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To my newest grandson, Cruz Kai DeBruyne. You are welcomed with so much love
and aloha.
LINDA KELLY DEBRUYNE
To my mom, Tina C. Pinna, who started me on the path to good nutritional

practices in my earliest years.
KATHRYN PINNA
iii
Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
About the Authors
LINDA KELLY DEBRUYNE, M.S., R.D., received her B.S. and her M.S. degrees in
nutrition and food science from Florida State University. She is a founding member
of Nutrition and Health Associates, an information resource center in Tallahassee,
Florida, where her specialty areas are life cycle nutrition and fitness. Her other publica-
tions include the textbooks Nutrition and Diet Therapy and Health: Making Life Choices
and a multimedia CD-ROM called Nutrition Interactive. As a consultant for a group of
Tallahassee pediatricians, she has taught infant nutrition classes to parents. She is a reg-
istered dietitian and maintains a professional membership in the Academy of Nutrition
and Dietetics.
KATHRYN PINNA, PH.D., R.D., received her M.S. and Ph.D. degrees in nutrition
from the University of California at Berkeley. She has taught nutrition, food science,
and human biology courses in the San Francisco Bay area for over 25 years and has also
worked as an outpatient dietitian, Internet consultant, and freelance writer. Her other
publications include the textbooks Understanding Normal and Clinical Nutrition and
Nutrition and Diet Therapy. She is a registered dietitian and a member of the American
Society for Nutrition and the Academy of Nutrition and Dietetics.
Brief Contents
Chapter 1 Chapter 13
Overview of Nutrition and Health 1 Nutrition Care and Assessment 371
Digestion and Absorption 39 Nutrition Intervention and Diet–Drug
Interactions 395
Chapter 3
Carbohydrates 63 Chapter 15
Enteral and Parenteral Nutrition
Chapter 4 Support 425
Lipids 91
Chapter 16
Chapter 5 Nutrition in Metabolic and Respiratory
Protein 119 Stress 459
Energy Balance and Body Composition 141 Nutrition and Upper Gastrointestinal
Disorders 479
Chapter 7
Weight Management 167 Chapter 18
Nutrition and Lower Gastrointestinal
Chapter 8
Disorders 503
The Vitamins 193
Chapter 19
Chapter 9
Nutrition and Liver Diseases 535
Water and the Minerals 231
Chapter 20
Chapter 10
Nutrition and Diabetes Mellitus 553
Nutrition through the Life Span: Pregnancy
and Lactation 265 Chapter 21
Nutrition and Cardiovascular
Chapter 11
Diseases 583
Nutrition through the Life Span: Infancy,
Childhood, and Adolescence 297 Chapter 22
Nutrition and Renal Diseases 611
Chapter 12
Nutrition through the Life Span: Later Chapter 23
Adulthood 343 Nutrition, Cancer, and HIV Infection 637
vii
Contents
Chapter 1 Chapter 3
Overview of Nutrition and Health 1 Carbohydrates 63
Food Choices 3 The Chemist’s View of Carbohydrates 64
The Nutrients 6 Monosaccharides 64
Six Classes of Nutrients 6 Disaccharides 65
kCalories: A Measure of Energy 7 Polysaccharides 65
Nutrient Recommendations 8 Digestion and Absorption of Carbohydrates 68
Dietary Reference Intakes 8 Regulation of Blood Glucose 68
Acceptable Macronutrient Distribution Ranges 10 Health Effects of Sugars and Alternative Sweeteners 69
National Nutrition Surveys 10 Sugars 69
Coordinating Nutrition Survey Data 11 Alternative Sweeteners: Sugar Alcohols 74
National Health Goals 11 Alternative Sweeteners: Nonnutritive Sweeteners 75
Dietary Guidelines and Food Guides 12 Health Effects of Starch and Dietary Fibers 77
Dietary Ideals 12 Carbohydrates: Disease Prevention
Dietary Guidelines for Americans 13 and Recommendations 77
Fitness Guidelines 16 Carbohydrates: Food Sources 80
The USDA Food Patterns 17 Carbohydrates: Food Labels and Health Claims 82
MyPlate 24 NUTRITION IN PRACTICE The Glycemic Index in Nutrition
Food Labels 24 Practice 86
The Ingredient List 24
Nutrition Facts Panel 25
Claims on Labels 27 Chapter 4
NUTRITION IN PRACTICE Finding the Truth about Nutrition 34 Lipids 91
Roles of Body Fat 92
Chapter 2 The Chemist’s View of Lipids 93
Triglycerides 93
Digestion and Absorption 39 Fatty Acids 94
Anatomy of the Digestive Tract 40 Phospholipids 97
The Digestive Organs 40 Sterols 97
The Involuntary Muscles and the Glands 42 Digestion and Absorption of Lipids 98
The Process of Digestion 45 Health Effects and Recommended Intakes of Fats 98
Digestion in the Mouth 45 Fats and Heart Health 99
Digestion in the Stomach 46 Recommendations 102
Digestion in the Small and Large Intestines 46
Fats in Foods 103
The Absorptive System 47 Finding the Fats in Foods 104
The Small Intestine 48 Cutting Solid Fats and Choosing Unsaturated Fats 106
Absorption of Nutrients 48
NUTRITION IN PRACTICE Figuring Out Fats 113
Transport of Nutrients 50
The Vascular System 50
The Lymphatic System 50 Chapter 5
Transport of Lipids: Lipoproteins 50
Protein 119
The System at Its Best 53
The Chemist’s View of Proteins 120
NUTRITION IN PRACTICE Food Safety 55
The Structure of Proteins 120
Nonessential and Essential Amino Acids 121
ix
Protein Digestion and Absorption 122 Reasonable Strategies for Weight Loss 176
Protein Turnover and Nitrogen Balance 122 A Healthful Eating Plan 177
Protein Turnover 122 Physical Activity 179
Nitrogen Balance 123 Behavior and Attitude 181
Weight Maintenance 183
Roles of Body Proteins 123
Strategies for Weight Gain 184
Protein and Health 126
Protein Deficiency 126 NUTRITION IN PRACTICE Fad Diets 190
Malnutrition 127
Protein Excess 128 Chapter 8
Protein and Amino Acid Supplements 129
Protein Recommendations and Intakes 130 The Vitamins 193
The Vitamins—An Overview 194
Protein in Foods 131
Protein Quality 131 The Fat-Soluble Vitamins 196
Protein Sparing 132 Vitamin A and Beta-Carotene 196
Protein on Food Labels 132 Vitamin D 201
Vitamin E 205
NUTRITION IN PRACTICE Vegetarian Diets 135
Vitamin K 206
The Water-Soluble Vitamins 208
Chapter 6 The B Vitamins 209
Energy Balance and Body Composition 141 Thiamin 210
Riboflavin 210
Energy Imbalance 142
Niacin 211
Feasting 142
Pantothenic Acid and Biotin 212
The Economics of Fasting 143
Vitamin B6 212
Energy Balance 145 Folate 213
Energy In 145 Vitamin B12 214
Energy Out 146 Non-B Vitamins 216
Estimating Energy Requirements 149 Vitamin C 216
Body Weight and Body Composition 150 NUTRITION IN PRACTICE Phytochemicals and Functional
Defining Healthy Body Weight 150 Foods 223
Body Composition 152
How Much Body Fat Is Too Much? 154
Chapter 9
Health Risks of Underweight and Obesity 154
Health Risks of Underweight 155 Water and the Minerals 231
Health Risks of Overweight and Obesity 155 Water and Body Fluids 232
Guidelines for Identifying Those at Risk from Obesity 156 Water Balance 232
Other Risks of Obesity 156 Fluid and Electrolyte Balance 234
NUTRITION IN PRACTICE Eating Disorders 160 Acid-Base Balance 235
The Major Minerals 235
Sodium 236
Chapter 7 Chloride 238
Weight Management 167 Potassium 238
Causes of Obesity 168 Calcium 239
Genetics and Weight 168 Phosphorus 243
Environmental Stimuli 171 Magnesium 244
Sulfate 244
Obesity Treatment: Who Should Lose? 173
The Trace Minerals 245
Inappropriate Obesity Treatments 173 Iron 245
Over-the-Counter Weight-Loss Products 174 Zinc 250
Other Gimmicks 174 Selenium 252
Aggressive Treatments of Obesity 174 Iodine 253
Obesity Drugs 175 Copper 254
Surgery 176 Manganese 254
x Contents
Fluoride 254 Energy and Nutrient Needs 328
Chromium 255 Food Choices and Health Habits 329
Other Trace Minerals 255 NUTRITION IN PRACTICE Childhood Obesity and the Early
NUTRITION IN PRACTICE Vitamin and Mineral Development of Chronic Diseases 337
Supplements 261
Chapter 12
Chapter 10
Nutrition through the Life Span: Later
Nutrition through the Life Span: Pregnancy Adulthood 343
and Lactation 265 Nutrition and Longevity 344
Pregnancy: The Impact of Nutrition on the Future 266 Slowing the Aging Process 345
Nutrition Prior to Pregnancy 266 Nutrition and Disease Prevention 347
Prepregnancy Weight 266 Nutrition-Related Concerns during Late Adulthood 348
Healthy Support Tissues 267 Cataracts and Macular Degeneration 348
The Events of Pregnancy 268 Arthritis 348
Nutrient Needs during Pregnancy 270 The Aging Brain 349
Food Assistance Programs 276
Weight Gain 276 Energy and Nutrient Needs during Late Adulthood 351
Weight Loss after Pregnancy 278 Energy and Energy Nutrients 352
Physical Activity 278 Vitamins and Minerals 354
Common Nutrition-Related Concerns of Pregnancy 279 Nutrient Supplements for Older Adults 355
Problems in Pregnancy 280 The Effects of Drugs on Nutrients 356
Practices to Avoid 281 Food Choices and Eating Habits of Older Adults 356
Adolescent Pregnancy 285 Individual Preferences 357
Breastfeeding 286 Meal Setting 357
Nutrition during Lactation 286 Depression 357
Contraindications to Breastfeeding 288 Food Assistance Programs 357
Meals for Singles 358
NUTRITION IN PRACTICE Encouraging Successful
Breastfeeding 294 NUTRITION IN PRACTICE Hunger and Community Nutrition 365
Nutrition through the Life Span: Infancy, Nutrition Care and Assessment 371
Childhood, and Adolescence 297 Nutrition in Health Care 372
How Illness Affects Nutrition Status 372
Nutrition of the Infant 298 Responsibility for Nutrition Care 373
Nutrient Needs during Infancy 298 Identifying Risk for Malnutrition 374
Breast Milk 300 The Nutrition Care Process 376
Infant Formula 303
The Transition to Cow’s Milk 304 Nutrition Assessment 377
Introducing First Foods 305 Historical Information 377
Looking Ahead 307 Dietary Assessment 378
Mealtimes 307 Anthropometric Data 381
Biochemical Analyses 384
Nutrition during Childhood 308 Physical Examination 387
Energy and Nutrient Needs 308
Hunger and Malnutrition in Children 312 NUTRITION IN PRACTICE Nutritional Genomics 391
Lead Poisoning in Children 313
Food Allergy 314 Chapter 14
Hyperactivity 316
Childhood Obesity 317 Nutrition Intervention and Diet–Drug
Mealtimes at Home 322 Interactions 395
Nutrition at School 325 Implementing Nutrition Care 396
Nutrition during Adolescence 327 Care Planning 396
Growth and Development during Adolescence 328 Approaches to Nutrition Care 398
Contents xi
Dietary Modifications 400 Nutrition Treatment of Acute Stress 463
Energy Intakes in Hospital Patients 400 Determining Nutritional Requirements 464
Modified Diets 401 Approaches to Nutrition Care in Acute Stress 466
Variations in the Diet Order 404 Nutrition and Respiratory Stress 467
Foodservice 406 Chronic Obstructive Pulmonary Disease 467
Food Selection 406 Respiratory Failure 470
Food Safety 407 NUTRITION IN PRACTICE Multiple Organ Dysfunction
Improving Food Intake 407 Syndrome 476
Diet–Drug Interactions 408
Drug Effects on Food Intake 408
Drug Effects on Nutrient Absorption 409 Chapter 17
Dietary Effects on Drug Absorption 410 Nutrition and Upper Gastrointestinal
Drug Effects on Nutrient Metabolism 410
Disorders 479
Dietary Effects on Drug Metabolism 411
Drug Effects on Nutrient Excretion 412 Conditions Affecting the Mouth and Esophagus 480
Dietary Effects on Drug Excretion 412 Dry Mouth 480
Drug–Nutrient Interactions and Toxicity 413 Dysphagia 480
Gastroesophageal Reflux Disease 484
NUTRITION IN PRACTICE Complementary and Alternative
Therapies 417 Conditions Affecting the Stomach 486
Dyspepsia 487
Nausea and Vomiting 487
Chapter 15 Gastritis 488
Peptic Ulcer Disease 488
Enteral and Parenteral Nutrition
Gastric Surgery 490
Support 425 Gastrectomy 490
Enteral Nutrition 426 Bariatric Surgery 493
Oral Supplements 426
NUTRITION IN PRACTICE Nutrition and Oral Health 499
Candidates for Tube Feedings 427
Tube Feeding Routes 427
Enteral Formulas 430 Chapter 18
Administration of Tube Feedings 434
Medication Delivery during Tube Feedings 437 Nutrition and Lower Gastrointestinal
Tube Feeding Complications 437 Disorders 503
Transition to Table Foods 439 Common Intestinal Problems 504
Parenteral Nutrition 440 Constipation 504
Candidates for Parenteral Nutrition 440 Intestinal Gas 506
Venous Access 440 Diarrhea 506
Parenteral Solutions 441 Malabsorption 508
Administering Parenteral Nutrition 445 Fat Malabsorption 508
Managing Metabolic Complications 446 Bacterial Overgrowth 512
Nutrition Support at Home 448 Lactose Intolerance 512
Candidates for Home Nutrition Support 448 Disorders of the Pancreas 513
Planning Home Nutrition Care 448 Pancreatitis 513
Quality-of-Life Issues 449 Cystic Fibrosis 515
NUTRITION IN PRACTICE Inborn Errors of Metabolism 454 Disorders of the Small Intestine 516
Celiac Disease 516
Inflammatory Bowel Diseases 519
Chapter 16 Short Bowel Syndrome 522
Nutrition in Metabolic and Respiratory Disorders of the Large Intestine 524
Stress 459 Irritable Bowel Syndrome 524
The Body’s Responses to Stress and Injury 460 Diverticular Disease of the Colon 525
Hormonal Responses to Stress 461 Colostomies and Ileostomies 526
The Inflammatory Response 461 NUTRITION IN PRACTICE Probiotics and Intestinal Health 532
xii Contents
Chapter 19 Stroke 595
Nutrition and Liver Diseases 535 Stroke Prevention 596
Stroke Management 596
Fatty Liver and Hepatitis 536
Fatty Liver 536 Hypertension 597
Hepatitis 536 Factors That Influence Blood Pressure 597
Factors That Contribute to Hypertension 598
Cirrhosis 538 Treatment of Hypertension 598
Consequences of Cirrhosis 539
Treatment of Cirrhosis 542 Heart Failure 602
Nutrition Therapy for Cirrhosis 542 Consequences of Heart Failure 602
Medical Management of Heart Failure 603
Liver Transplantation 546
NUTRITION IN PRACTICE Helping People with Feeding
NUTRITION IN PRACTICE Alcohol in Health and Disease 550 Disabilities 608
Nutrition and Diabetes Mellitus 553 Nutrition and Renal Diseases 611
Overview of Diabetes Mellitus 554 Nephrotic Syndrome 613
Symptoms of Diabetes Mellitus 554 Consequences of Nephrotic Syndrome 613
Diagnosis of Diabetes Mellitus 555 Treatment of Nephrotic Syndrome 613
Types of Diabetes Mellitus 555
Prevention of Type 2 Diabetes Mellitus 557 Acute Kidney Injury 616
Acute Complications of Diabetes Mellitus 557 Causes of Acute Kidney Injury 616
Chronic Complications of Diabetes Mellitus 559 Consequences of Acute Kidney Injury 616
Treatment of Acute Kidney Injury 617
Treatment of Diabetes Mellitus 561
Treatment Goals 561 Chronic Kidney Disease 619
Evaluating Diabetes Treatment 562 Consequences of Chronic Kidney Disease 619
Nutrition Therapy: Dietary Recommendations 563 Treatment of Chronic Kidney Disease 621
Nutrition Therapy: Meal-Planning Strategies 565 Kidney Transplants 626
Insulin Therapy 567 Kidney Stones 628
Antidiabetic Drugs 571 Formation of Kidney Stones 628
Physical Activity and Diabetes Management 571 Consequences of Kidney Stones 629
Sick-Day Management 573 Prevention and Treatment of Kidney Stones 629
Diabetes Management in Pregnancy 573 NUTRITION IN PRACTICE Dialysis 634
Pregnancy in Type 1 or Type 2 Diabetes 574
Gestational Diabetes 575
Chapter 23
NUTRITION IN PRACTICE Metabolic Syndrome 579
Nutrition, Cancer, and HIV Infection 637
Cancer 638
Chapter 21 How Cancer Develops 638
Nutrition and Cardiovascular Diseases 583 Nutrition and Cancer Risk 639
Atherosclerosis 584 Consequences of Cancer 641
Consequences of Atherosclerosis 585 Treatments for Cancer 642
Causes of Atherosclerosis 585 Nutrition Therapy for Cancer 644
Coronary Heart Disease 586 HIV Infection 649

