Nutrition and Diet Therapy

["176 PART II PUBLIC HEALTH NUTRITION PROGRESS CHECK ON ACTIVITY 1 Manufacturers can use structure-function claims FILL-IN without FDA authorization. They base their claims on their review and interpretation of the scientific litera- 1. The label of a dietary supplement should include: ture. Like all label claims, structure-function claims must be true and not misleading. Structure-function claims a. are easy to spot because, on the label, they must be ac- companied with the disclaimer \u201cThis statement has not b. been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or c. prevent any disease.\u201d d. Manufacturers who plan to use a structure-function claim on a particular product must inform the FDA of the e. use of the claim no later than 30 days after the product is first marketed. While the manufacturer must be able f. to substantiate its claim, it does not have to share the substantiation with the FDA or make it publicly avail- 2. Under the DSHEA and previous food labeling able. If the submitted claims promote the products as laws, supplement manufacturers are allowed to drugs instead of supplements, the FDA can advise the use, when appropriate, which three types of claims: manufacturer to change or delete the claim. a. Because there often is a fine line between disease claims and structure-function claims, the FDA has es- b. tablished criteria under which a label claim would or would not qualify as a disease claim. Among label factors c. are these: 3. Labels of dietary supplement include two 1. The naming of a specific disease or class of diseases portions: 2. The use of scientific or lay terminology to describe a. the product\u2019s effect on one or more signs or symp- toms recognized by healthcare professionals and con- b. sumers as characteristic of a specific disease or a number of different specific diseases MULTIPLE CHOICE 3. Product name 4. Statements about product formulation Circle the letter of the correct answer. 5. Citations or references that refer to disease 6. Use of the words disease or diseased 4. An official compendium applicable to dietary sup- 7. Art, such as symbols and pictures plements can be which of the following: 8. Statements that the product can substitute for an ap- proved therapy (for example, a drug) a. U.S. Pharmacopeia b. Homeopathic Pharmacopeia of the United If shoppers find dietary supplements whose labels state or imply that the product can help diagnose, treat, cure, States or prevent a disease (for example, \u201ccures cancer\u201d or c. National Formulary \u201ctreats arthritis\u201d), they should realize that the product is d. All of the above being marketed illegally as a drug and as such has not been evaluated for safety or effectiveness. 5. A supplement that carries the claim \u201chigh in cal- cium\u201d should have, per serving, at least: The FTC regulates claims made in the advertising of dietary supplements, and in recent years, that agency has a. 100 milligrams of calcium taken a number of enforcement actions against compa- b. 200 milligrams of calcium nies whose advertisements contained false and mislead- c. 400 milligrams of calcium ing information. The actions targeted, for example, erroneous claims that chromium picolinate was a treat- TRUE\/FALSE ment for weight loss and high blood cholesterol. An ac- tion in 1997 targeted ads for an ephedrine alkaloid Circle T for True and F for False. supplement because they understated the degree of the product\u2019s risk and featured a man falsely described as a 6. T F The FDA is authorized to test dietary supple- doctor. ments. 7. T F Under the DSHEA, firms cannot make state- ments about classical nutrient deficiency diseases- even though these statements disclose the prevalence of the disease in the United States.","CHAPTER 11 DIETARY SUPPLEMENTS 177 8. T F Manufacturers using health claims must have tification of folate as the nutrient needed to prevent the substantiation that the statements are truth- anemia of pregnancy. Dr. Wills demonstrated that the ful and not misleading and the product label anemia could be corrected by a yeast extract. Folate was must bear the statement \u201cThis statement has identified as the corrective substance in yeast extract in not been evaluated by the Food and Drug the late 1930s and was extracted from spinach leaves in Administration. This product is not intended 1941. Folate is necessary for the production and mainte- to diagnose, treat, cure, or prevent any disease.\u201d nance of new cells. This effect is especially important during periods of rapid cell division and growth such as 9. T F Ingredient and nutrition information labeling infancy and pregnancy. Folate is needed to make DNA of dietary supplements are strictly regulated. and RNA, the building blocks of cells. It also helps pre- vent changes to DNA that may lead to cancer. 10. T F Ingredients listed in the nutrition label of a di- etary supplement must also appear in the in- Both adults and children need folate to make normal gredient label. red blood cells and prevent anemia. Leafy greens such as spinach and turnip greens, dry beans and peas, forti- 11. T F Supplement suppliers have the burden to show fied cereals and grain products, and some fruits and veg- that new ingredients in their dietary supple- etables are rich food sources of folate. Some breakfast ments are reasonably safe. cereals (ready-to-eat and others) are fortified with 25% or 100% of the Daily Value (DV) for folic acid. 12. T F The Federal Trade Commission regulates the advertising of dietary supplements. NEED FOR EXTRA FOLIC ACID 13. T F FDA review and approval of supplement ingre- Women of childbearing age, people who abuse alcohol, dients and products is not required before anyone taking anticonvulsants or other medications that marketing. interfere with the action of folate, individuals diagnosed with anemia from folate deficiency, and individuals with 14. T F Food additives not generally recognized as safe malabsorption, liver disease, or who are receiving kid- must undergo the FDA\u2019s premarket approval ney dialysis treatment may benefit from a folic acid sup- process for new food ingredients. plement. Folic acid is very important for all women who may become pregnant. Adequate folate intake during the 15. T F Under the DSHEA, once a dietary supplement periconceptual period, the time just before and just after is marketed, the FDA has the responsibility for a woman becomes pregnant, protects against a number showing that a dietary supplement is unsafe of congenital malformations including neural tube de- before it can take action to restrict the prod- fects. Neural tube defects result in malformations of the uct\u2019s use. spine (spina bifida), skull, and brain (anencephaly). The risk of neural tube defects is significantly reduced when 16. T F Calcium can be claimed to have a link with a supplemental folic acid is consumed in addition to a lower risk of osteoporosis, if the supplement healthful diet prior to and during the first month follow- contains sufficient amounts of calcium. ing conception. Women who could become pregnant are advised to eat foods fortified with folic acid or take sup- 17. T F Nutrient-content claims describe the level of a plements in addition to eating folate-rich foods to reduce nutrient in a food or dietary supplement. the risk of some serious birth defects. Taking 400 micro- grams of synthetic folic acid daily from fortified foods 18. T F When nutrition support claims are used, the and\/or supplements has been suggested. label must mention the prevalence of the nutrient-deficiency disease in the United States. VITAMIN B12 AND FOLIC ACID 19. T F Structure-function claims refers to the sup- Folic acid supplements can correct the anemia associated plement\u2019s effect on the body\u2019s structure or with vitamin B12 deficiency. Unfortunately, folic acid will function, including its overall effect on a per- not correct changes in the nervous system that result son\u2019s well-being. from vitamin B12 deficiency. Permanent nerve damage can occur if vitamin B12 deficiency is not treated. Intake ACTIVITY 2: of supplemental folic acid should not exceed 1000 micro- grams (mcg) per day to prevent folic acid from masking Folate or Folic Acid symptoms of vitamin B12 deficiency. It is very important for older adults to be aware of the relationship between For basic information on this vitamin, consult Chapter 5. The information in this activity has been modified from fact sheets distributed by the Office of Dietary Supplements, National Institutes of Health. Folate and folic acid are forms of a water-soluble B vi- tamin. Folate occurs naturally in food. Folic acid is the synthetic form of this vitamin that is found in supple- ments and fortified foods. Folate gets its name from the Latin word folium for leaf. A key observation of re- searcher Lucy Wills nearly 70 years ago led to the iden-","178 PART II PUBLIC HEALTH NUTRITION FOLIC ACID AND METHOTREXATE FOR NONCANCEROUS DISEASES folic acid and vitamin B12 because they are at greater risk of having a vitamin B12 deficiency. Persons 50 years of Low-dose methotrexate is used to treat a wide variety of age or older should ask their physicians to check B12 sta- noncancerous diseases such as rheumatoid arthritis, lupus, tus before taking a supplement that contains folic acid. psoriasis, asthma, sarcoidosis, primary biliary cirrhosis, and inflammatory bowel disease. Low doses of methotrex- FOLIC ACID, HEART DISEASE, AND CANCER ate can deplete folate stores and cause side effects that are similar to folate deficiency. Both high-folate diets and sup- A deficiency of folate, vitamin B12, or vitamin B6 may in- plemental folic acid may help reduce the toxic side effects crease the level of homocysteine, an amino acid normally of low-dose methotrexate without decreasing its effective- found in your blood. There is evidence that an elevated ness. Anyone taking low-dose methotrexate for the health homocysteine level is an independent risk factor for heart problems listed here should consult with a physician about disease and stroke. The evidence suggests that high lev- the need for a folic acid supplement. els of homocysteine may damage coronary arteries or make it easier for blood clotting cells called platelets to HEALTH RISK clump together and form a clot. However, there is cur- rently no evidence available to suggest that lowering ho- The risk of toxicity from folic acid is low. The Institute of mocysteine with vitamins will reduce the risk of heart Medicine has established a tolerable upper intake level disease. Clinical intervention trials are needed to deter- (UL) for folate of 1000 mcg for adult men and women, mine whether supplementation with folic acid, vitamin and a UL of 800 mcg for pregnant and lactating (breast- B12, or vitamin B6 can lower the risk of developing coro- feeding) women less than 18 years of age. Supplemental nary heart disease. folic acid should not exceed the UL to prevent folic acid from masking symptoms of vitamin B12 deficiency. Some evidence associates low blood levels of folate with a greater risk of cancer. Folate is involved in the PROGRESS CHECK ON ACTIVITY 2 synthesis, repair, and functioning of DNA, our genetic map, and a deficiency of folate may result in damage to TRUE\/FALSE DNA that may lead to cancer. Several studies have asso- ciated diets low in folate with increased risk of breast, 1. T F Folate and folic acid are forms of a fat-soluble pancreatic, and colon cancer. Findings from a study of B vitamin. over 121,000 nurses suggested that long-term folic acid supplementation (for 15 years) was associated with a de- 2. T F Folate does not occur naturally in food. creased risk of colon cancer in women aged 55 to 69 years 3. T F Folate was identified as the corrective sub- of age. However, associations between diet and disease do not indicate a direct cause. Researchers are continu- stance in yeast extract in the late 1930s and ing to investigate whether enhanced folate intake from was extracted from spinach leaves in 1941. foods or folic acid supplements may reduce the risk of 4. T F Folate is not needed to make DNA and RNA, cancer. Until results from such clinical trials are available, the building blocks of cells, but it helps pre- folic acid supplements should not be recommended to vent changes to DNA that may lead to cancer. reduce the risk of cancer. 5. T F Breakfast cereals (ready-to-eat and others) are required to be fortified with folic acid. FOLIC ACID AND METHOTREXATE FOR 6. T F Folic acid is only important for all women who CANCER may become pregnant. 7. T F The risk of neural tube defects is significantly Folate is important for cells and tissues that rapidly divide. reduced when supplemental folic acid is con- Cancer cells divide rapidly, and drugs that interfere with sumed in addition to a healthful diet prior folate metabolism are used to treat cancer. Methotrexate to and during the first month following is a drug often used to treat cancer because it limits the conception. activity of enzymes that need folate. Unfortunately, 8. T F Folic acid supplements can correct the ane- methotrexate can be toxic, producing side effects such as mia associated with vitamin B12 deficiency but inflammation in the digestive tract that make it difficult not correct changes in the nervous system that to eat normally. Leucovorin is a form of folate that can result from vitamin B12 deficiency. help \u201crescue\u201d or reverse the toxic effects of methotrex- 9. T F Intake of supplemental folic acid should not ate. It is not known whether folic acid supplements can exceed 1000 micrograms (mcg) per day to pre- help control the side effects of methotrexate without de- vent folic acid from masking symptoms of vi- creasing its effectiveness in chemotherapy. It is impor- tamin B12 deficiency. tant for anyone receiving methotrexate to follow a medical doctor\u2019s advice on the use of folic acid supplements.","CHAPTER 11 DIETARY SUPPLEMENTS 179 10. T F There is evidence that an elevated homocys- The six commercial dietary supplements discussed in teine level is a dependent risk factor for heart this activity are kava kava, Ginkgo biloba, goldenseal, disease and stroke. echinacea, comfrey, and pulegone. 11. T F Folic acid supplements can help control the KAVA KAVA side effects of methotrexate without decreasing its effectiveness in chemotherapy. On March 25, 2002, the Food and Drug Administration (FDA) issued the following warning: 12. T F Low doses of methotrexate can deplete folate stores and cause side effects that are similar The FDA is advising consumers of the potential to folate deficiency. risk of severe liver injury associated with the use of kava-containing dietary supplements. Kava Piper 13. T F A megadose of folic acid may be toxic. methysticum is a plant indigenous to the islands in the South Pacific where it is commonly used to FILL-IN prepare a traditional beverage. Supplements con- taining the herbal ingredient kava are promoted 14. List seven groups of people who may benefit from for relaxation (e.g., to relieve stress, anxiety, and folic acid supplementation. tension), sleeplessness, menopausal symptoms, and other uses. The FDA has not made a determination a. about the ability of kava dietary supplements to provide such benefits. b. Liver-related risks associated with the use of kava have c. prompted regulatory agencies in other countries, includ- ing those in Germany, Switzerland, France, Canada, and d. the United Kingdom, to take action ranging from warn- ing consumers about the potential risks of kava use to re- e. moving kava-containing products from the marketplace. Although liver damage appears to be rare, the FDA be- f. lieves consumers should be informed of this potential risk. g. Kava-containing products have been associated with 15. Neural tube defects caused by folate deficiency re- liver-related injuries\u2014including hepatitis, cirrhosis, and sult in malformations of the: liver failure\u2014in over 25 reports of adverse events in other countries. Four patients required liver transplants. In a. the United States, the FDA has received a report of a pre- viously healthy young female who required liver trans- b. plantation, as well as several reports of liver-related injuries. c. Given these reports, people who have liver disease or 16. The recommended daily intake of folic acid either liver problems, or people who are taking drug products from fortified foods and\/or supplemented (syn- that can affect the liver, should consult a physician before thetic) folic acid is using kava-containing supplements. . Consumers who use a kava-containing dietary supple- ment and who experience signs of illness associated with ACTIVITY 3: liver disease should also consult their physician. Symptoms of serious liver disease include jaundice (yel- Kava Kava, Ginkgo Biloba, Goldenseal, lowing of the skin or whites of the eyes) and brown Echinacea, Comfrey, and Pulegone urine. Nonspecific symptoms of liver disease can include nausea, vomiting, light-colored stools, unusual tired- Currently, there are thousands of botanicals being sold as ness, weakness, stomach or abdominal pain, and loss of dietary supplements. This chapter is not the proper appetite. forum to discuss all of them. Rather, six popular ones are discussed here. To make sure that the information is The FDA urges consumers and their healthcare profes- based on science and not testimony, the data have been sionals to report any cases of liver and other injuries that derived from the following government documents: may be related to the use of kava-containing dietary sup- plements. Adverse events associated with the use of di- 1. National Institutes of Health, Office of Dietary etary supplements should be reported as soon as possible. Supplements 2. National Institutes of Health, National Toxicology Program 3. National Institutes of Health, National Institute of Aging","180 PART II PUBLIC HEALTH NUTRITION riety of medical conditions. In Europe and some Asian countries, standardized extracts from ginkgo leaves are The presence of kava in a supplement should be iden- taken to treat a wide range of symptoms, including dizzi- tified on the product label in the Supplement Facts box. ness, memory impairment, inflammation, and reduced The following are commonly used names for kava: blood flow to the brain and other areas of impaired cir- culation. Because Ginkgo biloba is an antioxidant, some ava claims have been made that it can be used to prevent ava pepper damage caused by free radicals (harmful oxygen mole- awa cules). Although Germany recently approved ginkgo ex- intoxicating pepper tracts (240 mg a day) to treat Alzheimer\u2019s disease, there kava is not enough information to recommend its broad use. kava kava kava pepper Research in the United States kava root kava-kava Researchers at the New York Institute for Medical kawa Research in Tarrytown, New York, conducted the first kawa kawa clinical study of Ginkgo biloba and dementia in the kawa-kawa United States. Their findings were published in the kew Journal of the American Medical Association (October Piper methysticum 22\/29, 1997). These scientists examined how taking 120 Piper methysticum Forst.f. mg a day of a Ginkgo biloba extract affected the rate of Piper methysticum G. Forst. cognitive decline in people with mild to moderately se- rauschpfeffer vere dementia caused by Alzheimer\u2019s disease and vascu- sakau lar dementia. At the end of the study, they reported a tonga small treatment difference in people given the Ginkgo wurzelstock biloba extract. yangona Three tests were used to measure changes in the con- The FDA will continue to investigate the relationship, dition of participants. First, participants showed a slight if any, between the use of dietary supplements contain- improvement on a test that measured their cognitive ing kava and liver injury. The agency\u2019s investigation in- function (mental processes of knowing, thinking, and cludes attempting to determine a biological explanation learning). Second, participants showed a slight improve- for the relationship and to identify the different sources ment on a test that measured social behavior and mood of kava in the United States and Europe. The agency will changes that were observed by their caregivers. Third, alert consumers, and if warranted, take additional action participants showed no improvement on a doctor\u2019s as- as more information becomes available. sessment of change test. GINKGO BILOBA Because 60% of the people did not complete the study, findings are difficult to interpret and may even be dis- Introduction torted. In addition, this study did not address the effect of Ginkgo biloba on delaying or preventing the onset of Ginkgo biloba, a readily available natural product, has Alzheimer\u2019s disease or vascular dementia. The re- been the focus of recent media reports as a potential searchers recommend more investigation to accomplish treatment for Alzheimer\u2019s disease. Although a 1997 study the following: determine if these findings are valid, un- in the United States suggests that a ginkgo extract may derstand how Ginkgo biloba works on brain cells, and be of some help in treating the symptoms of Alzheimer\u2019s identify an effective dosage and potential side effects. disease and vascular dementia, there is no evidence that Ginkgo biloba will cure or prevent Alzheimer\u2019s disease. The extract of the ginkgo leaf contains a balance of flavone glycosides (including one suspected high-dose In addition, some recent case studies imply that daily carcinogen, quercetin) and terpene lactones. Other use of Ginkgo biloba extracts may cause side effects, such claims are as follows: Ginkgo acts as a blood thinner; it as excessive bleeding, especially when combined with improves circulation and is therefore used to treat mi- daily use of aspirin. Much more research is needed before graine headaches, depression, and a range of lung and scientists will know whether and how Ginkgo biloba ex- heart problems. tracts benefit people. People should consult with their family doctors be- Research Outside of the United States fore using Ginkgo biloba extracts. This recommendation is especially true for those with disorders in blood circu- For centuries, extracts from the leaves of the ginkgo tree lation or blood clotting and those taking anticoagulants have been used as Chinese herbal medicine to treat a va- such as aspirin. Many different preparations of Ginkgo","CHAPTER 11 DIETARY SUPPLEMENTS 181 biloba extract are available over the counter. They vary in Applied externally, comfrey acts as an anti- content and active ingredients. Because not enough re- inflammatory to promote healing of bruises, sprains, and search has been done, no specific daily amount of a open wounds. The roots and leaves of the plant contain Ginkgo biloba extract can be recommended as safe or ef- the protein allantoin, which stimulates cell proliferation. fective at this time. Comfrey is said to help wounds to heal and broken bones to knit. It is also taken internally as an herbal tea to treat GOLDENSEAL gastric ulcers, rheumatic pain, arthritis, bronchitis, and colitis. This ingestion is a matter of some concern be- The root of the goldenseal plant is traditionally used to cause comfrey contains several pyrrolizidine alkaloids, treat wounds, ulcers, digestive problems, and eye and ear primarily symphytine, which have been linked to liver infections. Today, the herb is also used as a laxative, tonic, and lung cancer in rats. The hepatotoxic effects of and diuretic. Goldenseal is used in feminine products such pyrrolizidine alkaloids are well established in both ani- as vaginal douches and is claimed to help with menstrual mals and humans. disorders such as irregular cycle and excessive bleeding. Berberine, one of the chief active components in gold- The use of comfrey in dietary supplements is a serious enseal, has antimicrobial and vasodilatory properties and concern to the FDA. These plants contain pyrrolizidine may also be effective in