Name: NUTRITION, LIVER AND BILIARY TRACT DISEASES [CH 325-333, 336] (JAN 7, 2022)
Uploaded: 2022-03-04
Duration: 25 min 40 s
Description: . . Reporters:. MORALES, KIMBERLY C.. MEENAVALLI, AKHIL CHOWDARY.

. . Reporters:. MORALES, KIMBERLY C.. MEENAVALLI, AKHIL CHOWDARY. 

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. . TOPIC OUTLINE. 1
Nutrient Requirements and Dietary Assessment. 

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1
Nutrient Requirements and Dietary Assessment

2
Vitamin and Trace Mineral Deficiency and Excess

3
Malnutrition and Nutritional Assessment

5
Approach to the Patient with Liver Disease

10
Nonalcoholic Fatty Liver Diseases and Nonalcoholic
Steatohepatitis

. . Nutrient Requirements and Dietary Assessment. 

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Nutrient 
Requirements and 
Dietary Assessment

●
Nutrients are substances that are not synthesized in sufﬁcient amounts in the body and therefore must be supplied by the diet.
●
The absence of essential nutrients leads to growth impairment, organ dysfunction, and failure to maintain nitrogen balance or adequate status of protein and other nutrients.
●
The amounts of essential nutrients required by individuals differ by their age and physiologic state
●
Requirements for organic nutrients include 9 essential amino acids, several fatty acids, glucose, 4 fat- soluble vitamins, 10 water-soluble vitamins, dietary ﬁber, and choline. Several inorganic substances, including 4 minerals, 7 trace minerals, 3 electrolytes, and the ultratrace elements, must also be supplied by diet.
INTRODUCTION. 

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●
Nutrients are substances that are not synthesized in sufﬁcient 
amounts in the body and therefore must be supplied by the diet.
●
The absence of essential nutrients leads to growth impairment, 
organ dysfunction, and failure to maintain nitrogen balance or 
adequate status of protein and other nutrients.
●
The amounts of essential nutrients required by individuals differ by 
their age and physiologic state
●
Requirements for organic nutrients include 9 essential amino acids, 
several fatty acids, glucose, 4 fat- soluble vitamins, 10 water-soluble 
vitamins, dietary ﬁber, and choline. Several inorganic substances, 
including 4 minerals, 7 trace minerals, 3 electrolytes, and the 
ultratrace elements, must also be supplied by diet.
INTRODUCTION

●
Energy For weight to remain stable, energy intake must match energy output.
●
The average energy intake is ~2600 kcal/d for American men and ~1800 kcal/d for American women, although these estimates vary with body size and activity level.
●
Protein Dietary protein consists of both essential and nonessential amino acids that are required for protein synthesis.
●
The nine essential amino acids are histidine, isoleucine, leucine, lysine, methionine/ cystine, phenylalanine/tyrosine, threonine, tryptophan, and valine.
●
The need of protein increase during growth, pregnancy, lactation, and rehabilitation after injury or malnutrition.
●
Tolerance to dietary protein is decreased in renal insufﬁciency (with consequent uremia) and in liver failure.
ESSENTIAL NUTRIENTS REQUIREMENTS. 

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●
Energy For weight to remain stable, energy intake must match energy 
output.
●
The average energy intake is ~2600 kcal/d for American men and ~1800 
kcal/d for American women, although these estimates vary with body 
size and activity level.
●
Protein Dietary protein consists of both essential and nonessential 
amino acids that are required for protein synthesis.
●
The nine essential amino acids are histidine, isoleucine, leucine, lysine, 
methionine/ cystine, phenylalanine/tyrosine, threonine, tryptophan, and 
valine.
●
The need of protein increase during growth, pregnancy, lactation, and 
rehabilitation after injury or malnutrition.
●
Tolerance to dietary protein is decreased in renal insufﬁciency (with 
consequent uremia) and in liver failure.
ESSENTIAL NUTRIENTS REQUIREMENTS

●
Fat and Carbohydrate Fats are a concentrated source of energy and constitute, on average, 34% of calories in U.S. diets.
●
The brain requires ~100 g of glucose per day for fuel; other tissues use about 50 g/d.
●
However, for optimal health, fat intake should total no more than 30% of calories.
●
Water For adults, 1–1.5 mL of water per kilocalorie of energy expenditure is sufﬁcient under usual conditions to allow for normal variations in physical activity, sweating, and solute load of the diet.
●
Water losses include 50–100 mL/d in the feces; 500–1000 mL/d by evaporation or exhalation; and, depending on the renal solute load, ≥1000 mL/d in the urine.
●
Infants have high requirements for water because of their large surface. area to volume ratios, their inability to communicate their thirst, and the limited capacity of the immature kidney to handle high renal solute loads.. 

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●
Fat and Carbohydrate Fats are a concentrated source of energy and 
constitute, on average, 34% of calories in U.S. diets.
●
The brain requires ~100 g of glucose per day for fuel; other tissues use 
about 50 g/d.
●
However, for optimal health, fat intake should total no more than 30% of 
calories.
●
Water For adults, 1–1.5 mL of water per kilocalorie of energy expenditure 
is sufﬁcient under usual conditions to allow for normal variations in 
physical activity, sweating, and solute load of the diet.
●
Water losses include 50–100 mL/d in the feces; 500–1000 mL/d by 
evaporation or exhalation; and, depending on the renal solute load, 
≥1000 mL/d in the urine.
●
Infants have high requirements for water because of their large surface. 
area to volume ratios, their inability to communicate their thirst, and the 
limited capacity of the immature kidney to handle high renal solute 
loads.

●
However Water intake needs to be increased during pregnancy are ~30 mL/d. During lactation, milk production increases daily water requirements so that ~1000 mL of additional water is needed, or 1 mL for each milliliter of milk produced
DIETARY REFERENCE INTAKES AND RDAS
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The capacity for adaptation is not too much, as well as too little, intake of a nutrient can have adverse effects or alter the health beneﬁts conferred by another nutrient. Therefore, benchmark recommendations regarding nutrient intakes have been developed to guide clinical practice.
●
These quantitative estimates of nutrient intakes are collectively referred to as the dietary reference intakes (DRIs). The DRIs have supplanted the RDAs—the single reference values
●
DRIs include an estimated average requirement (EAR) for nutrients as well as other reference values used for dietary planning. 

