Manual of Clinical Nutrition 2013

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M A N U A L O F

Clinical Nutrition

Management

2013, 2011, 2008, 2007, 2006, 2005, 2003, 2002, 2000, 1997, 1994, 1993, 1991, 1988 by Morrison , Inc (a sector of Compass Group, Inc.).

No part of this book may be reproduced, stored in any retrieval system, or transmitted in any form or by any means,including electronic, mechanical, photocopying, recording or otherwise, without written permission from Morrison, Inc.


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Manual of Clinical Nutrition Management ii Copyright © 2013 Compass Group, Inc.All rights reserved.

E. Pediatric Diets ................................................................................................................................Nutrition Management of the Full-Term Infant ........................................................................................................... E-1

Infant Formula Comparison Chart ............................................................................................................................ E-4 Nutrition Management of the Toddler and Preschool Child .................................................................................. E-7 Nutrition Management of the School-Aged Child ........................................................................................................ E-9 Nutrition Management of the Adolescent .................................................................................................................... E- Ketogenic Diet .................................................................................................................................................................... ....

F. Modification of Minerals .............................................................................................................Sodium-Controlled Diet ................................................................................................................................................. ........

No Added Salt Diet (4,000-Mg Sodium Diet) ........................................................................................................ F-4 Food Guide — 3,000-Mg Sodium Diet ..................................................................................................................... F- 2,000 Mg And 1,500 Mg Sodium Restricted Diet Patterns ............................................................................. F-6 Food Guide — 1,000-Mg Sodium Diet ..................................................................................................................... F-

Nutrition Management of Potassium Intake .............................................................................................................. F-10 Potassium Content of Common Foods...................................................................................................................F-11

Nutrition Management of Phosphorus Intake ........................................................................................................... F-12 Phosphorous Content of Common Foods .............................................................................................................F-13

Nutrition Management of Calcium Intake ................................................................................................................... F-14 Calcium Content of Common Foods .......................................................................................................................F-15

G. Modification of Protein ...............................................................................................................Protein-Controlled Diet for Acute and Refractory Hepatic Encephalopathy .................................................. G-1

Protein-Based Exchanges .............................................................................................................................................. G Medical Nutrition Therapy for Chronic Kidney Disease .......................................................................................... G-7

Meal Patterns Using Healthy Food Guide ............................................................................................................ G-27 Simplified Renal Diet .............................................................................................................................................................

H. Diets for Sensitivity/Miscellaneous Intolerances .............................................................Gluten-Free Diet .....................................................................................................................................................................

Food Guide – Gluten-Free Diet ....................................................................................................................................H Tyramine-Restricted Diet ............................................................................................................................................. ...... H- Lactose-Controlled Diet ....................................................................................................................................................... H Nutrition Management of Food Hypersensitivities ................................................................................................. H-16

II. NUTRITION ASSESSMENT/INTERVENTION Body Weight Evaluation and Indicators of Nutrition-Related Problems ........................................................ II-1 Stature Determination .................................................................................................................................................... ........ Body Mass Index (BMI) ......................................................................................................................................................... Determining Ideal Body Weight (IBW) Based on Height to Weight: The Hamwi Method...................... II-7 Standard Body Weight (SBW) Determination Based On NHANES II ................................................................. II-8 Determination of Frame Size ............................................................................................................................................... II Estimation of Ideal Body Weight and Body Mass Index for Amputees .......................................................... II-10 Estimation of Energy Expenditures ................................................................................................................................ II-12 Estimation of Protein Requirements ................................................................................................ ............................. II-17 Laboratory Indices of Nutritional Status ..................................................................................................................... II-18 Classification of Some Anemias ........................................................................................................................................ II- Diagnostic Criteria for Diabetes Mellitus ..................................................................................................................... II-21 Major Nutrients: Functions and Sources ...................................................................................................................... II-23 Physical Signs of Nutritional Deficiencies ................................................................................................................... II-26 Food and Medication Interactions .................................................................................................................................. II-27 Herb and Medication Interactions ................................................................................................................................ .. II-34

III. CLINICAL NUTRITION MANAGEMENT Introduction ............................................................................................................................................................................. Anticoagulant Therapy ................................................................................................................................................... ....... I Burns ....................................................................................................................................................................................... Cancer ..................................................................................................................................................................................... Chronic Obstructive Pulmonary Disease ................................................................................................................... III-16 Corticosteroid Therapy .................................................................................................................................................. .... III Monitoring in Diabetes Mellitus ..................................................................................................................................... III-2


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Manual of Clinical Nutrition Management iii Copyright © 2013 Compass Group, Inc.All rights reserved.

Diabetes Mellitus: Considerations for Exercise .............................................................................................. III-23 Diabetes Mellitus: Considerations for Acute Illness ..................................................................................... III-25 Diabetes Mellitus: Gastrointestinal Complications ....................................................................................... III-27 Diabetes Mellitus: Oral Glucose-Lowering Medications and Insulin .................................................... III-29 Diabetes Mellitus: Fat Replacers and Nutritive/Nonnutritive Sweeteners ....................................... III-32

Dysphagia ...................................................................................................................................................... ......................... Relationship of Dysphagia to the Normal Swallow ...................................................................................... III-37

Enteral Nutrition: Management of Complications ................................................................................................. III-38

Gastroesophageal Reflux Disease (GERD) ................................................................................................................. III-40 Heart Failure ................................................................................................................................................ ........................... HIV Infection and AIDS....................................................................................................................................................... I Hypertension .......................................................................................................................................................................... Hypertriglyceridemia ......................................................................................................................................................... III Hypoglycemia ......................................................................................................................................................................... Inborn Errors of Metabolism ........................................................................................................................................... III-7 Iron Deficiency Anemia .................................................................................................................................................. .... II Nephrotic Syndrome ........................................................................................................................................................... III Obesity and Weight Management ................................................................................................................................. III-81 Pancreatitis.............................................................................................................................................................................. Parenteral Nutrition (PN): Metabolic Complications ........................................................................................... III-94 Calculating Total Parenteral Nutrition ........................................................................................................................ III-99

Peptic Ulcer .......................................................................................................................................................................... I Pneumonia .................................................................................................................................................... ........................ II Pressure Ulcers .................................................................................................................................................................. . III Management of Acute Kidney Injury and Chronic Kidney Disease (Stage V) ......................................... III-110

Nutrition Care Outcomes and Interventions In CKD (Stage V) Renal Replacement Therapy III-116 Wilson’s Disease ................................................................................................................................................................ . I

IV. APPENDIX Caffeine and Theobromine Content of Selected Foods and Beverages ........................................................... IV-1 Metric/English Conversions of Weight and Measures ............................................................................................ IV-2 Milligram/Milliequivalent Conversions ........................................................................................................................ IV-2 Salicylate Content of Selected Foods ............................................................................................................................... IV-3

INDEX


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Manual of Clinical Nutrition Management A-i Copyright © 2013 Compass Group, Inc.All rights reserved.

I. NORMAL NUTRITION AND MODIFIED DIETSA. Normal Nutrition

Statement on Nutritional Adequacy ........................................................................................................... A-1

Estimated Energy Requirement (EER):Male and Females Under 30 Years of Age..................... A-2

Estimated Energy Requirement (EER): Men and Women 30 Years Of Age ................................... A-2

Estimated Calorie Requirements (Kcal): Each Gender and Age Group at Three Levels ofPhysical Activity .......................................................................................................................................... A-3

Dietary Reference Intakes (DRIs): Recommended Intakes for Individuals, Macronutrients A-4

Dietary Reference Intakes (DRIs): Recommended Intakes for Individuals, Vitamins ............. A-5

Dietary Reference Intakes (DRIs): Recommended Intakes for Individuals, Elements ............ A-6

Dietary Reference Intakes (DRIs): Estimated Average Requirements .......................................... A-7

Dietary Reference Intakes (DRIs): Tolerable Upper Intake Levels, Vitamins ............................. A-8

Dietary Reference Intakes (DRIs): Tolerable Upper Intake Levels, Elements ............................ A-9

Food Fortification and Dietary Supplements ....................................................................................... A-10

Regular Diet – Adult ....................................................................................................................................... A-11 Food Guide For Americans (1800-2000 Calorie Pattern) ............................................................... A-12

High-Protein, High-Calorie Diet ................................................................................................................ A-13

Nutrition Management During Pregnancy and Lactation ................................................................ A-14 Daily Food Group Guidelines ....................................................................................................................... A-14 Table A-1: Guidelines For Weight Gain After The First Trimester Of Pregnancy .................. A-14

Nutrition And The Older Adult .................................................................................................................. A-22

Table A-2: Contributors To Unintended Weight Loss and Malnutrition in Older Adults ... A-25 Mechanical Soft (Dental Soft) Diet ............................................................................................................ A-28

Food Guide – Mechanical Soft (Dental Soft) Diet ................................................................................. A-29

Pureed Diet ....................................................................................................................................................... A-30 Food Guide – Pureed Diet .............................................................................................................................. A-3

Nutrition Management Of Fluid Intake And Hydration .................................................................... A-32 Fluid Content Of The Regular Diet - Sample .......................................................................................... A-33

Vegetarian Diets .............................................................................................................................................. A-36

Kosher Guidelines .......................................................................................................................................... A-40 Food Guide – Kosher Diet .............................................................................................................................. A-4


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Manual of Clinical Nutrition Management A-1 Copyright © 2013 Compass Group, Inc.All rights reserved.