Symptoms of Coronary Heart Disease 586 Prevention of HIV Infection 649
Evaluating Risk for Coronary Heart Disease 587 Consequences of HIV Infection 649
Lifestyle Management to Reduce CHD Risk 588 Treatments for HIV Infection 651
Vitamin Supplementation and CHD Risk 591 Nutrition Therapy for HIV Infection 653
Lifestyle Changes for Hypertriglyceridemia 593 NUTRITION IN PRACTICE Ethical Issues in Nutrition Care 659
Drug Therapies for CHD Prevention 593
Treatment of Heart Attack 595
Contents xiii
Appendix A Table of Food Composition A-2 Chapter 17
Appendix B WHO: Nutrition Recommendations Woman with GERD 486
Canada: Guidelines and Meal Planning B Nutrition Care after Gastric Surgery 493
Nutrition Recommendations from WHO B Chapter 18
Eating Well with Canada’s Food Guide B Patient with Short Bowel Syndrome 523
Beyond the Basics: Meal Planning for Healthy Eating, Young Adult with Irritable Bowel Syndrome 525
Diabetes Prevention and Management B-7 Chapter 19
Appendix C Choose Your Foods: Food Lists for Man with Cirrhosis 545
Diabetes C-1 Chapter 20
The Food Lists C-1 Child with Type 1 Diabetes 574
Serving Sizes C-1 Woman with Type 2 Diabetes 576
The Foods on the Lists C-1
Controlling Energy, Fat, and Sodium C-2 Chapter 21
Planning a Healthy Diet C-3 Patient with Cardiovascular Disease 602
Appendix D Physical Activity and Energy Chapter 22

