Nutrition 3 8

Nutrition for Young Children Handout 1
Nutrition for Young Children

Module Objectives:

Describe how nutritional intakes in childhood must match needs for growth.
Utilize and interpret growth charts; describe the parameters of normal growth.
List consequences of undernutrition on growth, and describe failure to thrive.
Provide age-appropriate dietary guidelines.
Describe the absorption of water, sodium and other nutrients.

Module Outline:
Introduction
Title and Authors
Table of Contents
Introduction & Module Objectives

Normal Growth
Normal Growth in Infancy
Growth in Childhood and Adolescence
Growth as a Nutrition Indicator
Growth Charts

Nutritional Needs for Growth
What Children Need for Growth
Macronutrient Needs in Childhood
Mineral Needs in Childhood

Nutrition-Related Problems in Children
Common Nutrition-Related Problems
Defining Overweight in Children
Screening for Overweight
Failure to Thrive
Criteria for Failure to Thrive
Practice Charts

Nutrients for Brain Development
Brain Growth
Choline
Taurine
Folate
Iron
Iron Deficiency
Problems with Restrictive Diets
Docosahexaenoic Acid (DHA)

Growth Case - Assess Growth
Meet the Patient
The Mother's Concern
Track Changes Over Time
Parental Height Assessment
Jessica's Growth Charts
Interpret the Growth Pattern

Infant Feedings
Introducing Solids
Transitioning to a Mixed Diet
Introducing New Foods
Food Transitions: Food Groups
Food Transitions: Timing
Adverse Food Reactions

Diarrhea
Water Absorption: Sodium-Potassium Pump
Water Absorption: SGLT-1
Water Absorption: Aquaporins
Water Absorption: Summary
Imbalanced Intestinal Secretions and Absorption
Oral Rehydration Therapy
Choose the Best Rehydration Beverage

Integrated Practice (Diarrhea Case)
Diarrhea Case

Protein Basics
Amino Acid Uses
Essential and Non-essential Amino Acids
Importance of Providing Essential Amino Acids
Transamination and Amination
Vitamin B6
Normal Protein Requirements
Marasmus and Kwashiorkor

Amino Acid Metabolism
Glucogenic and Ketogenic Amino Acids
Genetic Defects in Amino Acid Metabolism
Phenylketonuria
Homocysteinemia
Maple Syrup Urine Disease

Protein Quality
Definition of Protein Quality
Protein Quality of Foods
Vegetarian Diets and Protein

Preschooler's Nutritional Needs
Dietary Recommendations for Preschool Children
Fat Intake
Food Jags
Nutritional Problems in U.S. Preschoolers
Choking Hazards

Growth Case - Investigate Causes
Your Next Task
Rule Out Digestive Problems
24-hour Recall
Breakfast
Snacks and Lunch
Dinner and Snack
Ask Additional Questions
Compare to Standard Recommendations
Identify Primary Cause
Choose an Intervention
Two Referrals
Increasing Energy Density
Assign Homework
Goals for Catch-up Growth

Trace Minerals
Iron
Copper
Zinc
Regulation of Iron Absorption: Deficiency
Regulation of Iron Absorption: Repletion
Copper Absorption and Release
Zinc Absorption

Growth Case - Iron Deficiency
A Follow-up Visit
Consequences of Iron Deficiency
Conveying the Diagnosis
Determine the Treatment Plan
Correcting the Deficiency
Conclusion

Vitamin A
Vitamin A Metabolism
Vitamin A Precursors
Interaction: Retinal Content of Carotenoids
Retinol Activity Equivalents

Integrated Practice (Delayed Growth Case)
Delayed Growth Case

Objectives, Key Concepts, and Key Concept Summaries by Topic

Topic: Normal Growth

Objective:
Describe the parameters of normal growth and explain the use of CDC charts in tracking
growth.

Key Concept:
Growth spurts occur in infancy and adolescence; irregular patterns of growth can indicate
nutritional problems.

Growth is not linear. The most rapid period of growth occurs during the first year of life;
slower, steady growth then follows until adolescence, when the growth rate increases.
Body composition changes along with stature. Growth charts are useful for plotting
growth patterns for comparison to peer standards. In general, values between the 5th and
85th percentile are considered within normal range, as long as the pattern of growth
approximates the shape of the growth curve. Values out of this range, or significant
changes in growth, can identify potential problems of over- or undernutrition and warrant
further investigation. BMI-for-age charts can identify children who are obese,
overweight, or underweight.
________________________________________________________________________

Topic: Nutritional Needs for Growth

Objective:
Explain how the nutritional needs of children differ from those of adults.

Key Concept:
Needs for specific nutrients on a per-kilogram basis are highest early in life and later
decrease to adult levels.

Although young children need lower absolute amounts of nutrients, their needs on a per-
kilogram basis are much higher than those of adults. Infants may require some nutrients,
such as DHA, until they are able to synthesize enough on their own. Some organs and
tissues are sensitive to deficiencies, especially during growth. Relative to body size,
needs for calories and other nutrients generally decrease over the lifecycle. To meet their
relatively high needs, infants and children should consume foods that are rich in
micronutrients, not just high in calories and protein. For infants, human milk or iron-
fortified formula provides the majority of energy and nutrient intake. Children gradually
transition to more adult patterns of food
intake.__________________________________________________________________

Topic: Nutrition-Related Problems in Children

Objective:
Identify failure to thrive and overweight in children.

Key Concept:
The major nutrition-related problems in childhood range from undernutrition to
overnutrition.

The most common nutrition-related problems reflect poor dietary habits that can lead to
overweight, anemia, growth retardation, or dental caries. Children in the US are
considered overweight when their body mass index (BMI) values for age and gender
equal or exceed the 85th percentile. The term failure to thrive describes inadequate
growth and may result from insufficient nutrition, numerous medical conditions, and
environmental circumstances.
________________________________________________________________________

Topic: Nutrients for Brain Development

Objective:
Describe the influence of infant nutrition on brain growth and development.

Key Concept:
Important nutrients for brain growth and development include DHA, choline, taurine,
folate, and iron.

The brain grows rapidly during the first year of life. Certain nutrients have critical roles
in brain structure and function. Membranes and photoreceptor rods contain high
concentrations of docosahexaenoic acid (DHA). Choline is a precursor for phospholipid
and neurotransmitter biosynthesis. Taurine has roles in osmoregulation, neuroprotection,
and neuromodulation. Folate mediates one-carbon transfers and DNA synthesis. Iron is
necessary for energy metabolism, regulation of mRNA translation, and myelin synthesis.
Iron deficiency, the most common nutrient deficiency world-wide, can delay speech and
cognitive development, slow growth, and cause anemia. Children on highly restrictive
diets can have low intakes of iron, vitamin D, fat, and zinc. A lack of these nutrients can
impair optimal development of the brain and central nervous
system._________________________________________________________________

Topic: Infant Feedings

Objective:
Explain the process of introducing solid foods to an infant.

Key Concept:
Introducing solid foods to an infant should begin when the child is developmentally
ready, usually between 4 to 6 months.

Signs of readiness include: disappearance of the extrusion reflex, hand-to-mouth
movements, and ability to sit with support. Generally the appearance of these signs will
coincide with maturation of the gastrointestinal system and the kidneys. During the first
year of life, foods should be gradually introduced in the following order: cereals, fruits
and vegetables, and then meats and dairy products. At one year, children should be eating
70% liquids and 30% solids. Introducing foods earlier or later than recommended can
contribute to the development of food allergies. Delaying the introduction of solid foods
later than 6 months can increase risks of iron and zinc deficiency. Advise parents to
introduce foods one at a time so that food allergies/intolerances can be identified or
avoided.

________________________________________________________________________

Topic: Diarrhea

Objective:
Describe the use of oral rehydration therapy to treat diarrhea.

Key Concept:
Oral rehydration therapy utilizes sodium- and glucose-coupled transport to replenish
fluids following diarrhea.

More children under the age of five die from diarrhea than from any other cause. Oral
rehydration therapy (ORT), the gold standard for treating diarrhea in children, uses a
solution of sodium and glucose (along with chloride, potassium, and citrate) to promote
water uptake via the activity of the sodium-glucose co-transporter (SGLT-1). Sodium-
and glucose-coupled transport effectively replenishes fluids following diarrhea. Other
goals of ORT include maintenance of adequate hydration and attention to nutritional
status.

________________________________________________________________________

Topic: Protein Basics

Objective:
Explain the need for an adequate intake of protein during childhood.

Key Concept:
For proper growth and development, a young child must have adequate intakes of protein and
vitamin B6.

The body uses proteins to build tissues and synthesize many compounds. Proteins are also
catabolized for energy. Humans can synthesize some amino acids (non-essential) but not
others (essential). Synthesis of non-essential amino acids occurs via transamination and
amination reactions. Pyridoxal-5-phosphate, the active form of vitamin B6, functions as a
cofactor for many enzymes involved in protein metabolism. Protein requirements per kilogram
decrease rapidly after the first year of life. A lack of dietary protein may lead to the wasting
diseases marasmus and kwashiorkor.

________________________________________________________________________

Topic: Amino Acid Metabolism

Objective:
Describe normal amino acid metabolism and identify genetic defects that disrupt the
actions of key enzymes.

Key Concept:
All amino acids can be catabolized for energy; genetic defects in amino acid metabolism can
cause brain damage if untreated.

Most amino acids have carbon skeletons that can be converted to glucose. Some amino acids
are ketogenic and can generate acetyl CoA and ketone bodies. Certain genetic defects can
disrupt amino acid metabolism and, if untreated, can lead to the accumulation of toxic
compounds or cause deficiencies of critical products. Phenylketonuria, a relatively common
inborn error of metabolism, usually results from a defect in the enzyme phenylalanine
hydroxylase. Irreversible dementia may occur if phenylalanine intake is not restricted.
Homocysteinemia results from a defect in cystathione beta-synthase but can be treated with
dietary restrictions and supplementation. An infant with maple syrup urine disease cannot
metabolize branched-chain amino acids and must receive a special diet with reduced quantities
of valine, leucine, and isoleucine.

________________________________________________________________________

Topic: Protein Quality

Objective:
Define protein quality and describe strategies for meeting protein needs with a variety of
foods.

Key Concept:
Plant and animal proteins can meet nutritional needs.

Several factors determine the quality of a protein: its amino acid composition, its ability to
sustain growth, its effect on nitrogen retention, and the presence of compounds that interfere
with nutrient uptake and metabolism. The ability of a food to sustain growth and development
depends on the quantity and quality of its protein. The protein digestibility corrected amino
acid score (PDCAAS) is the standard method for determining protein quality. According to
this system, animal and soy products provide higher quality proteins than do grains and other
legumes. Plant proteins, though less digestible than animal proteins, can provide all of the
necessary amino acids and nitrogen if eaten in complementary mixtures throughout the day.
________________________________________________________________________

Topic: Preschoolers Nutritional Needs

Objective:
Describe the nutritional needs of preschool children and identify the major dietary
concerns for this age group.