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●
However Water intake needs to be increased during pregnancy are ~30 
mL/d. During lactation, milk production increases daily water 
requirements so that ~1000 mL of additional water is needed, or 1 mL for 
each milliliter of milk produced
DIETARY REFERENCE INTAKES AND RDAS
●
The capacity for adaptation is not too much, as well as too little, intake of 
a nutrient can have adverse effects or alter the health beneﬁts conferred 
by another nutrient. Therefore, benchmark recommendations regarding 
nutrient intakes have been developed to guide clinical practice.
●
These quantitative estimates of nutrient intakes are collectively referred 
to as the dietary reference intakes (DRIs). The DRIs have supplanted the 
RDAs—the single reference values
●
DRIs include an estimated average requirement (EAR) for nutrients as 
well as other reference values used for dietary planning

●
Estimated Average Requirement When ﬂorid manifestations of the classic dietary-deﬁciency diseases such as rickets (deﬁciency of vitamin D and calcium), scurvy (deﬁciency of vitamin C), xerophthalmia (deﬁciency of vitamin A), and protein-calorie malnutrition were common, nutrient adequacy was inferred from the absence of their clinical deﬁciency signs.
●
The EAR is the amount of a nutrient estimated to be adequate for half of the healthy individuals of a speciﬁc age and sex.
●
Recommended Dietary Allowances The RDA, the nutrient intake goal for planning diets of individuals, is the average daily dietary intake level that meets the nutrient requirements of nearly all healthy persons of a speciﬁc sex, age, life stage, or physiologic condition (e.g., pregnancy or lactation).
●
The risk of dietary inadequacy increases as one’s intake falls below the RDA.. 

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●
Estimated Average Requirement When ﬂorid manifestations of the 
classic dietary-deﬁciency diseases such as rickets (deﬁciency of vitamin 
D and calcium), scurvy (deﬁciency of vitamin C), xerophthalmia 
(deﬁciency of vitamin A), and protein-calorie malnutrition were 
common, nutrient adequacy was inferred from the absence of their 
clinical deﬁciency signs.
●
The EAR is the amount of a nutrient estimated to be adequate for half 
of the healthy individuals of a speciﬁc age and sex.
●
Recommended Dietary Allowances The RDA, the nutrient intake goal 
for planning diets of individuals, is the average daily dietary intake level 
that meets the nutrient requirements of nearly all healthy persons of a 
speciﬁc sex, age, life stage, or physiologic condition (e.g., pregnancy or 
lactation).
●
The risk of dietary inadequacy increases as one’s intake falls below the 
RDA.

●
On food labels, the nutrient content in a food is stated by weight or as a percent of the daily value (DV), a variant of the RDA used on the nutrition facts panel that, for an adult, represents the highest RDA for an adult consuming 2000 kcal.
●
Adequate Intake It is not possible to set an RDA for some nutrients that lack an established EAR.
●
Tolerable Upper Levels of Nutrient Intake Healthy individuals gain no established beneﬁt from consuming nutrient levels above the RDA or AI.
●
excessive nutrient intake can disturb body functions and cause acute, progressive, or permanent disabilities.
●
The tolerable UL is the highest level of chronic nutrient intake (usually daily) that is unlikely to pose a risk of adverse health effects for most of the population.. 

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●
On food labels, the nutrient content in a food is stated by weight or as a 
percent of the daily value (DV), a variant of the RDA used on the 
nutrition facts panel that, for an adult, represents the highest RDA for 
an adult consuming 2000 kcal.
●
Adequate Intake It is not possible to set an RDA for some nutrients 
that lack an established EAR.
●
Tolerable Upper Levels of Nutrient Intake Healthy individuals gain no 
established beneﬁt from consuming nutrient levels above the RDA or 
AI.
●
excessive nutrient intake can disturb body functions and cause acute, 
progressive, or permanent disabilities.
●
The tolerable UL is the highest level of chronic nutrient intake (usually 
daily) that is unlikely to pose a risk of adverse health effects for most of 
the population.

. . ●
Data on the adverse effects of large amounts of many nutrients are unavailable or too limited to establish a UL. Therefore, the lack of a UL does not mean that the risk of adverse effects from high intake is nonexistent.. 

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●
Data on the adverse effects of large amounts of many nutrients are 
unavailable or too limited to establish a UL. Therefore, the lack of a UL 
does not mean that the risk of adverse effects from high intake is 
nonexistent.

●
Total nutrient consumption, including that in foods, supplements, and 
over-the-counter medications (e.g., antacids), should not exceed RDA 
levels

●
Acceptable Macronutrient Distribution Ranges The AMDRs are not 
experimentally determined; rather they are rough ranges for 
energy-providing macronutrient intakes (protein, carbohydrate, and fat) 
that the National Academy of Medicine’s (formerly Institute of Medicine, 
IOM) Food and Nutrition Board considers to be healthful.

●
These ranges are 10–35% of calories for protein, 20–35% of calories for fat, 
and 45–65% of calories for carbohydrate. Alcohol, which also provides 
energy, is not a nutrient; therefore, no recommendations are not 
provided.

. . FACTORS ALTERING NUTRIENT NEEDS. ●
The DRIs are affected by age, sex, growth rate, pregnancy, lactation, physical activity level, concomitant diseases, drugs, and dietary com- position.. 

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●
The DRIs are affected by age, sex, growth rate, pregnancy, lactation, 
physical activity level, concomitant diseases, drugs, and dietary com- 
position.

●
Physiologic Factors Growth, strenuous physical activity, preg- nancy, 
and lactation all increase needs for energy and several essential 
nutrients.

●
Energy needs decrease with loss of lean body mass, the major 
determinant of REE.

●
The energy needs of older persons, especially those aged >70 years, 
tend to be lower than those of younger persons because lean tissue, 
physical activity, and health often decline with age.

●
Energy needs rise during pregnancy due to fetal growth demands 
and increased energy required for milk production during lactation.

. . DIETARY COMPOSITION. ●
Dietary composition affects the biological availability and use of nutrients.. 

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●
Dietary composition affects the biological availability and use of 
nutrients.

●
For example, iron absorption may be impaired by large amounts of 
calcium or lead; likewise, non-heme iron uptake may be impaired by a 
lack of ascorbic acid and amino acids in the meal.

●
Bodily protein may be decreased when essential amino acids are not 
present in sufﬁcient amounts

●
Animal foods, such as milk, eggs, and meat, have high biological values, 
with most of the needed amino acids present in adequate amounts

●
Plant proteins in corn (maize), soy, rice, and wheat have lower biological 
values and must be combined with other plant or animal proteins or 
fortiﬁed with the amino acids that are deﬁcient to achieve optimal use 
by the body.

. . Route of Intake. ●
The RDAs apply only to oral intakes. When nutrients are administered parenterally, similar values can sometimes be used for amino acids, glucose (carbohydrate), fats, sodium, chloride, potassium, and most vitamins because their intestinal absorption rate is nearly 100%.. 

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●
The RDAs apply only to oral intakes. When nutrients are administered 
parenterally, similar values can sometimes be used for amino acids, 
glucose (carbohydrate), fats, sodium, chloride, potassium, and most 
vitamins because their intestinal absorption rate is nearly 100%.

