Volume 2.

Medical Nutrition Therapy and Nutritional Biochemistry

Appendices

Appendix A. Recommended energy and nutrient intakes per day (2002)

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 Volume 2. Medical Nutrition Therapy and Nutritional Biochemistry

Appendix B. Recommended daily intakes for other minerals and vitamins per day

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Appendices

Appendix C.! Common computations and formulas

GENERAL COMPUTATIONS

A. DESIRABLE BODY WEIGHT 2. Children

1. Infants DBW (kg) = (no. of years × 2) + 8

a. First 6 months Example: 7-year-old child

DBW (kg) = (7 years × 2) + 8
DBW (g) = birth weight (g) + (age in months × 600) = 22 kg
• If birth weight is not known, use 3,000 g.
Example: 1-year-old child
Example: 4-month-old infant DBW (kg) = (1 years × 2) + 8
DBW (g)= 3000 g + (4 months × 600) = 5400 g = 10 kg
= 5.4 kg
3. Adults
b. 7–12 months
a. Body mass index (BMI)-based formulation
DBW (g) = birth weight (g) + (age in months × 500)
i. BMI
Example: 8-month-old infant
DBW (g) = 3000 g + (8 months × 500) = 7000 g Weight in kilogram (kg)
BMI =
= 7 kg (Height in meter)2
Classification:
c. DBW (kg) = (age in months/2) + 3 Normal Range: 20–24.9 kg/m2
Desirable BMI for men: 22 kg/m2
Example: 8-month-old infant Desirable BMI for women: 21 kg/m2
DBW (kg) = (8 months/2) + 3
= 7 kg

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d. Ador Dionisio’s method

ii. The following formula yield weight equivalent to BMI
of 22 for men and 21 for women: For 5 ft. height: DBW = 110 lbs (male)
= 100 lbs (female)
DBW (kg) = desirable BMI × Ht (m2)
For every inch above 5 ft, add 2 lbs
Example: Male; 5’3” tall For every 5 years complement between 25–50 years,
DBW (kg) = 22 kg/m2 × (1.6 m)2 add 2 lbs
= 22 (2.54)
= 56.32 kg e. Dr. Fernando’s method

b. Tannhauser’s method For 5 ft. height: DBW = 106 lbs (male)

= 100 lbs (female)
DBW (kg) = (height in cm -100) – 10% DBW
For every inch above 5 ft, add: 6 lbs for male
Note: the deduction of 10% is only applicable for 5 lbs for female
Filipinos due to the stature
For large frame = add 10%
Example: Height 5’2” For small frame= subtract 10%
DBW (kg) = (157.48 cm – 100) – 10% DBW
= 57.48 – 5.748 f. Hamwi method
= 51.732
= 52 kg Female: 100 lbs for first 5 ft. plus 5 lbs for every inch
above 5 ft
c. Adopted method Male: 106 lbs for first 5 ft plus 6 lbs for every inch above
5 ft
For 5 ft. use 105 pounds.
For every inch above 5 ft, add 5 pounds + 10% for large frame; – 10% for small frame

Example: height 5’2” B. ESTIMATION OF TOTAL CALORIE REQUIREMENTS

DBW (lbs) = 105 lbs = 2(5 lbs)
=105 + 10 lbs 1. Infants
= 115 lbs
Using the old Diet Manual

TER/day = (0–6 months) 120 kcal /kDBW

= (7–12 months) 110 kcal/kDBW

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Using the Revised Diet Manual (5th ed., 2010) 4. Adults

TER/day = (0–6 months) 95 Kcal/kDBW a. Method I (Cooper et al.)

= (7–12 months) 80 kcal/kDBW
BMR = Basal Metabolic Needs (BMN) + %Physical
Note: TER rounded off to the nearest 50 kcal Activity (PA)
BMN = 1 Kcal/KDBW/hour for males
Example: 4-month–old infant = 0.9 Kcal/KDBW/hour for females

TER = 5.4 kg × (120 cal/kDBW) Activity % Above Basal

= 648 kcal Bed Rest 10
= 650 kcal Sedentary 30
Light 50
or TER = 5.4 × 95 kcal/kDBW Moderate 75
= 513 kcal or 500 kcal Heavy 100

2. Children (Narins and Weil)

b. Method II (Krause)
TER/day = 1000 + (100 × age in years)
Activity KCal/KDBW/day
Example: 7-year-old child
Bed Rest 27.5
TER = 1000 + (100 × 7 years)
Sedentary 30
= 1700 kcal
Light 35
Moderate 40
3. Adolescents
Heavy 45
2002 RENI, Philippines
Example: 52 kg, moderate activity
13–15 years 55 (boys) kcal/kDBW 56
TER = (40 kcal/kDBW) × 52 kg
45 (girls) kcal/KDBW 45.9
= 2080 ≈ 2100 kcal
16–18 years 50 (boys) kcal/KDBW 49
40 (girls) kcal/KDBW 41
c. Harris–Benedict Energy Expenditure (HBEE)
average both sexes 45 kcal/kDBW
HBEE (male) = 66.47 + 13.75(wt in kg) + 5(height in cm)
– 6.75(age in years)

HBEE (female) = 655.1 + 9.56(wt in kg) = 1.85(height in

cm) – 4.67(age in years)
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C. DETERMINATION OF RESTING ENERGY EXPENDITURE

d. NDAP Formula (REE)

Activity Level Male Female 1. Mifflin-St Jeor (Mifflin et al., 1990)

In bed but mobile 35 30
Light 40 35 For adults 19–78 years of age:
Moderate 45 40 Female: 10 Wt + 6.25 Ht – 5 Age – 161
Heavy 50 — Male: 10 Wt + 6.25 Ht – 5 Age + 5

Example of activities: 2. Food and Nutrition Board (FNB), NRC, NAS USA, 1989.

Sedentary – secretary, clerk, typist (using electric type Equation for predicting resting energy expenditure (REE)
writer), administrator, cashier, bank teller from body weight alone
Sex and Age Range Equation to derive REE
Light – teacher, nurse, student, lab technician,
(Yrs.) in kcal/day
housewife with maids
Male
Moderate – housewife without a maid, vendor, 0–3 ( 60.9 × Wt in kg) – 54
mechanic, jeepney, and car driver 3–10 (22.7 × Wt in kg) + 495
10–18 (17.5 × Wt in kg) + 651
Heavy – farmer, laborer, cargador, coal miner, 18–30 (15.3 × Wt in kg) + 679
fisherman, heavy equipment operator 30–60 (11.6 × Wt in kg) + 879
>60 (13.5 × Wt in kg) + 487
5. Pregnant women Female
0–3 (61.0 × Wt in kg) – 51
TER/day = normal requirement + 300 kcal 3–10 (22.5 × Wt in kg) + 499
10–18 (12.2 × Wt in kg) + 746
6. Lactating women 18–30 (14.7 × Wt in kg) + 496
30–60 (8.7 × Wt in kg) + 829
TER/day = normal requirement + 500 kcal
>60 (10.5 × Wt in kg) + 596

3. WHO/FAO/UNU Formula: REE = 11.6 × WT in kg + 879

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D. DETERMINATION OF ENERGY NEEDS FOR PHYSICAL d. Calculate TEE (use D.1).

ACTIVITY/ THERMIC EFFECT OF EXERCISE
Calculate TEF
1. Method 1: Multiples of BMR depending on the level of
physical activity • TEF is usually 10% of the sum of 2 and 4. (If the
values used for BMR are RMR values then you don’t
Bed rest = 10% of BMR/RMR have to calculate TEF since it is already included).
Sedentary = 30% of BMR/RMR
Active/Light = 50% of BMR/RMR f. Add results from letter c, d, and e
Moderately Active = 75% of BMR/RMR
Very Active = 100% of BMR/RMR 2. Method 2

2. Method 2: Factorial Method (diary of activities) a. Calculate DBW.

b. Calculate basal metabolic rate.
a. The energy needs for physical activity can be c. Calculate cost of physical activity using factorial method
determined by recording all activities over 24-hour d. Calculate thermic effect of food (usually 10%).
period (diary of activities). e. Sum of b + c + d = total energy needs.
b. Instruction on how to accomplish the diary of activities
for 1 day: 3. Method 3

i. Select a typical day that represents the usual daily • Using DBW calculated as in method 1, multiply the DBW
activities. by one of the following factors which include basal,
ii. List all activities in detail activity, and TEF requirements:
iii. Classify the activities according to major categories,
such as lying, sitting, standing and walking. Calorie requirement based on level of physical
iv. Refer to tables for caloric expenditure for a given activity (Method 3)
activity. Amount of Calories Needed
Type of Activity
kcal/lb kcal/kg
E. ESTIMATION OF TER WITH TEE AND TEF Bed 12 25
Sedentary (light) 14 30
1. Method 1 Active (moderate) 16-18 35–40
Very Active (heavy) 18-20 40–45
a. Calculate DBW.
b. Calculate the BMR/RMR.
c. Correct BMR for sleep.
DBW × 0.1 kcal/kgDBW/hr of sleep