preventing the growth of cancer alkaloids, substances that are firmly established to be he- cells. The other major component of goldenseal, hydras- patotoxins in animals. Reports in the scientific literature tine (which can be made from berberine), has abortifa- clearly associate oral exposure of comfrey and pyrroli- cient effects and has been shown to induce labor in zidine alkaloids with the occurrence of veno-occlusive pregnant women when taken orally. Large internal doses disease (VOD) in animals. Moreover, outbreaks of hepatic of goldenseal may cause convulsions and irritation of the VOD have been reported in other countries over the mouth, throat, and stomach, tingling of the skin, paraly- years, and the toxicity of these substances in humans is sis, respiratory failure, and possibly death at very high generally accepted. The use of products containing com- doses. Chronic use may inhibit vitamin B absorption. frey has also been implicated in serious adverse incidents over the years in the United States and elsewhere. At present goldenseal is being studied by the federal However, while information is generally lacking to es- health authorities and clinical experts to determine its ef- tablish a cause-effect relationship between comfrey inges- fectiveness, safety, and toxicology. tion and observed adverse effects humans, the adverse effects that have been seen are entirely consistent with ECHINACEA the known effects of comfrey ingestion that have been described in the scientific literature. The pyrrolizidine This member of the daisy family is one of the top medic- alkaloids that are present in comfrey, in addition to being inal herb sellers in the United States. Although once used potent hepatotoxins, have also been shown to be toxic to for everything from snakebites to typhoid, echinacea as other tissues as well. There is also evidence that impli- a dietary supplement is most commonly used today as cates these substances as carcinogens. Taken together, an immunostimulant to treat the common cold, sore the clear evidence of an association between oral expo- throat, and flu. Echinacea is not known to have any se- sure to pyrrolizidine alkaloids and serious adverse health rious adverse side effects, although there have been re- effects and the lack of any valid scientific data that would ports of skin rash and insomnia among users. The herb enable the agency to determine whether there is an ex- is available in many forms-dried root or leaf, liquid ex- posure, if any, that would present no harm to consumers, tract, powder, capsules, tablets, creams, gels, and injec- indicates that this substance should not be used as an tions (outside of North America). It has yet to be ingredient in dietary supplements. determined how echinacea is best administered or ex- actly how\u2014or if\u2014the plant\u2019s complex mixture of polysac- Since 2000, the position of the FDA is as follows: charides, flavonoids, essential oils, and other compounds actually produces beneficial effects. Again, this dietary 1. The FDA believes that the available scientific informa- supplement is being studied for its clinical effect and tion is sufficient to firmly establish that dietary sup- safety. plements that contain comfrey or any other source of pyrrolizidine alkaloids are adulterated under the act. COMFREY 2. The FDA strongly recommends that firms marketing Certain dietary supplements contain the herbal ingredi- a product containing comfrey or another source of ent comfrey Symphytum officionale (common comfrey), pyrrolizidine alkaloids remove the product from the S. asperum (prickley comfrey), and S. x uplandicum market and alert its customers to immediately stop (Russian comfrey). Claims have been made about using the product. comfrey. 3. The FDA is prepared to use its authority and resources to remove products from the market that appear to vi- olate the act.","182 PART II PUBLIC HEALTH NUTRITION 5. T F Dietary supplements are considered as safe by manufacturers. Therefore, consumers do not 4. The FDA believes that manufacturers need to take ad- need to consult a physician before using them. equate steps to identify and report adverse events, es- pecially adverse events that may include liver 6. T F Ginkgo biloba is effective in preventing disorders, associated with any product that has an in- Alzheimer\u2019s disease. gredient that may contain pyrrolizidine alkaloids. 7. T F Daily use of Ginkgo biloba extracts is safe Further, since 2000, the Federal Trade Commission when used with other medications. (FTC) has also taken action against unsafe products con- taining comfrey. The FTC is against the marketing of any 8. T F Ginkgo biloba is an antioxidant, and can pre- comfrey-containing product intended for internal use or vent damage caused by free radicals. use on open wounds and requires a warning on comfrey products marketed for external uses. 9. T F Taking 120 mg a day of a Ginkgo biloba ex- tract may affect the rate of cognitive decline PULEGONE in people with mild to moderately severe de- mentia caused by Alzheimer\u2019s disease and vas- Pulegone is the active ingredient in pennyroyal and is cular dementia. also found in several other species of mint. Pennyroyal is traditionally used as a carminative, insect repellent, em- 10. T F Goldenseal root should not be taken by preg- menagogue, and abortifacient. Prior studies have demon- nant women. strated hepatic, renal, and pulmonary toxicity in humans, as well as central nervous system toxicity resulting in 11. T F Goldenseal root has antimicrobial properties seizure, coma, and death. Pulegone is toxic to the devel- and is therefore useful in treating eye and ear oping fetus. infections. PROGRESS CHECK ON ACTIVITY 3 12. T F Echinacea as a dietary supplement is most commonly used today as an immunostimulant FILL-IN to treat the common cold, sore throat, and flu. 1. Name five commercial dietary supplements: 13. T F Comfrey is safe when it is used for external treatment of wounds. a. 14. T F The main pyrrolizidine alkaloid in comfrey, b. symphytine, is hepatotoxic and carcinogenic. c. 15. T F Ingestion of pennyroyal can be fatal as it af- fects the central nervous system resulting in d. seizure and coma. e. 16. T F Pennyroyal should not be taken by pregnant women as it is toxic to a developing fetus. 2. Name five commonly used names for Piper methyleticum: ACTIVITY 4: a. An Example of Side Effects from Medications for Hyperactivity b. In the March-April 2002 issue of the FDA Consumer mag- c. azine, the FDA published an article titled \u201cTips for the savvy supplement user: Making informed decisions.\u201d A d. slightly modified version is presented here. e. The choice to use a dietary supplement can be a wise de- cision that provides health benefits. However, under cer- TRUE\/FALSE tain circumstances, these products may be unnecessary for good health, or they may even create unexpected risks. Circle T for True and F for False. Clearly, people choosing to supplement their diets 3. T F Kava has been used by Pacific islanders for with herbals, vitamins, minerals, or other substances centuries. Therefore kava-containing supple- want to know more about the products they choose so ments have no side effects. that they can make informed decisions about them. Given the abundance and conflicting nature of informa- 4. T F Supplements containing kava are effective for tion now available about dietary supplements, you may relaxation, sleeplessness, and menopausal need help to sort the reliable information from the ques- symptoms. tionable. The FDA has prepared these tips and resources to help you become a savvy dietary supplement user. The principles underlying these tips are similar to those prin- ciples a savvy consumer would use for any product.","CHAPTER 11 DIETARY SUPPLEMENTS 183 Do I need to think about my total diet? 3 weeks ahead of the procedure to avoid potentially dan- Yes. Dietary supplements are intended to supplement gerous supplement\/drug interactions-such as changes the diets of some people but not to replace the balance of in heart rate and blood pressure or increased bleeding- the variety of foods important to a healthy diet. While that could adversely affect the outcome of your surgery. you need enough nutrients, too much of some nutrients can cause problems. You can find information on the Who is responsible for ensuring the safety and effi- functions and potential benefits of vitamins and miner- cacy of dietary supplements? als, as well as upper safe limits for nutrients from many nonprofit organizations such as government agencies Under the law, manufacturers of dietary supplements (e.g., the FDA), university extension offices, American are responsible for making sure their products are safe Dietetic Association, and so on, including Chapters 3 to before they go to market. Manufacturers are also respon- 7 in this book. sible for determining that the claims on their labels are Should I check with my doctor or healthcare provider accurate and truthful. Dietary supplement products are before using a supplement? not reviewed by the government before they are mar- This is a good idea, especially for certain population keted, but the FDA can take action against any unsafe groups. Dietary supplements may not be risk-free under dietary supplement product that reaches the market. If certain circumstances: the FDA can prove that claims on marketed dietary sup- plement products are false and misleading, the agency \u2022 If you are pregnant, nursing a baby, or have a chronic may take action against these products. medical condition, such as diabetes, hypertension or heart disease, be sure to consult your doctor or phar- When searching the Web for information about di- macist before purchasing or taking any supplement. etary supplements, try using directory sites of respected organizations, rather than doing blind searches with a \u2022 While vitamin and mineral supplements are widely search engine. Ask yourself the following questions: used and generally considered safe for children, you may wish to check with your doctor or pharmacist be- \u2022 Who operates the site? fore giving these or any other dietary supplements to \u2022 Is the site run by the government, a university, or a your child. reputable medical or health-related association (such \u2022 If you plan to use a dietary supplement in place of as the American Medical Association, American drugs or in combination with any drug, tell your Diabetes Association, American Heart Association, healthcare provider first. Many supplements contain American Dietetic Association, National Institutes of active ingredients that have strong biological effects, Health, National Academy of Sciences, or the FDA)? and their safety is not always assured in all users. \u2022 Is the information written or reviewed by qualified health professionals, experts in the field, academia, \u2022 If you have certain health conditions and take these government, or the medical community? products, you may be placing yourself at risk. \u2022 What is the purpose of the site? \u2022 Is the purpose of the site to objectively educate the \u2022 Some supplements may interact with prescription and public or just to sell a product? over-the-counter (OTC) medicines. Taking a combina- tion of supplements or using these products together Be aware of practitioners or organizations whose main with medications (whether prescription or OTC drugs) interest is in marketing products, either directly or could, under certain circumstances, produce adverse through sites with which they are linked. Commercial effects, some of which could be life threatening. sites should clearly distinguish scientific information from advertisements. Most nonprofit and government Be alert to advisories about these products, whether sites contain no advertising, and access to the site and taken alone or in combination. For example, Coumadin materials offered are usually free. (a prescription medicine), Ginkgo biloba (an herbal sup- plement), aspirin (an OTC drug), and vitamin E (a vita- \u2022 What is the source of the information and does it have min supplement) can each thin the blood, and taking any references? any of these products together can increase the potential for internal bleeding. Combining St.-John\u2019s-wort with \u2022 Has the study been reviewed by recognized scientific certain HIV drugs significantly reduces their effective- experts and published in reputable peer-reviewed sci- ness. St.-John\u2019s-wort may also reduce the effectiveness of entific journals, such as the New England Journal of prescription drugs for heart disease, depression, seizures, Medicine? certain cancers, or oral contraceptives. \u2022 Does the information say \u201csome studies show . . .\u201d or Some supplements can have unwanted effects during does it state where the study is listed so that you can surgery. It is important to fully inform your doctor about check the authenticity of the references? For example, the vitamins, minerals, herbals, or any other supplements can the study be found in the National Library of you are taking, especially before elective surgery. You Medicine\u2019s database of literature citations? may be asked to stop taking these products at least 2 to \u2022 Is the information current? Check the date when the material was posted or updated. Often new research or","184 PART II PUBLIC HEALTH NUTRITION safe.\u201d Consumers can be misled if they assume this term assures wholesomeness, or that these foodlike other findings are not reflected in old material, for substances necessarily have milder effects, which example, side effects or interactions with other prod- makes them safer to use than drugs. The term nat- ucts or new evidence that might have changed ear- ural on labels is not well defined and is sometimes lier thinking. Ideally, health and medical sites should used ambiguously to imply unsubstantiated bene- be updated frequently. fits or safety. For example, many weight-loss prod- \u2022 How reliable are the Internet and e-mail solicitations? ucts claim to be \u201cnatural\u201d or \u201cherbal,\u201d but this While the Internet is a rich source of health informa- doesn\u2019t necessarily make them safe. Their ingredi- tion, it is also an easy vehicle for spreading myths, ents may interact with drugs or may be dangerous hoaxes, and rumors about alleged news, studies, prod- for people with certain medical conditions. ucts, or findings. To avoid falling prey to such hoaxes, Questionable Assumption 3: \u201cA product is safe when be skeptical and watch out for overly emphatic lan- there is no cautionary information on the product guage with UPPERCASE LETTERS and lots of excla- label.\u201d Dietary supplement manufacturers may not mation points!!!! Beware of such phrases such as: \u201cThis necessarily include warnings about potential ad- is not a hoax\u201d or \u201cSend this to everyone you know.\u201d verse effects on the labels of their products. If con- sumers want to know about the safety of a specific MORE TIPS AND TO-DO\u2019S dietary supplement, they should contact the man- ufacturer of that brand directly. It is the manufac- Ask yourself: turer\u2019s responsibility to determine that the supplement it produces or distributes is safe and \u2022 Does it sound too good to be true? that there is substantiated evidence that the label \u2022 Do the claims for the product seem exaggerated or claims are truthful and not misleading. Questionable Assumption 4: \u201cA recall of a harmful unrealistic? product guarantees that all such harmful prod- \u2022 Are there simplistic conclusions being drawn from a ucts will be immediately and completely removed from the marketplace.\u201d A product recall of a di- complex study to sell a product? etary supplement is voluntary, and, while many manufacturers do their best, a recall does not nec- While the Web can be a valuable source of accurate, re- essarily remove all harmful products from the liable information, it also has a wealth of misinforma- marketplace. Contact the manufacturer for more tion that may not be obvious. Learn to distinguish hype information about the specific product that you from evidence-based science. Nonsensical lingo can are purchasing. If you cannot tell whether the sound very convincing. Also, be skeptical about anec- product you are purchasing meets the same stan- dotal information from people who have no formal train- dards as those used in the research studies you ing in nutrition or botanicals, or personal testimonials read about, check with the manufacturer or dis- (from store employees, friends, or online chat rooms and tributor. Ask to speak to someone who can address message boards) about incredible benefits or results ob- your questions, some of which may include: What tained from using a product. Question these people on information does the firm have to substantiate the their training and knowledge in nutrition or medicine. claims made for the product? Be aware that some- times firms supply so-called proof of their claims Think twice about chasing the latest headline. Sound by citing undocumented reports from satisfied health advice is generally based on a body of research, consumers, or \u201cinternal\u201d graphs and charts that not a single study. Be wary of results claiming a \u201cquick could be mistaken for evidence-based research. fix\u201d that depart from previous research and scientific be- Does the firm have information to share about liefs. Keep in mind science does not proceed by dramatic tests it has conducted on the safety or efficacy of breakthroughs, but by taking many small steps, slowly the ingredients in the product? Does the firm have building towards a consensus. Furthermore, news sto- a quality control system in place to determine if ries about the latest scientific study, especially those on the product actually contains what is stated on the TV or radio, are often too brief to include important de- label and is free of contaminants? Has the firm re- tails that may apply to you or allow you to make an in- ceived any adverse event reports from consumers formed decision. using their products? Check your assumptions about the following: NURSING IMPLICATIONS Questionable Assumption 1: \u201cEven if a product may When a nurse is caring for a patient who is involved with not help me, at least it won\u2019t hurt me.\u201d It\u2019s best not dietary supplements (using them, intending to use them, to assume that this will always be true. When con- sumed in high enough amounts, for a long enough time, or in combination with certain other sub- stances, all chemicals can be toxic, including nutri- ents, plant components, and other biologically active ingredients. Questionable Assumption 2: \u201cWhen I see the term \u2018natural,\u2019 it means that a product is healthful and","CHAPTER 11 DIETARY SUPPLEMENTS 185 or asking questions about them), the major nursing im- about potential medical therapies when they or their plication is mainly patient education. families and friends might one day benefit from them. 1. Be prepared to teach clients how to do the following: Though often more difficult to do, consumers also a. Detect fraudulent products and deceptive adver- can protect themselves from economic fraud, a practice tising. in which the manufacturer substitutes part or all of a b. Purchase quality products if they intend to use product with an inferior, cheaper ingredient and then supplements. passes off the fake product as the real thing but at a lower c. Read product labels. cost. Avoid products sold for considerably less money d. File a report if side effects are experienced. than competing brands. e. Recognize that dietary supplements can cause harm, the reasons they can be harmful, and the Quality Products types of reactions that may occur. f. Reduce the chances of suffering adverse effects Poor manufacturing practices are not unique to dietary from supplement use. supplements, but the growing market for supplements in a less restrictive regulatory environment creates the po- 2. Counsel patients to seek expert advice from their tential for supplements to be prone to quality-control physicians before beginning any supplement regime. problems. For example, the FDA has identified several problems where some manufacturers were buying herbs, The following information will assist you in preparing plants, and other ingredients without first adequately a teaching plan. testing them to determine whether the product they or- dered was actually what they received or whether the in- Fraudulent Products gredients were free from contaminants. Consumers need to be on the lookout for fraudulent To help protect themselves, consumers should do the products. These are products that don\u2019t do what they say following: they can or don\u2019t contain what they say they contain. At the very least, they waste consumers\u2019 money, and they 1. Look for ingredients in products with the U.S.P. no- may cause physical harm. tation, which indicates the manufacturer followed standards established by the U.S. Pharmacopoeia. Fraudulent products often can be identified by the types of claims made in their labeling, advertising, and 2. Realize that the label term natural doesn\u2019t guarantee promotional literature. Some possible indicators of fraud, that a product is safe. Think of poisonous mushrooms\u2014 according to the National Council Against Health Fraud, they are natural. are the following: 3. Consider the name of the manufacturer or distribu- 1. Claims that the product is a secret cure and use of tor. Supplements made by a nationally known food such terms as breakthrough, magical, miracle cure, and drug manufacturer, for example, have likely been and new discovery. If the product were a cure for a se- made under tight controls because these companies rious disease, it would be widely reported in the media already have in place manufacturing standards for and used by healthcare professionals. their other products. 2. \u201cPseudomedical\u201d jargon, such as detoxify, purify, and 4. Write to the supplement manufacturer for more in- energize to describe a product\u2019s effects. These claims formation. Ask the company about the conditions are vague and hard to measure, and so they make it under which its products were made. easier for success to be claimed. Reading and Reporting 3. Claims that the product can cure a wide range of un- related diseases. No product can do that. Consumers who use dietary supplements should always read product labels, follow directions, and heed all 4. Claims that a product is backed by scientific studies warnings. but with no list of references or references that are in- adequate. For instance, if a list of references is pro- Supplement users who suffer a serious harmful effect vided, the citations cannot be traced, or if they are or illness that they think is related to supplement use traceable, the studies are out-of-date, irrelevant, or should call a doctor or other healthcare provider. He or poorly designed. she in turn can report it to the FDA. To file a report, con- sumers will be asked to provide: 5. Claims that the supplement has only benefits-and no side effects. A product \u201cpotent enough to help people 1. Name, address, and telephone number of the person will be potent enough to cause side effects.\u201d who became ill 6. Accusations that the medical profession, drug compa- 2. Name and address of the doctor or hospital providing nies, and the government are suppressing informa- medical treatment tion about a particular treatment. It would be illogical for large numbers of people to withhold information 3. Description of the problem 4. Name of the product and store where it was bought","186 PART II PUBLIC HEALTH NUTRITION not comply with the written instructions on the label. Instead of one tablet a day, three may be Consumers also should report the problem to the taken. Instead of swallowing a capsule, some open manufacturer or distributor listed on the product\u2019s label it and chew on the powder. and to the store where the product was bought. N Negative reactions in some individuals because of a specific sensitivity: The substance is harmless for Expert Advice the average adult but may be harmful to infants, small children, and some elderly. The substance is Before starting a dietary supplement, it is always wise to not harmless under normal circumstances but may check with a medical doctor. It is especially important be harmful to individuals with certain clinical con- for people who have the following characteristics: ditions, such as pregnancy, high blood pressure, and kidney diseases. 