Requirements D-1 Woman with Acute Kidney Injury 619
Man with Chronic Kidney Disease 626
Appendix E Nutrition Assessment: Supplemental
Information E-1 Chapter 23
Weight Gain during Pregnancy E-1 Woman with Cancer 648
Growth Charts E-1 Man with HIV Infection 655
Measures of Body Fat and Lean Tissue E-2
Nutritional Anemias E-8 How To Features
Cautions about Nutrition Assessment E-12 Chapter 1
Appendix F Aids to Calculation F-1 Calculate the Energy a Food Provides 7
Conversion Factors F-1 Chapter 3
Percentages F-1 Reduce Intakes of Added Sugars 72
Weights and Measures F-2
Chapter 4
Appendix G Enteral Formulas G Make Heart-Healthy Choices—by Food Group 106
Appendix H Answers to Self Check Questions H-1 Chapter 5
Glossary GL-1 Calculate Recommended Protein Intakes 130
Index I-1 Chapter 6
Estimate Energy Requirements 150
Case Studies Chapter 7
Apply Behavior Modification to Manage Body Fatness 182
Chapter 10
Woman in Her First Pregnancy 288 Chapter 8
Estimate Dietary Folate Equivalents 214
Chapter 11
Boy with Disruptive Behavior 317 Chapter 9
Cut Salt Intake 237
Chapter 12 Add Calcium to Daily Meals 243
Elderly Man with a Poor Diet 358 Add Iron to Daily Meals 251
Nutrition Screening and Assessment 388 Protect against Lead Toxicity 314
Implementing Nutrition Care 399 Turn Convenience Foods into Nutritious Meals 360
Chapter 15 Stretch Food Dollars and Reduce Waste 367
Injured Hiker Requiring Enteral Nutrition Support 439 Chapter 13
Patient with Intestinal Disease Requiring Parenteral Measure Length and Height 382
Nutrition 447 Measure Weight 383
Chapter 16 Estimate and Evaluate Changes in Body Weight 384
Patient with a Severe Burn 467
Elderly Man with Emphysema 471
xiv Contents
Chapter 14 Alter the Diet to Reduce Symptoms of Dumping
Estimate Appropriate Energy Intakes for Hospital Syndrome 492
Patients 401 Alter Dietary Habits to Achieve and Maintain Weight Loss after
Help Hospital Patients Improve Their Food Intakes 407 Bariatric Surgery 495
Prevent Diet–Drug Interactions 413 Chapter 18
Chapter 15 Follow a Fat-Restricted Diet 511
Help Patients Improve Intakes with Oral Supplements 427 Chapter 19
Help Patients Cope with Tube Feedings 435 Man with Cirrhosis 545
Plan a Tube Feeding Schedule 436
Administer Medications to Patients Receiving Tube Chapter 20
Feedings 437 Use Carbohydrate Counting in Clinical Practice 566
Express the Osmolar Concentration of a Solution 441 Chapter 21
Calculate the Macronutrient and Energy Content of a Implement a Heart-Healthy Diet 592
Parenteral Solution 444 Reduce Sodium Intake 601
Estimate Energy Needs Using Disease-Specific Stress Help Patients Comply with a Renal Diet 626
Factors 464 Chapter 23
Chapter 17 Increase kCalories and Protein in Meals 645
Improve Acceptance of Mechanically Altered Foods 483 Help Patients Handle Food-Related Problems 646
Manage Gastroesophageal Reflux Disease 486
Contents xv
Preface
We are pleased to present this sixth edition and new concepts to learn. This book contains abundant
pedagogy to help students master the subject matter.
of Nutrition for Health and Health Care, which provides Within each chapter, definitions of important terms
a solid foundation in nutrition science and the role appear in the margins. How To skill boxes help readers
of nutrition in clinical care. Health professionals and work through calculations or give practical suggestions
patients alike rank nutrition among their most serious for applying nutrition advice. The Nursing Diagnosis fea-
concerns, as good nutrition status plays critical roles in ture enables nursing students to correlate nutrition care
both disease prevention and the appropriate treatment with nursing care. Review Notes summarize the informa-
of illness. Moreover, medical personnel are frequently tion following each major heading; these summaries can
called upon to answer questions about foods and diets or be used to preview or review key chapter concepts. The
provide nutrition care. Although much of the material has Self Check at the end of each chapter provides questions
been written for nursing students and is relevant to nurs- to help review chapter information. Each chapter con-
ing care, this textbook can be useful for students of other cludes with a Nutrition on the Net feature, which lists
health-related professions, including nursing assistants, websites relevant to the topics covered in the chapter.
physician assistants, dietitians, dietary technicians, and In the life cycle and clinical chapters, Case Studies
health educators. guide readers in applying nutrition therapy to patient
Each chapter of this textbook includes essential nutri- care. Diet-Drug Interaction boxes in the clinical chapters
tion concepts along with practical information for identify important nutrient-drug and food-drug interac-
addressing nutrition concerns and solving nutrition tions. Clinical Applications throughout the text encourage
problems. The introductory chapters (Chapters 1 and 2) readers to practice mathematical calculations, synthesize
provide an overview of the nutrients and nutrition recom- information from previous chapters, or understand how
mendations and describe the process of digestion and dietary adjustments affect patients. Nutrition Assessment
absorption. Chapters 3 through 5 introduce the attributes Checklists remind readers of assessment parameters
and functions of carbohydrates, lipids, and protein and relevant to specific stages of the life cycle or medical
explain how appropriate intakes of these nutrients sup- problems.
port health. Chapters 6 and 7 introduce the concepts of The Nutrition in Practice sections that follow the chap-
energy balance and weight management and describe ters explore issues of current interest, advanced topics, or
the health effects of overweight, underweight, and eating specialty areas such as dental health or dialysis. Examples
disorders. Chapters 8 and 9 introduce the vitamins and of topics covered include foodborne illness, the glycemic
minerals, describing their roles in the body, appropriate index, vegetarian diets, alcohol in health and disease,
intakes, and food sources. Chapters 10 through 12 explain nutritional genomics, metabolic syndrome, and child-
how nutrient needs change throughout the life cycle. hood obesity and chronic disease.
Chapters 13 and 14 explore how health professionals can
use information from nutrition assessments to identify
and address a patient’s dietary needs. The remaining APPENDIXES
chapters (Chapters 15–23) examine nutrition therapy and The appendixes support the book with a wealth of infor-
its role in the prevention and treatment of common medi- mation on the nutrient contents of thousands of foods,
cal conditions. Canadian nutrient recommendations and food choices,
U.S. nutrient intake recommendations, food lists for dia-
FEATURES OF THIS TEXT betes, physical activity and energy requirements, nutrition
assessments, enteral formulas, aids to calculations, and
Students of nutrition often begin a nutrition course with answers to Self Check questions.
some practical knowledge of nutrition; after all, they may
purchase food, read food labels, and be familiar with
common nutrition problems such as obesity or lactose NEW TO THIS EDITION
intolerance. After just a few weeks of class, however, the Each chapter of this book has been updated to reflect
nutrition student realizes that nutrition is a biological and advances in research and clinical practice since the fifth
chemical science with a fair amount of new terminology edition. In addition, we have made the following changes:
xvi
Chapter 1 • In the Nutrition in Practice section, defined and dis-
• Defined empty kcalories, reorganized the fitness section, cussed RED-S (relative energy deficiency in sport) from
introduced the Dietary Guidelines for Americans 2015 the International Olympic Committee to replace female
• Added a new table of nutrients of concern athlete triad
• Created a new figure showing recommended and actual
intakes of food groups Chapter 7
• Added information about microbiota and obesity and
Chapter 2 defined microbiota
• Added definition of enzymes and more information • In the Nutrition in Practice section, enhanced the
about digestive enzymes in the glossary of digestive discussion of high-protein diets for weight loss and
glands and their secretions maintenance
• Improved the discussion of LDL and HDL
• In the Nutrition in Practice section, enhanced the Chapter 8
instructions for proper hand washing based on new • Added a list of vitamins of concern from the 2015
CDC guidelines Dietary Guidelines Advisory Committee
• Enhanced the discussion of vitamin D and obesity and
Chapter 3 other disease relationships
• Enhanced the discussion of cholesterol-lowering effects
of fiber Chapter 9
• Added more information to Figure 3-5 (Characteristics, • Added a list of minerals of concern from the 2015
Sources, and Health Effects of Fibers) Dietary Guidelines Advisory Committee
• Enhanced Figure 3-6 (Fiber in Selected Foods) by add-
ing tips to increase fiber intakes Chapter 10
• Added a discussion of added sugars and diabetes • Moved the section on infancy to Chapter 11 to focus
only on nutrition for the mother during pregnancy and
Chapter 4 lactation
• Moved the table of major sources of various lipids from • Included the latest FDA and EPA guidelines on fish
the Nutrition in Practice to the chapter consumption during pregnancy
• Added a new table of omega-3 fatty acids in fish and • Added a brief discussion about choline and
seafood pregnancy
• Included a new table of fat options among milk and
milk products Chapter 11
• Updated information on dietary cholesterol restrictions • Added a discussion of the importance of zinc in
based on American Heart Association and new Dietary complementary foods for breastfed infants
Guidelines information • Created a new table listing protective factors in breast
• Emphasized the importance of overall dietary patterns milk and how they function
when reducing the intake of saturated and trans fat • Restructured and simplified table of nutrient
supplements for infants
Chapter 5 • Added a new table: USDA Nutrition Standards for
• Reorganized the malnutrition discussion Foods Sold in Schools.
• Added definitions of wasting, stunting, and marasmic
kwashiorkor Chapter 12
• Included a new How to Calculate Protein Intakes box • Enhanced the discussion of protein needs for older
• In the Nutrition in Practice section, enhanced the glos- adults
sary of vegetarian diets and added a new figure showing • In the Nutrition in Practice section, included new
vegetarian sources and equivalents for protein foods definitions for food security and food insecurity
and milk and milk products • Revised the food security questionnaire
• Included the latest information from the 2013 • Updated nursing diagnoses
American Heart Association/American College of • Added a paragraph about C-reactive protein in the
Cardiology and The Obesity Society Guidelines for the section on biochemical analyses
management of overweight and obesity in adults • Revised the discussion on fluid retention
Preface xvii
• Expanded the section on estimating energy intakes in • Revised the paragraph on nutrition treatment for
hospital patients hepatitis
• Shortened the section on foodservice • Modified some of the sections about cirrhosis
• Modified the paragraph on isoniazid and vitamin B6 in complications
the “Diet–Drug Interactions” section • Revised the sections on the medical treatment and
• Modified the table showing examples of grapefruit nutrition therapy for cirrhosis, introduced the term
juice–drug interactions transjugular intrahepatic portosystemic shunt in the
• In the Nutrition in Practice section, modified the table discussion about ascites treatment, and eliminated the
listing examples of herb–drug interactions description of the peritoneovenous shunt
• Updated the feeding tube photo • Updated statistics throughout the chapter
• Introduced the term cyclic feedings in the section on • Added a note about the types of insulin used in the
formula delivery methods Diabetes Control and Complications Trial
• Shortened the section on discontinuing parenteral • Added a margin table comparing HbA1c and plasma
nutrition glucose levels
• In the Nutrition in Practice on inborn errors, added • Revised various sections on nutrition therapy
a photo showing phenylalanine-free formula and • Added inhaled insulin and sodium-glucose cotrans-
updated the medical foods and treatments used in porter 2 (SGLT2) inhibitors to the tables listing the
phenylketonuria different types of insulin and antidiabetic drugs
• Modified the sections on insulin in type 2 diabetes, use
Chapter 16 of antidiabetic drugs, and maintaining glycemic control
• Revised the section on estimating energy needs during during exercise
acute stress • Updated several sections in the Nutrition in Practice on
• Changed the table on using disease-specific stress fac- metabolic syndrome
tors for estimating energy needs to a “How To” box • Added a figure showing how metabolic syndrome
• Emphasized the Penn State equation in the table on varies among ethnic groups and removed the figure
predictive equations used in ventilator-dependent showing how it varies with age
patients
• Modified the discussion on the use of glutamine and Chapter 21
arginine during critical illness • Revised various paragraphs in the sections on ath-
• Modified some sections on nutrition therapy for respi- erosclerosis, CHD risk assessment, CHD lifestyle
ratory failure management, hypertension, and heart failure
• Eliminated the box on assessing risk of heart disease
Chapter 17 • Updated CHD recommendations to reflect the 2013
• Modified some of the material in the sections on dump- guidelines from the American Heart Association and
ing syndrome and bariatric surgery American College of Cardiology
• Added sleeve gastrectomy to the figure on surgical pro- • Updated the section on hypertension treatment to
cedures for severe obesity reflect 2013 guidelines from the Eighth Joint National
• In the Nutrition in Practice on oral health, revised the Committee (JNC 8).
table on nutrient deficiencies and development of den-
tal caries and modified several sections related to oral Chapter 22
diseases and chronic illness. • Modified sections related to nephrotic syndrome
• Revised the table on causes of acute kidney injury
Chapter 18 • Updated the section on nutrition therapy for acute
• Revised some of the material in the sections on intesti- kidney injury
nal gas, acute and chronic pancreatitis, cystic fibrosis, • Updated the section on the evaluation of chronic kid-
celiac disease, irritable bowel syndrome, and diverticu- ney disease to reflect new clinical practice guidelines
lar disease of the colon • Clarified and updated some sections related to the
• Introduced the concept of FODMAPs and added defini- nutrition therapy for chronic kidney disease to reflect
tions of bloating and bacterial translocation current recommendations
• Eliminated the photo of gluten-free foods and added • Modified the section on prevention of calcium oxalate
photos showing the effect of celiac disease on intestinal stones
tissue • Revised the table on food sources of oxalates
xviii Preface
Chapter 23 learning platform that works alongside your campus LMS
• Rearranged and revised the sections related to the to deliver course curriculum across the range of elec-
consequences of cancer tronic devices in your life. MindTap is built on an “app”
• Introduced the term oral mucositis, modified the model allowing enhanced digital collaboration and deliv-
section on hematopoietic stem cell transplantation, and ery of engaging content across a spectrum of Cengage and
introduced the term graft-versus-host disease non-Cengage resources. Includes the Diet & Wellness
• Revised the paragraph about protein and energy intakes Plus App that helps you understand how nutrition relates
for cancer patients to your personal health goals. Track your diet and activity,
• Revised the section about food safety concerns for generate reports, and analyze the nutritional value of the
immunosuppressed cancer patients food you eat.
• Rearranged and revised some sections related to the Instructor Companion Site: Everything you need for
consequences of HIV infection your course in one place! This collection of book-specific
• Revised some sections related to the nutrition therapy lecture and class tools is available online via www.cengage
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tions, images, instructor’s manual, videos, and more.
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Preface xix
Acknowledgments
Among the most difficult words to write are those that express the depth of our
gratitude to the many dedicated people whose efforts have made this book possible.
A special note of appreciation to Sharon Rolfes for her numerous contributions to the
chapters and Nutrition in Practice sections as well as to the Dietary Reference Intakes
on the inside front cover and the appendices. Many thanks to Fran Webb for sharing
her knowledge, ideas, and resources about the latest nutrition developments. Thanks
also to David L. Stone for his assistance with multiple sections in the clinical chap-
ters. Elesha Hyde’s critical eye, numerous suggestions, and unceasing support were
especially helpful in revising both the normal nutrition and the clinical chapters. We
also wish to acknowledge the efforts of the folks at Axxya for their assistance in creat-
ing the food composition appendix. We are indebted to our editorial team—Krista
Mastroianni, Miriam Myers, and Elesha Hyde—and our production team, especially
Carol Samet, for seeing this project through from start to finish. We would also like to
acknowledge Tom Ziolkowski for his marketing efforts. To the many others involved
in designing, indexing, typesetting, dummying, and marketing, we offer our thanks.
We are especially grateful to our associates, family, and friends for their continued
encouragement and support and to our reviewers who consistently offer excellent
suggestions for improving the text.
xx
Chapter 1 Overview of Nutrition
and Health
Chapter Sections and Learning Objectives (LOs)
1.1 Food Choices 1.5 Dietary Guidelines and Food Guides

LO1.1 Describe the factors that influence personal LO1.5 Explain how each of the dietary ideals can
food choices. be used to plan a healthy diet, and how the Dietary
Guidelines and USDA Food Patterns help make diet
1.2 The Nutrients planning easier.
LO1.2 Identify which of the major classes of
nutrients are organic and which yield energy. 1.6 Food Labels
LO1.6 Compare the information on food labels
1.3 Nutrient Recommendations to make selections that meet specific dietary and
LO1.3 Describe the four categories of the health goals.
Dietary Reference Intakes (DRI), the Estimated
Energy Requirement (EER), and the Acceptable 1.7 Nutrition in Practice: Finding the Truth
Macronutrient Distribution Ranges (AMDR). about Nutrition
LO1.7 Discuss how misinformation and reliable
1.4 National Nutrition Surveys nutrition information can be identified.
LO1.4 Describe the ways in which the kinds of
information collected by researchers from nutrition
surveys are used.
Rosenfeld/Flirt/Corbis
EVERY DAY, SEVERAL TIMES A DAY, YOU MAKE CHOICES THAT WILL EITHER
improve your health or harm it. Each choice may influence your health only a little, but
when these choices are repeated over years and decades, their effects become significant.
The choices people make each day affect not only their physical health but also their
wellness—all the characteristics that make a person strong, confident, and able to
function well with family, friends, and others. People who consistently make poor life-
style choices on a daily basis increase their risks of developing diseases. Figure 1-1 shows
how a person’s health can fall anywhere along a continuum, from maximum wellness
on the one end to total failure to function (death) on the other.
As nurses or other health care professionals, when you take responsibility for your
own health by making daily choices and practicing behaviors that enhance your well-
being, you prepare yourself physically, mentally, and emotionally to meet the demands
of your profession. As health care professionals, however, you have a responsibility to
your clients as well as to yourselves.* You have unique opportunities to make your
clients aware of the benefits of positive health choices and behaviors, to show them how
to change their behaviors and make daily choices to enhance their own health, and to
serve as role models for those behaviors.
This text focuses on how nutrition choices affect health and disease. The early chapters
introduce the basics of nutrition to promote good health and reduce disease risks. The
later chapters emphasize medical nutrition therapy and its role in supporting health and
in treating diseases and symptoms.
FIGURE 1-1 The Health Line
No matter how well you maintain your health today, you may still be able to improve
tomorrow. Likewise, a person who is well today can slip by failing to maintain health-
promoting habits.
Wellness—
optimal physical,
mental, emotional,
spiritual, and social health
Person takes responsibility Superior

