Nutrition Manual

MANUALOFCLINICALNUTRITIONMANAGEMENT

TABLEOFCONTENTSI. NORMALNUTRITIONANDMODIFIEDDIETSA. NormalNutrition StatementonNutritionalAdequacy................................................................................................................A1 EstimatedEnergyRequirement(EER)forMaleandFemalesUnder30YearsofAge...............A2 EstimatedEnergyRequirement(EER)forMenandWomen30YearsofAge...............................A2 EstimatedCalorieRequirements(InKilocalories)forEachGenderandAgeGroupat ThreelevelsofPhysicalActivity.....................................................................................................................A3 DietaryReferenceIntake(DRIs):RecommendedintakesforIndividuals,Macronutrients....A4 DietaryReferenceIntakes(DRIs):RecommendedIntakesforIndividuals,Vitamins...............A5 . DietaryReferenceIntakes(DRIs):RecommendedIntakesforIndividuals,Elements...............A6 DietaryReferenceIntakes(DRIs):EstimatedAverageRequirements............................................A7 DietaryReferenceIntakes(DRIs):TolerableUpperIntakeLevels(UL),Vitamins.....................A8 DietaryReferenceIntakes(DRIs):TolerableUpperIntakeLevels(UL),Elements.....................A9 FoodFortificationandDietarySupplementsPositionoftheAmericanDieteticAssoc(ADA)A10 RegularDietAdult...............................................................................................................................................A11 HighProtein,HighCalorieDiet........................................................................................................................A13 ImmunocompromisedDiet(NeutropenicDiet).........................................................................................A14 NutritionManagementDuringPregnancyandLactation......................................................................A15 NutritionandtheOlderAdult............................................................................................................................A22 MechanicalSoft(DentalSoft)Diet...................................................................................................................A27 PureedDiet................................................................................................................................................................A29 NutritionManagementofFluidIntakeandHydration............................................................................A31 VegetarianDiets......................................................................................................................................................A35 KosherGuidelines...................................................................................................................................................A39 B. TransitionalDiets ClearLiquidDiet.....................................................................................................................................................B1 . FullLiquidDiet........................................................................................................................................................B3 FullLiquidBlenderizedDiet...............................................................................................................................B4 NutritionManagementofDysphagia..............................................................................................................B6 DumpingSyndromeDiet.....................................................................................................................................B15 . NutritionManagementofBariatricSurgery................................................................................................B16 SpecializedNutritionSupport...........................................................................................................................B32 EnteralNutritionSupportforAdults..............................................................................................................B34 ParenteralNutritionSupportforAdults.......................................................................................................B48

C. ModificationofCarbohydrateandFat MedicalNutritionTherapyforDiabetesMellitus......................................................................................C1 MedicalNutritionTherapyforGestationalDiabetes.........................................................................C15 DietaryManagementwiththeExchangeSystem................................................................................C20 . SugarinModerationDiet.....................................................................................................................................C34 CalorieControlledDietforWeightManagement......................................................................................C35 MedicalNutritionTherapyforDisordersofLipidMetabolism...........................................................C39 FatControlledDiet.................................................................................................................................................C55 MediumChainTriglycerides(MCT)................................................................................................................C57

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D. ModificationofFiber FiberRestrictedDiets(LowFiber).................................................................................................................D1 HighFiberDiet........................................................................................................................................................D4 DietaryFiberContentofFoods...................................................................................................................D11 GastrointestionalSoftDiet..................................................................................................................................D13

E. PediatricDiets NutritionManagementoftheFullTermInfant.........................................................................................E1 InfantFormulaComparisonChart.............................................................................................................E4 NutritionManagementoftheToddlerandPreschoolChild.................................................................E7 NutritionManagementoftheSchoolAgedChild......................................................................................E9 NutritionManagementoftheAdolescent.....................................................................................................E12 KetogenicDiet..........................................................................................................................................................E14 F. ModificationOfMinerals SodiumControlledDiet.......................................................................................................................................F1 . FoodGuideforNoAddedSaltDiet(4000mgSodium)..........................................................................F4 . FoodGuidefor3,000mgSodiumDiet.....................................................................................................F5 2,000mgand1,500mgSodiumRestrictedDietPattern.................................................................F6 FoodGuidefor1,000mgSodiumDiet.....................................................................................................F8 NutritionManagementofPotassiumIntake................................................................................................F10 PotassiumContentofCommonFoods...................................................................................................F11 NutritionManagementofPhosphorusIntake............................................................................................F12 PhosphorusContentofCommonFoods................................................................................................F13 NutritionManagementofCalciumIntake....................................................................................................F14 . CalciumContentofCommonFoods........................................................................................................F15 G. ModificationOfProtein ProteinControlledDietforAcuteandRefractoryHepaticEncephalopathy.................................G1 ProteinBasedExchanges...............................................................................................................................G4 MedicalNutritionTherapyforChronicKidneyDisease.........................................................................G6 DeterminationofGlucoseAbsorptioninPeritonealDialysis.........................................................G16 DietaryManagementUsingtheHealthyFoodGuideforPeoplewithChronicKidneyDisease ..................................................................................................................................................................................G17 SimplifiedRenalDiet.............................................................................................................................................G28 H. DietsforSensitivity/MiscellaneousIntolerance GlutenFreeDiet......................................................................................................................................................H1 FoodGuideforGlutenFreeDiet..............................................................................................................H6 SuppliersofGlutenFreeandLowProteinProducts......................................................................H8 TyramineRestrictedDiet....................................................................................................................................H10 LactoseControlledDiet.......................................................................................................................................H12 . NutritionManagementofFoodHypersensitivities..................................................................................H16 I. Facility/TestDiets

II.

NUTRITIONASSESSMENT/INTERVENTIONBodyWeightEvaluationandNutritionalIndicatorsofNutritionRelatedProblems.........................II1 StatureDetermination..................................................................................................................................................II4 BodyMassIndex.............................................................................................................................................................II5 StandardBodyWeight(SBW)DeterminationBasedonNHANESII.........................................................II6 DeterminingIdealBodyWeight(IBW)BasedonHeighttoWeight:TheHAMWIMethod..............II7 DeterminationofFrameSize.....................................................................................................................................II8 EstimationofIdealBodyWeightandBodyMassIndexforAmputees....................................................II9


ii



EstimationofEnergyExpenditures........................................................................................................................II11 EstimationofProteinRequirements......................................................................................................................II15 LaboratoryIndicesofNutritionalStatus..............................................................................................................II16 ClassificationofSomeAnemias................................................................................................................................II18 DiagnosticCriteriaofDiabetesMellitus................................................................................................................II19 MajorNutrients:FunctionsandSources..............................................................................................................II21 . PhysicalSignsofNutritionalDeficiencies............................................................................................................II24 FoodandMedicationInteractions...........................................................................................................................II25 HerbandMedicationInteractions...........................................................................................................................II31