1. Pregnant or breastfeeding S Safety of the product has not been carefully evalu- 2. Chronically ill ated: In spite of legal requirements, many manufac- 3. Elderly turers have failed to conduct safety testing of their 4. Under 18 products. 5. Taking prescription or over-the-counter medicines. Any consumer who enjoys using dietary supplements for Certain supplements can boost blood levels of certain whatever reasons, for example, nutritional benefits, clin- drugs to dangerous levels. ical therapy, reversal of aging, is advised to perform a minimum amount of \u201chomework\u201d so that the chances Harm of suffering adverse effects can be reduced. The following HOPES criteria serve as a good start: Can dietary supplements be harmful? Under some cir- cumstances, anything we ingest can be harmful, even H Health status is an important clue. Are you sick? Do ordinary food, and the same applies to dietary supple- you have a terminal illness? Are you pregnant? You ments. A dietary supplement (DS), especially one with must be careful with the potential effect of any di- multiple ingredients, can be harmful under one of the etary supplement. The precaution applies even if following circumstances (REASONS), assuming it is not you are taking the dietary supplement with an in- a poison and it has been used by at least some individu- tention that it may cure your illness. als without adverse effects. Each circumstance has been substantiated by actual events of poisoning from dietary O Overacting is a human weakness. When it comes to supplements in some individuals: a dietary supplement, avoid it if you can. Even if it works and makes you feel better, there is no need R Raw impurities: The DS is not pure. It is mixed with to be excited. It may be a chance occurrence. Most some known or unknown ingredient or ingredients important of all, do not overdose immediately be- that are harmful at least to some individuals. cause it \u201cworks.\u201d That is, if the label recommends 2 tablets a day, do not take 4 or 5. E Excess levels of ingredients used: Intentionally or unintentionally the manufacturer has included P Product description is your major weapon for self- an excess level of some of the ingredients. The protection. Read the label several times. Ask yourself excess substances have proved harmful to some the following questions: Is there a name for the consumers. product? Are the ingredients listed? Is there a recom- mended daily dosage? Are there precaution state- A Allergic reactions to some ingredients in the di- ments? Is there a name and address for the etary supplement for some individuals: The occur- manufacturer? It is not a good idea to put some- rence of this type of adverse effects is probably one thing in your mouth if there is no name and address of the most common observations among the for the manufacturer. Why? Because, if there is consumers. something wrong, no one can trace it to the manu- facturer. The store where you buy it may have S Systemic poisoning: This means the ingredients in obtained it from a distributor. Without the manu- the dietary supplement are distributed via the blood facturer, no one knows what is inside, and your doc- stream to various parts of the body and produce tor cannot treat you if you show harmful effects. general poisonous effects in the body of some users. Most of the time, the cause of such poisoning is E Education is invariably a part of any health pro- difficult to assess. One possibility is the interac- gram. If you are serious about taking dietary sup- tion of ingredients in the body to a harmful by- plements and willing to spend money on one or product. Or, the ingredients interact with body or- more such products, then you have the responsibil- gans or fluid to produce general by-products that ity of educating yourself about dietary supplements. interact among themselves to produce another by- Talk to your friends with similar interest. Read up product that is harmful. O Overdosing oneself: This is another common situ- ation when adverse effects occur. Many users do","CHAPTER 11 DIETARY SUPPLEMENTS 187 on products, claims, and effects. Use the toll-free mented called \u201cCocaine.\u201d Its Web site use the following numbers for the FDA, FTC, and state consumer descriptions or claims: protection agencies to find out about any dietary supplement you are taking. \u2022 \u201cThe Legal Alternative\u201d S Symptoms from taking a dietary supplement are \u2022 The product name is \u201cCocaine,\u201d and the letters in the of course valuable indications that there is some- thing wrong with the product. If you detect a slight product name appear to be spelled out in a white gran- sign of unwelcome symptoms in your body, stop ular substance that resembles cocaine powder. the supplement immediately and seek medical \u2022 \u201cSpeed in a Can\u201d attention. \u2022 \u201cLiquid Cocaine\u201d \u2022 \u201cCocaine - Instant Rush\u201d Your HOPES of a minimum protection from adverse ef- \u2022 \u201cThe question you have to ask yourself is: \u2018Can I han- fects of any dietary supplement is to implement these dle the rush?\u2019\u201d five simple steps. \u2022 \u201cThis beverage should be consumed by responsible adults. Failure to adhere to this warning may result in FDA ENFORCEMENT excess excitement, stamina, . . . and possible feeling of euphoria.\u201d The FDA uses many tools to enforcement laws and reg- \u2022 Certain ingredients intended \u201cto prevent, treat, or cure ulations and some are described below: disease conditions.\u201d \u201cInositol . . . reduces cholesterol in the blood; it helps prevent hardening of the arter- 1. Warning letters: The FDA sends a warning letter to in- ies, and may protect nerve fibers from excess glucose form a manufacture that one or more of its products damage. Inositol has a natural calming effect and may is illegal or needs correction. Responses are then be used in the treatment of anxiety, depression, and processed between the FDA and the manufacturers. obsessive-compulsive disorder without the side effects of prescription medications.\u201d 2. Recalls: Recalls are actions taken by a firm to remove a product from the market. Recalls may be conducted According to the FDA, dietary supplements are prod- on a firm\u2019s own initiative, by FDA request, or by FDA ucts that are intended to supplement the diet. Street drug order under statutory authority. There are three alternatives, meaning products that claim to mimic the classes of recalls: effects of recreational drugs, are not intended to supple- \u2022 Class I recall\u2014A situation in which there is a rea- ment the diet and, as a result, cannot lawfully be mar- sonable probability that the use of or exposure to keted as dietary supplements. Also, a dietary supplement a violative product will cause serious adverse health may not bear claims that it prevents or treats a disease, consequences or death except for authorized health claims about reducing the \u2022 Class II recall\u2014A situation in which use of or ex- risk of a disease. posure to a violative product may cause temporary or medically reversible adverse health conse- Since the outcome of each varies with conditions such quences or where the probability of serious adverse as responses, remedies, legal actions, and so on, an inter- health consequences is remote ested party may access the FDA Web site to find more \u2022 Class III recall\u2014A situation in which use of or ex- details about accessing the FDA\u2019s archive of warning posure to a violative product is not likely to cause letters. adverse health consequences Recalls 3. Seizures: When the FDA decides that a product may Some examples of class I recalls are listed in Table 11-1. pose danger to the public and recall is not imple- mented, it will work with the appropriate law enforce- Seizures ment agency to seize the product and remove it from the market. On October 12, 2007, the FDA distributed this news release: Each of the above enforcement approach has been ap- plied to manufacturers whose dietary supplements have At the request of the FDA, U.S. Marshals seized raised the issues of safety or illegal claims. Some exam- ~$71,000 of products from FulLife Natural Options, ples follow. Inc., of Boca Raton, Florida, which marketed and distributed Charantea Ampalaya Capsules and Warning Letters Charantea Ampalaya Tea. In April 2007, the FDA sent a warning letter to the man- Although these products are labeled as dietary ufacturer of a dietary supplement affecting public safety supplements, they are being promoted by FulLife and illegal claims. The company sells a dietary supple- for use in treating serious conditions, such as dia- betes, anemia, and hypertension, both in printed","188 PART II PUBLIC HEALTH NUTRITION TABLE 11-1 Recalled Dietary Supplements Dietary Supplements Recalled Reason Recall Company Manufacturer Ebek, Inc, West Coast LIVIRO3 Natural Energy Enhancer Containing the legal prescription Los Angeles, CA Nutritional Supplement drug ingredient Tadalafil (treat- Laboratories Inc, ing erectile dysfunction) Hi-Tech Gardena, CA Recall: May 2007 Pharmaceutic als, Inc., Hi-Tech Avian-Rx tablets labeled to contain Unapproved drug claim that it can Norcross, GA Pharmaceuticals, herbal ingredients to bulletproof your prevent \u201cBird Flu\u201d Inc., Norcross, GA immune system. The primary ingredi- Confidence Inc., ents on the label: star anise extract, Port Island Vitamins Inc., shikimic acid, and Hypericum perfora- Washington, Farmingdale, NY tum. NY MegaCare Inc., Las Recall: July 2007 Barodon S.F., Vegas, NV Inc., Los Metaboslim All Natural Fat Eater Apple Containing undeclared sibutra- Angeles, CA H & L Industries, Cider Vinegar mine, an active legal pharmaceu- Inc., dba Natural tical ingredient used for weight America True Source Int\u2019l, Inc., Recall: October 2007 loss in treatment of obesity Man Health, LaVerne, CA Inc., West V.MAX Herbal Stamina Enhancer for Containing aminotadalafil, an ana- Covina, CA Botanical Men Dietary Supplement, Cordyceps logue of tadalafil, a legal drug Laboratories Inc., Militaries, L-Arginine, Psyllium Husk used to treat erectile dysfunction MOM Ferndale, WA Powder, Licorice Root, Astragalus Enterprises, Membranaceus, Steamed Panax Inc., San Ginseng Rafael, CA Recall: November 2007 True Man Sexual Energy Nutriment, Containing various analogues of Men\u2019s formula, Natural Herbs legal drug ingredients approved for treating erectile dysfunction Energy Max Energy Supplement Men\u2019s (ED) formula Natural Herbs Recall: December 2007 Gripe Water All Natural Apple Flavor. An Containing cryptosporidium, con- herbal supplement used to ease the firmed after investigating the gas and stomach discomfort often as- illness of a 6-week-old infant in sociated with colic, hiccups, and Minnesota who consumed the teething product. Cryptosporidium is a parasite that can cause intes- Recall: January 2008 tinal infections. and electronic (Web site) media distributed by the drugs. Despite FDA\u2019s warnings, the firm failed to company. bring its marketing into compliance with the law. During subsequent inspections, FDA inspectors FDA considers these products to be unapproved found that the offending claims were still being new drugs because they make claims related to the made. prevention or treatment of diseases in the prod- ucts\u2019 labeling. Such seizures protect consumers On August 23, 2007, at the request of FDA, U.S. who may rely on unapproved products and unsub- Marshals in the Northern District of Florida seized stantiated claims associated with these products an estimated $41,000 worth of inventory of when making important decisions about their Glucobetic, Neuro-betic, Ocu-Comp, Atri-Oxi, health. Super-Flex, MSM-1000, and Atri-E-400 capsules being promoted and distributed by Charron Following an investigation of the firm\u2019s market- Nutrition of Tallahassee, Florida, for use in treating ing practices, FDA officials advised FulLife that the diabetes, arthritis, and other serious health claims related to prevention or treatment of dis- conditions. eases made these products subject to regulation as","CHAPTER 11 DIETARY SUPPLEMENTS 189 PROGRESS CHECK ON ACTIVITY 4 18. T F When I see the term natural, it means that a product is healthful and safe. TRUE\/FALSE 19. T F A recall of a harmful product guarantees that Circle T for True and F for False. all such harmful products will be immediately and completely removed from the market- 1. T F I do not need to think about my total diet if I place. am taking dietary supplements. 20. T F It is appropriate to contact the manufacturer 2. T F Essential nutrients are safe, even when they for more information about the specific prod- are consumed in large doses. uct that one is purchasing. 3. T F I don\u2019t need to check with my doctor or health- 21. T F When a nurse is caring for a patient who is in- care provider before using supplements if I volved with dietary supplements (using them, have read the labels on these supplements. intending to use them, or asking questions about them), he or she should assist the pa- 4. T F All dietary supplements are risk free because tient in making appropriate choices through they are sold over the counter. educating the patient and family regarding their use. 5. T F Because vitamin and mineral supplements are widely used and generally considered safe, you 22. T F Fraudulent products often can be identified by may safely give them to your children. the types of claims made in their labeling, ad- vertising, and promotional literature. 6. T F If one plans to use a dietary supplement in place of drugs or in combination with any drug, 23. T F According to the National Council Against one should tell one\u2019s healthcare provider first. Health Fraud, a product may be fraudulent if it contains claims such as breakthrough, mag- 7. T F Dietary supplements, generally considered as ical, miracle cure, new discovery, detoxify, pu- safe, should not interact with prescription and rify, energize, cure a wide range of unrelated over-the-counter (OTC) medicines. diseases, and only benefits but no side effects. 8. T F When taking medication(s) or dietary supple- 24. T F Quality dietary supplements have no reason to ment(s), advisories about these products carry the U.S.P. notation for their ingredients. should not be taken too seriously. 25. T F Nationally known food and drug manufactur- 9. T F It is important to fully inform your doctor ers usually have tighter controls in their man- about the vitamins, minerals, herbals, or any ufacturing methods for their products. other supplements you are taking before elec- tive surgery. 26. T F When a consumer starts to take a dietary sup- plement, he or she must check with a medical 10. T F Under the law, manufacturers of dietary sup- doctor. plements are not responsible for making sure their products are safe before they go to 27. T F Dietary supplements often contain plant prod- market. ucts that may also be used in prescription medicine. 11. T F Manufacturers of dietary supplements are re- sponsible for determining that the claims on FILL-IN their labels are accurate and truthful. 28. Before starting a dietary supplement, it is always 12. T F If the FDA can prove that claims on marketed wise to check with a medical doctor. It is espe- dietary supplement products are false and mis- cially important for people who have the following leading, the agency may take action against characteristics: products with such claims. a. 13. T F When searching on the Web, the directory sites of organizations included in all search engines b. are reliable. c. 14. T F Most nonprofit and government sites contain no advertising, and access to the site and ma- d. terials offered are usually free. e. 15. T F While the Web can be a valuable source of ac- curate, reliable information, it also has a wealth 29. The following minimal criteria should be followed of misinformation that may not be obvious. when a person starts to take dietary supplements: 16. T F Information from trained people is usually H. more much more reliable than that from lay people. O. 17. T F Even if a product may not help me, at least it won\u2019t hurt me.","190 PART II PUBLIC HEALTH NUTRITION P. Jakubowski, H. (2003). On the health benefits of Allium E. sp. Nutrition, 19: 167\u2013168. S. Lagua, R. T., & Qaudio, V. S. (2004). Nutrition and Diet REFERENCES Therapy: Reference Dictionary (5th ed.). Ames, IA: Blackwell. American Dietetic Association. (2000). A Healthcare Professional\u2019s Guide to Evaluating Dietary Supple- Marian, M. J., Williams-Muller, P., & Bower, J. (2007). ments. Chicago: Author. Integrating Therapeutic and Complementary Nutri- tion. Boca Raton, FL: CRC Press. Bendich, A., & Deckelbaum, R. J. (Eds.). (2005). Preventive Nutrition: The Comprehensive Guide for Navarra, T. (2004). The Encyclopedia of Vitamins, Health Professionals (3rd ed.). Totowa, NJ: Humana Minerals, and Supplements. New York: Facts on File. Press. Ostlund, R. E. (2002). Phytosterols in human nutrition. Caballero, B., Allen, L., & Prentice, A. (Eds.). (2005). Annual Review of Nutrition, 22: 533\u2013549. Encyclopedia of Human Nutrition (2nd ed.). Boston: Elsevier\/Academic Press. Rosenburg, I. H. (2007). Challenges and opportunities in the translation of the science of vitamins. American Davis, W. M. (2006). Consumer\u2019s Guide to Dietary Journal of Clinical Nutrition, 85: 325s\u2013327s. Supplements and Alternate Medicines: Servings of Hope. New York: Pharmaceutical Products Press. Shils, M. E., & Shike, M. (Eds.). (2006). Modern Nutrition in Health and Disease (10th ed.). Philadelphia: Di Pasquale, M. G. (2008). Amino Acid and Proteins for Lippincott, Williams and Wilkins. the Athlete: The Anabolic Edge. Boca Raton, FL: CRC Press. Smith, A. D. (2007). Folic acid fortification: The good, the bad, and the puzzle of vitamin B-1. American Fairfield, K. (2007). Vitamin and mineral supplements Journal of Clinical Nutrition, 85: 3\u20135 [Erratum: 86, for cancer prevention: Issues and evidence. American 1256]. Journal of Clinical Nutrition, 85: 289s\u2013292s. Stanner, S. A. (2004). A review of epidemiological evi- Goodlad, R. A. (2007). Fiber can make your gut grow. dence for the \u2018antioxidant hypothesis\u2019. Public Health Nutrition, 23: 434\u2013435. Nutrition, 7: 407\u2013422. Higdon, J. (2007). An Evidence-Based Approach to Steyer, T. E. (2003). Use of nutritional supplements for Dietary Phytochemicals. New York: Thieme Medical. the prevention and treatment of hypercholes- terolemia. Nutrition, 19: 415\u2013418. Higdon, J. V. (2003). Tea catechins and polyphenols: Health effects, metabolism, and antioxidant functions. Temple, N. J., Wilson, T., & Jacobs, D. R. (2006). Nutrition Critical Reviews in Food Science and Nutrition, 43: Health: Strategies for Disease Prevention (2nd ed.). 89\u2013143. Totowa, NJ: Humana Press. Huang, H. Y. (2007). Multivitamin\/multimineral supple- Theobal, H. E. (2007). Low-dose docosahexanoic acid ments and prevention of chronic disease: Executive lowers diastolic blood pressure in middle-aged men summary. American Journal of Clinical Nutrition, 85: and women. Journal of Nutrition, 137: 973\u2013978. 265s\u2013268s. Vaysse-Boue, C. (2007). Moderate dietary intake of myris- tic acid and alpha-linolenic acids increases lecithin- cholesterol acyltransferase activity in humans. Lipids, 42: 717\u2013722.","OUTLINE 12C H A P T E R Objectives Alternative Medicine Glossary Background Information Time for Completion Progress Check on Background Activities: 11\u20442 hours Information Optional examination: 1\u20442 hour ACTIVITY 1: Categories or OBJECTIVES Domains of Complementary and Alternative Medicine Upon completion of this chapter the student should be able to do the following: Alternative Medical Systems 1. Identify five healing philosophies, approaches, and therapies not taught in Mind-Body Interventions Biological-Based Therapies medical schools. Manipulative and Body-Based 2. Define complementary and alternative medicine (CAM): Methods Energy Therapies a. Describe the five domains or categories of CAM. Progress Check on Activity 1 b. List at least two examples in each domain and state the principal meth- ACTIVITY 2: Products, Devices, and Services Related to ods used in each. Complementary and 3. Name at least five products or devices related to alternative medicine. Alternative Medicine 4. Describe the principle involved in using acupuncture as a complemen- Acupuncture Laetrile tary therapy in Western medicine. St.-John\u2019s-Wort 5. Discuss ways to evaluate and provide reliable information to clients regard- Nursing Implications Progress Check on Activity 2 ing the use of alternative medical treatment and practices. References GLOSSARY Acupuncture: the use of very fine, thin wire needles inserted into the skin at specific sites in the body. A complementary therapy widely employed by li- censed physicians. The needles used have received FDA approval. Alternative: therapy used alone to treat an illness. 191","192 PART II PUBLIC HEALTH NUTRITION ucational materials distributed by the National Center for Complementary and Alternative Medicine, a unit Biological-based: therapies employing herbs, special within the U.S. National Institutes of Health. foods, and treatment with megadose vitamins and minerals and other ingested substances, such as Complementary and alternative medicine (CAM) cov- laetrile or bee pollen. ers a broad range of healing philosophies, approaches, and therapies. Generally, it is defined as those treatments Complementary: therapy used in addition to conventional and healthcare practices not taught widely in medical therapy. schools, not generally used in hospitals, and not usually reimbursed by medical insurance companies. Complementary and alternative medicine (CAM): those therapies and medical practices not currently part of Many therapies are termed holistic, which means that conventional medicine. the healthcare practitioner considers the whole person, including physical, mental, emotional, and spiritual as- Conventional: therapies widely accepted and practiced pects. Many therapies are also known as preventive, which by the mainstream medical community. means that the practitioner educates and treats the per- son to prevent health problems from arising, rather than Energy therapy: a system that employs energy fields orig- treating symptoms after problems have occurred. inating within the body or from electromagnetic fields outside the body. People use these treatments and therapies in a variety of ways. Therapies are used alone, in combination with Holistic: therapy that includes treatment of the whole other alternative therapies, or in addition to conventional person. therapies. Some approaches are consistent with physio- logical principles of Western medicine, while others con- Homeopathic: a complete alternative medical system stitute healing systems with a different origin. While whose basic principle is \u201clike cures like.