
Panutsa, grated 5 ½ tbsp
Pastilyas, gatas 5 ½ tbsp
Pastilyas, langka 5 ½ pc - 5x2x ¾ cm
Peanut brittle 10 ½ bar - 8cm
Pili, matamis 15 1/8 cup
Pulburon 5 ¼ pc - 8x5 cm
Rimas, matamis 5 1/8 pc - 8x4 cm
Sampaloc, candy 5 1 pc
Sugars 5 1 tsp
Tira-tira 5 1 pc
Toffee candy 5 1 pc - 2 ½ cm x 1 ½ x 1 cm
Ubedol 5 ¼ bar - 5x2 cm
Ubi. Halaya 10 ½ tbsps
Yema 5 1 pc - 5 1 ¼ cm

BEVERAGE LISTS
FOOD Measure Calories
A. Diet Cola I bottle 237 ml 2
330 ml 1 can 3
B. Fruit concentrate
Grapefruit drink 100 ml 7 tbsp 40
Strawberry 125ml ½ cup 50
Orange Drink 100 ml 7 tbsp 40
C. Alcoholic Beverages - 7 kcal/gram. Its use should be planned with the

patient’s food habits, the dietitian, and the physician. The following are
considerations in the use of alcoholic beverages:
1. Use alcohol only when the diabetes is under control.

2. Use alcohols only with meals and snacks and in moderation.
3. Avoid or limit wines, liquors, beer and all sweetened mixed drinks because
the sugar content could cause hyperglycemia.
4. Substitute alcoholic beverages for the appropriate food choices. A small
amount of alcohol can be incorporated occasionally in the meal plan if the
person is at ideal body weight and provided the physician agrees.
5. A small amount of wine or alcohol may be used in cooking since it
evaporates.
6. If alcohol is used, subtract its energy value from the total calorie intake
defined in the diet prescription before the grams of carbohydrate, protein and
fat are calculated.
FOOD WT. (GRAMS) ENERGY SUGAR EQ.(tsp) MEASURE
Basi 170 185 9 1 glass 6 oz

Beer, cervesa 320 163 8 1 bottle 11 oz
Brandy, cognac 30 75 4 1 brandy glass 1 oz
Daiquiri 56 124 4 1 cocktail 2 oz
Gin, dry 43 107 5 1 jigger 1 ½ oz
Gin, (SMB) 360 832 42 1 bottle 12 oz
High ball 240 170 8 1 glass 8 oz
Manhattan 56 167 8 1 cocktail 2 oz
Martini 56 143 7 1 cocktail 2 oz
Mint Julep 240 217 11 1 glass 8 oz
Old Fashioned 240 183 9 1 glass 8 oz
Rum 43 107 5 1 jigger 1 ½ oz
Tom Collins 300 182 9 1 tall glass 10 oz
Tuba 240 89 4 1 cup 8 oz
Whisky, scotch 43 107 5 1 jigger 1 ½ oz
Wine, red 100 73 4 1 wine glass 3 ½ oz
Wine, white 100 85 4 1 wine glass 3 ½ oz
Wine, champagne 100 85 4 1 wine glass 3 ½ oz
Wine, port 100 160 8 1 wine glass 3 ½ oz
Wine, 100 108 5 1 wine glass 3 ½ oz
Vermouth, French
Wine, 100 170 8 1 wine glass 3 ½ oz

FREE FOODS
The following foods may be used freely unless specifically prohibited by the
physician. These foods may be used with other foods in the diet.
Bouillon Kamias Lemon

Clear broth Pepper Mustard
Coffee Pickle Tea
Garlic Tomato sauce Vinegar
Gelatin (unsweetened) Tomato paste
BEVERAGE LIST
BEVERAGE NET CONTENTS MEASURE SUGAR KCAL
(ml) EXCH.
Soft drink 237 1 bottle 5 100
Fruit Flavored 5 1 tsp 1 20
Concentrate
Powder juice 5 1 tsp 1 20
Mango, guyabano, 20 4 tsp 1 20
pineapple, pomelo
concentrate
Tetra –brick
Apple 250 1 tetra 6½ 130
Guyabano 250 brick 7½ 150
Mango 200 5½ 110
Melon 200 8½ 170
Orange 250 6½ 140
pineapple 250 6 120
COMMERCIALLY AVAILABLE MILK DRINKS
MILK DRINK ml MEASURE Kcal CHON Fat CHO

chocolate 250 1 tetra brick 200 8 5 31
Powdered milk 25 2 tbsps 57 2 0.1 12
Yoghurt 125 1 bottle 100 2 <1 20
References:
1. FNRI, DOST. Food Exchange List 2008 Reprint

2. Lagua RT and Claudio VS. Nutrition and Diet Therapy Dictionary
Philippine Edition. Manila: Merriam and Webster Inc., 2004
3. Nutritionists and Dietitians’ Association of the Philippines. Fundamentals
of Diet therapy. Manila 1987

PROBLEM I:
A Filipino employee working as a call center agent, 25 years of age 5 feet 6

inches tall, weighing 130 lbs, engaged in sedentary physical activity.
Nutrient distribution in % of TER:

Carbohydrate = 60% Protein = 10% Fat = 30%
Determine each of the following and show your computations:

SOLUTION AND ANSWER
Energy for BMR (Harris-Benedict)
TER = BMR x AF x Injury Factor
Ideal Body Weight
Amount of CHO/day (grams)
Amount of Protein/day (grams)
Amount of Fats/day (grams)

PROBLEM II
Determine your own TER per day based on the following data:
1. Your desired body weight (DBW) according to your height
2. Your physical activity is considered light.
3. Nutrient distribution:
Carbohydrate = 60% Protein = 15% Fat = 25%
Determine each of the following and show your computations:

Desirable body weight in kg
BMR (Harris-Benedict equation)
TER = BMR x AF x IF
Amount of CHO/day (grams)
Amount of Protein/day (grams)
Amount of Fats/day (grams)

PROBLEM III - FOOD EXCHANGE LIST
Dietary prescription for a adult diabetic male is as follows:

TER = 2000 Cal CHO = 255 g CHON = 43 g
Fat = 57 g
Number of exchanges for Veg A, B, Fruit , Milk and Sugar are given below.
Supply the missing answers to the numbered questions that are indicated by parenthesis
in the following table, using the given data.
FOOD # OF EXCH CHO (g) Protein (g) Fat (g) Energy (Kcal)
Veg A 4
Veg B 4
Fruit 4
Milk 2
Sugar 1
Rice
Meat
Fat
TOTAL
PROBLEM IV - CREATING A MEAL FOR A DAY

With the data obtained in Problem III, Plan a diet for a day using the table below.
Divide the Day’s Exchanges between meals.
Exchange group # of exchanges Breakfast Lunch PM snack Dinner
Veg A 4
Veg B 4
Fruit 4
Milk 2
Sugar 1
Rice
Meat/ Meat subs.
Fat
Total Kcal/Cal
TRANSLATING A DAY’S EXCHANGES INTO A DAY’S MEAL
BREAKFAST LUNCH PM SNACK DINNER

CHAPTER 3
NUTRITION FOR METABOLIC SYNDROME
Mari-Ann Benigno-Bringas, MD, MHM, FPAAB
Definition of Metabolic Syndrome
Metabolic syndrome is the constellation of Type 2 diabetes or impaired glucose

tolerance, with other CVD risk factors such as dyslipidemia, hypertension and
central obesity or with cardiovascular disease mortality. Metabolic syndrome is a
cluster of cardiometabolic risk factors associated with increased risk of multiple
chronic diseases, including cancer and cardiovascular disease (NCEP, 2001). It
is one of the major health problems associated with obesity not only in Western
and European countries, but also in the Asia-Pacific region. Using the definitions
by both the IDF and the National Cholesterol Education Program, Ford et al also
observed similar trends of metabolic syndrome prevalence in the United States,
with 28% in 1988–1994 and 31.9% in 2000 (Ford, 2005). The prevalence of
Metabolic syndrome increased from 1988 to 2012 and more than a third of all US
adults met the definition and criteria for metabolic syndrome agreed to jointly by
several international organizations (Moore et al, 2017).
While the main focus has been on insulin resistance and/or hyperinsulinemia as
the common etiological factor/s for the components of the Metabolic Syndrome,
there is considerable heterogeneity in these relationships between populations
(de Courten et al 1997b, Zimmet 1999). International Diabetes Federation has
identified insulin resistance and central obesity as the prime significant factors
that lead to Metabolic syndrome.
The Definition of Metabolic Syndrome has evolved thru the different international
organizations with insulin resistance as a primary requirement plus any 2 of the
abnormalities in glucose level, HDL cholesterol, Triglycerides, Obesity and
hypertension. EGIR: Group for the Study of Insulin Resistance; WHO: World
Health Organization; AACE: American Association of Clinical Endocrinologists
had similar criteria in 1999 and 2003.

Definitions of the Metabolic Syndrome
PARAMETERS NCEP ATP3 2005* IDF 2009
Number of ≥3 of: ≥3 of:
abnormalities
Glucose Fasting glucose ≥5.6 mmol/L Fasting glucose ≥5.6
(100 mg/dL) or drug treatment mmol/L (100 mg/dL) or
for elevated blood glucose diagnosed diabetes
HDL Cholesterol <1.0 mmol/L (40 mg/dL) (men); <1.0 mmol/L (40 mg/dL)
<1.3 mmol/L (50 mg/dL) (men); <1.3 mmol/L (50
(women) or drug treatment for mg/dL) (women) or drug
low HDL cholesterol§ treatment for low HDL
cholesterol
Triglycerides ≥1.7 mmol/L (150 mg/dL) or ≥1.7 mmol/L (150 mg/dL)
drug treatment for elevated or drug treatment for high
triglycerides§ triglycerides
Obesity Waist ≥102 cm (men) or ≥88 cm Waist ≥94 cm (men) or
(women)¥ ≥80 cm (women)
Hypertension ≥130/85 mmHg or drug ≥130/85 mmHg or drug
treatment for hypertension treatment for
hypertension
NCEP: National Cholesterol Education Program; IDF: International Diabetes Federation; HDL: high-density
lipoprotein; CVD: cardiovascular disease; BMI: body mass index.
* Most commonly agreed upon criteria for metabolic syndrome. Note that
abdominal obesity is not a prerequisite for diagnosis; the presence of any 3 of
the 5 risk criteria constitutes a diagnosis of metabolic syndrome.
https://www.uptodate.com/contents/image?imageKey=PC%2F53446&topicKey=GAST%2F3625&source=see_link
Etiology of Metabolic Syndrome
In most people with glucose intolerance or type 2 diabetes, there is a multiple set
of risk factors that commonly appear together, known as the ‘Metabolic
Syndrome’, but which has previously been termed ‘Syndrome X’, the ‘Deadly
Quartet’ and more recently, the ‘Insulin Resistance Syndrome’. This ‘clustering’
of metabolic abnormalities that occur in the same individual, and which appear to
confer a substantial additional cardiovascular risk over and above the sum of the
risk associated with each abnormality, has been the subject of intense debate
with such groups as the WHO and the National Cholesterol Education Program –
Third Adult Treatment Panel(NCEP ATP III) seeking to develop diagnosis and
management guidelines around the combined presence of elevated blood sugar
levels, an abnormal lipid profile, high blood pressure and abdominal obesity. If
diabetes is not present, the metabolic syndrome is a strong predictor for its
development, the risk for type 2 diabetes being five times more likely in
individuals with the syndrome (Stern et al 2004). While each individual component
of the metabolic syndrome confers an increased risk of cardiovascular-related
death, this risk is more pronounced when the metabolic syndrome itself is
present. The more components of the metabolic syndrome that are evident, the
higher is the cardiovascular mortality rate (Hu G et al 2004). The underlying
cause of the metabolic syndrome continues to challenge the experts but both
insulin resistance and central obesity are considered significant factors (Hu G et
al 2004). Genetics, physical inactivity, ageing, a pro-inflammatory state and
hormonal changes may also have a causal effect, but the role of these may vary
depending on ethnic group.
Insulin resistance
Insulin resistance occurs when cells in the body (liver, skeletal muscle and
adipose/fat tissue) become less sensitive and eventually resistant to insulin, the
hormone which is produced by the pancreas to facilitate glucose absorption.
Glucose can no longer be absorbed by the cells and remains in the blood,
triggering the need for more and more insulin (hyperinsulinaemia) to be produced
in an attempt to process the glucose. The production of ever-increasing amounts
of insulin strains and may eventually wear out the beta cells in the pancreas,
responsible for insulin production. Once the pancreas is no longer able to
produce enough insulin then a person becomes hyperglycaemic (too much
glucose in the blood) and will be diagnosed with type 2 diabetes. Even before
this happens, damage is occurring to the body, including a build-up of
triglycerides which further impairs insulin sensitivity and damage to the body’s
microvascular system (leading to kidney, eye and nerve damage). Strongly
associated with irregularities in both glucose and lipid metabolism, insulin
resistance is an underlying feature of the metabolic syndrome and type 2
diabetes.
Free fatty acids
The mechanisms by which insulin resistance may exert an atherogenic effect

include the build-up of triglycerides (TG) and free fatty acids (FFA). High
concentrations of plasma FFA are common in type 2 diabetes, with early
detection signifying a shift for the individual from impaired glucose tolerance
(IGT) to type 2 diabetes. Insulin resistance in adipose tissue (fat cells) results in
an efflux of FFA from the adipose tissue to the liver causing insulin resistance in
the liver and in peripheral tissues. Fatty acids block glucose oxidation and
glucose transport, but they also cause atherogenic dyslipidaemia by inducing
production in the liver of very low-density lipoprotein (LDL) particles that lead to
the elevation of TG and apolipoprotein B (ApoB) and the lowering of high-density
lipoprotein cholesterol (HDL-c). An increase in TG, in addition to high LDL-c
levels, significantly increases the risk for coronary heart disease (CHD) (Steinmetz
et al 2001), while low HDL-c is considered to be a particularly key risk factor for
CVD in both non diabetic and diabetic individuals, as confirmed in
epidemiological studies (Robins SJ et al 2003) and in the Lipid Research Clinics
Prevalence Study (Jacobs Jr et al 2003) which found HDL-C to be an independent
contributor to CVD in both men and women and a stronger risk factor for CVD in
people with diabetes compared with non diabetic individuals. Significantly, low
HDL-c and high TG are frequently found with insulin resistance, with or without
type 2 diabetes (Robins SJ et. Al. 2003). Abnormalities and elevated lipid profile,
observed with both type 2 diabetes and the metabolic syndrome, is an extremely
high risk factor for CVD as all of the abnormalities have been implicated as being
independently atherogenic.
Central obesity
Obesity is associated with insulin resistance and the metabolic syndrome.

Obesity may soon develop complications directly linked to hypertension, high
serum cholesterol, low HDL-c and hyperglycaemia, and is independently
associated with higher CVD risk (Carr DB et. Al. 2004). The risk of serious
health consequences in the form of type 2 diabetes, CHD and a range of other
conditions, including some forms of cancer, has been shown to rise with an
increase in body mass index (BMI), but it is an excess of body fat in the
abdomen, measured simply by waist circumference, that is more indicative of the
metabolic syndrome profile than BMI. Excessive body fat causes insulin
resistance and impairs glucose metabolism thereby an important cause of
increased FFA and TG in the skeletal muscle, which impairs insulin secretion,
raising blood glucose levels and the likelihood of developing diabetes. Excess
adipose tissue (particularly the visceral fat tissue in the abdomen) also releases
inflammatory cytokines that increase insulin resistance in the body’s skeletal
muscles. Central obesity is also associated with a decreased production of
adiponectin, which is the adipose-specific, collagen-like molecule found to have
antidiabetic, anti-atherosclerotic and anti-inflammatory functions (Matsuzawa Y et al
2004). Eighty-five per cent of obese individuals have some degree of insulin
resistance which can be improved with weight loss. Inactivity also plays a role via
the mechanism of GLUT-4, a chemical which facilitates glucose absorption by
the cells. Physical inactivity lowers levels of GLUT-4 making it less effective.
Lack of exercise may also increase levels of FFA in the blood thus stepping up
the storage of visceral fat, both of which are implicated in the etiology of insulin
resistance.

Nutrition Goals for Metabolic Syndrome
Dietary guideline for nutritional therapy:
Carbohydrate 40-60% of TER

Protein 10-20% of TER
Fats 20-30% of TER
Nutritional goals for nutrition therapy for Metabolic Syndrome:
• Reduction of carbohydrates to Increase in insulin sensitivity

• Reduction of blood glucose level
• Reduction of LDL cholesterol
• Increase in HDL cholesterol
• Control sodium intake
Simple sugars and saturated fats are avoided, but mono-and polyunsaturated
fats are encouraged, and even supplemented, including omega-3 fatty acids.
Research supports omega-3 role in reducing inflammation, and improving cell
membrane function. The classic Food Pyramid, currently recommended by
the USDA (which is strongly supported by the meat and dairy industries), is
NOT recommended because it is too high in carbohydrates.
Since most components of metabolic syndrome are related to lifestyle,

exercise and diet are critical aspects of treatment. Most patients will need to
reduce body weight. Some flexibility in dietary macronutrients is allowed,
depending on the patient's metabolic profile and responsiveness. Types of
fats and carbohydrates are particularly important. Artificial trans fats should be
eliminated as much as possible and saturated fats minimized.
Carbohydrates should be mainly unrefined and unprocessed, emphasizing

fiber and low glycemic index, while keeping added sugars low.
Monounsaturated fats are the best replacements for saturated fats and refined
carbohydrates within energy and total fat limits. Micronutrients that may be
beneficial for metabolic syndrome include vitamin D, calcium, magnesium,
and potassium from whole food sources. Excess sodium chloride, as well as
meal skipping, should be avoided.

DIETARY RECOMMENDATIONS for METABOLIC SYNDROME
Metabolic Components Dietary Recommendations

Abdominal/Central Obesity Healthy dietary pattern
Reduce caloric intake if weight loss is needed
Low sat fat, trans fat and cholesterol intake
High fruit, vegetables, and whole grains intake
Low refined carbohydrate intake
Elevated blood pressure DASH diet
Reduced sodium intake
Elevated triglyceride levels Reduced caloric intake if weight loss is needed
and low HDL cholesterol Mediterranean-style diet
Low sat fat, trans fat and cholesterol
High fruit, vegetables, and whole grains intake
Low refined carbohydrate intake
Moderate fat consumption from unsaturated fat
sources
Moderate fish consumption
Elevated fasting glucose Reduced caloric intake if weight loss is needed
concentration Low refined carbohydrate intake
Moderate carbohydrate intake rich in whole
grains
Pro-inflammatory and Reduce caloric intake if weight loss is needed
Pro-thrombotic states Low sat fat, trans fat and cholesterol intake
Carbohydrate Recommendations:
Weight gain, obesity, diabetes, and a number of other diseases has been the
result of excessive carbohydrate consumption. Recognition that such problems
may be associated with the excess consumption of the wrong carbohydrates
such as simple sugars or table sugar, but not with complex carbohydrates.
Healthy and varied proportions of complex carbohydrates (such as potatoes,
breads, corn, etc.) in the diet are recommended. Reduction in intake of refined
and simple carbohydrates will reduce sugar load. A low carbohydrate diet low in
refined high glycemic index should be the focus. Studies prove that a modified
low-carbohydrate diet (30% of TCR) that was higher in complex carbohydrates,
proteins, and monounsaturated fats led to more weight loss than a low fat, high
carbohydrate diet.

High-fiber diets have been well studied due to their association with decreased
incidence of several metabolic disorders related to the development of metabolic
syndrome
• Use of Glycemic Index - measures how rapidly glucose is absorbed from

the intestine into the blood when the quantity of the food that contains 50 g
of carbohydrate is eaten, relative to the rate of glucose absorption that
results from eating 50 g of pure glucose. The glycemic index (g.i.) is
defined as the rate blood sugar will rise following the ingestion of a
particular test food relative to the ingestion of a standard food (either white
bread or glucose).
⚫ Unrefined grain fiber in the diet has been beneficial in reducing the risk of
diabetes. Among the diet patterns, the Mediterranean diet has been
related to a lower incidence of diabetes and a reduction in the risk of death.
Studies for intervention in the prevention of type II diabetes have
suggested low-fat diets (reducing saturated and trans-fats), with a high
degree of fiber and low glycemic index. Clinical trials have shown diets
with small amounts of carbohydrates, low glycemic index and the
Mediterranean and DASH diets to be beneficial in reducing atherogenic
dyslipemia. There is currently no good evidence for choosing diets with
restricted carbohydrates.
⚫ Benefits of Glycemic Index Tool

➢ Improves metabolic syndrome
➢ Helps control weight
➢ You feel fuller sooner and longer.
➢ Increases the body cell’s sensitivity to insulin
➢ Stabilizes blood sugar and insulin levels
➢ Decreases dangerous fat stores
➢ Manages symptoms of PCOS
➢ Improves energy level
➢ Balances mood
➢ Helps keep your bowels regular

⚫ Glycemic load is the amount of carbohydrate in each service of food.
Foods with a glycemic load under 10 are good choices. Foods that fall
between 10 and 20 on the glycemic load scale have a moderate affect on
the blood sugar. Foods with a glycemic load above 20 will cause blood
sugar and insulin spikes.