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F. DISTRIBUTION OF THE TER INTO CHO,

PROTEIN, AND FAT G. OTHER COMPUTATIONS

1. Method I – by percentage distribution 1. Body frame = height (cm) / wrist circumference (cm)
% TER (using RENI)
Carbohydrates 55–70 (ave. of 60) Interpretation:
Proteins 10–15 MALE FEMALE
Fats Small frame 9.6 10.1
Infants 30–40 Medium frame 9.7–10.4 10.2–11
Others 20–30 Large frame 10.5 11.1
Note: 1 g CHO = 4 kcal
1 g Protein = 4 kcal 2. Chest / head circumference ratio
1 g Fat = 9 kcal
Note: CHO, protein and fat are rounded off to the < 1 (6 months to 5 years) ≈ muscle wasting on chest
nearest 5.
3. Waist / hip ratio
2. Method II – Non-Protein Calorie (NPC) method
>1 (male); >0.8 (female)
Normal Protein allowances/day ≈ Adiposity, highly associated with CVD, NIDDM, and other
Age Group g/KDBW g/KDBW disease related to obesity.
(based on old (based on
Diet Manual, 4th revised Diet 4. Arm muscle area (AMA)
ed) Manual, 5th ed)
Infants 1.6 1.5 ≈ protein mass / muscle mass
Children 1.5 2.0
Adolescents 1.2 1.3 AA (mm2) = (π / 4) × (MUAC2 / π)
Adults 1.1 1.1 AMA (mm2) = (MUAC – π triceps skinfold)2 /4π
CHO: 55–80% (average of 70%) AFA (mm) = AA – AMA
Fats: 20–45% (average of 30%) Subtract: 10 from AMA for males
6.5 from AMA for females
Note: In pediatric cases, 60-40 is used
5. MUAC
<12.5 cm undernutrition
12.5–13.5 cm risk of undernutrition
13.5–16 cm adequate nutrition

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Appendices

6. Knee-height measurement (non-ambulatory elderly to 10. Measurement of Total Body Fat (Arm Fat Area)
estimate the weight)
AFA (εm2) = [(MAC × TSF)/2] – [(π × (TSF) 2)/4]
Stature from Knee height (65-90 years old) MAC = mid arm circumference

Men: (2.02 × knee ht) – (0.04 × age) + 64.19 11. Measurement of skeletal protein mass
Women: (1.83 × knee ht) – (0.24 × age) + 84.88
MAMC (cm) = MAC (cm) – 3.14 TSF (cm)
7. Arm span and knee height as proxy indicator of height AMA (cm2) = [MAC (cm) – 3.14 (cm)]2/(4π)

Male adults: Bone Free AMA (cm2)

96.50 + (1.38 × knee height) – (0.08 × age) cm Women: AMA (cm2) = [(MAC (cm) – 3.14 TSF (cm))2 – 6.5
118.24 + (0.28 × arm span) – (0.07 × age) cm cm2]/(4π)
Female adults:
89.68 + (1.53 × knee height) – (0.17 × age) cm Men: AMA (cm2) = [(MAC (cm) – 3.14 TSF (cm))2 – 10
63.18 + (0.63 × arm span) – (0.17 × age) cm cm2]/(4π)

8. Calf circumference (weight) MAMC = mid upper arm muscle circumference

AMA = arm muscle area
Women: wt = (1.27 × cc) + (0.87 × kh) + (0.98 × MUAC) +
(0.4 × ssf) – 62.35 H. COMPUTATION BASED ON DISEASE CONDITIONS
Men: wt = (0.98 × cc) + (1.16 × kh) + (1.73 × MUAC) + (0.37
× ssf) – 81.69 1. ESTIMATING ENERGY REQUIREMENTS OF ADULTS

where: cc = calf circumference a. Harris Benedict Equation

kh = knee height
ssf = subscapular skinfold i. Males
MUAC = mid-upper arm HBEE = 66.47 + [13.75 ×wt (kg)] + [5.0 × ht (cm)] – [6.76
circumference × age (years)]

9. Hand grip strength ii. Females

HBEE = 655.1 + [9.56 × wt (kg)] + [1.85 × ht (cm)] –
≈ Poor nutrition status (dynamometer) [4.68 × age (years)]
(Muscle skeletal function)
To estimate TER, the HBEE must be multiplied by an
activity factor (AF) and an injury factor (IF).

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i.e. TER = HBEE × AF × IF b. Short method for estimating energy requirements

Activity Factors (AF) Stress Condition Kcal/kg BW

Bed rest 1.0–1.1 Overweight 20
Very light 1.2–1.3 Nonstress, bed rest 25
Light 1.4–1.5 Mild stress, bed rest ambulatory 35
Moderate 1.6–1.7 Severe stress, polytrauma, 45
Heavy 1.9–2.1 hypermetabolic sepsis
Strenuous/exceptional 2.2–2.4 Surgery: elective/minor 32
major, bed rest 35
Injury Factors (IF) ambulatory 38
No illness/non-stress 1.0 Moderate stress, bed rest, 40
Convalescence, mild 1.1 ambulatory
Malnutrition
Burn: major, bed rest 45–50
Postoperative (no complication)
ambulatory 55–60
Mild illness, non catabolic
Cancer 35–45
Confined to bed 1.2
Predialysis 40–50
Ambulatory/out of bed 1.3
Hemodialysis 35
Infectious stress/catabolic Peritoneal dialysis 30
Mild 1.2–1.3
Moderate 1.4–1.5 Rule of thumb. For those who want a quick answer, there is
Severe, catabolic 1.6–1.8 a rule of thumb that works quite well for many people of
Sepsis 2.0–2.2 relatively normal weight.
Burns: <20% BSA 1.2–1.4
20–40% 1.5–1.7 Energy Need = body weight (lb) × 12 sedentary woman
>40% BSA 1.8–2.0 14 sedentary man
Fracture, long bone 1.2–1.3 15 mild active woman
Respiratory/renal failure 1.4–1.5 17 mod. active man
COPD 1.4–1.8 18 active woman
Cancer with chemotherapy or 20 active man
Radiation cardiac cachexia 1.5–1.6
Surgery: minor/elective 1.1–1.2
Major surgery 1.2–1.3
Trauma: skeletal/blunt 1.3–1.4
Multiple head injury 1.5–1.6

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2. ESTIMATING PROTEIN REQUIREMENTS i. 35 mL/kg body weight

ii. 1 mL/kcal intake (referring to enteral formula)
Protein iii. 1500 mL/m2 body surface area
Stress level requirements iv. 100 mL/kg for the first 10 kg, plus 0.50 mL/kg for the
(gm/kgDBW/day)
next 10 kg, plus 0.25 mL/kg for the remaining weight
Normal 1.1
Mild stress 1.1–1.2
Moderate stress 1.3–1.4 b. Minimal fluid requirements
Severe stress 1.5–1.7
Polytrauma, infection 1.8–2.4 i. 500 mL/day urine output obligatory to excrete daily
Severe sepsis, major burn, head solute load
2.5–3.0
injury ii. 500–1000 mL/day of evaporative water loss
Surgery, minor/elective 1.2–1.3 iii. 300 mL/day of water produced from endogenous
Surgery, major 1.4–1.5 metabolism
Cancer, malabsorption iv. 2000–3000 mL/day intake to yield approximately
1.2–1.5
syndromes, tuberculosis
1000–1500 mL/day of urine output
Acute respiratory failure 1.3–1.4
v. Fluid requirements increase 150 mL/day of each
Acute renal failure 0.3–0.5
Hemodialysis 1.0–1.2 degree of body temperature over 37oC
Peritoneal dialysis 1.2–1.5 vi. Increased respiration, ambient and body
Post renal transplant 1.5–2.0 temperature, respiratory rate, and extra renal fluid
COPD 1.2–1.5 losses increase fluid requirements
Hepatitis, cirrhosis 1.5–2.0 vii. As a rule of thumb, one necessary bed change cue
Depleted protein stores, to respiration represents approximately 11 of fluid
decubiti, long bone fractures 1.6–1.7 lost.
drawing wounds
Chronic renal failure 0.55–0.06
c. Calculating fluid deficit

