Handbook of Vitamins, Fourth Edition (CLINICAL NUTRITION IN HEALTH AND DISEASE)

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Customers who bought this item also bought. Advanced Nutrition and Human Metabolism. Review "Maintaining the status as the highest quality reference in the field, the Handbook of Vitamins brings together leading experts in molecular biology, biochemistry, and physiology to incorporate these new discoveries into this updated and revised fourth edition. Read more. Try the Kindle edition and experience these great reading features:. No customer reviews. Share your thoughts with other customers. Write a customer review. There's a problem loading this menu right now. Studies indicate that women with hyperemesis have similar demographic characteristics to the general obstetric population racial status, marital status, age, and gravidity The pathogenesis of HG is not well understood.

Potential causes include hormonal changes, thyroid changes eg, hyperthyroidism , bacterial infection eg, underlying Helicobacter pylori infection , and increasing levels of human chorionic gonadotrophin hCG 26,30, Hyperemesis gravidarum often spontaneously resolves after the first trimester Treatment depends on the risk level of the patient and severity of symptoms, eg, the inability to meet nutritional needs orally and dehydration.

Intensive nutrition counseling and individualized meal planning is the first line of treatment In patients where nutrition and behavior modification does not alleviate symptoms medication is often prescribed, eg, reglan, zantac, compazine, zofran In patients whose symptoms are severe, hydration with IV fluids, electrolyte replacement and in some cases vitamin replacement is needed 26,30, Nutritional interventions for severe hyperemesis gravidarum may include naso-gastric, gastrostomy, jejunostomy feedings or TPN. Nearly all of the literature regarding nutrition support during pregnancy is anecdotal, consisting of case studies.

Treatment and intervention strategies are based on experience and patient need. If nutrition support is indicated, treatment is consistent with standards outlined for non-pregnant adults or in managing co-existing disease states, as outlined in Specialized Nutrition Support and as outlined in Specific Nutrient Requirements During Pregnancy.

Preeclampsia occurs more often in primigravid women and in women over 35 years old. PIH is also associated with marked changes in renal function that may lead to excessive extracellular fluid retention. When PIH is accompanied by convulsions, it is called eclampsia. Preeclampsia usually occurs after the 20th week of conception.

It is more common among adolescents, underweight women who fail to gain weight properly, and low-income populations, and when there are multiple fetuses. There is no evidence of a nutritional basis for the disease, but a well-balanced diet is advisable. Adequate calcium, protein, energy, and potassium are necessary. Diuretics should be avoided unless given under strict medical supervision.

Specific Nutrient Requirements During Lactation Energy: It is assumed that 3 kg of fat stored by the woman during pregnancy is available during the first 3 postpartum months. Excessive restriction of energy may compromise milk production. Protein: An additional 15 g of protein over the DRI is required during lactation 1. Fluids: Intake of 2 to 3 qt of fluid daily is encouraged to compensate for the volume of milk produced. Alcohol: Discourage consumption of alcohol unless permitted by the physician. Brown JE, Carlson M.

Nutrition and multifetal pregnancy. Institute of Medicine, Food and Nutrition Board. MRC Research Group. Prevention of neural tube defects: results of the Medical Research Council vitamin study. Recommendations for the use of folic acid to reduce the number of cases of spina bifida and other neural tube defects. American College of Obstetricians and Gynecologists. Folic acid for the prevention of recurrent neural tube defects. Nutrition and Women. Technical Bulletin Number Risks of orofacial clefts in children born to women using multivitamins containing folic acid periconceptionally.

Food and Drug Administration. Vitamin A and birth defects [press release]. October 6, Nutrition During Pregnancy. Nutrition Management During Pregnancy. Manual of Clinical Dietetics. Chicago, Ill: American Dietetic Association; Escott-Stump S. Nutrition and Diagnosis-Related Care. Fagen C. Nutrition during Pregnancy and Lactation. Maternal serum paraxanthine, a caffeine metabolite, and the risk of spontaneous abortion.

N Engl J Med. Maternal caffeine consumption and spontaneous abortion: a prospective cohort study. Suitor CW. Nutrition for woman in their childbearing years: a review of the literature and summary of expert recommendations. Nutr Clin Care. An indirect means of assessing potential nutritional effects of dietary olestra in healthy subgroups of the general population. J Nutr. Position of the American Dietetic Association: use of nutritive and nonnutritive sweeteners.