⚫ Use of High Fiber Diet: The intake of fruits and vegetables increases
satiety and therefore promotes weight loss. Since fiber holds more water
it gives good laxative effect. The binding properties of fiber helps increase
excretion of fats, excess cholesterol and toxins. Higher intakes of fruit and
vegetables are associated with a lower risk of the metabolic syndrome; the
lower risk may be the result of lower C-Reactive protein concentrations.
These findings support current dietary recommendations to increase daily
intakes of fruit and vegetables as a primary preventive measure against
cardiovascular disease. It appears that diets characterized by low total
and saturated fat intake and higher fruit and vegetable, whole grain, and
low fat dairy intake are protective against metabolic syndrome and its
components.
Fat Recommendations:
A well-balanced proportion of fat is the key to healthy aging. A diet too low in fat
may actually bring harm to health. The correct way is to discern the right type to
take and those to avoid. The overall fat intake as a percentage of dietary calories
should not fall below 30%. To have plenty of "good" MUFA like olive oil, seeds,
nuts, and cold-water fish that have high N3 content. Saturated fat is necessary
for good health. It could come from animal or plant sources. If animal source is
desired, choose free-range poultry or beef, organic eggs, and deep-water fatty
fish such as salmon. It is very important to avoid "bad" trans fat, like margarine
and fried foods. Moreover, the use of processed PUFA such as corn, safflower or
sunflower oil should be restricted.
Out of the 30 % recommended daily calorie from fat sources, less than one third
should be saturated fat, the rest should come from mono-unsaturated fat as
much as possible. Reduction of cholesterol intake should be followed. Studies
state that an intake of MUFA increase the level of HDL-C and decrease LDL-C.
This is opposite the effects contributed by a high saturated fat diet which
increases bad cholesterol and decreases good cholesterol therefore promoting
the development of CVD. The consumption of unsaturated fats, derived mostly
from vegetable oils such as safflower, corn, olive and soybean oil, may be able to
prevent atherogenesis, hypertension and consequently the metabolic syndrome.
The major problem with the focus on low fat is that carbohydrate diets can
contribute to increasing triglycerides and decreasing HDL concentrations.
Excessive carbohydrates consumption is associated with the development of
metabolic syndrome. Higher carbohydrate diets, particularly of the refined form
have also been associated with elevated blood pressure.
Practical tips to help obtain good quality fats and reduce cholesterol intake:
✓ Trim visible fat from all cuts of meat.
✓ Include one to two fish or seafood meals a week (total 8 ounces).
✓ Do not batter or fry fish in animal or hydrogenated vegetable fats; pan-
frying and deep-frying may decrease the omega-3 content of the fish.
✓ Switch to low fat or non-fat varieties of milk and other dairy products.
✓ Instead of frying foods, try steaming, stir-frying, or baking.
✓ Limit take-out foods, butter, potato chips, biscuits and cake, and other
processed food containing vegetable shortening (trans fat).
✓ Use a virgin olive oil, if available.
✓ Choose fat from unrefined sources - for example, oily fish, nuts, soy,
avocado, seeds (in bread), and virgin/cold pressed oil.
Protein Recommendations:
Maintain neutral protein balance with 1-2 grams of protein per kg weight.
Approximately 15% of your calories should be from protein. Animal proteins are
acceptable as long as they are not grain fed (contain up to 50% saturated fat) but
grass fed (contain less than 10% saturated fat and high in omega-3 oils.). Protein
use is not encouraged because its breakdown product, amino acid, enhances
insulin secretion. Fats do not do this. Excessive proteins also cause acidity in the
body.
Sodium Recommendations:
Sodium is an important mineral that our bodies need for maintaining fluid balance,
for the contraction of muscles and to aid in the conduction of nerve impulses. Our
bodies have a requirement of approximately 0.2 grams or 200 mgs. of sodium
per day. We consume more than that. The American Heart Association
recommends a daily limit of 2,300 mgs.
To give you a visual guide of what the levels mean:

• 1/4 teaspoon salt = 600 mg sodium
• 1/2 teaspoon salt = 1,200 mg sodium
• 3/4 teaspoon salt = 1,800 mg sodium
• 1 teaspoon salt = 2,400 mg sodium
• 1 teaspoon baking soda (sodium bicarbonate) = 1,000 mg sodium

The average person consumes about one to three teaspoons of salt per day.
Evidences from one large and one small trial showed that a low-sodium diet
helps to maintain lower blood pressure following withdrawal of antihypertensive
medications. Results from clinical trials of low-fat diets in which participants were
involved for more than two years showed significant reductions in the rate of
cardiovascular events and suggested protection from total mortality. The degree
of protection from cardiovascular events was statistically significant in patients
with a higher risk of cardiovascular disease.
For patients with elevated blood pressure, the Seventh Report of the Joint
National Committee on Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure (JNC 7) states that a systolic blood pressure of 120 to 139
mmHg or a diastolic pressure of 80 to 89 mmHg should be considered pre-
hypertensive and trigger lifestyle modifications to prevent cardiovascular disease.
According to the Dietary Approaches to Stop Hypertension (DASH) study,

patients who consumed a diet low in saturated fat and high in carbohydrates
experienced a significant reduction in blood pressure, even without weight
reduction. The DASH diet emphasizes fruits, vegetables, low-fat dairy foods,
whole grains, poultry, fish, and nuts, while reducing saturated fats, red meat,
sweets, and sugar-containing beverages. Reducing sodium intake can further
reduce blood pressure or prevent the increase in blood pressure that may
accompany aging.
Sodium- Restricted Diets
Sodium – restricted diets are used for the prevention, control, and
elimination of edema in many pathologic conditions, and occasionally for the
alleviation of hypertension.
The normal diet contains about 3-6 gms. Of sodium daily, although a
liberal intake of salty foods results in considerably higher sodium levels. The
normal diet may be modified for its sodium contents as follows:

Mild sodium restriction Some salt may be used in cooking, but
(2400 mg. or 1 tsp crude rock salt/day) no salty foods are permitted; no salt is
used at the table. This level is used as a
maintenance diet in cardiac and renal
diseases.
Moderate sodium restriction No salt in cooking.
(1200 mg or ½ crude rock salt/day)
Strict sodium restriction No salt used in cooking. This level may
(600 mg. or ¼ tsp. crude rock salt/day be used for CHF, occasionally in renal
diseases with edema, cirrhosis of the
liver.
The DASH Diet Eating Plan
The DASH diet is recommended to many people with high blood pressure. It has
been proven to lower blood pressure in studies sponsored by the National
Institutes of Health (Dietary Approaches to Stop Hypertension). The DASH
diet provides more than the traditional low salt or low sodium diet to reduce blood
pressure. It is based on an eating plan rich in fruits and vegetables, and low-fat
or non-fat dairy. The DASH eating plan has been proven to lower blood pressure
in just 14 days. Best response came in people whose blood pressure was only
moderately high, including those with prehypertension. For people with more
severe hypertension, who may not be able to eliminate medication, the DASH
diet can help improve response to medication, and help lower blood pressure.
The DASH diet can help lower cholesterol, and with weight loss and exercise can
reduce insulin resistance.
New research shows that following the DASH diet over time will reduce the risk
of stroke and heart disease. And the benefits of the DASH diet have also been
seen in teens with hypertension. The DASH diet truly is the diet for everyone.
The dietary approaches to stop hypertension diets (DASH) characterized by high

fruit and vegetable intake, low fat-dairy product intake, whole grains, poultry, fish,
and nuts and low saturated fat and total fat meats, sweets, and sugar drinks
reduced the components of metabolic syndrome.

Type of food Number of servings Servings on a 2000
for 1600 - 3100 Calorie diet
Calorie diets
Grains and grain products
(include at least 3 whole grain
foods each day) 6 - 12 7-8
Fruits 4-6 4-5
Vegetables 4-6 4-5
Low fat or non-fat dairy foods 2-4 2-3
Lean meats, fish, poultry 1.5 - 2.5 2 or less
Nuts, seeds, and legumes 3 - 6 per week 4 - 5 per week
Fats and sweets 2-4 limited
The Benefit of Regular Exercise:
Physical activity is an integral management strategy for weight reduction,

maintenance of the reduced state and prevention of weight gain. Regular
physical activity is also essential for maintaining physical and cardiovascular
fitness. Initially, for sedentary individuals, engaging in a moderate level of
physical activity, such as intermittent walking for 30 to 45 minutes, is
recommended. Subsequent increases in physical activity to 30 to 60 minutes on
most if not all days of the week need to be individualized and are generally
targeted to expend a total of 100 to 200 kcal. It may also be useful to focus on
reduction in sedentary time such as time spent watching television.
Resistance training exercise increases insulin sensitivity. While any exercise is

good for the body, resistance training exercise increase insulin sensitivity.
Aerobics exercise facilitate the burning of excessive sugar in the body and
reduce insulin requirement. To be effective, exercise should be consistent. A
total of 30 minutes of moderately intense aerobics exercise as tolerated ( broken
down in to 10 minute blocks is acceptable) is the minimum.

DIET AND PHYSICAL ACTIVITY
FOR METABLIC SYNDROME
Increase Physical Activity 150 minutes minimum/week

Lose weight At least 7% of initial body weight if BMI > 25
Decrease total and saturated fat Total fat not > 25-35% of Calories
Sat fat < 7% of calories
Emphasize monounsaturated fats Up to 20% of total calories
Decrease sugar and excess starch Carbohydrate intake not > 50-60% of total
calories with emphasis on whole grains, fruits
and vegetables
Decrease sodium Not > 2300mg/day; Not > 150 mg/day if middle
aged or older, black or hypertensive
Increase fiber Up to 25-30 mg/day
Increase anti-oxidants Up to 9 servings of fruits/ vegetables /day
Increase dietary magnesium, Per 2000 kcal: Mg 500 mg
calcium, potassium Ca 1200 mg
K 4700 mg
www2.medicine.wisc.edu/home/.../MedNutrHndbkMetbolSyn.newdoc.

When translated to food, the diet for Metabolic syndrome is similar to the healthy
Mediterranean Pyramid.
Key components of the Mediterranean diet
The Mediterranean diet emphasizes:

• Eating primarily plant-based foods, such as fruits and vegetables,
whole grains, legumes and nuts
• Replacing butter with healthy fats such as olive oil and canola oil
• Using herbs and spices instead of salt to flavor foods
• Limiting red meat to no more than a few times a month
• Eating fish and poultry at least twice a week
• Enjoying meals with family and friends
• Drinking red wine in moderation (optional)
• Getting plenty of exercise

THE KETOGENIC DIET
Carbohydrates-rich diet notably high in refined sugars and fructose are

associated with the metabolic syndrome (23). Various diets that are low-calorie
and high in protein have been suggested to treat obesity and metabolic
syndrome. Carbohydrate restriction has been proposed to be the single most
effective intervention for reducing all features of the metabolic syndrome (24-25).
The ketogenic diets (KD) diets are known for being very low in carbohydrates,
but usually high in fats and/or proteins. KD are characterized by a very low
content of carbohydrates of less than 50 g/day) and a notable increase in the
proportions of proteins and fats. KD are known to be efficient in the treatment of
seizures.
The biochemical mechanism

that would explain the
effectivity of ketogenic diet is
shown in the figure below.
Since the KD is a low-

carbohydrate, high-fat,
adequate protein diet, this
dietary pattern shifts the way
our body produces energy –
from a glucose fuelled system
to a ketone fuelled system.
The basic principle is to get
the body into a metabolic state known as ketosis where carbohydrate stores are
depleted and fat becomes the main energy source. This is also considered
gluconeogenesis where the body uses glycerol and amino acids to convert to
glucose in times of carbohydrate depletion. Ketosis is the state where
tmolecules that the liver starts to produce from fat to be used as fuel - ketone
bodies or ketones. Ketosis is different from ketoacidosis which is a pathological
state of having an accumulated level of ketone bodies that leads to metabolic
acidosis. Ketone-fuelling has become a lifestyle approach of choice since it
permits faster weight loss with increase in physical and mental performance
Standard composition of ketogenic diets in adults

* (calculated for a 2000 kcal diet/day).
Classical KD Defined as <130 g carbohydrate per day or <26%
of caloric intake by the American Diabetes
Association
Modified Atkins Diet 65% caloric intake from fat
30% protein
6% carbohydrates
Very low-carbohydrate KD Carbohydrates < 30 g/day
KD, Ketogenic Diet. * Adapted from Kossoff et al. [26], Feinman et al. [27], Accurso et al. [28].

CASE ON METABOLIC SYNDROME:
History
A 45 y/o female G3P3 (2-0-0-2) who comes in to discuss weight loss. She has
been obese since her teens, with maximum weight of 240 lbs. Average adult
body mass index (BMI) has been 35. (+) History of progressive weight gain for
the past 30 years.
Past Med Hx
Hypertension for 10 years with highest BP of 180/100, presently on Nifedipine
30mg OD
Diagnosed to have high cholesterol levels for the past 10 years and presently on
Atorvastatin 10 mg HS.
Family Hx
Obesity, DM-2, hypertension, coronary artery disease
Physical Exam
• Temperature, 98.8°F (37.1°C);
• Heart rate, 88 beats per minute;
• Respirations, 16 breaths per minute;
• Average BP reading of 144/90 mm Hg in both arms (repeated
measurements confirmed after 5 minutes of rest between readings);
• Weight, 210 lb (95 kg);
• Height, 63 in (1.60 m); and
• Calculated BMI, 37 kg/m2.
Studies (prior)
Fasting blood glucose 130; cholesterol 245, HDL 30, triglycerides 200; TSH 2.5.
Blood glucose profile ordered after a 3 day diet high in simple carbohydrates:
fasting glucose 105, fasting insulin 10; 2 hrs after a 75 gm glucola: insulin 107,
glucose 128. HBA1c = 8 mg/dl
QUESTIONS:
1. What is your diagnosis of the case? Justify.
2. How would you manage the patient?
3. What will be your diet goals for the patient?
4. Make a Diet based on the patient’s ideal body weight.
5. Create a one-day menu for the patient.

References:
1. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults.
Executive summary of the third report of the National Cholesterol Education Program (NCEP)
expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult
Treatment Panel III). JAMA 2001;285(19):2486–97. CrossRefPubMed
2. Ford ES. Prevalence of the metabolic syndrome defined by the International Diabetes Federation
among adults in the U.S. Diabetes Care 2005;28(11):2745–9. CrossRef PubMed
3. Nutritional programming of the metabolic syndrome. Symonds ME, Sebert SP, Hyatt MA, Budge H.
Nat Rev Endocrinol. 2009 Sep 29. [Epub ahead of print]
4. Metabolic Syndrome: a challenging health Issue in highly urbanized Union Territory of north India
Chetna Mangat, NK Goel, Dinesh K Walia, Neeraj Agarwal, Munesh K Sharma, Jasbinder Kaur,
Ram Singh, Gagandeep Singh
Diabetology & Metabolic Syndrome 2010, 2:19 (23 March 2010)
5. S. Yoo, T. Nicklas, T. Baranowski, et al. Comparison of dietary intakes associated with metabolic
syndrome risk factors in young adults: The Bogalusa Heart Study. Ant d Clin Nutr; 80:841-848
(October, 2004).
6. Kathleen J. Melanson, PhD, RD, LD ; Nutrition and Metabolic Syndrome. Department of Nutrition
and Food Sciences, University of Rhode Island, Kingston,
7. American Journal of Lifestyle Medicine, Vol. 2, No. 2, 113-117 (2008)
DOI: 10.1177/1559827607311977
8. Foreyt JP: The role of lifestyle modification in dysmetabolic syndrome management. Nestle Nutr
Workshop Ser Clin Perform Programme 2006, 11:197-205.
9. Bianchi C, Penno G, Daniele G, Benzi L, Del Prato S, Miccoli R: Optimizing management of
metabolic syndrome to reduce risk: focus on life-style. Intern Emerg Med 2008, 3(2):87-98’
10. Despres JP, Lemieux I: Abdominal obesity and metabolic syndrome. Nature 2006, 444(7121):881-
887.
11. Esmaillzadeh A, Kimiagar M, Mehrabi Y, Azadbakht L, Hu FB, Willett WC: Fruit and vegetable
intakes, C-reactive protein, and the metabolic syndrome. Am J Clin Nutr 2006, 84(6):1489-1497.
12. Feldeisen SE, Tucker KL: Nutritional strategies in the prevention and treatment of metabolic
syndrome. Appl Physiol Nutr Metab 2007, 32(1):46-60.
13. Wilson WF, Agostino R, Parise H, Sullivan L, Meigs J: Metabolic Syndrome as a precursor of
Cardiovascular Disease and Type 2 Diabetes Mellitus. Circulation 2005, 112:3066-72
14. Gotto AM Jr, Blackburn GL, Dailey GE III, Garber AJ, Grundy SM, Sobel BE, et al.: The metabolic
syndrome: A call to action. Coron Artery Dis 2006, 17:77-80.
15. Grundy SM: Metabolic syndrome pandemic. Arterioscler Thromb Vasc Biol 2008, 28(4):629-36.
16. Mohan V, Deepa M: The metabolic syndrome in developing countries. Diabetes Voice 2006, 51
17. Nutrition and metabolic syndrome. Rev Esp Salud Publica. 2007 Sep-Oct;81(5):489-505.
18. Mangat et al. Diabetology & Metabolic Syndrome 2010 2:19 doi:10.1186/1758-5996-2-19
19. http://dashdiet.org/metabolicsyndrome.asp
20. www2.medicine.wisc.edu/home/.../MedNutrHndbkMetbolSyn.newdoc
21. McKeown, N.M.; Meigs, J.B.; Liu, S.; Saltzman, E.; Wilson, P.W.F.; Jacques, P.F. Carbohydrate
nutrition,insulin resistance, and the prevalence of the metabolic syndrome in the Framingham
Offspring Cohort. Diabetes Care 2004, 27, 538–546. [CrossRef] [PubMed]
22. Volek, J.S.; Phinney, S.D.; Forsythe, C.E.; Quann, E.E.;Wood, R.J.; Puglisi, M.J.; Kraemer,W.J.;
Bibus, D.M.; Fernandez, M.L.; Feinman, R.D. Carbohydrate restriction has a more favorable impact
on the metabolic syndrome than a low fat diet. Lipids 2009, 44, 297–309. [CrossRef] [PubMed]
23. Volek, J.S.; Feinman, R.D. Carbohydrate restriction improves the features of Metabolic Syndrome.
Metabolic Syndrome may be defined by the response to carbohydrate restriction. Nutr. Metab.
2005, 2, 31. [CrossRef] [PubMed]
24. Kossoff, E.H.; Cervenka, M.C.; Henry, B.J.; Haney, C.A.; Turner, Z. A decade of the modified
Atkins diet (2003–2013): Results, insights, and future directions. Epilepsy Behav. 2013, 29, 437–
442. [CrossRef] [PubMed]
25. Feinman, R.D.; Pogozelski, W.K.; Astrup, A.; Bernstein, R.K.; Fine, E.J.; Westman, E.C.; Westman,
E.C.;Accurso, A.; Frassetto, L.; Gower, B.A.; et al. Dietary carbohydrate restriction as the first
approach in diabetes management: Critical review and evidence base. Nutrition 2015, 31, 1–13.
[CrossRef] [PubMed]
26. Accurso, A.; Bernstein, R.K.; Dahlqvist, A.; Draznin, B.; Feinman, R.D.; Fine, E.J.; Gleed, A.;
Jacobs, D.B.;Larson, G.; Lustig, R.H.; et al. Dietary carbohydrate restriction in type 2 diabetes
mellitus and metabolic syndrome: Time for a critical appraisal. Nutr. Metab. 2008, 5, 9. [CrossRef]
[PubMed]

CLINICAL NUTRITION ASSESSMENT and MEAL PLAN
STUDENT SECTION
NAME
TOPIC:
CASE
Data
Anthropometric
Measurements
Vital signs
Pertinent
Laboratory
Data
Clinical Data
Other
Observation

TOTAL ENERGY REQUIREMENT
Desirable body weight
kilogram
Adjusted IBW
(If required)
BMR
Harris-Benedict
Formula
TER =
BMR x AF x IF
Amount of Carbs/day
(grams)
Amount of Protein/day
(grams)
Amount of Fats/day
(grams)
PRINCIPLES FOR NUTRITIONAL THERAPY

FOOD EXCHANGE LIST COMPUTATION
Veg A
Veg B
Fruit
Milk
Sugar
Rice
Meat
Fat
TOTAL
DIVISION OF DAILY EXCHANGES BETWEEN MEALS
Number of meals in a day depends on dietary principle for disease.
Exchange # of Breakfast AM Lunch PM Dinner Late
group exchanges Snack snack Snack
Veg A
Veg B
Fruit
Milk
Sugar
Rice
Meat
Fat
TOTAL Cal
DAY’S MEAL PLAN
BREAKFAST Cal = AM SNACK Cal = LUNCH Cal =
DAY’S MEAL PLAN

PM SNACK Cal = DINNER Cal = LATE SNACK Cal =

Compare the 2 diets below.
MEDITERRANEAN DIET KETOGENIC DIET
Key Features and dietary distribution
Major Differences
Explain how the diet treat and prevent metabolic syndrome

CHAPTER 3
NUTRITION DURING ADULTHOOD

Donn Jerome Sto. Domingo M.D.
OVERVIEW
Nutritional support in adulthood especially in older age has important health and
social care implications. When adults’ nutritional needs are compromised by
malnourishment or obesity basic health and social care outcomes are
significantly affected. Based from the latest Philippine Nutrition Facts and Figures
survey in 2015 one out of ten adults was chronic energy deficient while
prevalence of android type of obesity is increasing in both adult men and women
warranting intervention. This chapter will discuss physiologic changes in
adulthood and its nutritional implication, nutritional care in adults and common
nutritional issues observed in this age group.
DIET FOR THE ADULT YEARS

A diet that maximizes long-term nutritional health in adulthood puts emphasis on
fat-free dairy products, low-fat, some lean meats and fish, plant-based proteins, a
variety of fruits and vegetables and considerable amount of whole-grains. Some
recommendations for a healthy nutrition in adulthood are as follows:
• Consume variety of nutrient-dense foods and drinks, while choosing foods limit
the intake of saturated fats, trans fats, cholesterol, added salts, sugars and
alcohol. Emphasize intake of fruits, vegetables, legumes, whole grains, and fat-
free or low-fat milk or equivalent dairy products.
• Maintain weight in a healthy range by balancing calorie intake and expenditure.
• Practice safe food handling when preparing food. This includes washing hands,
cleaning food contact surfaces, and fruits and vegetables before preparation, and
cooking foods to a safe temperature that will kill microorganisms
• Adults who rarely eats dairy products or calcium rich sources should be given
calcium supplements.
• Vegetarian adults may need to take a supplement containing vitamin B12
• All adults could benefit from limiting cured and smoked foods, obtaining adequate
fluoride to promote dental health and drinking plenty of fluids
The DOST-FNRI’s website presented the daily nutritional guide pyramid guide for
adults and older persons that can serve as a guide with regards to the portions
and servings of different food and beverages to maintain a healthy diet.