3. ADULT FLUID REQUIREMENTS Current total body water (TBW, 1) = 0.6 × current body
weight (kg)
a. Calculations (assuming normal renal and cardiac Desired TBW = Measured serum Na+ (mEq/l) × current TBW
function and euvolemia [normal hydration status]) Normal serum Na+ (mEq/l)
Body water deficit = desired TBW – current TBW

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4. BURNS c. TER = DBW × 24 = kcal for BMN + kcal from

increase of temperature
a. Energy d. TER = kcal from Step C x AF
e. kcal/day = kcal from Step C + kcal from Step D
i. Adults
Method 1: [20 kcal × kDBW] + [70 kcal × %BSA] 6. SURGERY
Method 2: [25 kcal × preburned body wt (kg)] + [40 kcal
× %TBSA burned] BEE × activity × injury = kcal/day

ii. Children Adjust weight for amputations

Method 1: [60 kcal × kDBW + 35 kcal × %BSA] Hand < 5%
Method 2: [ (kcal RDA for age/kg × preburned body wt Arm and shoulder 6.5%
(kg)] + [40 kcal × %TBSA] Below the knee 6.0%
Above the knee 12.0%
b. Protein Forearm 3.0%
Foot 2.0%
i. Adults At the knee 9.0%
Method 1: [Pro 1 g × kDBW] + [3 g × % BSA] Entire leg 19.0%
Method 2: [1.1 kcal × % preburned body wt (kg)] + [3 kg
× %TBSA burned] 7. EDEMA

iii. Children a. To determine dry weight

Method 1: [ 3 g × KDBW + 1 g × % BSA]
Method 2: [ Pro RDA for age/kg + (3 kg × TBSA i. Elevate leg 45o from bed
burned)] ii. Height elevated leg reading × 10 + 8 = actual weight

Note: TBSA = total body surface area

5. FEVERS AND INFECTIONS

a. Determine basal metabolic requirements by first

calculating the basal metabolic needs

b. Determine the % increase of BMR per oC or oF to adjust

BMR
13% – oC
7% – oF

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b. Estimating DBW in a person with edema/ascites 11. DIABETIC COMPUTATIONS

(from the Revised Diet Manual, 5th ed)
a. Diabetic Make-up Diet is given when a patient is
i. Multiply actual body weight (ABW) to 50% as the unable to eat foods in a certain meal time.
normal total body water (NTBW)
ii. Get the patient’s actual serum sodium (142 mEq/L Example: Patient left 1 cup lugaw and 1 slice 3 cm cube
as an average normal value) and use the formula of meat
below to derive his actual total body water:
Step1: Determine glucose that was not eaten
142 mEq/L × answer of NTBW
Actual serum Na CHO = 100% Protein = 58% Fat = 10%
CHO (g) Protein (g) Fat (g)
iii. Deduct step b from step a to get the estimated body
water (EBW) 1 cup lugaw 23 2
iv. Deduct EBW from ABW 1 slice meat (pork) 8 6
23 10 6
Available glucose × 1.0 × 0.58 × 1.0
8. WEIGHT LOSS ( 1–2 lbs/week) 23 5.8 0.6

TER = actual body weight × activity – (500–1000 kcal) for 23 + 5.8 + 0.6 = 29.4 grams glucose needed to be
people with BMI > 35 replaced
TER = usual intake – (300–500 kcal) for people with BMI
between 27 and 35 Step 2: Determine fruit servings needed to replace the
glucose
9. WEIGHT GAIN (1–2 lbs/week)
TER = actual body weight × activity + (500–1000 kcal) 29.4/10 (carbohydrates/exchange fruit)
3 exchanges of fruit may be given either as a
10. PERCENTAGE WEIGHT LOSS juice or as fruit juice
= [(Usual body weight – actual body weight)/ (usual body
weight)] × 100

Significant weight loss Severe weight loss

5% over 1 month >5% over 1 month
7.5% over 3 months >7.5% over 3 months
10% over 6 months >10% over 6 months

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Protein prescription
12. RENAL COMPUTATIONS Creatinine clearance Daily protein intake
(mL/minute) (g/kg)
a. Protein prescriptions 30–20 0.60
PROTEIN AND NITROGEN NEEDS IN 19–5 0.45
CHRONIC RENAL FAILURE <5 0.30
For children: No lower than 1–1.3 g/kg/day
Creatinine
Nitrogen* Protein
clearance 13. SALT SOLUTIONS
(g/day) (g/day)
(mL/minute)
40 and above Unrestricted Unrestricted Preparation of salt solution
10–40 9.6 60 Salt solution needed
5–20 6.4 40 mg Na
Lunch Supper
2–10 2.5–3.0 20 800 mg 1 tsp. 1 tsp.
8 and below Transplantation 1000 mg 1 ½ tsp. 1 ½ tsp.
Dialysis 1500 mg 3 tsp. 3 tsp.
Dialysis 2000 mg 4 ½ tsp. 4 ½ tsp.
* Total protein / 6.25
Regular diet contains 2800–6000 mg Na
Glomular filtration rate (GFR) Protein intake (g/kg day) (7–15 mg NaCl).
20–70 mL/minute 0.6–0.7
<25 mL/minute 0.28 (supplemented with To prepare salt solution
<5 mL/minute EAA)
1.0–1.2 (with dialysis) Mix 2T NaCl + 1 cup H2O
= 12,000 mg/cup
To calculate GFR (Based on the Revised Diet Manual, 5th 1T salt solution → 500 mg Na
ed.):

GFR (M) = weight (kg) × 140 – age 14. CONVERSIONS OF MILLIGRAMS TO

72 × serum creatinine (mg/dL) MILLIEQUIVALENTS (mEq)

GFR (W) = weight (kg) × 140 – age × 0.85 (Milligrams/atomic weight) × valence = milliequivalents
72 × serum creatinine (mg/dL) Sodium (Na): (mg Na/23) × 1
Potassium (K): (mg K/39) × 1
Phosphorus (P): (mg P/31) × 2
Calcium (Ca): (mg Ca/40) × 2

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15. HOW TO USE THE FOOD EXCHANGE LISTS FOR f. Compute the amount of fat coming from milk and meat.
PROTEIN, SODIUM, POTASSIUM, PHOSPHOROUS, Determine the number of fat exchanges. Specify the
CALCIUM, AND FLUID-CONTROLLED DIET type of fat.

a. Divide the prescribed protein into: g. Total the protein, electrolytes, carbohydrates, and fat
content of the proposed diet.
High Biologic Value (HBV) = 2/3 – ¾
Low Biologic Value (LBV) = 1/3 – ¼ h. Compute additional oral fluid: Fluid prescription –
inherent fluid
e.g. HBV prot. = 2/3 (30) = 20 g
LBV prot. = 1/3 (30) = 10 g i. Compute additional salt allowable: Prescribed Na –
inherent Na
b. Distribute HBV protein into foods. Consider patient’s
preferences in distributing HBV into milk and meat j. Determine calcium supplements that may be needed.
exchanges.
16. DIALYSATES
c. Specify the type of meat exchanges preferred. Note:
Since K and P are the electrolytes, which may have a. Multiply total volume of each dialysate exchange in liters
to be limited, their computation is a priority over by its glucose concentration per liter (grams of glucose)
other electrolytes. to obtain grams of glucose in the dialysate exchange.
Add the grams of glucose from each dialysate exchange
d. Distribute LBV protein into foods. to determine the total grams of glucose.

i. Determine exchanges of vegetables. Specify the b. Multiply total grams of glucose by the approximate
type. absorption rate of 80%.
ii. Determine the number of rice exchanges. Distribute
into different types preferred. c. Multiply total grams of glucose absorbed by the calories
per gram of glucose (3.7 kcal/g) to determine the total
e. Compute the amount of carbohydrates coming from calories absorbed from the dialysate solution.
milk, vegetable, and rice. Distribute remaining CHO into
foods. Example:
2L of 2.5% solution:
i. Consider K+ prescription in choosing fruits and 2 L × 25g glucose = 50 g total glucose
vegetables. 50 g glucose × 0.80 = 40 g glucose absorbed
ii. Determine exchanges of sugar. 40 g × 3.7 kcal/g = 148 kcal from dialysate solution

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17. STEPS IN CALCULATING A KETOGENIC DIET iv. Steps