for all health areas and level of
meets all needs. health
Good Person
Most people function level of covers most
near here—they meet health needs well,
needs at a minimum to but some
Person is prevent symptoms.
physically, areas lack
mentally, attention.
emotionally, Person relies on Moderate
spiritually, medicine to level of
health: a range of states with or socially treat symptoms; health
nonfunctional. needs are not
physical, mental, emotional, met.
spiritual, and social components. At a Marginal
minimum, health means freedom from level of
physical disease, mental disturbances, health
emotional distress, spiritual Death Poor
discontent, social maladjustment, and from level of
other negative states. At a maximum, disease health
health means wellness.
Person meets needs only to
wellness: maximum well-being; the reverse symptoms as they appear.
top range of health states; the goal
of the person who strives toward
realizing his or her full potential *Health care professionals generally use either client or patient when referring to an individual under their care.
physically, mentally, emotionally, The first 12 chapters of this text emphasize the nutrition concerns of people in good health; therefore, the term
spiritually, and socially. client is used in these chapters.
2 CHAPTER 1 Overview of Nutrition and Health
Food Choices
Sound nutrition throughout life does not ensure good health and long life, but
it can certainly help to tip the balance in their favor. Nevertheless, most people
choose foods for reasons other than their nourishing value. Even people who claim
to choose foods primarily for the sake of health or nutrition will admit that other
factors also influence their food choices. Because food choices become an integral
part of their lifestyles, people sometimes find it difficult to change their eating habits.
Health care professionals who help clients make diet changes must understand the
dynamics of food choices because people will alter their eating habits only if their
preferences are honored. Developing cultural competence is an important aspect of
honoring individual preferences, especially for health care professionals who help
clients to achieve a nutritious diet.1
Preference Why do people like certain foods? One reason, of course, is their
iofoto/Shutterstock.com
preference for certain tastes. Some tastes are widely liked, such as the sweet-
ness of sugar and the savoriness of salt. 2 Research suggests that genetics influ-
ence people’s taste preferences, a finding that may eventually have implications
for clinical nutrition.3 For example, sensitivity to bitter taste is an inheritable
trait. People born with great sensitivity to bitter tastes tend to avoid foods with Nutrition is only one of the many
bitter flavors such as broccoli, cabbage, brussels sprouts, spinach, and grape- factors that influence people’s food
fruit juice. These foods, as well as many other fruits and vegetables, contain choices.
bioactive food components —phytochemicals and nutrients—that may reduce
the risk of cancer. Thus, the role that genetics may play in food selection is gaining
importance in cancer research.4 Nutrition in Practice 8 addresses phytochemicals
and their role in disease prevention.
nutrition: the science of foods and
Habit Sometimes habit dictates people’s food choices. People eat a sandwich for lunch the nutrients and other substances
or drink orange juice at breakfast simply because they have always done so. Eating a they contain, and of their ingestion,
familiar food and not having to make any decisions can be comforting. digestion, absorption, transport,
metabolism, interaction, storage,
and excretion. A broader definition
Associations People also like foods with happy associations—foods eaten in the includes the study of the environment
midst of warm family gatherings on traditional holidays or given to them as children and of human behavior as it relates to
by someone who loved them. By the same token, people can attach intense and unal- these processes.
terable dislikes to foods that they ate when they were sick or that were forced on them
cultural competence: an awareness
when they weren’t hungry. and acceptance of one’s own and
others’ cultures, combined with the
Ethnic Heritage and Regional Cuisines Every country, and every region skills needed to interact effectively
of a country, has its own typical foods and ways of combining them into meals. The with people of diverse cultures.
foodways of North America reflect the many different cultural and ethnic backgrounds
of its inhabitants. Many foods with foreign origins are familiar items on North American bioactive food components:
compounds in foods (either nutrients
menus: tacos, egg rolls, lasagna, sushi, and gyros, to name a few. Still others, such as or phytochemicals) that alter
spaghetti and croissants, are almost staples in the “American diet.” North American physiological processes in the body.
regional cuisines such as Cajun and TexMex blend the traditions of several cultures.
Table 1-1 presents selected ethnic diets and food choices. phytochemicals (FIGH-toe-CHEM-
ih-cals): compounds in plants
that confer color, taste, and other
Values Food choices may reflect people’s environmental ethics, religious beliefs, and characteristics. Some phytochemicals
political views. By choosing to eat some foods or to avoid others, people make state- are bioactive food components in
ments that reflect their values. For example, people may select only foods that come functional foods. Nutrition in Practice
in containers that can be reused or recycled. A concerned consumer may boycott 8 provides details.
fruit or vegetables picked by migrant workers who have been exploited. People may foodways: the eating habits and
buy vegetables from local farmers to save the fuel and environmental costs of foods culinary practices of a people, region,
shipped from far away. Labels on some foods carry statements or symbols—known as or historical period.
ecolabels—that imply that the foods have been produced in ways that are considered
ethnic diets: foodways and cuisines
environmentally favorable. typical of national origins, races,
Religion also influences many people’s food choices. Jewish law sets forth an extensive cultural heritages, or geographic
set of dietary rules. Many Christians forgo meat on Fridays during Lent, the period locations.
Food Choices 3
TABLE 1-1 Selected Ethnic Cuisines and Food Choices
Grains Vegetables Fruits Protein Foods Milk
Asian Millet, Baby corn, bamboo Kumquats, Pork; duck and Soy milk
rice, rice shoots, bok choy, loquats, other poultry;
or wheat leafy greens (such lychee, fish, octopus,
Becky Luigart-Stayner/
Encyclopedia/Corbis
noodles as amaranth), mandarin sea urchin,

cabbages, mung oranges, squid, and
bean sprouts, melons, pears, other seafood;
scallions, seaweed, persimmon, soybeans, tofu;
snow peas, straw plums eggs; cashews,
mushrooms, water peanuts
chestnuts, wild yam
Mediterranean Bulgur, Artichokes, Berries, dates, Fish and other Feta, goat,
couscous, cucumbers, figs, grapes, seafood, mozzarella,
focaccia, eggplant, fennel, lemons, gyros, lamb, parmesan,
Italian grape leaves, leafy melons, olives, pork, sausage, provolone,
Photodisc, Inc./
Getty Images
bread, greens, leeks, oranges, chicken, fava and ricotta

pastas, onions, peppers, pomegranates, beans, lentils, cheeses;
pita pocket tomatoes raisins almonds, yogurt
bread, walnuts and yogurt
polenta, rice beverages
Mexican Hominy, Bell peppers, Avocado, Beans, refried Cheese, flan

masa cactus, cassava, bananas, beans, beef, (baked caramel
Photodisc/Getty Images
(corn flour chayote, chili guava, lemons, goat, pork, custard), milk
dough), tor- pepper, corn, limes, mango, chorizo, in beverages
Mitch Hrdlicka/
tillas (corn jicama, onions, oranges, chicken, fish,

or flour), summer squash, papaya, eggs
rice tomatoes, winter plantain
squash, yams
prior to Easter. In Islamic dietary laws, permitted or lawful foods are called
halal. Other faiths prohibit some dietary practices and promote others. Diet
planners can foster sound nutrition practices only if they respect and honor
each person’s values.
Social Interaction Social interaction is another powerful influence on

Monkey Business Images/Shutterstock.com
people’s food choices. Meals are often social events, and the sharing of food
is part of hospitality. Social customs invite people to accept food or drink
offered by a host or shared by a group—regardless of hunger signals.5 Food
brings people together for many different reasons: to celebrate a holiday or
special event, to renew an old friendship, to make new friends, to conduct
business, and many more. Sometimes food is used to influence or impress
someone. For example, a business executive invites a prospective new cli-
ent out to dinner in hopes of edging out the competition. In each case, for
Ethnic meals and family whatever the purpose, food plays an integral part of the social interaction.
gatherings nourish the spirit as
well as the body. Emotional State Emotions guide food choices and eating behaviors.6 Some people
cannot eat when they are emotionally upset. Others may eat in response to a variety of
emotional stimuli—for example, to relieve boredom or depression or to calm anxiety.
A depressed person may choose to eat rather than to call a friend. A person who has
returned home from an exciting evening out may unwind with a late-night snack. Eating
in response to emotions can easily lead to overeating and obesity but may be appropriate
at times. For example, sharing food at times of bereavement serves both the giver’s need
to provide comfort and the receiver’s need to be cared for and to interact with others as
well as to take nourishment.
Availability, Convenience, and Economy The influence of these factors on
people’s food selections is clear. You cannot eat foods if they are not available, if you
cannot get to the grocery store, if you do not have the time or skill to prepare them, or
if you cannot afford them. Consumers who value convenience frequently eat out, bring
home ready-to-eat meals, or have food delivered. Whether decisions based on conve-
nience meet a person’s nutrition needs depends on the choices made. Eating a banana
or a candy bar may be equally convenient, but the fruit provides more vitamins and
minerals and less sugar and fat.
Rising food costs have shifted some consumers’ priorities and changed their shop-
ping habits. They are less likely to buy higher-priced convenience foods and more likely
to buy less-expensive store brand items and prepare home-cooked meals. Those who
frequently prepare their own meals eat fast food less often and are more likely to meet
dietary guidelines for fat, calcium, fruits, vegetables, and whole grains. It is not sur-
prising that, when eating out, consumers choose low-cost fast-food outlets over more
expensive fine-dining restaurants. Foods eaten away from home, especially fast-food
meals, tend to be high in kcalories, sodium, saturated fat, and trans fat—which can
contribute to a variety of health problems.7
Some people have jobs that keep them away from home for days at a time, require
them to conduct business in restaurants or at conventions, or involve hectic schedules
that allow little or no time for meals at home. For these people, the kinds of restaurants
available to them and the cost of eating out so often may limit food choices.
Age Age influences people’s food choices. Infants, for example, depend on others to
choose foods for them. Older children also rely on others but become more active in
selecting foods that taste sweet and are familiar to them and rejecting those whose
taste or texture they dislike. In contrast, the links between taste preferences and food
choices in adults are less direct than in children. Adults often choose foods based on
health concerns such as body weight. Indeed, adults may avoid sweet or familiar foods
because of such concerns.
Body Weight and Image Sometimes people select certain foods and supplements
that they believe will improve their physical appearance and avoid those they believe
might be detrimental. Such decisions can be beneficial when based on sound nutrition
and fitness knowledge but may undermine good health when based on fads or carried
to extremes. Eating disorders are the topic of Nutrition in Practice 6.
Medical Conditions Sometimes medical conditions and their treatments (includ-

ing medications) limit the foods a person can select. For example, a person with heart
disease might need to adopt a diet low in certain types of fats. The chemotherapy
needed to treat cancer can interfere with a person’s appetite or limit food choices by
causing vomiting. Allergy to certain foods can also limit choices. The second half
of this text discusses how diet can be modified to accommodate different medical
conditions.
Health and Nutrition Finally, of course, many consumers make food choices
they believe will improve their health.8 Food manufacturers and restaurant chefs have
responded to scientific findings linking health with nutrition by offering an abundant
selection of health-promoting foods and beverages. Foods that provide health benefits
beyond their nutrient contributions are called functional foods.9 Whole foods—as natu-
ral and familiar as oatmeal or tomatoes—are the simplest functional foods. In other
cases, foods have been modified through fortification, enrichment, or enhancement.
Examples of these functional foods include orange juice fortified with calcium to build
strong bones, bread enriched with folate to promote normal fetal development, and functional foods: whole, fortified,
margarine enhanced with a plant sterol to lower blood cholesterol. Nutrition in Practice enriched, or enhanced foods that
have a potentially beneficial effect
8 offers more discussion of functional foods. on health when consumed as part of
Consumers typically welcome new foods into their diets, provided that these foods are a varied diet on a regular basis at
reasonably priced, clearly labeled, easy to find in the grocery store, and convenient to effective levels.
Food Choices 5
prepare. These foods must also taste good—as good as the traditional choices. Of course,
a person need not eat any “special” foods to enjoy a healthy diet; many “regular” foods
provide numerous health benefits as well. In fact, foods such as whole grains; vegetables
and legumes; fruits; lean meats, seafood, poultry, eggs, nuts, and seeds; and low-fat milk
products are among the healthiest choices a person can make.
Review Notes
• A person selects foods for many different reasons.
• Food choices influence health—both positively and negatively. Individual food
selections neither make nor break a diet’s healthfulness, but the balance of foods
selected over time can make an important difference to health.
• In the interest of health, people are wise to think “nutrition” when making their
food choices.
The Nutrients
You are a collection of molecules that move. All these moving parts are arranged in pat-
terns of extraordinary complexity and order—cells, tissues, and organs. Although the
arrangement remains constant, the parts are continually changing, using nutrients and
energy derived from nutrients.
Almost any food you eat is composed of dozens or even hundreds of different kinds
of materials. Spinach, for example, is composed mostly of water (95 percent), and most
of its solid materials are the compounds carbohydrates, fats (properly called lipids), and
proteins. If you could remove these materials, you would find a tiny quantity of miner-
als, vitamins, and other compounds.
nutrients: substances obtained from

Six Classes of Nutrients
food and used in the body to provide Water, carbohydrates, fats, proteins, vitamins, and minerals are the six classes of nutrients
energy and structural materials and to commonly found in spinach and other foods. Some of the other materials in foods, such
serve as regulating agents to promote as the pigments and other phytochemicals, are not nutrients but may still be important
growth, maintenance, and repair.
Nutrients may also reduce the risks of to health. The body can make some nutrients for itself, at least in limited quantities, but
some diseases. it cannot make them all, and it makes some in insufficient quantities to meet its needs.
Therefore, the body must obtain many nutrients from foods. The nutrients that foods
essential nutrients: nutrients must supply are called essential nutrients.
a person must obtain from food
because the body cannot make them
for itself in sufficient quantities to
Carbohydrates, Fats, and Proteins Four of the six classes of nutrients (carbohy-
meet physiological needs. drates, fats, proteins, and vitamins) contain carbon, which is found in all living things.
They are therefore organic (meaning, literally, “alive”).† During metabolism, three of
organic: in chemistry, substances these four (carbohydrates, fats, and proteins) provide energy the body can use.‡ These
or molecules containing carbon–
carbon bonds or carbon–hydrogen
energy-yielding nutrients continually replenish the energy you expend daily.
bonds. The four organic nutrients
are carbohydrate, fat, protein, and Vitamins, Minerals, and Water Vitamins are organic but do not provide energy
vitamins. to the body. They facilitate the release of energy from the three energy-yielding nutri-
ents. In contrast, minerals and water are inorganic nutrients. Minerals yield no energy
energy-yielding nutrients: the
nutrients that break down to yield
in the human body, but, like vitamins, they help to regulate the release of energy, among
energy the body can use. The their many other roles. As for water, it is the medium in which all of the body’s processes
three energy-yielding nutrients are take place.
carbohydrate, protein, and fat.
inorganic: not containing carbon