Fig. 1 Daily Nutritional Guide Pyramid for Filipino Adults and Older Persons
PHYSICAL ACTIVITY RECOMMENDATIONS
Based from WHO guidelines, for adults, physical activity can be undertaken as
part of recreation and leisure (play, games, sports, or planned exercise),
transportation (wheeling, walking and cycling), work or household chores, in the
context of daily occupational, educational, home and community settings. It is
recommended that:
• All adults should undertake regular physical activity

• Adults should do at least 150-300 minutes of moderate-intensity activity; or at
least 75-150 minutes of vigorous-intensity aerobic physical activity; or an
equivalent combination of moderate- and vigorous-intensity activity throughout
the week, for substantial health benefits.
• Adults should also do muscle-strengthening activities at moderate or greater
intensity that involve all major muscle groups on 2 or more days a week, as these
provide additional health benefits

PHYSIOLOGIC CHANGES IN ADULTHOOD AND ITS NUTRITIONAL
IMPLICATION
As one ages there is more variation in adults’ health status especially those over
the age of 50. This means that chronological age is not useful in predicting
physical health status. In order to foresee the nutritional problems in adults
especially for older population one should know the extent of physiological
change caused by aging and whether the person shows early warning signs for
long-term poor nutrition. The table below shows some of the physiologic changes
seen in older population and the recommended interventions for these changes.
Table 1. Age-Related Physiologic Changes

PHYSIOLOGIC CHANGES RECOMMENDED RESPONSES
¯ Appetite • Monitor weight and strive to eat enough
to maintain healthy weight.
• Use meal replacement products, such
as boost and Ensure plus.
¯ Sense of taste and smell • Vary the diet.
• Experiment with spices and herbs.
¯ Chewing ability • Work with a dentist to maximize
chewing ability
• Modify food consistency as necessary
• Eat calorie-rich snacks
¯ Sense of thirst • Consume plenty of fluid each day
• Stay alert for evidence of dehydration
(e.g., minimal urine output or dark-
colored urine).
¯ Bowel function • Consume enough fiber daily, choosing
primarily fruits, vegetables, and whole
grain breads and cereals.
• Meet fluid needs.
¯ Lactase production • Limit milk serving size at each use.
• Substitute yogurt or cheese for milk.
• Use reduced-lactose or lactose-free
products.
• Seek nondairy calcium sources.
¯ Iron Status • Include some lean meat and iron-
fortified foods in the diet.
• Monitor blood iron status.
¯ Liver function • Consume alcohol in moderation, if at
all.
• Avoid consuming excess vitamin A.
¯ Insulin function • Maintain healthy body weight.
• Perform regular physical activity.
¯ Kidney function • If necessary, work with physician and
registered physician to modify protein
and other nutrients in diet.
¯ Immune function • Meet nutrient needs, especially protein,
vitamin E, vitamin B6, and zinc.

¯ Lung function • Avoid tobacco products.
¯ Vision • Regularly consume sources of
carotenoids, vitamin C, vitamin E, and
zinc (e.g., fruits, vegetables and
wholegrain breads and cereals).
• Moderate total fat intake.
• Wear sunglasses in sunny conditions
• Avoid tobacco products
• Perform regular physical activity (to
lessen insulin resistance)
• In the case of diagnosed macular
degeneration, talk with physician about
following a protocol of zinc, copper,
vitamin E, vitamin C and beta-carotene
supplementation.
¯ Lean tissue • Meet nutrient needs, especially protein
and vitamin D
• Perform regular physical activity,
including strength training.
¯ Cardiovascular function • Use diet modification or physician-
prescribed medications to keep blood
lipids and blood pressure within
desirable ranges.
• Stay physically active.
• Achieve and maintain a healthy body
weight.
¯ Bone mass • Meet nutrient needs, especially calcium
and vitamin D
• Perform regular physical activity,
especially weight bearing exercise.
• Women should consider use of
approved osteoporosis medications at
menopause
• Remain at a healthy weight
¯ Mental function • Meet nutrient needs especially vitamin
E, vitamin C, vitamin B6, folate and
vitamin B12
• Strive lifelong learning
• Perform regular physical activity
• Obtain adequate sleep
- Fat stores • Avoid overeating
• Perform regular physical activity
ALTERNATIVE MEDICINE AND AGING
Adults in general and older adults in particular may be interested in using herbal
medicines as remedies for various conditions and identification of such
alternative medicines and including them in medication history is paramount as
they can have side effects and drug interactions that can affect medications

being taken by adult patients. A rational approach to the use of herbal products is
to use only one at a time, keep a diary of symptoms, and
check with one’s physician first before discontinuing a prescribed medication.
Table 2. Common food supplement and herbal medicines
Product Purported Effects Side effects Who Should Seek
Physician Guidance
Before Use
Black cohosh • Mild reduction of • Nausea • Women who have
postmenopausal • Fall in blood breast cancer
symptoms pressure • Pregnant women
(shown to be • Anyone taking
effective in some estrogen,
but not all hypertension
women; should medications, or blood-
not go beyond 6 thinning medications
months in
general)
Cranberry • Prevention or • Use of • People susceptible to
treatment of concentrated kidney stones
urinary tract tablets may • Anyone taking
infection (some increase the risk antidepressants or
evidence of of kidney stones prescription pain
efficacy) medications
Echinacea • Stimulation of the • Nausea • Anyone with
immune system • Skin irritation autoimmune disease
• Prevention or • Allergic reactions • Pre- or postsurgical
treatment of colds • Minor GI tract patients
or other infections upset • Anyone with allergies
(mild effect at • Increased to daisies
best) urination
Garlic • Antibiotic • GI upset (e.g., • Pre- or post-surgical
properties heartburn, patients
• Slight reduction of flatulence) • Perinatal women
blood cholesterol • Unpleasant odor • People with history of
or blood pressure gallstones
in some, but not • Anyone taking blood-
all, studies thinning medications
or antiretroviral
medications for AIDS
Ginseng • Increase energy • Hypertension • Anyone who takes
• Stress relief • Asthma attacks prescription drug
• Decreased • Irregular heart should consult a
weakness and beats physician before using
fatigue (efficacy • Insomnia • Women on hormone
largely unknown) • Headache replacement therapy
• Nervousness • Women who have
• GI upset breast cancer
• Reduced blood • Anyone with chronic
clotting GI tract disease
• Menstrual • Anyone with
irregularities and uncontrolled
breast hypertension
tenderness • Anyone with blood-

thinning medications,
diabetes medications,
antidepressants, or
heart failure
medications
Mangosteen • Antioxidant, anti- • Constipation, • Patients taking
inflammatory, bloating, nausea, anticoagulants and
anti-cancer, vomiting Donepezil (Aricept) for
promotes weight • May slow blood Alzheimer
loss clotting
• May increase the
effects of
donepezil
St. John’s wort • Alleviation of • Mild GI tract • Anyone who takes
depression (mild upset prescription drug
effect at best) • Rash • People with UV
• Tiredness sensitivity, including
• Restlessness that induced by
• Increase medications or other
sensitivity to treatments
sunlight • People with bipolar
disorder
• Anyone recovering
from a graft or organ
transplant
• Anyone taking Ritalin,
caffeine, HIV
medications, heart
failures medications,
cholesterol-lowering
medications, blood
thinning medications,
chemotherapy, OCP,
antidepressants,
antipsychotics, or
asthma medication
Turmeric • Hay fever • Stomach upset, • Patients with
symptoms such a nausea and gallbladder stones
sneezing, itching, vomiting, • People taking anti
runny nose, and dizziness, or coagulants
congestion diarrhea • Patients with hormone
• Depression sensitive conditions
• Anti-inflammatory like breast cancer,
• Fatty liver uterine cancer,
ovarian cancer,
endometriosis and
uterine fibroids
(curcumin acts like
hormone estrogen)
Valerian • Alleviation of • Impaired • Anyone taking central
restlessness and attention nervous system
other sleeping • Headache depressants
disorders that • Morning • Anyone who drinks
stem from grogginess alcohol
nervous • Irregular heart • People about to
conditions beat operate heavy
• Reduction of • GI tract upset machinery or drive
anxiety • Withdrawal
delirium
DIETARY ASSESSMENT
The use of dietary assessment is to obtain relevant information from the current
diet to identify dietary components that may raise or lower health risks. This
assessment determines which lifestyle and dietary changes might be appropriate,
and which existing nutritional habits should be encouraged.
Depending on the available time, dietary habits can be assessed quickly with a
few questions, or more formally using a more structured tools like 24-hour dietary
recall, food diary, or food frequency questionnaire.
24-hour dietary recall

The goal is to identify the day-to-day pattern of eating with a minimum of
reporting bias. The physician would ask what the patient consume in the last 24
hours, including beverages and if time will allow may also question about the
portion sizes of the foods. To save time, the physician may direct focus in the
nighttime meal and snacks consumed before going to bed which is often the area
of concern and changes from this alone can make beneficial difference.
The following questions can be asked in assessing the 24-hour dietary recall.
“What is the first thing you eat or drink yesterday?”; “Did you eat or drink anything
aside from that?”. Follow through questioning with timeframe, including snack
before going to sleep and any nighttime eating. Ask the time the patient went to
bed and when the last meal was taken (helpful is assessing GERD or IBD). Ask
about where foods are eaten (e.g., work, restaurants, home). This can help elicit
behaviors and lifestyle factors that underlie food choices. Most patients fail to
report alcohol and beverage consumption so it’s important to ask probing
question like “What did you have to drink with that?” Patient’s should also be
asked about quantity and frequency of alcohol consumption.
It is also prudent to ask food combinations such as cream in coffee or tea and
butter or cheese on bread. Avoid leasing questions. For example, “Did you put
butter on your bread?” or “Did you put creamer or your coffee?” instead ask them
if they has anything with bread or coffee.
Food diary
Another option to assess patient’s dietary choices is to ask patient to make a
food diary that contains a complete record of foods and beverages consumes
over those days. This significantly transfers the burden from the physician to the

patient. This is an excellent tool to help patients increase their awareness with
regards to their eating habits and encourage compliance with dietary regimens
Fig. 2 Sample My Food and Beverage Diary
Food frequency questionnaire
An abbreviated assessment can be done by getting only the frequency of typical

foods that are consumed in the diet. This tool covers typical intake over a period
of time (usually a week or a month). Focus on key areas that are correlated with
the patient’s most pressing health problems. For example, in a patient with high
low-density lipoproteins investigate sources of saturated fatty acids as well as
hydrogenated fats (trans-fats), at the same time for this patient you may look for
sources of soluble fiber that the patient may benefit from.

Table 3. Food frequency questionnaire
How often does patient Clinical evaluation Recommended amount
consume?
Fish How often is fish consumed? One or more times per week;
emphasize fatty fish and
encourage variety
Meat Lean, trimmed? <3 to 6 oz per day, as
appropriate
Poultry <3 to 6 oz skinless white meat
or thigh
Legumes Meat alternatives, dried Several times per week
beans, etc
Fruits Variety? (not just bananas) 2-3 whole fruits per day
Vegetables Variety? (not just potatoes and Volume should be one-half of
corn) the day’s intake, 2-3 cups per
day
Grains How much from white flour, Choose wholegrains most of
pasta? the time
Dairy What % milk fat? Cheese? Choose skim milk, lower-fat
cheeses; exercise portion
control
Sodium Added salt, canned foods, 2 grams sodium diet (less for
processed foods, cheese, certain conditions); no added
sauces, condiments, salt; less processed foods and
restaurants, and takeout cheese; decreased portions at
restaurants; buy low sodium
options
Nuts, seeds, good fats Ground flax, pumpkin, Approximate amount per
walnuts, other nuts and seeds, day: one-fourth cup nuts or
avocado, olive or canola oils one small handful, or 2
tablespoons good oils, or 2
tablespoons ground flaxseed
Added fats Cream, cheese, butter, oils, Choose small amounts of
sauces unsaturated, trans-fat-free
additions
Beverages Soda, juices, caloric Avoid regular use of
beverages sweetened beverages; water
down juices; caffeine in
moderation; increase water
instead of caloric beverages
Alcohol Is intake appropriate? Men: <2 drinks/day, women:
<1 drink/day; 1 drink is defined
as 12 oz of regular beer, 5 oz
of wine (12 percent alcohol), or
1.5 oz of 80-proof distilled
spirits
Minimal amounts best for

patient with elevated
triglycerides, diabetes, or
hypertension
Water Is intake appropriate? Fluid intake guided by thirst
except in patients with known

impairment of the thirst
mechanism
Friend foods Ask about preparation Encourage broiling, baking,
sautéing, boiling
Restaurant fare or takeout How many times/week or Specify healthy food
month? preparation methods and
encourage patient to request
more vegetables and ask for
low-sodium options; portion
control is essential
SCREENING FOR NUTRITIONAL STATUS
A significant number of adult patients in the hospital have covert malnutrition and
as healthcare providers we have a responsibility to identify and screen patients
for undernutrition. Features of the patient’s primary health concern are routinely
screened like dehydration, fever and vital signs and it is intolerable that nutritional
problems causing significant clinical risk are not identified.
The purpose of nutritional screening is to foresee the probability of a better or

worse outcome due to nutritional factors, and whether nutritional intervention in
likely to influence this. Outcomes from treatment may be assessed in a number
of ways:
• Improvement or at least prevention of deterioration in mental and physical

function.
• Reduced number of severity of complications of disease or its treatment.
• Accelerated recovery from disease and shortened convalescence.
• Reduced consumption of resources e.g. length of hospital stays and other
prescriptions
Screening tools are designed to detect energy and protein undernutrition, and/or
to foresee whether undernutrition is likely to develop or worsen under the present
or future condition of the patient. Therefore, a screening tool should be based on
the four main principles.
1. What is the condition now?

This is done by getting a baseline BMI or the mid-arm circumference in
critically ill patients wherein taking height and weight is not possible and
subsequently comparing it to percentiles of tables for that particular
population, age and sex.
2. Is the condition stable?

Recent weight loss is obtained from the patient’s history, or even better,
from previous measurements in medical records. Studies suggest that
weight loss in adults mainly in older adults, especially if non volitional, is

predictive of mortality. Weight loss is considered to be clinically significant
with the following criterion:
• ≥ 2% decrease from baseline body weight in one month
• ≥ 5% decrease in three months, or
• ≥ 10% decrease six months
3. Will the condition get worse?

The question may be answered by asking the patient or caregiver whether food
intake has been decreased up to the time of screening and is so how much and
how long.
4. Will the disease process accelerate?
Disease process may increase nutritional requirements due to increase in
the basal metabolic rate, anorexia and cachexia as well as sarcopenia.
SCREENING TOOLS
The screening tools discussed in this section are recommended by European

Society for Clinical Nutrition and Metabolism (ESPEN). Several screening tools
have been developed for identifying adults at risk for poor nutrition:
Malnutrition Universal Screening Tool (MUST)
This screening tool takes into account the patient’s BMI, weight loss in the past
3-6 months and anorexia for 5 days due to the patient’s current condition. It is a
five-step screening tool to identify adults who are malnourished, at risk of
malnutrition, or obese. It is used in both the community and hospital care setting.
The 5 ‘MUST’ Steps

Step 1
Measure height and weight to get a BMI score using chart provided. If unable to
obtain height and weight, use the alternative procedures shown in this guide.
Step 2
Note percentage unplanned weight loss and score using tables provided.
Step 3
Establish acute disease effect and score.
Step 4
Add scores from steps 1, 2, and 3 together to obtain overall risk of malnutrition.
Step 5
Use management guidelines and/or local policy to develop care plan

Fig 3. Algorithm for the Malnutrition Universal Screening Tool

For other alternative measurements when height and weight are unobtainable
and other tables you may visit https://www.bapen.org.uk/pdfs/must/must_full.pdf
The Nutritional Risk Screening (NRS) 2002

This screening tool consist of two components: a screening assessment for
undernutrition and an estimate for disease severity. Undernutrition is estimated
using three variables: Body Mass Index, percent weight loss, and change in food
intake. Disease severity ranges from a score of zero (those with chronic
illnesses) to three (those in ICU with an APACHE score of 10)
Table 4. The NRS tool

Mini Nutritional Assessment
The MNA is a validated nutrition screening and assessment tool that can identify
older patients age 65 and above who are malnourished or at risk of malnutrition.
It was developed in the 1990s and is most well validated nutrition tool for the
elderly. The purpose of MNA is to identify the presence of undernutrition and the
risk of developing undernutrition among older age groups in hospitals, home-care
facilities and nursing homes. It consists of a global assessment and subjective
perception of health, as well as questions specific to diet, and a series of
anthropometric measurements.