Institute of Medicine IOM. Jewell D, Young G. Interventions for nausea and vomiting in early pregnancy. Cochrane Database Syst Rev. Erick M. Battling morning noon and evening sickness: new approaches for an age-old problem. Wagner BA, Worthington P. Nutrition management of hyperemesis gravidarum. Nutr Clin Pract. Managing hyperemesis gravidarum with home parenteral nutrition: treatment parameters and clinical outcomes.

Cowan MJ. Hyperemesis gravidarum: implications for home care and infusion therapies. J Intraven Nurs. Maternal and fetal outcomes in hyperemesis gravidarum. Int J Gynaecol Obstet. Helicobacter pylori infection and persistent hyperemesis gravidarum. Am J Perinatol. Nelso-Percy C. Treatment of nausea and vomiting in pregnancy.

When should it be treated and what can be safely take? Drug Saf. Hyperolfaction and hyperemesis gravidarum: what is the relationship? Nutr Review. Its impact, however, is often ignored until adulthood. Progressive changes in body composition, sensory perception, functional status and physiologic functioning occur at all ages.

The rate of change is strongly influenced by the genetic background and life experiences of the individual Older adults display wide individual variations in aging processes and thus in nutritional needs and concerns. Maximizing and maintaining adult potential becomes the major health care objective. The nutritional care goal is to provide education and support to achieve this objective as decreases in metabolic needs, declining activity levels, illness, infirmity, economic hardship, loss of social support systems, and other variables mandate adjustments in food intake.

Each older adult should be viewed as a unique individual. Chronological age and functional capacity do not directly correlate. Diversity increases with age 4. Provision of quality nutritional care requires the regular, systematic, longitudinal assessment of each older individual as well as a nutritional care plan based on specific needs identified. The least restrictive regimen possible should be implemented. Dietary Considerations for the Older Adult Although the DRIs are the same for all people over 51 years of age, there are special considerations for the elderly defined as 65 to 74 years old, the moderately old defined as 74 to 84 years old, and the very old defined as more than 85 years old.

Taste and smell dysfunction tends to begin at around 60 years of age and becomes more severe in persons over 70 5. Two thirds of persons over 75 years of age are edentulous. More sweet flavorings or salty foods may be required to satisfy the appetite of elderly individuals. As BMR decreases with advancing age and physical activity is reduced, energy needs decrease.

Meeting the nutritional needs of the older adult is challenging because although caloric needs decrease, protein, vitamins and minerals remain the same or increase. The average daily calorie intake for persons over 51 years of age is calories for men and calories for women.

Health problems arise when the caloric intake is less than kcal per day 6. In , the Food and Nutrition Board concluded that protein should be 0. Metabolic and physical changes that affect the status of vitamin B6, B12, and folic acid may alter behavior and general health, whereas adequate intake of these nutrients prevents some decline in cognitive function associated with aging Deficiencies of these nutrients, along with inadequate intake of vitamin C and riboflavin, may result in poor memory Immune function affected by nutritional status may be improved by an increased intake or supplementation of protein, vitamins B6 and E, and zinc.

Vitamin D levels may be reduced in the elderly even with adequate exposure to the sunlight, and deficiency may be exacerbated by homebound status, use of sun block, poor dietary intake, decreased capabilities to synthesize cholecalciferol in the skin, and decreased number of gastrointestinal receptors 6,14, Supplementation of vitamin D and calcium may reduce the incidence of hip fractures and may increase bone density 9, Dehydration is a major problem for the elderly. Water intake needs are the same for the young and the old, but the elderly are prone to inadequate water intake.

Frequently, diseases will reduce the ability to recognize thirst, create an inability to express thirst, or decrease access to water 9, Even healthy elderly persons appear to have reduced thirst in response to fluid deprivation. Fear of incontinence and difficulty making trips to the toilet, due to arthritic pain or other immobility, may also interfere with adequate fluid consumption 9. Contributors to Poor Nutritional Status in the Elderly A variety of factors may contribute to poor nutritional status as individuals age Table IA-2 lists some of the factors frequently identified as potential causes of malnutrition.

Handbook of vitamin D in human health | Human Health Handbooks

These must be kept in mind when evaluating nutritional status and when developing a care plan to prevent, delay, or correct problems identified. For some conditions, cure is not possible but ameliorative or palliative nutritional interventions are often indicated 21, Improvement in the quality of life will frequently ensue. Include foods that can be easily chewed and not cause gastrointestinal discomfort.