●
The oral bioavailability of most mineral elements may be only half that 
obtained by parenteral administration

●
For some nutrients that are not readily stored in the body or that cannot 
be stored in large amounts, timing of administration may also be 
important.

●
For example, amino acids cannot be used for protein synthesis if they 
are not supplied together; instead, they will be used for energy 
production, although in healthy individuals eating adequate diets, the 
distribution of protein intake over the course of the day has little effect 
on health

. . TABLE 325-1 Dietary Reference Intakes (DRIs): Recommended Dietary Allowances and Adequate Intakes forVitamins LIFESTAGE GROUP Infants Birth to 6 mo 6-12 mo Children 1-3 y Males 9-13 y 14-18 y 19-30 y 31-50 y 51-70 y >70y Females 9-13 y 14-18 y 19-30 y 31-50 y 51-70 y >70y Pregnant Women 14-18 Y 19-30 y 31-50 y Lactating Women 14-18 y 19-30 y 31-50 y VITAMIN A (gg/d)' 40(Y 500' 300 700 700 700 700 700 750 770 770 1200 1300 1300 VITAMIN C (mg/d) 75 75 75 75 75 120 120 VITAMIN D (gg/d)b 10 10 20 20 VITAMINE VITAMIN K (gg/d) 55' 75' 120' 120' 120' 120' 19 19 19 THIAMIN RIBOFLAVIN (mg/d) 0.2 0.5 0.6 0.9 1.2 1.2 1.2 1.0 1.1 (mg/d) 0.5 0.6 0.9 NIACIN 16 17 17 17 VITAMIN (mg/d) 0.6 1.7 1.7 1.9 2.0 2.0 2.0 FOLATE (gg/d)' 200 300 300 VITAMIN B (vg/d) 0.9 2.4 2.4 2.4 2.4h 2.4h 2.4 2.4 2.4 2.4h 2.4h 2.6 2.6 2.6 2.8 2.8 2.8 PANTOTHENIC ACID (mg/d) BIOTIN (gg,'d) 12' 35 • 35 • CHOLINE (mg/d)' 125• 150• 200• 250' 375' 550' 550' 550' 550• 550' 373 425' 425' 425' 425' 45T 45T 450' 550' 550' 550'. 

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TABLE 325-1 Dietary Reference Intakes (DRIs): Recommended Dietary Allowances and Adequate Intakes forVitamins
LIFESTAGE
GROUP
Infants
Birth to 6 mo
6-12 mo
Children
1-3 y
Males
9-13 y
14-18 y
19-30 y
31-50 y
51-70 y
>70y
Females
9-13 y
14-18 y
19-30 y
31-50 y
51-70 y
>70y
Pregnant Women
14-18 Y
19-30 y
31-50 y
Lactating Women
14-18 y
19-30 y
31-50 y
VITAMIN A
(gg/d)'
40(Y
500'
300
700
700
700
700
700
750
770
770
1200
1300
1300
VITAMIN C
(mg/d)
75
75
75
75
75
120
120
VITAMIN D
(gg/d)b
10
10
20
20
VITAMINE VITAMIN K
(gg/d)
55'
75'
120'
120'
120'
120'
19
19
19
THIAMIN RIBOFLAVIN
(mg/d)
0.2
0.5
0.6
0.9
1.2
1.2
1.2
1.0
1.1
(mg/d)
0.5
0.6
0.9
NIACIN
16
17
17
17
VITAMIN
(mg/d)
0.6
1.7
1.7
1.9
2.0
2.0
2.0
FOLATE
(gg/d)'
200
300
300
VITAMIN
B (vg/d)
0.9
2.4
2.4
2.4
2.4h
2.4h
2.4
2.4
2.4
2.4h
2.4h
2.6
2.6
2.6
2.8
2.8
2.8
PANTOTHENIC
ACID (mg/d)
BIOTIN
(gg,'d)
12'
35 •
35 •
CHOLINE
(mg/d)'
125•
150•
200•
250'
375'
550'
550'
550'
550•
550'
373
425'
425'
425'
425'
45T
45T
450'
550'
550'
550'

. . LIFESTAGE GROUP Infants Birth to 6 6—12 Children Males 9-13 y 14-18 y 19-30 y 31-50 y 51-70 y >70y Females 9-13 y 14—18 y 19-30 y 31-50 y 51-70 y >70y TABLE 325-2 Dietary Reference Intakes (DRIs): Recommended Dietary Allowances and Adequate Intakes for Elements 2.3' 2.3' 2.3 2.3 2.3' 2.3' CALCIUM (mg/d) 200' 260' 700 1000 1300 1000 1000 1000 1300 1300 1000 1000 CHROMIUM COPPER FLUORIDE (mg/d) 0.01' IODINE IRON MAGNESIUM MANGANESE MOLYBDENUM (pg/d) 11 • 21 • 29' 45 • (gg,/d) 200' 220• 700 890 700 890 1000 1000 1000 1300 1300 (gg,/d) (mg/d) (mg/d) (mg/d) 0.003' 23 2.3' 2.3' 18 1.8' 2.6' (gg/d) 17 45 45 PHOSPHORUS (mg,/d) 100' 273 1250 700 700 700 700 1250 700 700 700 700 700 700 700 700 SELENIUM 15' 20 30 55 55 55 60 70 70 70 ZINC (mg,/d) 110' 130' 120 150 150 150 150 150 120 150 150 150 150 150 220 220 220 290 290 0.27' 11 10 11 8 8 8 8 15 18 18 8 27 27 27 10 9 9 130 420 240 360 310 320 320 320 350 360 360 310 320 POTASSIUM 4.7 • 4.7' 5.1' SODIUM 0.12' 0.37' 1.5' 1.3' 1.5' 1.5' 13 1.5' CHLORIDE 0.18' 0.57' 2.3 2.0' 1.8' 2.3' 2.3' 2.3' Pregnant Women 14-18 y 19-30 y 31-50 y 1300 1000 1000 Lactating Women 14—18 y 19-30 y 31-50 y 1300 1000 1000. 