\u201d some therapies are far outside the realm of accepted Western medical theory and practice, others are becom- Laetrile: an unapproved compound used as an anticancer ing established in mainstream medicine. treatment. Contains cyanide. Drug is not available in the United States. Side effects are severe and can cause Complementary and alternative health care and med- death. ical practices are those health care and medical practices that are not currently an integral part of conventional Manipulative or body-based: methods based on manipu- medicine. The list of practices that are considered CAM lation and\/or movement of the body, for example, chi- changes continually as CAM practices and therapies that ropractic or massage therapy. are proven safe and effective become accepted as \u201cmain- stream\u201d healthcare practices. Mind-body therapy: techniques employed to facilitate the mind\u2019s capacity to affect body function and systems. A therapy is generally called complementary when it Only two are considered mainstream: cognitive- is used in addition to conventional treatments; it is often behavioral approaches and patient education. called alternative when it is used instead of conventional treatment. (Conventional treatments are those that are Naturopathic: a complete alternative medical system that widely accepted and practiced by the mainstream medical emphasizes natural healing. community.) Depending on how they are used, some therapies can be considered either complementary or al- Preventive: therapy that seeks to prevent health prob- ternative. Complementary and alternative therapies are lems from arising. used in an effort to prevent illness, reduce stress, pre- vent or reduce side effects and symptoms, or control or St.-John\u2019s-wort: an herb used as an alternative treatment cure disease. for depression. Unlike conventional treatments for diseases, comple- BACKGROUND INFORMATION mentary and alternative therapies are often not covered by insurance companies. Patients should check with their For more than a decade alternative medicine has played insurance provider to find out about coverage for com- an increasing role in the health of Americans. In view plementary and alternative therapies. of the extensive claims about its effectiveness, the in- formation in this chapter is based on the following Patients considering complementary and alternative premises: therapies should discuss this decision with their doctor or nurse, as they would any therapeutic approach, be- 1. The purpose is to inform and not to recommend di- cause some complementary and alternative therapies agnosis, treatment, or cure. may interfere with their standard treatment or may be harmful when used with conventional treatment. 2. Although nutrition and diet therapy are the subject matters of this book, their role in alternative medicine is only one consideration. To provide a meaningful picture of alternative medicine, this chapter discusses its entire spectrum, which includes diet and nutri- tion or human metabolism. 3. To ensure its accuracy and the absence of bias, all in- formation in this chapter has been derived from ed-","CHAPTER 12 ALTERNATIVE MEDICINE 193 PROGRESS CHECK ON BACKGROUND INFORMATION ACTIVITY 1: FILL-IN Categories or Domains of Complementary and Alternative Medicine 1. Complementary and alternative medicine (CAM) are treatments and healthcare practices generally not: Today, CAM practices may be grouped within five major domains: (1) alternative medical systems, (2) mind-body a. interventions, (3) biologically based treatments, (4) ma- nipulative and body-based methods, and (5) energy ther- b. apies. The individual systems and treatments making up these categories are too numerous to list in this docu- c. ment. Thus, only limited examples are provided within each. 2. Holistic treatment generally means that the healthcare practitioner considers the whole per- ALTERNATIVE MEDICAL SYSTEMS son, including aspects that are: Alternative medical systems involve complete systems of a. theory and practice that have evolved independent of and often prior to the conventional biomedical approach. b. Many are traditional systems of medicine that are prac- ticed by individual cultures throughout the world, in- c. cluding a number of venerable Asian approaches. d. Traditional Chinese medicine emphasizes the proper balance or disturbances of qi (pronounced chi or chee), 3. Name six products or devices related to alternate or vital energy, in health and disease, respectively. medicine: Traditional Chinese medicine consists of a group of tech- niques and methods, including acupuncture, herbal med- a. icine, oriental massage, and qi gong (a form of energy therapy described more fully later). Acupuncture involves b. stimulating specific anatomic points in the body for ther- apeutic purposes, usually by puncturing the skin with a c. needle. d. Ayurveda is India\u2019s traditional system of medicine. Ayurvedic medicine (meaning \u201cscience of life\u201d) is a com- e. prehensive system of medicine that places equal empha- sis on body, mind, and spirit, and strives to restore the f. innate harmony of the individual. Some of the primary Ayurvedic treatments include diet, exercise, meditation, TRUE\/FALSE herbs, massage, exposure to sunlight, and controlled Circle T for True and F for False. breathing. 4. T F Preventive therapy that seeks to prevent health Other traditional medical systems have been developed problems from arising is generally taught in by Native American, Aboriginal, African, Middle Eastern, medical schools. Tibetan, and Central and South American cultures. 5. T F Biologically based therapies that employ herbs, Homeopathic and naturopathic medicine are also ex- special foods, and treatment with megadose amples of complete alternative medical systems. Home- vitamins and minerals and other ingested sub- opathic medicine is an unconventional Western system stances are completely ineffective in the eyes that is based on the principle that \u201clike cures like,\u201d of most of the conventional medical practi- namely, that the same substance that in large doses pro- tioners in the United States. duces the symptoms of an illness, in very minute doses cures it. Homeopathic physicians believe that the more di- 6. T F Cognitive-behavior approach is a mind-body lute the remedy, the greater its potency. Therefore, they therapy not widely accepted by the conven- use small doses of specially prepared plant extracts and tional medical practitioner. minerals to stimulate the body\u2019s defense mechanisms and healing processes to treat illness. 7. T F Patient education is critical in the employment of complementary and alternative medicine. 8. T F Acupuncture therapy uses very fine, thin nee- dles inserted into the skin at specific sites in the body to achieve certain healing effect. It is widely accepted by conventional medical prac- titioners in the United States.","194 PART II PUBLIC HEALTH NUTRITION tem may affect function elsewhere in the body, practice os- teopathic manipulation. Massage therapists manipulate Naturopathic medicine views disease as a manifesta- the soft tissues of the body to normalize those tissues. tion of alterations in the processes by which the body naturally heals itself and emphasizes health restoration ENERGY THERAPIES rather than disease treatment. Naturopathic physicians employ an array of healing practices, including diet and Energy therapies focus either on energy fields originating clinical nutrition; homeopathy; acupuncture; herbal within the body (biofields) or those from other sources medicine; hydrotherapy (the use of water in a range of (electromagnetic fields). Biofield therapies are intended to temperatures and methods of applications); spinal and affect the energy fields, whose existence is not yet exper- soft-tissue manipulation; physical therapies involving imentally proven, that surround and penetrate the human electric currents, ultrasound and light therapy; thera- body. Some forms of energy therapy manipulate biofields peutic counseling; and pharmacology. by applying pressure and\/or manipulating the body by placing the hands in, or through, these fields. Examples MIND-BODY INTERVENTIONS include Qi gong, Reiki, and Therapeutic Touch. Qi gong is a component of traditional Chinese medicine that com- Mind-body interventions employ a variety of techniques bines movement, meditation, and regulation of breath- designed to facilitate the mind\u2019s capacity to affect bodily ing to enhance the flow of vital energy (qi) in the body, to function and symptoms. Only a subset of mind-body in- improve blood circulation, and to enhance immune func- terventions are considered CAM. Many interventions that tion. Reiki, the Japanese word representing Universal Life have a well-documented theoretical basis, for example, Energy, is based on the belief that by channeling spiritual patient education and cognitive-behavioral approaches, energy through the practitioner the spirit is healed, and are now considered \u201cmainstream.\u201d Meditation; certain it in turn heals the physical body. Therapeutic Touch is de- uses of hypnosis; dance, music, and art therapy; and rived from the ancient technique of \u201claying-on of hands\u201d prayer and mental healing still are categorized as com- and is based on the premise that it is the healing force of plementary and alternative. the therapist that affects the patient\u2019s recovery and that healing is promoted when the body\u2019s energies are in bal- BIOLOGICAL-BASED THERAPIES ance. By passing their hands over the patient, these heal- ers identify energy imbalances. This category of CAM includes natural and biological-based practices, interventions, and products, many of which Bioelectromagnetic-based therapies involve the un- overlap with conventional medicine\u2019s use of dietary supple- conventional use of electromagnetic fields\u2014such as ments. Included in this category are herbal, special di- pulsed fields, magnetic fields, or alternating current or etary, orthomolecular, and individual biological therapies. direct current fields\u2014to, for example, treat asthma or cancer, or manage pain and migraine headaches. Herbal therapies employ individual or mixtures of herbs for therapeutic value. An herb is a plant or plant PROGRESS CHECK ON ACTIVITY 1 part that produces and contains chemical substances that act upon the body. Special diet therapies, such as those FILL-IN proposed by Drs. Atkins, Ornish, Pritikin, and Weil, are believed to prevent and or control illness as well as pro- 1. The five major domains of CAM practices are: mote health. Orthomolecular therapies aim to treat dis- ease with varying concentrations of chemicals, such as a. magnesium, melatonin, and megadoses of vitamins. Biological therapies include, for example, the use of b. laetrile and shark cartilage to treat cancer and bee pollen to treat autoimmune and inflammatory diseases. c. MANIPULATIVE AND BODY-BASED d. METHODS e. This category includes methods that are based on manip- ulation and\/or movement of the body. For example, chi- 2. Traditional Asian medicine consists of mainly the ropractors focus on the relationship between structure following techniques and methods: (primarily the spine) and function, and how that relation- ship affects the preservation and restoration of health, a. using manipulative therapy as an integral treatment tool. b. Some osteopaths, who place particular emphasis on the musculoskeletal system, believing that all of the body\u2019s c. systems work together and that disturbances in one sys- d.","CHAPTER 12 ALTERNATIVE MEDICINE 195 3. Name five of the primary Ayurvedic treatments: 12. T F Herbal therapies that employ individual or mixtures of herbs for therapeutic value are not a. effective means of treating any diseases. b. 13. T F Use of laetrile and shark cartilage to treat can- cer has been proven to be effective. c. 14. T F Bee pollen to treat autoimmune and inflam- d. matory diseases has not been proven to be effective. e. 15. T F Chiropractors focus on the relationship be- 4. Name five of the practices that naturopathic tween structure (primarily the spine) and physicians will employ in healing: function, and how that relationship affects the preservation and restoration of health by using a. manipulative therapy. b. 16. T F Energy therapies focus either on energy fields originating within the body (biofields) or those c. from other sources (electromagnetic fields). d. 17. T F Qi gong is a component of traditional Asian medicine that combines movement, medita- e. tion, and regulation of breathing to enhance the flow of vital energy (qi) in the body, to im- 5. Examples of energy therapy that manipulate prove blood circulation, and to enhance im- biofields by applying pressure and\/or manipulat- mune function. ing the body by placing the hands in, or through, these fields are: 18. T F Therapeutic Touch is very similar to the form of qi gong treatment that applies energy to the a. patient through an external source. b. ACTIVITY 2: c. Products, Devices, and Services Related to Complementary and Alternative Medicine TRUE\/FALSE According to Amazon.com, there are more than 500 Circle T for True and F for False. books on various products, devices, and services related to alternative medicine. The following are some that 6. T F Alternative medical systems involve complete have attracted much attention from the government and systems of theory and practice that have consumers: evolved independent of and often prior to the conventional biomedical approach. 1. Acupuncture 2. Cancell\/Entelev 7. T F Traditional Asian medicine emphasizes the 3. Gerson therapy proper balance or disturbances of qi (pro- 4. Gonzalez protocol nounced chi), or vital energy, in health and 5. Immuno-augmentative therapy disease, respectively. 6. Coenzyme Q10 7. Laetrile 8. T F The basic principles of traditional Asian med- 8. St.-John\u2019s-wort icine principles and Ayurvedic medicine are 9. Cartilage (bovine and shark) completely different. 10. Hydrazine sulfate 11. Mistletoe 9. T F Homeopathic physicians use small doses of specially prepared plant extracts and minerals This chapter is not the proper forum to explore all of to stimulate the body\u2019s defense mechanisms them. Instead, three specific examples are provided- and healing processes in order to treat illness. acupuncture, laetrile, and St.-John\u2019s-wort. Acupuncture has no dietary significance. It is included here as an illus- 10. T F Naturopathic medicine views disease as a man- tration of nondietary alternative medicine. Laetrile and ifestation of alterations in the processes by St.-John\u2019s-wort have direct relationships to our diet be- which the body naturally heals itself and em- cause they are ingested for desired effects. phasizes health restoration rather than disease treatment. 11. T F Meditation; certain uses of hypnosis; dance, music, and art therapy; and prayer and mental healing are ineffective therapies in the minds of conventional medical practitioners.","196 PART II PUBLIC HEALTH NUTRITION of pain or release other chemicals, such as hormones, that influence the body\u2019s self-regulating systems. The ACUPUNCTURE biochemical changes may stimulate the body\u2019s natural healing abilities and promote physical and emotional Introduction well-being. Acupuncture is one of the oldest, most commonly used There are three main mechanisms under consideration: medical procedures in the world. Originating in China more than 2000 years ago, acupuncture began to become \u2022 Conduction of electromagnetic signals: Western sci- better known in the United States in 1971, when New entists have found evidence that acupuncture points York Times reporter James Reston wrote about how doc- are strategic conductors of electromagnetic signals. tors in China used needles to ease his abdominal pain Stimulating points along these pathways through after surgery. Research shows that acupuncture is bene- acupuncture enables electromagnetic signals to be re- ficial in treating a variety of health conditions. In the layed at a greater rate than under normal conditions. past two decades, acupuncture has grown in popularity These signals may start the flow of pain-killing bio- in the United States. A Harvard University study pub- chemicals, such as endorphins, and of immune system lished in 1998 estimated that Americans made more than cells to specific sites in the body that are injured or five million visits per year to acupuncture practitioners. vulnerable to disease. The report from a Consensus Development Conference on Acupuncture held at the National Institutes of Health \u2022 Activation of opioid systems: Research has found that (NIH) in 1997 stated that acupuncture is being \u201cwidely\u201d several types of opioids may be released into the cen- practiced-by thousands of physicians, dentists, acupunc- tral nervous system during acupuncture treatment, turists, and other practitioners-for relief or prevention of thereby reducing pain. pain and for various other health conditions. NIH has funded a variety of research projects on acupuncture. \u2022 Changes in brain chemistry, sensation, and involun- These grants have been awarded by the National Center tary body functions: Studies have shown that for Complementary and Alternative Medicine (NCCAM), acupuncture may alter brain chemistry by changing the Office of Alternative Medicine (OAM, NCCAM\u2019s pred- the release of neurotransmitters and neurohormones ecessor), and other NIH institutes and centers. Tradi- in a positive way. tional Chinese medicine theorizes that there are more than 2000 acupuncture points on the human body, and Acupuncture also has been documented to affect the that these connect with 12 main and 8 secondary path- parts of the central nervous system related to sensation ways called meridians. Chinese medicine practitioners and involuntary body functions, such as immune reac- believe these meridians conduct energy, or qi (pro- tions and processes whereby a person\u2019s blood pressure, nounced chee or chi), throughout the body. Qi is believed blood flow, and body temperature are regulated. to regulate spiritual, emotional, mental, and physical bal- ance and to be influenced by the opposing forces of yin Preclinical studies have documented acupuncture\u2019s and yang. effects, but they have not been able to fully explain how acupuncture works within the framework of the Western According to traditional Chinese medicine, when yin system of medicine. and yang are balanced, they work together with the nat- ural flow of qi to help the body achieve and maintain Clinical Studies health. Acupuncture is believed to balance yin and yang, keep the normal flow of energy unblocked, and maintain According to the NIH Consensus Statement on or restore health to the body and mind. Acupuncture: Traditional Chinese medicine practices (including Acupuncture as a therapeutic intervention is widely acupuncture, herbs, diet, massage, and meditative phys- practiced in the United States. While there have ical exercise) all are intended to improve the flow of qi. been many studies of its potential usefulness, many Western scientists have found meridians hard to identify of these studies provide equivocal results because because meridians do not directly correspond to nerve or of design, sample size, and other factors. The issue blood circulation pathways. Some researchers believe is further complicated by inherent difficulties in that meridians are located throughout the body\u2019s con- the use of appropriate controls, such as placebos nective tissue; others do not believe that qi exists at all. and sham acupuncture groups. However, promis- ing results have emerged, for example, showing ef- Such differences of opinion have made acupuncture ficacy of acupuncture in adult postoperative and an area of scientific controversy. Several processes have chemotherapy nausea and vomiting and in post- been proposed to explain acupuncture\u2019s effects, primarily operative dental pain. There are other situations those on pain. Acupuncture points are believed to stim- such as addiction, stroke rehabilitation, headache, ulate the central nervous system (the brain and spinal menstrual cramps, tennis elbow, fibromyalgia, my- cord) to release chemicals into the muscles, spinal cord, ofascial pain, osteoarthritis, low back pain, carpal and brain. These chemicals either change the experience","CHAPTER 12 ALTERNATIVE MEDICINE 197 tunnel syndrome, and asthma, in which acupunc- uct. The chemical make-up of Laetrile patented in the ture may be useful as an adjunct treatment or an United States is different from the laetrile\/amygdalin pro- acceptable alternative or may be included in a com- duced in Mexico. The patented Laetrile is a semisynthetic prehensive management program. Further re- form of amygdalin, while the laetrile\/amygdalin manufac- search is likely to uncover additional areas where tured in Mexico is made from crushed apricot pits. acupuncture interventions will be useful. Amygdalin was first isolated in 1830 and was used as Increasingly, acupuncture is complementing conven- an anticancer agent in Russia as early as 1845. Its first tional therapies. For example, doctors may combine recorded use in the United States as a treatment for can- acupuncture and drugs to control surgery-related pain in cer was in the 1920s. The early pill form of amygdalin their patients. By providing both acupuncture and certain was considered too toxic, and work with the compound conventional anesthetic drugs, some doctors have found was discontinued. In the 1950s, a reportedly nontoxic, it possible to achieve a state of complete pain relief for semisynthetic form of amygdalin was developed and some patients. They also have found that using acupunc- patented in the United States as Laetrile. Laetrile gained ture lowers the need for conventional painkilling drugs popularity in the 1970s as a single anticancer agent and and thus reduces the risk of side effects for patients who as part of a metabolic therapy program consisting of a take the drugs. special diet, high-dose vitamin supplements, and pan- creatic enzyme proteins that aid in the digestion of food. Currently, one of the main reasons Americans seek By 1978, more than 70,000 people in the United States acupuncture treatment is to relieve chronic pain, espe- had reportedly been treated with Laetrile. cially from conditions such as arthritis or lower back dis- orders. Some clinical studies show that acupuncture is Laetrile is administered by mouth (orally) as a pill. It effective in relieving both chronic (long-lasting) and can also be given by injection into a vein (intravenously) acute or sudden pain, but other research indicates that or muscle. Laetrile is commonly given intravenously over it provides no relief from chronic pain. Additional re- a period of time and then orally as maintenance therapy search is needed to provide definitive answers. (treatment given to help extend the benefit of previous therapy). FDA\u2019s Role The side effects associated with laetrile treatment The U.S. Food and Drug Administration (FDA) approved are like the symptoms of cyanide poisoning. The symp- acupuncture needles for use by licensed practitioners in toms include nausea and vomiting, headache, dizziness, 1996. The FDA requires manufacturers of acupuncture bluish discoloration of the skin due to a lack of oxygen needles to label them for single use only. in the blood, liver damage, abnormally low blood pres- sure, droopy upper eyelid, difficulty walking due to dam- Relatively few complications from the use of acupunc- aged nerves, fever, mental confusion, coma, and death. ture have been reported to the FDA when one considers The side effects can be increased by eating raw almonds the millions of people treated each year and the number or crushed fruit pits; eating certain types of fruits and of acupuncture needles used. Still, complications have vegetables including celery, peaches, bean sprouts, and resulted from inadequate sterilization of needles and carrots; or taking high doses of vitamin C. The side ef- from improper delivery of treatments. When not deliv- fects of laetrile appear to depend on the method of ad- ered properly, acupuncture can cause serious adverse ef- ministration. More severe side effects are experienced fects, including infections and punctured organs. when laetrile is given by mouth than when it is given by injection. LAETRILE In nearly half a century, laetrile in the United States Laetrile is a compound that has been used as an anti- has gone through some \u201cstormy weathers\u201d scientifically, cancer treatment in humans worldwide. It is not ap- medically, legally, and commercially: proved by the Food and Drug Administration for use in the United States. The term laetrile is an acronym 1. Scientifically, it is the position of the federal govern- (laevorotatory and mandelonitrile) used to describe a pu- ment that there is no sound scientific evidence to rified form of the chemical amygdalin. Amygdalin is a support the therapeutic claims for laetrile. plant compound that contains sugar and produces cyanide. Amygdalin is found in the pits of many fruits 2. Medically, not all licensed physicians consider laetrile and raw nuts. It is also found in other plants, such as as a form of treatment for cancer. Physicians who use lima beans, clover, and sorghum. Cyanide is believed to this substance as a curative agent on cancer patients be the active cancer-killing ingredient in laetrile. are subject to prosecution. Although the names laetrile, Laetrile, and amygdalin 3. Legally, there are several fronts: are often used interchangeably, they are not the same prod- a. Several lawsuits have been filed on the constitu- tional rights of cancer patients to obtain laetrile to treat their conditions without interference from the government or the medical community.","198 PART II PUBLIC HEALTH NUTRITION Some people still hold outdated beliefs about depression, for example, that the emotional symptoms b. The FDA has declared it is illegal to sell interstate caused by depression are \u201cnot real.