†
Note that this definition of organic excludes coal, diamonds, and a few carbon-containing compounds that
or pertaining to living organisms. contain only a single carbon and no hydrogen, such as carbon dioxide ( CO2 ) .
The two classes of nutrients that are ‡
Metabolism is the set of processes by which nutrients are rearranged into body structures or broken down to
inorganic are minerals and water. yield energy.
kCalories: A Measure of Energy
The amount of energy that carbohydrates, fats, and proteins release can be measured
in calories—tiny units of energy so small that a single apple provides tens of thousands
of them. To ease calculations, energy is expressed in 1000-calorie metric units known
as kilocalories (shortened to kcalories, but commonly called “calories”). When you
read in popular books or magazines that an apple provides “100 calories,” understand
that it means 100 kcalories. This book uses the term kcalorie and its abbreviation kcal
throughout, as do other scientific books and journals.§ kCalories are not constituents
of foods; they are a measure of the energy foods provide. The energy a food provides
depends on how much carbohydrate, fat, and protein the food contains.
Carbohydrate yields 4 kcalories of energy from each gram, and so does protein. Fat
yields 9 kcalories per gram. Thus, fat has a greater energy density than either carbohy-
drate or protein. Chapter 7 revisits energy density with regard to weight management.
If you know how many grams of carbohydrate, protein, and fat a food contains, you can
derive the number of kcalories potentially available from the food. Simply multiply the
carbohydrate grams times 4, the protein grams times 4, and the fat grams times 9, and
add the results together (Box 1-1 describes how to calculate the energy a food provides).
Energy Nutrients in Foods Most foods contain mixtures of all three energy-
yielding nutrients, although foods are sometimes classified by their predominant
nutrient. To speak of meat as “a protein” or of bread as “a carbohydrate,” however, is
inaccurate. Each is rich in a particular nutrient, but a protein-rich food such as beef con-
tains a lot of fat along with the protein, and a carbohydrate-rich food such as cornbread
also contains fat (corn oil) and protein. Only a few foods are exceptions to this rule,
the common ones being sugar (which is pure carbohydrate) and oil (which is pure fat).
calories: a measure of heat
Energy Storage in the Body The body first uses the energy-yielding nutrients to energy. Food energy is measured in
build new compounds and fuel metabolic and physical activities. Excesses are then rear- kilocalories (1000 calories equal 1
kilocalorie), abbreviated kcalories
ranged into storage compounds, primarily body fat, and put away for later use. Thus, if or kcal. One kcalorie is the amount
you take in more energy than you expend, the result is an increase in energy stores and of heat necessary to raise the
weight gain. Similarly, if you take in less energy than you expend, the result is a decrease temperature of 1 kilogram (kg) of
in energy stores and weight loss. water 18C. The scientific use of the
term kcalorie is the same as the
Alcohol, Not a Nutrient One other substance contributes energy: alcohol. The popular use of the term calorie.
body derives energy from alcohol at the rate of 7 kcalories per gram. Alcohol is not a energy density: a measure of the
nutrient, however, because it cannot support the body’s growth, maintenance, or repair. energy a food provides relative to the
Nutrition in Practice 19 discusses alcohol’s effects on nutrition. amount of food (kcalories per gram).
BOX 1-1 How to Calculate the Energy a Food Provides

To calculate the energy available from a food, multiply the To determine the percentage of kcalories from fat, for exam-
number of grams of carbohydrate, protein, and fat by 4, 4, and ple, divide the 81 fat kcalories by the total 173 kcalories:
9, respectively. Then add the results together. For example,
one slice of bread with 1 tablespoon of peanut butter on it 81 fat kcal 4 173 total kcal 5 0.468 (rounded to 0.47)
contains 16 grams of carbohydrate, 7 grams of protein, and 9 Then multiply by 100 to get the percentage:
grams of fat:
0.47 3 100 5 47%
16 g carbohydrate 3 4 kcal / g 5 64 kcal
7 g protein 3 4 kcal / g 5 28 kcal Dietary recommendations that urge people to limit fat intake
9 g fat 3 9 kcal / g 5 81 kcal to 20 to 35 percent of kcalories refer to the day’s total energy
intake, not to individual foods. Still, if the proportion of fat
Total 5 173 kcal in each food choice throughout a day exceeds 35 percent of
From this information, you can calculate the percentage of kcalories, then the day’s total surely will, too. Knowing that this
kcalories each of the energy nutrients contributes to the total. snack provides 47 percent of its kcalories from fat alerts a person
to the need to make lower-fat selections at other times that day.
§
Food energy can also be measured in kilojoules (kJ). The kilojoule is the international unit of energy. One
kcalorie equals 4.2 kJ.
The Nutrients 7
Review Notes
• Foods provide nutrients—substances that support the growth, maintenance, and
repair of the body’s tissues.
• The six classes of nutrients are water, carbohydrates, fats, proteins, vitamins, and minerals.
• Vitamins, minerals, and water do not yield energy; instead, they facilitate a variety
of activities in the body.
• Foods rich in the energy-yielding nutrients (carbohydrates, fats, and proteins) provide the
major materials for building the body’s tissues and yield energy the body can use or store.
Dietary Reference Intakes
(DRI): a set of values for the • Energy is measured in kcalories.
dietary nutrient intakes of healthy
people in the United States and
Canada. These values are used for
planning and assessing diets.
Recommended Dietary Allowances Nutrient Recommendations
(RDA): a set of values reflecting the
Nutrient recommendations are used as standards to evaluate healthy people’s energy and
average daily amounts of nutrients
considered adequate to meet the nutrient intakes. Nutrition experts use the recommendations to assess nutrient intakes
known nutrient needs of practically and to guide people on amounts to consume. Individuals can use them to decide how
all healthy people in a particular life much of a nutrient they need to consume.
stage and gender group; a goal for
dietary intake by individuals.
Dietary Reference Intakes
Adequate Intakes (AI): a set of
Defining the amounts of energy, nutrients, and other dietary components that best support
values that are used as guides for
nutrient intakes when scientific health is a huge task. Nutrition experts have produced a set of standards that define the
evidence is insufficient to determine amounts of energy, nutrients, other dietary components, and physical activity that best sup-
an RDA. port health. These recommendations are called Dietary Reference Intakes (DRI) and reflect
requirement: the lowest continuing
the collaborative efforts of scientists in both the United States and Canada.* The inside front
intake of a nutrient that will maintain covers of this book present the DRI values. (A set of nutrient recommendations developed
a specified criterion of adequacy. by the World Health Organization for international use is presented in Appendix B.)
deficient: in regard to nutrient Setting Nutrient Recommendations: RDA and AI One advantage of
intake, describes the amount below
which almost all healthy people can the DRI is that they apply to the diets of individuals. The DRI committee offers
be expected, over time, to experience two sets of values to be used as nutrient intake goals by individuals: a set called the
deficiency symptoms. Recommended Dietary Allowances (RDA) and a set called Adequate Intakes (AI).
Based on solid experimental evidence and other reliable observations,
the RDA are the foundation of the DRI. The AI values are based on less
FIGURE 1-2 Nutrient Intake extensive scientific findings and rely more heavily on scientific judgment.
Recommendations The committee establishes an AI value whenever scientific evidence is
insufficient to generate an RDA. To see which nutrients have an AI and
The nutrient intake recommendations are which have an RDA, turn to the inside front cover.
set high enough to cover nearly everyone’s In the last several decades, abundant new research has linked nutrients
requirements (the boxes represent people).
in the diet with the promotion of health and the prevention of chronic
diseases. An advantage of the DRI is that, where appropriate, they take
Nutrients
EAR
a
RDA into account disease prevention as well as an adequate nutrient intake.
For example, the RDA for calcium is based on intakes thought to reduce
Number of people
the likelihood of osteoporosis-related fractures later in life.

To ensure that the vitamin and mineral recommendations meet the needs
of as many people as possible, the recommendations are set near the top end
of the range of the population’s estimated average requirements (see Figure
1-2). Small amounts above the daily requirement do no harm, whereas
amounts below the requirement may lead to health problems. When peo-
ple’s intakes are consistently deficient, their nutrient stores decline, and
20 30 40 50 60 70 over time this decline leads to deficiency symptoms and poor health.
Daily requirements (units/day)
a
Estimated Average Requirement *The DRI reports are produced by the Food and Nutrition Board, Institute of Medicine of
the National Academies, with active involvement of scientists from Canada.
Facilitating Nutrition Research and Policy: EAR In addition to the RDA
and AI, the DRI committee has established another set of values: Estimated Average
Requirements (EAR). These values establish average requirements for given life stage
and gender groups that researchers and nutrition policymakers use in their work. Nutri-
tion scientists may use the EAR as standards in research. Public health officials may use Estimated Average Requirements
them to assess nutrient intakes of populations and make recommendations. The EAR (EAR): the average daily nutrient
values form the scientific basis on which the RDA are set. intake levels estimated to meet the
requirements of half of the healthy
Establishing Safety Guidelines: UL The DRI committee also establishes upper individuals in a given age and gender
limits of intake for nutrients posing a hazard when consumed in excess. These values, group; used in nutrition research and
policymaking and as the basis on
the Tolerable Upper Intake Levels (UL), are indispensable to consumers who take sup- which RDA values are set.
plements. Consumers need to know how much of a nutrient is too much. The UL are
also of value to public health officials who set allowances for nutrients that are added to Tolerable Upper Intake Levels
(UL): a set of values reflecting the
foods and water. The UL values are listed on the inside front cover. highest average daily nutrient intake
levels that are likely to pose no risk
Using Nutrient Recommendations Each of the four DRI categories serves a of toxicity to almost all healthy
unique purpose. For example, the EAR are most appropriately used to develop and individuals in a particular life stage
evaluate nutrition programs for groups such as schoolchildren or military personnel. and gender group. As intake increases
The RDA (or AI, if an RDA is not available) can be used to set goals for individuals. above the UL, the potential risk of
The UL help to keep nutrient intakes below the amounts that increase the risk of toxic- adverse health effects increases.
ity. With these understandings, professionals can use the DRI for a variety of purposes. Estimated Energy Requirement
In addition to understanding the unique purposes of the DRI, it is important to keep (EER): the dietary energy intake
their uses in perspective. Consider the following: level that is predicted to maintain
energy balance in a healthy adult of
• The values are recommendations for safe intakes, not minimum requirements; a defined age, gender, weight, and
except for energy, they include a generous margin of safety. Figure 1-3 presents an physical activity level consistent with
accurate view of how a person’s nutrient needs fall within a range, with marginal good health.
and danger zones both below and above the range.
• The values reflect daily intakes to be achieved on average, over FIGURE 1-3 N aive versus Accurate View of
time. They assume that intakes will vary from day to day, and they Nutrient Intakes
are set high enough to ensure that body nutrient stores will meet
nutrient needs during periods of inadequate intakes lasting a day or The RDA or AI for a given nutrient represents
two for some nutrients and up to a month or two for others. a point that lies within a range of appropriate
• The values are chosen in reference to specific indicators of n utrient and reasonable intakes between toxicity and
adequacy, such as blood nutrient concentrations, normal growth, deficiency. Both of these recommendations are
and reduction of certain chronic diseases or other disorders when high enough to provide reserves in times of
appropriate, rather than prevention of deficiency symptoms alone. short-term dietary inadequacies, but not so high
as to approach toxicity. Nutrient intakes above
• The recommendations are designed to meet the needs of most healthy or below this range may be equally harmful.
people. Medical problems alter nutrient needs, as later c hapters describe.
• The recommendations are specific for people of both genders as
Danger
well as various ages and stages of life: infants, children, adolescents, of
men, women, pregnant women, and lactating women. toxicity
Setting Energy Recommendations In contrast to the vitamin Marginal

and mineral recommendations, the recommendation for energy, called Tolerable
the Estimated Energy Requirement (EER), is not generous because Safety Upper Intake
Level
excess energy cannot be excreted and is eventually stored as body fat.
Rather, the key to the energy recommendation is balance. For a person Safety
who has a body weight, body composition, and physical activity level
consistent with good health, energy intake from food should match RDA or AI
energy expenditure, so the person achieves energy balance. Enough
RDA Estimated
energy is needed to sustain a healthy, active life, but too much energy
Marginal Average
leads to obesity. The EER is therefore set at a level of energy intake pre- Requirement
dicted to maintain energy balance in a healthy adult of a defined age, Danger Danger
gender, weight, height, and physical activity level.* Another difference of
deficiency
*The EER for children, pregnant women, and lactating women includes energy needs Naive Accurate
associated with the deposition of tissue or the secretion of milk at rates consistent with view view
good health.
Nutrient Recommendations 9
between the requirements for other nutrients and those for energy is that each person
has an obvious indicator of whether energy intake is inadequate, adequate, or excessive:
body weight. Because any amount of energy in excess of need leads to weight gain, the
DRI committee did not set a Tolerable Upper Intake Level.
Acceptable Macronutrient Distribution Ranges