III. CLINICALNUTRITIONMANAGEMENTIntroduction......................................................................................................................................................................III1 AnticoagulantTherapy.................................................................................................................................................III4 Burns....................................................................................................................................................................................III7 Cancer..................................................................................................................................................................................III11 ChronicObstructivePulmonaryDisease.............................................................................................................III16 CorticosteroidTherapy...............................................................................................................................................III20 MonitoringinDiabetesMellitus...............................................................................................................................III21 DiabetesMellitus:ConsiderationsforExercise..........................................................................................III23 DiabetesMellitus:ConsiderationsforAcuteIllness.................................................................................III24 DiabetesMellitus:GastrointestinalComplications...................................................................................III26 DiabetesMellitus:OralGlucoseLoweringMedicationsandInsulin.................................................III28 DiabetesMellitus:FatReplacersandNutritive/NonnutritiveSweeteners....................................III31 Dysphagia...........................................................................................................................................................................III34 RelationshipofDysphagiatotheNormalSwallow...................................................................................III36 EnteralNutrition:ManagementofComplications............................................................................................III37 GastroesophagealRefluxDisease(GERD)............................................................................................................III39 HeartFailure.....................................................................................................................................................................III41 HIVInfectionandAIDS................................................................................................................................................III45 Hypertension....................................................................................................................................................................III60 Hypertriglyceridemia....................................................................................................................................................III67 Hypoglycemia...................................................................................................................................................................III69 InbornErrorsofMetabolism.....................................................................................................................................III71 IronDeficiencyAnemia................................................................................................................................................III73 NephroticSyndrome.....................................................................................................................................................III75 ObesityandWeightManagement............................................................................................................................III77 Pancreatitis.......................................................................................................................................................................III85 ParenteralNutrition(PN):MetabolicComplicationsofCentralParenteralNutrition(CPN).........III90 CalculatingTotalParenteralNutrition..................................................................................................................III94 PepticUlcer.......................................................................................................................................................................III98 Pneumonia.........................................................................................................................................................................III99 PressureUlcers................................................................................................................................................................III101 ManagementofAdultRenalinjuryandChronicRenalDisease..................................................................III105 NutritionApproachesinRenalReplacementTherapyBasedonPatientAssessment Parameters................................................................................................................................................................III110 WilsonsDisease..............................................................................................................................................................III113

IV. APPENDIXCaffeineandTheobromineContentofSelectedFoodsandBeverages....................................................IV1 . Metric/EnglishConversionsofWeightsandMeasures..................................................................................IV2 Milligram/MilliequivalentConversions................................................................................................................IV2 SalicylateContentofSelectedFoods......................................................................................................................IV3


iii



STATEMENTONNUTRITIONALADEQUACYThe Dietary Reference Intakes (DRIs) of the Food and Nutrition Board of the Institute of Medicine, National Academy of Sciences, are used as the standard for determining the nutritional adequacy of the regular and modifieddietsoutlinedinthismanual.DRIsreferencevaluesthatarequantityestimatesofnutrientintakesto beusedforplanningandassessingdietsforhealthypeople.TheDRIsconsistoffourreferenceintakes: RecommendedDailyAllowances(RDA),areferencetobeusedasagoalfortheindividual. TolerableUpperIntakeLevel(UL),theintakelevelgiventoassistinadvisingindividualsofwhatintake levelsmayresultinadverseeffectsifhabituallyexceeded. Estimated Average Requirement (EAR), the intake level which data indicates that the needs for 50% of individualsconsumingthisintakewillnotbemet. AdequateIntake(AI),arecommendedintakevalueforagrouporgroupsofhealthypeoplebasedonfewer dataandsubstantiallymorejudgmentthanusedinestablishinganEARandsubsequentlytheRDA. An AI is given when the RDA cannot be set. Both of these reference intakes are to be used as goals in planningandassessingdietsforhealthyindividuals(1,2).TheDRIsdonotcoverspecialneedsfornutrientsdue tovariousdiseaseconditions.DRIsarereferencevaluesappropriateforbothassessingpopulationintakesand planningdietsforhealthypeople(1,2). Whenreferringtoenergy,useEstimatedEnergyIntake(EER).EERistheaveragedietaryenergyintakethat ispredictedtomaintainenergybalanceinahealthyadultofadefinedage,gender,weight,heightandlevelof physicalactivity,consistentwithgoodhealth.Forchildren,pregnantandlactatingwomen,theEERincludes theneedsassociatedwithdepositionoftissuesorthesecretionofmilkatratesconsistentwithgoodhealth(7). ThesamplemenusthroughoutthismanualhavebeenplannedtoprovidetherecommendedDRIsformen, 31 to 50 years of age, unless indicated otherwise, and have been analyzed by a nutrient analysis software program.Forspecificvalues,refertothefollowingtablesofrecommendedDRIsfromtheFoodandNutrition Board of the National Academy of Sciences,. However, it is acknowledged that nutrient requirements vary widely.Thedietitiancanestablishanadequateintakeonanindividualbasis. TheDRIsareprovidedinaseriesofreports(37).Fulltextsofreportsareavailableatwww.nap.edu.

References 1. YatesAA,SchlickerSA,SuitorCW.DietaryReferenceIntakes:Thenewbasisforrecommendationsforcalciumandrelatednutrients, Bvitamins,andcholine.JAmDietAssoc.1998;98:699706. 2. TrumboP,YatesA,SchlickerS,PoosM.DietaryReferenceIntakes:VitaminA,VitaminK,Arsenic,Boron,Chromium,Copper,Iodine, Iron,Manganese,Molybdenum,Nickel,Silicon,Vanadium,andZinc.JAmDietAssoc.2001;101(3):294301. 3. InstituteofMedicine.DietaryReferenceIntakesforCalcium,Phosphorus,Magnesium,VitaminD,andFluoride.FoodandNutrition Board,Washington,DC:NationalAcademyPress;1997. 4. InstituteofMedicine.DietaryReferenceIntakesforThiamin,Riboflavin,Niacin,VitaminB6,Folate,VitaminB12,PantothenicAcid, Biotin,andCholine.FoodandNutritionBoard,Washington,DC:NationalAcademyPress;1998. 5. InstituteofMedicine.DietaryReferenceIntakesforVitaminC,VitaminE,Selenium,andCartotenoids.FoodandNutritionBoard, Washington,DC:NationalAcademyPress;2000. 6. InstituteofMedicine.DietaryReferenceIntakesforVitaminA,VitaminK,Arsenic,Boron,Chromium,Copper,Iodine,Iron,Molybdenum, Nickel,Silicon,VandiumandZinc.FoodandNutritionBoard.Washington,DC:NationalAcademyPress;2001. 7. Institute of Medicines Food and Nutrition Board. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. (Macronutrients). Washington, DC: National Academy of Sciences, 2005: 107180. ManualofClinicalNutritionManagement A1 Copyright2011MorrisonManagementSpecialists,Inc. Allrightsreserved.

ESTIMATEDENERGYREQUIREMENT(EER)FORMALEANDFEMALES UNDER30YEARSOFAGE Age 26mo 712mo 13y 48y 913y 1418y 1930y Sex M F M F M F M F M F M F M F BodyMass MedianReference Reference Index(kg/m2)a Heightbcm(in) Weightakg(lb) Kcal/day 62(24) 6(13) 570 62(24) 6(13) 520 71(28) 9(20) 743 71(28) 9(20) 676 86(34) 12(27) 1046 86(34) 12(27) 992 115(45) 20(44) 1,742 115(45) 20(44) 1,642 17.2 144(57) 36(79) 2,279 17.4 144(57) 37(81) 2,071 20.5 174(68) 61(134) 3,152 20.4 163(64) 54(119) 2,368 22.5 177(70) 70(154) 3,607c 21.5 163(64) 57(126) 2,403c

aTakenfromnewdataonmaleandfemalemedianbodymassindexandheightforagedatafromtheCentersforDiseaseControland PreventionNationalCenterforHealthStatisticsGrowthCharts(Kuczmarski,etal.,2000). bCalculatedfromCDC/NCHSGrowthCharts(Kuczmarskietal.,2000);medianbodymassindexandmedianheightforages4through 19years. cSubtract10kcal/dayformalesand7kcal/dayforfemalesforeachyearofageabove19years. Adaptedfrom:DietaryReferenceIntakesforEnergy,Carbohydrate,Fiber,Fat,FattyAcids,Cholesterol,Protein,andAminoAcids (Macronutrients).Washington,DC:NationalAcademiesPress,2002.