\u201d However, depression laetrile or products claimed to contain laetrile as is a real medical condition. It can be treated effectively an ingredient. The products from several compa- with conventional medicine, including antidepressant nies have been seized and some companies have drugs and certain types of psychotherapy. been prosecuted. St.-John\u2019s-wort has been used as an alternative ther- c. States and federal governments have prosecuted apy for depression. Some patients who take anti- licensed physicians who use laetrile to treat cancer depressant drugs do not experience relief from their patients. depression. Other patients have reported unpleasant side effects from their prescription medication, such as a dry The availability of laetrile in Mexico is a well known mouth, nausea, headache, or effects on sexual function fact. Many cancer patients and\/or their relatives and or sleep. Sometimes people turn to herbal preparations friends have visited Mexico to buy the substance. This is like St.-John\u2019s-wort because they believe \u201cnatural\u201d prod- the action of a private citizen, and it is difficult for the ucts are better for them than prescription medications, United States government to intervene unless the person or that natural products are always safe. Neither of these with the substance crosses the border between the two statements is true (discussed further later). Finally, cost countries. It is illegal to bring laetrile into this country. can be a reason. St.-John\u2019s-wort costs less than many an- tidepressant medications, and it is sold without a pre- ST.-JOHN\u2019S-WORT scription (over the counter). St.-John\u2019s-wort (Hypericum perforatum) is a long-living In Europe, St.-John\u2019s-wort is widely prescribed for de- plant with yellow flowers. It contains many chemical pression. In the United States, St.-John\u2019s-wort is not a compounds. Some are believed to be the active ingredi- prescription medication, but there is considerable pub- ents that produce the herb\u2019s effects, including the com- lic interest in it. St.-John\u2019s-wort remains among the top- pounds hypericin and hyperforin. selling herbal products in the United States. How these compounds actually work in the body is St.-John\u2019s-wort products are sold in the following not yet known, but several theories have been suggested. forms: Preliminary studies suggest that St.-John\u2019s-wort might work by preventing nerve cells in the brain from reab- \u2022 Capsules sorbing the chemical messenger serotonin, or by reduc- \u2022 Teas\u2014the dried herb is added to boiling water and ing levels of a protein involved in the body\u2019s immune system functioning. steeped for a period of time \u2022 Extracts\u2014specific types of chemicals are removed St.-John\u2019s-wort has been used for centuries to treat mental disorders as well as nerve pain. In ancient times, from the herb, leaving the desired chemicals in a con- doctors and herbalists (specialists in herbs) wrote about centrated form its use as a sedative and treatment for malaria as well as a balm for wounds, burns, and insect bites. Today, Does St.-John\u2019s-wort work as a treatment for depres- St.-John\u2019s-wort is used by some people to treat mild to sion? There has been scientific research to try to answer moderate depression, anxiety, or sleep disorders. this question. The general observation is as follows. In Europe, results from a number of scientific studies have Depressive illness comes in different forms. The three supported the effectiveness of certain extracts of St.- major forms are described here. Each can vary from per- John\u2019s-wort for depression. In the United States several son to person in terms of symptoms experienced and the clinical studies have concluded that this herb is not ef- severity of depression. fective in treating depression. Irrespective of scientific evidence, many consumers in this country take a sup- In major depression, people experience a sad mood or plement of St.-John\u2019s-wort regularly to treat depression. loss of interest or pleasure in activities for at least 2 weeks. In addition, they have at least four other symptoms of de- Are there any risks to taking St.-John\u2019s-wort for de- pression. Major depression can be mild, moderate, or se- pression? Yes, many so\u2014called natural substances can vere. If it is not treated, it can last for 6 months or more. have harmful effects\u2014especially if they are taken in too large a quantity or if they interact with something else In dysthymia, a milder, but more chronic form of de- the person is taking. pression, people experience a depressed mood for at least 2 years (1 year for children) accompanied by at least two Research from the NIH has shown that St.-John\u2019s-wort other symptoms of depression. interacts with some drugs\u2014including certain drugs used to control HIV infection (such as indinavir). It may also In bipolar disorder, also called manic depression, a per- interact with drugs that help prevent the body from reject- son has periods of depressive symptoms that alternate with ing transplanted organs (such as cyclosporine). Using St.- periods of mania. Symptoms of mania include an abnor- John\u2019s-wort limits these drugs\u2019 effectiveness. Also, mally high level of excitement and energy, racing thoughts, St.-John\u2019s-wort is not a proven therapy for depression. and behavior that is impulsive and inappropriate.","CHAPTER 12 ALTERNATIVE MEDICINE 199 If depression is not adequately treated, it can become se- professional associations, educational organizations, and vere and, in some cases, may be associated with suicide. research institutions that provide information about Consult a healthcare practitioner if you or someone you complementary and alternative medical practices. Many care about may be experiencing depression. People can organizations are developing Web sites. experience side effects from taking St.-John\u2019s-wort. The most common side effects include dry mouth, dizziness, Remember that these organizations may advocate a gastrointestinal symptoms, increased sensitivity to sun- specific therapy or treatment and may be unable to pro- light, and fatigue. vide complete and objective health information. Herbal products such as St.-John\u2019s-wort are classified How Can I Find a Practitioner in My Area? as dietary supplements by the U.S. Food and Drug Admin- istration (FDA), a regulatory agency of the federal govern- To find a qualified complementary and alternative med- ment. The FDA\u2019s requirements for testing and obtaining ical healthcare practitioner, you may want to contact approval to sell dietary supplements are less strict than medical regulatory and licensing agencies in your state. its requirements for drugs (see Chapter 11). Unlike drugs, These agencies may be able to provide information about herbal products can be sold without requiring studies on a specific practitioner\u2019s credentials and background. dosage, safety, or effectiveness. Many states license practitioners who provide alterna- tive therapies such as acupuncture, chiropractic services, The strength and quality of herbal products are often naturopathy, herbal medicine, homeopathy, and massage unpredictable. Products can differ in content not only therapy. from brand to brand, but from batch to batch. Informa- tion on labels may be misleading or inaccurate. You may also locate practitioners by asking your healthcare provider or by contacting a professional asso- Consult Chapter 11 on dietary supplements. ciation or organization. These organizations can provide names of local practitioners and provide information NURSING IMPLICATIONS about how to determine the quality of a specific practi- tioner\u2019s services. Regarding alternative medicine, the nurse\u2019s role is educational: When Considering Complementary and Alternative Therapies, What Questions Should 1. Be prepared to answer client questions. Patients Ask Their Healthcare Provider? 2. Evaluate all information before providing it to a The following are basic questions many patients ask: client. 3. Chart any alternative or complementary therapies the \u2022 What benefits can be expected from this therapy? \u2022 What are the risks associated with this therapy? client is using; some may be contraindicated to tra- \u2022 Do the known benefits outweigh the risks? ditional medicine. \u2022 What side effects can be expected? \u2022 Will the therapy interfere with conventional treat- Questions and answers for the nurse and the client are discussed in the following sections ment? \u2022 Is this therapy part of a clinical trial? If so, who is How Can I Find More Information About Complementary and Alternative sponsoring the trial? Medical Practices? \u2022 Will the therapy be covered by health insurance? Ask your healthcare provider about complementary and How Do I Evaluate Medical Resources alternative medical treatments and practices in general, on the Web? and about those particular practices used for your specific health problems. The number of Web sites offering health-related re- sources grows every day. Many sites provide valuable in- Increasingly, healthcare providers are becoming famil- formation, while others may have information that is iar with alternative treatments or are able to refer you to unreliable or misleading. This short guide contains im- someone who is. For scientific information about the portant questions you should consider as you look for safety and effectiveness of a particular treatment, ask your health information online. Answering these questions healthcare provider to obtain valid information for you. when you visit a new site will help you evaluate the in- formation you find. There are 10 things you should know: If your healthcare provider cannot provide informa- tion, medical libraries, public libraries, and popular book- 1. Who runs this site? Any good health-related Web site stores are good places to find information about particular should make it easy for you to learn who is respon- complementary and alternative medical practices. sible for the site and its information. Also, you may want to ask practitioners of comple- mentary and alternative health care about their prac- tices. Many practitioners belong to a growing number of","200 PART II PUBLIC HEALTH NUTRITION 2. Who pays for the site? It costs money to run a Web will not do with it. Many commercial sites sell \u201cag- site. The source of a Web site\u2019s funding should be gregate\u201d (collected) data about their users to other clearly stated or readily apparent. For example, Web companies, information such as what percentage of addresses ending in \u201c.gov\u201d denote a federal govern- their users are women with breast cancer, for exam- ment-sponsored site. You should know how the site ple. In some cases, they may collect and reuse infor- pays for its existence. Does it sell advertising? Is it mation that is \u201cpersonally identifiable,\u201d such as your sponsored by a drug company? The source of fund- ZIP code, gender, and birth date. Be certain that you ing can affect what content is presented, how the read and understand any privacy policy or similar content is presented, and what the site owners want language on the site, and don\u2019t sign up for anything to accomplish on the site. that you are not sure you fully understand. 10. How does the site manage interactions with visitors? 3. What is the purpose of the site? This question is re- There should always be a way for you to contact the lated to who runs and pays for the site. An \u201cAbout site owner if you run across problems or have ques- This Site\u201d link appears on many sites; if it is there, tions or feedback. If the site hosts chat rooms or use it. The purpose of the site should be clearly stated other online discussion areas, it should tell visitors and should help you evaluate the trustworthiness of what the terms of using this service are. Is it mod- the information. erated? If so, by whom, and why? It is always a good idea to spend time reading the discussion without 4. Where does the information come from? Many health joining in, so that you feel comfortable with the en- and medical sites post information collected from vironment before becoming a participant. other Web sites or sources. If the person or organi- zation in charge of the site did not create the infor- PROGRESS CHECK ON ACTIVITY 2 mation, the original source should be clearly labeled. FILL-IN 5. What is the basis of the information? In addition to identifying who wrote the material you are reading, 1. The three main proposed mechanisms for the site should describe the evidence that the mate- acupuncture are: rial is based on. Medical facts and figures should have references (such as to articles in medical journals). a. Also, opinions or advice should be clearly set apart from information that is \u201cevidence based\u201d (that is, b. based on research results). c. 6. How is the information selected? Is there an edito- rial board? Do people with excellent medical quali- 2. Name five side effects of laetrile treatment: fications review the material before it is posted? a. 7. How current is the information? Web sites should be reviewed and updated on a regular basis. It is partic- b. ularly important that medical information be cur- rent. The most recent update or review date should c. be clearly posted. Even if the information has not changed, you want to know whether the site owners d. have reviewed it recently to ensure that it is still valid. e. 8. How does the site choose links to other sites? Web sites usually have a policy about how they establish links 3. Name three places where information about com- to other sites. Some medical sites take a conservative plementary and alternative medicine (CAM) prac- approach and don\u2019t link to any other sites. Some link tices can be obtained: to any site that asks, or pays, for a link. Others only link to sites that have met certain criteria. a. 9. What information about you does the site collect, b. and why? Web sites routinely track the paths visi- tors take through their sites to determine what pages c. are being used. However, many health Web sites ask for you to \u201csubscribe\u201d or \u201cbecome a member.\u201d In 4. Important questions one should consider as one some cases, this may be so that they can collect a looks for health information online are: user fee or select information for you that is rele- vant to your concerns. In all cases, this will give the a. site personal information about you. Any credible health site asking for this kind of in- b. formation should tell you exactly what they will and","CHAPTER 12 ALTERNATIVE MEDICINE 201 c. sion but is of no benefit in treating major de- pression of moderate severity. d. 19. T F Since St.-John\u2019s-wort is classified by FDA as a dietary supplement, it is safe and has no side e. effects. 20. T F Regarding CAM, a nurse must be able to an- f. swer patient\u2019s questions and evaluate informa- tion before providing advice. g. 21. T F Healthcare practitioners are obligated to pro- vide complementary and alternative medical h. treatments and practices in general, and those particular practices used for your specific i. health problems. 22. T F CAM practitioners do not have to be certified j. in the United States. TRUE\/FALSE REFERENCES Circle T for True and F for False. Allison, D. B. (2001). Alternate treatments for weight loss: A review. Critical Reviews in Food Science and 5. T F Traditional Chinese medicine is based on the Nutrition, 41: 1\u201328. presence of qi and its travel in the body through the meridians, and the balance of yin and yang Baser, K. H. C. (2005). New trends in the utilization of med- that works with natural qi in the body. ical and aromatic plants. Acta Horticulturae, 676: 11\u201323. 6. T F Qi is believed to regulate spiritual, emotional, Bendich, A., Deckelbaum, R. J. (Eds.). (2005). Preventive mental, and physical balance and to be influ- Nutrition: The Comprehensive Guide for Health enced by the opposing forces of yin and yang. Professionals (3rd ed.). Totowa, NJ: Humana Press. 7. T F Traditional Chinese medicine practices (in- Coulston, A. M., Rock, C. L., & Monsen, E. L. (Eds.). cluding acupuncture, herbs, diet, massage, and (2001). Nutrition in the Prevention and Treatment of meditative physical exercise) all are intended Disease. San Diego, CA: Academic Press. to improve the flow of qi. Das, U. (2007). Functional food products and phytother- 8. T F Meridians exist in a form that can be identi- apy for chronic diseases. HerbGram, 75: 65\u201366. fied by Western scientists. Davis, W. M. (2006). Consumer\u2019s Guide to Dietary 9. T F One of the main reasons Americans seek Supplements and Alternate Medicines: Servings of acupuncture treatment is to relieve chronic Hope. New York: Pharmaceutical Products Press. pain, especially from conditions such as arthri- tis or lower back disorders. Eastwood, M. (2003). Principles of Human Nutrition (2nd ed.). Malden, MA: Blackwell Science. 10. T F Laetrile is an effective compound that has been used as an anticancer treatment in humans Etkin, N. L. (2006). Edible Medicines: An Ethnopharma- worldwide. cology of Food. Tuscon, AZ: University of Arizona Press. 11. T F The term laetrile is an acronym used to describe Evans, M. (2001). Ripe for study: Complementary and al- a purified form of the chemical amygdalin. ternative treatments for obesity. Critical Reviews in Food Science and Nutrition, 41: 35\u201337. 12. T F The names laetrile, Laetrile, and amygdalin mean the same product. Garrow, D. (2006). Association between complementary and alternative medicine use, preventive care prac- 13. T F The laetrile\/amygdalin manufactured in Mexico tices, and use of conventional medical services. is made from crushed apricot pits. Diabetes Care, 29: 15\u201319. 14. T F Laetrile is commonly given intravenously over Harrison, R. A. (2004). Who and how many people are a period of time and then orally as maintenance taking herbal supplements? A survey of 21,923 adults. therapy (treatment given to help extend the International Journal for Vitamin and Nutrition benefit of previous therapy). The side effects of Research, 74: 183\u2013186. laetrile treatment are usually fairly mild. Hollander, J. M. (2008). Complementary and alternate 15. T F The side effects of laetrile are similar regard- medicine and the management of the metabolic syn- less of the method of administration. drome. Journal of American Dietetic Association, 108: 495\u2013509. 16. T F St.-John\u2019s-wort is classified as a dietary sup- plement by the U.S. Food and Drug Adminis- Higdon, J. (2007). An Evidence-Based Approach to tration (FDA). Dietary Phytochemicals. New York: Thieme Medical. 17. T F The composition of St.-John\u2019s-wort and how it might work are well understood. 18. T F Scientific evidence shows that St.-John\u2019s-wort is useful for treating mild to moderate depres-","202 PART II PUBLIC HEALTH NUTRITION Shapiro, A. C. (2001). Guidelines for responsible nutri- tion counseling on complementary and alternate med- Mahan, L. K., Escott-Stump, S. (Eds.) (2008). Krause\u2019s icine. Nutrition Today, 36: 291\u2013297. Food and Nutrition Therapy (12th ed.). Philadelphia: Elsevier Saunders. Shils, M. E., & Shike, M. (Eds.). (2006). Modern Nutrition in Health and Disease (10th ed.). Philadelphia: Lippin- Marian, M. J., Williams-Muller, P., & Bower, J. (2007). cott, Williams and Wilkins. Integrating Therapeutic and Complementary Nutrition. Boca Raton, FL: CRC Press. Temple, N. J., Wilson, T. & Jacobs, D. R. (2006). Nutrition Health: Strategies for Disease Prevention (2nd ed.). Mathieu, J. (2005). Herbs and cancer treatment. Journal Totowa, NJ: Humana Press. of American Dietetic Association: 105, 22, 24. Touger-Decker, R. (2003). Complementary and alter- Mueller, M. S. (2005). Medical Plants in Tropical Use nate medicine: Competencies for dietetics profession- Experience Facts. Stuttgart, NY: Thieme. als. Journal of American Dietetic Association, 103: 1465\u20131469. Palmer, S. (2007). Can diet or supplements relieve your arthritis aches and inflammation? Environmental Vangsness, S. (2005). Education and knowledge of di- Nutrition, 30(8): 1, 4. etetic interns regarding herbs and dietary supple- ments: Preparing for practice. Topics in Clinical Pittler, M. H. (2005). Complementary therapies for re- Nutrition, 20: 269\u2013276. ducing body weight: A systematic review. Interna- tional Journal of Obesity and Related Metabolic Vickery, C. E. (2006). Complementary and alternate med- Disorders, 29: 1030\u20131038. icine education in dietetics programs: Existent but not consistent. Journal of American Dietetic Asso- Purcell, K. (2005). Survey shows 36% of U.S. adults use ciation, 106: 860\u2013866. CAM. HerbGram, 65: 66. Walker, A. F. (2006). Herbal medicine: The science of the Rivin, R. S. (2006). Is garlic alternate medicine? Journal art. Proceedings of Nutrition Society, 65: 145\u2013152. of Nutrition, 136: 713s\u2013715s. Sarkar, S. (2007). Functional foods as self-care and com- plementary medicine. Nutrition and Food Science, 37: 160\u2013167.","OUTLINE 13C H A P T E R Objectives Food Ecology Glossary Background Information Time for completion ACTIVITY 1: Food Safety Causes of Food-Borne Illness Activities: 1 hour Bacteria and Food Temperature Optional examination: 1\u20442 hour Safe Food-Preparation Practices Case Histories of Food OBJECTIVES Poisoning in the United Upon completion of this chapter, the student should be able to do the States following: Responsibilities of Health 1. Describe the appropriate methods for the safe handling, storage, and prepa- Personnel Progress Check on Activity 1 ration of food to prevent illness by: ACTIVITY 2: Nutrient a. recognizing agents that cause food-borne illness. Conservation b. knowing ways to minimize contamination. Storage c. becoming familiar with regulations regarding the protection of food. Preparation 2. Describe the appropriate methods for handling, storing, and preparing Cooking food to conserve nutrients by becoming knowledgeable about: Food Additives as Nutrients a. nutrition labeling. Summary b. pasteurization, enrichment, and fortification of foods. Responsibilities of Health Personnel GLOSSARY Progress Check on Activity 2 References Bacteria: small unicellular microorganisms. They are spherical (cocci), rod shaped (bacilli), comma shaped (vibrios), or spiral (spirochetes). The symp- toms produced by the bacteria depend on the type of bacteria ingested. Enrichment: the addition of thiamin, niacin, riboflavin, and iron to bread and cereal products. The amount added to foods is set by the federal government. 