Option 1. Use of regular fat a. Determine caloric requirements relative to age and
physical activity
i. Goal : Ketogenic 3 or 4 b. Calculate protein allowance using 1.0–1.5 g/KDBW
= c. Determine allowable CHO and fat
Antiketogenic 1 1

ii. Rationale: Ketogenic : Antiketogenic ratio of 3:1 will i. Kcal from protein (#2)
produce ketosis ii. Kcal from CHO (10–30 g)
Anticonvulsant effect of diet is due to high plasma levels iii. Kcal from Fat = TER [kcal from protein + kcal
of ketone bodies. from CHO]
iv. Convert each into grams
Ketogenic factors such as fatty acids and ketogenic AA
Antiketogenic factors such as carbohydrates, d. Check ketogenic to antiketogenic ratio, get ratio.
glucogenic AA, and the glycerol portion of fat.
Option 2. Use of MCT oil
Ketogenic factors 0.5 P + 0.9 F = _________________ 1 g MCT = 8.3 kcal
Antiketogenic factors 0.5 P + 0.1 + 1.0 C 15 mL (Tbsp) MCT = 14 g

iii. Guidelines a. Guidelines

a. Ketogenic factors = 90% of fat i. MCT = 50–70% of TER

50% of protein ii. CHO = maximum of 19% of TER
iii. Protein and CHO combined = 29% pf TER
b. Antiketogenic factors (glucogenic): 100% of CHO iv. Fats exclusive of MCT = min of 11% of TER
50% of Protein v. CHO = 10–30 g adults; 75 g children
10% of Fat

c. Fat allowance = 80– 90% of TER

d. Protein and CHO = 7% each
e. CHO = 10–30 g/day to induce ketosis

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b. Steps Day K: AK Ketogenic Antiketogenic Total Units

Ratio Calorie Calorie Per Day
i. Establish caloric requirements based on age & PA. Fat Protein + F + (P + C)
ii. Determine amount of MCT Carbohydrate
First 1.1:1 9.9 kcal 4.0 kcal 13.9 kcal
TER × 50–70% = kcal for MCT Second 1.6:1 14.4 kcal 4.0 kcal 18.4 kcal
Third 2.2:1 19.8 kcal 4.0 kcal 18.4 kcal
kcal (MCT) = kcal for MCT Fourth 2.8:1 25.2 kcal 4.0 kcal 29.2 kcal
8.3
iii. For grams of fat, multiply the number of units by the
g of MCT = no. of tbsp for MCT K value in the ratio of ketogenesis to
14 gm/tbsp antiketogenesis:

iii. Establish amount of calorie to be provided by food Grams of fat = Number of Units × K
exclusive of MCT.
iv. Establish protein allowance according to RDA and iv. For grams of protein and carbohydrate, multiply the
patient’s desires. number of units by the AK value (1) in the ratio of
v. Establish maximum calories in the form of CHO. ketogenesis to antiketogenesis:
vi. Establish maximum CHO and protein allowance
vii. Estimate minimum calories to be given as fat Grams of protein plus carbohydrate = Number of
exclusive of MCT. units × AK (1)

c. Option 3. Using units per day (Based on the Revised v. For grams of protein, determine the number of
Diet Manual, 5th ed.) grams needed according to age and kilograms of
body weight
i. Determine the total calorie requirement of the child.
ii. Divide the total calories by calories per unit: vi. For grams of carbohydrate, subtract the grams of
protein in the diet from the total units per day:
Total units per day = Total Calories
Calories per unit Grams of carbohydrate = Total units per day – grams of
protein

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I. NUTRITION SUPPORT

1. PARENTERAL

a. Dextrose and amino acid

i. Energy
1 g dextrose = 3.4 kcal/g
1 g amino acid = 4.0 kcal/g

ii. Osmolality
% D × 50 × 1 L (dextrose)
% AA × 100 × 1 L (amino acids)

b. Fat emulsions
10% = 1.1 kcal/ml
20% = 2.0 kcal/ml

2. ENTERAL: SOME COMMERCIAL FORMULA

Sustagen: 4.0 kcal/g
Ensure: 4.5 kcal/g
Isocal: 4.7 kcal/g
Amount of formula = TER/[kcal (com. form)]
Amount of H2O = Total Rx fluid – amount of
formula

J. OTHERS
Calorie from ethanol = 0.8 × proof × oz.
Proof = 2 × (% alcohol)

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Appendices

Appendix D.! Caffeine content of selected beverages

Beverage Caffeine (mg)

Mean per 5 oz (150 Mean per 100
mL) cup mL
Coffee
Instant 60 40
Percolated 117 78
Drip, automatic 137 91
Bagged tea
Black, 5 min. brew 46 33
Black, 1 min. brew 28 20
Loose tea
Black, 5 min. brew 54 36
Green, 5 min. brew 31 21
Oolong, 5 min. brew 40 27
Cocoa mix, 1 oz. Packet
made with water 1
Coca-cola, Regular and Diet 45 12
Dr. Pepper, Regular and Diet 40 11
Mountain Dew 54 15
Pepsi Cola, Regular 38 10
Pepsi Cola, Diet 36 10
Tab 45 12
Values derived from Pennington, J.A.T., and Church, H.N. Bowes and Church’s Food Values of
Portions Commonly Used, 14th edition, Philadelphia, PA; J.B. Lippincott Company, 1985.
Reprinted with permission.

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Appendix E.! Objectives, characteristics, and indications of normal and modified diets

Diet Objectives Characteristics Indication

A. Normal, Regular, Standard, To supply appropriate Include all foods normally eaten For patients whose condition/s
or Full Diet amount of calories, by a person in good health; does not require any
proteins, and other requires good menu planning; modification
nutrients. there are no particular food
restriction
B. Modifications in
Consistency and Texture
1. Clear Liquid To provide an oral source Highly restrictive and of little Pre-operative and post-
of fluids and small amounts nutritive value; it provides some operative cases, inflammation
of kilocalories and electrolytes, mainly in the form of of the GIT, diarrhea, vomiting,
electrolytes for: CHO; leaves no residue in the after colon surgery, or for a
a. preventing GIT; limited for use in 24–28 barium enema, as the first step
dehydration; hours; the amount of fluid in a in the oral alimentation of the
b. relief of thirst; and given feeding is usually restricted severely debilitated patient
c. reducing caloric to 30–60 mL/hour at first; May
residue to a allow the use of tea, broth
minimum

2. Cold Liquid To minimize pain, swelling, All foods are served cold or iced After tonsillectomy, dental
and reduce bleeding in the extraction or other minor
operated areas operations of the mouth or
throat

3. Full Liquid or General To provide an oral Consist of food that are liquid or Postoperative cases; as a
Liquid nourishment that is well easily liquefied at body transition between a clear
tolerated by patients who temperature; free from cellulose liquid and a soft or full diet; in
are acutely ill or who are and irritating condiments; can be patients with esophageal
unable to swallow or chew made nutritionally adequate and strictures; mandibular
solid foods used for 6 or more feedings fractures; fevers and
(ex. strained cereals, pureed infections; lesions in the mouth
vegetables & fruits, soft cooked and GIT
egg, strained meat, fish, chicken,
soft bean curd, cream, butter or

265
Appendices

Diet Objectives Characteristics Indication

margarine, custard, plain ice
cream, plain pudding)

4. Tube Feeding or To provide a source of May be administered through a As a means of enteral

Blenderized Feeding or complete nourishment in a polyvinyl tube (NGT) via alimentation when normal
Osterized Feeding form that will easily pass nasogastric route, or chewing and swallowing
Types: through a tube when oral jejunostomy; well planned and mechanisms are impaired
a. Homogenized or feeding methods are should adequately maintain
blenderized mixture contraindicated or not nutritional status
b. Commercially tolerated
prepared & pre-
sterilized feedings
c. Standard

5. Soft or Light Diet Transition between the full Soft in consistency, easy to Acute infections, some GIT
liquid and normal diets chew, made up of simple, easily disturbances, and following
digested food, and contains no surgery; fevers
harsh fibers, no rich or highly
flavored food; it is nutritionally
adequate

6. Mechanical Soft or To provide foods that Follows the pattern of the regular Poor dentures, elderly with
Dental Soft or Geriatic requires minimal chewing diet; regular foods are chopped, difficulty chewing, after oral
Soft ground, pureed, sieved, or surgery, oral lesions
reduced to small pieces by other
mechanical means

7. Bland To provide a diet which is Foods which do not unduly Atonic constipation,
chemically, thermally, and increase gastric acid production uncomplicated diverticulosis,
mechanically non-irritating and are non-irritating to the GIT; irritable bowel syndrome,
spices are eliminated atherosclerosis, diabetes
mellitus