ESTIMATEDENERGYREQUIREMENT (EER)FORMENANDWOMEN30YEARSOFAGEa Height (m[in]) PALb WeightforBMI of18.5kg/m2 (kg[lb]) WeightforBMI of24.99kg/m2 (kg[lb]) EER,Men(kcal/day) EER,Women(kcal/day) BMIof BMIof BMIof BMIof 18.5kg/m2 24.99kg/m2 18.5kg/m2 24.99kg/m2

1.50 Sedentary (59) Lowactive Active VeryActive 1.65 Sedentary (65) Lowactive Active VeryActive 1.80 Sedentary (71) Lowactive Active VeryActivea

41.6(92)

56.2(124)

1,848 2,009 2,215 2,554 2,068 2,254 2,490 2,880 2,301 2,513 2,782 3,225

2,080 2,267 2,506 2,898 2,349 2,566 2,842 3,296 2,635 2,884 3,200 3,720

50.4(111)

68.0(150)

59.9(132)

81.0(178)

1,625 1,803 2,025 2,291 1,816 2,016 2,267 2,567 2,015 2,239 2,519 2,855

1,762 1,956 2,198 2,489 1,982 2,202 2,477 2,807 2,221 2.459 2,769 3,141

Foreachyearbelow30,add7kcal/dayforwomenand10kcal/dayformen.Foreachyearabove30,subtract7kcal/dayforwomenand 10kcal/dayformen. bPhysicalactivitylevel. cDerivefromthefollowingregressionequationsbasedondoublylabeledwaterdata: Adultman:EER=661.89.53xAge(y)xPAx(15.91xWt[kg]+539.6xHt[m] AdultwomanEER=354.16.91xAge(y)xPAx(9.36xWt[kg]+726xHt[m]) WherePAreferstocoefficientforPhysicalActivityLevels(PAL) PAL=totalenergyexpenditure+basalenergyexpenditure. PA=1.0ifPAL>1.01.41.61.970y Females 913y 1418y 1930y 3150y 5170y >70y Pregnancy 1418y 1930y 3150y Lactation 1418y 1930y 3150y

(L/d)

(g/d)

(g/d) (g/d) (g/d)

(g/d)

(g/d)

0.7* 0.8*

60* 95*

ND ND

31* 30*

4.4* 4.6*

0.5* 0.5*

9.1* 11.0c

1.3* 1.7*

130 130

19* 25*

ND ND

7* 10*

0.7* 0.9*

13 19

2.4* 3.3* 3.7* 3.7* 3.7* 3.7*

130 130 130 130 130 130

31* 38* 38* 38* 30* 30*

ND ND ND ND ND ND

12* 16* 17* 17* 14* 14*

1.2* 1.6* 1.6* 1.6* 1.6* 1.6*

34 52 56 56 56 56

2.1* 2.3* 2.7* 2.7* 2.7* 2.7*

130 130 130 130 130 130

26* 26* 25* 25* 21* 21*

ND ND ND ND ND ND

10* 11* 12* 12* 11* 11*

1.0* 1.1* 1.1* 1.1* 1.1* 1.1*

34 46 46 46 46 46

3.0* 3.0* 3.0*

175 175 175

28* 28* 28*

ND ND ND

13* 13* 13*

1.4* 1.4* 1.4*

71 71 71

3.8* 3.8* 3.8*

210 210 210

29* 29* 29*

ND ND ND

13* 13* 13*

1.3* 1.3* 1.3*

71 71 71

NOTE:ThistablepresentsRecommendedDietaryAllowances(RDAs)inboldtypeandAdequateIntakes(AIs)inordinarytypefollowedby anasterisk(*).RDAsandAIsmaybothbeusedasgoalsforindividualintake.RDAsaresettomeettheneedsofalmostall(97to98percent) individualsinagroup.Forhealthyinfantsfedhumanmilk,theAIisthemeanintake.TheAIforotherlifestageandgendergroupsisbelieved tocovertheneedsofallindividualsinthegroup,butlackofdataoruncertaintyinthedatapreventbeingabletospecifywithconfidencethe percentageofindividualscoveredbythisintake. aTotalwaterincludesallwatercontainedinfood,beverages,anddrinkingwater. bBasedon0.8g/kgbodyweightforthereferencebodyweight. cChangefrom13.5inprepublicationcopyduetocalculationerror.

DietaryReferenceIntakes(DRIs):AdditionalMacronutrientRecommendations FoodandNutritionBoard,InstituteofMedicine,NationalAcademies Macronutrient Recommendation Dietarycholesterol Aslowaspossiblewhileconsuminganutritionallyadequatediet Transfattyacids Aslowaspossiblewhileconsuminganutritionallyadequatediet Saturatedfattyacids Aslowaspossiblewhileconsuminganutritionallyadequatediet Addedsugars Limittonomorethan25%oftotalenergy SOURCE:DietaryReferenceIntakesforEnergy,Carbohydrate,Fiber,Fat,FattyAcids,Cholesterol,Protein,andAminoAcids(2002).

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DietaryReferenceIntakes(DRIs):RecommendedDietaryAllowancesandAdequateIntakes,VitaminsFoodandNutritionBoard,InstituteofMedicine,NationalAcademiesLifeStage Group Infants 06mo 712mo Children 13y 48y Males 913y 1418y 1930y 3150y 5170y >70y Females 913y 1418y 1930y 3150y 5170y >70y VitA (g/d)a VitC (mg/d) VitD (g/d)b,c VitE (mg/d)d VitK (g/d) Thiamin (mg/d) Riboflavin (mg/d) Niacin (mg/d)e VitB6 (mg/d) Folate (g/d)f VitB12 (g/d) Pantothenic Acid(mg/d) Biotin (g/d) Cholineg (mg/d)