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LIFESTAGE
GROUP
Infants
Birth to 6
6—12
Children
Males
9-13 y
14-18 y
19-30 y
31-50 y
51-70 y
>70y
Females
9-13 y
14—18 y
19-30 y
31-50 y
51-70 y
>70y
TABLE 325-2 Dietary Reference Intakes (DRIs):
Recommended Dietary Allowances and Adequate Intakes for Elements
2.3'
2.3'
2.3
2.3
2.3'
2.3'
CALCIUM
(mg/d)
200'
260'
700
1000
1300
1000
1000
1000
1300
1300
1000
1000
CHROMIUM COPPER
FLUORIDE
(mg/d)
0.01'
IODINE IRON MAGNESIUM MANGANESE MOLYBDENUM
(pg/d)
11 •
21 •
29'
45 •
(gg,/d)
200'
220•
700
890
700
890
1000
1000
1000
1300
1300
(gg,/d) (mg/d) (mg/d)
(mg/d)
0.003'
23
2.3'
2.3'
18
1.8'
2.6'
(gg/d)
17
45
45
PHOSPHORUS
(mg,/d)
100'
273
1250
700
700
700
700
1250
700
700
700
700
700
700
700
700
SELENIUM
15'
20
30
55
55
55
60
70
70
70
ZINC
(mg,/d)
110'
130'
120
150
150
150
150
150
120
150
150
150
150
150
220
220
220
290
290
0.27'
11
10
11
8
8
8
8
15
18
18
8
27
27
27
10
9
9
130
420
240
360
310
320
320
320
350
360
360
310
320
POTASSIUM
4.7 •
4.7'
5.1'
SODIUM
0.12'
0.37'
1.5'
1.3'
1.5'
1.5'
13
1.5'
CHLORIDE
0.18'
0.57'
2.3
2.0'
1.8'
2.3'
2.3'
2.3'
Pregnant Women
14-18 y
19-30 y
31-50 y
1300
1000
1000
Lactating Women
14—18 y
19-30 y
31-50 y
1300
1000
1000

. . 6—12 Children 1—3 y Males 9-13 y 14—18 y 19—30 y 31-50 Y 51—70 y Females 9—13 y 14—18 y 19—30 y 31-50 Y 51—70 y Pregnant 14—18 y 19-30 y 31-50 y TABLE 325-3 Dietary Reference Intakes (DRIs): Recornmended Dietary Allowances and Adequate Intakes for Total Water and Macronutrients LIFE-STAGE GROUP Infants Birth to 6 mo 0.8 0.5 3.3 3.8 TOTAL WATER- 3.7 3.7 3.o• 3.0* CARBOHYDRATE (g/d) 130 130 130 130 130 130 130 130 130 130 130 130 175 175 175 210 210 TOTAL FIBER ( g,/d) ND 31 • 30 • 21' FAT (g/d) ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND LINOLEIC ACID IT IT a-LINOLENIC ACID (g/d) 0.5' Women Lactating Women 14—18 19—30 y 31—50 y PROTEINO (g/d) 9.1 • 11.0 19 71 71. 

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6—12
Children
1—3 y
Males
9-13 y
14—18 y
19—30 y
31-50 Y
51—70 y
Females
9—13 y
14—18 y
19—30 y
31-50 Y
51—70 y
Pregnant
14—18 y
19-30 y
31-50 y
TABLE 325-3
Dietary Reference Intakes (DRIs): Recornmended Dietary Allowances and Adequate Intakes for Total Water and Macronutrients
LIFE-STAGE
GROUP
Infants
Birth to 6 mo
0.8
0.5
3.3
3.8
TOTAL WATER-
3.7
3.7
3.o•
3.0*
CARBOHYDRATE
(g/d)
130
130
130
130
130
130
130
130
130
130
130
130
175
175
175
210
210
TOTAL FIBER
( g,/d)
ND
31 •
30 •
21'
FAT (g/d)
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
LINOLEIC ACID
IT
IT
a-LINOLENIC
ACID (g/d)
0.5'
Women
Lactating Women
14—18
19—30 y
31—50 y
PROTEINO (g/d)
9.1 •
11.0
19
71
71

. . Nutrition assessment in clinical situations is an iterative process that involves:. 

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Nutrition assessment in clinical situations is an iterative process that involves:

2.
Assessing the diet and other data to establish either the absence or the 
presence of malnutrition and its possible causes,

3.
Planning and implementing the most appropriate nutritional therapy, 
and

4.
Reassessing intakes to make sure that they have been consumed.

The factors that are usually assessed include abnormal weight for height or 
body mass index (e.g., BMI <19 or >25); reported weight change (involuntary 
loss or gain of >5 kg in the past 6 months);diagnoses with known nutritional 
implications (e.g., metabolic disease, any disease affecting the gastrointestinal 
tract, alcoholism); present therapeutic dietary prescription; chronic poor 
appetite; presence of chewing and swallowing problems or major food 
intolerances; need for assistance with preparing or shopping for food, eating, 
or other aspects of self-care; and social isolation.

. . ACUTE CARE SETTINGS. ●
In acute-care settings, anorexia, various other diseases, test procedures, and medications can compromise dietary intake the goal is to identify and avoid inadequate intake and to assure appropriate alimentation.. 

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●
In acute-care settings, anorexia, various other diseases, test procedures, 
and medications can compromise dietary intake the goal is to identify and 
avoid inadequate intake and to assure appropriate alimentation.

●
Dietary assessment focuses on what patients are currently eating, 
whether or not they are able and willing to eat, and whether or not they 
experience any problems with eating.

●
The objective is to gather enough information to establish the likelihood 
of malnutrition due to poor dietary intake or other causes in order to 
assess whether nutritional therapy is indicated

●
Acutely ill patients with diet-related diseases such as diabetes need 
assessment because an inappropriate diet may exacerbate these 
conditions and adversely affect other therapies.

. . ●
Most therapeutic diets offered in hospitals are calculated to meet individual nutrient requirements and the RDA if they are eaten Exceptions include clear liquids, some full-liquid diets, and test diets (such as those adhered to in preparation for gastrointestinal procedures), which are inadequate for several nutrients and should not be used, if possible, for more than 24 h.. 

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●
Most therapeutic diets offered in hospitals are calculated to meet 
individual nutrient requirements and the RDA if they are eaten 
Exceptions include clear liquids, some full-liquid diets, and test diets (such 
as those adhered to in preparation for gastrointestinal procedures), which 
are inadequate for several nutrients and should not be used, if possible, 
for more than 24 h.

●
However, because as much as half of the food served to hospitalized 
patients is not eaten, it cannot be assumed that the intakes of 
hospitalized patients are adequate.

●
Nutritional monitoring is especially important for patients who are very ill 
and who have extended lengths of hospital stay.

●
Patients who are fed by enteral and parenteral routes also require special 
nutritional assessment and monitoring by physicians and/or dietitians 
with certiﬁcation in nutritional support

Ambulatory Settings
●
The aim of dietary assessment in the outpatient setting is to determine whether or not the patient’s usual diet is a health risk in itself or if it contributes to existing chronic disease-related problems.
●
The assessment should focus on the dietary constituents that are most likely to be involved or compromised by a speciﬁc diagnosis as well as on any comorbidities that are present
●
More than one day’s intake should be reviewed to provide a better representation of the usual diet, upon which personalized dietary recommendations can be base
●
There are many ways to assess the adequacy of a patient’s habitual diet a commonly used food guide for healthy persons is the USDA’s Choose My Plate, which is useful as a rough guide for avoiding inadequate intakes of essential nutrients as well as likely excesses in the amounts of fat (especially saturated and trans fats), sodium, sugar, and alcohol consume. 