As noted earlier, the DRI committee considers prevention of chronic disease as well as
nutrient adequacy when establishing recommendations. To that end, the committee
established healthy ranges of intakes for the energy-yielding nutrients—carbohydrate,
fat, and protein—known as Acceptable Macronutrient Distribution Ranges (AMDR).
Each of these three energy-yielding nutrients contributes to a person’s total energy
(kcalorie) intake, and those contributions vary in relation to each other. The DRI com-
mittee has determined that a diet that provides the energy-yielding nutrients in the
following proportions provides adequate energy and nutrients and reduces the risk of
chronic disease:
• 45 to 65 percent of kcalories from carbohydrate
• 20 to 35 percent of kcalories from fat
• 10 to 35 percent of kcalories from protein
Review Notes
• The Dietary Reference Intakes (DRI) are a set of nutrient intake values that can be
used to plan and evaluate dietary intakes for healthy people.
• The Estimated Average Requirement (EAR) defines the amount of a nutrient that
supports a specific function in the body for half of the population.
• The Recommended Dietary Allowance (RDA) is based on the EAR and establishes a
goal for dietary intake that will meet the needs of almost all healthy people.
• An Adequate Intake (AI) serves a similar purpose as the RDA when an RDA cannot
be determined.
• The Tolerable Upper Intake Level (UL) establishes the highest average daily nutrient
intake level that appears safe for almost all healthy people.
• The Estimated Energy Requirement (EER) defines the energy intake level needed to
maintain energy balance in a healthy adult of a defined age, gender, weight, height,
and physical activity level.
• The Acceptable Macronutrient Distribution Ranges (AMDR) define the proportions
contributed by carbohydrate, fat, and protein to a healthy diet.
National Nutrition Surveys

How do nutrition experts know whether people are meeting nutrient recommenda-
tions? The Dietary Reference Intakes and other major reports that examine the relation-
ships between diet and health depend on information collected from nutrition surveys.
Researchers use nutrition surveys to learn which foods people are eating and which
Acceptable Macronutrient supplements they are taking, to assess people’s nutritional health, and to determine
Distribution Ranges (AMDR): ranges people’s knowledge, attitudes, and behaviors about nutrition and how these relate to
of intakes for the energy-yielding health. The resulting wealth of information can be used for a variety of purposes. For
nutrients that provide adequate
energy and nutrients and reduce the example, Congress uses this information to establish public policy on nutrition educa-
risk of chronic disease. tion, assess food assistance programs, and regulate the food supply. The food industry
uses the information to guide decisions in public relations and product development.
malnutrition: any condition caused
by deficient or excess energy or Scientists use the information to establish research priorities. One of the first nutrition
nutrient intake or by an imbalance surveys, taken before World War II, suggested that up to a third of the U.S. population
of nutrients. might be eating poorly. Programs to correct malnutrition have been evolving ever since.
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the red glare and the muffled tom-toms. There are vocal qualities
peculiar to men, and vocal qualities peculiar to beasts; and it is
terrible to hear the one when the source should yield the other.
Animal fury and orgiastic license here whipped themselves to
demoniac heights by howls and squawking ecstasies that tore and
reverberated through those nighted woods like pestilential tempests
from the gulfs of hell. Now and then the less organized ululations
would cease, and from what seemed a well-drilled chorus of hoarse
voices would rise in singsong chant that hideous phrase or ritual:
"Ph'nglui mglw'nafh Cthulhu R'lyeh wgah'nagl fhtagn."
Then the men, having reached a spot where the trees were thinner,
came suddenly in sight of the spectacle itself. Four of them reeled,
one fainted, and two were shaken into a frantic cry which the mad
cacophony of the orgy fortunately deadened. Legrasse dashed
swamp water on the face of the fainting man, and all stood trembling
and nearly hypnotized with horror.
In a natural glade of the swamp stood a grassy island of perhaps an
acre's extent, clear of trees and tolerably dry. On this now leaped
and twisted a more indescribable horde of human abnormality than
any but a Sime or an Angarola could paint. Void of clothing, this
hybrid spawn were braying, bellowing and writhing about a
monstrous ring-shaped bonfire; in the center of which, revealed by
occasional rifts in the curtain of flame, stood a great granite monolith
some eight feet in height; on top of which, incongruous in its
diminutiveness, rested the noxious carven statuette. From a wide
circle of ten scaffolds set up at regular intervals with the flame-girt
monolith as a center hung, head downward, the oddly marred bodies
of the helpless squatters who had disappeared. It was inside this
circle that the ring of worshipers jumped and roared, the general
direction of the mass motion being from left to right in endless
bacchanale between the ring of bodies and the ring of fire.
It may have been only imagination and it may have been only
echoes which induced one of the men, an excitable Spaniard, to
fancy he heard antiphonal responses to the ritual from some far and
unillumined spot deeper within the wood of ancient legendry and
horror. This man, Joseph D. Galvez, I later met and questioned; and
he proved distractingly imaginative. He indeed went so far as to hint
of the faint beating of great wings, and of a glimpse of shining eyes
and a mountainous white bulk beyond the remotest trees—but I
suppose he had been hearing too much native superstition.
Actually, the horrified pause of the men was of comparatively brief
duration. Duty came first; and although there must have been nearly
a hundred mongrel celebrants in the throng, the police relied on their
firearms and plunged determinedly into the nauseous rout. For five
minutes the resultant din and chaos were beyond description. Wild
blows were struck, shots were fired, and escapes were made; but in
the end Legrasse was able to count some forty-seven sullen
prisoners, whom he forced to dress in haste and fall into line
between two rows of policemen. Five of the worshipers lay dead,
and two severely wounded ones were carried away on improvised
stretchers by their fellow-prisoners. The image on the monolith, of
course, was carefully removed and carried back by Legrasse.
Examined at headquarters after a trip of intense strain and
weariness, the prisoners all proved to be men of a very low, mixed-
blooded, and mentally aberrant type. Most were seamen, and a
sprinkling of negroes and mulattoes, largely West Indians or Brava
Portuguese from the Cape Verde Islands, gave a coloring of
voodooism to the heterogeneous cult. But before many questions
were asked, it became manifest that something far deeper and older
than negro fetishism was involved. Degraded and ignorant as they
were, the creatures held with surprizing consistency to the central
idea of their loathsome faith.
They worshiped, so they said, the Great Old Ones who lived ages
before there were any men, and who came to the young world out of
the sky. Those Old Ones were gone now, inside the earth and under
the sea; but their dead bodies had told their secrets in dreams to the
first man, who formed a cult which had never died. This was that
cult, and the prisoners said it had always existed and always would
exist, hidden in distant wastes and dark places all over the world
until the time when the great priest Cthulhu, from his dark house in
the mighty city of R'lyeh under the waters, should rise and bring the
earth again beneath his sway. Some day he would call, when the
stars were ready, and the secret cult would always be waiting to
liberate him.
Meanwhile no more must be told. There was a secret which even
torture could not extract. Mankind was not absolutely alone among
the conscious things of earth, for shapes came out of the dark to visit
the faithful few. But these were not the Great Old Ones. No man had
ever seen the Old Ones. The carven idol was great Cthulhu, but
none might say whether or not the others were precisely like him. No
one could read the old writing now, but things were told by word of
mouth. The chanted ritual was not the secret—that was never
spoken aloud, only whispered. The chant meant only this: "In his
house at R'lyeh dead Cthulhu waits dreaming."
Only two of the prisoners were found sane enough to be hanged,

and the rest were committed to various institutions. All denied a part
in the ritual murders, and averred that the killing had been done by
Black-winged Ones which had come to them from their immemorial
meeting-place in the haunted wood. But of those mysterious allies no
coherent account could ever be gained. What the police did extract
came mainly from an immensely aged mestizo named Castro, who
claimed to have sailed to strange ports and talked with undying
leaders of the cult in the mountains of China.
Old Castro remembered bits of hideous legend that paled the
speculations of theosophists and made man and the world seem
recent and transient indeed. There had been eons when other
Things ruled on the earth, and They had had great cities. Remains of
Them, he said the deathless Chinamen had told him, were still to be
found as Cyclopean stones on islands in the Pacific. They all died
vast epochs of time before man came, but there were arts which
could revive Them when the stars had come round again to the right
positions in the cycle of eternity. They had, indeed, come themselves
from the stars, and brought Their images with Them.
These Great Old Ones, Castro continued, were not composed
altogether of flesh and blood. They had shape—for did not this star-
fashioned image prove it?—but that shape was not made of matter.
When the stars were right, They could plunge from world to world
through the sky; but when the stars were wrong, They could not live.
But although They no longer lived, They would never really die. They
all lay in stone houses in Their great city of R'lyeh, preserved by the
spells of mighty Cthulhu for a glorious resurrection when the stars
and the earth might once more be ready for Them. But at that time
some force from outside must serve to liberate Their bodies. The
spells that preserved Them intact likewise prevented Them from
making an initial move, and They could only lie awake in the dark
and think whilst uncounted millions of years rolled by. They knew all
that was occurring in the universe, for Their mode of speech was
transmitted thought. Even now They talked in Their tombs. When,
after infinities of chaos, the first men came, the Great Old Ones
spoke to the sensitive among them by molding their dreams; for only
thus could Their language reach the fleshly minds of mammals.
Then, whispered Castro, those first men formed the cult around
small idols which the Great Ones showed them; idols brought in dim
eras from dark stars. That cult would never die till the stars came
right again, and the secret priests would take great Cthulhu from His
tomb to revive His subjects and resume His rule of earth. The time
would be easy to know, for then mankind would have become as the
Great Old Ones; free and wild and beyond good and evil, with laws
and morals thrown aside and all men shouting and killing and
reveling in joy. Then the liberated Old Ones would teach them new
ways to shout and kill and revel and enjoy themselves, and all the
earth would flame with a holocaust of ecstasy and freedom.
Meanwhile the cult, by appropriate rites, must keep alive the memory
of those ancient ways and shadow forth the prophecy of their return.
In the elder time chosen men had talked with the entombed Old
Ones in dreams, but then something had happened. The great stone
city R'lyeh, with its monoliths and sepulchers, had sunk beneath the
waves; and the deep waters, full of the one primal mystery through
which not even thought can pass, had cut off the spectral
intercourse. But memory never died, and high priests said that the
city would rise again when the stars were right. Then came out of the
earth the black spirits of earth, moldy and shadowy, and full of dim
rumors picked up in caverns beneath forgotten sea-bottoms. But of
them old Castro dared not speak much. He cut himself off hurriedly,
and no amount of persuasion or subtlety could elicit more in this
direction. The size of the Old Ones, too, he curiously declined to
mention. Of the cult, he said that he thought the center lay amid the
pathless deserts of Arabia, where Irem, the City of Pillars, dreams
hidden and untouched. It was not allied to the European witch-cult,
and was virtually unknown beyond its members. No book had ever
really hinted of it, though the deathless Chinamen said that there
were double meanings in the Necronomicon of the mad Arab Abdul
Alhazred which the initiated might read as they chose, especially the
much-discussed couplet:
"That is not dead which can eternal lie,

And with strange eons even death may die."
Legrasse, deeply impressed and not a little bewildered, had inquired

in vain concerning the historic affiliations of the cult. Castro,
apparently, had told the truth when he said that it was wholly secret.
The authorities at Tulane University could shed no light upon either
cult or image, and now the detective had come to the highest
authorities in the country and met with no more than the Greenland
tale of Professor Webb.
The feverish interest aroused at the meeting by Legrasse's tale,