Fig 4. Mini Nutritional Assessment tool for older patients
NUTRITIONAL ISSUES IN OLDER ADULTS
Why Nutrition is Important: Patient Over the Age of 65
• As aging coincides with various physical, mental, and lifestyle developments that
affect food intake, the prevalence of malnutrition in geriatric population becomes
significantly higher.
• Chronic diseases are more prevalent in older adults and treatment for such
diseases may interfere with proper nutrient absorption leading to undernutrition.
• Dementia is one of the diseases common in older age group that affects
nutritional status; complications range from dysphagia to anorexia, and therefore
inhibit proper nutrition.
• Malnutrition is associated with a variety of health complications, including
increased mortality, immune suppression, muscle wasting, longer length of
hospital stay and higher healthcare cost.
MALNUTRITION
Physiologic changes that occurs with normal aging increases nutritional risk for
older population. Aging is characterized by weakened homeostatic controls and
diminished organ reserves. Comparing young adults with older adults,
undernutrition is common in the later and have a greater impact on outcomes,
including physical function, health care utilization and length of stay for surgical
hospitalizations. Studies of acute hospitalization in older age groups found that
malnutrition and weight loss are independent predictors of length of hospital stay
(LOS) and low scores in mini-nutritional assessment (MNA) test that assess
malnutrition is a predictor of mortality.
Nutritional needs of older population are determined by:

• Specific health problems and related organ system compromise
• Individual’s level of activity, energy expenditure and caloric requirements
• Ability to prepare, access, ingest and digest food
• Personal food preferences

DIAGNOSTIC CRITERIA FOR MALNUTRITION
The criteria for the diagnosis of malnutrition based from the recommendation of
the Global Leadership Initiative on Malnutrition (GLIM) includes a two-step model
for risk screening and diagnosis. The first key step is to evaluate who are “at risk”
by using any of the validated screening tool (table 1) followed by the second step
of assessment for diagnosis as well as severity grading described below.
Table 5.
After identification of patients at risk it is then followed by diagnosis which

requires the combination of at least one etiologic and one phenotype
criteria:
Etiologic criteria
• Reduced food intake or assimilation
o Less than or equal to 50% of energy requirement for more than 1 week or
any reduction for 2 weeks, or any chronic GI condition that adversely
impacts food assimilation or absorption.
• Disease burden or inflammation
o Acute disease/injury
o Chronic disease-related
Phenotype criteria
• Non-volitional weight loss
o >5% within the past 6 months or
o >10% beyond 6 months

• Low body mass index (BMI)
o <20% if <70 years, or
o <22 if >70 years
Asia:
o <18.5 if <70 years, or
o <20 if >70 years
• Reduced muscle mass
o Reduced by validated body composition measuring techniques. Examples
include dual-energy absorptiometry or corresponding standards like
bioelectrical impedance analysis, CT or MRI. When not available physical
examination or standard anthropometric measures like mid arm and calf
muscle circumference may be used. Functional assessments like hand-
grip strength may be considered as supportive measure
Table 6.
Fig 1. GLIM diagnostic scheme for screening, assessment, diagnosis and grading of malnutrition

Etiology-based diagnosis classification has been endorsed by the GLIM from
previous consensus. The classification includes:
• Malnutrition related to
o Chronic disease with inflammation
o Chronic disease with minimal or no perceived inflammation
o Acute disease or injury with severe inflammation
o Starvation including hunger/food storage associated with socio-economic
or environmental factors
OVERNUTRITION
According to WHO about 13% of the world’s adult population (11% of men and
15% of women) were obese in 2016. Overweight and obesity are linked to more
deaths worldwide than underweight owing to morbidities related to it such as
cardiovascular diseases, diabetes mellitus, and some forms of cancer. It can also
cause highly disabling condition like osteoarthritis that lowers one’s quality of life.
However, several researches suggest that the relationship of overweight or
obesity to mortality diminishes over time.
Although the mortality risk of obese may decrease with age, there are still
functional and metabolic benefits to losing weight in obese older adults such as
improvement in physical function, better blood glucose and cholesterol levels,
and quality of life. Recommendations to lose weight should be individualized to
the risk profile of a patient. Patients who are experiencing significant adverse
effects associated with overnutrition (such as pain from osteoarthritis, poor
mobility, and obstructive sleep apnea) should be encouraged to pursue a careful
and monitored weight loss.
There are several ways to determine overnutrition but commonly used tools in
adults are the BMI, Waist circumference and Waist-Hip Ratio
Body Mass index
BMI is commonly used to classify overweight and obesity in adults. This provides
the most useful population-level measure of overweight and obesity as the
standards are the same for both sexes, and in the case of adults, the same for all
ages. The formula for obtaining the Body Mass Index is
The cut-off points used to classify adults according to their BMI as recommended
by WHO and Asia-Pacific Consortium are shown below. Studies among Asians
have shown that BMI levels may not correspond to the same degree of fatness in
Asian population compared to Western counterparts due to in part, to different
body proportion.
Table 7. BMI cut-off points. WHO
Table 8. BMI cut-off points, Asia-Pacific Consortium
Waist circumference
In addition to getting BMI it is suggested that measuring waist circumference in

patients considered as overweight or obese to assess abdominal adiposity and
provides an independent risk information that is not accounted for by BMI. Waist
circumference is measured using a measuring tape placed on a horizontal plane
at the level of the iliac crest. A waist circumference of more than or equal to 31
inches (80 cm) in Asian females and more than or equal to 35 inches (90 cm) in
Asian males is considered abnormal.
Patients with abdominal obesity (also known as visceral, android, central, or

male-type obesity) are at increased risk for diabetes, hypertension, heart disease,

dyslipidemia, nonalcoholic fatty liver disease and have higher overall mortality
rates.
Waist-Hip Ratio
Waist-Hip Ratio is a useful indicator of body fat distribution and adiposity. It also
serves as a guide in evaluating health risk like diabetes and cardiovascular
diseases. The WHR is obtained by dividing the circumference of the waist at its
narrowest point by the widest point of the hip circumference
The recommended WHR in men is less than 1.0 and less than 0.85 for women.
Equal or greater than the recommended WHR in men and women is an indicator
that an individual has an android obesity which is correlated to the development
of disease mentioned above. The type of obesity where fats are deposited
outside the abdomen or around the thighs and buttocks is called gynoid (pear
shape) obesity. This is not usually associated with chronic diseases that is more
common in women.
MICRONUTRIENT DEFICIENCIES IN OLDER ADULTS (tables of RDA for

micronutrients)
The current perspective of diet-related disorders focuses on obesity and weight-

related diseases with the emphasis on reducing energy intake. This can have
nutritional consequences in the elderly especially with the physiologic changes
related to aging. Commonly affected micronutrients are vitamin B12, calcium and
vitamin D that will be the focus of this section.
Vitamin B12
The prevalence of cobalamin deficiency in geriatric age group ranges between

10-20% or higher due to under diagnosis. The age-related decrease in gastric
acid secretion and decrease consumption of animal products may be some of the
reason putting elderlies at risk. Some medications commonly taken may also
interfere with vitamin B12 absorption (e.g., proton pump inhibitors, metformin)
contributing to its prevalence. Because vitamin B12 malabsorption is common in
this age group with significant effect on the nervous system, individuals >51
years of age should take supplements containing vitamin B12, or eat fortified
food products. Diagnosis can be done by getting the serum vitamin B12 or in
borderline values, methylmalonic acid and homocysteine to differentiate it with
folic acid deficiency.

Vitamin D
Lack of sun exposure, impaired dermal synthesis of pre-vitamin D, and

decreased kidney hydroxylation with advancing age as well as low dietary intake
contributes to borderline low levels of vitamin D in many older adults. Several
studies have shown that inadequate vitamin D is linked to muscle weakness,
functional impairment, depression, and increased risk for falls and fractures.
25-hydroxyvitamin D the major circulating form is found to be low (<20ng/ml or

50nmol/L) in many older adults. Individuals who are at higher risk for vitamin D
deficiency are those who are in nursing homes or homebound, have limited sun
exposure, obese, darker skin, and has conditions like osteoporosis or
malabsorption. Monitoring 25-hydroxyvitamin D in these individuals with a goal of
reaching levels of ≥30 ng/ml should be targeted. Laboratory testing at 3-4 months
after initiation of supplementation, if needed, should be done to assure that target
levels has been achieved.
Calcium
Calcium nutrition is strongly influenced by age due to the fact the its absorption
from the gastrointestinal tract significantly diminishes after 60 years of age. Older
individuals between 70 and 90 years old absorb approximately one-third less
calcium than do younger adults. Given the impact of calcium deficiency on
cortical bone loss, the Food and Nutrition Institute recommended daily intake of
calcium at least 800mg for both men and women ages 60 and above.
Table 9. Food and Drinks with calcium

References:
1. Wardlaw, Gorndon M. & Smith, Ann M. (2009). Contemporary Nutrition 7th

edition: McGraw-Hill
2. Christine Ritchie, MDm MSPH & Michi Yukawa MD, MPH. Geriatric
nutrition: Nutritional issues in older adults. UptoDate.com
3. Barbara Olendzki, RD, MPH, LDN. Dietary assessment in adults.

UptoDate.com
4. Malnutrition Solution Center. Retrieved from

http://www.nutritioncare.org/Guidelines_and_Clinical_Resources/Malnutriti
on_Solution_Center/
5. Nutritional Guidelines for Filipinos (revised edition 2012). Retrieved from

https://www.fnri.dost.gov.ph/images/images/standardtools/NGF-2012.pdf
6. Philippines Nutrition Facts and Figures 2018 Expanded National Nutrition

Survey. Retrieved from
http://enutrition.fnri.dost.gov.ph/site/uploads/2018_ENNS_Facts_and_Figu
res.pdf
7. WHO Guidelines on Physical Activity and Sedentary Behavior. World

Health Organization (2020)
8. Cederholm T, et. al., GLIM criteria for the diagnosis of malnutrition – A

consensus report from the global clinical nutrition community, Clinical
Nutrition (2018), https://doi.org/10.1016/j.clnu.2018.08.002

STUDENT SECTION
NAME
TOPIC:
CASE
Data
Anthropometric
Measurements
Vital signs
Pertinent
Laboratory
Data
Clinical Data
Other
Observation

kilogram
Adjusted IBW
(If required)
BMR
Harris-Benedict
Formula
TER =
BMR x AF x IF
Amount of Carbs/day
(grams)
(grams)
Amount of Fats/day
(grams)

Veg A
Veg B
Fruit
Milk
Sugar
Rice
Meat
Fat
TOTAL
Veg A
Veg B
Fruit
Milk
Sugar
Rice
Meat
Fat
TOTAL Cal
DAY’S MEAL PLAN
DAY’S MEAL PLAN


CHAPTER 4
NUTRITION DURING PREGNANCY AND LACTATION
Anna Belen Ignacio-Alensuela, MD, FPOGS
INTRODUCTION
An obstetrician’s job is difficult. One cares for two individuals simultaneously:

pregnant mother and growing child in womb. The objective of prenatal care is to
ensure maternal and fetal well-being for an optimum pregnancy outcome.
The Philippine Situation: Demographic factors
Across socioeconomic quintiles, the crude fertility rate was highest in the poorest
socioeconomic quintile (6.5), almost 3 times the rate in the richest quintile (2.1).
The high birth rates ensure the greater vulnerability of the poorest mothers during
their pregnancy and delivery, and increase the risks for their infants [24].
The Philippine situation: Maternal mortality
Currently, according to the WHO, the Philippine maternal mortality rate remains
high. One hundred sixty (160) women die for every 100,000 deliveries. This
means 10 women die daily due to complications of pregnancy and childbirth.
This is one of the highest rates in Asia.
Nationwide data from accredited hospitals, indicate that the top causes of
obstetric deaths are: hemorrhage (33.6%), hypertension (24.7%), infection
(9.9%) and vascular accidents (3.28%) (Philippine Obstetrical and Gynecologic
Society CNS Statistics, 2001). Six million of the estimated 14 million women, 15-
49 years old, are considered high risk. They are too young (in their teens) or too
old (above age 40 years), have had four or more pregnancies, have less than 15
months interval between births, or are poorly nourished or otherwise unhealthy
(Situation of Children and Women in the Philippines, 1997).
Factors contributing to these deaths include closely spaced pregnancies, poor
prenatal care, inadequate systems for detecting and managing high-risk
pregnancies, an inadequate referral system, inadequate competence of birth
attendants, and poor nutrition.
The World Health Organization reports that only 28% of deliveries in the
Philippines occur in health facilities (72% outside of health facilities) and that only
53% of deliveries have a skilled attendant (NDHS 1998). Government field data
(FHSIS 2000) showed that only 69% receive assistance at delivery from a doctor,
nurse, or midwife; and 31% are assisted by TBAs (hilots). Overall, midwives
provide the largest percentage of delivery care at 40.7%.
Only modest improvements in antenatal care have been made. Overall, only
64.8% of pregnant women have had three or more prenatal visits (FHSIS 2000).
Linked to poor coverage for antenatal care is the low coverage for immunization
and nutritional supplementation. Immunization coverage for tetanus toxoid is only
62% (FHSIS 2000). Only 46.9% of pregnant women received complete iron
supplementation (FHSIS 1999), and 57% received iodine supplementation
(National Demographic Health Survey, 1998). According to alternative data in
2000, 60.3% of women received iodine capsules and 78.5% took iron
supplements related to the pregnancy with their youngest surviving child
(Maternal and Child Health Survey, 2000).
There are wide regional differences in these indicators of prenatal care (FHSIS
2000). Generally, a higher percentage of women living in urban areas than in
rural areas took iron and iodine supplements. There is no national program or
national data for folic acid supplementation. However, a field survey of 2,336
women conducted over a 5 year period found very low rates – 3.2-16.7% for
urban mothers and 4.5-8.2% for rural mothers (Festin et al., 2000). This is
unfortunate because conditions now thought to be prevented by folic acid
supplementation are prevalent in the Philippines, including neural tube defects
and other congenital anomalies, such as cleft lip and palate, limb defects, and
some heart defects.
Postpartum indicators are faring even worse. Overall, only about 74% of women
receive postpartum visits and only 57% of lactating women receive vitamin A.
Even in the urbanized National Capital Region, prenatal and postpartum care
rates are not significantly better than the national averages.
Summarizing the report of Basics Support for Institutionalizing Child Survival
Project (BASICS II) in 2004, the gaps in maternal health in our country are as
follows [24]:
Poor coverage and quality of antenatal care
• Low tetanus toxoid immunization rate

• High rates of iron deficiency anemia
• High prevalence of goiter
• Low awareness of danger signs
• Low folic acid supplementation
Therefore, this article serves to educate young physicians in taking care of

maternal nutrition during pregnancy and lactation.

HIGH RISK PREGNANCIES
Some pregnancies jeopardize the life and health of the mother and the infant.
The following table identifies several characteristics of a high risk pregnancy. All
pregnant women, especially those in high risk categories, need prenatal care
including dietary advice.
The infant’s survival is closely linked to the health and nutritional status of the
mother, her ability to space the births of her children, and the care she receives
during pregnancy, child birth and the postnatal period.
High risk pregnancy factors:
Factor Condition that raises risk

Maternal Prior to pregnancy Pre-pregnancy BMI either < 19.8 or > 26
weight During pregnancy Insufficient or excessive pregnancy weight
gain
Maternal nutrition Nutrient deficiencies or toxicities
Socioeconomic status Poverty, lack of family support, low level of
education, limited food available
Lifestyle habits Smoking, alcohol, or drug abuse
Age Teens, especially 15 years or younger;
women 35 years or older
Previous Number < 20 years old; 3 or more pregnancies
pregnancies ≥ 20 years old; 4 or more pregnancies
Interval Short intervals (<18 months) or long (>59
months)
Outcomes Previous history of problems
Multiple births Twins or triplets
Birth weight SGA or LGA babies
Maternal Hypertension Pre-eclampsia/eclampsia
health Diabetes GDM
Chronic diseases DM, CVD, renal disease, genetic disorders

Maternal weight prior to pregnancy
According to the NICE (National Institute for Clinical Excellence) Fertility

Guidelines from the RCOG (Royal College of Obstetrics and Gynecolocy), the
following are the effects of malnutrition in fertility:
1. Women who have a body mass index of more than 29 should be informed that
they are likely to take longer to conceive. (Level of evidence B)
2. Women who have a body mass index of more than 29 and who are not ovulating
should be informed that losing weight is likely to increase their chance of
conception. (Level of evidence B)
3. Women should be informed that participating in a group programme involving
exercise and dietary advice leads to more pregnancies than weight loss advice
alone. (Level of evidence A)
4. Men who have a body mass index of more than 29 should be informed that they
are likely to have reduced fertility. (Level of evidence C)
5. Women who have a body mass index of less than 19 and who have irregular
menstruation or are not menstruating should be advised that increasing body
weight is likely to improve their chance of conception. (Level of evidence B)
Weight gain during pregnancy
Many women in developing countries restrict their food intake during pregnancy
because they wanted to have smaller infants. These women believe that smaller
infants will carry a lower risk of delivery complications. Inadequate weight gain
during the second half of pregnancy has been known to predict an adverse
pregnancy outcome. Thus it is imperative that weight gain during pregnancy be
monitored. For the first half of the 20th century, it was recommended that weight
gain during pregnancy be limited to less than 20 lb (9.1 kg). It was believed that
such restriction would prevent pregnancy hypertensive disorders and fetal
macrosomia resulting in operative deliveries. By the 1970s, however, women
were encouraged to gain at least 25 lb (11.4 kg) to prevent preterm birth and fetal
growth restriction, a recommendation that subsequent research continues to
support (Ehrenberg and associates, 2003). In 1990, the Institute of Medicine
recommended a weight gain of 25 to 35 lb (11.5 to 16 kg) for women with a
normal prepregnancy body mass index (BMI). Weight gains recommended by the
Institute of Medicine (1990) according to prepregnant BMI categories are shown
in the table below. The American Academy of Pediatrics and the American
College of Obstetricians and Gynecologists (2002) have endorsed these
guidelines. Of note, in 2001, almost 1 in 3 women had weight gains outside the
Institute of Medicine guidelines [6].

Recommended Ranges of Total Weight Gain for Pregnant Women by Pre-
pregnancy Body Mass Index (BMI) for Singleton Gestation
Weight-for-Height Category Recommended Total Weight Gain
Category BMI Kg Lb
Low <19.8 12.5 – 18 28 – 40
Normal 19.8-26 11.5 – 16 25 – 35
High 26-29 7 – 11.5 15 – 25
Obese >29 7  15
Effects of Faulty Maternal Nutrition
The nutritional status of the mother is closely associated with the health of the
newborn, including whether the newborn is carried to full term and its weight at
birth. Based on the weight for height reference standard for Filipino pregnant
women, 14.7% were classified as nutritionally at risk. Teenage pregnant women,
age less than 20 years, were at higher risk due to poor nutrition (18.4%),
compared to those over 20 years of age (14.3%) (FNRI Survey, 1998). In 1993,
the FNRI nutrition survey found that 43.6% of pregnant and 43.0% of lactating
women suffered from iron deficiency anemia. The Fourth National Nutrition
Survey (NNS) reported that, among 778 pregnant women, 23% had goiter, which
suggests that even more women suffer from an iodine deficiency disorder not yet
indicated by goiter.
Faulty maternal nutrition can lead to infertility, complications in embryogenesis

and
problems in fetal growth.
Malnutrition prevents women from carrying a child to term. Studies have shown
that among pregnant malnourished women, 40% will end up in abortion on or
before 8 weeks AOG and another 10% will likewise be aborted before the
completion of 20 weeks AOG. Of the 50% who will go beyond 20 weeks AOG,
25% will end up in fetal death. Therefore, only 25% of pregnant malnourished
women will have viable pregnancies.
Likewise, among the 10 leading causes of infant mortality in our country, faulty
maternal nutrition has also been implicated. This includes the following:
Respiratory conditions of the newborn and fetus, Pneumonia, Congenital
anomalies, Diarrheal diseases, Birth injuries, Septicemia, Measles,
Meningitis, Other disease of the respiratory system, Avitaminoses and
other nutritional deficiency.

The common congenital anomalies in the Philippines include neural tube defects,
cardiovascular malformations, orofacial clefts, limb deficiencies, urinary tract
defects and anomalies of the alimentary tract. Of these, neural tube defects
remain the leading cause of infant mortality. Neural tube defects are known to be
secondary to folic acid deficiency.
In a classic study of Guthne et al in 1995, he demonstrated that inadequate food

intake and poor nutrient utilization can lead to fetal growth retardation (IUGR).
Inadequate food intake and poor nutrient utilization can lead to maternal
malnutrition. This in turn will lead to reduced blood volume expansion,
inadequate increase in cardiac output, eventually leading to decreased blood and
nutrient supply to the fetus. This reduction will cascade leading to reduced
placental size and reduced nutrient transfer, both of which will cause IUGR [2].
Babies born to unhealthy mothers will have serious health problems in the future.
Susser et al in 1999 suggested that such infants have had to adapt to a limited
supply of nutrients and that in so doing their physiology and metabolism are
permanently challenged [3]. Furthermore, Barkr earlier in 1997 stated that
evidence suggests that infants who are small or disproportionate at birth have an
increased health risk later in life [4].
Two factors determine fetal growth: Pre-pregnant nutritional status and weight
gain during pregnancy.
According to the Philippine Food and Nutrition Research Institute (FNRI), the
average Filipino woman may not be able to meet the required dietary allowances
except for vitamin A. This is a clear evidence that Filipinas are already
nutritionally deficient even prior to pregnancy, therefore, they are at potential risk
including the possible damage to their offspring.
Adolescent pregnancy may also lead to adverse maternal and fetal outcomes
because of competition between the developing mother and the growing fetus.
This is a growing concern in our country.
The average age of initiation to sex is 17.5 years (2002). The number of youth
who have had sex before age 15 has increased eight-fold from less than 2% in
1994 to around 16% in 2002. One-third of women age 20-24 years have already
given birth to their first child before reaching their 21st birthday (YAFS 2).
Teenagers who have begun childbearing are increasing from the 9% reported in
1993 to 11% in 1998 (National Demographic Survey, 1993 and 1998). Worth
noting also is that at age 18, 10% of girls are already mothers; at age 20, 25%
are mothers; at age 24, 50% are mothers. One third of Filipino young women
already have 2-3 children [24].