STATEMENT ON NUTRITIONAL ADEQUACYThe Dietary Reference Intakes (DRIs) of the Food and Nutrition Board of the Institute of Medicine, NationalAcademy of Sciences, are used as the standard for determining the nutritional adequacy of the regular andmodified diets outlined in this manual. DRIs reference values that are quantity estimates of nutrient intakes tobe used for planning and assessing diets for healthy people. The DRIs consist of four reference intakes:

Recommended Daily Allowances (RDA), a reference to be used as a goal for the individual.

Tolerable Upper Intake Level (UL), the intake level given to assist in advising individuals of what intakelevels may result in adverse effects if habitually exceeded. Estimated Average Requirement (EAR), the intake level which data indicates that the needs for 50% of

individuals consuming this intake will not be met. Adequate Intake (AI), a recommended intake value for a group or groups of healthy people based on fewer

data and substantially more judgment than used in establishing an EAR and subsequently the RDA.

An AI is given when the RDA cannot be set. Both of these reference intakes are to be used as goals inplanning and assessing diets for healthy individuals (1,2). The DRIs do not cover special needs for nutrientsdue to various disease conditions. DRIs are reference values appropriate for both assessing populationintakes and planning diets for healthy people (1,2).

When referring to energy, use Estimated Energy Intake (EER). EER is the average dietary energy intake

that is predicted to maintain energy balance in a healthy adult of a defined age, gender, weight, height andlevel of physical activity, consistent with good health. For children, pregnant and lactating women, the EERincludes the needs associated with deposition of tissues or the secretion of milk at rates consistent with goodhealth (3) .

The sample menus throughout this manual have been planned to provide the recommended DRIs for men,31 to 50 years of age, unless indicated otherwise, and have been analyzed by a nutrient analysis softwareprogram. For specific values, refer to the following tables of recommended DRIs from the Food and NutritionBoard of the National Academy of Sciences. However, it is acknowledged that nutrient requirements varywidely. The dietitian can establish an adequate intake on an individual basis.

Nutrient analysis of the menus is available from Webtrition and reflects available nutrient information.Webtrition pulls nutrient information from either the USDA Standard Reference database (which includes 36

of the 41 RDA/DRI nutrients) or the manufactures information (manufactures are required only to provide 13of the 41 RDA/DRI nutrients). Because of this, nutritional analysis data may be incomplete for some foodsand/or some nutrients that are listed in the DRI. The Menu Nutrient Analysis Report in Webtrition uses a (+)to indicate a partial nutritional value and a (-) to indicate no nutritional value available.

The DRIs are provided in a series of reports (3-7) . Full texts of reports are available at www.nap.edu .

References1. Yates AA, Schlicker SA, Suitor CW. Dietary Reference Intakes: The new basis for recommendations for calcium and related nutrients,

B vitamins, and choline. J Am Diet Assoc. 1998;98:699-706.2. Trumbo P, Yates A, Schlicker S, Poos M. Dietary Reference Intakes: Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine,

Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. J Am Diet Assoc. 2001;101(3):294-301.3. Institute of Medicine’s Food and Nutrition Board. Dietary Reference Intakes for Energy, C arbohydrate, Fiber, Fat, Fatty Acids,

Cholesterol, Protein, and Amino Acids. (Macronutrients). Washington, DC: National Academy of Sciences, 2005: 107-180.4. Institute of Medicine. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Food and Nutrition

Board, Washington, DC: National Academy Press;1997.5. Institute of Medicine. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid,Biotin, and Choline. Food and Nutrition Board, Washington, DC: National Academy Press;1998.

6. Institute of Medicine. Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Cartotenoids . Food and Nutrition Board,Washington, DC: National Academy Press;2000.

7. Institute of Medicine. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Molybdenum,Nickel, Silicon, Vandium and Zinc . Food and Nutrition Board. Washington, DC: National Academy Press; 2001.

http://www.nap.edu/http://www.nap.edu/http://www.nap.edu/http://www.nap.edu/


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ESTIMATED ENERGY REQUIREMENT (EER) FOR MALE AND FEMALESUNDER 30 YEARS OF AGE

Age SexBody Mass

Index (kg/m 2) a Median Reference

Height bcm(in)Reference

Weight a kg (lb) Kcal/day2-6 mo M 62(24) 6(13) 570

F 62(24) 6(13) 5207-12 mo M 71(28) 9(20) 743

F 71(28) 9(20) 676

1-3 y M 86(34) 12(27) 1046F 86(34) 12(27) 992

4-8 y M 115(45) 20(44) 1,742F 115(45) 20(44) 1,642

9-13 y M 17.2 144(57) 36(79) 2,279F 17.4 144(57) 37(81) 2,071

14-18 y M 20.5 174(68) 61(134) 3,152F 20.4 163(64) 54(119) 2,368

19-30 y M 22.5 177(70) 70(154) 3,607 c F 21.5 163(64) 57(126) 2,403 c

aTaken from new data on male and female median body mass index and height-for-age data from the Centers for DiseaseControl and Prevention National Center for Health Statistics Growth Charts (Kuczmarski, et al., 2000).

bCalculated from CDC/NCHS Growth Charts (Kuczmarski et al., 2000); median body mass index and median height for ages4 through 19 years.

cSubtract 10 kcal/day for males and 7 kcal/day for females for each year of age above 19 years.

Adapted from: Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and AminoAcids (Macronutrients). Washington, DC: National Academies Press, 2002.

ESTIMATED ENERGY REQUIREMENT (EER)FOR MEN AND WOMEN 30 YEARS OF AGEa

Height(m[in])

PAL b Weight for BMIof 18.5 kg/m 2

(kg [lb])

Weight for BMIof 24.99 kg/m 2

(kg [lb])

EER, Men (kcal/day) c EER, Women (kcal/day) c

BMI of18.5 kg/m 2

BMI of24.99 kg/m 2

BMI of18.5 kg/m 2

BMI of24.99 kg/m 2

1.50(59)

SedentaryLow activeActiveVery Active

41.6 (92) 56.2 (124) 1,8482,0092,2152,554

2,0802,2672,5062,898

1,6251,8032,0252,291

1,7621,9562,1982,489

1.65(65)


50.4 (111) 68.0 (150) 2,0682,2542,4902,880

2,3492,5662,8423,296

1,8162,0162,2672,567

1,9822,2022,4772,807

1.80(71)


59.9 (132) 81.0 (178) 2,3012,5132,7823,225

2,6352,8843,2003,720

2,0152,2392,5192,855

2,2212.4592,7693,141

aFor each year below 30, add 7 kcal/day for women and 10 kcal/day for men. For each year above 30, subtract 7 kcal/day for womenand 10kcal/day for men.

bPhysical activity level.cDerive from the following regression equations based on doubly labeled water data:

Adult man: EER=661.8-9.53xAge (y)xPAx(15.91xWt [kg]+539.6xHt[m]Adult woman EER=354.1 – 6.91xAge(y)xPAx(9.36xWt [kg] + 726xHt [m])

Where PA refers to coefficient for Physical Activity Levels (PAL)PAL=total energy expenditure + basal energy expenditure.

PA=1.0 if PAL >1.0 < 1.4 (sedentary).PA=1.12 if PAL > 1.4 1.6 1.9 < 2.5 (very active).

Source: Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (2002).This report may be accessed via www.nap.edu. Copyright 2002 by the National Academy of Sciences. All rights reserved.

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ESTIMATED CALORIE REQUIREMENTS (IN KILOCALORIES) FOR EACHGENDER AND AGE GROUP AT THREE LEVELS OF PHYSICAL ACTIVITY(1) a

Estimated amounts of calories needed to maintain energy balance for various gender and age groups at threedifferent levels of physical activity. The estimates are rounded to the nearest 200 calories and were determinedusing the Institute of Medicine equation.

Activity Level b Gender Age (years) Sedentar yb Moderately Active Active Child 2-3 1,000 —1,200 c 1,000-1,400 c 1,000-1,400 c Female d 4-8

9-1314-1819-3031-50

51+

1,200-1,4001,400-1,600

1,8001,800-2,000

1,8001,600

1,400-1,6001,600-2,000

2,0002,000-2,200

2,0001,800

1,400-1,8001,800-2,200

2,4002,4002,200

2,000-2,200Male 4-8

9-1314-1819-3031-50

51+

1,200-1,4001,600-2,0002,000-2,4002,400-2,6002,200-2,4002,000-2,200

1,400-1,6001,800-2,2002,400-2,8002,600-2,8002,400-2,6002,200-2,400

1,600-2,0002,000-2,6002,800-3,200

3,0002,800-3,0002,400-2,800

aBased on Estimated Energy Requirements (EER) equations, using reference heights (average) and reference weights (healthy) for eachage/gender group. For children and adolescents, reference height and weight vary. For adults, the reference man is 5 feet 10 inches talland weighs 154 pounds. The reference woman is 5 feet 4 inches tall and weighs 126 pounds. EER equations are from the Institute ofMedicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington(DC): The National Academies Press; 2002.

bSedentary means a lifestyle that includes only the light physical activity associated with typical day-to-day life. Moderately active means alifestyle that includes physical activity equivalent to walking about 1.5 to 3 miles per day at 3 to 4 miles per hour, in addition to the lightphysical activity associated with typical day-to-day life. Active means a lifestyle that includes physical activity equivalent to walkingmore than 3 miles per day at 3 to 4 miles per hour, in addition to the light physical activity associated with typical day-to-day life.

cThe calorie ranges shown are to accommodate needs of different ages within the group. For children and adolescents, more calories areneeded at older ages. For adults, fewer calories are needed at older ages.

dEstimates for females do not include women who are pregnant or breastfeeding.