203","204 PART II PUBLIC HEALTH NUTRITION Once you reach a Web site, you can search for relevant words or phrases such as: Fortification: the addition of one or more nutrients not originally present in the food. \u2022 Enrichment \u2022 Cooking and nutrients GRAS: generally recognized as safe. These are additives \u2022 Food labels that have been used for a long time without known ill effects. Substances and additives sanctioned by the ACTIVITY 1: FDA prior to 1958. Food Safety Pasteurization: the practice of heating milk to 140\u00b0F for 30 seconds to kill disease-producing bacteria, or to CAUSES OF FOOD-BORNE ILLNESS 161\u00b0F for 15 seconds. The three most common biological agents of illness that Restoration: replacing food nutrients that were present are transmitted to people from the food supply are bac- before processing but were destroyed by the processing. teria, parasites, and viruses. The two most common fac- tors causing transmission are human carelessness and URI: upper respiratory infection. lack of knowledge of food handling. Examples of causative Virus: a minute microorganism much smaller than a bac- factors include: terium. It has no independent cell activity. Viruses 1. Contamination of the water supply reproduce inside a host cell. More than 200 disease- 2. Sewage seeping into livestock food producing viruses have been identified. 3. Poor personal hygiene\u2014for example, from the oral- BACKGROUND INFORMATION fecal route, not washing hands after using the toilet 4. Improper storage of raw foods, especially eggs, No matter how thorough an individual\u2019s knowledge is regarding the nutritional value of foods, unless the food meats, fish, poultry, and dairy products is safe, there can be no optimal diets. No matter how 5. Improper storage of cooked foods\u2014for example, carefully selected, food can only provide nourishment and health if it has been handled in such a way that it is using deep pans for storage of hot food, which slows neither contaminated nor a source of food-borne illness. the cooling of food Certain organisms that are transmitted to humans 6. Improper preparation of foods\u2014for example, under- through food cause illness and sometimes death. cooking food, especially pork and pork products 7. Improper holding temperatures\u2014that is, above 40\u00b0F Modern food technology and sanitation practices have and below 140\u00b0F; improper thawing of frozen food, greatly reduced the threat of commercial food contami- such as at room temperature nation. Food labelings have enabled consumers to be 8. Poor health practices, especially in group settings; aware of the contents of food purchased. However, unsafe examples include sneezing and coughing onto food, food-handling practices and nutrient losses from food blowing nose over food, not washing hands before preparation persist and continue to create problems even handling food, and handling food with hands that in modern societies. This is especially true in any group- have open sores or boils eating environments, including healthcare facilities, shel- 9. Contamination by organisms transmitted from food ter and retirement centers, schools, and restaurants. handler to food or equipment and cross-contamination between foods Information on food safety has been derived from the 10. Lack of knowledge by food handlers of the potential following Web sites of U.S. government agencies: hazards of the organisms they carry 1. U.S. Department of Agriculture (USDA): www.usda.gov For reference purposes, Table 13-1 describes the char- 2. Food Safety Inspection Service of the USDA: www.fsis. acteristics of some common food-borne diseases. gov BACTERIA AND FOOD TEMPERATURE 3. Food and Drug Administration: www.fda.gov 4. Centers for Disease Controls: www.cdc.gov To minimize the risk of food-borne illnesses, all individ- 5. A combined government Web site: www.foodsafety.gov uals should take care to keep food clean to prevent bac- teria from multiplying, and to adequately cook fresh and Once you reach a Web site, you can search for such frozen meat, fish, poultry, and eggs. relevant words or phrases as: The majority of cases of food poisoning are from bac- \u2022 Salmonella teria or toxin from the bacteria. If we know what causes \u2022 Food poisoning bacteria to multiply, we can take preventive measures. \u2022 Recalls Given a few pathogens and favorable conditions, a harm- \u2022 Meat contamination less food can quickly become a source of illness. As for nutrient status in foods, the two most common government Web sites are: 1. U.S. Department of Agriculture: www.usda.gov 2. Food and Drug Administration: www.fda.gov","CHAPTER 13 FOOD ECOLOGY 205 TABLE 13-1 Characteristics of Different Food-Borne Diseases Disease and Organism Source of Illness Symptoms Prevention Methods That Causes It Salmonellosis Salmonella May be found in raw meats, Onset: 12\u201348 hours after eat- Handling food in a sanitary (bacteria; more than 1,700 poultry, eggs, fish, milk, ing. Nausea, fever, manner. kinds) and products made with headache abdominal them. Multiplies rapidly at cramps, diarrhea, and Thorough cooking of foods. room temperature. sometimes vomiting. Prompt and proper refrigera- Can be fatal in infants, the tion of foods. elderly, and the infirm. Staphylococcal food The toxin is produced when Onset: 1\u20138 hours after eating. Sanitary food handling poisoning food contaminated with the bacteria is left too long Diarrhea, vomiting, nausea, practices. Staphylococcal enterotoxin at room temperature. (produced by Meats, poultry, egg prod- abdominal cramps, and Prompt and proper refrigera- Staphylococcus aureus ucts, tuna, potato and prostration. tion of foods. bacteria) macaroni salads, and cream-filled pastries are Mimics flu. Lasts 24\u201348 good environments for these bacteria to produce hours. Rarely fatal. toxin. Botulism Bacteria are widespread in Onset: 8\u201336 hours after eat- Using proper methods for the environment. However, ing. Neurotoxic symptoms, canning low-acid foods. Botulinum toxin (produced bacteria produce toxin including double vision, in- by Clostridium botulinum only in an anaerobic (oxy- ability to swallow, speech Avoidance of commercially bacteria) genless) environment of difficulty, and progressive canned low-acid foods with little acidity. Types A, B, paralysis of the respiratory leaky seals or with bent, and F may result from in- system. bulging, or broken cans. adequate processing of low-acid canned foods, Obtain medical help immedi- Toxin can be destroyed after such as green beans, ately. Botulism can be fatal. a can is opened by boil- mushrooms, spinach, ing contents hard for olives, and beef. Type E 10 minutes\u2014not normally occurs in fish. recommended. Perfringens food poisoning Bacteria are widespread in Onset: 8\u201322 hours after eat- Sanitary handling of foods, environment. Generally ing (usually 12). Abdominal especially meat and meat Clostridium perfringens found in meat and poultry dishes and gravies. (rod-shaped bacteria) and dishes made with pain and diarrhea. them. Multiply rapidly when foods are left at Sometimes nausea and Thorough cooking of foods. room temperature too long. Destroyed by vomiting. Prompt and proper cooking. Symptoms last a day or less refrigeration. and are usually mild. Can be more serious in older or debilitated people. Shigellosis (bacillary Food becomes contaminated Onset: 1\u20137 days after eating. Handling food in a sanitary dysentery) when a human carrier with Abdominal pain, cramps, manner. poor sanitary habits han- diarrhea, fever, sometimes Shigella (bacteria) dles liquid or moist food vomiting, and blood, pus, Proper sewage disposal. that is then not cooked or mucus in stools. thoroughly. Organisms Proper refrigeration of foods. multiply in food stored Can be serious in infants, the above room temperature. elderly, or debilitated Found in milk and dairy people. products, poultry, and potato salad. continues","206 PART II PUBLIC HEALTH NUTRITION TABLE 13-1 (continued) Disease and Organism Source of Illness Symptoms Prevention Methods That Causes It Campylobacterosis Bacteria found on poultry, Onset: 2\u20135 days after eating. Thorough cooking of foods. cattle, and sheep and can Diarrhea, abdominal Campylobacter jejuni (rod- contaminate the meat and cramping, fever, and some- Handling food in a sanitary shaped bacteria) milk of these animals. times bloody stools. manner. Chief food sources: raw poultry and meat and un- Lasts 2\u20137 days. Avoiding unpasteurized milk. pasteurized milk. Gastroenteritis Ubiquitous in nature, carried Onset: 2\u20135 days after eating. Thorough cooking of foods. in food and water. Bacteria Yersinia enterocolitica (non- multiply rapidly at room Fever, headache, nausea, Sanitizing cutting instru- spore-forming bacteria) temperature, as well as at diarrhea, and general ments and cutting boards refrigerator temperatures malaise. Mimics flu. before preparing foods that (4\u00b0 to 9\u00b0C). Generally found in raw vegetables, An important cause of gas- are eaten raw. meats, water, and unpas- teurized milk. troenteritis in children. Avoidance of unpasteurized Can also infect other age milk and unchlorinated groups and, if not treated, water. can lead to other more seri- ous diseases (such as lym- phadenitis, arthritis, and Reiter\u2019s syndrome). Cereus food poisoning Illness may be caused by the Onset: 1\u201318 hours after eat- Sanitary handling of foods. bacteria, which are wide- ing. Two types of illness: Bacillius cereus (bacteria spread in the environment, (1) abdominal pain and di- Thorough cooking of foods. and possibly their toxin) or by an enterotoxin cre- arrhea, and (2) nausea and ated by the bacteria. Found vomiting. Prompt and adequate refrig- in raw foods. Bacteria mul- eration. tiply rapidly in foods stored Lasts less than a day. at room temperature. Cholera Found in fish and shellfish Onset: 1\u20133 days. Sanitary handling of foods. Vibrio cholera (bacteria) harvested from waters con- taminated by human Can range from \u201csubclinical\u201d Thorough cooking of seafood. sewage. (Bacteria may also (a mild uncomplicated bout occur naturally in Gulf with diarrhea) to fatal (in- Coast waters.) Chief food tense diarrhea with dehy- sources: seafood, especially dration). Severe cases types eaten raw (such as require hospitalization. oysters). Hemorrhagic colitis (gas- Undercooked or raw ham- The illness is characterized by Handling food in a sanitary troenteritis, intestinal dis- burger (ground beef) has orders) Escherichia coli been implicated in many of severe cramping (abdomi- manner. Thorough cook- O157:H7 (entero- hemor- the documented outbreaks; rhagic E. coli or EHEC) however, E. coli O157:H7 nal pain) and diarrhea, ing of foods. Prompt and outbreaks have implicated alfalfa sprouts, unpasteur- which is initially watery but proper refrigeration of ized fruit juices, dry-cured salami, lettuce, game meat, becomes grossly bloody. foods. and cheese curds. Raw milk was the vehicle in a Occasionally vomiting oc- school outbreak in Canada. curs. Fever is either low- grade or absent. The illness is usually self-limited and lasts for an average of 8 days. Some individuals ex- hibit watery diarrhea only. Parahaemolyticu food Organism lives in salt water Onset: 15\u201324 hours after eat- Sanitary handling of foods. poisoning and can contaminate fish ing. Abdominal pain, nau- Thorough cooking of seafood. and shellfish. Thrives in sea, vomiting, and Vibrio parahaemolyticus warm weather. diarrhea. Sometimes fever, continues (bacteria) headache, chills, and mucus and blood in the stools. Lasts 1\u20132 days. Rarely fatal.","CHAPTER 13 FOOD ECOLOGY 207 TABLE 13-1 (continued) Disease and Organism Source of Illness Symptoms Prevention Methods That Causes It Sanitary handling of foods. Gastrointestinal disease Viruses exist in the intestinal Onset: After 24 hours. Use of pure drinking water. tract of humans and are Adequate sewage disposal. Enteroviruses rotaviruses expelled in feces. Severe diarrhea, nausea, and Adequate cooking of foods. parvoviruses Contamination of foods vomiting. Respiratory can occur in three ways: symptoms. (1) when sewage is used to enrich garden\/farm soil; Usually lasts 4\u20135 days but (2) by direct hand-to-food may last for weeks. contact during the prepa- ration of meals; and (3) when shellfish-growing waters are contaminated by sewage. Hepatitis Chief food sources: shellfish Jaundice, fatigue. May cause Sanitary handling of foods. Hepatitus A virus harvested from contami- liver damage and death. Use of pure drinking water. nated areas, and foods that Adequate sewage disposal. are handled a lot during Adequate cooking of foods. preparation and then eaten raw (such as vegetables). Listeriosis Associated with such foods as The onset time to serious Handling food in a sanitary L. Monocytogenes. raw milk, supposedly pas- forms of listeriosis is un- manner. Thorough cook- teurized fluid milk, known but may range from ing of foods. Prompt and cheeses (particularly soft- a few days to 3 weeks. The proper refrigeration of ripened varieties), ice onset time to gastrointesti- foods. cream, raw vegetables, fer- nal ymptoms is unknown mented raw-meat but is probably greater sausages, raw and cooked than 12 hours. poultry, raw meats (all types), and raw and The manifestations of listerio- smoked fish. Its ability to sis include septicemia, grow at temperatures as meningitis (or meningoen- low as 3\u00b0C permits multi- cephalitis), encephalitis, plication in refrigerated and intrauterine or cervical foods. infections in pregnant women, which may result in spontaneous abortion (2nd\/3rd trimester) or still- birth. The onset of the aforementioned disorders is usually preceded by influenza-like symptoms including persistent fever. It was reported that gas- trointestinal symptoms such as nausea, vomiting, and diarrhea may precede more serious forms of liste- riosis or may be the only symptoms expressed. Mycotoxicosis Produced in foods that are May cause liver and\/or kidney Checking foods for visible Mycotoxins (from molds) relatively high in moisture. disease. mold and discarding those Chief food sources: beans that are contaminated. and grains that have been stored in a moist place. Proper storage of susceptible foods. continues","208 PART II PUBLIC HEALTH NUTRITION TABLE 13-1 (continued) Disease and Organism Source of Illness Symptoms Prevention Methods That Causes It Giardiasis Protozoa exist in the intes- Diarrhea, abdominal pain, Sanitary handling of foods. tinal tract of humans and flatulence, abdominal dis- Giardia lamblia (flagellated are expelled in feces. tention, nutritional distur- Avoidance of raw fruits and protozoa) Contamination of foods bances, \u201cnervous\u201d vegetables in areas where can occur in two ways: symptoms, anorexia, nau- the protozoa is endemic. (1) when sewage is used to sea, and vomiting. enrich garden\/farm soil; Proper sewage disposal. and (2) by direct hand-to- food contact during the preparation of meals. Chief food sources: foods that are handled a lot during preparation. Amebiasis Tenderness over the colon or Sanitary handling of foods. Entamoeba histolytica liver, loose morning stools, Avoidance of raw fruits and (amoebic protozoa) recurrent diarrhea, change vegetables in areas where in bowel habits, \u201cnervous\u201d the protozoa is endemic. symptoms, loss of weight, and fatigue. Anemia may be Proper sewage disposal. present. Source: C. L. Ballentine and M. L. Herndon, FDA Consumer, July\u2013August 1982, pp. 25\u201328. Bacteria thrive in foods that are moist, warm, good The following guidelines apply to the food environment: sources of protein, and low in acid. A few thrive in the ab- sence of oxygen supply (anaerobic). These bacteria are 1. All kitchen equipment and utensils should be thor- usually in home-canned low-acid foods where they pro- oughly cleaned before being used with any foods. duce the deadly botulism toxin. 2. Cooked foods should not be allowed to stand at room The time-temperature factor is critical in preventing temperature for more than two to three hours when- bacteria from multiplying. After purchasing food, it is ever feasible. Exposure of food to temperatures be- essential to minimize the opportunity for bacteria incu- tween 5\u00b0C and 60\u00b0C (40\u00b0F and 140\u00b0F) should be kept bation by properly storing, preparing, and handling food. to a minimum. The practice of preparing foods a day Figure 13-1 depicts the effects of temperature on poten- or several hours before eating should be done with tial disease-producing organisms. care and avoided if possible. Observation of safe food preparation practices is an ef- 3. Hot foods should never be allowed to cool slowly to fective way to prevent food-borne illness. These practices, room temperature before refrigerating. The slow cool- which all family members should observe, are listed below. ing period provides an ideal growth temperature for bacteria. Foods should be refrigerated immediately SAFE FOOD-PREPARATION PRACTICES after removing from a steam table or warming oven. A shallow pan, cold running water, or ice bath can be Observe personal hygiene: used to cool foods rapidly for storage. A large amount of food in a big container requires additional cooling 1. Hands should always be clean whenever food is han- time before all the contents are below 7\u00b0C (45\u00b0F), po- dled. Hot water and soap should be used to wash tentially creating an environment for bacteria to hands after going to the bathroom, before handling grow. cooked foods, and after handling raw food. 4. When leftovers are served, the food should be heated 2. A person who is ill should not prepare food. until all parts reach a temperature of 74\u00b0C (165\u00b0F). 3. During food preparation, contact between hands and This destroys all vegetative cells of bacteria. Whenever applicable, food should be chopped into small pieces the mouth, nose, or hair should be avoided, as should and boiled to destroy any susceptible vegetative cells coughing and sneezing over foods. Tissues or hand- of the bacteria. No cooling should be permitted after kerchiefs should be used to prevent contamination. preparation\u2014the food should be served hot. 4. Tasting food with fingers and utensils used during preparation is not advised, even if the cooking tem- 5. Certain popular foods\u2014stuffed turkey, gravies, cream perature is very hot. pies and puddings, sandwiches, and salads\u2014are","CHAPTER 13 FOOD ECOLOGY 209 250\u00b0F Canning temperatures for low-acid ble. Gravy or broth should not be held in the refrig- 240 vegetables, meat, and poultry in erator more than one or two days, and it should be re- 212 pressure canner. heated or boiled for several minutes before serving. A 165 reheated dressing should not be permitted to stay at 140 Canning temperatures for fruits, room temperature. 125 tomatoes, and pickles in waterbath 7. Cream pies and puddings are also often involved in 60 canner. food poisoning. People dislike keeping these items in the refrigerator, because they can become soggy. 40 Cooking temperatures destroy most However, leaving them at room temperature can 32 bacteria. Time required to kill bacteria allow bacteria to multiply rapidly. Ideally, such pas- 0 decreases as temperature is increased. tries should be prepared as close to serving time as possible. Warming temperatures prevent 8. Items such as ham sandwiches, turkey and chicken growth but allow survival of some salads, and deviled eggs require special attention. One bacteria. good practice is to freeze the sandwiches immediately after preparation and thaw them whenever they are Some bacterial growth may occur. needed. Chicken salads may be prepared by using Many bacteria survive. frozen chicken cubes, which will thaw as the salad stands. The entire salad dish should be kept cool. Danger zone CASE HISTORIES OF FOOD POISONING IN Foods held more than 2 hours in this THE UNITED STATES zone are subject to rapid growth of bacteria and the production of toxins Salmonella by some bacteria. On April 12, 2008, the Food and Drug Administration Some growth of food poisoning (FDA) announced that at least 21 people in 13 states have bacteria may occur. been diagnosed with salmonellosis that was caused by the same strain of Salmonella that was found in the re- Cold temperatures permit slow growth cently recalled unsweetened Puffed Rice and unsweet- of some bacteria that cause spoilage. ened Puffed Wheat Cereals produced by Malt-O-Meal. Freezing temperatures stop growth The recalled products were distributed nationally bacteria, but may allow bacteria to under the Malt-O-Meal brand name as well as under pri- survive. Foods can spoil at vate label brands including Acme, America\u2019s Choice, Food temperatures below freezing. Do not Club, Giant, Hannaford, Jewel, Laura Lynn, Pathmark, store food above 10\u00b0 for more than a Shaw\u2019s, ShopRite, Tops, and Weis Quality. few weeks. Salmonella is a type of bacteria that can cause serious Do not store raw meats for more than and sometimes fatal infections in young children, frail 5 days or poultry, fish, or ground meat or elderly people, and others with weakened immune sys- for more than 2 days in the tems. Symptoms of food-borne Salmonella infection in- refrigerator. clude nausea, vomiting, fever, diarrhea, and abdominal cramps. In persons with poor health or weakened im- FIGURE 13-1 Temperature Guide to Food Safety mune systems, Salmonella can invade the bloodstream Source: Distributed by the U.S. Department of Agriculture. and cause life-threatening infections. frequent culprits in food poisoning. When preparing Listeriosis roast turkey, do not stuff the bird but cook the stuff- ing separately. If turkey is stuffed with raw fillers, On November 13, 2000, healthcare providers at a hospi- avoid stuffing it the night before. If stuffing is cooked tal in Winston-Salem, North Carolina, contacted the local separately, it should be cooked immediately after mix- health department about three cases of listeriosis within ing, especially if in a large quantity. Stuffing is an ex- a 2-week period in recent Mexican immigrants. cellent place for bacteria to grow, and if a large amount of lukewarm stuffing is permitted to stand The FDA together with the local authorities investi- at room temperature, the organisms will surely gated this outbreak of Listeria monocytogenes infections, multiply. implicating noncommercial, homemade, Mexican-style 6. Gravies and broths are quite susceptible to bacterial fresh soft cheese produced from contaminated raw milk contamination, especially as leftovers. These foods sold by a local dairy farm as the causative agent. should be placed in the refrigerator as soon as possi-","210 PART II PUBLIC HEALTH NUTRITION 2. Intense training of grandmothers in the Hispanic communities since they are usually the ones making Culturally appropriate education efforts are impor- the soft cheeses. tant to reduce the risk for L. monocytogenes transmis- sion through Mexican-style fresh soft cheese. 3. Stringent regulatory action on use of raw milk and re- sponsibility of sellers (vendors, grocery stores). All patients were Hispanic and 10 were pregnant women. Infection with L. monocytogenes resulted in five RESPONSIBILITIES OF HEALTH PERSONNEL stillbirths, three premature deliveries, and two infected newborns. On hospital admission, the women reported A health practitioner should emphasize the following symptoms that included fever, chills, headache, abdom- when educating a client, an institution, or the general inal cramps, stiff neck, vomiting, and photophobia. public: Patients had eaten the following food items purchased from door-to-door vendors: Queso fresco, a Mexican-style 1. Observe sanitary practices that minimize the likeli- fresh soft cheese; and hotdogs. Illness was not associated hood of food-borne illness. with purchases at specific markets or supermarkets, eat- ing raw fruits or vegetables, deli products, other cheeses 2. Teach all family members the principles of cleanli- (e.g., American, cheddar, mozzarella, and blue\/Gorgonzola), ness. or other dairy products. 