Short intervals between births: Close spacing of pregnancies may deplete
nutritional stores and affect subsequent progeny. Inter-pregnancy intervals
shorter than 18 months and longer than 59 months are significantly associated
with increased risk of adverse perinatal outcomes [5]. Inter-pregnancy intervals <
6 months were associated with increased risks of preterm birth, low birth weight,
and SGA babies.
Obesity is associated with a higher incidence of fetal macrosomia, operative

deliveries, gestational diabetes mellitus, pre-eclampsia, perinatal mortality, late
fetal death (3-4x increased), and early neonatal death (2x).
THE CRITICAL PERIOD
Maternal nutrition before and during pregnancy affects both the mother’s health
and the infant’s growth. As the infant develops through its 3 stages – the zygote,
the embryo, and the fetus – its organs and tissues grow, each on its own
schedule. Critical periods are times of intense development and rapid cell
division. It is critical in the sense that those cellular activities can occur only at
those times. If cell division and number are limited during a critical period, full
recovery will not occur. These times of intense development depend on nutrients
to proceed smoothly. Optimizing maternal and fetal health with maternal nutrition
is the key for a healthier community.
COMPONENTS OF NUTRITION:
Nutrition is composed of energy, carbohydrates, proteins and fats.

Likewise, there are important micronutrients like vitamins and minerals needed
during pregnancy and lactation. To better understand the concepts, we shall
answer frequently asked questions relevant to maternal nutrition.
FREQUENTLY ASKED QUESTIONS (FAQ):
1. Do I need to eat for 2 now that I am pregnant?

2. How should my diet change now that I am pregnant?
3. What other nutrients do I need for a healthy pregnancy?
4. Should I take multivitamins during pregnancy?
5. What should I avoid during pregnancy?

FAQ: 1. Do I need to eat for 2 now that I am pregnant?
Answer: No.
Additional caloric requirement is only 300 kcal starting the second trimester
onwards.
The following table supplies information for the recommended energy and
nutrient intakes (RENI) for the Filipinos [7].
Population group Weight (kg) Energy (kcal) Protein (g)

Non-pregnant, y
10 – 12 35 1920 49
13 – 15 49 2250 63
16 – 18 50 2050 59
19 – 29 51 1860 58
30 – 49 51 1810 58
50 – 64 51 1620 58
65+ 51 1410 58
Pregnant
ST
66
1 Trimester
nd
+300 66
2 Trimester
rd
+300 66
3 Tirmester
Lactating 0-6 mos +500 81
Lactating 7- 12 mos +500 76
Since there is no increased caloric requirement during the first trimester, is

it safe to presume that I don’t need to change my diet during the first 3
monthsnow that I am pregnant?
The quality of a woman's diet during pregnancy has a profound influence on

positive fetal and maternal outcomes. Dietary quality, particularly during the first
trimester of pregnancy, exerts a strong influence on fetal and placental
development and on subsequent fetal growth and maternal well-being
(Carmichael & Abrams, 1997; Siega-Riz, Adair, & Hobel, 1996; Smith, 2004).
During the first two months of pregnancy, the embryo and placenta undergo a
process of rapid cell differentiation and division and are particularly sensitive to
excesses and deficiencies in micronutrients. Adequate maternal nutritional status
is an essential component of the intrauterine environment during this critical time
of fetal development. Additionally, recent research suggests that inadequate
levels of maternal nutrients during this crucial period of fetal development may
lead to “reprogramming” within the fetal tissues that predisposes the infant to
chronic illnesses in adulthood (Godfrey & Barker, 2001).
Adequate maternal nutritional status is an essential component of the intrauterine
environment during this critical time of fetal development [8].
FAQ: 2. How should my diet change now that I am pregnant?
Answer: If you are eating a healthy diet before pregnancy, only a few
changes are needed to meet the nutritional demands of pregnancy.
CARBOHYDRATES: Major source of energy. Sources include whole grains,

cereals, vegetables, dried beans, peas. Daily requirement increases from 150
g/day in the 1st trimester to 225 g/day in the 3rd trimester. Deficiency could lead
to low blood sugar, resulting in weight loss, and fetal growth retardation. Excess
on the other hand is associated with LBW babies and small placentas, and
maternal hyperglycemia and fetal macrosomia.
FATS: The most concentrated forms of energy. In pregnancy, its concentration

and utilization are elevated to spare glucose. It is the first one to be mobilized
when baby is supplied with energy. It functions as carriers of fat-soluble vitamins
and essential fatty acids. It is a vital structural component of tissues. ESSENTIAL
FATTY ACIDS (EFA) are building blocks or precursors of DHA (docosahexanoic

acid) which is important for the normal development of cell walls of the baby’s
brain and eyes. Deficiency in cholesterol and lipoproteins leads to low levels of
progesterone and estrogen, which translates into poor fetal growth and
development.
PROTEIN: It is essential for growth and repair. Deficiency can cause LBW babies
with low placental weights, hypochromic anemia, nutritional edema, and poor
calcium absorption. Pre-pregnant RENI is 58 grams/day plus 8 grams during
pregnancy and 23 grams during the first 6 months and 18 grams during the next
6 months of lactation. Sources include meat, milk, eggs, cheese, poultry, fish,
legumes, grains. It is utilized at up to 70% efficiency in pregnancy, peaking at 29
weeks AOG when fetal growth is maximal. Balanced energy/protein
supplementation improves fetal growth and may reduce the risk of fetal and
neonatal death. High-protein or balanced protein supplementation alone is not
beneficial and may be harmful to the infant. Protein/energy restriction of pregnant
women who are overweight or exhibit high weight gain is unlikely to be beneficial
and may be harmful to the infant [9].
Pregnant women should increase their usual servings from the 4 basic food
groups (1800 - 2100 kcal/day) as follows: FNRI
• 1-1.5 cups fruits and 2 cups of vegetables daily for vitamins and minerals
• 3.5 to 4.5 cups of whole-grains or enriched Breads/Cereals
• 2 – 3 cups of low-fat or non-fat milk, yogurt, or other dairy products like
cheese for calcium
• 5 – 6 oz of meat and beans
• 40 grams of additional fat
Water carries the nutrients from the food to the fetus. It helps prevent
constipation, hemorrhoids, excessive swelling, and UTI. Coffee, soft drinks, and
teas that have caffeine activity actually reduce the amount of fluid in the body.
The National Women’s Health Information Center, US DOHHS suggested that
pregnant women should drink at least 6 8-ounce glasses of water per day.
Should I limit how much fish I eat when I’m pregnant?
Some fish have mercury, which in high doses, can hurt the baby’s growing brain
and nervous system. [The National Women’s Health Information Center, US
DOHHS]
• Do NOT eat any shark, swordfish, king mackerel, or tilefish (golden or
white snapper)
• Do not eat > 6 ounces of “white” or “albacore” tuna or tuna steak each
week
• Don’t eat uncooked or undercooked meats or fish. Choose shrimp,
salmon, pollock, catfish, or “light” tuna
• Limit fish intake to no more than 2 servings (12 ounces total) per week.
This is based on a study of Sato et al where in an island state with high
levels of fish consumption, women were 3 times more likely to have
elevated cord blood mercury levels, compared with the national average
[10].
How about vitamins and minerals? Is supplementation really needed?
Pregnant Filipino women are eating heavier but not necessarily better. The 2003
national survey by the Food and Nutrition Research Institute (FNRI) show that
niacin and iodine are the only nutrients adequately ingested by childbearing
women despite higher intakes of meat and poultry on top of the continuing
preponderance of rice in the Filipino diet. The new "no deficiency" state of iodine
among pregnant women and children are attributed to inroads made by the
national salt-fortification program.
Intake of critical prenatal nutrients, notably iron and calcium, remains dismally
low at 28.8 percent and 52.3 percent of the daily recommended energy and
nutrient intakes (RENI), the new dietary standards which replaced recommended
daily allowance (RDA) since 2002. While folate, another important maternity
nutrient, did not fall under the ambit of the survey, the relative decline in the
consumption of vegetables and fruits and low intakes of potentially folate-fortified
foods like non-rice cereals and milk do not augur well. Folate, a foil against
neural-tube defects (NTDs), is also not as bioavailable in its naturally occurring
state as synthetic folic acid.

MINERALS
The body is incapable of manufacturing minerals. Without them, the body cannot
assimilate vitamins
Recommended Dietary Allowances and Intakes for non-pregnant, non-lactating
women; and pregnant women
MINERALS Non-pregnant, Pregnant, Lactating
rd
non-lactating 3 trimester
FNRI* WHO FNRI* WHO FNRI* WHO
16-49 1981 16-49 1981 16-49 1981
Calcium (mg) 750 800 800 1200 750 1200
Phosphorus (mg) 700 700 700
Magnesium (mg) 205 205 250
Iron (mg) 27 18 38 $$$ 30 $$$
Zinc (mg) 4.5 15 9.6 20 11.5 25
Iodide (g) 150 200 200
Selenium (g) 31 35 40
Copper (mg) - - -
Modified from Nutrition in Pregnancy: Mineral and Vitamin supplements, Am J Nutr 2000;72(suppl):280S-
90S USA 2000, American Society for Clinical Nutrition
*FNRI, 2002
$$$ increased requirement cannot be obtained from the diet and supplementation is recommended
CALCIUM: Calcium intake is crucial during pregnancy and lactation. The fetus in
utero and the neonate through breast-feeding are dependent on maternal
sources for the total calcium load. Thus, Thomas et al suggested that adequate
maternal calcium intake can affect fetal bone health positively. Studies indicate
that calcium consumption should be encouraged, especially during pregnancy
and lactation, to replace maternal skeletal calcium stores that are depleted during
these periods [11].
Mineral metabolism in the mother must adapt to the demand created by

the fetus and placenta, which together draw calcium and other minerals from the
maternal circulation to mineralize the developing fetal skeleton. Similarly, mineral
metabolism must adapt in the lactating woman to supply sufficient calcium to milk
and the suckling neonate. Potential adaptations include increased intake of
mineral, increased efficiency of intestinal absorption of mineral, mobilization of
mineral from the skeleton, and increased renal conservation of mineral. Despite a
similar magnitude of calcium demand by pregnant and lactating women, the
adjustments made in each of these reproductive periods differ significantly (see
figure below). These hormone-mediated adjustments normally satisfy the needs
of the fetus and infant with short-term depletions of maternal skeletal calcium
content, but without long-term consequences to the maternal skeleton. In states
of maternal malnutrition and vitamin D deficiency, however, the depletion of

skeletal mineral content may be proportionately more severe and may be
accompanied by increased skeletal fragility [12].
The developing fetal skeleton accretes about 30grams of calcium by term

and about 80% of it during the 3rd trimester. This demand of calcium is largely
met by a doubling of maternal intestinal calcium absorption mediated by vitamin
D3 or calcitriol. In contrast, during lactation, skeletal calcium resorption is the
dominant mechanism by which calcium is supplied to the breast milk; renal
calcium conservation is also apparent. Lactation produces an obligatory skeletal
calcium loss regardless of maternal calcium intake, but the calcium is completely
restored to the skeleton after weaning through mechanisms that are not
understood.
The breast is a central regulator of skeletal demineralization during

lactation. Suckling induces release of prolactin. Suckling and prolactin inhibit the
hypothalamic gonadotropin-releasing hormone (GnRH) pulse center, which
suppresses the gonadotropins (luteinizing hormone [LH], follicle-stimulating
hormone [FSH]), leading to low levels of the ovarian sex steroids (estradiol and
progesterone). PTHrP production and release from the breast is controlled by
several factors, including suckling, prolactin, and the calcium receptor. PTHrP
enters the bloodstream and combines with systemically low estradiol levels to
upregulate bone resorption markedly. Increased bone resorption releases
calcium and phosphate into the bloodstream, which reach the breast ducts and
are actively pumped into the breast milk. PTHrP also passes into the milk at high
concentrations, but whether PTHrP plays a role in regulating calcium physiology
of the neonate is unknown. Calcitonin (CT) may inhibit skeletal responsiveness to
PTHrP and low Estradiol. During lactation, the combined effects of PTHrP
(secreted by the breast) and estrogen deficiency increase skeletal resorption,
reduce renal calcium losses, and raise the blood calcium, but calcium is directed
into the breast milk. [13].

The more important role of calcium during pregnancy is the fact that recent
studies have shown that calcium during pregnancy can prevent pre-eclampsia. In
a recent meta-analysis of studies on calcium, it has been shown that calcium
supplementation appears to almost halve the risk of pre-eclampsia, and to
reduce the rare occurrence of the composite outcome 'death or serious morbidity'.
There were no other clear benefits, or harms [14].
Proper calcium consumption can be attained through DIET or supplementation.

According to the WHO, daily requirement is 1200 mg per day. The following table
shows the food exchange suggested by the Philippine Orthopedic Association.
Common food Calcium content

8 oz glass milk 300-500 mg
2 oz cheese 300
1 cup yogurt 300
Calcium fortified juice 300
4 oz tin of canned sardines or salmon 300
a cup of cooked spinach 300
1and ½ cup of ice cream 300
100 gm tofu 161
100 gm dilis 2184
100 gm malungay 346
100 gm sigarilyas 338
100 gm saluyot 488
100 gm soya 303

There are two forms of calcium supplement preparation: calcium carbonate or
calcium citrate. Taking supplements in divided doses avoids the side effects.
Absorption of supplements is optimal in doses of 500 mg or less because the
percent of calcium absorbed declines as the amount of calcium intake increases.
Best to take 1000mg in two divided doses of 500 mg BID instead of as single
dose [15].
IRON: Iron is essential for hemoglobin synthesis to ensure the efficiency of the
oxygen-carrying capacity of the blood.
Anemia is a major global problem that affects women in all countries.
There are an estimated 2 billion cases of anaemia worldwide. In developing

countries, anaemia prevalence rates are estimated to be about 50% in pregnant
women and infants under 2 years, 40% in school-aged children and 25–55% in
other women and children. Iron deficiency is estimated to be responsible for
around 50% of all anaemia cases. There are approximately 1 billion cases of
iron-deficiency anaemia and a further 1 billion cases of iron deficiency without
anaemia worldwide.
The prevalence is higher in developing countries where malnutrition is a major

concern. Deficiency in these areas is often due to malnutrition and infectious
disease like hookworm anemia. Oftentimes, there is also a deficiency in some of
the micronutrients like zinc, iodine, Vitamins A, B12, folic acid and proteins. In
general, the prevalence rate of iron deficiency anemia (IDA) in developing
countries is estimated to be 40% (Yeung and Kwan 2002). It is even higher in
the two risk groups of menstruating women and small children by as much as
70% (Ramakrishnan, 2002).
Iron deficiency anaemia: The challenge. Iron deficiency is the most common and
widespread nutritional disorder in the world. As well as affecting a large number
of children and women in developing countries, it is the only nutrient deficiency
which is also significantly prevalent in industralized countries. The numbers are
staggering: 2 billion people – over 30% of the world’s population – are anaemic,
many due to iron deficiency, and in resource-poor areas, this is frequently
exacerbated by infectious diseases. Malaria, HIV/AIDS, hookworm infestation,
schistosomiasis, and other infections such as tuberculosis are particularly
important factors contributing to the high prevalence of anaemia in some areas.
Iron deficiency affects more people than any other condition, constituting a public
health condition of epidemic proportions. More subtle in its manifestations than,
for example, protein-energy malnutrition, iron deficiency exacts its heaviest
overall toll in terms of ill-health, premature death and lost earnings.

Iron deficiency and anaemia reduce the work capacity of individuals and entire
populations, bringing serious economic consequences and obstacles to national
development. Overall, it is the most vulnerable, the poorest and the least
educated who are disproportionately affected by iron deficiency, and it is they
who stand to gain the most by its reduction.
The Philippine Obstetrical and Gynecological Society, all pregnant women should
be screened for iron deficiency anemia. (Level of evidence III, B) [16]
The cut off values used were the values suggested in the Center for Disease
control and are as follows:
Iron Sufficiency Iron deficiency Iron deficiency

without anemia anemia
Pregnancy: 20 Hgb: 110 g/L Hgb: 110 g/L Hgb: < 110 g/L
wks to delivery Ferritin: 12 μg/L Ferritin: < 12 μg/L Ferritin: <12 μg/L
Post partum: 6 Hgb: 120 g/L Hgb: 120 g/L Hgb: < 120 g/L
months Ferritin: 15 μg/L Ferritin: <15 μg/L Ferritin: < 15 μg/L
In a meta-analysis of studies on iron supplementation during pregnancy, by

JP Pena-Rosas, FE Viteri suggest that daily antenatal iron supplementation
increases haemoglobin levels in maternal blood both antenatally and postnatally.
Women who receive daily antenatal iron supplementation are less likely to have
iron deficiency and iron-deficiency anaemia at term as defined by current cut-off
values [18].
Consequences of IDA during pregnancy [16]:

1. Anemia with hemoglobin levels less than 6g/dl is associated with poor
pregnancy outcome like prematurity, spontaneous abortions, LBW, and
fetal deaths. (Level of Evidence III, Grade B)
2. Severe anemia with maternal hemoglobin levels less that 6g/dL has been
associated with abnormal fetal oxygenation resulting in non-reassuring
fetal heart rate patterns, reduced amniotic fluid volume, fetal cerebral
vasodilatation, and fetal death. (Level of Evidence III, Grade B)
3. IDA during pregnancy has been associated with an increased risk of
postpartum depression; with poor results in mental and psychomotor
performance testing in offspring. (Level of Evidence III, Grade B)

Approaches to the Prevention of IDA
A. Food-based approaches: These represent the most desirable and

sustainable method of preventing micronutrient malnutrition particularly iron
deficiency. Such approaches are designed to increase micronutrient intake
through the diet. According to the FNRI, daily RENI for iron is 27 mg/day during
the non-pregnant state increasing to 38 mg/day during the 3rd trimester of
pregnancy. However, the WHO stated that the requirement for iron is big for the
development of the fetus and the placenta and for erythrocyte production and
excretion. Demands during pregnancy and lactation cannot be met by diet alone
and supplementation is necessary. Iron requirement may also be higher in some
developing countries were access to a variety of foods is limited [17]. (Level of
Evidence II-2, Grade B)
1. Dietary improvement: Iron is present in a variety of foods of both plant

and animal. Liver and glandular organs are the richest sources of iron.
Among the plant foods the legume family, green leafy vegetables,
seaweeds and dried foods such as prunes are the best iron sources. Iron
from raw food is absorbed better. During pregnancy, eating raw food is
discouraged.
2. Food fortification: Adding of nutrient during the processing of food is an
effective long-term approach to improving the iron status of populations.
Several iron fortificants have been used successfully in a variety of
national programs particularly in rice, flour, cereals and milk products. A
complete list of Iron-Fortified Food products “Sangkap Pinoy” under the
Philippine Food Fortification Program has been approved and released by
the DOH and BFAD.
B. Iron supplementation: Iron supplementation is the most common strategy

currently used to prevent and correct IDA.
The following are guidelines in the oral therapy for IDA taken from the
POGS CPG on Iron Deficiency Anemia, 2009 [16]
Preventive Iron supplementation:
1. Routine low dose (30 mg) iron supplementation beginning at the
first prenatal visit decreases the prevalence of maternal anemia at
delivery. (Level of Evidence II-2, Grade A)
2. Iron supplementation results in significantly longer gestation
durations and increased infant birth weight but did not reduce the
risk of preterm delivery. (Level of Evidence I, Grade A)
3. Iron requirement is 1.8 times higher for vegetarians because of the
lower intestinal absorption of non-heme iron in plant foods.
Vegetarians should consider consuming non-heme iron sources
together with a good source of vitamin C, such as citrus fruits, to
improve the absorption of non-heme iron. (Level of Evidence III,
Grade C)
Iron therapy:
1. All pregnant women should be screened for iron deficiency anemia.
(Level of Evidence III, Grade B)
2. All pregnant women with IDA should be treated with supplemental
iron, in addition to prenatal vitamins. (Level of Evidence III, Grade
C)
3. Pregnant women with IDA should receive 60-120 mg iron plus 400
μg folic acid daily up to three months postpartum and should
continue preventive supplementation regimen. (Level of Evidence
III, Grade C)
4. Ferrous sulfate is recommended over newer iron preparations as
first-line therapy of iron deficiency. (Level of Evidence I, Grade B)
5. Empiric iron therapy may be initiated in patients without evidence of
causes of anemia other that iron deficiency, without first obtaining
iron test results. (Level of Evidence III, Grade C)
6. A hemoglobin level of <7 g/dL is an indication for blood transfusion
especially in the symptomatic and the pregnant patient. (Level of
Evidence III, Grade C)
7. Evaluate the hemoglobin concentration at subsequent prenatal
visits within 2-3 weeks of starting oral iron supplementation. (Level
of Evidence II-3, Grade B)
8. Failure to respond to iron therapy should prompt further
investigation and may suggest an incorrect diagnosis, coexisting
disease, malabsorption, non-compliance, or blood loss. (Level of
Evidence II-3, Grade B)
Practical issues about Iron therapy [16]:

• Oral iron supplements must dissolve rapidly in the stomach so that the
iron can be absorbed in the duodenum and the upper jejunum. Enteric –
coated or delayed-release preparations may have fewer side-effects but
are not as well absorbed, and may be less effective since they do not
dissolve in the stomach. They are usually NOT recommended. (Level of
Evidence II, Grade B)
• Daily iron supplementation should be divided in two or three equally
spaced doses since the amount of iron absorbed decreases as the doses
get larger. (Level of Evidence II, Grade C)
• Iron supplements are absorbed better if taken an hour before meals.
(Level of Evidence II, Grade B)

• Iron is better taken with vitamin C or orange juice as vitamin C increases
the absorption of iron. (Level of Evidence III, Grade C)
• Iron should not be taken together with milk, caffeine, tea, wine, legumes,
whole grains, antacids, H2 receptor blockers, proton pump inhibitors and
calcium supplements as they decrease iron absorption. (Level of Evidence
II, Grade C)
IODINE: Iodine is present in the body in minute amounts, mainly in the thyroid
gland. Its only confirmed role is in the synthesis of thyroid hormones. Iodine
deficiency is a major public health problem for populations throughout the world,
but particularly for young children and pregnant women, and in some settings
represents a significant threat to national social and economic development. The
most devastating outcome of iodine deficiency is mental retardation: it is currently
one of the world’s main causes of preventable cognitive impairment. This is the
primary motivation behind the current worldwide drive to eliminate iodine
deficiency disorders (IDD).
The importance of iodine deficiency disorders (IDD). An estimated 2 billion

people have inadequate iodine nutrition and therefore are at risk of iodine
deficiency disorders. Iodine deficiency, through its effects on the developing brain,
has condemned millions of people to a life of few prospects and continued
underdevelopment. On a worldwide basis, iodine deficiency is the single most
important preventable cause of brain damage. People living in areas affected by
severe iodine deficiency may have an intelligence quotient (IQ) of up to 13.5
points below that of those from comparable communities in areas where there is
no iodine deficiency. This mental deficiency has an immediate effect on child
learning capacity, women’s health, the quality of life in communities, and
economic productivity.
On the other hand, IDD are among the easiest and least expensive of all nutrient
disorders to prevent. The addition of a small, constant amount of iodine to the
salt that people consume daily is all that is needed. The elimination of IDD is a
critical development issue, and should be given the highest priority by
governments and international agencies.
UNICEF , ICCIDD, and WHO recommend that the daily intake of iodine should
be as follows:
• 90 μg for preschool children (0 to 59 months);
• 120 μg for schoolchildren (6 to 12 years);
• 150 μg for adolescents (above 12 years) and adults;
• 250 μg for pregnant and lactating women

The most critical period is from the second trimester of pregnancy to the third
year after birth [19]. Normal levels of thyroid hormones are required for optimal
development of the brain. In areas of iodine deficiency, where thyroid hormone
levels are low, brain development is impaired. In its most extreme form, this
results in cretinism, but of much greater public health importance are the more
subtle degrees of brain damage and reduced cognitive capacity which affects the
entire population. As a result, the mental ability of ostensibly normal children and
adults living in areas of iodine deficiency is reduced compared to what it would
be otherwise.
The spectrum of iodine deficiency disorders (IDD) [19]

Physiological Health Consequences of Iodine Deficiency
groups
All Ages Goitre, Hypothyroidism, Increased susceptibility to nuclear
radiation
Fetus Spontaneous abortion, Stillbirth, Congenital anomaly
Perinatal mortality
Neonate Endemic cretinism including mental Deficiency with a mixture of
Mutism, Spastic dysplegia, hypothyroidism and short stature
Infant Mortality
Child and Impaired mental function, Delayed physical development
Adolescent Iodine Induced Hyperthyroidism
Adults Impaired Mental function
Iodine Induced Hyperthyroidism
Universal salt iodization (USI )
In 1994, a special session of the WHO and UNI CEF Joint Committee on Health
Policy recommended USI as a safe, cost-effective, and sustainable strategy to
ensure sufficient intake of iodine by all individuals. In nearly all countries where
iodine deficiency occurs, it is now well recognized that the most effective way to
achieve the virtual elimination of IDD is through USI .
USI involves the iodization of all human and livestock salt, including salt used in
the food industry. Adequate iodization of all salt will deliver iodine in the required
quantities to the population on a continuous and self-sustaining basis.
In the Philippines, Republic Act 8172 or ASIN Law (An Act promoting Salt
Iodization Nationwide) was passed in 1995. 2003 -2005 FNRI Survey have
shown that currently, the household Iodised salt coverage is only 56%, still far
below that the USI target of 96%. Sources of Dietary Iodine include Iodine in soil,
water and crops, Seafood, Dairy Products, and Iodised salt and other fortified
foods

VITAMINS
Vitamins are needed to help regulate metabolism, convert fat and carbohydrates
into energy, and assist in forming bones and tissues
Recommended Dietary Allowances and Intakes for non-pregnant, non-lactating

women; and pregnant women
VITAMINS Non-pregnant, Pregnant, Lactating
non-lactating rd
3 trimester
FNRI* WHO FNRI* WHO FNRI* WHO
16-49 1981 16-49 1981 16-49 1981
Vitamin A (mg) 500 800 300 1000 900 1200
Vitamin D (mg) 5 7.5 5 12.5 5 12.5
Vitamin E (mg) 12 8 12 10 16 11
Vitamin K (mg) 51 51 51
Vitamin C (mg) 70 60 80 80 105 100
Vit B1Thiamine (mg) 1.1 1.5 1.6
Vit B2 Riboflavin (mg) 1.3 1.6 1.8
Niacin (mg) 14 18 17
Vitamin B6 (mg) 1.3 2.0 1.9 2.6 2 2.5
Folate (mg) 400 400 600 800 500 500
Vitamin B 12 2.4 2.4 2.6
VITAMIN A. Vitamin A is essential for normal maintenance and functioning of

body tissues, and for growth and development, including during pregnancy when
the fetus makes demands on the mother’s vitamin A stores, and during the
postpartum period when the newborn is growing rapidly. Although the increased
requirement during pregnancy is relatively small, in many countries where
vitamin A deficiency (VAD) is endemic, women often experience deficiency
symptoms such as night blindness that continue during the early period of
lactation. Both severe VAD and vitamin A overload are teratogenic in animals
and are associated with adverse reproductive outcomes. Although similar
outcomes in deficient human populations are not documented, the possibility of
risk must be considered. Providing a diet adequate in vitamin A—neither too little
nor too much—is the safest solution to meeting needs during pregnancy and
lactation. Data suggest that total dietary intake above 15 000 IU, or above 10 000
IU if from supplements alone, increased the risk of these defects.
In the light of the above considerations, WHO convened a consultation to
consider both the safe dosage of vitamin A during pregnancy [25] and the first
six months postpartum [26].

During Pregnancy.
For fertile women, independent of their vitamin A status, 10 000 IU (3000 μgRE)
is the maximum daily supplement to be recommended at any time during
pregnancy.
Where VAD is endemic among children under school age and maternal diets are
low in vitamin A, health benefits are expected for the mother and her developing
fetus with little risk of detriment to either, from:
• either a daily supplement not exceeding 10 000 IU vitamin A (3000 μg RE)
at any time during pregnancy;
• or a weekly supplement not exceeding 25 000 IU vitamin A (8500 μg RE).
In this regard:
o a single dose > 25 000 IU is not advisable, particularly between day
15 and day 60 following conception (day 0);
o beyond 60 days after conception, the advisability of providing a
single dose of > 25 000 IU is uncertain; any risk for non-teratogenic
developmental toxicity is likely to diminish as pregnancy advances.
In the case of a pregnant woman who may be reached only once
during pregnancy, health workers should balance possible benefits
from improved vitamin A status against potential risk of adverse
consequences from receiving a supplement.
During Lactation.
In most cultures, the young infant depends on breast milk to obtain adequate
amounts of the vitamin. Breast milk from deficient mothers is likely to contain
insufficient vitamin A to build —or even to maintain —vitamin A stores in nursing
infants. The fact that VAD is known to be associated with increased child
mortality after six months of age is a convincing argument for improving maternal
vitamin A nutrition as a child survival strategy. There may also be an additional
direct benefit to maternal health, though this is not well documented.
Liver stores of vitamin A at birth are sufficient to supply an infant’s requirements
for only a few days, even if the mother is well-nourished during pregnancy. The
breastmilk vitamin A concentration of well-nourished women is at least 50 μg/dl.
In regions of the world where vitamin A deficiency is a problem, breastmilk
vitamin A concentrations are lower. In most regions of the world, initiation of
breastfeeding is nearly universal; however, exclusive breastfeeding for six
months is very rare. Therefore, it is important to consider that when breastmilk
vitamin A concentrations are below 50 μg/dl or when breastmilk intake volumes
are less than 600 ml per day, vitamin A intakes will not be sufficient to promote
adequate vitamin A stores by six months of age.

There are two options for improving the vitamin A status of breastfed infants:
improving the vitamin A status of mothers, and thus the vitamin A content of
breastmilk; or supplementing the infant. Both strategies should be employed.
Breastfeeding mothers need to receive more vitamin A postpartum. The current
policy of giving them 200,000 IU of vitamin A during postpartum is not enough to
meet their increased vitamin A requirements for lactation during that period. Non-
breastfeeding women can also benefit from postpartum doses of vitamin A to
replete their own liver stores.
These are now the newer recommendations on Vitamin A supplementation

postpartum and during lactation [26].
1. Exclusive breastfeeding for the first four to six months of life should
continue to be promoted as the primary way to prevent vitamin A
deficiency in young infants.
2. The postpartum dose of vitamin A to mothers should be increased to
400,000 IU (120,000 μg RE) and should be given as two doses of 200,000
IU (60,000 μg RE) each, the first dose immediately after delivery and the
second dose later on within the safe infertile postpartum period. It is
important that the second dose be given at least 24 hours after the first
dose, when the first dose will have been metabolized and taken up by the
liver. However, a longer interval is preferred, because it will allow for better
retention of the second dose.. Postpartum supplementation should be
given to both breastfeeding and nonbreastfeeding mothers, within their
respective safe infertile periods, i.e., within eight weeks of delivery for
breastfeeding women and within six weeks of delivery for
nonbreastfeeding women. Postpartum women should be screened for
eligibility to receive vitamin A supplementation at any health contacts, in
particular at the first postpartum visit within the first week following delivery
or at the child immunization contact.
3. In situations where the mother cannot be recontacted any time soon after
birth, a single dose of 400,000 IU (120,000 μg RE) could be given at once,
but this should be considered as exceptional and avoided as much as
possible, because the evidence that a single dose of 400,000 IU (120,000
μg RE) of vitamin A is safe is still limited and further investigation is
needed.
4. As an alternative to large-dose supplementation, mothers can receive
vitamin A at any time postpartum, given as a low dose not exceeding
10,000 IU (3,000 μg RE) per day or 25,000 IU (7,500 μg RE) per week.
FOLIC ACID. Folic acid is vital for cell division, erythropoiesis, and feto-placental
growth. Its requirement increases by 50% during pregnancy because this is a
time of additional blood formation and rapid growth both for the mother and baby.
Deficiency states are known to cause neural tube defects (especially in the first
28 days of pregnancy), LBW babies, and high abortion rates. Patients
predisposed to low folate status are women who smoke, do not supplement with
vitamins and minerals, Are on oral contraceptives, have a high parity, and
women who are pregnant.
In a meta-analysis of randomized clinical controlled trials of the effect of folic acid
supplementation, it has been found that periconceptional folate supplementation
has a strong protective effect against neural tube defects. Furthermore, it was
suggested that information about folate should be made more widely available
throughout the health and education systems. Women whose fetuses or babies
have neural tube defects should be advised of the risk of recurrence in a
subsequent pregnancy and offered continuing folate supplementation. The
benefits and risks of fortifying basic food stuffs, such as flour, with added folate
remain unresolved [20].
FAQ: 4. Should I take multivitamins during pregnancy?
Answer: Yes. The average Filipino woman may not be able to meet the
required dietary allowances for all nutrients, except Vitamin A.
This may be contrary to what is suggested by the ACOG. In a meta-analysis by

Haider et al in 2006 [21] showed that scientific evidence is insufficient to suggest
replacement of iron and folate supplementation with a multiple-micronutrient
supplement. A reduction in the number of low birthweight and small-for-
gestational-age babies and maternal anaemia has been found with a multiple-
micronutrient supplement against supplementation with two or less
micronutrients or none or a placebo, but analyses revealed no added benefit of
multiple-micronutrient supplements compared with iron folic acid
supplementation. These results are limited by the small number of studies
available. There is also insufficient evidence to identify adverse effects and to
say that excess multiple-micronutrient supplementation during pregnancy is
harmful to the mother or the fetus. Since macro and micronutrient malnutrition is
common in our country, the value of supplementation cannot be underscored.
FAQ: 5. What should I avoid during pregnancy?
Answer: The following should be avoided during pregnancy: drinking

alcohol, smoking, taking non-prescription medicine, artificial sweeteners,
heavy metal contaminants, caffeine, and strenuous physical activity.
ALCOHOL crosses the placenta. There is no known safe level of intake during
pregnancy, thus it is advised to be avoided during pregnancy. It adversely affects
blastogenesis and cell differentiation. Fetal sequelae range from intrauterine

growth retardation to severely damaged infants. FETAL ALCOHOL SYNDROME
or FASD is the end result of chronic alcohol abuse during pregnancy.
SMOKING: FETAL EFFECTS of smoking include LBW, premature labor,

premature rupture of membranes, abruptio placenta, and hemorrhage. It is
presumed that carbon monoxide inactivates fetal and maternal hemoglobin and
nicotine causes vasoconstriction and abruptio placenta
Artificial Sweeteners: Saccharin was found to be weakly carcinogenic in

rats. The current controversy about the risks of their use to human health has
surfaced from research findings that report an increased incidence of cancer,
primarily of the urinary bladder, in certain animal species and man chronically
exposed to these agents. The April 1977 proposal by the Food and Drug
Administration to restrict use of saccharin was based on these investigations [22].
Aspartame, likewise in a study by Soffriti et al in 2007 showed similar results for
aspartame (APM). Their results show a) a significant dose-related increase of
malignant tumor-bearing animals in males rats; b) a significant increase in
incidence of lymphomas/leukemias in male rats and c) a significant dose-related
increase in incidence of mammary cancer in female rats. The results of this
carcinogenicity bioassay confirm and reinforce the first experimental
demonstration of APM's multipotential carcinogenicity at a dose level close to the
acceptable daily intake for humans. Furthermore, the study demonstrates that
when life-span exposure to APM begins during fetal life, its carcinogenic effects
are increased [23].
Heavy metal contaminants such as Mercury, Lead and Cadmium might lead to
teratogenicity and to toxicities that could harm both the mother and the infant.
Since high levels of mercury was found in cord blood of neonates born in areas
where seafood consumption is high, fish intake has been limited during
pregnancy as suggested by Sato et al [10].
Caffeine is found in colas, coffee, tea, chocolate & cocoa. It is a diuretic and can
dehydrate body of valuable water. Caffeine crosses the placenta. Its effect on the
developing human fetus is unclear, but animal studies have shown that it can
cause fetal abnormalities or low birth weight babies. Excess intake may affect
fetal heart rate and breathing. Intake during pregnancy should likewise be limited
to no more than 2 5-ounces cups daily.
Strenuous physical activity should be avoided. Walking, climbing stairs,

swimming and cycling are recommended.

Exercise Guidelines during Pregnancy:
• Do exercise regularly at least 3x a week
• So warm up with 5-10 minutes of light activity
• Do exercise for 20-30 minutes at your target heart rate.
• Do cool down with 5-10 minutes of slow activity and gentle stretching.
• Do drink water before, during and after exercise.
• Do eat enough to support the additional needs of pregnancy plus exercise.
• DON’T exercise vigorously after long periods of inactivity.
• DON’T exercise in hot humid weather.
• DON’T exercise when sick with fever.
• DON’T exercise while lying on your back after the first trimester of
pregnancy or stand motionless for long periods of time.
• DON’T exercise if you experience any pain or discomfort.
• DON’T participate in any activities that may harm the abdomen pr involve
jerky, bouncy movements.
COMMON NUTRITION-RELATED CONCERNS OF PREGNANCY
Nausea. Not all women have uneasy stomachs in the early months of
pregnancy, but many do. The nausea of the “morning” “morning sickness” ranges
from mild queasiness to debilitating nausea and vomiting. Severe and continued
vomiting may require hospitalization if it results in acidosis, dehydration or
excessive weight loss. The hormonal changes of early pregnancy seem to be
responsible for a woman’s sensitiveness to the appearance, texture, or smell of
foods. Strategies to alleviate this include:
On waking, arise slowly, Eat dry toast or crackers, Chew gum or suck hard
candies, Eat small frequent meals. Eat smaller meals each day ~ 6-8
small meals instead of 3 larger ones; Avoid being without food for long
periods of time; Avoid foods with offensive odors; Avoid greasy, fried, or
highly spiced food;Drink fluids between, but not with, meals; When
nauseated, do not drink citrus juice, water, milk, coffee, or tea; Rest when
you are tired; Drink Vitamin B6 30 mg per day or Ginger capsules
Constipation and hemorrhoids. As the hormones of pregnancy alter

muscle tone and the growing fetus crowds intestinal organs, an expectant mother
may experience constipation. She may also develop hemorrhoids. These may be
painful and straining during bowel movements may cause bleeding. She can
gain relief by:
Eating foods high in fiber;Exercising regularly; Drinking at least 8 glasses
of liquids a day; Responding promptly to the urge to defecate; Using
laxatives only as prescribed by a physician. Do not use mineral oil,
because it interferes with absorption of fat-soluble vitamins.
Heartburn is another common complaint during pregnancy. The hormones of
pregnancy relax the digestive muscles, and the growing fetus puts increasing
pressure on the mother’s stomach. This combination allows the stomach acid to
back up into the lower esophagus and create a burning sensation near to the
heart. Tips to help relieve heartburn are:
Relax and eat slowly; Chew food thoroughly; Eat small frequent meals;
Drink liquids between meals; Avoid spicy or greasy foods; Sit up while
eating, elevate the head while sleeping; Wait an hour after eating before
lying down; Wait two hours after eating before exercising.