Key Concept:
By the age of five, children should be eating a diet similar to that of adults.

After the age of two, a child should gradually decrease fat intake to about 30% of total
calories. Occasionally children will go through periods where they will only eat a limited
number of foods. These periods, called food jags, are usually not of great concern unless
they persist for more than a few weeks. Many preschool children in the US have a diet
that needs improvement or is poor. Problem areas include inadequate intakes of iron,
fluid, and fiber, as well as over-consumption of sweets, which may lead to dental caries.
Certain foods pose a choking hazard and should not be given to children under four years
of age; these include whole grapes, cherries with pits, hot dog slices, hard candies, nuts,
and popcorn.
________________________________________________________________________
Topic: Trace Minerals

Objective:
Explain how iron, zinc and copper are critical for normal growth and development.

Key Concept:
Many enzymes require trace minerals (iron, copper, and zinc) for proper function.

Iron, an essential mineral, participates in oxygen transport, respiration, defense against free
radicals, and in the metabolism of many compounds. Deficiency symptoms include anemia,
growth retardation, and impaired immune function. Low iron status stimulates the expression
of proteins that promote iron uptake. Copper, a cofactor for many enzymes, has a role in
energy production and protects against oxidative damage. Deficiencies rarely occur, but high
levels of dietary iron and zinc may decrease copper absorption. Zinc is a constituent of so
many critical enzymes that deficiencies have severe consequences, including growth
retardation, delayed wound healing, immune dysfunction, and cognitive impairment.
Excessive iron intake decreases zinc absorption.

________________________________________________________________________

Topic: Vitamin A

Objective:
Describe the functions of vitamin A precursors and metabolites.

Key Concept:
Vitamin A is needed for vision, regulation of gene expression, and control of cell
proliferation and differentiation.

In intestinal cells, retinol is esterified for transport to the liver via chylomicrons. Retinol
is either stored in the liver as retinyl esters or bound by retinol-binding protein and
transthyretin for transport in plasma. Biologically active forms of vitamin A include
retinol metabolites, which control cell growth; retinal, needed for vision; and retinoic
acid, which regulates gene expression. Vitamin A deficiency impairs vision and
compromises the immune system. Note that excess intake of preformed retinol, but not
provitamin A carotenoids, can cause birth defects. Only a few carotenoids have the right
structure to generate retinal. To determine the vitamin A content of foods, use conversion
factors to express retinol and carotenoids as retinol activity equivalents.
________________________________________________________________________
Bibliography

2000 CDC growth charts: United States. Available at www.cdc.gov/growthcharts/
Accessed 4 April 2007.

Himes JH, Deitz WH. Guidelines for overweight in adolescent preventive services:
recommendations form an expert committee. The Expert Committee on Clinical
Guidelines for Overweight in Adolescent Preventive Services. Am J Clin Nutr. 1994;
59:307-16.

Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol,
Protein, and Amino Acids (Macronutrients). Institute of Medicine, National Academy
Press, Washington, DC. 2005. Available at www.nap.edu

Dietary Reference Intakes for Calcium and Vitamin D. Institute of Medicine, National
Academy Press, Washington, DC. 2010. Available at www.nap.edu

Olsen EM. Failure to thrive: still a problem of definition. Clin Pediatr (Phila).
2006;45(1):1-6.

Leigh SR. Brain ontogeny and life history in Homo erectus. J Hum Evol. 2006;50(1):104-
8.

Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin
B12, Pantothenic Acid, Biotin, and Choline. Institute of Medicine, National Academy

Dominy J, Eller S, Dawson R Jr. Building biosynthetic schools: reviewing
compartmentation of CNS taurine synthesis. Neurochem Res. 2004;29(1):97-103.

Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium,
Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc.
Institute of Medicine, National Academy Press, Washington, DC. 2000. Available at
www.nap.edu

Cunnane SC, Francescutti V, Brenna JT, Crawford MA. Breast-fed infants achieve a
higher rate of brain and whole body docosahexaenoate accumulation than formula-fed
infants not consuming dietary docosahexaenoate. Lipids. 2000;35(1):105-11.

Wright CM, Cheetham TD. The strengths and limitations of parental heights as a
predictor of attained height. Arch Dis Child. 1999 Sep;81(3):257-60.

American Dietetic Association. Start healthy, stay healthy: feeding guidelines. Available
at http://www.eatright.org/ada/files/infant_book.pdf Accessed 5/03/07.

Burks AW, Jones SM, Boyce JA, Sicherer SH, Wood RA, Assa'ad A, Sampson HA.
NIAID-sponsored 2010 guidelines for managing food allergy: applications in the
pediatric population. Pediatrics. 2011;128:955-65. Review. PMID: 21987705

World Health Organization. Oral Rehydration Salts - Production of the new ORS. 2006.
Available at www.who.int/child-adolescent-
health/New_Publications/CHILD_HEALTH/WHO_FCH_CAH_06.1.pdf Accessed
5/4/07

ASPEN Board of Directors and the Clinical Guidelines Task Force. Guidelines for the
use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter
Enteral Nutr: 2002 Jan-feb;26(1 Suppl):1SA-138SA.

Messina V, Mangels R, Messina R. The dietitian's guide to vegetarian diets. 2nd edition.
Jones and Bartlett Publishers, Inc. Sudbury, MA. 2004.

Information available at mypyramid.gov Accessed 5/08/07.

U.S. Department of Agriculture, Center for Nutrition Policy and Promotion. The Healthy
Eating Index. 1995. Available at www.cnpp.usda.gov/publications/hei/HEI89-
90report.pdf Accessed 9 May 2007.

Schwartz, I. David. Failure To Thrive: An Old Nemesis in the New Millennium.
Pediatrics in Review 2000 21: 257-264

Monsen ER. Iron nutrition and absorption: dietary factors which impact iron
bioavailability. J Am Diet Assoc. 1988;88(7):786-90.

Prasad AS, Kucuk O. Zinc in cancer prevention. Cancer Metastasis Rev. 2002;21(3-
4):291-5.

Fleming RE, Bacon BR. Orchestration of iron homeostasis. N Engl J Med. 2005
28;352(17):1741-4.

Sharp P. The molecular basis of copper and iron interactions. Proc Nutr Soc.
2004;63(4):563-9.

Liuzzi JP, Cousins RJ. Mammalian zinc transporters. Annu Rev Nutr. 2004;24:151-72.

Blomhoff R, Blomhoff HK. Overview of retinoid metabolism and function. J Neurobiol.
2006;66(7):606-30.

Readings

Center for Disease Control, Atlanta, Georgia.
http://www.cdc.gov/nccdphp/dnpa/bmi/bmi-for-age.htm

Nutrition for School Aged Children Handout 1
Nutrition for School Age Children

Module Objectives:

Characterize the nutritional requirements of school-aged children.
Describe the roles of nutrients involved in bone growth and development.
Explain the major steps of macronutrient digestion and absorption, and the causes
and consequences of malabsorption.
Describe the spectrum of eating behaviors, including eating disorders, and
disordered eating.
List common nutritional deficiencies at different ages.

Module Outline:
Introduction
Title and Authors
Table of Contents
Introduction and Module Objectives

Nutritional Needs during the School Years
Energy Needs in Childhood
Glucose Metabolism in the Fasting State
Glucose Metabolism in the Fed State
Nutritional Concerns in Children

Micronutrients in Energy Metabolism
Thiamin, Biotin, Pantothenate
Thiamin
Thiamin Deficiency
Biotin
Review Carboxylases
Pantothenate

Intestinal Absorption
Predigestion
Pancreatic Secretions
Fat Digestion
Brushborder
Malabsorption Overview
Exocrine Pancreatic Insufficiency
Inadequate Bile
Loss of Intestinal Mucosa Function
Is it Maldigestion or Malabsorption

Cystic Fibrosis Case - part 1
A Child with Chronic Illness
Introduce the Student

Concerns About Weight Gain
Nicole's Weight-for-Age Chart
Nicole's Stature-for-Age Chart
Interpret the Growth Pattern
About Cystic Fibrosis
Interview the Patient
Identify the Problem
Fat Malabsorption
Changing Digestive Enzyme Needs

Nutritional Outcomes
Healthy Habits Last a Lifetime
Dental Caries
Breakfast and Mental Performance

Integrated Practice (Fuel Metabolism)
Fuel Metabolism Case

Growth Needs & Spurts
Body Composition Changes During Growth
Gender Differences in Adolescence and Into Adulthood
Diverging Growth Patterns
Nutritional Problems in Prepuberty/Puberty

Bone Minerals
Bone Mineral Density
Bone Mineralization
Calcium
Calcium Intakes
Phosphate

Bone Regulation
Vitamin D Metabolism
Vitamin D Nutriture

Cystic Fibrosis Case - part 2
Fat Malabsorption
Bone Development
Resistance
Plan for Follow-Up
Conclusion

Dietary Patterns in Teens
Teens' Nutritional Needs
Problem Nutrients for Teens
Identifying Nutritional Concerns

Food Choices/Healthy Eating
Vegetarianism
Athletic Performance
Hydration and Fluids

Body Image
Changes During Adolescence
Spectrum of Eating Behaviors
Development of Eating Disorders
Types of Eating Disorders

Adolescent Case
Introduction to the Patient
Consider Potential Diagnoses
Need to Assess Diet and Symptoms
Adolescence: A Time of Change
Rapid Weight Loss
Investigate Contributing Factors
Summary of Cassandra's Responses
Make a Determination
Address the Issue with the Patient
A Team Approach
Early Intervention
Focus on Common Goals
Medical Clearance
Conclusion

Teen Pregnancy
Teen Pregnancy Concerns
Nutrients of Concern During Pregnancy

Integrated Practice (Teen Athlete)
Teen Athlete Case


Topic: Nutritional Needs during the School Years

Objective:
Explain how the flux of macronutrients between organs while fasting helps the growing
body meets its high energy needs.

Key Concept:
During fasting the brain depends on glucose sent into the bloodstream by the liver.

Children have much higher energy and macronutrient needs per weight than adults. Four
to six-year-old children have nearly the same energy and fat requirements as an adult
woman, because they have higher activity levels and must sustain growth. The brain
depends on a continuous supply of glucose. After meals glucose is supplied directly from
absorbed carbohydrates. During fasting, the liver converts glycogen stores or precursors
(amino acids, lactate, and other intermediates) to glucose for release into blood.
Nutritional concerns in children include overall dietary quality, including improving
intake of fruits and vegetables, ensuring adequate calcium, vitamin D, and iron intake,
and moderating fat intake.

________________________________________________________________________

Topic: Nutrients in Energy Metabolism

Objective:
Describe how the micronutrients thiamin, biotin, and pantothenate are essential for fuel
metabolism.