400* 500*

40* 50*

15* 15*

4* 5*

2.0* 2.5*

0.2* 0.3*

0.3* 0.4*

2* 4*

0.1* 0.3*

65* 80*

0.4* 0.5*

1.7* 1.8*

5* 6*

125* 150*


300 400

15 25

15* 15*

6 7

30* 55*

0.5 0.6

0.5 0.6

6 8

0.5 0.6

150 200

0.9 1.2

2* 3*

8* 12*

200* 250*

600 900 900 900 900 900

45 75 90 90 90 90

15* 15* 15* 15* 15* 20*

11 15 15 15 15 15

60* 75* 120* 120* 120* 120*

0.9 1.2 1.2 1.2 1.2 1.2

0.9 1.3 1.3 1.3 1.3 1.3

12 16 16 16 16 16

1.0 1.3 1.3 1.3 1.7 1.7

300 400 400 400 400 400

1.8 2.4 2.4 2.4 2.4i 2.4i

4* 5* 5* 5* 5* 5*

20* 25* 30* 30* 30* 30*

375* 550* 550* 550* 550* 550*

600 700 700 700 700 700

45 65 75 75 75 75

15* 15* 15* 15* 15* 20*

11 15 15 15 15 15

60* 75* 90* 90* 90* 90*

0.9 1.0 1.1 1.1 1.1 1.1

0.9 1.0 1.1 1.1 1.1 1.1

12 14 14 14 14 14

1.0 1.2 1.3 1.3 1.5 1.5

300 400i 400i 400i 400 400

1.8 2.4 2.4 2.4 2.4h 2.4h

4* 5* 5* 5* 5* 5*

20* 25* 30* 30* 30* 30*

375* 400* 425* 425* 425* 425*

A5

Pregnancy 1418y 1930y 3150y Lactation 1418y 1930y 3150

750 770 770

80 85 85

15* 15* 15*

15 15 15

75* 90* 90*

1.4 1.4 1.4

1.4 1.4 1.4

18 18 18

1.9 1.9 1.9

600j 600j 600j

2.6 2.6 2.6

6* 6* 6*

30* 30* 30*

450* 450* 450*

1,200 1,300 1,300

115 120 120

15* 15* 15*

19 19 19

75* 90* 90*

1.4 1.4 1.4

1.6 1.6 1.6

17 17 17

2.0 2.0 2.0

500 500 500

2.8 2.8 2.8

7* 7* 7*

35* 35* 35*

550* 550* 550*

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NOTE:Thistable(takenfromtheDRIreports,seewww.nap.edu)presentsRecommendedDietaryAllowances(RDAs)inboldtypeandAdequateIntakes(AIs)inordinarytypefollowedbyanasterisk(*).AnRDAistheaveragedaily dietaryintakelevel;sufficienttomeetthenutrientrequirementsofnearlyall(97to98percent)healthyindividualsinagroup.ItiscalculatedfromanEstimatedAverageRequirement(EAR).Ifsufficientscientificevidenceisnotavailable toestablishanEAR,andthuscalculateanRDA,anAIisdeveloped.Forhealthybreastfedinfants,theAIisthemeanintake.TheAIforotherlifestageandgendergroupsisbelievedtocoverneedsofallhealthyindividualsinthegroup,but lackofdataoruncertaintyinthedatapreventbeingabletospecifywithconfidencethepercentageofindividualscoveredbythisintake. aAsretinolactivityequivalents(RAEs).1RAE=1mgretinol,12mgbcarotene,24mgacarotene,or24mgbcryptoxanthin.TheRAEfordietaryprovitaminAcarotenoidsistwofoldgreaterthanretinolequivalents(RE),whereasthe RAEforpreformedvitaminAisthesameasRE. bAscholecalciferol.1gcholecalciferol=40IUvitaminD. cIntheabsenceofadequateexposuretosunlight. dAsatocopherol.aTocopherolincludesRRRatocopherol,theonlyformofatocopherolthatoccursnaturallyinfoods,andthe2Rstereoisomericformsofatocopherol(RRR,RSR,RRS,andRSSatocopherol)thatoccurinfortified foodsandsupplements.Itdoesnotincludethe2Sstereoisomericformsofatocopherol(SRR,SSR,SRS,andSSSatocopherol),alsofoundinfortifiedfoodsandsupplements. eAsniacinequivalents(NE).1mgofniacin=60mgoftryptophan;06months=preformedniacin(notNE). fAsdietaryfolateequivalents(DFE).1DFE=1gfoodfolate=0.6goffolicacidfromfortifiedfoodorasasupplementconsumedwithfood=0.5gofasupplementtakenonanemptystomach. gAlthoughAIshavebeensetforcholine,therearefewdatatoassesswhetheradietarysupplyofcholineisneededatallstagesofthelifecycle,anditmaybethatthecholinerequirementcanbemetbyendogenoussynthesisatsomeof thesestages. hBecause10to30percentofolderpeoplemaymalabsorbfoodboundB12,itisadvisableforthoseolderthan50yearstomeettheirRDAmainlybyconsumingfoodsfortifiedwithB12orasupplementcontainingB12. iInviewofevidencelinkingfolateintakewithneuraltubedefectsinthefetus,itisrecommendedthatallwomencapableofbecomingpregnantconsume400gfromsupplementsorfortifiedfoodsinadditiontointakeoffoodfolatefrom avarieddiet. jItisassumedthatwomenwillcontinueconsuming400gfromsupplementsorfortifiedfooduntiltheirpregnancyisconfirmedandtheyenterprenatalcare,whichordinarilyoccursaftertheendofthepericonceptionalperiodthe criticaltimeforformationoftheneuraltube.

SOURCES: Dietary Reference Intakes for Calcium, Phosphorous, Magnesium, Vitamin D, and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid,Biotin,andCholine(1998);DietaryReferenceIntakesforVitaminC,VitaminE,Selenium,andCarotenoids(2000);DietaryReferenceIntakesforVitaminA,VitaminK,Arsenic,Boron,Chromium,Copper, Iodine,Iron,Manganese,Molybdenum,Nickel,Silicon,Vanadium,andZinc(2001);DietaryReferenceIntakesforWater,Potassium,Sodium,Chloride,andSulfate(2005);andDietaryReferenceIntakesforCalcium andVitaminD(2011).Thesereportsmaybeaccessedviawww.nap.edu.

DietaryReferenceIntakes(DRIs):RecommendedDietaryAllowancesandAdequateIntakes,ElementsFoodandNutritionBoard,InstituteofMedicine,NationalAcademiesLifeStage Group Infants 06mo 712mo Children 13y 48y Males 913y 1418y 1930y 3150y 5170y >70y Females 913y 1418y 1930y 3150y 5170y >70y Pregnancy 1418y 1930y 3150y Lactation 1418y 1930y 3150y Calcium (mg/d) Chromium (g/d) Copper (g/d) Fluoride (mg/d) Iodine (g/d) Iron (mg/d) Magnesium (mg/d) Manganese (mg/d) Molybdenum (g/d) Phosphorus (mg/d) Selenium (g/d) Zinc (mg/d) Potassium (g/d) Sodium (g/d) Chloride (g/d) ManualofClinicalNutritionManagement

200* 260*

0.2* 5.5*

200* 220*

0.01* 0.5*

110* 130*

0.27* 11

30* 75*

0.003* 0.6*

2* 3*

100* 275*

15* 20*

2* 3

0.4* 0.7*

0.12* 0.37*

0.18* 0.57*

700* 1,000*

11* 15*

340 440

0.7* 1*

90 90

7 10

80 130

1.2* 1.5*

17 22

460 500

20 30

3 5

3.0* 3.8*

1.0* 1.2*

1.5* 1.9*

1,300* 1,300* 1,000* 1,000* 1,000* 1,200*

25* 35* 35* 35* 30* 30*

700 890 900 900 900 900

2* 3* 4* 4* 4* 4*

120 150 150 150 150 150

8 11 8 8 8 8

240 410 400 420 420 420

1.9* 2.2* 2.3* 2.3* 2.3* 2.3*

34 43 45 45 45 45

1,250 1,250 700 700 700 700

40 55 55 55 55 55

8 11 11 11 11 11

4.5* 4.7* 4.7* 4.7* 4.7* 4.7*

1.5* 1.5* 1.5* 1.5* 1.3* 1.2*

2.3* 2.3* 2.3* 2.3* 2.0* 1.8*

1,300* 1,300* 1,000* 1,000* 1,200* 1,200*

21* 24* 25* 25* 20* 20*

700 890 900 900 900 900

2* 3* 3* 3* 3* 3*

120 150 150 150 150 150

8 15 18 18 8 8

240 360 310 320 320 320

1.6* 1.6* 1.8* 1.8* 1.8* 1.8*

34 43 45 45 45 45

1,250 1,250 700 700 700 700

40 55 55 55 55 55

8 9 8 8 8 8

4.5* 4.7* 4.7* 4.7* 4.7* 4.7*

1.5* 1.5* 1.5* 1.5* 1.3* 1.2*

2.3* 2.3* 2.3* 2.3* 2.0* 1.8*

A6

1,300* 1,000* 1,000*

29* 30* 30*

1,000 1,000 1,000

3* 3* 3*

220 220 220

27 27 27

400 350 360

2.0* 2.0* 2.0*

50 50 50

1,250 700 700

60 60 60

12 11 11

4.7* 4.7* 4.7*

1.5* 1.5* 1.5*

2.3* 2.3* 2.3*


1,300* 1,000* 1,000*

44* 45* 45*

1,300 1,300 1,300

3* 3* 3*

290 290 290

10 9 9

360 310 320

2.6* 2.6* 2.6*

50 50 50

1,250 700 700

70 70 70

13 12 12

5.1* 5.1* 5.1*

1.5* 1.5* 1.5*

2.3* 2.3* 2.3*

NOTE:Thistable(takenfromtheDRIreports,seewww.nap.edu)presentsRecommendedDietaryAllowances(RDAs)inboldtypeandAdequateIntakes(AIs)inordinarytypefollowedbyanasterisk(*).AnRDAistheaveragedaily dietaryintakelevel;sufficienttomeetthenutrientrequirementsofnearlyall(97to98percent)healthyindividualsinagroup.ItiscalculatedfromanEstimatedAverageRequirement(EAR).Ifsufficientscientificevidenceisnotavailable toestablishanEAR,andthuscalculateanRDA,anAIisdeveloped.Forhealthybreastfedinfants,theAIisthemeanintake.TheAIforotherlifestageandgendergroupsisbelievedtocoverneedsofallhealthyindividualsinthegroup,but lackofdataoruncertaintyinthedatapreventbeingabletospecifywithconfidencethepercentageofindividualscoveredbythisintake.