ReferenceDietary Guidelines for Americans 2010. Available at:http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/PolicyDoc.pdf Accessed Jan 31, 2011.

http://www.health.gov/dietaryguidelines/dga2005/document/html/chapter2.htm#foota3#foota3http://www.health.gov/dietaryguidelines/dga2005/document/html/chapter2.htm#foota3#foota3http://www.health.gov/dietaryguidelines/dga2005/document/html/chapter2.htm#foota3#foota3http://www.health.gov/dietaryguidelines/dga2005/document/html/chapter2.htm#footb3#footb3http://www.health.gov/dietaryguidelines/dga2005/document/html/chapter2.htm#footb3#footb3http://www.health.gov/dietaryguidelines/dga2005/document/html/chapter2.htm#footb3#footb3http://www.health.gov/dietaryguidelines/dga2005/document/html/chapter2.htm#footb3#footb3http://www.health.gov/dietaryguidelines/dga2005/document/html/chapter2.htm#footb3#footb3http://www.health.gov/dietaryguidelines/dga2005/document/html/chapter2.htm#footb3#footb3http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/PolicyDoc.pdfhttp://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/PolicyDoc.pdfhttp://www.health.gov/dietaryguidelines/dga2005/document/html/chapter2.htm#footb3#footb3http://www.health.gov/dietaryguidelines/dga2005/document/html/chapter2.htm#footb3#footb3http://www.health.gov/dietaryguidelines/dga2005/document/html/chapter2.htm#foota3#foota3


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DIETARY REFERENCE INTAKES (DRIS): RECOMMENDED INTAKES FORINDIVIDUALS, MACRONUTRIENTS

Food and Nutrition Board, Institute of Medicine, National AcademiesTotal Total Linoleic α -Linolenic

Life Stage Group Water a Carbohydrate Fiber Fat Acid Acid Protein b (L/d) (g/d) (g/d) (g/d) (g/d) (g/d) (g/d)

Infants0–6 mo 0.7* 60* ND 31* 4.4* 0.5* 9.1*7–12 mo 0.8* 95* ND 30* 4.6* 0.5* 11.0 c Children1–3 y 1.3* 130 19* ND 7* 0.7* 134–8 y 1.7* 130 25* ND 10* 0.9* 19Males9–13 y 2.4* 130 31* ND 12* 1.2* 3414 –18 y 3.3* 130 38* ND 16* 1.6* 5219 –30 y 3.7* 130 38* ND 17* 1.6* 5631 –50 y 3.7* 130 38* ND 17* 1.6* 5651 –70 y 3.7* 130 30* ND 14* 1.6* 56> 70 y 3.7* 130 30* ND 14* 1.6* 56Females9–13 y 2.1* 130 26* ND 10* 1.0* 3414 –18 y 2.3* 130 26* ND 11* 1.1* 4619 –30 y 2.7* 130 25* ND 12* 1.1* 4631 –50 y 2.7* 130 25* ND 12* 1.1* 4651 –70 y 2.7* 130 21* ND 11* 1.1* 46> 70 y 2.7* 130 21* ND 11* 1.1* 46Pregnancy14 –18 y 3.0* 175 28* ND 13* 1.4* 7119 –30 y 3.0* 175 28* ND 13* 1.4* 7131 –50 y 3.0* 175 28* ND 13* 1.4* 71Lactation

14 –18 y 3.8* 210 29* ND 13* 1.3* 7119 –30 y 3.8* 210 29* ND 13* 1.3* 7131 –50 y 3.8* 210 29* ND 13* 1.3* 71NOTE: This table presents Recommended Dietary Allowances (RDAs) in bold type and Adequate Intakes (AIs) in ordinary type followed by

an asterisk (*). RDAs and AIs may both be used as goals for individual intake. RDAs are set to meet the needs of almost all (97 to 98percent) individuals in a group. For healthy infants fed human milk, the AI is the mean intake. The AI for other life stage and gendergroups is believed to cover the needs of all individuals in the group, but lack of data or uncertainty in the data prevent being able to specifywith confidence the percentage of individuals covered by this intake.

a Total water includes all water contained in food, beverages, and drinking water.b Based on 0.8 g/kg body weight for the reference body weight.c Change from 13.5 in prepublication copy due to calculation error.

Dietary Reference Intakes (DRIs): Additional Macronutrient Recommendations Food and Nutrition Board, Institute of Medicine, National Academies

Macronutrient RecommendationDietary cholesterol As low as possible while consuming a nutritionally adequate dietTrans fatty acids As low as possible while consuming a nutritionally adequate dietSaturated fatty acids As low as possible while consuming a nutritionally adequate dietAdded sugars Limit to no more than 25% of total energy

SOURCE: Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (2002).


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NOTE: This table (taken from the DRI reports, see www.nap.edu) presents Recommended Dietary Allowances (RDAs) in bold type and Adequate Intakes (AIs) in ordinary type followed by an asterisk (*). An RDA is the averagedaily dietary intake level; sufficient to meet the nutrient requirements of nearly all (97 to 98 percent) healthy individuals in a group. It is calculated from an Estimated Average Requirement (EAR). If sufficient scientific evidenceis not available to establish an EAR, and thus calculate an RDA, an AI is developed. For healthy breastfed infants, the AI is the mean intake. The AI for other life stage and gender groups is believed to cover needs of all healthyindividuals in the group, but lack o f data or uncertainty in the data prevent being able to specify with confidence the percentage of individuals covered by this intake.

a As retinol activity equivalents (RAEs). 1 RAE = 1 mg retinol, 12 mg b-c arotene, 24 mg a-carotene, or 24 mg b-cryptoxanthin. The RAE for dietary provitamin A carotenoids is twofold greater than retinol equivalents (RE), whereasthe RAE for preformed vitamin A is the s ame as RE.

b As cholecalciferol. 1 µg cholecalciferol = 40 IU vitamin D.c In the absence of adequate exposure to sunlight.d As a-tocopherol. a-Tocopherol includes RRR-a-tocopherol, the only form of a-tocopherol that occurs naturally in foods, and the 2R-stereoisomeric forms of a-tocopherol ( RRR-, RSR-, RRS -, and RSS -a-tocopherol) that occur in

fortified foods and supplements. It does not include the 2S -stereoisomeric forms of a-tocopherol ( SRR-, SSR-, SRS -, and SSS -a-tocopherol), also found in fortified foods and supplements.e As niacin equivalents (NE). 1 mg of niacin = 60 mg of tryptophan; 0 –6 months = preformed niacin (not NE). f As dietary folate equivalents (DFE). 1 DFE = 1 µg food folate = 0.6 µg of folic acid from fortified food or as a supplement consumed with food = 0.5 µg of a supplement taken on an empty stomach. g Although AIs have been set for choline, there are few data to assess whether a dietary supply of choline is needed at all stages of the life cycle, and it may be that the choline requirement can be met by endogenous synthesis at

some of these stages.h Because 10 to 30 percent of older people may malabsorb food-bound B12, it is advisable for those older than 50 years to meet their RDA mainly by consuming foods fortified with B12 or a supplement containing B12.i In view of evidence linking folate intake with neural tube defects in the f etus, it is recommended that all women capable of becoming pregnant consume 400 µg from supplements or fortified foods in addition to intake of food

folate from a varied diet. j It is assumed that women will continue consuming 400 µg from su pplements or fortified food until their pregnancy is confirmed and they enter prenatal care, which ordinarily occurs after the end of the periconceptional period —

the critical time for formation of the neural tube.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, and Choline

(1998); Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000); Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel,Silicon, Vanadium, and Zinc (2001); Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate (2005); and Dietary Reference Intakes for Calcium and Vitamin D (2011). These reports may be accessed viawww.nap.edu .