Scene 20

Ambulatory Settings
●
The aim of dietary assessment in the outpatient setting is to determine 
whether or not the patient’s usual diet is a health risk in itself or if it 
contributes to existing chronic disease-related problems.
●
The assessment should focus on the dietary constituents that are most 
likely to be involved or compromised by a speciﬁc diagnosis as well as on 
any comorbidities that are present
●
More than one day’s intake should be reviewed to provide a better 
representation of the usual diet, upon which personalized dietary 
recommendations can be base
●
There are many ways to assess the adequacy of a patient’s habitual diet a 
commonly used food guide for healthy persons is the USDA’s Choose My 
Plate, which is useful as a rough guide for avoiding inadequate intakes of 
essential nutrients as well as likely excesses in the amounts of fat 
(especially saturated and trans fats), sodium, sugar, and alcohol consume

●
The Choose Myplate graphic emphasizes a balance between calories and nutritional needs, encouraging increased intake of fruits and vegetables, whole grains, and low-fat milk in conjunction with reduced intake of sodium and high-calorie sugary drinks
●
Patients who follow ethnic or unusual dietary patterns may need extra instruction on how foods should be categorized and on the appropriate portion sizes that constitute a serving.
●
Reviewing the guide with patients helps them transition to healthier dietary patterns and identiﬁes food groups eaten in excess of recommendations or in insufﬁcient quantities.. 

Scene 21

●
The Choose Myplate graphic emphasizes a balance between calories and 
nutritional needs, encouraging increased intake of fruits and vegetables, 
whole grains, and low-fat milk in conjunction with reduced intake of 
sodium and high-calorie sugary drinks
●
Patients who follow ethnic or unusual dietary patterns may need extra 
instruction on how foods should be categorized and on the appropriate 
portion sizes that constitute a serving.
●
Reviewing the guide with patients helps them transition to healthier 
dietary patterns and identiﬁes food groups eaten in excess of 
recommendations or in insufﬁcient quantities.

. . DIETARY '-m OF MEASURE Fruits, cups (Focus fruits.) Vegetables, cups (Vary vegetables.) Grains, oz eq (Make at least half of grains whole.)a Protein foods, oz eq (Go lean with protein.)b Dairy, cups or ozc (Choose calcium-rich foods.) "Empty" calories, kcald Sodium, mg Physical activity, min 5 5 3 120 3 260 <2300 at all energy I eve I s At least 150 min vigorous physical activity per at all energy levels. 

Scene 22

DIETARY '-m
OF MEASURE
Fruits, cups (Focus
fruits.)
Vegetables, cups (Vary
vegetables.)
Grains, oz eq (Make
at least half of grains
whole.)a
Protein foods, oz eq (Go
lean with protein.)b
Dairy, cups or ozc
(Choose calcium-rich
foods.)
"Empty" calories, kcald
Sodium, mg
Physical activity, min
5
5
3
120
3
260
<2300 at all energy
I eve I s
At least 150 min vigorous physical activity per
at all energy levels

. . Vitamin and Trace. Mineral Deﬁciency and. Excess. 

Scene 23

. . ●
Vitamins are required constituents of the human diet since they are synthesized inadequately or not at all in the human body. Only small amounts of these substances are needed to carry out essential biochemical reactions. 

Scene 24

●
Vitamins are required constituents of the human diet since they are 
synthesized inadequately or not at all in the human body. Only small 
amounts of these substances are needed to carry out essential 
biochemical reactions

●
Moreover, subclinical vitamin and trace mineral deﬁciencies, as 
diagnosed by laboratory testing, are quite common in the normal 
population, especially in the geriatric age group.

●
Conversely, because of the widespread use of nutrient supplements, 
nutrient toxicities are gaining pathophysiologic and clinical importance.

●
Body stores of vitamins and minerals vary tremendously. For example, 
stores of vitamins B12 and A are large, and an adult may not become 
deﬁcient until ≥1 year after beginning to eat a deﬁcient diet

. . ●
Therapeutic modalities can deplete essential nutrients from the body; for example, hemodialysis or diuretics remove water-soluble vitamins, which must be replaced by supplementation.. 

Scene 25

●
Therapeutic modalities can deplete essential nutrients from the 
body; for example, hemodialysis or diuretics remove water-soluble 
vitamins, which must be replaced by supplementation.

●
Vitamins and trace minerals play several roles in diseases:

●
(1)Deﬁciencies of vitamins and minerals may be caused by disease 
states such as malabsorption;

●
 (2) either deﬁciency or excess of vitamins and minerals can cause 
disease in and of itself (e.g., vitamin A intoxication and liver disease); 
and

●
 (3) vitamins and minerals in high doses may be used as drugs (e.g., 
niacin for hypercholesterolemia

. . VITAMINS. THIAMINE (VITAMIN B1). ●
Thiamine was the ﬁrst B vitamin to be identiﬁed and therefore is referred to as vitamin B1.. 

Scene 26

●
Thiamine was the ﬁrst B vitamin to be identiﬁed and therefore is referred 
to as vitamin B1.

●
Thiamine functions in the decarboxylation of α-ketoacids (e.g., pyruvate 
α-ketoglutarate) and branched-chain amino acids and thus is essential for 
energy generation.

●
The median intake of thiamine in the United States from food alone is 2 
mg/d.

●
Primary food sources for thiamine include yeast, organ meat, pork, 
legumes, beef, whole grains, and nuts. Milled rice and grains contain little 
thiamine.

●
Tea, coffee, raw ﬁsh, and shellﬁsh contain thiaminases, which can destroy 
the vitamin. Thus, drinking large amounts of tea or coffee could 
theoretically lower thiamine body stores.

Deﬁciency Most dietary deﬁciency of thiamine worldwide is the result of poor dietary intake.
●
In Western countries, the primary causes of thiamine deﬁciency are alcoholism and chronic illnesses such as cancer.
●
Alcohol interferes directly with the absorption of thiamine and with the synthesis of thiamine pyrophosphate, and it increases urinary excretion thus Thiamine should always be replenished when a patient with alcoholism is being refed, as carbohydrate repletion without adequate thiamine can precipitate acute thiamine deﬁciency with lactic acidosis.
●
Alcoholic patients with chronic thiamine deﬁciency also may have central nervous system (CNS) manifestations known as Wernicke’s encephalopathy
●
Thiamine deﬁciency in its early stage induces anorexia and non- speciﬁc symptoms (e.g., irritability, decrease in short-term memory). Prolonged thiamine deﬁciency causes beriberi, which is classically categorized as wet or dry although there is considerable overlap between the two categories.. 