Key Concept:
The vitamins thiamin, biotin, and pantothenate are critical cofactors in energy
metabolism in both fed and fasted states.

Thiamin deficiency may cause edema, wasting and congestive heart failure, most likely
due to the critical role of thiamin triphosphate (TPP) in fuel metabolism of muscle and
neuron function. The best sources of thiamin are pork, fortified grains, legumes, and
yeast. Biotin-dependent carboxylases replenish TCA intermediates, regulate lipid
metabolism, and metabolize some amino acids. Biotin is found in food and intestinal
flora. Pantothenate as coenzyme A participates in the metabolism of most nutrients; good
sources include yogurt, other fermented dairy products, broccoli, legumes, chicken, milk,
sweet potato, and intestinal bacteria. The deficiency symptoms of these vitamins reflect
their role in fuel metabolism. Thiamin deficiency is commonly seen with alcohol abuse,
but in most cases, deficiencies of thiamin, biotin and pantothenate are rare.

________________________________________________________________________

Topic: Intestinal Absorption

Objective:
Explain major steps of macronutrient digestion and absorption, and causes and
consequences of malabsorption.

Key Concept:
Nutrient digestion and absorption requires enzymes, water and ions from saliva, stomach,
pancreas, bile and intestine.

Nutrient digestion and absorption of most foods is dependent on adequate function of the
entire intestinal tract. A lack of pancreatic enzymes limits absorption of fat and fat-
soluble vitamins, proteins, and complex carbohydrates. Lack of bile interferes with
absorption of fat and fat-soluble vitamins. Loss of brushborder function limits digestion
and uptake of peptides, sugars and many micronutrients including folate and B12.

________________________________________________________________________

Topic: Nutritional Outcomes

Objective:
Explain the importance of parental role modeling, eating breakfast, and a low cariogenic
diet.

Key Concept:
Having a good role model and developing healthy habits during childhood is important to
avoid adverse nutritional outcomes.

Parents are important role models for their children. Parents should strive to get enough
exercise and consume adequate and appropriate amounts of fruits, vegetables, whole
grains, and low-fat dairy. Dental caries can be avoided by choosing foods that help
protect against caries such as cheese, raw vegetables, and hard breads. At the same time,
cariogenic foods (sticky foods high in sugar) should be avoided as these cause prolonged
exposure of teeth to fermentable carbohydrate. Skipping breakfast should be discouraged
because this can lead to decreased performance on mental function tests. It is important to
develop healthy habits during childhood, not only to avoid adverse nutritional outcomes,
but to promote health into adulthood as well.

________________________________________________________________________

Topic: Growth Needs & Spurts

Objective:
Relate how the growth spurt of puberty changes stature and body composition and
influences nutrient needs.

Key Concept:
Puberty is a time of great gains in mass and height in both males and females.

In girls, puberty begins at 10-11 and peaks at age 12 while in boys it begins at age 12-13
and peaks at 14 years. Females grow ~15 cm (~6 in) and gain ~16 kg (~35 lbs) while
males grow ~20 cm (8 in) and gain ~20.5 kg (45 lbs). The biggest difference in growth
patterns during this time is body fat: in females fat mass increases to ~23% while in
males is declines to ~12%. Failure to meet energy needs for growth can prevent the
adolescent from reaching their full potential for body height and delay sexual maturation.
Particularly in girls, dietary quality declines during adolescence. Significant bone
mineralization occurs during this period, while inadequate calcium and vitamin D intakes
are common. Zinc is needed for muscle growth and sexual maturation. Iron requirements
are increased in males due to muscle mass expansion and in females due to menses.

________________________________________________________________________

Topic: Bone Minerals

Objective:
Describe the roles of nutrients involved in bone growth and development.

Key Concept:
Calcium, phosphorus, vitamin D, ascorbate, copper, magnesium and other nutrients are
essential to bone formation.

Bones require calcium, phosphorus, vitamin D, ascorbate, copper, magnesium, protein,
and other nutrients to form properly. Lack of critical nutrients interferes with bone
growth and mineralization, especially during growth spurts. Accumulation of bone
minerals continues until the mid-twenties. Adolescent girls fail to consume enough
calcium for bone development, and excessive consumption of phosphate-rich foods by
children and adolescents often decreases calcium absorption and retention.
________________________________________________________________________

Topic: Bone Regulation

Objective:
Describe the metabolism of vitamin D and identify its role in the body.

Key Concept:
itamin D, coming from dietary sources or skin synthesis, is essential for bone regulation.

Vitamin D is obtained from dietary sources and from light-dependent synthesis in the skin
(although sunscreen blocks this process). Ultraviolet light induces the conversion of 7-
dehydrocholesterol to cholecalciferol. Additional UV exposure inactivates intermediates of
the reaction which tightly limits synthesis in skin and avoids toxic effects. Dietary vitamin D,
in contrast, is absorbed without limit and risks toxicity from overdoses. The hydroxylated
form 1-25-dihydroxy vitamin D acts on many different DNA segments, promoting the
translation of some and inhibiting that of others. It promotes absorption of calcium from the
intestine, calcium mobilization in bone (the 1,25 dihydroxy form) and reabsorption from renal
tubules. When intakes are low, young children are at especially high risk of slow bone matrix
growth and poor bone mineralization.

________________________________________________________________________

Topic: Dietary Patterns in Teens

Objective:
Identify the nutrients of concern for adolescents.

Key Concept:
The typical dietary patterns of teenagers do not match their nutritional needs.

Teenagers typically skip meals, choose sodas or soft drinks as beverages and consume
fast foods. In addition, they have a low fruit and vegetable intake. In general, the diets of
teens are low in calcium, vitamin D, iron (in females) and folate and may be low in
vitamins A, C, E, riboflavin, magnesium, zinc and potassium. Often the diets of teens are
high in fat, saturated fat, cholesterol and sodium. This pattern puts them at risk for
elevated lipid levels (potentially leading to adult heart disease) and overweight
(potentially leading to adult obesity, diabetes and cardiovascular disease). Vegetarianism
and athletic performance warrant special dietary recommendations.
________________________________________________________________________

Topic: Body Image

Objective:
Describe the spectrum of eating behaviors, including eating disorders, and disordered
eating.

Key Concept:
Body image issues that may occur during growth warrant monitoring of teens for signs of
an eating disorder.

Adolescent bodies undergo vast changes in terms of body composition, height, and
secondary sex characteristics, which can create issues around body image and self-
esteem. Anorexia nervosa, bulimia nervosa, and binge eating disorder present serious
medical and psychological concerns. In anorexia nervosa the individual relentlessly
pursues weight loss, seeing oneself as fat despite extreme thinness and emaciation.
Individuals with bulimia nervosa engage in cycles of bingeing and purging, upsetting
electrolyte balance and endangering cardiac function. Binge eating disorder is less
prevalent in teens, but is characterized by binge eating without compensatory actions to
maintain or lose weight. Eating disorders have the highest mortality rate of any
psychiatric illness and necessitate prompt medical attention. Prevention or early
intervention is vital.
________________________________________________________________________

Topic: Teen Pregnancy

Objective:
Relate the concerns for pregnancy outcomes and nutrient needs in a pregnant adolescent.

Key Concept:
Pregnancy during adolescence poses many nutritional challenges.

A pregnant adolescent needs to meet the high nutrient demands of her own growing body
and those of her unborn child. Of the greatest concern are getting sufficient intakes of
iron (27 mg/d needed) and calcium (1300 mg/day or more). An extra 25 g/day of protein
are needed, but energy needs are only 340-450 calories above her normal needs (in the
second and third trimesters respectively), necessitating nutrient-rich dietary choices.
Physically immature teenagers often need to gain 16 kg (35 lbs) during pregnancy if they
were of normal weight status pre-pregnancy. Nutrition-related concerns about pregnant
teens focus on maternal iron-deficiency anemia, low birth-weight, still birth, and birth
defects.

________________________________________________________________________

Bibliography


Report Card on the Diet Quality of Children Ages 2 to 9. Nutrition Insight 25 (a
publication of the USDA Center for Nutrition Policy and Promotion).
http://www.cnpp.usda.gov/Publications/NutritionInsights/Insight25.pdf. Accessed 9 April
2008.

Borowitz D, Baker RD, Stallings V. Consensus report on nutrition for pediatric patients
with cystic fibrosis. J Pediatr Gastroenterol Nutr. 2002 Sep;35(3):246-59. Review.

American Dental Association. Fluoridation facts (2005). Available at
www.ada.org/public/topics/fluoride/facts/fluoridation_facts.pdf. Accessed 3 April 2007.

Tanner JM, Whitehouse RH. Revised standards for triceps and subscapular skinfolds in
British children. Arch Dis Childhood 1975; 50: 142-145.

Freedman DS, Kettel Khan L, Serdula MK, Dietz WH, Srinivasan SR, Berenson GS.
Racial differences in the tracking of childhood BMI to adulthood. Obesity Research
2005;13:928-935.

Dinour LM, Bergen D, Yeh MC. The food insecurity-obesity paradox: a review of the
literature and the role food stamps may play. J Am Diet Assoc. 2007 Nov;107(11):1952-
61.


Briefel RR, Johnson CL.Secular trends in dietary intake in the United States. Annu Rev
Nutr. 2004;24:401-31. Review.

Holick MF. Vitamin D deficiency. N Engl J Med. 2007;357(3):266-81.

www.ChooseMyPlate.gov

Song WO, Chun OK, Kerver J, Cho S, Chung CE, Chung SJ. Ready-to-eat breakfast
cereal consumption enhances milk and calcium intake in the US population. J Am Diet
Assoc. 2006 Nov;106(11):1783-9.

Perry CL, Mcguire MT, Neumark-Sztainer D, Story M.Characteristics of vegetarian
adolescents in a multiethnic urban population. J Adolesc Health. 2001 Dec;29(6):406-16.

Committee on Sports Medicine and Fitness, American Academy of Pediatrics. Climatic
heat stress and the exercising child and adolescent. Pediatrics 2000;106:158-9.

Bulik CM, Reba L, Siega-Riz AM, Reichborn-Kjennerud T. Anorexia nervosa:
definition, epidemiology, and cycle of risk. Int J Eat Disord. 2005;37 Suppl:S2-9;
discussion S20-1. Review.


Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and
Fluoride.Institute of Medicine, National Academy Press, Washington, DC. 1997.
Available at.www.nap.edu

Readings

www.ChooseMyPlate.gov

Nutrition During Pregnancy: Part I: Weight Gain, Part II: Nutrient Supplements Institute
of Medicine, National Academy Press, Washington, DC. 1990. Available at
www.nap.edu

Infants with Special Needs Handout 1
Infants With Special Needs

Module Objectives:

Compare the nutrient needs for pre-term infants with those born at term.
Describe how digestive tract maturity relates to nutritional needs.
Explain the causes and consequences of malabsorption in infants.
Characterize appropriate enteral feedings for preterm infants.
Name four inborn errors of metabolism that contribute to failure to thrive.