Dietary Reference Intakes (DRIs): Recommended Dietary Allowances and Adequate Intakes, VitaminsFood and Nutrition Board, Institute of Medicine, National Academies

Life Stage Vit A Vit C Vit D Vit E Vit K Thiamin Riboflavin Niacin Vit B 6 Folate Vit B 12 Pantothenic Biotin CholinGroup (µg/d) a (mg/d) (µg/d) b,c (mg/d) d (µg/d) (mg/d) (mg/d) (mg/d) e (mg/d) (µg/d) f (µg/d) Acid (mg/d) (µg/d) (mg/d)

Infants0–6 mo 400* 40* 15* 4* 2.0* 0.2* 0.3* 2* 0.1* 65* 0.4* 1.7* 5* 125*

7–12 mo 500* 50* 15* 5* 2.5* 0.3* 0.4* 4* 0.3* 80* 0.5* 1.8* 6* 150*Children

1–3 y 300 15 15* 6 30* 0.5 0.5 6 0.5 150 0.9 2* 8* 200*4–8 y 400 25 15* 7 55* 0.6 0.6 8 0.6 200 1.2 3* 12* 250*

Males

9–13 y 600 45 15* 11 60* 0.9 0.9 12 1.0 300 1.8 4* 20* 375*14 –18 y 900 75 15* 15 75* 1.2 1.3 16 1.3 400 2.4 5* 25* 550*19 –30 y 900 90 15* 15 120* 1.2 1.3 16 1.3 400 2.4 5* 30* 550*31 –50 y 900 90 15* 15 120* 1.2 1.3 16 1.3 400 2.4 5* 30* 550*51 –70 y 900 90 15* 15 120* 1.2 1.3 16 1.7 400 2.4 i 5* 30* 550*

> 70 y 900 90 20* 15 120* 1.2 1.3 16 1.7 400 2.4 i 5* 30* 550*

Females9–13 y 600 45 15* 11 60* 0.9 0.9 12 1.0 300 1.8 4* 20* 375*

14 –18 y 700 65 15* 15 75* 1.0 1.0 14 1.2 400 i 2.4 5* 25* 400*19 –30 y 700 75 15* 15 90* 1.1 1.1 14 1.3 400 i 2.4 5* 30* 425*31 –50 y 700 75 15* 15 90* 1.1 1.1 14 1.3 400 i 2.4 5* 30* 425*51 –70 y 700 75 15* 15 90* 1.1 1.1 14 1.5 400 2.4 h 5* 30* 425*

> 70 y 700 75 20* 15 90* 1.1 1.1 14 1.5 400 2.4 h 5* 30* 425*

Pregnancy14 –18 y 750 80 15* 15 75* 1.4 1.4 18 1.9 600 j 2.6 6* 30* 450*19 –30 y 770 85 15* 15 90* 1.4 1.4 18 1.9 600 j 2.6 6* 30* 450*31 –50 y 770 85 15* 15 90* 1.4 1.4 18 1.9 600 j 2.6 6* 30* 450*

Lactation14 –18 y 1,200 115 15* 19 75* 1.4 1.6 17 2.0 500 2.8 7* 35* 550*19 –30 y 1,300 120 15* 19 90* 1.4 1.6 17 2.0 500 2.8 7* 35* 550*31–50 1,300 120 15* 19 90* 1.4 1.6 17 2.0 500 2.8 7* 35* 550*

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Dietary Reference Intakes (DRIs): Recommended Dietary Allowances and Adequate Intakes, ElementsFood and Nutrition Board, Institute of Medicine, National Academies

Life Stage Calcium Chromium Copper Fluoride Iodine Iron Magnesium Manganese Molybdenum Phosphorus Selenium Zinc Potassium Sodium ChlorideGroup (mg/d) (µg/d) (µg/d) (mg/d) (µg/d) (mg/d) (mg/d) (mg/d) (µg/d) (mg/d) (µg/d) (mg/d) (g/d) (g/d) (g/d)Infants 0–6 mo 200* 0.2* 200* 0.01* 110* 0.27* 30* 0.003* 2* 100* 15* 2* 0.4* 0.12* 0.18*

7–12 mo 260* 5.5* 220* 0.5* 130* 11 75* 0.6* 3* 275* 20* 3 0.7* 0.37* 0Children

1–3 y 700* 11* 340 0.7* 90 7 80 1.2* 17 460 20 3 3.0* 1.0* 14–8 y 1,000* 15* 440 1* 90 10 130 1.5* 22 500 30 5 3.8* 1.2* 1Males 9–13 y 1,300* 25* 700 2* 120 8 240 1.9* 34 1,250 40 8 4.5* 1.5* 2

14 –18 y 1,300* 35* 890 3* 150 11 410 2.2* 43 1,250 55 11 4.7* 1.5* 219 –30 y 1,000* 35* 900 4* 150 8 400 2.3* 45 700 55 11 4.7* 1.5* 231 –50 y 1,000* 35* 900 4* 150 8 420 2.3* 45 700 55 11 4.7* 1.5* 251 –70 y 1,000* 30* 900 4* 150 8 420 2.3* 45 700 55 11 4.7* 1.3* 2> 70 y 1,200* 30* 900 4* 150 8 420 2.3* 45 700 55 11 4.7* 1.2* 1

Females 9–13 y 1,300* 21* 700 2* 120 8 240 1.6* 34 1,250 40 8 4.5* 1.5* 2

14 –18 y 1,300* 24* 890 3* 150 15 360 1.6* 43 1,250 55 9 4.7* 1.5* 219 –30 y 1,000* 25* 900 3* 150 18 310 1.8* 45 700 55 8 4.7* 1.5* 231 –50 y 1,000* 25* 900 3* 150 18 320 1.8* 45 700 55 8 4.7* 1.5* 251 –70 y 1,200* 20* 900 3* 150 8 320 1.8* 45 700 55 8 4.7* 1.3* 2> 70 y 1,200* 20* 900 3* 150 8 320 1.8* 45 700 55 8 4.7* 1.2* 1

Pregnancy

14 –18 y 1,300* 29* 1,000 3* 220 27 400 2.0* 50 1,250 60 12 4.7* 1.5* 219 –30 y 1,000* 30* 1,000 3* 220 27 350 2.0* 50 700 60 11 4.7* 1.5* 231 –50 y 1,000* 30* 1,000 3* 220 27 360 2.0* 50 700 60 11 4.7* 1.5* 2

Lactation 14 –18 y 1,300* 44* 1,300 3* 290 10 360 2.6* 50 1,250 70 13 5.1* 1.5* 219 –30 y 1,000* 45* 1,300 3* 290 9 310 2.6* 50 700 70 12 5.1* 1.5* 231 –50 y 1,000* 45* 1,300 3* 290 9 320 2.6* 50 700 70 12 5.1* 1.5* 2

NOTE: This table (taken from the DRI reports, see www.nap.edu) presents Recommended Dietary Allowances (RDAs) in bold type and Adequate Intakes (AIs) in ordinary type followed by an asterisk (*). An RDA is the average dailydietary intake level; sufficient to meet the nutrient requirements of nearly all (97 to 98 percent) healthy individuals in a group. It is calculated from an Estimated Average Requirement (EAR). If su fficient scientific evidence is notavailable to establish an EAR, and thus calculate an RDA, an AI i s developed. For healthy breastfed infants, the AI is the mean intake. The AI for other life stage and gender groups is believed to cover needs of all heal thy individuals in thegroup, but lack of data or uncertainty in the data prevent being able to specify with confidence the percentage of individuals covered by this intake.

SOURCES : Dietary Reference Intakes for Calcium, Phosphorous, Magnesium, Vitamin D, and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B 6 , Folate, Vitamin B 12 , Pantothen Acid,Biotin, and Choline (1998); Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000); Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper,Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc (2001); Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate (2005); and Dietary Reference Intakes forCalcium and Vitamin D (2011). These reports may be accessed via www.nap.edu .

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Dietary Reference Intakes (DRIs): Estimated Average RequirementsFood and Nutrition Board, Institute of Medicine, National Academies

Life StageGroup

Cal-cium

(mg/d)

CHO(g/d)

Protein(g/kg/d)

Vit A(mg/d) a

Vit C(mg/d)

Vit D( µg/d)

Vit E(mg/d)

b

Thia-min

(mg/d)

Ribo-flavin(mg/d)

Niacin(mg/d) c

Vit B6(mg/d)

Folate(mg/d) d

VitB12

(mg/d)

Cop-per

(mg/d)

Iodine(mg/d)

Iron(mg/d)

Magnes-ium

(mg/d)

Molyb-denum(mg/d)

Phos-phorus(mg/d)

Sele-nium

(mg/d)

Infants0 to 6 mo6–12 mo 1.0 6.9 Children1–3 y 500 100 0.87 210 13 10 5 0.4 0.4 5 0.4 120 0.7 260 65 3.0 65 13 380 17 4–8 y 800 100 0.76 275 22 10 6 0.5 0.5 6 0.5 160 1.0 340 65 4.1 110 17 405 23 Males9–13 y 1,100 100 0.76 445 39 10 9 0.7 0.8 9 0.8 250 1.5 540 73 5.9 200 26 1,055 35 14 –18 y 1,100 100 0.73 630 63 10 12 1.0 1.1 12 1.1 330 2.0 685 95 7.7 340 33 1,055 45 8

19 –30 y 800 100 0.66 625 75 10 12 1.0 1.1 12 1.1 320 2.0 700 95 6 330 34 580 45 931 –50 y 800 100 0.66 625 75 10 12 1.0 1.1 12 1.1 320 2.0 700 95 6 350 34 580 45 951 –70 y 800 100 0.66 625 75 10 12 1.0 1.1 12 1.4 320 2.0 700 95 6 350 34 580 45 9

> 70 y 1,000 100 0.66 625 75 10 12 1.0 1.1 12 1.4 320 2.0 700 95 6 350 34 580 45 9Females9–13 y 1,100 100 0.76 420 39 10 9 0.7 0.8 9 0.8 250 1.5 540 73 5.7 200 26 1,055 35 14 –18 y 1,100 100 0.71 485 56 10 12 0.9 0.9 11 1.0 330 2.0 685 95 7.9 300 33 1,055 45 719 –30 y 800 100 0.66 500 60 10 12 0.9 0.9 11 1.1 320 2.0 700 95 8.1 255 34 580 45 631 –50 y 800 100 0.66 500 60 10 12 0.9 0.9 11 1.1 320 2.0 700 95 8.1 265 34 580 45 651 –70 y 1,000 100 0.66 500 60 10 12 0.9 0.9 11 1.3 320 2.0 700 95 5 265 34 580 45 6