Scene 27

Deﬁciency Most dietary deﬁciency of thiamine worldwide is the result of 
poor dietary intake.
●
In Western countries, the primary causes of thiamine deﬁciency are 
alcoholism and chronic illnesses such as cancer.
●
Alcohol interferes directly with the absorption of thiamine and with the 
synthesis of thiamine pyrophosphate, and it increases urinary excretion 
thus Thiamine should always be replenished when a patient with 
alcoholism is being refed, as carbohydrate repletion without adequate 
thiamine can precipitate acute thiamine deﬁciency with lactic acidosis.
●
Alcoholic patients with chronic thiamine deﬁciency also may have central 
nervous system (CNS) manifestations known as Wernicke’s 
encephalopathy
●
Thiamine deﬁciency in its early stage induces anorexia and non- speciﬁc 
symptoms (e.g., irritability, decrease in short-term memory). Prolonged 
thiamine deﬁciency causes beriberi, which is classically categorized as 
wet or dry although there is considerable overlap between the two 
categories.

TREATMENT ●
In acute thiamine deﬁciency with either cardiovascular or neurologic signs, 200 mg of thiamine three times daily should be given intravenously until there is no further improvement in acute symptoms; oral thiamine (10 mg/d) should subsequently be given until recovery is complete. Toxicity
●
Although anaphylaxis has been reported after high intravenous doses of thiamine.
●
Thiamine supplements may be bought over the counter in doses of up to 50 mg/d.. 

Scene 28

TREATMENT 
●
In acute thiamine deﬁciency with either cardiovascular or neurologic 
signs, 200 mg of thiamine three times daily should be given 
intravenously until there is no further improvement in acute symptoms; 
oral thiamine (10 mg/d) should subsequently be given until recovery is 
complete. 
Toxicity
●
Although anaphylaxis has been reported after high intravenous doses of 
thiamine.
●
Thiamine supplements may be bought over the counter in doses of up to 
50 mg/d.

. . RIBOFLAVIN (VITAMIN B2 ). ●
Riboﬂavin is important for the metabolism of fat, carbohydrate, and. 

Scene 29

●
Riboﬂavin is important for the metabolism of fat, carbohydrate, and

protein, acting as a respiratory coenzyme and an electron donor.

●
The vitamin also plays a role in drug and steroid metabolism,

●
Riboﬂavin deﬁciency is manifested principally by lesions of the

mucocutaneous surfaces of the mouth and skin. In addition, corneal

vascularization, anemia, and personality changes

. . Deﬁciency and Excess. ●
Riboﬂavin deﬁciency almost always is due to dietary deﬁciency.. 

Scene 30

●
Riboﬂavin deﬁciency almost always is due to dietary deﬁciency.

●
Milk, other dairy products, and enriched breads and cereals are the

most important dietary sources of riboﬂavin although lean meat,

ﬁsh, eggs, broccoli, and legumes are also good sources.

●
Laboratory diagnosis of riboﬂavin deﬁciency can be made by

determination of red blood cell or urinary riboﬂavin concentrations

or by measurement of erythrocyte glutathione reductase activity,

NIACIN (VITAMIN B3 )
●
The term niacin refers to nicotinic acid and nicotinamide and their biologically active derivatives. Nicotinic acid and nicotinamide serve as precursors of two coenzymes, nicotinamide adenine dinucleotide (NAD) and NAD phosphate (NADP),which are important in numerous oxidation and reduction reactions in the body.
Metabolism and Requirements
●
Nicotinic acid and nicotinamide are absorbed well from the stomach and small intestine. The bioavailability of niacin from beans, milk, meat, and eggs is high
Deﬁciency
●
Niacin deﬁciency causes pellagra The early symptoms of pellagra include loss of appetite, generalized weakness and irritability, abdominal pain, and vomiting. ●
Bright red glossitis then ensues and is followed by a characteristic skin rash that is pigmented and scaling, particularly in skin areas exposed to sunlight. ●
This rash is known as Casal’s necklace, it is seen in advanced cases the 4Ds
1.
Dermatitis
2.
Diarrhea
3.
Dementia
4.
Death. 

Scene 31

NIACIN (VITAMIN B3 )
●
The term niacin refers to nicotinic acid and nicotinamide and their biologically active 
derivatives. Nicotinic acid and nicotinamide serve as precursors of two coenzymes, 
nicotinamide adenine dinucleotide (NAD) and NAD phosphate (NADP),which are 
important in numerous oxidation and reduction reactions in the body.
Metabolism and Requirements
●
Nicotinic acid and nicotinamide are absorbed well from the stomach and small 
intestine. The bioavailability of niacin from beans, milk, meat, and eggs is high
Deﬁciency
●
Niacin deﬁciency causes pellagra The early symptoms of pellagra include loss of 
appetite, generalized weakness and irritability, abdominal pain, and vomiting. 
●
Bright red glossitis then ensues and is followed by a characteristic skin rash that is 
pigmented and scaling, particularly in skin areas exposed to sunlight. 
●
This rash is known as Casal’s necklace, it is seen in advanced cases the 4Ds
1.
Dermatitis
2.
Diarrhea
3.
Dementia
4.
Death

. . TREATMENT. Treatment of pellagra consists of oral supplementation with 100–200 mg of nicotinamide or nicotinic acid three times daily for 5 days. Toxicity. 

Scene 32

Treatment of pellagra consists of oral supplementation with 100–200 mg 
of nicotinamide or nicotinic acid three times daily for 5 days.
 
Toxicity

●
Prostaglandin-mediated ﬂushing due to binding of the vitamin to a 
G protein–coupled receptor has been observed at daily nicotinic acid 
doses as low as 30 mg taken as a supplement or as therapy for 
dyslipidemia.

●
Hepatic toxicity is the most serious toxic reaction caused by 
sustained-release niacin and may present as jaundice with elevated 
aspartate aminotransferase (AST) and alanine aminotransferase 
(ALT) levels.

. . PYRIDOXINE (VITAMIN B6). ●
Vitamin B6 refers to a family of compounds that includes pyridoxine, pyridoxal, pyridoxamine, and their 5′-phosphate derivatives. 5′-Pyridoxal phosphate (PLP) is a cofactor for >100 enzymes involved in amino acid metabolism.. 

Scene 33

●
Vitamin B6 refers to a family of compounds that includes pyridoxine, 
pyridoxal, pyridoxamine, and their 5′-phosphate derivatives. 5′-Pyridoxal 
phosphate (PLP) is a cofactor for >100 enzymes involved in amino acid 
metabolism.

●
Vitamin B6 also is involved in heme and neurotransmitter synthesis and in 
the metabolism of glycogen, lipids, steroids, sphingoid bases, and several 
vitamins, including the conversion of tryptophan to niacin.

●
Plants contain vitamin B in the form of pyridoxine, whereas animal tissues 
contain PLP and pyridoxamine phosphate.