SOURCES: Dietary Reference Intakes for Calcium, Phosphorous, Magnesium, Vitamin D, and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid,Biotin,andCholine(1998);DietaryReferenceIntakesforVitaminC,VitaminE,Selenium,andCarotenoids(2000);DietaryReferenceIntakesforVitaminA,VitaminK,Arsenic,Boron,Chromium,Copper,Iodine, Iron,Manganese,Molybdenum,Nickel,Silicon,Vanadium,andZinc(2001);DietaryReferenceIntakesforWater,Potassium,Sodium,Chloride,andSulfate(2005);andDietaryReferenceIntakesforCalciumand VitaminD(2011).Thesereportsmaybeaccessedviawww.nap.edu.

.

DietaryReferenceIntakes(DRIs):EstimatedAverageRequirementsFoodandNutritionBoard,InstituteofMedicine,NationalAcademiesLifeStage Group Infants 0to6mo 612mo Children 13y 48y Males 913y 1418y 1930y 3150y 5170y >70y Females 913y 1418y 1930y 3150y 5170y >70y Pregnancy 1418y 1930y 3150y Lactation 1418y 1930y 3150y Cal cium(mg/d)

CHO(g/kg/d)

Protein (g/kg/d) 1.0 0.87 0.76 0.76 0.73 0.66 0.66 0.66 0.66 0.76 0.71 0.66 0.66 0.66 0.66 0.88 0.88 0.88 1.05 1.05 1.05

VitA(mg/d)a

VitC (mg/d)

VitD(g/d)

VitE(mg/d)b

Thia min(mg/d)

Ribo flavin (mg/d)

Niacin(mg/d)c

VitB6(mg/d)

Folate(mg/d)d

Vit B12(mg/d)

(mg/d)

Cop per

Iodine (mg/d)

Iron(mg/d)

Magnes ium (mg/d)

Molyb denum (mg/d)

Phos phorus (mg/d)

Sele nium(mg/d)

Zinc(mg/d)


500 800 1,100 1,100 800 800 800 1,000 1,100 1,100 800 800 1,000 1,000 1,000 800 800 1,000 800 800

100 100 100 100 100 100 100 100 100 100 100 100 100 100 135 135 135 160 160 160

210 275 445 630 625 625 625 625 420 485 500 500 500 500 530 550 550 885 900 900

6.9 13 22 39 63 75 75 75 75 39 56 60 60 60 60 66 70 70 96 100 100 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 5 6 9 12 12 12 12 12 9 12 12 12 12 12 12 12 12 16 16 16 0.4 0.5 0.7 1.0 1.0 1.0 1.0 1.0 0.7 0.9 0.9 0.9 0.9 0.9 1.2 1.2 1.2 1.2 1.2 1.2 0.4 0.5 0.8 1.1 1.1 1.1 1.1 1.1 0.8 0.9 0.9 0.9 0.9 0.9 1.2 1.2 1.2 1.3 1.3 1.3 5 6 9 12 12 12 12 12 9 11 11 11 11 11 14 14 14 13 13 13 0.4 0.5 0.8 1.1 1.1 1.1 1.4 1.4 0.8 1.0 1.1 1.1 1.3 1.3 1.6 1.6 1.6 1.7 1.7 1.7 120 160 250 330 320 320 320 320 250 330 320 320 320 320 520 520 520 450 450 450 0.7 1.0 1.5 2.0 2.0 2.0 2.0 2.0 1.5 2.0 2.0 2.0 2.0 2.0 2.2 2.2 2.2 2.4 2.4 2.4 260 340 540 685 700 700 700 700 540 685 700 700 700 700 785 800 800 985 1,00 0 1,00 0 65 65 73 95 95 95 95 95 73 95 95 95 95 95 160 160 160 209 209 209 3.0 4.1 5.9 7.7 6 6 6 6 5.7 7.9 8.1 8.1 5 5 23 22 22 7 6.5 6.5 65 110 200 340 330 350 350 350 200 300 255 265 265 265 335 290 300 300 255 265 13 17 26 33 34 34 34 34 26 33 34 34 34 34 40 40 40 35 36 36 380 405 1,055 1,055 580 580 580 580 1,055 1,055 580 580 580 580 1,055 580 580 1,055 580 580 17 23 35 45 45 45 45 45 35 45 45 45 45 45 49 49 49 59 59 59

2.5 2.5 4.0 7.0 8.5 9.4 9.4 9.4 9.4 7.0 7.3 6.8 6.8 6.8 6.8 10.5 9.5 9.5 10.9 10.4 10.4

A7


NOTE:AnEstimatedAverageRequirements(EAR),istheaveragedailynutrientintakelevelestimatedtomeettherequirementsofhalfofthehealthyindividualsinagroup.EARshavenotbeenestablishedfor vitaminK,pantothenicacid,biotin,choline,chromium,fluoride,manganese,orothernutrientsnotyetevaluatedviatheDRIprocess. aAsretinolactivityequivalents(RAEs).1RAE=1gretinol,12gbcarotene,24gacarotene,or24gcryptoxanthin.TheRAEfordietaryprovitaminAcarotenoidsistwofoldgreaterthanretinol equivalents(RE),whereastheRAEforpreformedvitaminAisthesameasRE. bAstocopherol.TocopherolincludesRRRtocopherol,theonlyformoftocopherolthatoccursnaturallyinfoods,andthe2Rstereoisomericformsoftocopherol(RRR,RSR,RRS,andRSStocopherol) thatoccurinfortifiedfoodsandsupplements.Itdoesnotincludethe2Sstereoisomericformsoftocopherol(SRR,SSR,SRS,andSSStocopherol),alsofoundinfortifiedfoodsandsupplements. cAsniacinequivalents(NE).1mgofniacin=60mgoftryptophan. dAsdietaryfolateequivalents(DFE).1DFE=1gfoodfolate=0.6goffolicacidfromfortifiedfoodorasasupplementconsumedwithfood=0.5gofasupplementtakenonanemptystomach. SOURCES: Dietary Reference Intakes for Calcium, Phosphorous, Magnesium, Vitamin D, and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid,Biotin,andCholine(1998);DietaryReferenceIntakesforVitaminC,VitaminE,Selenium,andCarotenoids(2000);DietaryReferenceIntakesforVitaminA,VitaminK,Arsenic,Boron,Chromium,Copper,Iodine, Iron,Manganese,Molybdenum,Nickel,Silicon,Vanadium,andZinc(2001);DietaryReferenceIntakesforEnergy,Carbohydrate,Fiber,Fat,FattyAcids,Cholesterol,Protein,andAminoAcids(2002/2005);andDietary ReferenceIntakesforCalciumandVitaminD(2011).Thesereportsmaybeaccessedviawww.nap.edu.