> 70 y 1,000 100 0.66 500 60 10 12 0.9 0.9 11 1.3 320 2.0 700 95 5 265 34 580 45 6Pregnancy14 –18 y 1,000 135 0.88 530 66 10 12 1.2 1.2 14 1.6 520 2.2 785 160 23 335 40 1,055 49 1

19 –30 y 800 135 0.88 550 70 10 12 1.2 1.2 14 1.6 520 2.2 800 160 22 290 40 580 49 931 –50 y 800 135 0.88 550 70 10 12 1.2 1.2 14 1.6 520 2.2 800 160 22 300 40 580 49 9Lactation14 –18 y 1,000 160 1.05 885 96 10 16 1.2 1.3 13 1.7 450 2.4 985 209 7 300 35 1,055 59

19 –30 y 800 160 1.05 900 100 10 16 1.2 1.3 13 1.7 450 2.4 1,000

209 6.5 255 36 580 59

31 –50 y 800 160 1.05 900 100 10 16 1.2 1.3 13 1.7 450 2.4 1,000

209 6.5 265 36 580 59

NOTE: An Estimated Average Requirements (EAR), is the average daily nutrient intake level estimated to meet the requirements of half of the healthy individuals in a group. EARs have not been established forvitamin K, pantothenic acid, biotin, choline, chromium, fluoride, manganese, or other nutrients not yet evaluated via the DRI process.

a As retinol activity equivalents (RAEs). 1 RAE = 1 µg retinol, 12 µg b-carotene, 24 µg a-carotene, or 24 µg β-cryptoxanthin. The RAE for dietary provitamin A carotenoids is two-fold greater than retinolequivalents (RE), whereas the RAE for preformed vitamin A is the same as RE.

b As α-tocopherol. α -Tocopherol includes RRR-α -tocopherol, the only form of α -tocopherol that occurs naturally in foods, and the 2R-stereoisomeric forms of α -tocopherol ( RRR-, RSR-, RRS -, and RSS -α-tocothat occur in fortified foods and supplements. It does not include the 2S -stereoisomeric forms of α -tocopherol ( SRR-, SSR-, SRS -, and SSS -α-tocopherol), also found in fortified foods and supplements.

c As niacin equivalents (NE). 1 mg of niacin = 60 mg of tryptophan.d As dietary folate equivalents (DFE). 1 DFE = 1 µg food folate = 0.6 µg of folic acid from fortified food or as a supplement consumed with food = 0.5 µg of a supplement taken on an empty stomach.

SOURCES : Dietary Reference Intakes for Calcium, Phosphorous, Magnesium, Vitamin D, and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B 6 , Folate, Vitamin B 12 , Pantothen Acid,Biotin, and Choline (1998); Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000); Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, IodinIron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc (2001); Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (2002/2005); andDietary Reference Intakes for Calcium and Vitamin D (2011). These reports may be accessed via www.nap.edu .


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Dietary Reference Intakes (DRIs): Tolerable Upper Intake Levels, VitaminsFood and Nutrition Board, Institute of Medicine, National Academies

Life Stage Vitamin A Vitamin C Vitamin D Vitamin E Vitamin K Thiamin Ribo- Niacin Vitamin B 6 Folate Vitamin B 12 Pantothenic Biotin Choline Carote-

Group (µg/d) a (mg/d) (mg/d) (mg/d) b,c flavin (mg/d) c (mg/d) (mg/d)c Acid (g/d) noids

Infants0-6 mo 600 ND e 25 ND ND ND ND ND ND ND ND ND ND ND ND

7-12 mo 600 ND 37.5 ND ND ND ND ND ND ND ND ND ND ND NDChildren

1-3 y 600 400 62.5 200 ND ND ND 10 30 300 ND ND ND 1.0 ND4-8 y 900 650 75 300 ND ND ND 15 40 400 ND ND ND 1.0 ND

Males 9-13 y 1,700 1,200 100 600 ND ND ND 20 60 600 ND ND ND 2.0 ND

14-18 y 2,800 1,800 100 800 ND ND ND 30 80 800 ND ND ND 3.0 ND

19-30 y31-50 y

3,0003,000

2,0002,000

100100

1,0001,000

NDND

NDND

NDND

3535

100100

1,0001,000

NDND

NDND

NDND

3.53.5

NDND

51-70 y 3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND ND ND 3.5 ND> 70 y 3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND ND ND 3.5 ND

Females

9-13 y 1,700 1,200 100 600 ND ND ND 20 60 600 ND ND ND 2.0 ND14-18 y 2,800 1,800 100 800 ND ND ND 30 80 800 ND ND ND 3.0 ND19-30 y31-50 y

3,0003,000

2,0002,000

100100

1,0001,000

NDND

NDND

NDND

3535

100100

1,0001,000

NDND

NDND

NDND

3.53.5

NDND

51-70 y 3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND ND ND 3.5 ND> 70 y 3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND ND ND 3.5 ND

Pregnancy

14 –18 y 2,800 1,800 100 800 ND ND ND 30 80 800 ND ND ND 3.0 ND19-30 y 3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND ND ND 3.5 ND31-50 y 3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND ND ND 3.5 ND

Lactation14 –18 y 2,800 1,800 100 800 ND ND ND 30 80 800 ND ND ND 3.0 ND19-30 y 3,000

3,0002,0002,000

100100

1,0001,000

NDND

NDND

NDND

3535

100100

1,0001,000

NDND

NDND

NDND

3.53.5

NDND31-50 y

NOTE: A Tolerable Upper Intake Level (UL) is the highest level of daily nutrient intake that is likely to pose no risk of adverse effects to almost all individuals in the general population. Unless otherwise specified, the UL representstotal intake from food, water, and supplements. Due to lack of suitable data, ULs could not be established for vitamin K, thiamin, riboflavin, vitamin B 12, pantothenic acid, biotin, carotenoids. In the absence of ULs, extra caution maybe warranted in consuming levels above recommended intakes. Members of the general population should be advised not to routinely exceed the UL. The UL is not meant to apply to individuals who are treated with the nutrientunder medical supervision or to individuals with predisposing conditions that modify their sensitivity to the nutrient.

a As preformed vitamin A only.b As α-tocopherol; applies to any form of supplemental α-tocopherol.d The ULs for vitamin E, niacin, and folate apply to synthetic forms obtained from supplements, fortified foods, or a combination of the two.d b-Carotene supplements are advised only to serve as a provitamin A source for individuals at risk of vitamin A deficiency.e ND = Not determinable due to lack of data of adverse effects in this age group and concern with regard to lack of ability to handle excess amounts. Source of intake should be from food only to prevent

high levels of intake.SOURCES: Dietary Reference Intakes for Calcium, Phosphorous, Magnesium, Vitamin D, and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B 6 , Folate, Vitamin B 12 ,

Pantothenic Acid, Biotin, and Choline (1998); Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000); and Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron,Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc (2001); and Dietary Reference Intakes for Calcium and Vitamin D (2011). These reports may be accessed viawww.nap.edu.


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Dietary Reference Intakes (DRIs): Tolerable Upper Intake Levels, ElementsFood and Nutrition Board, Institute of Medicine, National Academies

LifeStage

Arsenic a Boron Calcium Chromium Copper Fluoride Iodine IronMagne-sium b

Manga-nese

Molyb-denum Nickel

Phos-phorus Selenium Silicon

c Vana-dium d

Zinc Sodium CGroup (mg/d) (mg/d) (µg/d) (mg/d) (µg/d) (mg/d) (mg/d) (mg/d) (µg/d) (mg/d) (g/d) (µg/d) (mg/d) d (mg/d) (g/d) (g

Infants

0-6 mo NDe ND 1,000 ND ND 0.7 ND 40 ND ND ND ND ND 45 ND ND 4 ND 7-12 mo ND ND 1,500 ND ND 0.9 ND 40 ND ND ND ND ND 60 ND ND 5 ND

Children

1-3 y ND 3 2,500 ND 1,000 1.3 200 40 65 2 300 0.2 3 90 ND ND 7 1.5 24-8 y ND 6 2,500 ND 3,000 2.2 300 40 110 3 600 0.3 3 150 ND ND 12 1.9 2

Males

9-13 y ND 11 3,000 ND 5,000 10 600 40 350 6 1,100 0.6 4 280 ND ND 23 2.2 3.

14-18 y ND 17 3,000 ND 8,000 10 900 45 350 9 1,700 1.0 4 400 ND ND 34 2.3 319-30 y ND 20 2,500 ND 10,000 10 1,100 45 350 11 2,000 1.0 4 400 ND 1.8 40 2.3 3.631-50 y ND 20 2,500 ND 10,000 10 1,100 45 350 11 2,000 1.0 4 400 ND 1.8 40 2.3 3.651-70 y ND 20 2,000 ND 10,000 10 1,100 45 350 11 2,000 1.0 4 400 ND 1.8 40 2.3 3.6

>70 y ND 20 2,000 ND 10,000 10 1,100 45 350 11 2,000 1.0 3 400 ND 1.8 40 2.3 3.6

Females

9-13 y ND 11 3,000 ND 5,000 10 600 40 350 6 1,100 0.6 4 280 ND ND 23 2.2 3.14-18 y ND 17 3,000 ND 8,000 10 900 45 350 9 1,700 1.0 4 400 ND ND 34 2.3 3.19-30 y ND 20 2,500 ND 10,000 10 1,100 45 350 11 2,000 1.0 4 400 ND 1.8 40 2.3 3.631-50 y ND 20 2,500 ND 10,000 10 1,100 45 350 11 2,000 1.0 4 400 ND 1.8 40 2.3 3.651-70 y ND 20 2,000 ND 10,000 10 1,100 45 350 11 2,000 1.0 4 400 ND 1.8 40 2.3 3.6

>70 y ND 20 2,000 ND 10,000 10 1,100 45 350 11 2,000 1.0 3 400 ND 1.8 40 2.3 3.6

Pregnancy

14 –18 y ND 17 3,000 ND 8,000 10 900 45 350 9 1,700 1.0 3.5 400 ND ND 34 2.3 3.19-30 y ND 20 2,500 ND 10,000 10 1,100 45 350 11 2,000 1.0 3.5 400 ND ND 40 2.3 3.31-50 y ND 20 2.500 ND 10,000 10 1,100 45 350 11 2,000 1.0 3.5 400 ND ND 40 2.3 3.