Sodium-restricted diets should be used with caution in the elderly. Response to medical nutrition therapy to improve the albumin level is longer in the older individual. Depression, use of many medications, underlying medical illnesses, and other factors should be addressed to correct this condition. Dwyer J. White JV. Risk factors for poor nutritional status. Primary Care. Gopalan C. Dietetics and nutrition: impact of scientific advances and development. National Research Council. Schiffman SS. Changes in taste and smell: drug interactions and food preferences.

Nutr Rev. Harris NG. Nutrition in Aging. Increased protein requirements in elderly people: new data and retrospective reassessments. Am J Clin Nutr. Nutrition, exercise, and healthy aging. Position of The American Dietetic Association: nutrition, aging, and the continuum of care. Tripp F. The use of dietary supplements in the elderly: current issues and recommendations. Nutritional factors in physical and cognitive functions of elderly people. Blumberg J. Nutrient requirements of the healthy elderly-should there be specific RDAs? Daily micronutrient supplements enhance delayed hyposensitivity skin test responses in older people.

Major issues in geriatrics over the last five years. J Am Geriatr Soc. Vitamin D-3 and calcium to prevent hip fractures in elderly women. Nutrition and the Older Adult Vitamin D deficiency in homebound elderly persons. Dehydration: evaluation and management in older adults.

Risk factors associated with poor nutritional status. Niedert K, ed. Nutrition Care of the Older Adult. White J. Risk factors associated with poor nutritional status in older Americans. Consensus of the Nutrition Screening Initiative: risk factors and indicators of poor nutritional status in older Americans. Goodwin J. Social, psychological and physical factors affecting the nutritional status of elderly subjects: separating cause and effect. Roe D. Geriatric nutrition.

Clin Geriatric Med. For the greatest variety of foods, all foods that are easily masticated are included in the diet. Indications The Mechanical Soft Diet is indicated for the patient who has difficulty in chewing or swallowing. For the patient progressing in dysphagia rehabilitation, any additional needs such as thickened liquids should be specified in the diet order. Planning the Diet The menu selection and the individual patient tolerances should be considered when planning a Mechanical Soft Diet.

Fruit juices Ripe banana, melon, peeled peaches, pears, strawberries, seedless grapes Applesauce Any cooked or frozen fruit Citrus sections Stewed prunes; other tender stewed dried fruit Canned peaches, pears, apricots, pineapple, fruit cocktail. Tender meat, fish, or poultry Soft cheese Chopped or ground meats, poultry Soft casseroles Meat, fish, or egg salads Hard cooked or scrambled eggs Peanut butter; liverwurst. Cake; tender cookies Ice cream; sherbet; gelatin; custard; pudding Pie: cream, custard, pumpkin, soft fruit pies Flavored yogurt.

Desserts containing nuts, coarse dried fruit, or tough fruit Desserts baked to a hard consistency. Diet following temporomandibular joint surgery: Foods such as breads, crackers, and cookies should be broken up into small pieces before eating so as to avoid biting down or opening the mouth wide. Foods that may not be tolerated include: toast, meats not ground, snack chips, foods containing coconut, corn.

Smyrna, Ga; Morrison Management Specialists; : smooth and thickened. Indications The Pureed Diet is used for patients with problems in chewing and swallowing or esophageal inflammation or varices. Include any other special instructions. As desired. For dysphagic patients, thickened per diet order. Doughnuts, pancakes, waffles, French toast, bread prepared in a slurry; regular soft bread and crackers may be used for patients if swallowing ability permits.

All cooked cereals; strained oatmeal; milk-soaked or well-moistened dry cereal if Cereals and Grains swallowing ability permits. Applesauce; pureed thickened fruits; fruit juices. Butter, margarine, cream, gravy, mayonnaise. Fats All smooth cream or broth-base soups with pureed ingredients. Regular versions of these foods if swallowing ability permits. Sugar, jelly, honey, syrup. Sugar and Sweets. The amount of fluid required to maintain the optimum hydration level varies with the medical condition of the patient. Indications In the healthy individual, normal sensations of thirst promote the consumption of adequate fluid and the maintenance of optimum hydration.

However, some patients may not recognize thirst, may not be able to communicate thirst, or may not freely consume liquids. Risk factors for dehydration include any of the following: — unconscious; semiconscious and confused state — severe depression — tranquilizer or sedative use — enteral feeding — must be fed or require assistance with feeding — diarrhea — poor appetite — immobility — diuretic use — frequent laxative use — perspiration in hot weather where air conditioning is unavailable.