8. High Fiber To increase the volume and Approximately 13 or more grams Used for a short term in acute
the weight of the residue crude fiber daily; emphasis on phases of diverticulosis,
that reaches the distal increasing intake of whole grain ulcerative colitis or infectious

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Diet Objectives Characteristics Indication

colon; to increase breads and cereals, fresh fruits & enterocolitis, when bowel is
gastrointestinal motility; to vegetables that are high in fiber markedly inflamed, stenosis of
decrease intraluminal content the intestinal or esophageal
colonic pressure in patients varices
with increased pressures

9. Fiber Restricted Diet To prevent the formation of A diet that contains a minimum Short bowel syndrome, GI
an obstructing bolus by of fiber and connective tissue; fistulas, inflammatory bowel
high fiber foods in patients decrease the weight and bulk of disease, acute diarrhea, and
with narrowed intestinal or the stool and delay intestinal post-operative management of
esophageal lumens transit patients with colonic or rectal
surgery, pre-operative bowel
preparation
10. Residue Restricted Diet To provide a diet that Limits the use of fruits and
leaves a minimum residue vegetables high in fiber, beans,
to the GIT for fecal milk and dairy products, raw and
formation. soft-cooked egg, butter, lard,
and lactose.
C. Modifications in
Composition
1. Kilocalorie To provide a diet to reduce A diet limited in kilocalories to a Overweight and obese
a. Kilocalorie body weight and fat and for prescribed level significantly persons, HPN, osteoarthritis
Restricted Diet weight loss and below normal requirements
maintenance
Increased amounts and types of Underweight, hyperthyroidism,
b. High Calorie Diet To provide a diet with an food which are energy dense convalescence, fevers,
energy value above that pregnancy and lactation.
required for maintenance in
order to produce a gain in
weight, to meet increase
caloric requirements, or to
prevent or minimize
catabolism of body tissues

267
Appendices

Diet Objectives Characteristics Indication

2. Carbohydrates
a. Low CHO To reduce available CHO comprises 40% or less of Traditional regimen for DM,
glucose when CHO TER (but should not be less than weight reduction and epilepsy;
metabolism is impaired 100g/day); simple sugars are hyperinsulinism, dumping
eliminated syndrome, celiac disease,
certain types of
hyperlipoproteinemias,
stimulative and alimentary
hypoglycemias

b. High CHO To allow for glycogen CHO comprises 70–80% of TER; Liver disease, Addison’s
formation, ensure sufficient emphasis is on foods high in disease, fasting hypoglycemia,
calories to spare protein, available CHO such as sugar, acute glomerulonephritis,
and to minimize tissue syrups, jellies and jams, and uremia, pernicious vomiting,
catabolism sweets, should comprise no and toxemias of pregnancy
more than 10% of total calories;
majority of CHO must come from
complex sources

c. Galactose Free Control of galactosemia Lactose free Primary or secondary lactase

and the prevention of deficiency; primary lactase
severe mental retardation, deficiency as in Holzel
cataracts and other syndrome, Durand syndrome;
symptoms secondary lactase deficiency
as in celiac disease,
kwashiorkor, GI milk protein
allergy, irritable bowel
syndrome, regional enteritis,
and ulcerative colitis

d. Lactose Free Control of galactosemia A diet that eliminates virtually all Congenital or acquired severe
and the prevention of known sources of the sucrase-isomaltase deficiency;
severe mental retardation, disaccharide lactose like milk post-operative complications
cataracts and other and milk products in Hirshpruing’s disease and

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 Volume 2. Medical Nutrition Therapy and Nutritional Biochemistry

Diet Objectives Characteristics Indication

symptoms severe gastroenteritis

e. Sucrose Restricted To ameliorate or prevent Excludes all foods containing

symptoms of primary or more than 2% sucrose daily,
secondary sucrase- cakes, cookies, and pastries are
isomaltase deficiency either eliminated or restricted;
glucose, lactose or fructose are
used as substitute sweetening
agents
3. Protein
a. High Protein To provide for the Should provide 1.65–2.2 g/kg Primary or secondary protein-
nutritional rehabilitation of body weight for adults; 2.0–2.5 kilocalorie undernutrition; in
the protein and kilocalorie g/kg body weight for preparing a nutritionally
malnourished patient or to adolescents; 3–4 g/kg body wasted patient for surgery, in
prevent weight loss and weight for children or 50–100% hypermetabolic or catabolic
tissue wasting above the normal allowance; states as fevers or
allows 20% of TER from protein thyrotoxicosis, severely
burned patients

b. Protein Restricted To achieve and maintain Contains food of high biologic Acute renal failure, chronic
adequate NS; to lighten the value as milk, egg and meats renal failure
work of the kidney by supplying at least 1/2 – 2/3 of the
reducing the urea, uric daily PRO allowance
acid, creatinine that must
be excreted; to replace
protein that are lost to the
body because of impaired
renal function; or to replace
protein losses in dialysis

• Zero Protein Should be used for 2–3 days only Hepatic coma
as condition improves, protein
intake should be gradually
increased to 5, 10, and 15, 20
gm and so on per day. Fruit and
fruit juices increase the

269
Appendices

Diet Objectives Characteristics Indication

potassium content of the diet.

• 20gm Protein (GG Contains limited amount of Chronic renal failure, acute
Diet) protein with at least 1/2 – 2/3 glomerulonephritis
from HBV sources. Sugars fats
and fruits are used generously to
meet caloric needs.

• 40gm Protein More palatable than 20 gm Chronic uremia, chronic

(Modified GG protein, more variety of foods glomerulonephritis,
Diet) can be included in planning, at maintenance diet in between
least 1/2 – 2/3 should come from dialysis
HBV sources

c. Protein
Constituents
• Purine Restricted To lower serum uric acid A diet in which uric acid and its Gout, uric acid calculi
levels in the management precursors, specifically, sources
of gout of purines such as glandular
meats, dried legumes, lentils,
and meat extracts, are
eliminated. Purine content of the
diet is about 120–150 mg (regular
diet contains as much as 600–
1000 mg/day); relatively high in
CHO and fluids and low in fat

• Phenylalanine Permit normal growth and A diet in which the intake of the Phenylketonuria (PKU)
Restricted development and adequate amino acid phenylalanine is
nutritional status; to limited to a prescribed level
prevent mental retardation governed by patient intolerances
and allow the fullest usually 250–500 mg
development of intellectual phenylalanine/day.
potential

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 Volume 2. Medical Nutrition Therapy and Nutritional Biochemistry

Diet Objectives Characteristics Indication

• Gluten restricted, To eliminate toxic glutens Diet that is free of toxic glutens Celiac disease, non-tropical
Gliadin Free Diet in order to ameliorate such as those in wheat, rye, oat, sprue, dermatitis
symptoms of retarded and barley protein, or their
growth, jejunal mucosal derivatives, e.g. malt from barley
and immunological
abnormalities, secondary
steatorrhea, sterility and
possibly osteomalacia in
patients with celiac disease

4. Vegetarians Diet To replace part or the entire One that includes some or all of
animal sources of protein the: vegetables, fruits, enriched
with plant sources or whole breads and cereals,
beans, nuts, and milk
Types:
• Vegan Diet or Strict It is designed for individuals who
Vegetarian Diet wish to exclude all animal
products; an example is the Zen
Macrobiotic Diet

• Lacto-vegetarian Diet One that includes dairy products

plus some or all of the ff. foods:
vegetables, fruits, enriched or
whole grain breads & cereals, dry
beans, nuts. Diet excludes meat,
poultry, fish, and eggs

• Lacto-ovo-vegetarian One that includes eggs and dairy

Diet products

• Zen Macrobiotic Diet A dietary regimen composed of Ecological and religious

ten basic diets ranging from the concerns
lowest level, diet 3, which
includes 10% cereals, 30%
vegetables, 10% soup, 30%
animal products; 15% salads

271
Appendices

Diet Objectives Characteristics Indication

and fruits, 5% desserts, to diet 7.
Highest level of the regimen is
100% cereal. Vit. B12
supplement is recommended

5. Fat
a. Low Fat Limits all types of fat ingested, Chronic pancreatitis, gall
regardless of source to less than bladder diseases,
10–15% of TER or less than 30 cardiovascular diseases,
gm/day disorder in the digestion,
absorption, and transport of
fat
b. Ketogenic Diet To induce and maintain a
state of ketosis in the body A diet very low in carbohydrates Epilepsy; Glut-1 deficiency;
in order to achieve an where fat is the primary fuel. A Dravet syndrome
anticonvulsant effect ketogenic ratio of 4:1 or 3:1 is
targeted to induce ketosis.
c. Low Cholesterol To lower elevated levels of
serum cholesterol to Dietary cholesterol is reduced to Atherosclerosis,
reduce the risk of heart less than 300 mg/day hypercholesterolemia type II-V,
disease hyperlipoproteinemia,
coronary artery disease

d. Modified Fatty Acid To maintain P/S ratio of 1:1 Fat content is at normal level but Coronary artery disease, DM,
Ratio to 2:1 foods with PUFA are hypercholesterolemia,
emphasized; corn oil, cottonseed hypertriglyceridemia,
oil, safflower oil, fish nuts (except atherosclerosis, Types II-V
cashew, peanut, and coconut) hyperlipo-proteinemia

6. Mineral Content To restore normal sodium Vary with degree of restriction, Ascites, HPN, CHF, renal
a. Sodium Restricted balances to the body by usual prescription ranging from disease with edema,
(Low Salt, Low effecting loss of excess Na 500 mg to 3–4 g daily (Filipino adrenocorticoid therapy,
Sodium) & water from extra cellular diet usually contains 2600–6000 toxemias of pregnancy
fluid compartments. mg or 7–15 g of NaCl/day).
Foods containing large amounts

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Diet Objectives Characteristics Indication

of natural Na or commercially
processed foods with Na
containing compound are either
eliminated or restricted in
amount.