DietaryReferenceIntakes(DRIs):TolerableUpperIntakeLevels,VitaminsFoodandNutritionBoard,InstituteofMedicine,NationalAcademiesLifeStage ManualofClinicalNutritionManagement Group Infants 06mo 712mo Children 13y 48y Males 913y 1418y 1930y 3150y 5170y >70y Females 913y 1418y 1930y 3150y 5170y >70y Pregnancy 1418y 1930y 3150y Lactation 1418y 1930y 3150y VitaminA (g/d)a VitaminC (mg/d) VitaminD (mg/d) VitaminE (mg/d)b,c VitaminK Thiamin Ribo flavin

ND ND

ND ND

Niacin (mg/d)c

VitaminB6 (mg/d)

Folate (mg/d)c

VitaminB12

Pantothenic Acid

Biotin

Choline (g/d)

Carote noidsd

ND ND

ND ND

600 600

NDe ND

25 37.5

ND ND

ND ND ND ND

ND ND

ND ND

ND ND ND ND

ND ND

600 900

400 650

62.5 75

200 300

ND ND

ND ND

ND ND

10 15

30 40

300 400

ND ND

ND ND

ND ND

1.0 1.0

ND ND

1,700 2,800 3,000 3,000 3,000 3,000

1,200 1,800 2,000 2,000 2,000 2,000

100 100 100 100 100 100

600 800 1,000 1,000 1,000 1,000

ND ND ND ND ND ND

ND ND ND ND ND ND

ND ND ND ND ND ND

20 30 35 35 35 35

60 80 100 100 100 100

600 800 1,000 1,000 1,000 1,000

ND ND ND ND ND ND

ND ND ND ND ND ND

ND ND ND ND ND ND

2.0 3.0 3.5 3.5 3.5 3.5

ND ND ND ND ND ND

1,700 2,800 3,000 3,000 3,000 3,000

1,200 1,800 2,000 2,000 2,000 2,000

100 100 100 100 100 100

600 800 1,000 1,000 1,000 1,000

ND ND ND ND ND ND

ND ND ND ND ND ND

ND ND ND ND ND ND

20 30 35 35 35 35

60 80 100 100 100 100

600 800 1,000 1,000 1,000 1,000

ND ND ND ND ND ND

ND ND ND ND ND ND

ND ND ND ND ND ND

2.0 3.0 3.5 3.5 3.5 3.5

ND ND ND ND ND ND

A8

2,800 3,000 3,000

1,800 2,000 2,000

100 100 100

800 1,000 1,000

ND ND ND

ND ND ND

ND ND ND

30 35 35

80 100 100

800 1,000 1,000

ND ND ND

ND ND ND

ND ND ND

3.0 3.5 3.5

ND ND ND


2,800 3,000 3,000

1,800 2,000 2,000

100 100 100

800 1,000 1,000

ND ND ND

ND ND ND

ND ND ND

30 35 35

80 100 100

800 1,000 1,000

ND ND ND

ND ND ND

ND ND ND

3.0 3.5 3.5

ND ND ND

NOTE:ATolerableUpperIntakeLevel(UL)isthehighestlevelofdailynutrientintakethatislikelytoposenoriskofadverseeffects toalmostallindividualsinthegeneralpopulation.Unlessotherwisespecified,theULrepresents totalintakefromfood,water,andsupplements.Duetolackofsuitabledata,ULscouldnotbeestablishedforvitaminK,thiamin,riboflavin,vitaminB12,pantothenicacid,biotin,carotenoids.IntheabsenceofULs,extracautionmaybe warrantedinconsuminglevelsaboverecommendedintakes.MembersofthegeneralpopulationshouldbeadvisednottoroutinelyexceedtheUL.TheULisnotmeanttoapplytoindividualswhoaretreatedwiththenutrientunder medicalsupervisionortoindividualswithpredisposingconditionsthatmodifytheirsensitivitytothenutrient.

AspreformedvitaminAonly. Astocopherol;appliestoanyformofsupplementaltocopherol. dTheULsforvitaminE,niacin,andfolateapplytosyntheticformsobtainedfromsupplements,fortifiedfoods,oracombinationofthetwo. dbCarotenesupplementsareadvisedonlytoserveasaprovitaminAsourceforindividualsatriskofvitaminAdeficiency. eND=Notdeterminableduetolackofdataofadverseeffectsinthisagegroupandconcernwithregardtolackofabilitytohandleexcessamounts.Sourceofintakeshouldbefromfoodonlytoprevent highlevelsofintake.a b

SOURCES:DietaryReferenceIntakesforCalcium,Phosphorous,Magnesium,VitaminD,andFluoride(1997);DietaryReferenceIntakesforThiamin,Riboflavin,Niacin,VitaminB6,Folate,VitaminB12, PantothenicAcid,Biotin,andCholine(1998);DietaryReferenceIntakesforVitaminC,VitaminE,Selenium,andCarotenoids(2000);andDietaryReferenceIntakesforVitaminA,VitaminK,Arsenic,Boron, Chromium,Copper,Iodine,Iron,Manganese,Molybdenum,Nickel,Silicon,Vanadium,andZinc(2001);andDietaryReferenceIntakesforCalciumandVitaminD(2011).Thesereportsmaybeaccessedvia www.nap.edu.

.

DietaryReferenceIntakes(DRIs):TolerableUpperIntakeLevels,ElementsFoodandNutritionBoard,InstituteofMedicine,NationalAcademies

LifeStage Group Infants 06mo 712mo Children 13y 48y Males 913y 1418y 1930y 3150y 5170y >70y Females 913y 1418y 1930y 3150y 5170y >70y Pregnancy 1418y 1930y 3150y Lactation

Arse Nica

Boron (mg/d)

Calci um (mg/d)

Chrom ium

Copper (g/d)

Fluor ide (mg/d)

Iodine (g/d)

Iron (mg/d)

Magnes ium (mg/d)b

Manga nese (mg/d)

Molyb denum (g/d)

Nickel (mg/d)

Phos phorus (g/d)

Selen ium (g/d)

Sili con c

Vana dium (mg/d)d

Zinc (mg/d)

Sodi um (g/d)

Chlor ide (g/d)


NDe ND

ND ND

1,000 1,500

ND ND

ND ND

0.7 0.9

ND ND

40 40

ND ND

ND ND

ND ND

ND ND

ND ND

45 60

ND ND

ND ND

4 5

ND ND

ND ND

ND ND

3 6

2,500 2,500

ND ND

1,000 3,000

1.3 2.2

200 300

40 40

65 110

2 3

300 600

0.2 0.3

3 3

90 150

ND ND

ND ND

7 12

1.5 1.9

2.3 2.9

ND ND ND ND ND ND

11 17 20 20 20 20

3,000 3,000 2,500 2,500 2,000 2,000

ND ND ND ND ND ND

5,000 8,000 10,000 10,000 10,000 10,000

10 10 10 10 10 10

600 900 1,100 1,100 1,100 1,100

40 45 45 45 45 45

350 350 350 350 350 350

6 9 11 11 11 11

1,100 1,700 2,000 2,000 2,000 2,000

0.6 1.0 1.0 1.0 1.0 1.0

4 4 4 4 4 3

280 400 400 400 400 400

ND ND ND ND ND ND

ND ND 1.8 1.8 1.8 1.8

23 34 40 40 40 40

2.2 2.3 2.3 2.3 2.3 2.3

3.4 3.6 3.6 3.6 3.6 3.6

ND ND ND ND ND ND

11 17 20 20 20 20

3,000 3,000 2,500 2,500 2,000 2,000

ND ND ND ND ND ND

5,000 8,000 10,000 10,000 10,000 10,000

10 10 10 10 10 10

600 900 1,100 1,100 1,100 1,100

40 45 45 45 45 45

350 350 350 350 350 350

6 9 11 11 11 11

1,100 1,700 2,000 2,000 2,000 2,000

0.6 1.0 1.0 1.0 1.0 1.0

4 4 4 4 4 3

280 400 400 400 400 400

ND ND ND ND ND ND

ND ND 1.8 1.8 1.8 1.8

23 34 40 40 40 40

2.2 2.3 2.3 2.3 2.3 2.3

3.4 3.6 3.6 3.6 3.6 3.6

A9Copyright2011MorrisonManagementSpecialists,Inc. Allrightsreserved.