3. Check closely for sanitary, safe practices being fol- Various members of the Hispanic immigrant commu- lowed among all personnel working in a healthcare nity made the Mexican-style fresh soft cheese from raw setting. milk in their homes. Inspectors found unlabeled home- made cheese in all three of the small local Latino grocery 4. Make your clients aware that bacteria are a major stores they visited in Winston-Salem. In addition, many cause of food-borne illness, and that they thrive in a persons regularly sold the cheese in parking lots and by warm, moist environment. going door to door. Owners of two local dairies reported selling raw milk. Milk samples were obtained from these 5. Foods kept at a temperature between 60\u00b0F and 125\u00b0F two Forsyth County dairies and from three dairies in for more than two hours may not be safe to eat. neighboring counties. L. monocytogenes isolates were obtained from nine patients, three cheese samples from 6. Observe good hand-washing technique. two stores, one cheese sample from the home of a pa- 7. Advise individuals not to work with or around food tient, and one raw milk sample from a manufacturing grade dairy. when they are ill or have any skin lesions. 8. If insecticides are used, counsel extreme caution in As a result of this outbreak, North Carolina health au- thorities stopped the sale of raw milk by the dairy farm cooking and eating areas to prevent contamination to noncommercial processors and educated store owners of food. that it is illegal to sell unregulated dairy products. 9. Regularly inspect all areas where food is stored and Officials cited the outbreak as sufficient reason to prepared. strengthen laws prohibiting the sale of raw milk except 10. Perform laboratory cultures on a regular basis in to regulated processors. healthcare facilities. 11. Encourage mandatory regular teaching of food per- Despite laws prohibiting the sale and consumption of sonnel and demonstrations of appropriate tech- raw milk and raw milk products, such practices persist in niques of safe food handling. some communities as a result of consumers\u2019 taste pref- 12. Check the source of supply of food items (supplier). erences and for cultural reasons. The popularity of queso 13. Purchase only those food items that meet govern- fresco has resulted in several outbreaks in Hispanic com- ment regulations for safety, such as pasteurized milk munities since the 1980s. In 1985, an outbreak of septic and dairy products, USDA inspected meats, and fish. abortions attributed to L. monocytogenes occurred among Hispanics in Los Angeles and Orange counties, PROGRESS CHECK ON ACTIVITY 1 California. In 1997, three outbreaks occurred in Hispanic communities in northern California and Washington. FILL-IN Because queso fresco in these communities is pro- 1. Describe five ways in which a food may be con- duced in private homes, food safety regulations are diffi- taminated by a food handler. cult to enforce. However, the following approaches have some success: a. 1. Massive education programs using Spanish-speaking b. health providers with background on cultural prac- tices. The targets are Hispanic consumers, especially c. pregnant women. d. e.","CHAPTER 13 FOOD ECOLOGY 211 2. The storage temperature of perishable foods must cook is not concerned because she has plans to re- heat it before serving. be below \u00b0F or above \u00b0F in order to retard the growth of bacteria. a. 32, 200 12. The cook takes several cans of green beans from a b. 40, 140 cupboard to heat and two of them are rusty at the c. 60, 170 seams. One has a little leakage, but none of the d. 80, 190 cans is bulging. Should you warn her not to use them? Explain. 3. What is the major causative agent in food-borne illness? 4. Describe how temperature and moisture affect the growth of organisms. 5. List five prevention methods for contamination of 13. The cook assembles the ingredients for potato foods. salad before she begins preparation. She then a. takes a break and runs a few errands before she b. prepares the potato salad. c. d. 14. The cook takes the cutting board from under the e. sink near the water pipes and cuts and finely chops all the vegetables, fruits, and meats she 6. List the most common gastrointestinal symptoms plans to use for the next two meals. She then puts of food-borne illness. them in a deep, open pan and refrigerates them. TRUE\/FALSE ACTIVITY 2: Circle T for True and F for False. Nutrient Conservation 7. T F Leftover food should be cooled completely be- Nutrients may also be lost during processing or preser- fore it is refrigerated. vation of foods. At home, nutrients can also be lost dur- ing storage, preparation, and cooking of foods. 8. T F Cooking reduces the number of pathogenic bacteria but does not destroy all of them. Using good food-preparation methods to maximize nutrient retention is especially important when the diet 9. T F Cooking may not provide protection against is limited or low in certain nutrients. The following meas- food contaminated with staphylococcus. ures are recommended to minimize loss during storage, preparation, and cooking. 10. T F Cooking destroys most parasites and viruses. STORAGE Case Study 1. Avoid bruising soft, fresh produce such as berries and You are invited to the residence of a friend who runs a day care peaches. center for the elderly. She has six residents plus her own fam- ily, and has hired a person to cook who has had no previous 2. Store perishable items at the recommended temper- training. While you are visiting, you observe the following pro- ature, usually in the refrigerator or freezer. cedures (comment on the food-handling practices in each in- stance given): 3. Store foods, except fresh meats, in containers that allow little room for air to circulate, or wrap the foods 11. A pot of homemade beef vegetable soup was made in moisture- and vapor-proof material. the night before and left on the counter overnight because there was not room to refrigerate it. The","212 PART II PUBLIC HEALTH NUTRITION ing grains such as rice. Small amounts of cooking liquid can be saved and stored in the freezer. 4. Package green vegetables in such a way that they stay 9. Do not add baking soda when cooking vegetables, crisp. Keep them slightly moist, not wet. (Washed let- even though it makes green vegetables stay brightly tuce keeps well if wrapped loosely in a clean towel colored. and enclosed in a plastic bag.) FOOD ADDITIVES AS NUTRIENTS 5. Store less perishable items (such as canned foods, dry cereals, cooking oils) in a cool, dry place. To process food and preserve nutrients, chemical sub- stances are added to foods. While these procedures are 6. If foods are not stored in opaque or colored glass con- necessary, they have confused the consumer and changed tainers, store away from the light. the nutrient content of many foods. In addition, new foods are being introduced to the consumer daily for 7. Use fresh foods as quickly after harvesting as possible. which the nutrient content is unknown. Some measures 8. Store food in glass jars in a dark place. to protect and enlighten the consumer have been estab- 9. Plan for fast turnover of food on the shelf or in the re- lished by the government. frigerator to avoid long storage times. Use leftovers as The FDA enforces laws and regulations to ensure that soon as possible. food is safe, wholesome, and properly labeled. Outside substances are present, intentionally and accidentally, in PREPARATION food as a result of processing, storage, or packaging. Some substances are intentionally added to food to en- 1. Prepare fresh produce as close to time of use as is hance its nutritional value. This takes two forms: practical. 1. Enrichment: The addition of thiamin, niacin, ri- 2. Use a very sharp knife for cutting fresh produce. boflavin, and iron to bread, flour, and cereal products 3. Avoid soaking cut fruits and vegetables, especially if in amounts set by the government. The word restora- tion is sometimes used when the addition of nutrients they are your major source of any water-soluble to a food is to restore it to its original quality. These nutrients. are nutrients that have been lost through manufac- 4. When appropriate, scrub vegetables instead of paring turing or processing. them and leave them whole instead of cutting them. 5. If paring is desired, pare as thinly as possible. If prac- 2. Fortification: Addition to food of one or more nutri- tical (as for beets and potatoes), peel after cooking. ents not originally present or occurring only in 6. Use clean fresh vegetable parings for making stock minute amounts. Some examples are: adding vitamin for soup. D to milk, adding vitamins A and D to skim milk and 7. Use the liquid from canned fruit as an ingredient in nonfat dry milk; adding iodine to salt; and adding flu- homemade fruit punch. oride to water. 8. Save time, fuel, and nutrients by eating raw fruits and vegetables often. Nonnutritive additives do not improve quality. They 9. Avoid reheating leftover cooked vegetables by using preserve food and prevent unwanted changes (for exam- them in cold salads. ple, antioxidants). 10. Discard bruised or dried outside leaves of vegetables. All additives to food must be approved by the FDA. COOKING There is a category of additives generally recognized as safe (known as GRAS). These substances are sanctioned 1. Cook vegetables for the shortest time possible, just by the FDA and have been in widespread use over a long until tender. period of time without known ill effects. All others must undergo rigid testing before being added to foods. 2. If cooking any type of vegetable in water, make sure it is boiling rapidly before vegetable is added. To protect consumers and educate them about their nutrient intakes, the FDA has established regulations for 3. Cook vegetables in the smallest amount of water prac- food labeling. tical for the type of pan, but take care not to scorch them. A small volume of water is especially helpful Nutritional labeling is mandatory on FDA-regulated to reduce nutrient loss when cooking vegetables that products as of January 1993 (see Chapter 1). There is a are cut into small pieces. Cover the pan tightly to standardized format for presenting the information. minimize the amount of water needed. SUMMARY 4. Steam, microwave, or pressure cook clean, whole, unpeeled vegetables. The government\u2019s role and the individual\u2019s role in con- serving nutrients are important considerations for health 5. Stir-fry vegetables the Asian way. personnel. 6. Plan meals so that vegetables can be served as soon as they are cooked. 7. Heat canned vegetables in the liquid in which they are packed. 8. Use cooking liquid from vegetables and drippings from meat for gravy, sauces, soup stock, or for cook-","CHAPTER 13 FOOD ECOLOGY 213 Safeguarding the food supply, appropriate selection and c. purchase of foods, label reading, and knowledge of nutri- d. tion principles can prevent illness and improve health. e. f. RESPONSIBILITIES OF HEALTH PERSONNEL Define the following terms: 5. Enrichment When counseling a client, an institution, or the general 6. Fortification public, a health practitioner should do the following: 7. Restoration 8. Name two types of food additives and give one ex- 1. Teach clients that many foods lose nutrients, espe- ample of each. cially vitamins, during storage. a. b. 2. Teach clients that food storage at warm temperatures increases nutrient loss as well as bacterial and insect REFERENCES growth. Balkin, K. F. (2004). Food-Borne Illnesses. San Diego, 3. Make clients aware that nutrients are lost by unnec- CA: Greenhaven Press. essary trimming, dissolving, soaking, or cooking foods in water. Brennfleck, J. (2006). Diet and Nutrition Sourcebook. Detroit, MI: Omnigraphics. 4. Teach clients that nutrients are lost by overcooking. 5. Teach clients and families that proper food storage, Curtis, P. A. (2005). Guide to Food Laws and Regulations. Ames, IA: Blackwell. preparation, and cooking techniques can improve their nutritional status. D\u2019Mello,. P. F. (Ed.). (2003). Food Safety: Contaminants 6. Educate consumers about the advantages of properly and Toxins. Cambridge, MA: CABI. reading nutrition labels. 7. Encourage clients to learn the general principles of De Leon, S. Y., Meacham, S. L., & Claudio, V. S. (2003). nutrition. Global Handbook on Food and Water Safety: For the 8. Encourage food producers to maintain high-quality Education of Food Management, Food Handlers, and products. Consumers. Springfield, IL: Charles C. Thomas. PROGRESS CHECK ON ACTIVITY 2 Entis, P. (2007). Food Safety: Old Habits, New Perspec- tives. Washington, DC: ASM Press. FILL-IN Food and Agriculture Organization. 2006. Food Safety 1. Nutrition labeling is not mandatory in which two Risk Analysis: A Guide for National Food Safety circumstances? Authorities. Rome, Italy: Author. a. Friedman, M., Mottram, D. S. (Eds.). (2005). Chemistry and Safety of Acrylamide. New York: Springer. b. Griffin, C. (Ed.). (2005). Consumer Food Safety. Bradford, 2. List three advantages to nutrition labeling. England: Emerald Group. a. Griffiths, M. (Ed.). (2005). Understanding Pathogen Behaviour Virulence, Stress Response and Resistance. b. Cambridge, MA: Woodhead. c. Grover, J. (Ed.). (2008). Food. Detroit, MI: Greenhaven Press. 3. Identify three practices to preserve nutrient con- tent of foods during storage. Harris, N. (Ed.). (2004). Genetically Engineered Foods. San Diego, CA: Greenhaven Press. a. Hoffmann, S. A., & Taylor, M. R. (Eds.). (2005). Toward b. Safer Food. Washington, DC: Resources for the Future. c. Jongen, W. (Ed.). (2005). Improving the Safety of Fresh Fruit and Vegetables. Boca Raton, FL: CRC Press. 4. Identify at least six food preparation and cooking practices that keep nutrient loss at a minimum. Kallen, S. A. (2005). Food Safety. Detroit, MI: Greenhaven Press. a. Lasky, T. (2007). Epidemiological Principles and Food b. Safety. Oxford, England: Oxford University Press.","214 PART II PUBLIC HEALTH NUTRITION Rasco, B. A., & Bledsoe, G. (2005). Bioterrorism and Food Safety. Boca Raton, FL: CRC Press. Marrion, N. (2006). What to Eat. New York: North Point Press. Roberts, J. A. (2006). The Economics of Infectious Disease. Oxford, England: Oxford University Press. Matthews, K. R. (2006). Microbiology of Fresh Produce. Washington, DC: ASM Press. Schmidt, R. H., & Rodrick, G. E. (Eds.). (2003). Food Safety Handbook. Hoboken, NJ: Wiley-Interscience. McElhatton, A., & Marshall, R. J. (2007). Food Safety: A Practical and Case Approach. New York: Springer. United States government Web sites: a. U.S. Department of Agriculture: www.usda.gov McSwane, D., Rue, N. R., & Linton, R. (2005). Essentials b. Food Safety Inspection Service of the USDA: www. of Food Safety and Sanitation. Upper Saddle River, fsis.gov NJ: Pearson\/Prentice Hall. c. Food and Drug Administration: www.fda.gov d. Centers for Disease Controls: www.cdc.gov National Restaurant Association Educational Foundation. e. A combined government Web site: www.foodsafety. (2007). Food Preparation: Competency Guide. Upper gov Saddle River, NJ: Pearson-Prentice Hall. Ortega, Y. R. (Ed.). (2006). Foodborne Parasites. New York: Springer.","IIIP A R T Nutrition and Diet Therapy for Adults Chapter 14 Overview of Therapeutic Nutrition Chapter 15 Chapter 16 Diet Therapy for Surgical Conditions Chapter 17 Diet Therapy for Cardiovascular Disorders Chapter 18 Chapter 19 Diet and Disorders of Ingestion, Digestion, and Absorption Chapter 20 Chapter 21 Diet Therapy for Diabetes Mellitus Chapter 22 Diet and Disorders of the Liver, Gallbladder, and Pancreas Diet Therapy for Renal Disorders Nutrition and Diet Therapy for Cancer Patients and Patients with HIV Infection Diet Therapy for Burns, Immobilized Patients, Mental Patients, and Eating Disorders 215","","OUTLINE 14C H A P T E R Objectives Overview of Glossary Therapeutic Nutrition Background Information Progress Check on Background Time for completion Information Activities: 1 hour ACTIVITY 1: Principles and Optional examination: 1\u20442 hour Objectives of Diet Therapy OBJECTIVES Progress Check on Activity 1 ACTIVITY 2: Routine Hospital Upon completion of this chapter, the student should be able to do the following: Diets 1. Define the principles of diet therapy. Regular Diets 2. Explain the objectives of diet therapy. Mechanically Altered or Fiber- 3. Describe the methods used to adapt a normal diet to treat a specific clin- Restricted Diets ical disorder. Liquid Diets 4. Identify the most common therapeutic diets used in clinical care. Diet for Dysphagia Progress Check on Activity 2 GLOSSARY ACTIVITY 3: Diet Modifications Acculturation: traditions, values, or religious beliefs that compose a way of life for Therapeutic Care (see Chapter 2). Modifying Basic Nutrients Modifying Energy Value Ascites: an abnormal accumulation of fluid in the peritoneal cavity resulting Modifying Texture or in distention of the abdomen. Consistency Diet therapy: The use of any diet for restoring or maintaining optimal nutri- Modifying Seasonings tional status and body homeostasis. Nursing Implications Progress Check on Activity 3 Distention: stretching, enlarging. ACTIVITY 4: Alterations in Edema: abnormal accumulation of fluid in body tissues (intercellular space). Gastritis: inflammation of the stomach. Feeding Methods Liquid diet: a modified diet consisting of foods that pour or become liquid at Special Enteral Feedings (Tube body temperature (see Activity 2). Feedings) 217 Parenteral Feedings via Peripheral Vein Parenteral Feeding via Central Vein (Total Parenteral Nutrition [TPN]) Nursing Implications Progress Check on Activity 4 References","218 PART III NUTRITION AND DIET THERAPY FOR ADULTS Mechanically altered diet: a regular diet that has been food selections both for the patient and the kitchen modified in texture and\/or seasoning, depending on personnel. the medical needs of the patient (see Activity 2). It is important to emphasize that in the practice of med- Milieu: surroundings, environment. ical nutrition therapy one must consider the following: Modified diet: a regular diet that has been altered to meet 1. The professional healthcare providers in each clinic, specific requirements of individuals with a disease or hospital, or other medical institution practice diet disorder. therapy according to their experience, available re- Peritoneal: pertaining to the serous membrane lining sources and cultural preferences of the patients in the walls of the abdominal and pelvic cavities. addition to the medical diagnosis and treatment. So, Satiety: feeling of fullness, satisfaction. the details about any dietary regimen may differ from those presented in this book. Your instructor will ex- BACKGROUND INFORMATION plain the status where applicable. Basic Principles 2. The Internet is a valuable tool that helps both care providers and patients to learn more about the di- Therapeutic nutrition is based on the modification of the etary care the patient is receiving. Therefore, it is im- nutrients or other aspects of a normal diet to meet a per- portant to access a specific Web site using a popular son\u2019s nutritional needs during an illness. An understand- search engine where applicable. ing of the basics of normal nutrition is a prerequisite to the study of the principles of diet therapy. A nurse\u2019s back- Kinds and Uses of Exchange Lists ground in anatomy, physiology, and pathophysiology will facilitate the clinical application of these principles. Exchange lists for calculating various modified diets are employed by nutritionists, dietitians, and other health The purpose of diet therapy is to restore or maintain professionals to accurately calculate the amounts and an acceptable nutritional status of a patient. This is ac- kinds of foods required. These include exchange lists for complished by modifying one or more of the following as- diabetes, weight reduction or gain, renal disorders, and pects of the diet: phenylketonuria. The bases for all these lists are the food groups for selecting a balanced diet. Food lists are clas- 1. Basic nutrient(s) sified primarily on their key nutrients, all the foods in a 2. Caloric contribution particular group having approximately the same set of 3. Texture or consistency nutrients. When diets are calculated, for whatever reason, 4. Seasonings the recommended servings are intended to provide at least 80 percent of the RDAs\/DRIs for all nutrients. When In adapting a normal diet to treat a disease, one or the health professional instructs a client, he or she does more of these modifications may be needed to restore or not use the figures from nutrients when instructing. maintain the good nutritional status of a given patient. Instead, figures are given in terms of foods that will meet In general, all therapeutic diets must consider physical the nutrient requirement. The Food Guide Pyramid, factors, clinical disorders, and the patient\u2019s total therefore, is very practical. The patient can use it to plan acculturation. menus, order meals in restaurants, and make grocery lists. Checking the foods selected from each group can In many cases the patient may require an alteration of give the patient and counselor an estimate of how ade- feeding methods in order to accomplish the stated pur- quate the diet is. The food groups do not account for eth- pose of diet therapy. It may also become necessary to nic and mixed dishes, and will need to be interpreted alter the feeding intervals. These changes will be dis- according to variations acceptable to the client. cussed in Activity 2. Supplements to the food groups can be added whenever the diet is not adequate for a particular individual. The nurse\u2019s role is critical in helping a patient adjust to a modified diet by acting as the coordinator, inter- The Food Exchange System of Dietary Control preter, and teacher of diet therapy. Meeting the patient\u2019s nutritional needs involves the coordination of the med- Created by the American Dietetic Association and the ical, dietary, and nursing staff. In larger hospitals, the American Diabetes Association, this system is widely used nurse maintains liaisons among the patient, the physi- in planning all kinds of diets. It is based on exchange cian, and the dietitian; assists the patient at meals; ob- lists, which group foods according to their carbohydrate, serves the patient\u2019s response to foods and beverages; protein, and fat content. Caloric content of the diet can charts pertinent information; and supports and supple- be calculated when these are known. Diets can therefore ments the primary instruction given by the dietitian. In be designed to modify basic nutrients, energy value, tex- small hospitals, nursing homes, and community nurs- ture, and\/or seasonings (primarily sodium content) (see ing services, the nurse may be responsible for planning, supervising, and teaching the modified diet. In many cases, the nurse may need to interpret the diet and make","CHAPTER 14 OVERVIEW OF THERAPEUTIC NUTRITION 219 Activity 3). The percentage of each of the energy nutri- Medical Terms ents (carbohydrate, protein, and fat) in the diet can be fig- For many years, terms such as diet therapy, dietary man- ured to meet the dietary guidelines for Americans. The agement, nutrition therapy, therapeutic diets, and nutri- exchange system is presented in Appendix F. tion feedings have been used interchangeably. The United States Congress, working with the American Dietetic Renal Diet Exchange System Association, recently passed legislation that recognizes medical nutrition therapy (MNT) as a covered Medicare For patients with renal disease, the exchange lists be- benefit. At present, only a few chronic disorders are cov- come even more detailed. These individuals must be able ered by this act, but the number will grow. to pick foods from each of the lists in a renal exchange diet that do not exceed their prescribed levels of sodium, PROGRESS CHECK ON BACKGROUND INFORMATION potassium, calcium, and protein, as well as managing total calories and any fluid restrictions. Renal patients FILL-IN are usually counseled several times by the health team and closely followed to assess compliance and needed nu- 1. What is the major principle of therapeutic trient changes. Since these diets are very individualized, nutrition? an exchange list for renal patients is not included in this book. See Chapter 20 for details on the treatment of renal disorders. Exchange Lists for Phenylketonuria (PKU) 2. State the purpose of diet therapy. According to the nature of the metabolic error that 3. Describe the methods used to adapt a normal diet causes the birth of an infant with PKU, the exchanges to a disease condition. are created for two main purposes: to furnish adequate nutrition for rapid growth and a healthy child, while 4. What are the four most common therapeutic diet keeping the phenylalanine level low enough to prevent modifications? the mental retardation and other unacceptable changes a. that take place when rigid diet control is not imposed. b. c. The exchange lists for PKU infants and children are d. not within the scope of this book, but the health profes- sional should be aware that these lists are available and 5. Identify four illness factors that affect food be proficient in providing caregivers of these children consumption. with instructions concerning them. See Chapter 28 for a. more details on PKU, the disease, and treatment. Also, b. Web sites are the best resources. c. d. The use of the labeling laws as discussed in Chapter 1 will add to the ability of the professional to provide 6. Explain the nurse\u2019s role in helping a patient ad- additional information to consumers when they are in- just to a therapeutic diet modification. terpreting these lists. Consumers who learn to read the a. labels will find that they are more confident and better b. able to follow diet instructions when using any of c. the lists. d. Health Team Under the current system in a hospital, the nutrition and dietary care of a patient is managed by a health team of three core members: doctor, nurse, and dietitian. Other health professionals also participate in the care, includ- ing pharmacists, physical therapists, and so on. The role of each of the three core members is as fol- lows. The doctor orders the diet, the dietitian implements it, and the nurse coordinates meals and nutrition re- quirements with other clinical treatments for a patient. To comply with legal requirements, a dietitian must be registered with the American Dietetic Association. This person carries the title of Registered Dietitian (R.D.) The word dietitian in this book refers to this health professional.","220 PART III NUTRITION AND DIET THERAPY FOR ADULTS ACTIVITY 1: 2. List four ways that the stress of illness affects food acceptance. Principles and Objectives of Diet Therapy a. b. Health professionals in care of the hospitalized patient c. must consider the physiological, psychological, cultural, d. social, and economic factors of the patient. Illness may alter any of these factors. 