• 200–300 mg (9–
13 mEq) Extreme No salt used in cooking. Careful Liver cirrhosis with ascites,
Sodium selection of foods low in sodium, CHF if severe Na restriction is
Restriction low sodium milk recommended. ineffective

• 500–700 mg (22–
30 mEq) Severe No salt used in cooking. Careful Severe CHF, occasionally in
Sodium selection of foods in measured renal diseases with edema &
Restriction amounts. May use regular milk. cirrhosis with ascites

• 1000–1500 mg
(43–65 mEq) No salt used in cooking. Careful Patients with strong family
Moderate Sodium selection of foods low in Na but history of HPN, borderline
Restriction may include measured amounts HPN
of salts, or salted bread and
butter.

• 2000–3000 mg To prevent hyperkalemia Some salt may be used in Maintenance diet in cardiac
(87–130 mEq) cooking, but no salty foods are and renal diseases
Mild Sodium permitted. No salt is used at the
Restriction table.

b. Potassium To prevent the depletion of Limits K intake to 1.0–1.8 g (25 to Acute renal failure & adrenal
Restricted body K reserves 46 mEq) per day. The average insufficiency, CHF with
diet contains about 2 to 6 gm K hyperkalemia, Addison’s
(50 mEq) disease

Used in combination with Provides a minimum of 170 mEq Diarrhea, intestinal or biliary
c. High Potassium oxalate and fat restrictions (6,630 mg) or K daily fistulas, vomiting, or
to prevent renal stones nasogastric suction, oliguria

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Appendices

Diet Objectives Characteristics Indication

and anuria, diuretic phase in
tubular necrosis, uncontrolled
DM, therapy with K-wasting
diuretics, or corticosteriods,
Cushing’s syndrome

d. Calcium Restricted To bring about a reduction Provide Ca level from 200–400 Calcium oxalate stones,
in the pH of urine (normal mg/day (normal adult hypercalcemia in prolonged
range is 4.5 to 7.5) requirement is 500 mg/day). immobilization,
hyperparathyroidism,
leukemia, lymphoma, therapy
with Vitamin D metabolites
7. Ash content
a. Acid-Ash* To bring about an increase Increased use of acid-forming Renal stones consisting of Ca,
in the pH of urine (those containing sulfur, Mg, phosphate, carbonates
phosphorus, and chloride) such and oxalates
as meat, fish, eggs,
b. Alkaline-Ash**
Increased intake of alkaline Uric acid and cystine stones
forming foods (those containing
Na, K, Mg, Ca) such as fruits,
vegetables, and milk

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 Volume 2. Medical Nutrition Therapy and Nutritional Biochemistry

ACID, ALKALINE, AND NEUTRAL FOODS

Food Potentially acid or acid-ash food* Potentially alkaline or alkaline-ash Potentially neutral foods
group food**
Meat Meat, fish, fowl, shellfish, eggs, all
types of cheese, peanut butter,
peanut
Milk Milk and milk products, cream,
buttermilk
Fat Bacon, nuts (Brazil nuts, filberts, Nuts (almonds, chestnuts, coconut) Butter, margarine, cooking
walnuts) fats, oils
Starch All types of bread (especially whole- Arrowroot, corn, tapioca
wheat), cereal, crackers, macaroni,
spaghetti, noodles, rice
Vegetables Corn, lentils All types (except corn, lentils), specially
beets, beet greens, Swiss chard,
dandelion greens, kale, mustard green,
spinach, turnip greens
Fruit Cranberries, plums, prunes All types (except cranberries, plums
and prunes)
Desserts Plain cakes, cookies Molasses
Sweets Plain candies, sugar, syrup,
honey
Beverage Coffee, tea

275
Appendices

Appendix F.! Management of Non-specific Nutritional Problems

1. Xerostomia (dry mouth) 6. Anorexia

• Soft bland foods, especially cool or cold foods with high • Small, frequent feedings
fluid content • Drink liquids before eating.
• Try pureed diet or full liquid diet , if necessary • Serve food attractively
• Citric acid containing beverages, lemon drops or gums • Drugs may be taken after mealtime to improve intake at
to increase salivation meals.
• Lightly flavored foods, hot foods, wine, and a variety of
2. Thick viscous saliva foods considering the patient’s references to stimulate
• Give clear liquid. appetite
• Saline rinses before eating may help. • Appetite stimulant drugs, if prescribed
• Dining with friends or family in pleasant surroundings
3. Hypogeusia (diminished taste perception) • Encourage eating when feeling best
• In the absence of oral or esophageal lesions, give
flavorful (e.g. spicy) foods. 7. Nausea and vomiting
• Serve attractively prepared food. • Clear liquids
• Eat and drink slowly
4. Hypergeusia (heightened taste perception) • Avoid low fat and strongly flavored odors
• Serve bland foods. • Salty or light flavored for electrolyte replenishment
• Serve cold foods or foods with minimal odors.
8. Heart burn
5. Taste blindness (dysgeusia) • Bland diet
• Healthy snack alternatives, high protein • Small frequent feedings
• Small frequent feeding • Do not lie down for two to three hours after meals.
• Keep head and chest elevated with pillows or put a six-
inch bed block under the head of the bed.

9. Indigestion
• Small frequent feeding: bland diet.
• Avoid overeating and foods that may cause indigestion.

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 Volume 2. Medical Nutrition Therapy and Nutritional Biochemistry

10. Bloating

• Eat frequent small meals.

• Avoid fatty, fried and greasy foods, gas-forming
vegetables (broccoli, cabbage, cauliflower, corn,
cucumber, beans, green peppers, sauerkraut and
turnips), carbonated beverages, chewing gum and milk.
• Eat slowly.
• Sit up or walk around after meals.

11. Dehydration

• Liquids – juices and high water containing food items

12. Neurologic complications

These include impairment of motor functions, confusion,

dementia and neuropathy.

• Simplify meal tray; use special utensils, if available.

• Modify food consistency if there is difficulty of
swallowing.
• In advanced cases of neurologic involvement, the
patient may need feeding assistance, or consider tube
feeding, and special feeding devices

277
Appendices

Appendix G.! Test diets

A. TEST FOR GASTRIC FUNCTION B. GALLBLADDER SERIES

1. Test for gastric secretory activity This is a test of gallbladder function as visualized by X-ray.

A light supper is given on the evening before the 1. A light low-fat meal consisting of the following foods is
examination. On the morning of the test, a meal that will given the evening before the test:
stimulate gastric acid secretion is given. One of the Fruit or fruit juice
following meals may be used: Fresh or cooked soft vegetable without added fat
Rice or toast with jelly
a. Boa’s Test Meal Canned fruit or plain gelatin
Coffee or tea with sugar, no milk
i. 2 slices of fat-free or plain toast bread
1 cup of weak tea without sugar or cream 2. A high-fat diet consisting of the following foods is given on
ii. 4 large soda crackers or arrowroot cookies the day of the test:
1–1/2 glasses of water or weak tea without cream or Bacon or fried eggs
sugar Toast with butter
Milk or eggnog
b. Riegel Meal: consists of 200 mL of beef broth, 150–200 Fruit (optional)
g of broiled beef, and 100 g of potato.
C. GLUCOSE TOLERANCE TEST
2. Test for gastric motility
1. Blood sugar test is done 2 hours after a meal high in
A light supper is given on the evening before the test. On carbohydrate (at least 150 g) or after drinking a standard 75
the morning of the test, a meal with readily recognized fibers mg glucose dose.
is given. One of the following motor meals may be given:
The test meal consists of either of the following:
a. Rice and raisin or berries with seeds, or
b. Meat sandwich and 30 raisins, or a. Bread – 2 slices
c. Meal with stewed prunes. Jelly – 2 T
Kalamansi with 5 tbsp sugar

b. Kalamansi Juice with 8–1/2 tbsp glucose

2. The standard glucose tolerance test makes use also of a 75

g glucose dose in 500 mL of distilled water consumed

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within 5 minutes. Fasting and hourly blood sugar

determinations up to 5–6 hours post-glucose loading are
done.