●
The vitamin B6 contained in plants is less bioavailable than that in animal 
tissues

●
Rich food sources of vitamin B6 include legumes, nuts, wheat bran, and 
meat, although it is present in all food groups.

●
Deﬁciency Symptoms of vitamin B6 deﬁciency include epithelial changes, as seen frequently with other B vitamin deﬁciencies.
●
In addition, severe vitamin B6 deﬁciency can lead to peripheral neuropathy, abnormal electroencephalograms, and personality changes that include depression and confusion In infants, diarrhea, seizures, and anemia have been reported.
●
vitamin B6 is necessary for the conversion of homocysteine to cystathionine, it is possible that chronic low-grade vitamin B6 deﬁciency may result in hyperhomocysteinemia and increased risk of cardiovascular disease
●
The increased ratio of AST to ALT seen in alcoholic liver disease reﬂects the relative vitamin B6 dependence of ALT.. 

Scene 34

●
Deﬁciency Symptoms of vitamin B6 deﬁciency include epithelial changes, 
as seen frequently with other B vitamin deﬁciencies.
●
In addition, severe vitamin B6 deﬁciency can lead to peripheral 
neuropathy, abnormal electroencephalograms, and personality changes 
that include depression and confusion In infants, diarrhea, seizures, and 
anemia have been reported.
●
vitamin B6 is necessary for the conversion of homocysteine to 
cystathionine, it is possible that chronic low-grade vitamin B6 deﬁciency 
may result in hyperhomocysteinemia and increased risk of cardiovascular 
disease
●
The increased ratio of AST to ALT seen in alcoholic liver disease reﬂects the 
relative vitamin B6 dependence of ALT.

. . ●
Vitamin B6 dependency syndromes that require pharmacologic doses of vitamin B6 are rare; they include cystathionine β-synthase deﬁciency, pyridoxine- responsive anemias, and gyrate atrophy with chorioretinal degeneration due to decreased activity of the mitochondrial enzyme ornithine aminotransferase. In these situations, 100–200 mg/d of oral vitamin B6 is required for treatment.. 

Scene 35

●
Vitamin B6 dependency syndromes that require pharmacologic doses of 
vitamin B6 are rare; they include cystathionine β-synthase deﬁciency, 
pyridoxine- responsive anemias, and gyrate atrophy with chorioretinal 
degeneration due to decreased activity of the mitochondrial enzyme 
ornithine aminotransferase. In these situations, 100–200 mg/d of oral 
vitamin B6 is required for treatment.

●
The safe upper limit for vitamin B has been set at 100 mg/d, although no 
adverse effects have been associated with high intakes of vitamin B6 from 
food sources only.

●
When toxicity occurs, it causes severe sensory neuropathy, leaving 
patients unable to walk. Some cases of photosensitivity and dermatitis 
have been reported.

VITAMIN - C
●
Actions of vitamin C include antioxidant activity, promotion of nonheme iron absorption, carnitine biosynthesis, conversion of dopamine to norepinephrine, and synthesis 2313 of many peptide hormones.
●
Vitamin C is also important for connective tissue metabolism and cross-linking (proline hydroxylation), and it is a component of many drug-metabolizing enzyme systems, particularly the mixed-function oxidase systems.
ABSORPTION And Dietary sources
●
Vitamin C is almost completely absorbed if <100 mg is administered in a single dose however, only ≤50% is absorbed at doses >1 g. Enhanced degradation and fecal and urinary excretion of vitamin C occur at higher intake levels.
●
Good dietary sources of vitamin C include citrus fruits, green vegetables, tomatoes, and potatoes. Consumption of ﬁve servings of fruits and vegetables a day provides vitamin C in excess of the RDA of 90 mg/d for men and 75 mg/d for women.. 

Scene 36

VITAMIN - C
●
Actions of vitamin C include antioxidant activity, promotion of nonheme 
iron absorption, carnitine biosynthesis, conversion of dopamine to 
norepinephrine, and synthesis 2313 of many peptide hormones.
●
Vitamin C is also important for connective tissue metabolism and 
cross-linking (proline hydroxylation), and it is a component of many 
drug-metabolizing enzyme systems, particularly the mixed-function 
oxidase systems.
ABSORPTION And Dietary sources
●
Vitamin C is almost completely absorbed if <100 mg is administered in a 
single dose however, only ≤50% is absorbed at doses >1 g. Enhanced 
degradation and fecal and urinary excretion of vitamin C occur at higher 
intake levels.
●
Good dietary sources of vitamin C include citrus fruits, green vegetables, 
tomatoes, and potatoes. Consumption of ﬁve servings of fruits and 
vegetables a day provides vitamin C in excess of the RDA of 90 mg/d for 
men and 75 mg/d for women.

. . DEFICIENCY. ●
Vitamin C deﬁciency also can occur in young adults who eat severely unbalanced diets and can also causes scurvy. 

Scene 37

●
Vitamin C deﬁciency also can occur in young adults who eat severely 
unbalanced diets and can also causes scurvy

●
In children, vitamin C deﬁciency may cause impaired bone growth 
Laboratory diagnosis of vitamin C deﬁciency is based on low plasma or 
leukocyte levels.

●
High-dose vitamin C supplementation may slightly decrease the 
symptoms and duration of upper respiratory tract infections

●
Taking >2 g of vitamin C in a single dose may result in abdominal pain, 
diarrhea, and nausea.

●
vitamin C may be metabolized to oxalate, it is feared that chronic high 
dose vitamin C supplementation could result in an increased prevalence 
of kidney stones.

VITAMIN - A
●
Vitamin A, in the strictest sense, refers to retinol. However, the oxidized metabolites retinaldehyde and retinoic acid are also biologically active compounds.
●
Retinaldehyde is the form of vitamin A that is required for normal vision, whereas retinoic acid is necessary for normal morphogenesis, growth, and cell differentiation.
●
Vitamin A is found in the human food supply in two forms: pre- formed as esters and provitamin A in car
●
The liver contains ~90% of the vitamin A reserves and secretes vitamin A in the form of retinol, which is bound in the circulation to retinol-binding protein.. 

Scene 38

VITAMIN - A
●
Vitamin A, in the strictest sense, refers to retinol. However, the oxidized 
metabolites retinaldehyde and retinoic acid are also biologically active 
compounds.
●
Retinaldehyde is the form of vitamin A that is required for normal vision, 
whereas retinoic acid is necessary for normal morphogenesis, growth, and 
cell differentiation.
●
Vitamin A is found in the human food supply in two forms: pre- formed as 
esters and provitamin A in car
●
The liver contains ~90% of the vitamin A reserves and secretes vitamin A in 
the form of retinol, which is bound in the circulation to retinol-binding 
protein.