Lactation

14 –18 y ND 17 3,000 ND 8,000 10 900 45 350 9 1,700 1.0 4 400 ND ND 34 2.3 3.19-30 y ND 20 2,500 ND 10,000 10 1,100 45 350 11 2,000 1.0 4 400 ND ND 40 2.3 3.631-50 y 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.

NOTE: A Tolerable Upper Intake Level (UL) is the highest level of daily nutrient intake that is likely to pos e no risk of adverse effects to almost all individuals in the general population. Unless otherwise specified, the UL represents total

intake from food, water, and supplements. Due to lack of suitable data, ULs could not be established for vitami n K, thiamin, riboflavin, vitamin B 12, pantothenic acid, biotin, carotenoids. In the absence of ULs, extra caution may bewarranted in consuming levels above recommended intakes. Members of the general population should be advised not to routinely exceed the UL. The UL is not meant to apply to individuals who are treated with the nutrient undermedical supervision or to individuals with predisposing conditions that modify their sensitivity to the nutrient.

a Although the UL was not determined for arsenic, there is no justification for adding arsenic to food or supplements.b The ULs for magnesium represent intake from a pharmacological agent only and do not include intake from food and water.c Although silicon has not been shown to cause adverse effects in humans, there is no justification for adding silicon to supplements.d Although vanadium in food has not been shown to cause adverse effects in humans, there is no justification for adding vanadium to food and vanadium supplements should be used with caution. The UL is based on adverse effects in

laboratory animals and this data could be used to set a UL for adults but not children and adolescents.e ND = Not determinable due to lack of data of adverse effects in this age group and concern with regard to lack of ability to handle excess amounts. Source of intake should be from food only to prevent high levels of intakes.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, and Choline

(1998); Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000); Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel,Silicon, Vanadium, and Zinc (2001); Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate (2005); and Dietary Reference Intakes for Calcium and Vitamin D (2011). These reports may be accessed viahttp://www.nap.edu/ .


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FOOD FORTIFICATION AND DIETARY SUPPLEMENTSPOSITION OF THE ACADEMY OF NUTRITION AND DIETETICS*

“It is the position of the American Dietetic Association (ADA) * that the best nutritional strategy for promotingoptimal health and reducing the risk of chronic disease is to wisely choose a wide variety of foods. Additionalvitamins and minerals from fortified foods and/or supplements can help some people meet their nutritionalneeds as specified by science-based nutrition standards such as the Dietary Reference Intakes (DRIs) (1,2) .”

Recommendations regarding supplementation and the therapeutic use of vitamins and minerals fortreating specific conditions may be found in the corresponding sections of this manual. The latestrecommendations from the Food and Nutrition Board for the first time include recommendations thatsupplements or fortified foods be used to obtain desirable amounts of some nutrients, eg, folic acid andcalcium, in certain population groups.

Under the Dietary Supplement Health and Education Act of 1994, manufacturers must adhere torestrictions regarding the types of claims that are allowed on product labels. Statements regarding theefficacy of specific products in the treatment or prevention of particular conditions are prohibited. A claimstatement is allowed if the “statement claims a benefit related to a classical nutrient deficiency disease anddiscloses the prevalence of such disease in the United States, describes the role of a nutrient or dietaryingredient intended to affect the structure or function in humans, characterizes the documented mechanismby which a nutrient or dietary ingredient acts to maintain such structure or function, or describes generalwell-being from consumption of a nutrient or dietary ingredient (1) .”

The manufacturer must specify that the claims are truthful and not misleading. The following statementmust also accompany any claims, “This statement has not bee n evaluated by the Food and DrugAdministration. This product is not intended to diagnose, treat, cure, or prevent any disease (1) ”. In addition,all supplements must have the identity and strength of contents listed on the label, and meet appropriatespecifications for quality, purity and composition (3) .

*The American Dietetic Association (ADA) is now known as The Academy of Nutrition and Dietetics (AND).

References1. Position of the American Dietetic Association: Nutrient Supplementation. J Am Diet Assoc. 2009; 109:2073-2085.2. Position of the American Dietetic Association: Functional foods. J Am Diet Assoc. 2009;109: 735-746.3. Dietary Supplement Health and Education Act of 1994. Public Law (S.784)(1994)(codified at 42 USC 287C-11).


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REGULAR DIET – ADULT DescriptionThe diet includes a wide variety of foods to meet nutritional requirements and individual preferences ofhealthy adults. It is used to promote health and reduce the risks of developing major, chronic, or nutrition-related disease.

IndicationsThe diet is served when specific dietary modifications are not required.

Nutritional AdequacyThe diet can be planned to meet the Dietary Reference Intakes (DRIs) as outlined in Section IA: Statement onNutritional Adequacy. The diet uses the 1800 - 2,000 kilocalorie level as the standard reference level foradults. Specific calorie levels may need to be adjusted based on age, gender and physical activity.

How to Order the DietOrder as “Regular Diet,” indicating any special instructions.

Planning the Diet The Dietary Guidelines for Americans and portion sizes use the USDA Food Guide and the DASH (DietaryApproaches to Stopping Hypertension) Eating Plan as the basis for planning the menu (1) . The DietaryGuidelines 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 foodintake, which frequently requires “comfort foods,” such as soup, sandwiches, a nd other foods the patient isaccustomed to. With that consideration, the number of servings of foods from each food group may differfrom the recommendations. However, the meal will still be planned to meet the DRIs whenever possible.

Dietary Guidelines for Americans encompasses two overarching concepts (1) :

Maintain calorie balance over time to achieve and sustain a healthy weight Focus on consuming nutrient-dense foods and beverages within basic food groups while controlling

calorie and sodium intake

Recommended healthy eating pattern:

Daily sodium intake to less than 2,300 mg and further reduce intake to 1,500 mg among person who are51 and older and any age who are African American or have hypertension diabetes, or chronic kidneydisease. At the same time, consume foods with more potassium, dietary fiber, calcium and vitamin D.

Increase daily intake of fruits and vegetables, whole grains, and nonfat or low-fat milk and milk products. Consume less than 10 percent of calories from saturated fatty acids by replacing with monounsaturated

and polyunsaturated fatty acids. Oils should replace solid fats when possible. Keep trans fat as low as possible. Reduce the intake of calories from solid fats and added sugars. Limit consumption of foods that contain refined grains, especially refined grain foods that contain solid

fats, added sugars, and sodium. If you drink alcoholic beverages, do so in moderation, for only adults of legal age. Keep food safe to eat.


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Regular Diet - Adult


FOOD GUIDE FOR AMERICANS (1800-2000 calorie pattern) (1)

Food Group Recommended Daily Serving Size Fruits 3 – 4 servings

Consume citrus fruits, melons, berries, Medium-size orange, apple, or bananaand other fruits regularly ½ cup of chopped, cooked, or canned fruit (no sugar added)

½ cup of 100% fruit juiceVegetables 5 servings

Dark-green leafy vegetables: 3 1 cup of raw leafy vegetables: spinach, lettuceOrange vegetables: 2 cups/week ½ cup of other vegetables, cooked or chopped rawLegumes: 3 cups/week ½ cup of vegetable juiceStarchy vegetables: 3 cups/weekOther vegetable: 6 ½ cups/week

Grains 6 servingsWhole-grain products: 3 daily 1 slice of breadOther grains: 3 daily 2 large or 4 small crackers

½ cup cooked cereal, rice, or pasta1 cup ready-to-eat cereal1 small roll or muffin½ English muffin, bagel, hamburger bun, or large roll

Meat, Poultry, 5-5 ½ ounces dayDry Beans, Choose fish, dry beans, peas, poultry 1 ounce of cooked fish, poultry, or lean meatEggs, and Nuts without skin, and lean meat ¼ cup cooked dry beans or tofu

1 egg1 Tbsp peanut butter½ ounce nuts or seeds

Milk, Yogurt, and 3 servingsCheese Choose skim milk and nonfat yogurt 1 cup of milk or yogurt

Choose part-skim and lowfat cheeses 1 ½ ounces of natural cheese(Mozzarella, Swiss, Cheddar)2 ounces of processed cheese (American)

Oils 5 tsp dailyOils and soft margarines include

vegetables oils and soft vegetable oiltable spreads that are low in saturatedfat and are trans-free

SAMPLE MENUBreakfast Noon EveningOrange Juice Rotisserie Baked Chicken Braised Beef and Noodles Oatmeal Rice Pilaf Seasoned Green BeansScrambled Egg Steamed Broccoli with Carrots Sliced Tomato SaladBiscuit Whole-wheat Roll French DressingMargarine Margarine Peach halvesJelly Fruit Cup Dinner Roll

Lowfat Milk Lowfat Milk MargarineCoffee Iced Tea Lowfat Milk

References1. Dietary Guidelines for Americans 2010. Available at:

http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/PolicyDoc.pdf. Accessed Jan 31, 2011.

http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/PolicyDoc.pdfhttp://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/PolicyDoc.pdf


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HIGH-PROTEIN, HIGH-CALORIE DIET

Description Additional foods and supplements are added to meals or between meals to increase protein and energy intake.