Nutritional Adequacy See statement pertaining to diet order. Order should include amount of fluid to be given by Food and Nutrition Services with meals and snacks and amount of fluid to be given by nursing i. Planning the Diet When the dietitian calculates the intake of fluids, foods that are liquid at room temperature should be counted by cubic centimeters. Such foods include water, carbonated beverages, coffee and tea, gelatin, milk, water ices and popsicles, soups, supplements, eggnog, ice cream and sherbet, and milk shakes.

Treatment is accomplished by increasing oral intake of fluid and electrolytes as needed. Patients with more severe cases and those who are unable to take fluids by mouth are treated by appropriate intravenous fluid replacement. Note: Internal sequestering, also known as third spacing, may create a deficit of water in some compartments, although total body water is unaltered. Replacement water requirements may be greatly increased in peritonitis, pancreatitis, enteritis, ileus, or portal vein thrombosis.

An evaluation of fluid requirements should be made on an individual basis. A precise intake and output record is necessary to determine and meet fluid requirements. The magnitude of factors determining water loss precludes the setting of a general rule for estimating minimal water requirements. General guidelines for calculating fluid needs based on age are: 1.

One bed change due to perspiration represents approximately 1 L of fluid lost Patients receiving mechanical ventilation or other source of humidified oxygen can absorb up to an additional cc of fluid daily, whereas unhumidified oxygen therapy can result in a net loss of fluid Patients treated on air-fluidized beds may become dehydrated easily due to evaporative water loss.

Evaporative loss can increase two to four times the normal amount. Fluid loss has also been correlated to the bed temperature. Serial assessment of body weight is probably the most reliable parameter, especially because water makes up such a large proportion of total body weight Along with serial assessment, the following physical alterations can be assessed to help determine hydration status 13, Serum sodium is the best indicator of intracellular fluid disorders. The hematocrit reflects the proportion of blood plasma to red blood cells. Fluid loss causes hemoconcentration and serum osmolality; fluid gain causes hemodilution and decreases serum osmolality.

Aging increases the risk for dehydration based on the physical and psychological changes. Refer to the following section for further information: See Enteral Nutrition, in Section IB for discussion of calculation of free water in tube feeding. Fluid Restriction In congestive heart failure, ascites, end-stage renal disease, and other disorders, patients retain fluid.

A fluid restriction is often useful in the management of these conditions. Kleiner SM, Water an essential but overlooked nutrient. Manual of Pediatric Nutrition. Appendix B: Macronutrient requirements. Philadelphia, Pa: W. Saunders Co; Pediatric Manual of Clinical Dietetics.

Fluid intake in the institutionalized elderly. Dietitians in nutrition support: fluid requirements. Support Line. Chernoff R. Meeting the nutritional needs of the elderly in the institutionalized setting. Fluid intake compared with established standards and symptoms of dehydration among elderly residents of a long-term care facility. Pressure ulcer protocol. Dolan JT. Fluid and Electrolyte Physiology and pathophysiology.

In: Dolan JT, ed. Critical Care Nursing. Breslow RA. Nutrition and air-fluidized beds: a literature review. Adv Wound Care. Methany NM. Fundamental concepts and definitions. In: Methany NM, ed. Fluid and Electrolyte Balance: Nursing Considerations. Philadelphia, Pa: JB Lippincott; Lysen L. Quick Reference to Clinical Dietetics. Gaithersburg, Md: Aspen Publishers; A wide spectrum of dietary practices are considered vegetarian. Ovolactovegetarian: Milk and milk products as well as eggs are the only animal products included.

Lactovegetarian: Milk and milk products are the only foods of animal origin included. Ovovegetarian: Eggs are the only animal product included. Total vegetarian vegan : The diet consists of foods of plant origin only. Indications Vegetarian diets are adapted for a variety of health, ecological, economical, philosophical, and ethical reasons 1. Many epidemiologic data suggest a positive relationship between vegetarian lifestyles and risk reduction for several chronic degenerative diseases such as obesity, coronary artery disease, hypertension, diabetes mellitus, and some types of cancer.

However, this relationship likely is due to lifestyle factors in addition to diet 1. Nutritional Adequacy Vegetarian diets are healthful and nutritionally adequate when appropriately planned 1. Nutrients that are often of concern are vitamins B12 and D, calcium, iron, zinc, and linolenic acid. All vegan children should have a reliable source of vitamin B12, and if sun exposure is limited, vitamin D supplements or fortified foods should be emphasized Pregnant and lactating vegans should receive, respectively, supplements of 2 mg and 2.