Module Outline:
Introduction
Title and Authors
Table of Contents

Preterm Concerns
Rate of Protein and Fat Gain
Feeding Pre-term Infants
Increased Nutrient Needs
Gut Function in Normal Newborn
Gut Function in Immature Newborn

Milk Composition
Human Milk Composition
Changes over Time
Proteins and Amino Acids
Lactoferrin and Iron
Focus on DHA

Beneficial Components
Major Protective Factors
Other Important Components

Failure to Thrive
Methods for Assessing Infant Growth
Failure to Thrive
Criteria for Failure to Thrive
Why Don't They Gain Weight?

Malabsorption
Malabsorption
Normal Intestinal Lactose Absorption
Lactose Malabsorption
Normal Intestinal Triglyceride Absorption
Triglyceride Malabsorption
Normal Protein Absorption
Protein Malabsorption

Inborn Errors of Metabolism
Inborn Errors of Metabolism
Galactosemia
Cystic Fibrosis
Phenylketonuria
Homocystinuria

Special Feedings
Special Feedings
Human Milk Fortifier
Pre-term Formula
Low-phenylalanine Formula

Integrated Practice (Premature Infant)
Premature Infant Case

Preterm Infant Case
An Infant Delivered at 30 Weeks
Nutritional Concerns for Preterm Infants
Preventing Preterm Birth


Topic: Preterm Concerns

Objective:
Compare the nutrient needs for pre-term infants with those born at term.

Key Concept:
Immaturity increases nutrient needs while at the same time feeding ability and nutrient
utilization are impaired.

On a per weight basis, newborn infants with low birth weight have increased nutrient
needs because the normal rate of growth before birth is greater than after birth and
because they did not have time to build up needed nutrient stores. The relatively
immature gut and kidneys are less effective for nutrient transfer than a healthy placenta,
and some metabolic pathways for the conversion of nutrients (e.g., DHA) are not fully
active, yet. The small size of the stomach and the intestine limits feeding volume. Renal
excretion of urea and retention of minerals are limited. Until late in pregnancy, there is
only a partial barrier that blocks normal gut bacteria from penetrating the intestinal wall
and reaching the bloodstream. Feeding even small amounts promotes the full function of
this intestinal barrier. Colonization with healthy intestinal microflora depends on
feeding.
________________________________________________________________________

Topic: Milk Composition

Objective:
Characterize the composition of human milk.

Key Concept:
Human milk contains optimal nutrients and immunoprotective agents.

Human milk contains macronutrients, vitamins, minerals, and water. In addition to its
nutritional components, human milk also provides the infant with immunoprotection and
stimulates the gastrointestinal tract. The four phases of human milk include colostrum,
transitional milk, mature milk, and milk produced during weaning. Milk contains
proteins, such as lactoferrin, that facilitate the absorption of vitamins and minerals.
Lactoferrin enhances iron absorption. Human milk also has a high fat content and
contains the lipid DHA, which is important in brain development. Newborns have a
limited capacity to synthesize DHA and need to get some DHA from the
diet.____________________________________________________________________

Topic: Beneficial Components

Objective:
Identify protective factors in human milk.

Key Concept:
Human milk contains many protective factors.

Human milk not only contains antimicrobial and anti-inflammatory factors (e.g.,
lactoferrin and lysozyme) but also has components that support the growth of beneficial
bacteria (e.g., bifidus factor and oligosaccharides). Immunoglobulins in milk have the
capacity to bind specific antigens. Other important components in human milk include
hormones that promote growth and enzymes that enhance digestion and absorption. The
amino acid taurine promotes brain and eye maturation, conjugation of bile acids, and
intestinal growth. Nucleotides in milk may also enhance the growth and function of the
intestinal
tract.___________________________________________________________________

Topic: Failure to Thrive

Objective:
Describe how failure to thrive is identified.

Key Concept:
Failure to thrive is a term to describe inadequate growth in children.

Criteria used to identify infants with failure to thrive include growth below the 5th
percentile on standard CDC growth charts, weight less than 80-90% of the median
weight-for-age, or a drop in weight or stature across two or more percentile lines.
Underlying causes of failure to thrive could be faulty breast or bottle feeding techniques,
infections or illness causing increased energy needs or reduced consumption, or in rare
cases, malabsorption or inborn errors of
metabolism.______________________________________________________________

Topic: Malabsorption

Objective:
Describe the causes and consequences of malabsorption in infants.

Key Concept:
Lack of enzymes causes malabsorption of carbohydrate and fat.

When there is a lack of brush-border enzymes, some or all of the lactose in milk or
formula may escape digestion. Enteral infection can reduce lactase activity, while genetic
defects in lactase or sugar transporters are much less common. Malabsorption of
carbohydrates and fat can lead to flatulence, pain, and diarrhea, as well as poor fat-
soluble vitamin uptake and poor weight gain. Dietary proteins are cleaved by pepsin from
the stomach, trypsin, chymotrypsin, elastase, and carboxypeptidase from the pancreas,
and brushborder aminopeptidases and dipeptidases in the small intestine. The precursors
of the gastric and pancreatic enzymes have to be activated by cleavage. Infants with
pancreatic insufficiency typically have poor growth
rates.___________________________________________________________________

Topic: Inborn Errors of Metabolism

Objective:
Identify four inborn errors of metabolism that contribute to failure to thrive in infants.

Key Concept:
Genetic disorders such as galactosemia, phenylketonuria, homocystinuria and cystic
fibrosis can cause growth failure.

Failure to thrive in young infants is most often due to inadequate feeding amounts,
technique, or infection. Genetic causes tend to be rare. Routine newborn screening
usually identifies cystic fibrosis, phenylketonuria (PKU), and a few other genetic
disorders, but will not detect each of the other thousands of rare metabolic disorders.
Failure to thrive may give the first indication of an inborn error of metabolism, and the
underlying causes need to be carefully resolved. Mental retardation and other serious
consequences often can be prevented, if nutritional therapy is started early
enough._________________________________________________________________

Topic: Special Feedings

Objective:
Identify methods of feeding infants with special needs.

Key Concept:
Special supplements and specialized formulas exist to meet the need of some infants.

Some infants need special enteral formulas that limit or omit a potentially harmful
compound, increase energy or protein, or fortify human milk. Children with PKU must
consume a diet with reduced phenylalanine content from the day of birth to avoid brain
damage from the accumulation of toxic breakdown products. Very immature infants may
benefit from increased intakes of conditionally essential nutrients. The needs of preterm
infants can be met by supplementing human milk with a fortifier to increase calories,
protein, calcium, and
phosphorus.______________________________________________________________

Bibliography

Clinical guidelines for the establishment of exclusive breastfeeding. International
Lactation Consultant Association. 2005. Available at www.ilca.org

Legrand D, Elass E, Carpentier M, Mazurier J. Lactoferrin: a modulator of immune and
inflammatory responses. Cell Mol Life Sci. 2005;62(22):2549-59.

2000 CDC growth charts: United States. Available at www.cdc.gov/growthcharts/
Accessed 4 April 2007.

Olsen EM. Failure to thrive: still a problem of definition. Clin Pediatr (Phila).
2006;45(1):1-6.

Kaye CI and the Committee on Genetics. Newborn Screening Fact Sheets. Pediatrics
2006;118;e934-e963.

Ridel KR, Leslie ND, Gilbert DL. An updated review of the long-term neurological
effects of galactosemia. Pediatr Neurol. 2005 Sep;33(3):153-61.

Davies JC, Alton EW, Bush A. Cystic fibrosis. BMJ. 2007 Dec 15;335(7632):1255-9.

Giovannini M, Verduci E, Salvatici E, Fiori L, Riva E. Phenylketonuria: dietary and
therapeutic challenges. J Inherit Metab Dis. 2007 Apr;30(2):145-52. Epub 2007 Mar 8.

Yap S. Classical homocystinuria: vascular risk and its prevention. J Inherit Metab Dis.
2003;26(2-3):259-65.

Quigley M, Henderson G, Anthony MY, McGuire W. Formula milk versus donor breast
milk for feeding preterm or low birth weight infants. Cochrane Database Syst Rev. 2007
Oct 17;(4):CD002971.

Nutrition Support Handouts 1
Nutrition Support

Module Objectives:

Explain the alterations in energy metabolism in stress and starvation.

Assess energy requirements of patients during stress and starvation.

Summarize feeding routes, indications, and risks for patients who cannot eat.

Describe the consequences of bypassing the gut during feeding.

Outline the pathophysiology and treatment of refeeding syndrome, and identify
patients at risk.

Module Outline:
Introduction
Title and Authors
Table of Contents

Gut Nutrition
GI Tract and Metabolism
Normal and Altered Intestine
GI Hormone Response
Glutamine
Glutamine Metabolism in Stress
Sources of Glutamine
Short-Chain Fatty Acids

Feeding Route
Feeding Route
Importance of Enteral and Parenteral Nutrition
Enteral and Parenteral Feeding
Nutrient Transport with Oral or Enteral Feeding
Nutrient Transport with Parenteral Feeding

Patient Case - Nutrition support
Consider Tyler's Nutrition
What Tyler Needs Next
Supplemental Nutrition Support Plan
Tyler's Energy Needs

Energy Expenditure
Components of Energy Expenditure
Basal Energy Expenditure and Thermic Effect of Food
Growth and Lactation
Physical Activity
Body Composition in Non-Obese Individuals
Body Compartments
Creatinine

Calorimetry
Indirect Calorimetry
Oxidation
Respiratory Quotient
Indirect Calorimetry: Sample Calculation

Energy Assessment
Introduction
Prediction Equations
Hypermetabolism and Fever

Refeeding Syndrome
Pathophysiology of Refeeding Syndrome
Patients at Risk for Refeeding
Preventing Refeeding Syndrome

TPN
Implementation
Short-Bowel Syndrome
Complications of Long-Term TPN

Enteral Feeding
Implementation
Complications

Patient Case - Transitioning
A Chocolate Milkshake
Potential Complications
Bowel Sounds Present
The Next Step
Increasing Enteral Feeding
Short Bowel Syndrome
Ready for Discharge
Clear Liquids by Mouth
Conclusion

Nutrition Plan
Nutrition Assessment
The Nutrition Plan
Under- or Overfeeding
Feeding Route

Integrated Practice (Nutrition Support)
Nutrition Support


Topic: Gut Nutrition

Objective:
Explain the effect of feeding via the GI tract on metabolism.

Key Concept:
Bypassing the gut by feeding intravenously alters the structure and function of the
gastrointestinal tract.