ND ND ND

17 20 20

3,000 2,500 2.500

ND ND ND

8,000 10,000 10,000

10 10 10

900 1,100 1,100

45 45 45

350 350 350

9 11 11

1,700 2,000 2,000

1.0 1.0 1.0

3.5 3.5 3.5

400 400 400

ND ND ND

ND ND ND

34 40 40

2.3 2.3 2.3

3.6 3.6 3.6

1418y ND 17 3,000 ND 8,000 10 900 45 350 9 1,700 1.0 4 400 ND ND 34 2.3 3.6 1930y ND 20 2,500 ND 10,000 10 1,100 45 350 11 2,000 1.0 4 400 ND ND 40 2.3 3.6 3150y ND 20 2,500 ND 10,000 10 1,100 45 350 11 2,000 1.0 4 400 ND ND 40 2.3 3.6 NOTE:ATolerableUpperIntakeLevel(UL)isthehighestlevelofdailynutrientintakethatislikelytoposenoriskofadverseeffectstoalmostallindividualsinthegeneralpopulation.Unlessotherwisespecified,theULrepresents total intakefromfood,water,andsupplements.Duetolackofsuitabledata,ULscouldnotbeestablishedforvitaminK,thiamin,riboflavin,vitaminB12,pantothenicacid,biotin,carotenoids.IntheabsenceofULs,extracautionmaybe warrantedinconsuminglevelsaboverecommendedintakes.MembersofthegeneralpopulationshouldbeadvisednottoroutinelyexceedtheUL.TheULisnotmeanttoapplytoindividualswhoaretreatedwiththenutrientunder medicalsupervisionortoindividualswithpredisposingconditionsthatmodifytheirsensitivitytothenutrient.

AlthoughtheULwasnotdeterminedforarsenic,thereisnojustificationforaddingarsenictofoodorsupplements. TheULsformagnesiumrepresentintakefromapharmacologicalagentonlyanddonotincludeintakefromfoodandwater. cAlthoughsiliconhasnotbeenshowntocauseadverseeffectsinhumans,thereisnojustificationforaddingsilicontosupplements. dAlthoughvanadiuminfoodhasnotbeenshowntocauseadverseeffectsinhumans,thereisnojustificationforaddingvanadiumtofoodandvanadiumsupplementsshouldbeusedwithcaution.TheULis basedonadverseeffectsinlaboratoryanimalsandthisdatacouldbeusedtosetaULforadultsbutnotchildrenandadolescents. eND=Notdeterminableduetolackofdataofadverseeffectsinthisagegroupandconcernwithregardtolackofabilitytohandleexcessamounts.Sourceofintakeshouldbefromfoodonlytopreventhigh levelsofintakes.a b

SOURCES:DietaryReferenceIntakesforCalcium,Phosphorous,Magnesium,VitaminD,andFluoride(1997);DietaryReferenceIntakesforThiamin,Riboflavin,Niacin,VitaminB6,Folate,VitaminB12, PantothenicAcid,Biotin,andCholine(1998);DietaryReferenceIntakesforVitaminC,VitaminE,Selenium,andCarotenoids(2000);DietaryReferenceIntakesforVitaminA,VitaminK,Arsenic,Boron, Chromium,Copper,Iodine,Iron,Manganese,Molybdenum,Nickel,Silicon,Vanadium,andZinc(2001);DietaryReferenceIntakesforWater,Potassium,Sodium,Chloride,andSulfate(2005);andDietaryReference IntakesforCalciumandVitaminD(2011).Thesereportsmaybeaccessedviahttp://www.nap.edu.

FOODFORTIFICATIONANDDIETARYSUPPLEMENTS POSITIONOFTHEAMERICANDIETETICASSOCIATION(ADA) ItisthepositionoftheAmericanDieteticAssociation(ADA)thatthebestnutritionalstrategyforpromoting optimalhealthandreducingtheriskofchronicdiseaseistowiselychooseawidevarietyoffoods.Additional vitaminsandmineralsfromfortifiedfoodsand/orsupplementscanhelpsomepeoplemeettheirnutritional needsasspecifiedbysciencebasednutritionstandardssuchastheDietaryReferenceIntakes(DRIs)(1,2). Recommendations regarding supplementation and the therapeutic use of vitamins and minerals for treating specific conditions may be found in the corresponding sections of this manual. The latest recommendations from the Food and Nutrition Board for the first time include recommendations that supplements or fortified foods be used to obtain desirable amounts of some nutrients, eg, folic acid and calcium,incertainpopulationgroups. Under the Dietary Supplement Health and Education Act of 1994, manufacturers must adhere to restrictions regarding the types of claims that are allowed on product labels. Statements regarding the efficacyofspecificproductsinthetreatmentorpreventionofparticularconditionsareprohibited.Aclaim statementisallowedifthestatementclaimsabenefitrelatedtoaclassicalnutrientdeficiencydiseaseand discloses the prevalence of such disease in the United States, describes the role of a nutrient or dietary ingredientintendedtoaffectthestructureorfunctioninhumans,characterizesthedocumentedmechanism by which a nutrient or dietary ingredient acts to maintain such structure or function, or describes general wellbeingfromconsumptionofanutrientordietaryingredient(1). The manufacturer mustspecify that theclaims are truthful and notmisleading. The followingstatement must also accompany any claims, This statement has not been evaluated by the Food and Drug Administration.Thisproductisnotintendedtodiagnose,treat,cure,orpreventanydisease(1).Inaddition, all supplements must have the identity and strength of contents listed on the label, and meet appropriate specificationsforquality,purityandcomposition(3).

References 1. PositionoftheAmericanDieteticAssociation:NutrientSupplementation.JAmDietAssoc.2009;109:20732085125. 2. PositionoftheAmericanDieteticAssociation:Functionalfoods.JAmDietAssoc.2009;109:735746. 3. DietarySupplementHealthandEducationActof1994.PublicLaw(S.784)(1994)(codifiedat42USC287C11). . ManualofClinicalNutritionManagement

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REGULARDIETADULTDescription The diet includes a wide variety of foods to meet nutritional requirements and individual preferences of healthyadults.Itisusedtopromotehealthandreducetherisksofdevelopingmajor,chronic,ornutrition relateddisease.

Indications Thedietisservedwhenspecificdietarymodificationsarenotrequired.

NutritionalAdequacy ThedietcanbeplannedtomeettheDietaryReferenceIntakes(DRIs)asoutlinedinStatementonNutritional Adequacy in Section IA. The diet uses the 2,000 kilocalorie level asthe standardreference level foradults. Specificcalorielevelsmayneedtobeadjustedbasedonage,genderandphysicalactivity.

HowtoOrdertheDiet OrderasRegularDiet,indicatinganyspecialinstructions.