References:
1. Philippine Department of Health statistics, 2008

2. Guthne et al HA. Relationship Between Maternal & Fetal Malnutrition. Human Nutrition. Mosby
USA, 1995
3. Susser M, Levin B. Ordeals for the fetal programming, Br Med J 1999; 318:855-6
4. Barkr DJ. Maternal Nutrition, Fetal Nutrition and disease in later life. Nutrition 1997; 13:807-13
5. Conde-Agudelo A et al. Birth Spacing and Risk of Adverse Perinatal Outcomes: A Meta-Analysis.
JAMA. 2006;295:1809-1823
6. F. Gary Cunningham, Kenneth L. Leveno, Steven L. Bloom, John C. Hauth, Larry C. Gilstrap III,
Katharine D. Wenstrom. William’s Obstetrics, 22nd edition
7. Recommended Energy and nutrient Intakes Philippines, 2002 edition Philippine Journal of Nutrition
2003, vol 50, nos 1-2
8. Eileen R. Fowles, PhD, RNC. What's a Pregnant Woman to Eat? A Review of Current USDA
Dietary Guidelines and MyPyramid. J Perinat Educ. 2006 Fall; 15(4): 28–33
9. Kramer MS, Kakuma R. Energy and protein intake in pregnancy. Cochrane Database of Systematic
Reviews 2003, Issue 4. Art. No.: CD000032. DOI: 10.1002/14651858.CD000032.
10. Sato RL et al. Antepartum seafood consumption and mercury levels in newborn cord blood. Am J
of Obstet & Gynecol June 2006 194 (6); 1683-1688
11. Thomas M et al et al. Calcium supplementation during pregnancy and lactation: Effects on the
mother and the fetus. AJOG Apr 2006;194(4):937-945
12. Christopher S. Kovacs, MDa,*, Ghada El-Hajj Fuleihan, MD, MPHb,* Calcium and Bone Disorders
During Pregnancy and Lactation Endocrinol Metab Clin N Am 35 (2006) 21–51
13. Kovacs CS. Calcium and bone metabolism during pregnancy and lactation. JMammary Gland Biol
Neoplasia 2005;10(2):105–18.2005 Springer Science and Business Media BV
14. Hofmeyr GJ, Atallah AN, Duley L. Calcium supplementation during pregnancy for preventing
hypertensive disorders and related problems. Cochrane Database of Systematic Reviews 2006,
Issue 3. Art. No.: CD001059. DOI: 10.1002/14651858.CD001059.pub2.
15. Heaney RP et.al. Calcium absorption as a function of calcium intake. J Lab Clin Med 1975;85:881-
90. Heaney RP et.al.Variability of calcium absorption. Am J Clin Nutr 1988;47:262-64.
16. POGS: Clinical Practice Guidelines on Iron Deficiency Anemia, 2009
17. Institute of Medicine (US). Dietary reference intakes of Vitamin A, vitamin K, arsenic, boron,
chromium, copper, iodide, iron, manganese, molybdenum, nickel, silicon, vanadium, and zinc.
Washington DC; National Academy press 2002.
18. Pena-Rosas JP, Viteri FE. Effects of routine oral iron supplementation with or without folic acid for
women during pregnancy. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.:
CD004736. DOI: 10.1002/14651858.CD004736.pub2.
19. Assessment of iodine deficiency disorders and monitoring their elimination. WHO 2007
20. Lumley J, Watson L, Watson M, Bower C. Periconceptional supplementation with folate and/or
multivitamins for preventing neural tube defects. Cochrane Database of Systematic Reviews 2001,
Issue 3. Art. No.: CD001056. DOI: 10.1002/14651858.CD001056.
21. Haider BA, Bhutta ZA. Multiple-micronutrient supplementation for women during pregnancy.
Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD004905. DOI:
10.1002/14651858.CD004905.pub2.
22. RK Kalkhoff and ME Levin. The saccharin controversy. American Diabetes Association. Diabetes
Care, Vol 1, Issue 4 211-222
23. Soffritti M, Belpoggi F, Tibaldi E, Esposti DD, Lauriola M. Life-span exposure to low doses of
aspartame beginning during prenatal life increases cancer effects in rats. Environ Health Perspect.
2007 September; 115(9): 1293–1297.
24. Newborn Health in the Philippines: A Situation Analysis. Published by the Basics Support for
Institutionalizing Child Survival Project (BASICS II) for the United States Agency for International
Development. Arlington, Virginia, June 2004.
25. WHO. Safe vitamin A dosage during pregnancy and lactation: Recommendations and report of a
consultation. WHO/NLJT/98.4
26. Bruno de Benoist, José Martines, and Tracey Goodman. Vitamin A supplementation and the
control of vitamin A deficiency: Conclusions. Food and Nutrition Bulletin, vol. 22, no. 3 © 2001, The
United Nations University

STUDENT SECTION
NAME
TOPIC:
CASE
Data
Anthropometric
Measurements
Vital signs
Pertinent
Laboratory
Data
Clinical Data
Other
Observation

kilogram
Adjusted IBW
(If required)
BMR
Harris-Benedict
Formula
TER =
BMR x AF x IF
Amount of Carbs/day
(grams)
(grams)
Amount of Fats/day
(grams)

Veg A
Veg B
Fruit
Milk
Sugar
Rice
Meat
Fat
TOTAL
Veg A
Veg B
Fruit
Milk
Sugar
Rice
Meat
Fat
TOTAL Cal
DAY’S MEAL PLAN
DAY’S MEAL PLAN


CHAPTER 5
NUTRITION IN CRITICALLY ILL PATIENTS
May Gabaldon-Asis, MD, FPOGS
I. OVERVIEW
CRITICALLY ILL
• Includes victims of trauma (gunshot wounds, stabbing, motor vehicle
accidents); closed head injury (from fall); burns; severe inflammations such as
in pancreatitis; cancer; sepsis; hypoxic injury as seen in acute renal failure;
and necrosis of tissues as in gangrene or after major surgery.
IMPLICATIONS
METABOLIC PROCESS STATUS
Calorie reserves Strained
Protein reserves On the “empty” level
Substrates involved in inflammatory processes, Dangerously low to
infection, injury healing and tissue repair empty status
Processes involved in oxygenation and tissue Slowed or impaired
perfusion
METABOLIC ALTERATIONS IN CRITICAL ILLNESS
Critical illness is generally recognized as a hyper-metabolic state with catabolic

response to acute injury or disease and with energy expenditure (EE) being
proportional to the amount of stress.
Characteristic of critical illness is the so-called “diabetes of stress” with

hyperglycemia and insulin resistance.
Hyperglycemia and insulin resistance is brought about by:

• increased hepatic gluconeogenesis (from amino acids and lactate) mainly due
to the action of catabolic hormones such as glucagon, epinephrine, and
cortisol.
• decrease in the normal suppressive action of exogenous glucose and insulin
on hepatic gluconeogenesis
• decreased peripheral glucose utilization in insulin-dependent tissues (muscle
and fat).

The most striking metabolic feature of critical illness is protein catabolism and
negative nitrogen balance wherein the major mediators are the catabolic
hormones glucagon, epinephrine, and cortisol and the reduced anabolic
influence of growth hormone, insulin and testosterone.
Consequences of sustained hyper-catabolism:

• substantial loss of lean body mass (LBM)
• muscle weakness
• decreased immune function
The increased catecholamines and cortisol levels in stress states stimulate

lipolysis in peripheral adipose tissues. Metabolic stress is the hypermetabolic,
catabolic response to acute injury or disease.
Summary of major metabolic abnormalities in “stress response”

1. increase in catabolic hormones (cortisol, glucagon, and catecholamines)
2. decrease in anabolic hormones (growth hormone and testosterone)
3. marked increase in metabolic rate
4. sustained increase in body temperature
5. marked increase in glucose demands and liver gluconeogenesis
6. rapid skeletal muscle breakdown with amino acids used as energy source
7. lack of ketosis, indicating that fat is not the major calorie source
8. unresponsiveness of catabolism to nutrient intake
The stress response is a progression through 3 phases.
1. Ebb phase
• Encompasses the immediate period after injury (2 – 48 hours)
• Characterized by shock resulting from hypovolemia and decreased
oxygen availability to tissues
• The decrease in blood volume results in decrease in cardiac output
and urinary output.
• The goals of therapy include restoration of blood flow to organs,
maintain oxygenation to all tissues, and stop all haemorrhage.
2. Flow phase
• Encompasses the classic signs and symptoms of metabolic stress
such as hypermetabolism, catabolism, altered immune and hormonal
response
3. Final adaptation phase or recovery phase

• Indicates resolution of stress with a return to anabolism and normal
metabolic rate.
Negative nitrogen balance is a consistent sign during metabolic stress brought
about by substantial nitrogen loss and complications that accompany skeletal
muscle catabolism which include:
• Immunosuppression
• Increased infection rates
• Delayed or impaired wound healing
• Increased mortality
According to Gisher et al., 2000. Up to 43% of patients in ICU are malnourished.
Causes of malnutrition in critically ill patients

• Impaired intake
• Impaired digestion and absorption
• Altered nutritional requirements
• Excess nutrient losses
Consequences of malnutrition:
• Weight loss
• Weakness and fatigue
• Impaired ventilator drive
• Depression and apathy
• Poor wound healing
• Impaired immune function
Rationale for feeding the critically ill patient

1. Provision of nutritional substrates to meet protein and energy
requirements
2. Protect vital organs and reduce breakdown of skeletal muscles
3. Provide nutrients needed for repair and healing of wounds and injuries
4. Maintenance of gut barrier function
5. Modulation of stress response and improve outcome
II. SPECIALIZED NUTRITION SUPPORT (SNS)

• Given to patients who are unable to maintain their nutritional status using
oral diets, supplements, or appetite stimulants.
• It refers to administration of nutrients with therapeutic intent. This includes
the provision of total enteral and parenteral nutrition support and the
provision of therapeutic nutrients to maintain or restore health (ASPEN,
2002)

Benefits of nutrition support in critically-ill patients
1. Improved wound healing
2. Decreased catabolic response to injury
3. Improved gastrointestinal structure and function
4. Improved clinical outcome
• Reduction in complication rates
• Reduction in length of hospital stay
• Accompanying cost savings
II.A. ENTERAL NUTRITION
A. Definition
• The use of “dietary foods for special medical purposes”. Includes oral
nutritional supplements (ONS) and tube feeding (ESPEN Guidelines on
Enteral Nutrition, 2006.)
• Feeding thru the gastrointestinal tract via a tube, catheter or stoma that
delivers nutrients distal to (or beyond) the oral cavity (ASPEN, 2005)
• From the Greek word “enteron” or “intestine”
• Used interchangeably with “enteral feeding” and “tube feeding”
• It is recommended that enteral feeds commence within 24 – 48 hours in
hemo-dynamically stable patients following admission to ICU.
• It is the preferred route over the parenteral route.
B. Advantages of enteral nutrition support over parenteral nutrition

a. Cost-effectiveness
b. Reduced rate of infectious and metabolic compliocations
c. Relative ease and safety of administration
d. Improved wound healing
e. Reduced surgical interventions
f. Maintenance of gastrointestinal function or preservation of gut mucosal
integrity
C. Indications:
a. patients with functioning GIT but cannot feed themselves adequately
b. patients with little or no appetite for extended periods especially the
malnourished
c. patients in coma
d. patients on mechanical ventilators
e. If oral dietary intake remains compromised or is contraindicated for more
than 5 – 7 days artificial nutritional support in the form of enteral tube
feeding may be necessary.

Indications Conditions
Hypermetabolism Major surgery, sepsis, trauma, burns,
organ transplantation, HIV/AIDS
Neurological Disease Stroke, motor neuron disease,
multiple sclerosis, head injury,
demyelinating disease
Gastrointestinal disease Esophageal obstruction, inflammatory
• swallowing dysfunction bowel syndrome, pancreatic
• patients with disorders of the upper GIT that insufficiency, gastrectomy
can be bypassed by inserting a feeding tube
below the dysfunction
• patients with impaired digestive function and
who are able to ingest hydrolysed formulas
only
• patients who have undergone intestinal
resections
Cancer chemotherapy or radiotherapy,
surgery
Psychiatric disease Anorexia nervosa, severe depression,
• patients who are mentally incapacitated confusion, dementia, neurologic
difficulties
Organ system failure Respiratory failure, renal failure,
cardiac failure, hepatic failure
Learning disability Cerebral palsy, Rett Syndrome
D. Contraindications:
a. When there is a need to give rest to the GIT
b. In the presence of altered GIT integrity and/or function
c. When oral diet or enteral tube feeding is insufficient to meet patient’s nutritional
needs
Potential Specific Conditions
Contraindications • Terminal illness
(relative or • Short bowel
temporary) • Obstruction
• GI bleeding
• Vomiting and diarrhea
• Fistulas
• GI ischemia
• Ileus
• GI inflammation
• Pancreatitis

E. Types of Enteral Feeds and Formulations
Most enteral feeds are a mixture of fat, CHO, proteins, vitamins, minerals, water,
electrolytes and fibre in proportions that mimic a balanced diet, or a diet designed
for a specific disease or medical condition.
Some enteral feeds (e.g. Pulmocare) provide a greater percentage of calories as
fat (less CHO means less CO2 produced, thereby assisting ventilator weaning).
Other specialized feeds provide elemental solutions of amino acids or peptides
for patients with short-bowel syndrome, malabsorption or severe inflammatory
bowel disease.
Type of Enteral Characteristics Indication
Formulation
Intact Formula “meal replacement formula” For patients who are
(Polymeric Formula) Composed of intact proteins, able to digest and
disaccharides and absorb nutrients without
polysaccharides and variable difficulty
amounts of fats, residue, and
lactose
1. Standard polymeric Lactose free; low osmolality
- Ensure, Isocal, Nutren
optimum
2. High nitrogen Lactose free; low-moderate
polymeric osmolality
- Ensure plus Designed to meet increased
protein demands
3. Fiber-containing Lactose free; low osmolality
• Fresubin fiber, nutren Fiber from natural food sources
fiber, ensure gold or from added soy
polysaccharide
4. Blenderized formula Usually lactose containing; very
high viscosity; moderate
osmolality; composed of
mixture of ordinary foods with
oils, vitamins and minerals
added as necessary
Hydrolyzed Formulas Usually hyperosmolar; lactose- For patients who cannot
(pre-digested/ free; generally low in total fat digest certain nutrients
monomeric or elemental and may contain branched- or who have smaller
formulas) chain amino acids than normal area of
Oligomeric/ Peptide- Have unpleasant taste, more absorbing nutrients
based: Peptamen expensive than standard
Monomeric/ Elemental: formulas with intact nutrients
Alitraq
Modular Formulas Composed of single pre- Patients with specific
(Polycose) digested nutrients (e.g. protein, metabolic or fluid
CHO, fat) imbalances that
May be added to another preclude the
formula administration of a
Do not contain vitamins, standard formula
minerals, and electrolytes
thereby may require
supplementation
Specialty Formulas Some are unpalatable Patients requiring
• Cancer: Polycose, Most are very expensive different proportions or
Supportan May be constructed from types of protein, amino
• Critical Care: reconvan modular formulas acids, CHO, fat and
• Renal: Nepro electrolytes (e.g. liver,
• DM: Glucerna, Nutren renal, pulmonary
diabetes, Diben diseases and DM)
• Liver Disease:
Aminoleban
Modified from the NDAP Diet Manual, 5th ed. 2010
ESPEN Recommendations on type of formula for different conditions

Cancer In all cancer patients undergoing major abdominal surgery
peroperative EN preferably with immune modulating
substrates (arginine, omega-3 fatty acids and nucleotides)
is recommended for 5-7days independent of their nutritional
status (Grade A).
Intensive Care Immune-modulating formula ( formula enriched with
arginine, nucleotides and omega-3 fatty acids) are superior
to standard enteral formula:
a. In elective upper surgical patients(A)
b. In patients with mild sepsis (B)
c. In patients with severe sepsis, however immune-modulating
formula may be harmful and are therefore not recommended.
(B)
d. In patients with trauma (A)
e. In patients with ARDS (formula containing omega-3 fatty acids
and antioxidants (B)
Glutamine should be added to standard enteral formula in:
(Grade A)
a. Burned patients
b. Trauma patients
Liver Disease • Whole protein formulas are generally recommended (C).
• More concentrated high-energy formula s are preferable in
patients with ascites in order to minimize fluid overload(C).
• BCAA-enriched formula should be used in patients with
hepatic encephalopathy arising during EN (A).
• Oral BCAA supplementation can improve clinical outcome in
advanced cirrhosis (B)
Renal Acute Renal Failure
• Standard formulas are adequate for the majority of patients
(C)

• In case of electrolyte derangements formula specific for CRF
can be advantageous (C).
Chronic Renal Failure
• Use standard formula for short term EN in undernourished
CRF patients (C)
• For EN> 5 days, use special or disease specific formula
(protein restricted formula with reduced electrolyte content)
(C).
Patients on maintenance hemodialysis therapy (HD)
• For tube feeding prefer HD-specific formula (C).
• The formula content in phosphorus and potassium should be
checked (C).
Gastroenterology Crohn’s Disease
• There are no significant differences in the effect of free amino
acids, peptide-based and whole protein formula protein for
tube feeding .Free amino acid or peptide-based formula are
not generally recommended (A)
• Modified EN formula (fat modified, omega-3 fatty acids,
glutamine) are not recommended because no clear benefits
have been shown (A)
Short Bowel Syndrome
• No specific substrate composition is required per se (C).
• Depending on the extent of malabsorption a significant
increase in energy and a modification of substrate intake may
be necessary (C).
COPD • In patients with stable COPD there is no additional advantage
of disease specific low CHO, high fat ONS over standard or
high protein or high energy ONS (B).
• Frequent smaller amounts of ONS are preferred to avoid
postprandial dyspnea and satiety and to improve compliance
(B).
Diabetes/glucose • Benefits of Low CHO-high MUFA Formula
intolerance • Glycemic control: Several studies report lower mean, fasting
and postprandial glucose levels compared to high CHO, low
MUFA (HCLM) formulas;
• Lipid Profile: Reduced plasma triglycerides and total
cholesterol, rise in HDL cholesterol level

Blenderized (Natural Foods)
• Food Selection for Blenderized Formulas

a. Vegetables: low cellulose or succulent vegetables e.g. squash, carrots,
chayote
b. Fruits: all fruits without skin and seeds
c. Milk: all type
d. Rice and equivalents: lugao, oatmeal, sliced bread, pandesal; potato
e. meat/poultry/fish: low fat meat e.g. lean beef, chicken breast, fish fillet,
chicken egg
f. Fat: vegetable oils
• Advantages of Blenderized Formulas

a. Less costly
b. Increased amounts of fiber can be added
c. Sense of “being different” is lessened
• Disadvantages of Blenderized Formulas

a. Special equipments are needed
b. More energy and time are needed for preparation
c. May need vitamin and mineral supplementation
d. Higher risk of contamination
F. Components of Enteral Feeds

a. Proteins
• Usually derived from soy or casein
• Usual amount = 10 – 15% of Kcal; high protein formulas contain 25%
of kcal
• Some formulas are supplemented with specialized amino acids
(glutamine or arginine)
b. Carbohydrates
• Includes monosaccharides, oligosaccharides, dextrins and
maltodextrin; lactose-free formulas, sucrose rarely used.
• Fibre is added to improve bowel function
c. Lipids
• Include corn and soy oil which are long and medium chain fatty acids.
• Newer products contain omega-3-fatty acids from fish and plant
sources.
d. Vitamins and Minerals
• For stress and wound healing

e. Immunonutrients
• Nutrients that modulate immune system function
f. Glutamine
• Most abundant amnio acid in the body; accounts for 60% of the
intracellular amino acid pool
• Considered to be conditionally essential because deficiency can occur
rapidly after injury
• Used as energy source after the stress response since it is released
from cells to undergo gluconeogenesis in the liver. It is the primary
fuel source for rapidly dividing cells like epithelial cells during healing.
• Component of glutathione (antioxidant)
• Used as a substrate for metabolism by leucocytes and enterocytes; it
can therefore augment lymphocyte and macrophage function
• It has anticatabolic and anabolic properties and is the rate-limiting
agent for new protein synthesis
g. Arginine
• A conditionally essential amino acid whose level decreases after
major trauma and wounds
• Improves T-cell function
• Increase tissue collagen content and enhances collagen and total
protein deposition at the wound site
• Stimulates the release of hormones including insulin, prolactin and
growth hormone
• Needed for nitric oxide production which regulates blood flow
• Studies have shown that arginine supplementation in patients with
sepsis is associated with higher mortality. Therefore, it is not
recommended in critically-ill patients with severe sepsis (ESPEN,
2006)
G. Enteral Formulations
• Any dietary food for special medical purposes designed for use in tube
feeding or as an ONS.
• May be purchased in ready to use liquid or powdered form or may be
prepared from liquid and blenderized common foods.