Indications A high-protein, high-calorie diet is served when protein and energy requirements are increased by stress,protein loss (protein losing enteropathy, nephrotic syndrome), and catabolism. This diet may be indicated inpatients with:

protein-energy malnutrition failure to thrive cancer burns cystic fibrosis human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) chronic gastrointestinal diseases

This diet may also be indicated in preparation for surgery. An increase in energy is required to promote the

efficient utilization of proteins for anabolism.

Nutritional Adequacy The diet can be planned to meet the Dietary Reference Intakes (DRIs) as outlined in Section IA: Statement onNutritional Adequacy.

How to Order the Diet Order as “High -Protein, High- Calorie Diet.” The dietitian determines a target level of protein and energy tomeet individual needs based on guidelines as stated in Section II: Estimation of Protein Requirements.

Planning the DietThe diet is planned as a Regular Diet with addition of between-meal supplements that increase energy intakeby at least 500 kcal and protein intake by 25 g for adults. Examples of high-protein, high-energy supplements

are milk shakes, eggnogs, puddings, custards, and commercial supplements.

For children, the diet generally should provide 120% to 150% of the Dietary Reference Intakes (DRIs) forener gy and protein. The actual amounts of energy and protein provided will depend on the child’s oradolescent’s age, height, weight, medical status, and nutrition goals.


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NUTRITION MANAGEMENT DURING PREGNANCY AND LACTATIONDescription Diets for pregnant or lactating women include additional servings of food from the Regular Diet to meet theincreased requirement for nutrients during pregnancy and lactation.

Nutritional Adequacy The food patterns will meet the Dietary Reference Intakes (DRIs) for pregnancy and lactation, as outlined inSection IA: Statement on Nutritional Adequacy, except for the iron requirements in the second and thirdtrimesters of pregnancy. Factors that may increase nutritional requirements above the estimated demands ofpregnancy include: poor nutritional status; young maternal age; multiple pregnancy; closely spaced births;breast-feeding during pregnancy; continued high level of physical activity; certain disease states; and the useof cigarettes, alcohol, and legal or illegal drugs. Dietary intake of iron, folate, zinc, protein, and calcium shouldbe carefully assessed for adequacy (1) . Supplementation is justified when evidence suggests that theinadequate intake of specific nutrients can increase the risk of an adverse effect on the mother, fetus, orpregnancy outcome. Vegetarians who exclude all animal products need 2 mg of vitamin B 12 daily (1) . Also seeSection IA: Vegetarian Diets. How to Order the Diet Order as “Regular Diet – Pregnancy” or “Regular Diet – Lactation.” A ny special instructions should beindicated in the diet order.

Planning the Diet Daily Food Group Guidelines (2)

No. of ServingsFood Group Pregnant Women Lactating WomenGrains, Breads, and Cereals nine six to elevenFruits three two to fourVegetables four three to fiveLow-fat Meat, Poultry, Fish, and Eggs two or more (6 oz) two or more (7-8 oz)Low-fat Milk, Yogurt, Cheese three or four four or fiveFats, Oils, and Sweets As needed to provide energy

Specific Nutrient Requirements During Pregnancy Weight gain: The National Academy of Sciences’ Food and Nutrition Board has stated that the optimal weight gainduring pregnancy depends on the moth er’s weight at the beginning of pregnancy (1) . The target range for weightgain is associated with a full-term, healthy baby, weighing an average of 3.1 to 3.6 kg (6.8 to 7.9 lb) (3) . Theoptimum weight gain for a woman of normal prepregnancy weight for her height (body mass index (BMI), 19.8 to26 kg/m 2) who is carrying a single fetus is 25 to 35 lbs; however, there are individual differences based onmaternal anthropometry and ethnic decent (3) . The pattern of weight gain is more significant than the absoluteweight gain. The desired pattern of weight gain is approximately 3 to 8 lb in the first trimester and about 1lb/week during the last two trimesters.

The BMI, defined as weight divided by the height squared (kg/m 2) (2) , is a better indicator of maternalnutritional status than is weight alone. Recommendations for weight gain during pregnancy should beindividualized according to the prepregnancy BMI (1,3) . (See Section II: Body Mass Index.) To identify the BMIcategories and appropriate weight gain, use Table A-1 (1) .

Table A-1: Guidelines for Weight Gain After the First Trimester of Pregnancy (1,3,4)

BMI (kg/m2

) Recommended Weight Gain Intervention Suggested Overall Weight Gain3.5 lb/wk, 30.0(obese)

Individualized 2.5 lb/wk 11-20 lb


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Nutrition Management During Pregnancy and Lactation


Table A-1: Guidelines for Weight Gain After the First Trimester of Pregnancy (1,3,4) BMI (kg/m 2) Recommended Weight Gain Intervention Suggested Overall Weight GainTwin pregnancy

Normal BMIOverweightObese

Triplet pregnancy

Individualized

Individualized

Individualized

Individualized

37-54 lb31-50 lb25-42 lb

45-55 lb (4)

The updated Institue of Medicine (IOM) guidelines are based on the World Health Organization (WHO) BMIcategories and formulated as a range of weight gain for each category of prepregnancy BMI (1) . The recommendedweight gain ranges for short women and for racial or ethnic groups are the same as those for the whole population(1) . In addition, teenagers who are pregnant should use the adult BMI categories to determine their weight gainrange until more research is done to determine whether special categories are needed for them (1) . Women whoare pregnant with twins are given provisional guidelines (1) . Those in the normal weight range should aim to gain37 to 54 lbs; overweight, 31 to 50 lbs; and obese, 25 to 42 lbs (1) . For women pregnant with triplets, a weight gain of45-55 lbs has been suggested (4) . The newer guidelines include a specific and relatively narrow range ofrecommended gain for obese women (1) . For many women, this will mean gaining less weight, which may beparticularly challenging for women who are overweight or obese at conception (1) .

Energy: The total energy needs during pregnancy range between 2,200 and 2,900 kcal/day for most women(3,5) . However, the mother’s age, prepregnancy BMI, rate of weight gain, and physiologic appetite must be

considered when determining individual needs (3) . Based on a review of evidence, an average additionalintake of approximately 340 to 452 kcal/day is suggested in the second and third trimesters (6) . For normalweight and overweight women in developed countries, the additional energy need may actually be less than300 kcal/day, especially in sedentary women (3) . Appropriate weight gain and appetite are better indicatorsof energy sufficiency than the amount of energy consumed (3) . It has been suggested that an additional 500kcal/day for a twin pregnancy is added to the calculated needs. There is no absolute recommendation in theliterature for the amount of additional energy needed for a multiple pregnancy. The indication is to add 500kcal/day in the first trimester as soon as the multiple pregnancy is diagnosed, because these pregnanciesusually do not go to term and the goal is to maximize the early weight gain (4). Pregnant women shouldconsume a variety of foods according to the Dietary Guidelines to meet nutrient needs and gain therecommended amounts of weight (3) . MyPyramid guidelines include MyPyramid for Moms , which containsfood plans for pregnant women (3) .

Protein: The 2002 DRIs list the recommended daily allowances for protein for all age groups duringpregnancy and lactation to be 1.1 g/kg per day or an additional 25 g/day in addition to the 0.8 g/kg per dayfor a nonpregnant state (6) . On average, this recommendation equates to approximately 71 g, but for womenwith greater energy needs, the protein needs may need to be adjusted. For a twin pregnancy, an additional 50g/day of protein above the recommended daily allowance of 0.8 g/kg per day for a nonpregnant state issuggested during the second and third trimesters (6) . Protein utilization depends on energy intake.Therefore, adequate energy intake is important so that protein may be spared.

Vitamins and minerals: A multivitamin and mineral supplement is recommended in several circumstances(1,3) . Pregnant women who smoke or abuse alcohol or drugs should take a multivitamin and mineralsupplement (3) . For women infected with the human immunodeficiency virus, especially women who receiveantiretroviral treatment, a supplement containing B-complex, vitamin E, and vitamin C may slow theprogression of disease and reduce complications (3) . A multivitamin and mineral supplement is alsorecommended for women with iron deficiency anemia or poor-quality diets and women who consume animalproducts rarely or not at all (3) . B12 supplementation is recommended for persons who follow a vegetariandiet pattern, including the lacto-ovo vegetarian diet pattern (3) . Women carrying two or more fetuses are alsoadvised to consume a multivitamin and mineral supplement (3) . Additional nutrients that may need to besupplemented include folic acid, iron, zinc, copper, calcium, and vitamin D. The Food and Nutrition Boardrecommends the use of supplements or fortified foods to obtain desirable amounts of some nutrients, such asiron. The Food and Nutrition Board also recommends 400 g/day of synthetic folic acid from fortified foods,supplements, or both for women who are trying to become pregnant and 600 g/day for women who arepregnant (7) .