corroborated as it was by the statuette, is echoed in the subsequent
correspondence of those who attended, although scant mention
occurs in the formal publication of the society. Caution is the first
care of those accustomed to face occasional charlatanry and
imposture. Legrasse for some time lent the image to Professor
Webb, but at the latter's death it was returned to him and remains in
his possession, where I viewed it not long ago. It is truly a terrible
thing, and unmistakably akin to the dream-sculpture of young Wilcox.
That my uncle was excited by the tale of the sculptor I did not
wonder, for what thoughts must arise upon hearing, after a
knowledge of what Legrasse had learned of the cult, of a sensitive
young man who had dreamed not only the figure and exact
hieroglyphics of the swamp-found image and the Greenland devil
tablet, but had come in his dreams upon at least three of the precise
words of the formula uttered alike by Eskimo diabolists and mongrel
Louisianans? Professor Angell's instant start on an investigation of
the utmost thoroughness was eminently natural; though privately I
suspected young Wilcox of having heard of the cult in some indirect
way, and of having invented a series of dreams to heighten and
continue the mystery at my uncle's expense. The dream-narratives
and cuttings collected by the professor were, of course, strong
corroboration; but the rationalism of my mind and the extravagance
of the whole subject led me to adopt what I thought the most
sensible conclusions. So, after thoroughly studying the manuscript
again and correlating the theosophical and anthropological notes
with the cult narrative of Legrasse, I made a trip to Providence to see
the sculptor and give him the rebuke I thought proper for so boldly
imposing upon a learned and aged man.
Wilcox still lived alone in the Fleur-de-Lys Building in Thomas Street,
a hideous Victorian imitation of Seventeenth Century Breton
architecture which flaunts its stuccoed front amidst the lovely
Colonial houses on the ancient hill, and under the very shadow of
the finest Georgian steeple in America. I found him at work in his
rooms, and at once conceded from the specimens scattered about
that his genius is indeed profound and authentic. He will, I believe,
be heard from sometime as one of the great decadents; for he has
crystallized in clay and will one day mirror in marble those
nightmares and fantasies which Arthur Machen evokes in prose, and
Clark Ashton Smith makes visible in verse and in painting.
Dark, frail, and somewhat unkempt in aspect, he turned languidly at
my knock and asked me my business without rising. When I told him
who I was, he displayed some interest; for my uncle had excited his
curiosity in probing his strange dreams, yet had never explained the
reason for the study. I did not enlarge his knowledge in this regard,
but sought with some subtlety to draw him out.
In a short time I became convinced of his absolute sincerity, for he
spoke of the dreams in a manner none could mistake. They and their
subconscious residuum had influenced his art profoundly, and he
showed me a morbid statue whose contours almost made me shake
with the potency of its black suggestion. He could not recall having
seen the original of this thing except in his own dream bas-relief, but
the outlines had formed themselves insensibly under his hands. It
was, no doubt, the giant shape he had raved of in delirium. That he
really knew nothing of the hidden cult, save from what my uncle's
relentless catechism had let fall, he soon made clear; and again I
strove to think of some way in which he could possibly have received
the weird impressions.
He talked of his dreams in a strangely poetic fashion; making me see
with terrible vividness the damp Cyclopean city of slimy green stone
—whose geometry, he oddly said, was all wrong—and hear with
frightened expectancy the ceaseless, half-mental calling from
underground: "Cthulhu fhtagn," "Cthulhu fhtagn."
These words had formed part of that dread ritual which told of dead
Cthulhu's dream-vigil in his stone vault at R'lyeh, and I felt deeply
moved despite my rational beliefs. Wilcox, I was sure, had heard of
the cult in some casual way, and had soon forgotten it amidst the
mass of his equally weird reading and imagining. Later, by virtue of
its sheer impressiveness, it had found subconscious expression in
dreams, in the bas-relief, and in the terrible statue I now beheld; so
that his imposture upon my uncle had been a very innocent one. The
youth was of a type, at once slightly affected and slightly ill-
mannered, which I could never like; but I was willing enough now to
admit both his genius and his honesty. I took leave of him amicably,
and wish him all the success his talent promises.
The matter of the cult still remained to fascinate me, and at times I
had visions of personal fame from researches into its origin and
connections. I visited New Orleans, talked with Legrasse and others
of that old-time raiding-party, saw the frightful image, and even
questioned such of the mongrel prisoners as still survived. Old
Castro, unfortunately, had been dead for some years. What I now
heard so graphically at first hand, though it was really no more than
a detailed confirmation of what my uncle had written, excited me
afresh; for I felt sure that I was on the track of a very real, very
secret, and very ancient religion whose discovery would make me an
anthropologist of note. My attitude was still one of absolute
materialism, as I wish it still were, and I discounted with almost
inexplicable perversity the coincidence of the dream notes and odd
cuttings collected by Professor Angell.
One thing which I began to suspect, and which I now fear I know, is
that my uncle's death was far from natural. He fell on a narrow hill
street leading up from an ancient waterfront swarming with foreign
mongrels, after a careless push from a negro sailor. I did not forget
the mixed blood and marine pursuits of the cult-members in
Louisiana, and would not be surprized to learn of secret methods
and poison needles as ruthless and as anciently known as the
cryptic rites and beliefs. Legrasse and his men, it is true, have been
let alone; but in Norway a certain seaman who saw things is dead.
Might not the deeper inquiries of my uncle after encountering the
sculptor's data have come to sinister ears? I thing Professor Angell
died because he knew too much, or because he was likely to learn
too much. Whether I shall go as he did remains to be seen, for I
have learned much now.
3. The Madness from the Sea.

If heaven ever wishes to grant me a boon, it will be a total effacing of
the results of a mere chance which fixed my eye on a certain stray
piece of shelf-paper. It was nothing on which I would naturally have
stumbled in the course of my daily round, for it was an old number of
an Australian journal, Sydney Bulletin for April 18, 1925. It had
escaped even the cutting bureau which had at the time of its
issuance been avidly collecting material for my uncle's research.
I had largely given over my inquiries into what Professor Angell
called the "Cthulhu Cult," and was visiting a learned friend of
Paterson, New Jersey, the curator of a local museum and a
mineralogist of note. Examining one day the reserve specimens
roughly set on the storage shelves in a rear room of the museum, my
eye was caught by an odd picture in one of the old papers spread
beneath the stones. It was the Sydney Bulletin I have mentioned, for
my friend has wide affiliations in all conceivable foreign parts; and
the picture was a half-tone cut of a hideous stone image almost
identical with that which Legrasse had found in the swamp.
Eagerly clearing the sheet of its precious contents, I scanned the
item in detail; and was disappointed to find it of only moderate
length. What it suggested, however, was of portentous significance
to my flagging quest; and I carefully tore it out for immediate action.
It read as follows:
MYSTERY DERELICT FOUND AT SEA
Vigilant Arrives With Helpless Armed New Zealand Yacht in Tow.
One Survivor and Dead Man Found Aboard. Tale of Desperate Battle
and Deaths at Sea. Rescued Seaman Refuses Particulars of
Strange Experience. Odd Idol Found in His Possession. Inquiry to
Follow.
The Morrison Co.'s freighter Vigilant, bound from Valparaiso, arrived

this morning at its wharf in Darling Harbour, having in tow the battled
and disabled but heavily armed steam yacht Alert of Dunedin, N. Z.,
which was sighted April 12th in S. Latitude 34° 21', W. Longitude
152° 17', with one living and one dead man aboard.
The Vigilant left Valparaiso March 25th, and on April 2d was driven
considerably south of her course by exceptionally heavy storms and
monster waves. On April 12th the derelict was sighted; and though
apparently deserted, was found upon boarding to contain one
survivor in a half-delirious condition and one man who had evidently
been dead for more than a week.
The living man was clutching a horrible stone idol of unknown origin,
about a foot in height, regarding whose nature authorities at Sydney
University, the Royal Society, and the Museum in College Street all
profess complete bafflement, and which the survivor says he found
in the cabin of the yacht, in a small carved shrine of common pattern.
This man, after recovering his senses, told an exceedingly strange
story of piracy and slaughter. He is Gustaf Johansen, a Norwegian of
some intelligence, and had been second mate of the two-masted
schooner Emma of Auckland, which sailed for Callao February 20th,
with a complement of eleven men.
The Emma, he says, was delayed and thrown widely south of her
course by the great storm of March 1st, and on March 22d, in S.
Latitude 49° 51´, W. Longitude 128° 34´, encountered the Alert,
manned by a queer and evil-looking crew of Kanakas and half-
castes. Being ordered peremptorily to turn back, Capt. Collins
refused; whereupon the strange crew began to fire savagely and
without warning upon the schooner with a peculiarly heavy battery of
brass cannon forming part of the yacht's equipment.
The Emma's men showed fight, says the survivor, and though the
schooner began to sink from shots beneath the waterline they
managed to heave alongside their enemy and board her, grappling
with the savage crew on the yacht's deck, and being forced to kill
them all, the number being slightly superior, because of their
particularly abhorrent and desperate though rather clumsy mode of
fighting.
Three of the Emma's men, including Capt. Collins and First Mate
Green, were killed; and the remaining eight under Second Mate
Johansen proceeded to navigate the captured yacht, going ahead in
their original direction to see if any reason for their ordering back had
existed.
The next day, it appears, they raised and landed on a small island,
although none is known to exist in that part of the ocean; and six of
the men somehow died ashore, though Johansen is queerly reticent
about this part of his story and speaks only of their falling into a rock
chasm.
Later, it seems, he and one companion boarded the yacht and tried
to manage her, but were beaten about by the storm of April 2nd.
From that time till his rescue on the 12th, the man remembers little,
and he does not even recall when William Briden, his companion,
died. Briden's death reveals no apparent cause, and was probably
due to excitement or exposure.
Cable advices from Dunedin report that the Alert was well known
there as an island trader, and bore an evil reputation along the
waterfront. It was owned by a curious group of half-castes whose
frequent meetings and night trips to the woods attracted no little
curiosity; and it had set sail in great haste just after the storm and
earth tremors of March 1st.
Our Auckland correspondent gives the Emma and her crew an
excellent reputation, and Johansen is described as a sober and
worthy man.
The admiralty will institute an inquiry on the whole matter beginning
tomorrow, at which every effort will be made to induce Johansen to
speak more freely than he has done hitherto.
This was all, together with the picture of the hellish image; but what a
train of ideas it started in my mind! Here were new treasuries of data
on the Cthulhu Cult, and evidence that it had strange interests at sea
as well as on land. What motive prompted the hybrid crew to order
back the Emma as they sailed about with their hideous idol? What
was the unknown island on which six of the Emma's crew had died,
and about which the mate Johansen was so secretive? What had the
vice-admiralty's investigation brought out, and what was known of
the noxious cult in Dunedin? And most marvelous of all, what deep
and more than natural linkage of dates was this which gave a malign
and now undeniable significance to the various turns of events so
carefully noted by my uncle?
March 1st—our February 28th according to the International Date
Line—the earthquake and storm had come. From Dunedin the Alert
and her noisome crew had darted eagerly forth as if imperiously
summoned, and on the other side of the earth poets and artists had
begun to dream of a strange, dank Cyclopean city whilst a young
sculptor had molded in his sleep the form of the dreaded Cthulhu.
March 23rd the crew of the Emma landed on an unknown island and
left six men dead; and on that date the dreams of sensitive men
assumed a heightened vividness and darkened with dread of a giant
monster's malign pursuit, whilst an architect had gone mad and a
sculptor had lapsed suddenly into delirium! And what of this storm of
April 2nd—the date on which all dreams of the dank city ceased, and
Wilcox emerged unharmed from the bondage of strange fever? What
of all this—and of those hints of old Castro about the sunken, star-
born Old Ones and their coming reign; their faithful cult and their
mastery of dreams? Was I tottering on the brink of cosmic horrors
beyond man's power to bear? If so, they must be horrors of the mind
alone, for in some way the second of April had put a stop to
whatever monstrous menace had begun its siege of mankind's soul.
That evening, after a day of hurried cabling and arranging, I bade my

host adieu and took a train for San Francisco. In less than a month I
was in Dunedin; where, however, I found that little was known of the
strange cult-members who had lingered in the old sea taverns.
Waterfront scum was far too common for special mention; though
there was vague talk about one inland trip these mongrels had
made, during which faint drumming and red flame were noted on the
distant hills.
In Auckland I learned that Johansen had returned with yellow hair
turned white after a perfunctory and inconclusive questioning at
Sydney, and had thereafter sold his cottage in West Street and
sailed with his wife to his old home in Oslo. Of his stirring experience
he would tell his friends no more than he had told the admiralty
officials, and all they could do was to give me his Oslo address.
After that I went to Sydney and talked profitlessly with seamen and
members of the vice-admiralty court. I saw the Alert, now sold and in
commercial use, at Circular Quay in Sydney Cove, but gained
nothing from its non-committal bulk. The crouching image with its
cuttlefish head, dragon body, scaly wings, and hieroglyphed
pedestal, was preserved in the Museum at Hyde Park; and I studied
it long and well, finding it a thing of balefully exquisite workmanship,
and with the same utter mystery, terrible antiquity, and unearthly
strangeness of material which I had noted in Legrasse's smaller
specimen. Geologists, the curator told me, had found it a monstrous
puzzle; for they vowed that the world held no rock like it. Then I
thought with a shudder of what old Castro had told Legrasse about
the primal Great Ones: "They had come from the stars, and had
brought Their images with Them."
Shaken with such a mental revolution as I had never before known, I
now resolved to visit Mate Johansen in Oslo. Sailing for London, I re-
embarked at once for the Norwegian capital; and one autumn day
landed at the trim wharves in the shadow of the Egeberg.
Johansen's address, I discovered, lay in the Old Town of King Harold
Haardrada, which kept alive the name of Oslo during all the
centuries that the greater city masqueraded as "Christiania." I made
the brief trip by taxicab, and knocked with palpitant heart at the door
of a neat and ancient building with plastered front. A sad-faced
woman in black answered my summons, and I was stung with
disappointment when she told me in halting English that Gustaf
Johansen was no more.
He had not long survived his return, said his wife, for the doings at
sea in 1925 had broken him. He had told her no more than he had
told the public, but had left a long manuscript—of "technical matters"
as he said—written in English, evidently in order to safeguard her
from the peril of casual perusal. During a walk through a narrow lane
near the Gothenburg dock, a bundle of papers falling from an attic
window had knocked him down. Two Lascar sailors at once helped
him to his feet, but before the ambulance could reach him he was
dead. Physicians found no adequate cause for the end, and laid it to
heart trouble and a weakened constitution.
I now felt gnawing at my vitals that dark terror which will never leave
me till I, too, am at rest; "accidentally" or otherwise. Persuading the
widow that my connection with her husband's "technical matters"
was sufficient to entitle me to his manuscript, I bore the document
away and began to read it on the London boat.
It was a simple, rambling thing—a naive sailor's effort at a post-facto
diary—and strove to recall day by day that last awful voyage. I can
not attempt to transcribe it verbatim in all its cloudiness and
redundance, but I will tell its gist enough to show why the sound of
the water against the vessel's sides became so unendurable to me
that I stopped my ears with cotton.
Johansen, thank God, did not know quite all, even though he saw
the city and the Thing, but I shall never sleep calmly again when I
think of the horrors that lurk ceaselessly behind life in time and in
space, and of those unhallowed blasphemies from elder stars which
dream beneath the sea, known and favored by a nightmare cult
ready and eager to loose them on the world whenever another
earthquake shall heave their monstrous stone city again to the sun
and air.
Johansen's voyage had begun just as he told it to the vice-admiralty.