Food in the stomach stimulates gastrin secretion and gastric acid production. The
presence of food and a low pH in the duodenum causes cholecystokinin (CCK) secretion
and secretin stimulation. Parenteral feeding bypasses the GI tract and therefore does not
stimulate secretion of intestinal hormones. Absence of CCK secretion can stop bile flow
(cholestasis). With parenteral feeding, changes in the intestinal mucosa can occur. Over
time, intestinal atrophy may allow bacteria and toxins to enter the bloodstream and may
impair nutrient absorption. Glutamine, a conditionally essential amino acid, is an
important oxidative fuel for the intestinal mucosa. During stress the demand for
glutamine may exceed the supply. Inadequate supplies of glutamine can result in
deterioration of the mucosal barrier.
________________________________________________________________________

Topic: Feeding Route

Objective:
Describe feeding routes for patients who cannot eat.

Key Concept:
Patients who cannot eat should receive enteral or parenteral nutrition.

Nutrition can be provided through alternate routes, such as enterally (into the stomach or
small intestine) or parenterally (into a central or peripheral vein). When the GI tract is not
functional, patients should be fed parenterally. In such cases, enteral feeding should begin
as soon as ability to digest and absorb nutrients resumes, even if the majority of nutrition
is provided parenterally. Patients with normal lower GI function, but who cannot
swallow or maintain adequate oral intake should be fed enterally. Appropriate nutrition
decreases length of hospital stay, reduces the risk of post-op complications, and
improves wound healing. There are metabolic consequences to intravenous feedings
because it bypasses the normal absorption and transport processes-- intravenous lipids
enter the circulation as droplets without the apoproteins found on chlyomicrons.

________________________________________________________________________

Topic: Energy Expenditure

Objective:
Describe the components of and factors that influence total energy expenditure.

Key Concept:
Basal metabolism, physical activity, and thermic effect of food comprise total energy
expenditure in healthy individuals.

Total energy expenditure has three components: basal metabolic rate (BMR), physical
activity, and diet-induced thermogenesis (thermic effect of food). BMR represents the
energy used by the body in a restful, awake state. This is the energy needed for ion
pumping, protein synthesis, and all homeostatic functions. BMR depends mainly on body
size and composition. Understanding body composition is important to clinical
assessment of nutritional status. In both stress and malnutrition, body composition is
altered because of loss of protein mass. Energy expenditure increases in stressed patients;
the amount of increase depends upon the degree of illness. Changes in nutritional
recommendations are concurrent with changes in body composition. Physical activity is
the most variable component of total energy expenditure in healthy individuals.
________________________________________________________________________

Topic: Calorimetry

Objective:
Specify how indirect calorimetry can be used to estimate energy expenditure.

Key Concept:
Indirect calorimetry can be used to estimate energy expenditure by using the respiratory
quotient.

Indirect calorimetry is a method of estimating energy expenditure based on CO2
production and O2 uptake. It is often used in a clinical setting to get a reliable estimate of
energy expenditure and prevent over- or under-feeding of critically ill, malnourished, or
extremely obese patients. A metabolic cart can take the measurements, determine the
respiratory quotient (RQ; ratio of CO2 to O2), and convert the RQ into estimated
expenditure. The equations for the oxidation of carbohydrates and fats show that known
amounts of O2 and CO2 correspond to predictable amounts of energy production.
Because glucose and fat are completely oxidized, energy production from glucose or fat
oxidation can be predicted by measuring consumption of oxygen and production of
carbon dioxide. Protein oxidized can be calculated from urinary nitrogen excretion.
________________________________________________________________________

Topic: Energy Assessment

Objective:
Describe how energy needs may be estimated in clinical settings.

Key Concept:
Standardized prediction equations exist for estimating energy expenditure but have
limited usefulness in critically ill patients.

Indirect calorimetry is a reliable method for determining an individual's energy
expenditure, but it is not always feasible in clinical practice. Many standardized formulas
exist to estimate energy expenditure based on a patient's age, height, weight, and physical
activity level. Many of these, however, were developed for healthy people and thus are
not appropriate for critically ill patients. Furthermore, during stress, hypermetabolism and
fever cause energy needs to increase. Stressed patients have high energy expenditures and
increased protein turnover due to the hypermetabolism characteristic of the stress
response. Hypermetabolism increases with severity of the trauma. With many diseases
and traumas, fever is also present. Each degree rise in temperature above 37 degrees C
elevates metabolic rate by about 10%.
________________________________________________________________________

Topic: Refeeding Syndrome

Objective:
Outline the pathophysiology and treatment of refeeding syndrome, and identify patients
at risk.

Key Concept:
Refeeding syndrome is characterized by metabolic events that occur upon feeding
severely malnourished patients.

Refeeding syndrome can occur with any type of feeding following a period of nutritional
deprivation. Glucose moves into cells, and along with it, phosphorous, potassium, and
magnesium, causing the serum concentrations of these minerals to drop abruptly. The
severe mineral and fluid imbalances that occur with refeeding can lead to cardiac arrest,
neuromuscular complications, or respiratory dysfunction. Malnourished patients with
poor nutritional stores due to limited intake (i.e. anorexia nervosa, elderly patients with
depression or dementia, cancer cachexia, malnutrition due to hunger, stress, or fasting)
are at-risk. Refeeding syndrome can be prevented by avoiding sudden overfeeding,
avoiding excess glucose, replacing phosphorus, magnesium, and potassium, restricting
fluid intake, initiating sodium administration slowly, and providing thiamin.
________________________________________________________________________

Topic: TPN

Objective:
List three complications that can occur from long-term parenteral feeding.

Key Concept:
Complications can occur from long-term parenteral feeding.

When nutrition is provided directly into the bloodstream, determining the patient's
nutritional needs as accurately as possible becomes critically important. Short-bowel
syndrome is one condition that may require long-term parenteral feeding. Parenteral
feeding is not without risk. Catheter-related infection, metabolic bone disease, liver
disease, and micronutrient deficiencies are serious risks of long-term parenteral feeding.
________________________________________________________________________

Topic: Enteral Feeding

Objective:
Describe complications that can occur with enteral feeding.

Key Concept:
Enteral feeding is not without risks.

When nutrition is provided directly into the GI tract, determining the patient's nutritional
needs as accurately as possible becomes critically important. Enteral feeding can lead to
reflux of stomach contents into the lungs, which can lead to aspiration pneumonia.
Diarrhea can be a common problem in enterally fed patients. Other serious problems may
include refeeding syndrome, or altered glucose, lipid, or acid-base balance.
________________________________________________________________________

Topic: Nutrition Plan

Objective:
Characterize the factors considered in formulating a nutrition plan.

Key Concept:
Formulating a nutrition plan is essential in the care of critically ill patients.

Nutrition assessment provides a picture of the patient's nutritional risk. This requires
collecting and evaluating information obtained from the patient's history, physical exam,
anthropometric measurements, and labs. From the information obtained in the nutritional
assessment, a plan for the patient is formulated. The plan must be individualized to meet
the patient's requirements for protein, energy, and other nutrients. It should also include
the goals for nutritional intake, and the most appropriate route of feeding and formula
composition to achieve those goals. In the stressed patient, the goal is usually to prevent
further depletion of lean body mass. Underfeeding can result in poor wound healing,
weakness, and malnutrition as protein is used as an energy source. Overfeeding can result
in hyperglycemia, carbon dioxide retention, and fatty liver.
________________________________________________________________________

Bibliography

ASPEN Board of Directors and the Clinical Guidelines Task Force. Guidelines for the
use of parenteral and enteral nutrition in adult and pediatric patients.JPEN J Parenter
Enteral Nutr. 2002 Jan-Feb;26(1 Suppl):1SA-138SA.

Skipper, Annalynn. Dietitian?s Handbook of Enteral and Parenteral Nutrition. Jones &
Bartlett Publishers, Inc. 1998.

Pediatric Manual of Clinical Dietetics, Nutrition Support in Critical Care, 1998 copy, p.
548.

Brehm BJ, Spang SE, Lattin BL, Seeley RJ, Daniels SR, D'Alessio DA. The role of
energy expenditure in the differential weight loss in obese women on low-fat and low-
carbohydrate diets. J Clin Endocrinol Metab. 2005 Mar;90(3):175-82. Epub 2004 Dec 14.

Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Energy,
Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino
Acids(Macronutrients). The National Academics Press, Washington, DC 2002.

Levine JA. Nonexercise activity themogenesis(NEAT): environment and biology. AM J
Physiol Endocrinol Metab 2004;286:E675-E685.

Kattlemann et al, Preliminary evidence for a medical nutrition therapy protocol: enteral
feedings for critically ill patients. J Am Diet Assoc. 2006 Aug;106(8):1226-41. Review.

McCray S, Walker S, Parrish CR. Much Ado About Refeeding. Practical
Gastroenterology January 2005; series #23:26-44.

Readings

Loucks AB. Energy balance and body composition in sports and exercise. J Sports Sci
2004;2;1-14
Dietary Supplements: Decision Making Handouts 1
Dietary Supplements: Decision Making

Module Objectives:

Outline the steps in the decision-making process.
Identify credible sources to advise patients on safety and efficacy of dietary
supplements.
Explain the concept of bioavailability as it pertains to dietary supplements.
Identify individuals at risk for nutrient inadequacy.
Explain the basis for appropriate nutrient supplementation

Module Outline:
Introduction
Title and Authors
Table of Contents
Introduction & Module Objectives

Assessing Your Beliefs
Beliefs Assessment

Decision Making
Four Pillars of Decision Making
A Good Research Question
Good Question vs. Poor Question
Defining the Research Question

Folate-Does It Work?
Neural Tube Closure
Bioavailability
Research Central: Folate Efficacy
Folate Efficacy: Results
Mandatory Food Fortification
Voluntary Food Fortification
Nutrient Recommendations Change

Assessing Folate, B6, and B12 Intake
Assessing Folate, B6, and B12 Intake
Patient scenarios
Folate
Vitamin B6: Pyridoxine
Vitamin B12: Cobalamin

Folate-Is It Safe?
Risks From Excessive Micronutrient Intake
Research Central: Folate Safety
Folate Safety: Results

Is Natural Better?
Evaluating Supplement Use
Decision Analysis
Natural Safe

The Case of a Healthy Baby
Prepare for a Patient Case Assignment
First, Two Questions
Assess Nutrients Related to NTD Risk
Summary of Findings
Advise the Patient
A Targeted Intervention
Revisit Two Questions

Antioxidant Promises
Free Radicals

Bioavailability
Nutrient Excretion and Storage
Natural vs. Synthetic Vitamins
Bioavailability
Ingestion Action
Vitamin E Bioavailability

Vitamin E-Does It Work
Research Central: Vitamin E Efficacy
Vitamin E Efficacy: Results
Dietary Reference Intakes
Assess Your Patient's Intake

Assessing Vitamin E, C, Carotenoid Intake
Assessing Vitamin E, C, and Carotenoid Intake
Patient Scenarios
Vitamin E
Vitamin C
Carotenoids

Vitamin E-Is It Safe?
Risks Associated with Supplementation
Botanicals and Drug Interactions
Efficacy Safety
Research Central: Vitamin E Safety
Vitamin E Safety: Results
Problems with Antioxidant Supplements

Evaluating Research
Reliability of Research Study Results
Rating the Evidence: Assigning Weight
Randomized, Controlled Clinical Trial
Prospective Cohort/Case Control
Clinical Observation/Ecological Study
Limitations of Trials
Confounding Factors
Statistical Power and Sample Size

Is More Better?
Studies on Vitamin E
Decision Analysis
The Dose Makes the Difference

The Antioxidant Case
First, Two Questions
Targeted Diet Assessment Questions
Make an Assessment
Dietary vs. Supplement Intake
Advise the Patient
Potential Interactions
Mr. Bradley's Intake
Resistance to Change
A Negotiation
Formulating a Plan
Conclusion
Revisit Two Questions

Revisiting Your Beliefs
Beliefs Review


Topic: Decision Making

Objective:
Outline the steps in the decision making process.