PlanningtheDiet The Dietary Guidelines for Americans and portion sizes use the USDA Food Guide and the DASH (Dietary Approaches to Stopping Hypertension) Eating Plan as the basis for planning the menu (1). The Dietary Guidelines are intended for all Americans, healthy and those at increased risk of chronic disease. However, modifications may be required while treating patients who are ill, as the main goal is to encourage food intake,whichfrequentlyrequirescomfortfoods,suchassoup,sandwiches,andotherfoodsthepatientis accustomed to. With that consideration, the number of servings of foods from each food group may differ fromtherecommendations.However,themealwillstillbeplannedtomeettheDRIswheneverpossible. DietaryGuidelinesforAmericansencompassestwooverarchingconcepts(1): Maintaincaloriebalanceovertimetoachieveandsustainahealthyweight Focusonconsumingnutrientdensefoodsandbeverageswithinbasicfoodgroupswhilecontrolling calorieandsodiumintake Recommendedhealthyeatingpattern: dailysodiumintaketolessthan2,300mgandfurtherreduceintaketo1,500mgamongpersonswhoare 51 and older and any age who are African American or have hypertension diabetes, or chronic kidney disease.Atthesametime,consumefoodswithmorepotassium,dietaryfiber,calciumandvitaminD. increasedailyintakeoffruitsandvegetables,wholegrains,andfatfreeorlowfatmilkandmilkproducts consumelessthan10percentofcaloriesfromsaturatedfattyacidsbyreplacingwithmonounsaturated andpolyunsaturatedfattyacids.Oilsshouldreplacesolidfatswhenpossible. keeptransfataslowaspossible. reducetheintakeofcaloriesfromsolidfatsandaddedsugars. limit consumption offoods that containrefined grains, especially refinedgrainfoods thatcontain solid fats,addedsugars,adsodium. ifyoudrinkalcoholicbeverages,dosoinmoderation,foronlyadultsoflegalage keepfoodsafetoeat ManualofClinicalNutritionManagement

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RegularDietAdult

FOODGUIDEFORAMERICANS(18002000caloriepattern)(1) FoodGroup Fruits Vegetables Grains Meat,Poultry, DryBeans, Eggs,andNuts Milk,Yogurt,and Cheese Oils RecommendedDaily 34servings Consumecitrusfruits,melons,berries, andotherfruitsregularly 5servings Darkgreenleafyvegetables:3 Redandorangevegetables:5 cups/week Legumes:1cups/week Starchyvegetables:5cups/week Othervegetable:4cups/week ServingSize Mediumsizeorange,apple,orbanana cupofchopped,cooked,orcannedfruit(nosugaradded) cupof100%fruitjuice 1cupofrawleafyvegetables:spinach,lettuce cupofothervegetables,cookedorchoppedraw cupofvegetablejuice

6servings 1sliceofbread Wholegrainproducts:3daily Othergrains:3daily 2largeor4smallcrackers cupcookedcereal,rice,orpasta 1cupreadytoeatcereal 1smallrollormuffin English muffin,bagel,hamburgerbun,orlargeroll 55ouncesday Choosefish,drybeans,peas,poultry 1ounceofcookedfish,poultry,orleanmeat withoutskin,andleanmeat cupcookeddrybeansortofu 1egg 1Tbsppeanutbutter ouncenutsorseeds 3servings Chooseskimmilkandfatfree yogurt 1cupofmilkoryogurt Choosepartskimandlowfatcheeses 1ouncesofnaturalcheese (Mozzarella,Swiss,Cheddar) 2ouncesofprocessedcheese(American) 35tspdaily Oilsandsoftmargarinesinclude vegetablesoilsandsoftvegetableoil tablespreadsthatarelowinsaturated fatandaretransfree SAMPLEMENU Breakfast Noon Evening OrangeJuice RotisserieBakedChicken BraisedBeefandNoodles Oatmeal RicePilaf SeasonedGreenBeans ScrambledEgg SteamedBroccoliwithCarrots SlicedTomatoSalad Biscuit WholewheatRoll FrenchDressing Margarine Margarine Peachhalves Jelly FruitCup DinnerRoll LowfatMilk LowfatMilk Margarine Coffee IcedTea LowfatMilk References 1. DietaryGuidelinesforAmericans2010.Availableat: http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/PolicyDoc.pdf.AccessedJan31,2011.

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HIGHPROTEIN,HIGHCALORIEDIETDescription Additional foods and supplements are added to meals or between meals to increase protein and energy intake. Indications A highprotein, highcalorie diet is served when protein and energy requirements are increased by stress, proteinloss(proteinlosingenteropathy,nephroticsyndrome),andcatabolism.Thisdietmaybeindicatedin patientswith: proteinenergymalnutrition failuretothrive cancer burns cysticfibrosis humanimmunodeficiencyvirus(HIV)/acquiredimmunodeficiencysyndrome(AIDS) chronicgastrointestinaldiseases Thisdietmayalsobeindicatedinpreparationforsurgery.Anincreaseinenergyisrequiredtopromotethe efficientutilizationofproteinsforanabolism. NutritionalAdequacy ThedietcanbeplannedtomeettheDietaryReferenceIntakes(DRIs)asoutlinedinStatementonNutritional AdequacyinSectionIA. HowtoOrdertheDiet OrderasHighProtein,HighCalorieDiet.Thedietitiandeterminesatargetlevelofproteinandenergyto meetindividualneedsbasedonguidelinesasstatedinEstimationofProteinRequirementsinSectionII. PlanningtheDiet ThedietisplannedasaRegularDietwithadditionofbetweenmealsupplementsthatincreaseenergyintake byatleast500kcalandproteinintakeby25gforadults.Examplesofhighprotein,highenergysupplements aremilkshakes,eggnogs,puddings,custards,andcommercialsupplements. Forchildren,thedietgenerallyshouldprovide120%to150%oftheDietaryReferenceIntakes(DRIs)for energy and protein. The actual amounts of energy and protein provided will depend on the childs or adolescentsage,height,weight,medicalstatus,andnutritiongoals.


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IMMUNOCOMPROMISEDDIET(NeutropenicDiet)Description The Immunocompromised Diet eliminates certain foods in order to serve a diet requiring a lower level of bacteriathanispresentinatypicalhospitaldiet.FoodsfromtheRegularDietareservedwiththeexceptionof unwashed raw fruits and vegetables; meat cooked less than welldone, cured meats, yogurt, aged cheese and preparedsalads. Indications Personswithdecreasedimmunefunctionduetochemotherapyorradiationareatahigherriskofdevelopinga foodrelatedinfection.Therearenotcontrolledstudiesthatdocumenttheefficacyofthisdiet.Thepremiseof the diet is to avoid specific foods that could potentially introduce infection causing organisms into the gastrointestinaltract.Whenthedietisbeingconsidered,thelengthoftimethepatienthasbeenneutropenic (absoluteneutrophilcountof 250 mg/dL and ketosis is present, and use caution if glucoselevelsare>300mg/dLandnoketosisispresent. Ingestaddedcarbohydrateifglucoselevelsare240 mg/dL and moderate to large amounts of ketones are a danger signal for diabetic ketoacidosis. Patients with ketoacidosis require additional insulin and immediate managementoffluidsandelectrolytes(2).

ApproachesfortheHospitalSetting Guidelinesforpatientswithtype1ortype2diabetesmellitus: 1. Contactphysicianwhenvomitingordiarrheacontinuesfor3to4hours(1). 2. For insulinrequiring patients or patients who are pregnant, test urine for ketones. Contact physician whentestshowsamoderatetolargeamountofketones(1,2). 3. Fordiabeticcriticalcarepatients,contactphysicianwhenbloodglucoselevelremainsabove180mg/dL even after supplemental insulin (as arranged with physician). In critically ill patients insulin therapy shouldbeinitiatedfortreatmentofpersistanthyperglycemiastartingatathresholdofnogreaterthan 180mg/dL(1).Onceinsulintherapyisstarted,aglucoserangeof140to180mg/dLisrecommendedfor the majority of critically ill patients (1). Criticalcare patients will usually require intravenous insulin protocolthathasdemonstratedefficacyandsafetyinachievingdesiredglucoserangewithoutincreasing riskforhypglycemia(1). 4. For diabetic noncritically ill patients there is no clear evidence for specific blood glucose goals (1). If treated with insulin, the premeal blood glucose levels should generally be

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Nutrition Manual