D. KIDNEY FUNCTION TEST

Collection of urine before and after the test to determine the

variation of specific gravity and the volume of the urine

Test meal:
1. Regular diet, one pint of water, tea and coffee followed
by NPO
2. Urine Collection

E. INTRAVENOUS PYELOGRAPHY

Determination of the problems of the kidney

Test Meal consists of light supper, 30 cc castor oil, NPO,
enema

F. OTHER TESTS

1. Test for occult blood in stools: A meat-free or

hemoglobin-free diets given for three days prior to stool
collection. The following foods are allowed:

Cheese Vegetables (nonleafy)

Milk Cereals, refined
Eggs Fruits or juices

Highly colored foods like dark green leafy vegetables

and iron supplements are avoided, as these tend to
interfere with the test.

279
Appendices

2. Test for calcium metabolism: Use low calcium standard (100 mg Ca) diet

Breakfast Lunch Supper

• ½ cup juice • 2 oz fried chicken (flesh, • 2 oz broiled beef (with
• 2 oz bologna or 1 hotdog with salt and pepper salt and pepper only)
or 2 slices bacon only) • 100 g raw tomato
• 1 pandesal • 100 g potato • ¾ cup rice
• 2 tsp butter • ¾ cup Rice • 1 slice canned pineapple
• Coffee with sugar only • 1 banana
• Tea with sugar

3. Measurement of fecal fat

Patient is fed with a high fat diet, 50–100 g several days before and during the collection of stools. Stools are tested for radioactivity
using triolein.

4. Lactose tolerance test

Use of 50–100 g lactose before testing blood glucose.

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Appendix H.! Tests for Nutritional Assessment

1. Blood tests
Laboratory test/ Deviation in disease
Normal Range Decreased Increased
Albumin Nephrotic syndrome, PEM, PTB, cancer, burns, Dehydration IV albumin administration
3.5–5.5 g/dL prolonged fever and infections, overhydration
severe hepatic disease; renal and GI loss; acute
catabolic status
Alkaline phosphate Hypoparathyroidism, low phosphorus diet, low Liver and certain bone diseases, congestive
20–72 µg/L dietary Vitamin C, scurvy, celiac diseases, excess heart failure, peptic ulcer/ulcerative colitis,
Vitamin D, malnutrition, pernicious anemia, renal hyperparathyroidism, calcium deficiency
insufficiency
Ascorbic acid Vitamin C deficiency, scurvy Oxalate stone/elevated uric acid
0.2–1.5 mg/dL
Bilirubin, total Hepatitis, biliary obstruction, drug toxicity,
<1 mg/dL hemolytic disease, prolonged fasting
Bicarbonate Diabetic ketosis, starvation, lactic acidosis, Metabolic alkalosis, protracted vomiting with
24–30 mEq/L diarrhea with Co2 loss, renal failure K+ loss, heart failure with edema
Blood urea nitrogen (BUN) Hepatic failure, nephrosis, acute low protein intake, Hyperparathyroidism, multiple myeloma,
5–25 mg/dL malabsorption osteolytic disease, immobilization, excess
Vitamin D
Calcium Renal disease, hyperparathyroidism, chronic Hyperparathyroidism, multiple myeloma,
8.5–10.5 mg/dL rickets, sprue/celiac disease, malabsorption osteolytic disease, immobilization, excess
Vitamin D
Chlorides Diabetic acidosis, K deficiency, Addison’s disease Renal insufficiency, nephrosis, fever,
100–106 mE/qL dehydration
Cholesterol Malnutrition, hyperthyroidism, pernicious anemia Atherosclerosis, biliary obstruction,
130–250 mg/dL myxedema, uncontrolled diabetes, renal
disease
Creatinine Muscle catabolism, myocardial infarct,
0.7–1.5 mg/dL acute/chronic renal disease, use of
cephalothin, ibuprofen
Ferritin Iron deficiency Iron overload, over-transfusion, dehydration
30–250 mg/dL

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Appendices

Laboratory test/ Deviation in disease

Normal Range Decreased Increased
Fibronectin Acute catabolic states; disseminated intravascular
coagulation (DIC)
Globulin Malnutrition Infections, liver disease, leukemia,
2.3–3.5 g/dL hyperlipidemia
Glucose Hyperinsulinemia, pancreatic tumors, liver disease, Diabetes mellitus, pancreatic dysfunction,
70–100 g/dL pituitary dysfunction, malnutrition hyoperthyroidism, malignancies, burns,
Cushing’s disease
Hematocrit Anemias (sickle cell & iron deficiency), blood loss, Polycythemia vera, severe pancreatitis,
Females: 37–47% uremia, Vitamins B & C deficiency dehydration
Males: 42–52%
Hemoglobin Prolonged iron deficiency, blood loss Polycythemia vera, dehydration, chronic
Female: 13.5–15 g/dL hypoxia, chronic lung disease, transplant
Male: 14–16 g/dL rejection
Iron Iron deficiency cirrhosis Iron overload, hemolytic anemia, acute
40–160 µg /dL hepatitis, estrogen therapy
Lipase Pancreas “burn-out” Acuter pancreatitis, biliary tract infection, renal
1.5 IU/mL disease
Lymphocyte Count malnutrition → impaired immune function
1500–4000/mm3
Magnesium PEM, malabsorption, diarrhea, vomiting, diabetic Oliguric renal failure, dehydration
1.4–2.3 mE/qL acidosis, congestive heart failure, renal failure
without oliguria, hypercalcemia, pancreatitis
Mean cell corpuscular volume Chronic disease, iron deficiency, polycythemia, Macrocytic anemia/folate deficiency
(MCY) lead poisoning, congenital spherocytosis
81–100 µg
Phosphorus Vitamin D deficiency, hyperinsulinism, Renal insufficiency, hyperparathyroidism,
2.5–4.5 mg/dL hyperparathyroidism, osteomalacia nephritis, bone diseases
Potassium Diuretic therapy, vomiting, diarrhea, malabsorption, Renal insufficiency, tissue catabolism,
3.5–5.0 mE/qL hypermagnesemia, Cushing Syndrome, laxative circulatory failure or shock, Addison’s
abuse disease, acidosis, dehydration, hyperglycemia
Prealbumin (thyroxine-binding Acute catabolic states; hyperthyroidism; Renal failure; dehydration
prealbumin, transthyretin) inadequate protein intake; severe liver disease,
overhydration

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Laboratory test/ Deviation in disease

Normal Range Decreased Increased
Protein, total Malnutrition, malabsorption, cirrhosis, steatorrhea, Dehydration, acute and chronic infectious
6–8.4 g/dL edema, nephritic syndrome, chronic illness diseases, leukemia, Hodgkin’s disease,
multiple myelomia

Red blood cells Anemia, hemorrhage, chronic infectious, diseases, Polycythemia, dehydration, reduced plasma
(erythrocytes) iron deficiency volume
4.5–5 million/mm3
Reticulocyte count Reflects bone marrow activity
25,000–75,000 cells
Retinol-binding protein Vitamin A deficiency; acute catabolic states; Renal disease
hyperthyroidism; zinc deficiency; severe liver
disease
SGOT Pyridoxine deficiency, beriberi, possibly in chronic Burns, trauma, myocardial infarct, cirrhosis,
0–43 µg/dL dialysis neoplastic disease, infections
SGPT 1–21 µg/dL Cirrhosis, hepatitis, neoplastic disease
SODUM Diabetic, acidosis, Addison’s disease, diarrhea, Dehydration, diabetes insipidus, steroid
139–144 mEq/L burns, starvation, adrenal insufficiency, nephritis, therapy
hyperglycemia, hyperproteinemia
Somatomedin C Protein-energy malnutrition; growth hormone Hypothyroidism; renal failure; cirrhosis
deficiency
Total iron binding capacity Cirrhosis, malnutrition, collagen disease, chronic Chronic iron deficiency, pregnancy,
250–425 mg/dL disease/infection, iron overload alchoholism, acute hepatitis
Transferrin saturation Absolute or relative iron deficit; severe liver Hemolytic, megaloblasticand sideroblastic
20–50% disease; acute catabolic status, overhydration anemia, iron overload, dehydration
Tryglycerides Malnutrition, malabsorption Liver disease, gout, pancreatitis, diabetes,
40–150 mg/dL steroid use, nephritic syndrome
Uric acid High doses of salycilates, high BP triglycerides, Gout, renal insufficiency, leukemia,
20–5.5 mg/dL arteriosclerosis hypoparathyroidism, starvation, anemia,
myeloma, psoriasis, thiazide diuretics
White blood cells Chemotherapy Leukemia, acute inflammation/infection, fever,
4.5–10.5 thousand/mm3 anemia
Zinc Hypergeusia, malnutrition
101–130 µg/dL