Key Concept:
A good clinical question specifies target group, intervention and expected outcome.

Phrasing a clear question is the first step in decision making. It is important to consider
the target group (age, gender, race, health status), define the intervention (characteristics
of supplement, dose and mode of administration, duration of use) and what the
intervention is compared to (bad diet, standard medication), and list the outcomes in
question (abating symptoms, subjective relief, lower disease risk). Most importantly,
there should always be consideration of the impact on overall health and mortality risk.
________________________________________________________________________

Topic: Folate-Does It Work?

Objective:
Identify credible sources to make nutrient recommendations; advise patients on
bioavailability of compounds.

Key Concept:
The DRIs provide current recommendations for nutrient intakes; effectiveness of
supplements depends on bioavailability.

The Institute of Medicine, a division of the National Academy of Sciences of the US,
publishes the "Dietary Reference Intakes" (DRIs) defining required and excessive intake
levels. These authoritative publications provide completely referenced information
regarding typical levels of intake, established benefits and known or potential risks.
Differences in potency of nutrients and other supplement ingredients often are due to
differences in bioavailability, which indicates what percentage of a compound reaches its
target. Nutrients and phytochemicals from herbal and other 'natural' sources may not be
more effective than synthetic compounds. Synthetic folic acid (in supplements and
fortified foods) has higher bioavailability than the polyglutamyl folate in green leafy
vegetables and oranges, and a greater percentage becomes available to cells.
________________________________________________________________________

Topic: Assessing Folate, B6, and B12 Intake

Objective:
Identify individuals at risk for folate, B6 or B12 inadequacy.

Key Concept:
You should memorize assessment questions and criteria related to folate, vitamin B6 and
vitamin B12 intakes.

People with restricted diets who do not take supplements may be at risk for vitamin
deficiency. Good sources of folate are breakfast cereal, dark-green vegetables, legumes,
orange juice, and liver. People who don't like greens and legumes, who consume <3
servings/d of these foods are at risk for deficiency. All women of childbearing age should
take a folate supplement to prevent neural tube defects during a potential pregnancy.
Good sources of vitamin B6 are potato, sweet potato, meat, poultry, fish, banana,
breakfast cereal, watermelon, and corn. Consuming <3 servings/d of these foods is a red
flag for potential deficiency, usually occurring in people who eat very little overall.
Vitamin B12 is found in foods of animal origin: beef, pork, poultry, fish, seafood, milk,
dairy, and eggs. Less than 1 serving/d puts a person at risk.
______________________________________________________

Topic: Folate-Is It Safe?

Objective:
Give examples of the types of risks that may occur with supplement use.

Key Concept:
Common risks of supplement use include dangerous interactions and neglect of good
health practices.

Some nutrients may be harmful even with moderately excessive intakes, especially from
supplements (e.g. vitamins A and D, iron). Many dietary supplements, whether they
contain nutrients, herbal or other ingredients, cause concern because they may interact
with nutrients or medications. Another important concern is that supplement users may
feel that supplements protect their health and that they can disregard important health
practices, such as undergoing necessary medical treatment or maintaining a healthy diet.
________________________________________________________________________

Topic: Is Natural Better?

Objective:
Explain when use of a dietary supplement is reasonable.

Key Concept:
Use of a supplement is reasonable when benefits outweigh harm and cost.

Use of a dietary supplement makes sense when the benefits are large and certain, and
adverse effects known to be rare or of little consequence. When the benefits are small or
uncertain and potentially harmful or costly, supplement use is questionable and should
not be encouraged. Physicians need to know about patients' health practices, including
supplement use. It is important that patients do not feel judged about their preferences.
Only when dosage or composition is of concern, is there a strong need to dissuade
patients from use.
________________________________________________________________________

Topic: Antioxidant Promises

Objective:
Describe the function of antioxidants and their potential role in disease prevention and
treatment.

Key Concept:
Antioxidant nutrients interact with free radicals, one another, and some medications.

Antioxidant nutrients like vitamins E, C, beta carotene and selenium at desirable intake
levels are needed to prevent oxidative damage to tissues from excessive free radicals that
can lead to cancer or heart disease. Some nutrients, like vitamins E and C, work
synergistically. The effects of excessive nutrient intakes on the balance between nutrients
are unclear. Furthermore, taking extremely high doses of a nutrient like vitamin E can
have undesirable effects, such as disrupting blood coagulation. Some nutrients can
interact with medications. For example, vitamin E can interact with blood thinning agents
such as warfarin to increase risk of hemorrhagic stroke.
________________________________________________________________________

Topic: Bioavailability

Objective:
Describe factors influencing nutrient absorption and bioavailability.

Key Concept:
A nutrient's form influences its bioavailability; some nutrients persist in the body while
others are rapidly excreted.

The form of a nutrient determines absorption, uptake, metabolism, and excretion.
"Natural" is not always better. Folate is absorbed best as monofolylglutamate (the
synthetic form of supplements), while the natural isoform of vitamin E (RRR-alpha-
tocopherol) is more effective than synthetic forms. The presence of fiber, oxalates, or
phytates in the gut, or malabsorptive factors, can impair nutrient absorption. Because
some nutrients (e.g., iron, zinc, and copper) compete for the same transport mechanisms
severe imbalances in intake can negatively impact the uptake and transport of a nutrient.
Excess of most water-soluble vitamins is rapidly excreted, except for vitamin B12, which
can be stored at levels sufficient to meet needs for several years. Stores of minerals and
fat-soluble vitamins last for a long time, except vitamin K.
________________________________________________________________________

Topic: Vitamin E-Does It Work

Objective:
Describe and apply the Dietary Reference Intakes (DRIs).

Key Concept:
The Dietary Reference Intakes provide current nutrient intake recommendations.

The Dietary Reference Intakes (DRIs) are a set of guidelines for nutrient intakes that will
meet the needs of nearly all healthy people. They are periodically revised by the Food
and Nutrition Board of the Institute of Medicine. The DRIs provide information on the
Estimated Average Requirement (EAR; the level at which 50% of people will have
inadequate intakes), the Recommended Dietary Allowance (RDA; the level at which 97-
98% of the healthy population will meet their nutrient needs), and the tolerable Upper
Intake Level (UL; the highest level for safe intake. An Adequate Intake (AI),
corresponding to the mean intake level of healthy people, is used when data are
insufficient to determine an EAR.
________________________________________________________________________

Topic: Assessing Vitamin E, C, Carotenoid Intake

Objective:
Identify individuals at risk for inadequate antioxidant vitamin intakes.

Key Concept:
You should memorize assessment questions and criteria related to inadequate vitamin E,
C, and carotenoid intakes.

People with restricted diets who do not take supplements may be at risk for vitamin
deficiency. Vitamin E is found in oils, fats, nuts, and seeds. People who use mainly fat-
free foods and avoid added fat are at risk for deficiency. Good sources of vitamin C are
fruits and vegetables such as citrus, berries, tomatoes, broccoli, cauliflower, and peppers.
A person who eats < 1 serving/d of fruits and vegetables should raise a red flag for
potential deficiency. Carotenoids are found in orange, yellow, or dark-green fruits and
vegetables. Less than 1 serving/d puts a person at risk.
________________________________________________________________________

Topic: Vitamin E-Is It Safe?

Objective:
Describe how toxicity, interaction, and lifestyle effects must be considered when
evaluating supplement safety.

Key Concept:
Toxicity, interaction, and lifestyle effects are important considerations when evaluating
supplement safety.

When it comes to safety, three aspects of supplement use must be considered: toxicity,
interaction, and lifestyle. Toxicity may occur with a single dose (e.g. vitamin A and fetal
damage), or with accumulation to toxic levels (e.g. iron). The toxic effects may be
unrelated to the normal biologic action of a nutrient (excessive doses of vitamin E inhibit
blood coagulation, a vitamin K-dependent process). Interaction effects include those
between supplement ingredients (zinc and copper), supplement ingredients and drugs
(vitamin E and warfarin), or between medications and herbs (e.g. St. John's Wort and
birth control pills). Lifestyle concerns arise when patients use supplements instead of
proven treatments or when they use supplements to make up for poor dietary or lifestyle
habits (e.g. lack of exercise, smoking).
________________________________________________________________________
Topic: Evaluating Research

Objective:
Explain which types of research studies provide a reliable basis for the assessment of
supplement claims.

Key Concept:
Well-executed double-blind, randomized, placebo-controlled studies are the gold
standard for evaluating supplements.

Double-blind, randomized, placebo controlled studies are the only types of studies that
can establish the effectiveness of a particular intervention. Subjects are randomized to
receive intervention or no intervention. Both the subjects and the investigators cannot
know which treatment is being given to maintain objectivity in reporting outcome
measures; the placebo helps to maintain blinding. Unfortunately, these types of studies
are not available for many dietary supplements due to the large numbers of subjects
required, amount of time, and expense involved. Studies must have sufficient numbers
(sample size) of the right types of subjects (age, gender, etc.) in order to apply their
conclusions to similar populations. Confounding can lead to wrong interpretations, since
an outcome seen in a study could be due to some factor not taken into account.
________________________________________________________________________

Topic: Is More Better?

Objective:
Explain the concept of optimal intake of a nutrient.

Key Concept:
Current science cannot determine optimal intake level for most nutrients.

Optimal intake refers to the amount of a nutrient that promotes health, well-being, and
longevity without overwhelming metabolic capacity or otherwise causing damage. For
most nutrients, the optimal intake level is not known. High intakes of many nutrients may
do more harm than good.
________________________________________________________________________

Bibliography

Dietary reference intakes for thiamin, riboflavin, niacin, vitamin B6, folate, vitamin B12,
pantothenic acid, biotin, and choline. Institute of Medicine, Food and Nutrition Board.
National Academy Press, Washington, DC. 1998.