Composition of Enteral Formulas
Carbohydrates
Sources maltodextrin, modified cornstarch, corn syrup, sucrose
Composition - The size of individual CHO polymers is defined by dextrose
equivalents (DE)
- A low DE indicates a complex CHO source; a high DE value
indicates a simpler source.
- The percentage of energy contributed by
CHO varies from <30% to <90% depending on the condition for
which the product is formulated.
In pediatric products: 42%-58%
In infant formulas: 40%-54%
Fats
Sources Vegetable oils (corn, canola, soybean, sunflower and
safflower
Composition/ - Vegetable oils with LCT contribute essential fatty acids (EFA),
Characteristics moderate osmolality and enhance palatability
- MCT oil is useful as an alternative source for patients with
malabsorption; it does not require bile salts or pancreatic lipase
for absorption.
- Percentage of energy from fats
• adult formulas: 1% to 55%
• pediatric formulas: 25% to 46%
• infant formulas: 35% to 50%
Protein
Sources Intact Formula: cow milk protein, whey protein, caseinates,
soy protein, milk protein concentrate
Characteristics - Peptide based formulas (oligomeric/semi-elemental):
enzymatically hydrolyzed casein, whey, lactalbumin, wheat and
soy or meat protein
- Elemental (monomeric) formula contains free amino acids
Other amino 1. BCAA (valine, leucine and isoleucine)
acids added to - Acts as key nitrogen source for synthesis of protein and amino
enteral acids (glutamine and alanine) during periods of stress.
formulas - Promoted for use in liver disease when disorders of the aromatic
amino acids (AAA) metabolism occur.
2. Glutamine
- A conditionally essential amino acids during stress-induced
conditions.
- Preferred energy source for rapidly replicating cells in both the
small intestinal mucosa and the immune system.
- Formulas supplemented with glutamine has been associated
with
a. improved microbial colonization patterns
b. reduced bacterial overgrowth,
c. improved clinical outcome

3. Arginine
- Conditionally EAA during stress and infection.
- Serves as substrate for the production of nitric oxide.
- Benefits:
a. Improves cell mediated immunity
b. Promotes wound healing (enhancing proliferation of
fibroblasts and collagen)
c. Improves nitrogen balance in critically ill patients
Fiber
Common 1. Soy polysaccharide
types of fiber - Insoluble fiber
added to - most prevalent fiber source in fiber-containing formulas.
enteral - Benefits
formulas • May prevent constipation
• increase stool volume
• decrease GI transit time in critically ill patients
2. Soluble fibers (gum Arabic, guar gum, and pectin)
- Products with soluble fibers may:
▪ Improve glucose tolerance
▪ Lower serum cholesterol
▪ Maintain the ileal and colonic mucosal production of short
chain fatty acids
3. Fructooligosaccharides (FOS)
- Are naturally occuring, non-digestible sugars that are selectively
used by the bifidobacteria in the human intestinal tract.
- FOS can:
▪ Improve intestinal flora
▪ Relieve constipation
▪ Improve blood lipids
▪ Suppress production of putrefactive substances
Water - Energy density of a formula is dictated largely by the amount of
water in the formulation.
- Formulas that provide 1kcal/ml are approximately 75-85% water.
- 2kcal/ml formulas – 70% water
Micronutrients

Distinguishing Characteristics of Enteral Formulas
NUTRIENT - Standard formula provide about 1.0 kcal per millimeter.
DENSITY - Nutrient dense formulas provide about 1.2 to 2.0 kcal per
millimeter, and meet energy and nutrient needs in a smaller
volume.
RESIDUE - most standard formulas have low to moderate residue
CONTENT content.
- low residue formulas are least likely to cause gas and
abdominal distention and benefits patients with:
▪ GI tract disorders
▪ Post-op GI tract surgery patients
- Hydrolyzed formulas are almost completely absorbed; they
leave little residue in the intestine.
FIBER CONTENT - Fiber-enriched formulas benefits:
▪ Patients who depend on tube feedings for long period
of time
▪ Patients with constipation
▪ Patients with short bowel syndrome
MACRONUTRIENT - High Protein Formula: contain 20% or more of total energy
CONTENT from protein
- High Lipid Formula: contain more than 40% of total energy
from lipids
OSMOLALITY a measure of the concentration of particles in solution,
expressed as number of milliosmoles per kilogram.
Isotonic a formula with an osmolality similar to that of blood serum
Formula (300 mOsm/kg)
Hypertonic a formula with an osmolality greater than that of blood serum.
formula

H. Complications of Enteral Feeding
Cause Complications
Mechanical Tube misplacement; clogged, twisted or kinked feeding
tubes
Gastrointestinal Diarrhea, abdominal discomfort, nausea and vomiting
Metabolic Hyperglycemia, fluid and electrolyte imbalance
Aspiration Increased risk among patients who are sedated, those
with ET or those with difficulty swallowing.
May be avoided by elevating the patient’s head higher
than his stomach or at an angle of 45 degrees during
feeding
Tube feeding Hyperosmolar-nonketotic dehydration; develops in
syndrome patients with insufficient fluid intake.
Prevented by giving sufficient fluid (1mL/kcal) with
feeding
I. Tube feeding Placement Sites

Insertion Method Description Advantages Disadvantages
Transnasal Feeding tubes are Does not require • Easy to remove
inserted through surgery or by disoriented
the nose and incision for clients
passed into the placement • Long term use
stomach or may irritate the
intestine. nasal passages,
throat, and
esophagus
Enterostomy • A gastric or • allow lower • require general
jejunal opening esophageal anesthesia for
made surgically or sphincter to insertion
under local remain closed, • greater risk of
anesthesia reducing the risk complications
through which a of aspiration. from the insertion
feeding tube can • more comfortable procedure
be passed. than transnasal • greater risk of
• PEG- for long term use infection
percutaneous
endoscopic
gastrostomy
• PEJ-
percutaneous
endoscopic
jejunostomy

Feeding Site Indication Advantages Disadvantages
Nasogastric • Intact gag reflex • Easiest to insert Highest risk of
• Nose to stomach • Normal gastric and confirm aspiration in
emptying placement compromised
• No esophageal • Can be given patients
reflux intermittently and
• Short term without an
feeding infusion pump
Nasoduodenal • Impaired gastric Lower risk of • More difficult to
• Nose to emptying aspiration insert and confirm
duodenum • Absent gag reflex placement
• Esophageal reflux • Feedings require
• Potential GI an infusion pump
intolerance for administration
• Short term
feeding
Nasojejunal • Impaired gastric
• Nose to jejunum emptying
• Absent gag reflex
• Esophageal reflux
• Gastric
dysfunction due to
trauma or surgery
• Short term
feeding
Gastrostomy • Swallowing • Feedings can be Moderate risk of
• Tube inserted dysfunction given aspiration in high-
to the stomach, • Long term feeding intermittently and risk patients
may be surgical without a pump
or nonsurgical • Easier to insert
(PEG) that jejunostomy
Jejunostomy • Esophageal reflux • Lower risk of • More difficult to
• Tube inserted • Long term feeding aspiration insert
to the intestine; • Impaired gastric • Allows for earlier • Feedings require
endoscopic or emptying enteral nutrition an infusion pump
laparoscopic following severe for administration
procedure or stress
may be
nonsurgical
(PEG)

J. Administration of Tube Feeding
a. Factors to consider in selection of feeding method
1. Risk of Aspiration
2. Patient comfort
3. Tube placement
4. Condition of the GIT
5. Expected Duration of feeding
b. Methods of administration
Method of Description Indications/ Disadvantages
Feeding Advantages
Continuous • Controlled delivery of a • People intolerant • Decreased
prescribed volume of of large formula nitrogen retention
formula (50 – 125 mL/hr) volumes • Elevated
at a constant rate over a • Enable rapid respiratory
continuous period of time achievement of quotient
using an infusion pump to caloric goal • Reduced
ensure accurate and • Associated with mobilization of fat
constant flow rates lower residual
• Small bowel feedings volume
• Reduce risk of
aspiration
• Requires less
supervision
• Recommended
method for
children
Intermittent • Pump assisted Non critically-ill • High risk of
• Home tube feeding patients aspiration,
• Requires formula with nausea, vomiting,
more calories and protein abdominal pain,
• Feedings are infused distention and
several times a day over diarrhea
longer period than bolus • Potential GI
feeding (usually 20 – 30 intolerance to goal
min) tube feeding
infusion rate
Bolus • Rapid instillation of Easiest method of More susceptible
Intermittent feeding via syringe or administering to diarrhea and
bulb feedings (no need distention
• Home tube feeding for infusion pump) Higher risk for
• Feeding over short period Most physiologic aspiration
(usually <10 min) in method (gut can Extra calories are
volumes of ≈250 – 450
rest between burned because
mL several times a day
feedings) of intraprandial
• Used primarily for gastric
feeding and postprandial
thermogenesis

Cyclic • Pump assisted Potential GI
Intermittent • Home tube feeding intolerance to
• Beneficial for transitioning goal tube feeding
tube feeding to oral diet infusion rate
• Requires formula with
high calories and protein
density
• Requires high infusion
rate over short period (8
– 16 hrs/period)
Safety measures to observe when feeding the patient
1. Elevate patient’s upper body to at least 45 degrees angle to reduce risk of

aspiration::
• during the feeding
• 30 minutes after the feeding
2. Check gastric residual

Gastric residual is the volume of formula that remains in the stomach from a
previous feeding
If gastric residual volume (GRV) is more than 500 ml or more than 200ml on two
successive assessments, feeding should be held or delayed for an hour or two.
K. Causes and Prevention of Tube feeding Complications

Complication Possible Cause/s Preventive/Corrective Measures
Aspiration Compromised • Use nasoenteric, gastrostomy,
gastroesophageal or jejunostomy feedings in
sphincter high-risked patients
• elevate head of bed during
and 45 minutes after feeding
Delayed gastric check gastric residuals

emptying
Clogged formula too thick for tube • select appropriate tube size
Feeding Tube • flush tubing before and after
giving formula
Meds delivered through • use infusion pump
the feeding tube • use oral, liquid or injectable
meds
• give medications individually

Constipation low fiber formula • Provide additional fluids
• Use high fiber formula
Lack of exercise Encourage walking and other

activities, if appropriate
Diarrhea, bacterial contamination • use fresh formula every 24
Cramps, hours
Abdominal • store opened or mixed formula
Distention in a refrigerator
• prepare formula with clean
hands
Lactose intolerance use lactose-free formula

rapid formula • slow administration or
administration continuous drip feeding
Nausea and Obstruction discontinue tube feeding
Vomiting
Delayed gastric • Check gastric residual
emptying • Slow administration or use
continuous drip feeding
Intolerance to • Use small volume of formula
concentration or volume • use continuous drip feeding
of formula
Skin irritation leakage of GI secretions • Keep site clean
at and friction caused by • inspect area for redness,
enterostomy the tube tenderness, and drainage
site • use protective skin cream
L. Termination of Tube Feeding
The patient should be eating about two-thirds of the estimated nutrient needs by
mouth before tube feeding is discontinued.
M. Computations of Tube feeding
Step 1: Compute for Total Energy Requirement
Method 1: Using Harris Benedict Formula

HBEE (males) = 66.47 + 13.75(W) + 5(H) – 6.78(A)
HBEE (females)= 655.1 + 9.56 (W) +1.85(H) – 4.68(A)
Where:
W = weight in kg.
H= Height in cm.
A= Age in years

Method 2: Based on kcal per kg body weight
20-35kcal per body weight
Step 2: Compute for Protein Requirement

Method I- by percentage distribution
% of TER
Carbohydrates 50-70%
Proteins
Infants 10%
Adults 10-15%
Fats
Normal Adults 20-25%
Children, adolescents 30-35%
Method II- NPC Method
Determine the protein calories first according to the normal allowances in

gms/KgBWand divide the non-protein calories (NPC) into:
CHO: 55-80% or an average of 70%

Fats: 20-45 % or an average of 30%
Normal protein allowances per day

gm/KgBW
Infants 1.6
Children 1.5-2.0
Adolescents 1.2
Adults 1.0
Stressed/catabolic 1.2 -2.0 gm/KgBW
Impaired renal function 0.6-0.8 gm/KgBW
Step 3: Compute for fluid requirement

20 to 40ml/kg/day or 1.0 to 1.5ml/kcal
Should be individualized based on patient’s fluid input and outputs and
estimates of insensible losses
Step 4: Distribution of TER into Carbohydrates, Protein, and Fats

II.B. Algorithm in the choice of Specialized Nutrition Support
The algorithm guides us in delivering adequate nutrition to the patient. The key
factor is the status of the gastrointestinal tract. When it is functional, one must
make all effort to use it, however, when the intake falls below the minimum
adequate level (<75%) then parenteral nutrition has to be given. Enteral route
access through the stomach or small bowel has to be decided based on the
capacity of the oral route to be restored. A.S.P.E.N. Board of Directors.
Guidelines for the use of parenteral and enteral nutrition in adult and pediatric
patients, III: nutritional assessment – adults. J Parenter Enteral Nutr 2002;
26(suppl): 9 – 12 SA.
II.C. PARENTERAL NUTRITION

• Sometimes called central venous nutirion (CVN) or intravenous
hyperalimentation (IVH) should be used only when the enteral route is
either not possible or cannot provide sufficient nutrient input.
The distinguishing feature of TPN (total parenteral nutrition) is administration of
concentrated macronutrients, vitamins, minerals and electrolytes into a large
central vein so that the volume of blood flow is sufficient to immediately dilute the
concentrated parenteral solutions.
Peripheral parenteral nutrition (PPN) and Peripheral venous nutrition refer to

administration of large-volume, dilute solutions of nutrients into vein in the arm or
back of the hand.
Disadvantages of PPN
• Irritating to the small veins and peripheral access is difficult to maintain for
more than a few days.
• Provides insufficient calories for many patients
INDICATIONS FOR PARENTERAL NUTRITION
PN is indicated in those clinical situations where the patient is unable to meet

nutritional needs either by an oral diet or thru the use of EN such as:
• Inability to digest and absorb nutrients such as in malabsorption
• Massive bowel resection or short bowel syndrome
• Intractable vomiting
• GI tract obstruction
• Impaired GI motility
• Abdominal trauma, injury, or infection
• Severe pancreatitis
• Postsurgery, if bowel function is likely to be disturbed
COMPOSITION OF PARENTERAL NUTRITION

PN contains a balanced mixture of protein, CHO, and lipid, together with water,
vitamins, minerals, and electrolytes.
Composition Description
Protein • In the form of individual amino acids in amounts consistent
with recommendations of the WHO and FAO
• Balanced solution of essential (40%) and nonessential
(60%) amino acids
• Protein requirements usually range from 0.8g/kg for normal
adults to 1.5 – 1.8g/kg for patients with burns, trauma, or
healing wounds (ASPEN, 2002).
• Protein restrictions are occasionally needed for patients with
renal failure who are not receiving dialysis.
Carbohydrate • Primary function is to serve as energy source
• Dextrose monohydrate is used, it provides 2.4kcal/g
• Minimum CHO intake: 130g/day. Approximately 100g of
CHO is required daily to allow for protein sparing
• Excessive CHO may contribute to hyperglycemia and
excessive CO2 production. This may jeopardize respiratory
status and result in difficulty weaning from the mechanical
ventilator
Lipid in PN • An emulsion of soybean of safflower oil
• Provides EFA and concentrated source of energy
• Common clinical practice is to provide a minimum of 10% of
kcal requirements as lipid but may provide 20 – 30 of total
kcal. Reduces the need for energy from dextrose and
lowers the risk of hyperglycemia in glucose intolerant
patients

Fluids and • Daily fluid needs:
Electrolytes - Young Adults: 30 – 40 mL/kBW
- Older Adults: 30 mL/KBW
- Daily average: 1500 – 2500 mL
• Electrolytes include Na, K, Cl, Ca, Mg, and P.
• Blood tests to monitor electrolyte status must be done daily
until patient has stabilized.
Vitamins and • All water soluble vitamins are supplied, as well as vitamin A,
Minerals D, E; vitamin K is often omitted and must be added
separately
• Trace minerals added include zinc, copper. Chromium,
selenium, and manganese. Iron is excluded because it
alters the stability of other components.
COMPLICATIONS OF TPN
Source Complications
Technical complications • Catheter-related injury related to insertion
(hemothorax, pneumothorax, air embolism,
subclavian artery injury, etc.)
• Sepsis secondary to contamination of central venous
catheter
Metabolic complications • Glucose abnormalities (hyperglycemia), electrolyte
disturbances, vitamin deficiencies, etc.
GIT related Gut mucosal atrophy, hepatobillary dysfunction
III. Clinical practice evidence-based guidelines for nutrition support in adult

critically-ill patients (ASPEN, 2009)
Recommendation
Use of PN vs. EN Use of EN over PN is strongly recommended
because EN compared to PN is associated with
reduction in the number of infectious complications,
lower incidence of hyperglycemia, and cost savings.
Early vs. Delayed EN within 24 – 48 hrs following admission to ICU is
nutrient intake recommended.
Early EN improves nutritional intake and is
associated with reduction in mortality and reduction
in infectious complications.
Immune-enhancing diets Use of glutamine in PN is strongly recommended
but this is not recommended in critically-ill patients
receiving EN.
Effects of PN with Glutamine:

• Reduction in mortality
• Reduction in length of stay in the hospital
• Reduction in infectious complications
•

Dose of Glutamine: 0.2 – 0.57g/kg/day
Use of EN with arginine is not recommended for

critically-ill patients, given the possible harm in
septic patients and the increased costs. Also,
studies noted the lack of treatment effect with
respect to mortality and infections.
EN with fish oils (OXEPA: fish oil, borage oil,

antioxidants) are recommended in patients with
acute lung injury (ALI) and acute respiratory
distress syndrome (ARDS); no evidence of a
treatment effect in septic patients without lung
injury.
Effects in patients with ALI and ARDS

• Significant reduction in mortality
• Lower incidence of newly acquired pneumonia
• Significant reduction in ICU length of stay
• Significant reduction in ventilated days
• Significant reduction in new organ failures
Proteins/ Peptides in EN When initiating enteral feeds, the use of whole
protein formulas (polymeric) instead of peptide-
based formulas is recommended.
Fiber in EN No sufficient dats to support the routine use of fiber
(pectin or soy polysaccharides) in enteral feeding
formulas
Motility agents Metoclopramide
They have physiologic effect on GI motility and may
improve tolerance to EN
Recommended in patients who experience feed
intolerance (high gastric residuals; emesis)
EN via the small bowel Small bowel feeding was associated with significant
reduction in infections (pneumonia) when compared
with gastric feeding. This is specially recommended
for patients at high risk for regurgitation and
aspiration (nused in supine position) and those who
are not tolerating adequate amounts of EN
delivered into the stomach. Small bowel feeding
improves calorie and protein intake.
Body position Patients receiving EN should have the head of the
bed elevated to 45 degrees (semirecumbent
position). This position is associated with a
significant decrease in the incidence of ventilation-
associated pneumonia.

PN in combination with Studies showed a trend towards harm. There was
EN increase in mortality which could not be explained
by overfeeding.
Blood sugar control Intensive insulin therapy to control blood sugar level
between 4.4 – 6.1 mmol/L should be considered in
all critically-ill patients. It was associated with lower
incidence of sepsis, reduction in ventilator days,
and reduced ICU and hospital mortality.
Vitamins and minerals Recommended for critically-ill patients


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Far Eastern University

Nicanor Reyes Medical Foundation

BIOCHEMISTRY AND NUTRITION

Anna Belen Ignacio-Alensuela, MD

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Therapeutic diet is a normal diet that is quantitatively and/or qualitatively

Nutritional therapy is a system of healing based on the belief that food, as

THE DIET PRESCRIPTION

DETERMINATION OF NUTRITIONAL STATUS:

1. Obesity - actual body weight is > 20% of IBW

ASSESSMENT OF NUTRITIONAL STATUS

COMPONENTS OF NUTRITIONAL ASSESSMENT:

BACKGROUND HISTORIES: Medical history

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CARBOHYDRATES- major source of energy

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RENI FOR Carbohydrates: 55-70% of TCR

FATS - provides high caloric diet with satiety value

B. Cholesterol - vital substance in human metabolism

Essential Fatty Acids:

Omega 3 Fatty Acids: Alpha-linolenic acid

Properties of Omega 3 FA:

Sources of EPA and DHA: Fish oils

RENI for Fats: 20-30% of TCR

PROTEIN - most abundant of the organic compounds in the body

Essential Amino Acids:

B. Additional amino acids essential for infants

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RENI For Proteins: 10-15% of TCR

RECOMMENDED ENERGY AND NUTRIENT INTAKES (RENI)

The revised edition of the dietary standards is changed from "Recommended

Uses and Applications:

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ENERGY. The recommended energy requirement of an individual is the level of

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MODIFICATIONS OF A NORMAL DIET:

1. Change in caloric content

INDICATIONS FOR INCREASING THE CALORIC CONTENT OF DIET

1. Growth 4. Marasmus/ Kwashiorkor

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CARBOHYDRATES. Carbohydrates may contribute 55-70% of TDE, 70% of which

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DESIRABLE CONTRIBUTION OF CARBOHYDRATES, FATS AND

Minimum Daily Requirements for Electrolytes

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E.g. Tea, broth, carbonated beverages, strained fruit juices.

Soft Diet. This is an adequate diet characterized by being moderately low in

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FOOD SELECTION GUIDELINES FOR SOFT DIET

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3. Food and Agriculture Organization/World Health Organization (FAO/WHO). Human vitamin

11. Food and Agriculture Organization/Word Health Organization/United Nations University

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DIET PLANNING USING THE FOOD EXCHANGE LIST

DIET PLANNING PRINCIPLES

• Adequacy providing all the essential nutrients, fiber, and

IMPORTANT POINTS TO CONSIDER IN PLANNING