The Emma, in ballast, had cleared Auckland on February 20th, and
had felt the full force of that earthquake-born tempest which must
have heaved up from the sea-bottom the horrors that filled men's
dreams. Once more under control, the ship was making good
progress when held up by the Alert on March 22nd, and I could feel
the mate's regret as he wrote of her bombardment and sinking. Of
the swarthy cult-fiends on the Alert he speaks with significant horror.
There was some peculiarly abominable quality about them which
made their destruction seem almost a duty, and Johansen shows
ingenuous wonder at the charge of ruthlessness brought against his
party during the proceedings of the court of inquiry. Then, driven
ahead by curiosity in their captured yacht under Johansen's
command, the men sight a great stone pillar sticking out of the sea,
and in S. Latitude 47° 9', W. Longitude 126° 43' come upon a
coastline of mingled mud, ooze, and weedy Cyclopean masonry
which can be nothing less than the tangible substance of earth's
supreme terror—the nightmare corpse-city of R'lyeh, that was built in
measureless eons behind history by the vast, loathsome shapes that
seeped down from the dark stars. There lay great Cthulhu and his
hordes, hidden in green slimy vaults and sending out at last, after
cycles incalculable, the thoughts that spread fear to the dreams of
the sensitive and called imperiously to the faithful to come on a
pilgrimage of liberation and restoration. All this Johansen did not
suspect, but God knows he soon saw enough!
I suppose that only a single mountain-top, the hideous monolith-
crowned citadel whereon great Cthulhu was buried, actually
emerged from the waters. When I think of the extent of all that may
be brooding down there I almost wish to kill myself forthwith.
Johansen and his men were awed by the cosmic majesty of this
dripping Babylon of elder demons, and must have guessed without
guidance that it was nothing of this or of any sane planet. Awe at the
unbelievable size of the greenish stone blocks, at the dizzying height
of the great carven monolith, and at the stupefying identity of the
colossal statues and bas-reliefs with the queer image found in the
shrine on the Alert, is poignantly visible in every line of the mate's
frightened description.
Without knowing what futurism is like, Johansen achieved something
very close to it when he spoke of the city; for instead of describing
any definite structure or building, he dwells only on the broad
impressions of vast angles and stone surfaces—surfaces too great
to belong to anything right or proper for this earth, and impious with
horrible images and hieroglyphs. I mention his talk about angles
because it suggests something Wilcox had told me of his awful
dreams. He had said that the geometry of the dream-place he saw
was abnormal, non-Euclidean, and loathsomely redolent of spheres
and dimensions apart from ours. Now an unlettered seaman felt the
same thing whilst gazing at the terrible reality.
Johansen and his men landed at a sloping mud-bank on this
monstrous Acropolis, and clambered slipperily up over titan oozy
blocks which could have been no mortal staircase. The very sun of
heaven seemed distorted when viewed through the polarizing
miasma welling out from this sea-soaked perversion, and twisted
menace and suspense lurked leeringly in those crazily elusive
angles of carven rock where a second glance showed concavity after
the first showed convexity.
Something very like fright had come over all the explorers before
anything more definite than rock and ooze and weed was seen.
Each would have fled had he not feared the scorn of the others, and
it was only half-heartedly that they searched—vainly, as it proved—
for some portable souvenir to bear away.
It was Rodriguez the Portuguese who climbed up the foot of the
monolith and shouted of what he had found. The rest followed him,
and looked curiously at the immense carved door with the now
familiar squid-dragon bas-relief. It was, Johansen said, like a great
barn-door; and they all felt that it was a door because of the ornate
lintel, threshold, and jambs around it, though they could not decide
whether it lay flat like a trap-door or slantwise like an outside cellar-
door. As Wilcox would have said, the geometry of the place was all
wrong. One could not be sure that the sea and the ground were
horizontal, hence the relative position of everything else seemed
fantasmally variable.
Briden pushed at the stone in several places without result. Then
Donovan felt over it delicately around the edge, pressing each point
separately as he went. He climbed interminably along the grotesque
stone molding—that is, one would call it climbing if the thing was not
after all horizontal—and the men wondered how any door in the
universe could be so vast. Then, very softly and slowly, the acre-
great panel began to give inward at the top; and they saw that it was
balanced.
Donovan slid or somehow propelled himself down or along the jamb
and rejoined his fellows, and everyone watched the queer recession
of the monstrously carven portal. In this fantasy of prismatic
distortion it moved anomalously in a diagonal way, so that all the
rules of matter and perspective seemed upset.
The aperture was black with a darkness almost material. That
tenebrousness was indeed a positive quality; for it obscured such
parts of the inner walls as ought to have been revealed, and actually
burst forth like smoke from its eon-long imprisonment, visibly
darkening the sun as it slunk away into the shrunken and gibbous
sky on flapping membranous wings. The odor arising from the newly
opened depths was intolerable, and at length the quick-eared
Hawkins thought he heard a nasty, slopping sound down there.
Everyone listened, and everyone was listening still when It lumbered
slobberingly into sight and gropingly squeezed Its gelatinous green
immensity through the black doorway into the tainted outside air of
that poison city of madness.
Poor Johansen's handwriting almost gave out when he wrote of this.
Of the six men who never reached the ship, he thinks two perished
of pure fright in that accursed instant. The Thing can not be
described—there is no language for such abysms of shrieking and
immemorial lunacy, such eldritch contradictions of all matter, force,
and cosmic order. A mountain walked or stumbled. God! What
wonder that across the earth a great architect went mad, and poor
Wilcox raved with fever in that telepathic instant? The Thing of the
idols, the green, sticky spawn of the stars, had awaked to claim his
own. The stars were right again, and what an age-old cult had failed
to do by design, a band of innocent sailors had done by accident.
After vigintillions of years great Cthulhu was loose again, and
ravening for delight.
Three men were swept up by the flabby claws before anybody
turned. God rest them, if there be any rest in the universe. They
were Donovan, Guerrera and Angstrom. Parker slipped as the other
three were plunging frenziedly over endless vistas of green-crusted
rock to the boat, and Johansen swears he was swallowed up by an
angle of masonry which shouldn't have been there; an angle which
was acute, but behaved as if it were obtuse. So only Briden and
Johansen reached the boat, and pulled desperately for the Alert as
the mountainous monstrosity flopped down the slimy stones and
hesitated floundering at the edge of the water.
Steam had not been suffered to go down entirely, despite the
departure of all hands for the shore; and it was the work of only a
few moments of feverish rushing up and down between wheels and
engines to get the Alert under way. Slowly, amidst the distorted
horrors of that indescribable scene, she began to churn the lethal
waters; whilst on the masonry of that charnel shore that was not of
earth the titan Thing from the stars slavered and gibbered like
Polypheme cursing the fleeing ship of Odysseus. Then, bolder than
the storied Cyclops, great Cthulhu slid greasily into the water and
began to pursue with vast wave-raising strokes of cosmic potency.
Briden looked back and went mad, laughing shrilly as he kept on
laughing at intervals till death found him one night in the cabin whilst
Johansen was wandering deliriously.
But Johansen had not given out yet. Knowing that the Thing could
surely overtake the Alert until steam was fully up, he resolved on a
desperate chance; and, setting the engine for full speed, ran
lightning-like on deck and reversed the wheel. There was a mighty
eddying and foaming in the noisome brine, and as the steam
mounted higher and higher the brave Norwegian drove his vessel
head on against the pursuing jelly which rose above the unclean
froth like the stern of a demon galleon. The awful squid-head with
writhing feelers came nearly up to the bowsprit of the sturdy yacht,
but Johansen drove on relentlessly.
There was a bursting as of an exploding bladder, a slushy nastiness
as of a cloven sunfish, a stench as of a thousand opened graves,
and a sound that the chronicler would not put on paper. For an
instant the ship was befouled by an acrid and blinding green cloud,
and then there was only a venomous seething astern; where—God
in heaven!—the scattered plasticity of that nameless sky-spawn was
nebulously recombining in its hateful original form, whilst its distance
widened every second as the Alert gained impetus from its mounting
steam.
That was all. After that Johansen only brooded over the idol in the
cabin and attended to a few matters of food for himself and the
laughing maniac by his side. He did not try to navigate after the first
bold flight, for the reaction had taken something out of his soul. Then
came the storm of April 2nd, and a gathering of the clouds about his
consciousness. There is a sense of spectral whirling through liquid
gulfs of infinity, of dizzying rides through reeling universes on a
comet's tail, and of hysterical plunges from the pit to the moon and
from the moon back again to the pit, all livened by a cachinnating
chorus of the distorted, hilarious elder gods and the green, bat-
winged mocking imps of Tartarus.
Out of that dream came rescue—the Vigilant, the vice-admiralty
court, the streets of Dunedin, and the long voyage back home to the
old house by the Egeberg. He could not tell—they would think him
mad. He would write of what he knew before death came, but his
wife must not guess. Death would be a boon if only it could blot out
the memories.
That was the document I read, and now I have placed it in the tin box
beside the bas-relief and the papers of Professor Angell. With it shall
go this record of mine—this test of my own sanity, wherein is pieced
together that which I hope may never be pieced together again. I
have looked upon all that the universe has to hold of horror, and
even the skies of spring and the flowers of summer must ever
afterward be poison to me. But I do not think my life will be long. As
my uncle went, as poor Johansen went, so I shall go. I know too
much, and the cult still lives.
Cthulhu still lives, too, I suppose, again in that chasm of stone which
has shielded him since the sun was young. His accursed city is
sunken once more, for the Vigilant sailed over the spot after the April
storm; but his ministers on earth still bellow and prance and slay
around idol-capped monoliths in lonely places. He must have been
trapped by the sinking whilst within his black abyss, or else the world
would by now be screaming with fright and frenzy. Who knows the
end? What has risen may sink, and what has sunk may rise.
Loathsomeness waits and dreams in the deep, and decay spreads
over the tottering cities of men. A time will come—but I must not and
can not think! Let me pray that, if I do not survive this manuscript, my
executors may put caution before audacity and see that it meets no
other eye.
[1] Found among the papers of the late Francis Wayland

Thurston, of Boston.

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Nutrition for Health and Health

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Nutrition for Health and Health Care (MindTap Course

Nutrition for Health and Health Care 7th Edition

Nutrition for Health and Health Care (MindTap Course

Health Care Ethics (6th Edition ) 6th Edition

Diet and Nutrition Sourcebook (Health Reference), 6th

Modern Nutrition in Health and Disease (Modern

Family Health Care Nursing: Theory, Practice, and

(eBook PDF) Advanced Health Assessment & Clinical

To my mom, Tina C. Pinna, who started me on the path to good nutritional

Coronary Heart Disease 586 HIV Infection 649

Appendix D Physical Activity and Energy Chapter 22

Chapter Sections and Learning Objectives (LOs)

1.1 Food Choices 1.5 Dietary Guidelines and Food Guides

FIGURE 1-1 The Health Line

Person takes responsibility Superior

2 CHAPTER 1 Overview of Nutrition and Health

noodles as amaranth), mandarin sea urchin,

bread, greens, leeks, oranges, chicken, fava and ricotta

Mexican Hominy, Bell peppers, Avocado, Beans, refried Cheese, flan

tillas (corn jicama, onions, oranges, chicken, fish,

Social Interaction Social interaction is another powerful influence on

4 CHAPTER 1 Overview of Nutrition and Health

Medical Conditions Sometimes medical conditions and their treatments (includ-

nutrients: substances obtained from

inorganic: not containing carbon

6 CHAPTER 1 Overview of Nutrition and Health

BOX 1-1 How to Calculate the Energy a Food Provides

the likelihood of osteoporosis-related fractures later in life.

8 CHAPTER 1 Overview of Nutrition and Health

Setting Energy Recommendations In contrast to the vitamin Marginal

Acceptable Macronutrient Distribution Ranges

National Nutrition Surveys

10 CHAPTER 1 Overview of Nutrition and Health

Only two of the prisoners were found sane enough to be hanged,

"That is not dead which can eternal lie,

Legrasse, deeply impressed and not a little bewildered, had inquired

The feverish interest aroused at the meeting by Legrasse's tale,

3. The Madness from the Sea.

The Morrison Co.'s freighter Vigilant, bound from Valparaiso, arrived

That evening, after a day of hurried cabling and arranging, I bade my

Johansen's voyage had begun just as he told it to the vice-admiralty.

[1] Found among the papers of the late Francis Wayland

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