Centers for Disease Control and Prevention (CDC). Folate status in women of
childbearing age, by race/ethnicity--United States, 1999-2000, 2001-2002, and 2003-
2004. MMWR Morb Mortal Wkly Rep. 2007 Jan 5;55(51-52):1377-80.

Bjelakovic G, Nikolova D, Gluud LL, Simonetti RG, Gluud C. Mortality in randomized
trials of antioxidant supplements for primary and secondary prevention: systematic
review and meta-analysis. JAMA. 2007 Feb 28;297(8):842-57.

Dietary reference intakes for vitamin C, vitamin E, selenium, and carotenoids. Institute of
Medicine, Food and Nutrition Board. National Academy Press, Washington, DC. 2000.

Massey LK, Liebman M, Kynast-Gales SA. Ascorbate increases human oxaluria and
kidney stone risk. J Nutr 2005;1673-1677.

Becque MC, et al. Effects of oral creatine supplementation on muscular strength and
body composition. Medicine & Science in Sports & Exercise 2000 32(3):654-8.

Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico. Dietary
supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial
infarction: results of the GISSI-Prevenzione trial. Lancet 1999;354:447-55.

Readings

Miller ER, Pastor-Barriuso R, Dalal D, Riemersma RA, Appel LJ, Guallar E. Meta-
analysis: High-dosage vitamin E supplementation my increase all-cause mortality. Ann
Intern Med 2005;142:37-46.

Dietary Supplements: Reality Check Handouts 1
Dietary Supplements: Reality Check

Module Objectives:

Describe the regulation of supplements, medical drugs, food, and additives.
Outline the safety concerns associated with supplement use.
Explain the importance and process of taking a dietary supplement history.
Describe why new or unusual claims require very good evidence to become
credible.
Explain which types of studies provide a reliable basis for assessing supplement
claims.

Module Outline:
Introduction
Title and Authors
Table of Contents
Assessing Your Beliefs
Beliefs Assessment

Supplements and Food Extracts
Supplement Labels and Claims
Supplement Composition
Food Extracts

Soy - Does It Work?
Common Mechanisms of Disease Prevention
Activation and Detoxification
Research Central: Soy Efficacy
Soy Efficacy: Results

Assessing Calcium, Vit D, and Phosphate
Assessing Calcium, Vitamin D, and Phosphate Intake
Patient Scenarios
Calcium
Vitamin D
Phosphate

Soy - Is It Safe?
Red Flags
Regulation of Dietary Supplements, Foods, and Drugs in the U.S.
Generally Recognized as Safe (GRAS)
Research Central: Soy Safety
Soy Safety: Results

Decision Analysis: Soy
Decision Analysis

Diet Insurance
Not a "Quick Fix"
Functional Foods

The Case of the Novel Food
Prepare for a Patient Case Assignment
A Medical Conundrum
Mrs. Jordan's Supplement Intake
Advise the Patient
A Nonjudgmental Attitude
Conclusion

Supplement Interview
The Importance of Taking a Dietary Supplement History
The Interview Process

Athletes & Supplements
Supplements in Sports
Interview: Sports Supplements

Creatine - Does It Work?
Fuel Sources for Exercising Muscle
Creatine
Nutritional Requirements of Athletes
Evaluating Supplements
Research Central: Creatine Efficacy
Evaluating Creatine Studies
Creatine Efficacy: Results
Evaluating Efficacy

Assessing Thiamin, Riboflavin, and Protein
Assessing Thiamin, Riboflavin, and Protein Intake
Patient Scenarios
Thiamin
Riboflavin: Vitamin B2
Protein

Creatine - Is It Safe?
Concerns with Ergogenic Aids
Research Central: Creatine Safety
Creatine Safety: Results
Evaluating Risk Information

Decision Analysis: Creatine
Decision Analysis
Wishful Thinking

The Case of the Ergogenic Aid
Summary of Findings
Evaluate Mr. Lohmann's Intake
Make a Recommendation
Creatine: Efficacy and Safety
Rationale for Recommendations
Importance of Taking a Supplement History
Conclusion

Revisiting Your Beliefs
Beliefs Review


Topic: Supplements and Food Extracts

Objective:
Describe how reliable information about the composition of a supplement is needed for
the evaluation of claimed effects.

Key Concept:
Information about the composition of a supplement is the basis for any evaluation of
claimed effects.

Evaluation of a dietary supplement should start with a determination of its composition.
All information on a product must be truthful and conform to FDA rules, but the label
does not have to state the amount of active ingredients. While the product cannot be said
to prevent, treat or cure a disease, allowed claims about structural or functional properties
may appear to promise such a benefit. Other product information may suggest that a
supplement is as good as a healthful food. This claim should not be accepted until proven
because active components may be left out during the manufacturing process, or the
product may contain concentrated doses of potentially harmful compounds.
________________________________________________________________________

Topic: Soy - Does It Work?

Objective:
Explain how a meta-analysis or systematic review can be used to judge the efficacy of a
particular dietary modification.

Key Concept:
A meta-analysis, which combines data from multiple studies with statistical methods,
may be used to evaluate efficacy.

Food compounds may protect against disease by modifying lipoprotein metabolism, free
radical scavenging, regulating gene expression, or promoting the excretion of toxic
compounds. Options for determining the health benefits of a particular compound include
a literature search, a systematic review, published government guidelines, and a Web
search. A systematic review uses predefined selection and interpretation criteria to collate
current knowledge on a particular question. A meta-analysis goes one step further,
assigning weights to the data sets and combining them with statistical methods. Many
libraries and literature search engines provide access to the Cochrane Database of
Systematic Reviews for information on the efficacy and safety of nutrients and herbal
medicines. Consult the most current reviews for the latest research findings.
________________________________________________________________________

Topic: Assessing Calcium, Vit D, and Phosphate

Objective:
Identify individuals at increased risk for inadequate mineral status.

Key Concept:
You should memorize assessment questions and criteria related to calcium, vitamin D,
and phosphate intakes.

The risk for inadequate mineral status increases with low consumption of fish or fortified
milk, plus high intakes of phosphate from colas, meat, and processed cheese. Because
both vitamin D and phosphate influence calcium absorption and retention, these three
nutrients should always be evaluated together. Good dietary sources of calcium include
dairy products and calcium-fortified juice. Consume at least three servings of these foods
each day to ensure an adequate intake of calcium. Sunlight and fortified milk, fish, and
eggs provide vitamin D, which greatly increases calcium absorption. Phosphate, on the
other hand, reduces the absorption and retention of calcium. Having more than five
servings of soda and processed foods each day increases the risk of calcium deficiency.
________________________________________________________________________

Topic: Soy - Is It Safe?

Objective:
Explain how whole foods and food extracts differ regarding health risks.

Key Concept:
Compared with food extracts, whole foods contain relatively low levels of active
compounds.

Potentially beneficial compounds that exist in small doses in whole foods may become
harmful when concentrated as food extracts. Dietary supplements do not carry any
assurance of quality, purity, safety, or effectiveness, they may contain undeclared
substances, and they are not subject to the same laws and regulations as food additives
and medical drugs. Some food substances are Generally Recognized as Safe (GRAS) for
their intended use. In general, compounds in whole foods do not pose safety risks, but
supplements may contain high levels of potentially harmful compounds.
________________________________________________________________________

Topic: Diet Insurance

Objective:
Explain the limitations of supplements as a cure for a bad diet, and identify the purpose
of functional foods.

Key Concept:
Supplements cannot replace good food choices.

Although carefully chosen dietary supplements can provide health benefits, they cannot
offset all of the negative consequences of an unhealthy diet. Foods in an unhealthy meal
may not only lack essential nutrients but may also contain excessive amounts of fat,
sugar, and salt, as well as other ingredients that should be consumed in moderation.
When a food has been modified to enhance health, it is called a "functional food."
Examples of functional foods include fortified beverages, cereals, baked goods, etc.
FDA-approved health claims may appear on the labels of functional foods when scientific
evidence supports the claim.
________________________________________________________________________

Topic: Athletes & Supplements

Objective:
Explain the importance of taking a dietary supplement history.

Key Concept:
Ask your patients targeted questions about their use of dietary supplements.

An increasing number of people use dietary supplements to improve their health or sports
performance. Always ask your patients about supplement use when taking a diet history.
Ask specific questions about all forms of supplements, including herbal products. If
possible, examine the supplement label, and note the brand name, active ingredients, and
dose. Evaluate each supplement for possible interactions with prescription medications
or other health concerns. Supplement use without proper guidance may endanger the
health of your patients.
________________________________________________________________________

Topic: Creatine - Does It Work?

Objective:
Explain why evidence for the effect of a supplement applies only to a specific dose and
type of user.

Key Concept:
Evidence for supplement efficacy supports a specific use and effect.

Foods can provide all the nutrition an athlete needs. Athletes have higher fluid and
energy requirements and slightly increased protein needs. Use every opportunity to ask
athletes about their intake of ergogenic aids and any dietary practices they follow to
enhance performance. When evaluating supplements-especially ergogenic aids-consider
the variables involved in the evaluation. Often the findings cannot be extrapolated to
other uses, doses, populations, outcomes, etc. To evaluate efficacy, begin with systematic
reviews and reliable review articles. If these are not available, look for reports of
randomized controlled clinical trials to provide the highest level of evidence; prospective
cohort studies, and case-control studies may also offer useful information.
________________________________________________________________________

Topic: Assessing Thiamin, Riboflavin, and Protein

Objective:
Identify individuals at increased risk for imbalanced intakes of protein and vitamins.

Key Concept:
You should memorize assessment questions and criteria related to thiamin, riboflavin,
and protein intakes.

People who severely restrict their intake of carbohydrates, meats, or total energy have an
increased likelihood of becoming deficient in thiamin and riboflavin. These vitamins
serve as precursors for coenzymes in many critical metabolic processes. Good food
sources of thiamin include grains and pork. Thiamin deficiency can damage the heart and
nervous system. Riboflavin deficiency can cause edema, dermatitis, and anemia. Good
food sources of riboflavin include grains, meats, and milk. Protein deficiency,
particularly in children living in third-world countries, may cause malnutrition and
adversely affect the immune system. On the other hand, many people in developed
countries run the risk of consuming too much protein. Excess protein intake may
contribute to a nutritionally inadequate diet as the protein replaces other healthful foods.
________________________________________________________________________

Topic: Creatine - Is It Safe?

Objective:
Find information on the safety of dietary supplements.

Key Concept:
To evaluate the safety of dietary supplements, you must often rely on an effective
literature search.

When DRIs have not been established and systematic reviews do not exist, search the
literature for review articles by credible professional organizations, such as the American
College of Sports Medicine, or the American Dietetic Association. In the absence of
reliable reviews, look for reports of randomized, controlled clinical trials to provide the
highest level of evidence.
________________________________________________________________________

Bibliography

Anderson JW, Johnstone BM, Cook-Newell ME. Meta-analysis of the effects of soy
protein intake on serum lipids. N Engl J Med. 1995;333(5):276-82.