Keep to a minimum the intake of foods with low-nutrient density, such as sweets and fatty foods. Choose a variety of foods, including fruits, vegetables, whole grains, legumes, nuts, seeds, and, if desired, dairy products and eggs. Choose whole or unrefined grain products whenever possible, instead of refined products. If milk products are consumed, use lower fat versions. Include a regular source of vitamin B12, along with a source of vitamin D if sun exposure is limited. Protein: Although vegetarian diets usually meet or exceed requirements for protein, they typically provide less protein than nonvegetarian diets.

Although plant foods contain less of the essential amino acids than do equivalent quantities of animal foods, a plantbased diet can provide adequate amounts of amino acids when a varied diet is consumed on a daily basis. A mixture of different proteins from unrefined grains, legumes, seeds, nuts, and vegetables will complement each other in their amino acid profiles so that deficits in one are made up by the others.

Different types of protein that complement each other should be eaten over the course of the day. Vitamin B A vegan should supplement his or her diet with vitamin B12 by using a cobalamin supplement or by selecting fortified foods such as fortified soy milk or breakfast cereals, to ensure an adequate intake of the active form of the nutrient. Although the requirement for vitamin B12 is minute, vegetarians must include a reliable source. Supplements are advised for all older vegetarians because absorption of vitamin B12 becomes less efficient as the body ages 1.

Calcium: Calcium intake of ovolactovegetarians is comparable or higher than that of nonvegetarians. It should be noted that vegans may have lower calcium needs than nonvegetarians because diets that are low in total protein and have more alkaline have been shown to have a calcium-sparing effect. If vegans do not meet calcium requirements from food, dietary supplements are recommended 1. Vitamin D: Reliance on sunlight alone, particularly in northern climates or in cultures where most of the body is concealed in clothing, may not provide all of the vitamin D needed.

A vitamin D supplement may be necessary for persons who do not ingest vitamin D-fortified milk products or cereals or do not obtain 5 to 15 minutes of exposure to sunlight daily 5 , especially for dark-skinned individuals 1,5. Energy: Vegan diets tend to be high in bulk, making it more challenging for them to meet energy needs, especially for infants, children, and adolescents.

Frequent meals, snacks, and eating foods higher in fat can help vegetarian children meet energy needs 1. Iron: The non-heme iron found in plant foods is more sensitive than heme iron to both inhibitors and enhancers of iron absorption 1. Western vegetarians have a relatively high intake of iron from plant foods, such as dark-green leafy vegetables, iron-fortified cereals, and whole grains. Although vegetarian diets are higher in total iron than nonvegetarian diets, iron stores are lower because iron from plant foods are poorly absorbed. However, the frequency of anemia is not any higher in the vegetarian population than in the nonvegetarian population.

Zinc: Vegetarians should strive to meet or exceed the DRI for zinc due to the low bioavailability of zinc from plant sources and because the effects of marginal zinc status are poorly understood. Linolenic Acid: Diets that do not include fish or eggs lack the long chain n-3 fatty acid docosasahexaenoic acid DHA. It is recommended that vegetarians include good sources of linolenic acid in their diets, such as walnuts, canola oil, and linseed oil.

Position of The American Dietetic Association: vegetarian diets. Holuck MF. Vitamin D and bone health.

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Nutrition During Lactation. Specker BL. Nutritional concerns of lactating women consuming vegetarian diets. Position of the American Dietetic Association: Vegetarian diets. Copyright The American Dietetic Association. The collective term for the Jewish laws and customs relating to the types of foods permitted for consumption and their preparation is kashruth. The observance of kosher dietary laws varies according to the traditions of the individual and interpretations of the dietary laws. In a nonkosher food service facility, observance of dietary laws usually involves service of commercially prepared kosher dinners on disposable plastic ware for the patient following a strict kosher diet.

For patients not following a strict kosher diet or if the patient so wishes, the foods usually prepared by the Food and Nutrition Services Department can be served, as long as milk and milk products are separated from meat and meat products and certain forbidden foods are excluded see the following list. The strict observance of the kashruth by the kosher food service requires separate sets of equipment, dishes, and silverware, as well as kosher food suppliers for many items.

Dairy foods are stored and prepared separately from meat and meat products. Indications Kosher diets may be ordered for individuals of the Jewish faith if they so desire. Guidelines for Food Selection: 1. Kosher meats and poultry may come only from animals that have cloven hooves, chew their cud, and are slaughtered according to the humane and specific guidelines prescribed by the Jewish dietary laws. In addition, kosher meats undergo a process called koshering, in which blood is extracted by soaking in salt or broiling on a regular grill. Pan grilling is not acceptable.