Iron: To meet the DRI of 27 mg/day of ferrous iron during pregnancy, a low-dose supplement isrecommended at the first prenatal visit (1,3,6). An iron supplement containing 150 mg of ferrous sulfate, 300


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mg of ferrous gluconate, or 100 mg of ferrous fumarate can fulfill this additional need. Iron deficiency anemiais the most common anemia during pregnancy. If the maternal iron stores are low, 60 to 120 mg of iron maybe recommended (4) , in addition to a multivitamin supplement containing 15 mg of zinc and 2 mg of copper,since iron may interfere with the absorption of zinc and copper (3) . If the laboratory values indicatemacrocytic anemia, vitamin B 12 and folate levels should be assessed.

Zinc and copper: Iron can interfere with the absorption of other minerals. Therefore, women who take dailysupplements with more than 30 mg of iron should add 15 mg of zinc and 2 mg of copper (3) . These amounts ofzinc and copper are routinely found in prenatal vitamins.

Folate: The DRI for folate for women 19 to 50 years of age is 600 g/day (7,8) . This level of folate should beconsumed through synthetic folic acid from fortified foods or supplements or both, in addition to the intake offolate from a varied diet (3,6) . Compared to naturally occurring folate found in foods, the folic acid containedin fortified foods and supplements is almost twice as well absorbed, so that 1 g from these sources isequivalent to 1.7 g of dietary folate (3) . Women who take folic acid at the time of conception are less likely togive birth to a child with neural tube defects (9-12) . To ensure that blood vitamin levels are adequate at thetime of neural tube closure, supplementation should begin at least 1 month before conception (3) . Womenwho take multivitamins containing folic acid 1 to 2 months before conception have a reduced risk of having achild with orofacial clefts (13) . Research also indicates that abnormal folate metabolism may play a role inDown syndrome and other birth defects (3) . Women who have delivered an infant with neural tube defectsmay need to consume more than the recommended amount of dietary folate equivalents (3) . Until moreevidence is available, it is recommended that women older than 19 years of age not exceed the tolerableupper limit of 1,000 g/day of folate from foods, fortified foods, and supplements (3) . Although extensivepublic education about the importance of folic acid has occurred in the past decade, the percentage of womenwho take folic acid remains low at approximately 33% (3) . Dietitians should provide nutrition education andcounseling as to the importance of folic acid consumption, especially for women who are nonwhite, Hispanic,low-income, or young or who lack a high school education (3) .

Calcium: Due to the increased efficiency of calcium absorption during pregnancy, calcium requirements forpregnant women are similar to the requirements for women who are not pregnant. A daily intake of 1,000mg is recommended for pregnant and lactating women (13) older than 19 years (


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Risk factors at the onset of pregnancy:

Adolescence: younger than 15 years old attime of conception or less than 3 years sincethe onset of menses

Older than 35 years of age Three or more pregnancies within 2 years History of poor obstetric or fetal performance

Low income

Unusual dietary practices Smoking Excessive alcohol intake Recreational drug use a Chronic systemic disease Obesity Prepregnancy BMI 29.9

kg/m 2 Multiple gestation

aRecreational drugs or over-the-counter medications or dietary supplements that have adverse effects (eg, laxatives, antacids, or herbalremedies containing teratogens)

Risk factors during pregnancy (1,3):

Hemoglobin level


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Treatment of hyperemesis gravidarum depends on the risk level of the patient and the severity ofsymptoms, such as dehydration and the inability to meet nutrition needs orally. Intensive nutritioncounseling and individualized meal planning is the first line of treatment (24,25) . If nutrition and behaviormodification does not alleviate symptoms, medications, such as metoclopramide (Reglan) and ranitidine(Zantac), or antiemetic drugs, such as prochlorperazine (Compazine) and ondansetron (Zofran), are oftenprescribed (26) . Patients with severe symptoms may require hydration with intravenous fluids, electrolytereplacement, or vitamin replacement with vitamin B 6 (pyridoxine) and vitamin B 1 (thiamin) (25,26) . If patientsdo not achieve the DRIs for thiamin (1.4 mg/day) and pyridoxine (1.9 mg/day) during pregnancy, dietary

supplementation should be provided (25) . A small percentage of patients with hyperemesis gravidarum mayrequire nasogastric, gastrostomy, or jejunostomy feedings or total parenteral nutrition to ensure adequatenutrition support. Only 2% to 5% of women with hyperemesis gravidarumrequire total parenteral nutrition(25) . Nearly all of the literature regarding nutrition support during pregnancy is anecdotal, consisting of casestudies. Treatment and intervention strategies are based on experience and patient needs. If nutritionsupport is indicated, treatment should be consistent with standards outlined for nonpregnant adults or inmanaging coexisting medical conditions or risks (eg, refeeding syndrome). Refer to Section IB: SpecializedNutrition Support and to Specific Nutrient Requirements During Pregnancy earlier in this section.

ObesityObesity in pregnancy not only increases risks for pregnant women during gestation, but also increases risksfor the future health of the child (27) . Obesity during pregnancy has been associated with gestational diabetes,gestational hypertension, pre-eclampsia, birth defects, Cesarean delivery, fetal macrosomia, perinatal deaths,

postpartum anemia, and childhood obesity (27,28) . More women are beginning pregnancy with high BMI’s, andmore are gaining weight in excess of the 1990 Institute of Medicine (IOM) recommendations for gestationalweight gain (27) . Overweight and obese women are more likely to maintain excess weight with eachsuccessive pregnancy. Those who gain more are more likely to retain it and continue at a higher weightthroughout their lifetime, as compared to women who gain less weight during pregnancy (27, 28) . Weight gainduring pregnancy has also been shown to have implications for the child’s future risk of being overweight (1,27,28) . It is the position of The Academy of Nutrition and Dietetics and the American Society for Nutrition thatall overweight and obese women of reproductive age should receive counseling prior to pregnancy, duringpregnancy, and in the interconceptional period on the roles of diet and physical activity in reproductivehealth (27) . During pregnancy overweight and obese clients should target IOM gestational weight gain targets,be advised not to lose weight during pregnancy, and counseled about healthful eating habits (27) . In additionencouragement should be given to breastfeed and be made aware of the benefits for both the mo m’s and herchild’s health (27) .

Gestational Hypertension (3) Gestational hypertension is defined as systolic blood pressure of 140 mm Hg or greater or diastolic bloodpressure of 90 mm Hg or greater with onset after 20 weeks ’ gestation (29) . About 25% of women withgestational hypertension will develop preeclampsia, which is characterized by proteinuria (>300 mg in a 24-hour urine sample). Preeclampsia occurs more often in primigravid women and in women older than 35years with chronic hypertension or renal disease.

Gestational hypertension is associated with marked changes in renal function that may lead to excessiveextracellular fluid retention. Preeclampsia accompanied by grand mal seizures is a condition called eclampsia(3,29) . Preeclampsia usually occurs after the 20th week of conception. Preeclampsia is more common inwomen with chronic hypertension and renal disease, adolescents, underweight women with inadequateweight gain, women who are older than 35 years, obese women, women with a history of preeclampsia, and

women who are carrying multiple fetuses (3) .

No specific nutrition therapy has been proven to be effective in preventing or delaying preeclampsia andimproving pregnancy outcomes (3,29) . Adequate calcium, protein, energy, and potassium may be necessary. Ameta-analysis of 17 randomized controlled trials concluded that calcium supplements (1 to 2 g/day) reducedblood pressure and the risk of preeclampsia but had no significant effect on reducing maternal and infantmorbidity and mortality (30) . Studies of other nutrients, such as vitamins C and E, have yielded inconclusiveresults. The efficacy of dietary modifications, including sodium restriction, magnesium supplements, zincsupplements, and consumption of fatty fish oils, has not been proven (3,31) . Diuretics should be avoided unlessstrict medical supervision is provided.


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Specific Nutrient Requirements During Lactation It is the position of the Academy of Nutrition and Dietetics that exclusive breastfeeding provides optimalnutrition and health protection for the first 6 months of life and breastfeeding with complementary foods from 6months until at least 12 months of age is the ideal feeding pattern for infants (32) . Breastfeeding is associatedwith a reduced risk of otitis media, gastroenteritis, respiratory illness, sudden infant death syndrome,necrotizing enterocolitis, obesity, and hypertension. Breastfeeding is also associated with improved maternaloutcomes, including a reduced risk of breast and ovarian cancer, type 2 diabetes, and postpartum depression(32) .

Energy: The average energy costs of lactation are 500 kcal/day (6) in the first 6 months and 400 kcal/day in thesecond 6 months (6) . Excessive restriction of energy (


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Fluoride . Washington, DC: National Academy Press; 1997.14. Food and Drug Administration. Vitamin A and birth defects [press release]. October 6, 1995.15. Institute of Medicine. Nutrition During Pregnancy . Washington, DC: National Academy Press; 1990:19.16. Higdon JV, Frei B. Coffee and health: a review of recent human research. Crit Rev Food Sci Nutr . 2006; 46:101-123.17. Klebanoff MA, Levine RJ, DerSimonian R, Clemens JD, Wilkins DG. Maternal serum paraxanthine, a caffeine metabolite, and the risk

of spontaneous abortion. N Engl J Med . 1999;341:1639-1644.18. CARE Study Group. Maternal caffeine intake during pregnancy and risk of fetal growth restriction: a large prospective

observational study. BMJ . 200

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Manual of Clinical Nutrition 2013