Information available at www.cfsan.fda.gov Accessed on 26 July 2007.

Trock BJ, Hilakivi-Clarke L, Clarke R. Meta-analysis of soy intake and breast cancer
risk. J Natl Cancer Inst. 2006;98(7):459-71.

Wallimann T, Wyss M, Brdiczka D, Nicolay K, Eppenberger HM. Intracellular
compartmentation, structure and function of creatine kinase isoenzymes in tissues with
high and fluctuating energy demands: the 'phosphocreatine circuit' for cellular energy
homeostasis. Biochem J. 1992;281 ( Pt 1):21-40.

American College of Sports Medicine; American Dietetic Association; Dietitians of
Canada. Joint Position Statement: nutrition and athletic performance. American College
of Sports Medicine, American Dietetic Association, and Dietitians of Canada. Med Sci
Sports Exerc. 2000;32(12):2130-45.

McGuine TA, Sullivan JC, Bernhardt DT. Creatine supplementation in high school
football players. Clin J Sport Med. 2001 Oct;11(4):247-53.

Rawson ES, Volek JS. Effects of creatine supplementation and resistance training on
muscle strength and weightlifting performance. J Strength Cond Res. 2003;17(4):822-31.

Readings

Reynolds K, Chin A, Lees KA, Nguyen A, Bujnowski D, He J. A meta-analysis of the
effect of soy protein supplementation on serum lipids. Am J Cardiol. 2006;98(5):633-40.

Dietary Supplements: Use in Practice Handouts 1
Dietary Supplements: Use in Practice

Module Objectives:

Provide basic rationales for supplement use.
Explain regulations for supplement production.
Identify important nutritional problems by patient type.
List common high-risk supplement practices.

Module Outline:
Introduction
Title and Authors
Table of Contents

Supplement Use and Production
Supplement Use: Sensible or Questionable
Good Manufacturing Practices
Health Claims

Supplements Across the Lifecycle
Overview
Pregnancy
Infancy
Childhood & Adolescence
Menopause & Aging

Supplements for Health Concerns
Weight Loss
Vegetarianism
Constipation

Supplements in Illness
Nutritional Supplements in Disease
Common Cold
Heart Disease
Diabetes
AIDS
Depression
Cancer
Bone Disease

Fat-Soluble Vitamins
Overview
Vitamin A
Vitamin D
Vitamin E
Vitamin K
Pop Quiz

Water-Soluble Vitamins
Overview
Vitamin C
Folate
Thiamin
Riboflavin: Vitamin B2
Niacin
Vitamin B6: Pyridoxine
Vitamin B12: Cobalamin
Pantothenate
Biotin

Minerals & Trace Elements
Overview
Iron
Copper
Zinc
Calcium
Selenium
Phosphate
Potassium
Magnesium
Sodium
Chromium

Other Nutrients
Overview
Choline
Amino Acids
Essential and Non-essential Amino Acids
Importance of Providing Essential Amino Acids
Carotenoids


Topic: Supplement Use and Production

Objective:
Explain basic rationales for supplement use and describe regulations for supplement
production.

Key Concept:
Advise patients to avoid dietary supplements with significant potential for harm and that
the quality varies greatly.

In general, use of a dietary supplement is reasonable if the type and amount of ingredients
are known to improve health and are very unlikely to cause harm. When the claimed
benefits are uncertain, even minor or rare risks must be viewed with concern. Usually it
is the health professional's role to inform about the balance of known benefit and
potential for harm. It is then up to patients to choose whether to follow that guidance or
not. No binding standards regulate source material, processing, or storage of dietary
supplements. Manufacturers of dietary supplements have to observe 'Good
Manufacturing Practices' (GMP) for foods but there is no guarantee that the composition
is what the label claims. Dietary supplements are NOT guaranteed to be effective or even
safe.

________________________________________________________________________

Topic: Supplements Across the Lifecycle

Objective:
Identify the role of dietary supplements in treating nutritional problems that occur during
specific lifecycle stages.

Key Concept:
The most critical nutritional problems differ by gender, age, health status, and lifestyle.

Health professionals need to anticipate typical nutritional problems that their patients
may experience. Requirements per weight for most nutrients are highest during infancy
and decline towards adulthood. Childbearing poses critical nutritional challenges for
women, with hard-to-meet needs from the first days (folate, B12, B6) to the final months
(iron). The unborn child, infants who are breastfeeding, and young children are especially
vulnerable to inappropriate supplement use. Adolescents often engage in risky behaviors,
and this includes a ready willingness to try unproven supplements if they think it might
enhance appearance. Boys especially may consume dangerous supplements in an attempt
to bulk up. Advancing age or onset of menopause may impair use of some nutrients (B12,
vitamin D, calcium), while promoting excess of others
(iron).__________________________________________________________________

Topic: Supplements for Health Concerns

Objective:
Describe recommendations for supplement use by patients concerned about weight loss,
vegetarianism, or constipation.

Key Concept:
In most cases, good dietary habits and regular exercise are superior to supplements for
treating health concerns.

Weight loss efforts often include diets that are not nutritionally balanced or sustainable
over time. Ginseng, and licorice can be particularly harmful for individuals with high
blood pressure, and ephedra is downright dangerous. Proper nutrition and consistent
exercise are almost always sufficient for weight management. Vegetarians should be
advised that the more animal products that are excluded from the diet, the higher the
potential for marginal intakes of certain vitamins and minerals (iron, calcium, zinc,
vitamin D, vitamin B12, iodine). A general multi-vitamin/mineral supplement with
100% of the RDAs is sufficient to meet the needs of most vegetarians. Regulated use of
high-fiber supplements along with plenty of fluids can help re-establish normal bowel
movements, but are no substitute for good dietary habits and regular exercise.
________________________________________________________________________

Topic: Supplements in Illness

Objective:
Discuss the use of supplements to prevent and treat illness.

Key Concept:
Supplements are often used to prevent and treat illness, but should not be substituted for
appropriate medical treatment.

There are no government recommendations for nutrient intake in disease states. You must
evaluate each patient and supplement individually. It is important to consider if the
patient is eating a balanced diet, if the supplement is safe, and if there is potential for a
harmful supplement-medication interaction. Supplements are often used to treat illnesses
such as the common cold, heart disease, diabetes, AIDS, depression, cancer, and bone
disease. A well-balanced diet that supports a healthy weight and includes adequate
intakes of fruits, vegetables, and micronutrients is important for reduction of disease risk.
In general, obtaining nutrients from whole foods is preferred to taking isolated
compounds in a pill form.
________________________________________________________________________

Topic: Fat-Soluble Vitamins

Objective:
Name and describe key functions of the fat-soluble vitamins.

Key Concept:
The fat-soluble vitamins are A, D, E, and K.

Fat-soluble vitamins are absorbed with micelles. Malabsorption of fat will limit
absorption of these vitamins. Vitamins A, D, and E are stored extensively in the body.
Vitamin K is not. Vitamin A is needed for vision, immune function, and growth. It is
consumed in the diet as retinol or pro-vitamin A carotenoids. Vitamin D is needed for
growth regulation, calcium absorption, bone health, and immune function. It is consumed
with fish or fortified foods, and produced in sun-exposed skin. Vitamin E is an
antioxidant consumed with fatty foods, mainly those containing seed oils, or
supplements. Vitamin K is needed for bone and vascular health. It is consumed mainly
with cooked dark-green vegetables.

Topic: Water-Soluble Vitamins

Objective:
Name and describe functions of the water-soluble vitamins.

Key Concept:
Many of the B vitamins are critical cofactors for normal fuel metabolism.

The water-soluble vitamins have very diverse functions. Thiamin, riboflavin, niacin,
vitamin B6, pantothenate, and biotin are essential for normal fuel metabolism. Vitamin C
is both an antioxidant and an enzyme cofactor; it regenerates vitamin E. Folate is
involved in DNA synthesis and one-carbon transfers (amino acid metabolism and
choline, serotonin, and epinephrine synthesis). Vitamin B6 is required for transamination
of amino acids and glycogen storage. Pyridoxal-5-phosphate is a cofactor for many
enzymes. Vitamin B12 is a cofactor for methionine synthase and L-methylmalonyl coA.
________________________________________________________________________

Topic: Minerals & Trace Elements

Objective:
Name and describe the functions of 10 minerals and trace elements.

Key Concept:
There are more than 20 essential minerals and trace elements.

Most minerals and trace elements are stored extensively, some in bone (calcium,
magnesium, phosphate), and some as part of metalloproteins (iron, copper, zinc, iodine,
selenium, molybdenum). Iron, copper, and selenium are potentially toxic when long-term
intakes even moderately exceed needs; excess of most others causes milder, but still
significant, adverse effects. Because an excess of most minerals and trace elements
causes significant to severe toxic effects, supplement use requires particular caution.
________________________________________________________________________

Topic: Other Nutrients

Objective:
Describe the physiologic functions of choline, amino acids, and carotenoids.

Key Concept:
Choline, amino acids, and carotenoids have diverse physiologic functions.

Choline is an important nutrient thought to support early brain development and possibly
protect against cancer. It is a precursor for phospholipids and neurotransmitters. Eggs are
a rich source of choline. Choline becomes an essential nutrient during periods of high
demand (during pregnancy and the first year of life). Amino acids are essential (have
carbon skeletons that cannot be synthesized in the body) or non-essential (can be made in
the body, although under certain conditions some of them may not be synthesized in
sufficient amounts). Quality of a dietary protein depends on its proportions of essential
vs. non-essential amino acids and on the potential presence of antiabsorptive factors.
Carotenoids, found in colorful fruits and vegetables, have diverse antioxidant functions.
________________________________________________________________________

Bibliography

World Cancer Research Fund / American Institute for Cancer Research. Food, Nutrition,
Physical Activity, and the Prevention of Cancer: a Global Perspective. Washington, DC:
AICR, 2007

Blomhoff R, Blomhoff HK. Overview of retinoid metabolism and function. J Neurobiol.
2006;66(7):606-30.

Massey LK, Liebman M, Kynast-Gales SA. Ascorbate increases human oxaluria and
kidney stone risk. J Nutr 2005;1673-1677.

Monsen ER. Iron nutrition and absorption: dietary factors which impact iron
bioavailability. J Am Diet Assoc. 1988;88(7):786-90.

Prasad AS, Kucuk O. Zinc in cancer prevention. Cancer Metastasis Rev. 2002;21(3-
4):291-5.


Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium,
Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc.
Institute of Medicine, National Academy Press, Washington, DC. 2000. Available at
www.nap.edu

Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin
B12, Pantothenic Acid, Biotin, and Choline. Institute of Medicine, National Academy

Readings

AREDS Report No.13. Arch Ophthalmol 2004;122:716-726

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