Foods are classified as dairy, meat, or pareve. Meals are classified either as dairy or meat. Meat and meat products are not to be combined with any dairy products in recipe, food preparation, or service. Pareve foods may be served at dairy or meat meals. The strict observance of the Kashruth requires separate sets of equipment, dishes, and silverware for dairy or meat meals. In a kosher kitchen, dairy foods are stored and prepared separately from meat and meat products.

For patients not following a strict kosher diet or if the patient so wishes, the usual foods prepared by the dietary department can be served, as long as milk and milk products are separated from meat and meat products and certain forbidden foods are excluded. Processed foods: No product should be considered kosher unless so certified by a reliable rabbinic authority whose name of insignia appears on the sealed package.

The insignia, U which is the copyrighted symbol of the Union of Orthodox Jewish Congregations of America, indicates that the product is certified as to its kosher nature. Packages marked with other symbols may be suitable for certain but not all kosher diets. It is important that a kosher food package remains sealed when presented to the user.

Nonkosher foods may be used if considered essential in the treatment of an ill person. However, a rabbi should be consulted before waiving dietary restrictions. Bread made with lard or animal shortening. Note: Breads and cereals containing any dairy products are classified as dairy Eggs containing blood spots.

Fish having both fins and scales: halibut, flounder, cod, tuna, haddock, pollack, turbot, salmon, trout, whitefish, herring, etc. Imitation sour cream or whipped topping with pareve certification Sugar, jam, jelly, syrup Candy without milk. Coffee, tea, carbonated beverages Alcoholic beverages Nondairy creamer with pareve certification Those made with milk or milk products are considered to be a part of the dairy group. Desserts made with lard or animal shortening Monoglycerides and diglycerides and emulsifiers that may be from animal fats.

The diet as served will yield approximately to kcal when calorie-containing clear liquids are served between meals. Indications The Clear Liquid Diet is indicated for the following:.

Handbook of Vitamins, Third Edition (Clinical Nutrition in Health and Disease)

Nutritional Adequacy The diet is inadequate in all food nutrients and provides only fluids, energy, and some vitamin C. Low-residue food supplements are desirable if the diet is for prolonged use. A diet order specifying the number of meals or days of liquids or the diet progressions, as tolerated, will ensure that this nutritionally inadequate diet is advanced or evaluated. The diet provides nourishment that is easy to consume and digest with very little stimulation to the gastrointestinal tract.

Indications The Full Liquid Diet may be indicated following oral surgery or plastic surgery of the face or neck area in the presence of chewing or swallowing dysfunction for acutely ill patients. The Full Liquid Diet has been traditionally used as a postoperative transitional diet. The diet is intended for short-term use only; therefore, attempts are not usually made to increase the variety of foods offered to provide for the total adequacy of nutrients.

Contraindications Due to the liberal use of milk and foods made with milk, the diet is high in lactose.

Handbook of Vitamins, Fourth Edition CLINICAL NUTRITION IN HEALTH AND DISEASE

A temporary lactose intolerance may occur in some patients following surgery. Symptoms of lactose intolerance upon ingestion of a Full Liquid Diet may result, and the diet should be modified for the patient. It may not meet the protein and caloric requirements of the individual. The diet as served will provide approximately kcal and 40 g of protein.

When between-meal nourishment is added, the intake is increased to to kcal and 65 g of protein. Protein and caloric intake can be increased through the use of additional full liquid foods at meals and between meals. The diet can be nutritionally adequate when supplements are offered and consumed in sufficient amounts. A diet order specifying the duration of the diet or the diet progression, as tolerated, will ensure that this nutritionally inadequate diet is advanced or evaluated.

The diet also includes foods that, if eaten by spoon, will turn to a liquid consistency in the mouth. Such information is vital to clinicians, users of vitamin D supplements of all ages and those interested in public policy. The authors document and define many of the key health related roles of vitamin D. Its traditional application in bone and muscle health as well as therapy of arthritis is expanded and clarified with new research. A better understanding of the effects of vitamin D inadequacy is modelled using problems ranging from infant growth retardation to chronic kidney and periodontal disease.

Mechanistic understanding of vitamin D's actions is enhanced by looking into its effects on immune modulation and inflammation. Expansion of the role of sunlight in stimulating vitamin D production is discussed relative to the reduction in a variety of cancers. Clearly vitamin D is like a two edged sword with great benefits but also some risks.

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