. . DIETARY SOURCES. ●
Liver, ﬁsh, and eggs are excellent food sources for preformed vitamin A; vegetable sources of provitamin A carotenoids include dark green and deeply colored fruits and vegetables.. 

Scene 39

●
Liver, ﬁsh, and eggs are excellent food sources for preformed vitamin A; 
vegetable sources of provitamin A carotenoids include dark green and deeply 
colored fruits and vegetables.

●
Exclusive breastfeeding can cover the vitamin A needs of infants if the mother 
has an adequate vitamin A status and a large enough volume of milk.

●
Vitamin A status is usually assessed by measuring serum retinol (normal range, 
1.05–3.50 μmol/L [30–100 μg/dL]) or blood-spot retinol or by tests of dark 
adaptation.

●
vitamin A deﬁciency worldwide is present in 190 million preschool-age 
children, among whom >5 million have an ocular manifestation of deﬁciency 
termed xerophtha

●
Maternal vitamin A deﬁciency may also exacerbate already low vitamin A 
nutrition and associated risks for the newborn.

●
single oral dose (50,000 IU) of vitamin A shortly after birth has reduced infant 
mortality by ≥10%,

. . TREATMENT. ●
Any stage of xerophthalmia should be treated with 60 mg (or RAE) or 200,000 IU of vitamin A in oily solution, usually contained in a soft-gel capsule.. 

Scene 40

●
Any stage of xerophthalmia should be treated with 60 mg (or RAE) or 
200,000 IU of vitamin A in oily solution, usually contained in a soft-gel 
capsule.

●
The same dose is repeated 1 and 14 days later. Doses should be 
reduced by half for patients 6–11 months of age.

●
A common approach to prevention is to provide vitamin A 
supplementation every 4–6 months to young children 6 months to 5 
years of age (both HIV-positive and HIV-negative) in high-risk areas

●
Children hospitalized with measles should receive two 60-mg doses of 
vitamin A on two consecutive days.

. . VITAMIN - D. ●
Vitamin D is thought to be important for maintaining normal function of many non skeletal tissues such as muscle, for immune function, and for inﬂammation as well as for cell proliferation and differentiation.. 

Scene 41

●
Vitamin D is thought to be important for maintaining normal function of 
many non skeletal tissues such as muscle, for immune function, and for 
inﬂammation as well as for cell proliferation and differentiation.

●
The biologic effects of this vitamin are mediated by vitamin D receptors, 
which are found in most tissues; binding with these receptors potentially 
expands vitamin D actions to many different cell systems and organs in 
addition to the classic endocrine effects on calcium and phosphate 
metabolism and bone health.

●
vitamin D may be useful as adjunctive treatment for tuberculosis, 
psoriasis, and multiple sclerosis or for the prevention of certain cancers.

●
The skin is a major source of vitamin D, which is synthesized upon skin 
exposure to ultraviolet B radiation.

Deﬁciency ●
Vitamin D status has been assessed by measuring serum levels of 25-dihydroxyvitamin D (25[OH] vitamin D); however, there is no consensus on a uniform assay or on optimal serum levels. ●
The optimal level might, in fact, differ according to the targeted disease entity. ●
Risk factors for vitamin D deﬁciency are old age, lack of sun exposure, dark skin (especially among residents of northern latitudes), fat malabsorption, and obesity. ●
Rickets represents the classic disease of vitamin D deﬁciency. Signs of deﬁciency are muscle soreness, weakness, and bone pain. ●
The consumption of fortiﬁed or enriched foods as well as suberythemal sun exposure should be encouraged for people at risk for vitamin D deﬁciency.
● If adequate intake is impossible, vitamin D supplements should be taken, especially during the winter months
●
Vitamin D deﬁciency can be treated by the oral administration of 50,000 IU/week for 6–8 weeks followed by a maintenance dose of 800 IU/d (20 μg/d) from food and supplements once normal plasma levels have been attained.. 

Scene 42

Deﬁciency 
●
Vitamin D status has been assessed by measuring serum levels of 
25-dihydroxyvitamin D (25[OH] vitamin D); however, there is no consensus 
on a uniform assay or on optimal serum levels. 
●
The optimal level might, in fact, differ according to the targeted disease 
entity. 
●
Risk factors for vitamin D deﬁciency are old age, lack of sun exposure, dark 
skin (especially among residents of northern latitudes), fat malabsorption, 
and obesity. 
●
Rickets represents the classic disease of vitamin D deﬁciency. Signs of 
deﬁciency are muscle soreness, weakness, and bone pain. 
●
The consumption of fortiﬁed or enriched foods as well as suberythemal sun 
exposure should be encouraged for people at risk for vitamin D deﬁciency.
●
 If adequate intake is impossible, vitamin D supplements should be taken, 
especially during the winter months
●
Vitamin D deﬁciency can be treated by the oral administration of 50,000 
IU/week for 6–8 weeks followed by a maintenance dose of 800 IU/d (20 
μg/d) from food and supplements once normal plasma levels have been 
attained.

Toxicity ●
The upper limit of intake has been set at 4000 IU/d
●
Contrary to earlier beliefs, acute vitamin D intoxication is rare and usually is caused by the uncontrolled and excessive ingestion of supplements or by faulty food fortiﬁcation practices. High plasma levels of 1,25(OH) vitamin D and calcium are central features of toxicity and 2 mandate discontinuation of vitamin D and calcium supplements; in addition, treatment of hypercalcemia may be required.. 

Scene 43

Toxicity 
●
The upper limit of intake has been set at 4000 IU/d
●
Contrary to earlier beliefs, acute vitamin D intoxication is rare and usually 
is caused by the uncontrolled and excessive ingestion of supplements or 
by faulty food fortiﬁcation practices. High plasma levels of 1,25(OH) vitamin 
D and calcium are central features of toxicity and 2 mandate 
discontinuation of vitamin D and calcium supplements; in addition, 
treatment of hypercalcemia may be required.

VITAMIN - E
●
Vitamin E is the collective designation for all stereoisomers of tocopherols and tocotrienols, although only the RR tocopherols meet human requirements.
● It acts as a chain-breaking antioxidant and is an efﬁcient peroxyl radical scavenger that protects low-density lipoproteins and polyunsaturated fats in membranes from oxidation. A network of other antioxidants (e.g., vitamin C, glutathione) and enzymes maintains vitamin E in a reduced state. ●
Vitamin E also inhibits prostaglandin synthesis and the activities of protein kinase C and phospholipase A2.
Absorption and Metabolism
● After absorption, vitamin E is taken up from chylomicrons by the liver, and a hepatic α-tocopherol transport protein mediates intracellular vitamin E transport and incorporation into very low density lipoprotein. ●
The transport protein has a particular afﬁnity for the RRR isomeric form of α-tocopherol; thus, this natural isomer has the most biologic activity.. 