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2. Skin test
Deviation in disease
Laboratory test Normal value
Increase Decrease
Delayed* cutaneous Healthy persons __________ Infection, uremia, liver
hypersensitivity reexposed to antigens disease, inflammatory
(DCH) intradermally will have T- bowel disease (IBD),
cell proliferation and malignant disease,
release of mediators steroids,
causing inflammation at immunosuppressants,
the injection site; skin warfarin, cimetidine
inflammation is often
reduced in malnutrition
*Low specificity for diagnosing protein-energy malnutrition

3. Urine test
Test Purpose Calculation Normal range Factors influencing test
Creatinine Reasonable See equation Protein depletion: Test requires:
height index assessment of in footnote** <40% = severe Normal renal function
(CHI) lean body mass in 40–50% = moderate Normal hydration
healthy adults; 60–80% = mild Normal Urine Output
derived from No prolonged bed rest or strenuous exercise
catabolism of No recent intake of creatine or creatinine (meat)
creatinine No extremes of age (i.e., < 2 months)
phosphate, a No acute catabolic illness
metabolite found Diet and renal function can significantly alter results
mainly in muscle Eliminate exogenous sources (i.e., meat)
Any event that increase muscle turnover (i.e., sepsis,
Methyl Measure of 24-hour urine trauma, starvation) invalidates this test as a predictor of
Histidine (an skeletal protein collection skeletal muscle
amino acid) stores and Effects of age, sex, nutrition, exercise, hormonal status,
turnover as it is and injury on test results have not been quantified
mainly derived
from the
breakdowm of
skeletal muscle
proteins (actin and
myosin) and is

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Test Purpose Calculation Normal range Factors influencing test

excreted without
being further
metabolized
Nitrogen Determine net See equation +2 to –2 = balance Incomplete collection (<24 hours) or urine collection >24
Balance (NB) protein in footnote *** ≥2 = positive hours. It is simple to check and ensure a 24-hour urine
breakdown over a ≤2 = negative collection is complete; usual creatinine excretion is 10–
24-hour period 25 mg creatinine per kg

Catabolic Estimate degree See equation <0 = no stress

index (CI) of stress or in footnote**** 0–5 = moderate stress
catabolism >5 = severe stress

**CHI (%) = 24-hour urine creatinine (mg) × 100

Normal 24-hour urine creatinine excretion for height
***NB = Protein intake (g/24 hours) – nitrogen output (g/24 hours)
6.25
where nitrogen output equals: urine nitrogen (UUN) insensible losses (4 g), diarrhea (2.5 g), GI fistula drainage (1.0 g), blood urea nitrogen (BUN) accumulation during
study period. If UNN >30, estimate insensible losses at 6 g.
****CI = [UNN (g) + change in BUN (g) – 3] – 0.5 × N intake (g)]

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4. Urine analysis
Test Normal findings Abnormalities/deviations
Color Straw to light amber Discolor used by biliary disease (urobilin) hematuria,
hemoglobulinuria, porphyria, drugs, foods (beets can cause a red
color).
pH Clear  Cloudy urine may be due to presence of blood, pus, phosphate,
bacteria, fat, and Vitamin C.
 Urine pH (acidic): diabetic ketoacidosis, starvation, uremia, renal
acidosis, high-protein, or high fat diet, acidic drugs, intracellular
acidosis.
 Urine pH (alkaline): metabolic alkalosis, hyperventilation, vomiting,
alkali administration, UTI secondary to proteus
Protein None to slight trace Proteinuria: glomerulonephritis, nephrotic syndrome, nephrotoxicity
from drugs or chemicals, pregnancy/prostatitis.
Glucose None Glucosiria: diabetes or low renal threshold for glucose reabsorption
(if blood glucose within normal limits)
Ketones Negative Ketonuria: diabetic ketoacidosis, starvation, prolonged vomiting,
toxemia, Gierke’s disease, increased fat or decreased carbohydrate
diet, fever, thyrotoxicosis
Sediment (RBCs, None to little (kidney  RBCs: calculi, tumors, hematuria, hemorrhagic cystitis,
WBCs, casts, membranes are  WBCs: infection, pyelonephritis
crystals) effective filters)  Casts: infection or damage to renal tubules
 Crystals: calcium oxalate, hypercalcemia
Specific gravity 1.008–1.030 Value increased: fever, acute glomerulonephritis, nephrosis, toxemia,
congestive heart failure (CHF), fluid intake; Value decreased: chronic
glomerulonephritis, or pyelonephritis, systemic lupus erythomatosus
(SLE), parenteral nutrition, fluid intake, hypothermia, diabetes
insipidus

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Appendix I.! Fatty Acid and Cholesterol Content of Selected Foods per Exchange

SFA PUFA MUFA Cholesterol

Food group Amount
g g g mg
Vegetables A and B ½ cup — — — —
Fruit varies — — — —
Milk, evaporated ½ cup 5.5 3.3 0.4 33
Powdered skim 4 tbsp — — — 7
Rice or bread 1 exch. — — — —
Low fat meat group
Lean fish (tuna) 30 g 0.27 0.36 0.25 11
Lean beef 30 g 0.48 0.02 0.44 21
Lean pork 30 g 0.36 0.09 0.42 32
Chicken without skin 30 g 0.32 0.22 0.38 25
Shrimp, crabmeat 30 g — — — 38
Egg 1 med. 1.6 0.40 2.2 275
Fat exchanges
Butter 1 tsp. 2.75 0.2 1.65 125
Coconut oil 1 tsp. 4.30 0.1 0.30 —
Corn oil 1 tsp. 0.65 3.0 1.20 —
Olive oil 1 tsp. 0.65 0.4 3.70 —
Peanut butter 1 tbsp. 1.82 1.75 3.15 —
Peanut oil 1 tsp. 0.85 1.60 2.30 —
Sesame oil 1 tsp. 0.70 2.10 1.90 —
Soybean oil 1 tsp. 0.75 2.95 1.00 —
Fatty acids computed from percentage composition of total fat in these foods. Sources: Home Economics
Research Report No. 7, Agricultural Research Service, USDA; National Heart, Lung and Blood Inst. Publication 88
– 2696; and Composition of Food – Raw Processed and Prepared, USDA Handbook No. 8.
MUFA, monounsaturated fatty acids; PUFA, polyunsaturated fatty acids; SFA, saturated fatty acids.

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Appendices

Appendix J.! Classification of Foods According to Purine Content

Category 1 Category 2 Category 3

Very large; 150–1000 mg Large; 75 < 150 mg Moderate; <75 mg
Total purines/100 mg Total purines/100 mg Total purines/100 mg
Legumes and dried beans
(all)
Organ meats Organ meats Organ meats
Hog: liver, spleen, small Hog: lung, kidney, tongue, Hog: uterus, blood
and large intestines heart
Cattle: liver, spleen Cattle: lung, uterus, kidney, Cattle: small and large
heart, brain, reticulum intestines, blood, tripe,
omassum
Carabao: liver, spleen Carabao: lung, kidney, Carabao: uterus, small and
tripe, reticulum large intestines, tripe,
omassum
Chicken: liver, kidney,
gizzard, intestine
Finfishes and shellfishes Finfishes and shellfishes
Alumahan Dalagang bukid
Bangus Galunggong
Dilis Halaan
Matang baka Hasa-hasa
Tamban Hipon, puti
Tanigi Maya, maya
Tunsoy Pusit
Bisugo Tahong
Tulingan Tambakol
Talaba
Tilapya
Tulya
Tuwakang
Adopted from William’s Criteria. Source: Lontoc, A.V. et al., Purine content of some Philippine foods. Kimika
9: 15-22, 1993.

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