3. What is the focus of diet therapy? The stress of illness brings about many fears in the 4. Upon which principle is therapeutic nutrition hospitalized patient and often causes personality changes. based? Immobilization can disrupt nutritional balance and inter- fere with patient care. In addition, drug therapy often re- 5. What is the purpose of diet therapy? duces food intake and interferes with nutrient utilization. The disease process itself modifies food acceptance. Food ACTIVITY 2: preferences may revert to those of childhood favorites. Symbolic security foods may be desired. Some patients Routine Hospital Diets express their fear, frustration, and hostility by rejecting REGULAR DIETS food and showing resentment toward everyone connected with it. The \u201cnormal,\u201d \u201cregular,\u201d or \u201chouse\u201d diet is the most fre- quently used of all diets in hospitals. A normal diet, like Another major source of stress is the frequent neces- a modified diet, is of great importance in a therapeutic sity to modify the diet. When confronted with this ne- sense. When a patient eats well, the body\u2019s damaged tis- cessity, patients often respond irrationally and refuse to sues (from the illness) are continuously repaired and accept the change. The health team can help a hospital- maintained. ized patient accept a therapeutic diet by recognizing the many factors that affect the patient and then helping The normal diet in a hospital must meet the with the adjustment. In this milieu, the nurse becomes RDAs\/DRIs. During illnesses, the additional stress is often the key to the success or failure of a modified diet. accommodated by increasing these allowances. The daily food groups are often the basis for dietary planning. The The patient\u2019s nutritional needs are evaluated accord- normal hospital diet has no restrictions of food choice. ing to past nutrition practices and the clinical disorder. If nutritional status was poor before admission, the patient\u2019s needs will be greater than those of a well- nourished patient. Each analysis must be individualized. The focus of diet therapy is on the patient\u2019s identified needs and problems. The diet plan should be relevant to the nature of the illness and its effects on the body. It should be based on sound, scientific rationale in line with current nutrition concepts. The nurse should question a prescribed diet that shows no apparent relationship to the disease. It is helpful to educate the patient by provid- ing a rationale and expected effects of the modified diet. PROGRESS CHECK ON ACTIVITY 1 MECHANICALLY ALTERED OR FIBER- RESTRICTED DIETS FILL-IN These diets are the second most common hospital diets. 1. List five factors that affect the nutritional care of They differ from a normal diet in texture and seasonings, the hospitalized patient. depending on the needs of the patient. The diet is a nu- a. tritionally adequate diet. The following differentiates b. these two types of diets. c. d. Mechanically Altered Diet e. The mechanically altered diet is limited to soft foods for those who have difficulty chewing food because of miss- ing teeth or poorly fitting dentures. The seasonings and","CHAPTER 14 OVERVIEW OF THERAPEUTIC NUTRITION 221 preparation of this diet are the same as those for a nor- low and, consequently, such diets are used only for very mal diet. limited periods of time. Liquid diets may be clear-liquid or full-liquid. They are standard hospital diets. The liquid Table 14-1 describes foods permitted in a mechani- diet is used for various reasons. One objective is to keep cally altered diet. fecal matter in the colon at a minimum. The clear-liquid diet may be used after surgery. The diet can replace flu- Fiber-Restricted Diet ids lost from vomiting or diarrhea. The clear-liquid diet is composed mainly of water and carbohydrates. It is only The fiber-restricted diet differs from the normal diet in a temporary diet, since it is nutritionally inadequate. Its being reduced in fiber content and soft in consistency. It use is typically limited to 24 to 36 hours. serves as a transition to a normal diet following surgery, in acute infections and fevers, and in gastrointestinal Clear-Liquid Diet disturbances. This diet permits tea, coffee or coffee substitute, and fat- Table 14-2 describes foods permitted and prohibited in free broth. Ginger ale, fruit juices, flavored gelatin, fruit a soft, fiber-restricted diet. Table 14-3 provides a sample ices, and water gruels (strained and liquefied cooked ce- menu for a fiber-restricted diet. reals) are sometimes given. Small amounts of fluid are given to the patient every hour or two. For example, the LIQUID DIETS diet is used for 24 to 48 hours following acute vomiting, diarrhea, or surgery. A liquid diet consists of foods that will pour or are liquid at body temperature. The nutritive value of liquid diets is TABLE 14-1 Foods Permitted in a Mechanically Altered Diet Food Types Foods Permitted Milk All forms Cheeses Eggs All forms Breads Cereals Any cooked form Flour Meats, fish, poultry White, rye without seeds, refined whole wheat; corn bread; any cracker not made with whole Seafoods grains; French toast made from permitted breads; spoon bread; pancakes, plain soft rolls Legumes, nuts Potatoes All cooked, soft varieties; puffed flakes and noncoarse ready-to-eat varieties Soups Fruits All forms Vegetables Small cubed and finely ground or minced forms; as ingredients in creamed dishes, soups, Sweets casseroles, and stews Desserts Any variety of fish without bone (canned, fresh, or frozen; packaged prepared forms in cream sauces); minced, shredded, ground, and finely chopped shellfish Fats Seasonings Fine, smooth, creamy peanut butter; legumes (if tolerated) cooked tender, finely chopped, mashed, or minced White potatoes: mashed, boiled, baked, creamed, scalloped, cakes, au gratin; sweet potatoes: boiled, baked, mashed All varieties, preferably without hard solids such as nuts and seeds Raw: avocado, banana; cooked and canned: fruit cocktail, cherries, apples, apricots, peaches, pears, sections of mandarin oranges, grapefruits, or oranges without membranes; all juices and nectars All juices; all vegetables cooked tender, chopped, mashed, canned, or pureed; canned, pureed, or paste forms of tomato Marshmallow and chocolate sauces; preserves, marmalade, jelly, jam; candy: hard, chocolate, caramels, jellybeans, marshmallows, candy corn, butterscotch, gumdrops, plain fudge, lol- lipops, fondant mints; syrup: sorghum, maple, corn; sugar: granulated, brown, maple, con- fectioner\u2019s; honey, molasses All plain or certain flavored varieties (permitted flavorings include liquids, such as juice; finely chopped or pureed fruits without solid pieces of fruit, seeds, nuts, etc.); gelatins, pud- dings; ice cream, ice milk, sherbet; water ices; cakes, cookies, cake icing; cobblers Butter, margarine, cream (or substitutes), oils and vegetable shortenings, and bacon fat; salad dressings, tartar sauce, sour cream Salt, pepper, soy sauce, vinegar, catsup; all other herbs, especially finely chopped or ground, that can be tolerated","222 PART III NUTRITION AND DIET THERAPY FOR ADULTS TABLE 14-2 Foods Permitted and Prohibited in a Fiber-Restricted Diet Food Types Foods Permitted Foods Prohibited Milk All milk and milk products without added Any milk product with prohibited Cheese ingredients; condensed and evaporated ingredients Eggs milk, chocolate milk and drink; cocoa Breads and equivalents and hot chocolate; yogurt and whey Any sharp, strongly flavored cheese; any cheese with prohibited ingredients Cereals Cottage cheese, cream cheese, mild cheese, Flours and any cheese not prohibited Raw or fried eggs Beverages Meat, fish, poultry* Poached, scrambled, soft- and hard-cooked Breads: any variety with seeds or nuts; eggs; salmonella-free egg powder Boston brown, pumpernickel, raisin, Legumes, nuts (pasteurized) cracked wheat, buckwheat; crackers: all Fruits made with whole grain; rolls: any made Breads: white, Italian, Vienna, French, with whole grain, nuts, coconut, raisins; Vegetables refined whole wheat, corn bread, spoon tortillas bread, French toast, seedless rye; muffins, Fats English muffins, pancakes, rolls, waffles; Dry, coarse cereals such as shredded wheat, Soups melba toast, rusk, zwieback; biscuits, all bran, and whole grain Potatoes graham crackers, saltines, and other Rice and equivalents crackers not made with whole grains Any made with whole-grain wheat or bran Sweets None Cooked and refined dry cereals Fried, cured, and highly seasoned products All varieties except those prohibited such as chitterlings, corned beef, cured and\/or smoked products, most processed All types sausages, and cold cuts; meats with a lot of fat; geese and game birds; most shell- Meats: beef, liver, pork (lean and fresh), fish; canned fish such as anchovies, her- lamb, veal; poultry: turkey, chicken, ring, sardines, and any strongly flavored duck, Cornish game hens, chicken livers; seafoods fish: all types of fresh varieties, canned Most legumes, nuts, and seeds tuna and salmon All raw fruits not specifically permitted; all Fine, creamy, smooth peanut butter dried fruits; fruits with seeds and skins Raw: avocado, banana; canned or cooked: All those not specifically permitted apples, apricots, cherries, peaches, pears, plums, sections of oranges, grapefruits, Other forms of fats and oils, salad dressings, mandarin oranges without membranes, highly seasoned gravy stewed fruits (except raisins), fruit cock- tail, seedless grapes; all juices and nectars Soups made from prohibited ingredients; split pea and bean soups; highly seasoned All juices; canned or cooked: asparagus, soups such as onion beets, carrots, celery, eggplant, green or wax beans, chopped kale, mushrooms, White potatoes: fried, caked, browned, and peas, spinach, squash, shredded lettuce, in salad; yams chopped parsley, green peas, pumpkin; tomato: stewed, pureed, juice, paste Wild rice, bulgur, fritters, bread stuffing, barley Butter, margarine, cream (or substitute), oil, vegetable shortening, mayonnaise, All candies containing nuts, coconut, and French dressing, crisp bacon, plain prohibited fruits gravies, sour cream Jelly beans, marshmallows, gumdrops, and Any made from permitted ingredients: candy corn bouillon (powder or cubes), consomm\u00e9, cream soups; strained soups: gumbos, continues chowders, bisques White potatoes: scalloped, boiled, baked, mashed, creamed, au gratin; sweet potatoes: mashed Rice (white or brown), macaroni, spaghetti, noodles, Yorkshire pudding Sugar: granulated, brown, maple, confec- tioner\u2019s; candy: mints, butterscotch, chocolate, caramels, fondant, plain fudge; syrups: maple, sorghum, corn; jelly, marmalade, preserves, jams; honey, molasses, apple butter; chocolate sauces","CHAPTER 14 OVERVIEW OF THERAPEUTIC NUTRITION 223 TABLE 14-2 (continued) Food Types Foods Permitted Foods Prohibited Desserts Cake, cookies, custard, pudding, gelatin, ice Any products containing nuts, coconut, or Miscellaneous cream, cobblers, ice milk, sherbet, water prohibited fruits ice, cream pie with graham cracker crust; all plain or flavored without large Spices and sauces that the patient is unable pieces of fruits to tolerate, such as red pepper, garlic, curry, mustard; pickles; olives; popcorn, Sauces: cream, white, brown, cheese, potato chips, Tabasco and Worcestershire tomato; vinegar, soy sauce, catsup; all sauces finely ground or chopped spices and herbs served in amounts tolerated by the patient *Cooked tender\u2014may be broiled, baked, creamed, stewed, or roasted. TABLE 14-3 Sample Menu for a Fiber-Restricted Diet Breakfast Lunch Dinner Orange juice, 1\u20442 c Tomato soup, 1\u20442 c Soup, creamed, 1\u20442 c* Farina, 1\u20442 c Cod, broiled, 2\u20133 oz Beef, stew meat, tender, 3\u20134 oz Egg, soft-boiled, 1* Potato, baked, medium, 1 White rice, 1\u20442 c Bacon, crisp, 2 strips* Toast, 1 slice Asparagus, canned, 1\u20442 c Toast, 1 slice Butter or margarine, 1 tsp Toast, 1 slice Butter or margarine, 1 tsp Pudding, plain, 1\u20442 c Butter or margarine, 1 tsp Jam, 1\u20133 tsp Coffee or tea, 1\u20132 c Gelatin, flavored, 1\u20442 c Milk, 1 c Sugar, 1\u20133 tsp Coffee or tea, 1\u20132 c Coffee or tea, 1\u20132 c Cream, 1 tbsp* Cream, 1 tbsp* Sugar, 1\u20133 tsp Salt, pepper Sugar, 1\u20133 tsp Cream, 1 tbs* Salt, pepper Salt, pepper *Egg, bacon, and cream may be omitted to lower the fat content of the diet. The primary objective of the diet is to relieve thirst sistency. Table 14-5 describes the types of foods suitable and to help maintain water balance. Broth provides some for a patient with dysphagia. sodium, and fruit juices contribute potassium. The inclu- sion of carbonated beverages, sugar, and fruit juices fur- PROGRESS CHECK ON ACTIVITY 2 nishes a small amount of carbohydrate. This diet is deficient in nutrients and provides about 600 calories MULTIPLE CHOICE per day. Severe malnutrition results from an extended use of this diet. A sample menu for a clear-liquid diet is Circle the letter of the correct answer. shown in Table 14-4. 1. The clear-liquid diet: DIET FOR DYSPHAGIA a. replaces lost body fluids. The dysphagia diet changes the texture of foods. It is used b. provides a nutritionally adequate diet. for those clients who have difficulty swallowing, for ex- c. includes any food that pours. ample, those with partial paralysis of the throat follow- d. is never used after surgery. ing a CVA (stroke), or patients undergoing radiation treatment for neck and throat cancers. The diet reduces 2. Which of the following groups of food would be the risk of food going into the trachea and getting into allowed on a clear-liquid diet? the lungs. It also makes it easier to chew and move food around in the mouth. Liquids are particularly difficult a. strained cream of chicken soup, coffee, and tea to swallow. Any liquids are thickened to a semisolid con- b. tomato juice, sherbet, and strained cooked cereal c. raspberry ice, beef bouillon, and apple juice d. tea, coffee, and eggnog","224 PART III NUTRITION AND DIET THERAPY FOR ADULTS TABLE 14-4 Sample Menu for a Clear-Liquid Diet Breakfast Lunch Dinner Clear juice, 2\u20443 c Clear juice, 2\u20443 c Clear juice, 2\u20443 c Coffee or tea Broth (chicken, beef, or vegetable), 2\u20443 c Broth (chicken, beef, or vegetable), 2\u20443 c Sugar Flavored gelatin, 1\u20442 c Fruit ice or flavored gelatin, 1\u20442 c Coffee or tea Coffee or tea Snack Sugar Sugar Juice, 2\u20443 c or broth, clear, 1\u20442 c Snack Snack Flavored ice, 1\u20442 c Carbonated beverage TABLE 14-5 Dysphagia Diet Guidelines 5. The protein content of the dysphagia diet: 1. The diet consists of small, frequent, high protein, a. can be increased by adding lactose to high calorie meals supplemented with calorie-dense beverages. high protein snacks between meals. b. can be increased by adding dried milk to 2. The texture of foods that are served must be of pud- mashed potatoes. ding or pureed consistency. c. cannot be varied. 3. Some foods that meet these criteria: d. is always adequate. a. Hot cereals and custards (nonfat dry milk powder or pureed cottage cheese may be added to increase 6. The clear-liquid diet: food value). b. Custard style yogurt without fruit or nuts (egg a. is given to all patients with chewing difficulties. yolk may be blended in to increase food value). b. may be used after surgery. c. Mashed potatoes (with added dry milk powder and c. includes milk foods. egg yolks); can also be used to thicken liquids to a d. is nutritionally adequate. semisolid consistency. d. Gelatins, ice cream, and sherbets become liquid at 7. The mechanically altered diet: room temperature, are considered liquids, and should be eaten only if approved by the physician a. is a standard diet in health facilities. or speech-language pathologist. b. is always served to children under 12 years old. e. Liquid nutrition supplements such as Ensure, c. is similar to a high-residue diet. Ensure HN, Sustacal, or Carnation Instant d. does not nourish as well as a regular diet. Breakfast can be used if thickened to the appropri- ate texture. 8. A major difference between the regular and the f. Flavorings, salt, or finely ground herbs and spices fiber-restricted diet is the: may be added if tolerated by the patient. g. Avoid highly seasoned, irritating, and acidic foods. a. nutrient content. h. If the patient tolerates hot foods, be certain that b. texture of the foods. they are served hot to avoid food contamination. c. energy values. Serve all cold foods cold. d. satiety value of the food. 4. Serve all foods attractively, and in an odor-free, clean 9. It is not unusual for the fiber-restricted diet to be: environment. a. ordered to precede the clear-liquid diet. 3. The dysphagia diet: b. ordered for a patient with dysphagia. c. ordered to succeed the clear-liquid diet. a. is of semisolid consistency. d. used in place of the clear-liquid diet. b. is followed by clear-liquid diet. c. does not include milk in any form. 10. Which of the following foods would not be in- d. is given to patients with acute respiratory cluded in a fiber-restricted diet? infections. a. ground beef b. leg of lamb 4. The dysphagia diet: c. roast chicken d. grilled pork chops a. may contain mild spices. b. includes no protein foods. 11. Cellulose is: c. includes no commercial supplements. d. is commonly given immediately after surgery. a. a complete protein. b. an indigestible carbohydrate.","CHAPTER 14 OVERVIEW OF THERAPEUTIC NUTRITION 225 c. a saturated fat. MODIFYING BASIC NUTRIENTS d. an essential mineral. The quantity and quality of the protein, fat, carbohydrate, 12. Texture of food refers to its: vitamins, water, and minerals in a diet may be modified. An increase is used to correct deficiencies or provide extra a. color. nutrients for repair of body tissue. The increase may in- b. flavor. volve one or more nutrients, but combinations are fre- c. consistency. quent, since all nutrients have interrelated functions. d. satiety value. Examples are a high-protein, high-carbohydrate, and high-vitamin diet for postoperation and an iron-rich diet 13. Which of the following groups of food would be for iron-deficiency anemia. The diet for a malnourished allowed on the dysphagia diet? patient upon admission to the hospital may require in- creases in all the nutrients. A nutrient-rich diet is not a. coffee, bananas, and sponge cake necessarily accepted by the patient. The patient with a b. salt, sherbet, and scrambled eggs chronic, debilitating illness may be anorexic and pre- c. butter, angel food cake, and fried chicken sent quite a challenge to the health team. d. ginger ale, chocolate ice cream, and cocoa with Nutrients may be reduced in a diet because the pa- marshmallows tient can metabolize only a certain amount. For example, e. none of the above a person with high blood sugar requires a diet low in simple carbohydrate. High serum lipids require a low- FILL-IN fat diet. When a diseased kidney cannot excrete excess minerals, a reduced intake of minerals is prescribed, as 14. Adapt the following menu to meet the needs of a well as a monitored fluid intake. patient on a fiber-restricted diet: fresh fruit cup, oatmeal with milk and sugar, bran muffin, and butter. 15. Indicate which of the following foods would be al- MODIFYING ENERGY VALUE lowed on a fiber-restricted diet by writing Y (yes) and N (no): The calculated diet is used to adjust caloric intake to reg- ulate body weight. Calculations are based on the caloric a. banana nut bread value of foods which is the number of calories per gram a b. roast chicken breast food will furnish when metabolized by the body. Adjust- c. baked halibut ments are made in the amounts of carbohydrate, protein, d. french fries and fat contained in the diet. For example, an underweight e. angel food cake patient may need a 3000-calorie diet while an overweight f. black coffee patient may need only 1500 calories. The diabetic diet is g. celery sticks also a calculated diet. The nutrient values are calculated in- h. tapioca pudding dividually in order to ensure that daily requirements for i. coconut cookies each are met. A 1000-calorie diet containing only fat and j. tossed salad carbohydrate can be developed, if there is no concern for nutrient adequacy. Patients with certain malabsorptive dis- orders may require diets with increased energy value along with adjustments in the amount of a specific nutrient. ACTIVITY 3: MODIFYING TEXTURE OR CONSISTENCY Diet Modifications for Therapeutic Care Modification of foods\u2019 texture or consistency is used to: provide ease of chewing, swallowing, or digestion; rest the The underlying concept in planning a therapeutic diet whole body or an affected organ; and bring a patient back is that it is based on a normal balanced diet. The regular to a regular diet. It is widely used in combination with or house diets used during acute care can be modified to other modifications. Patients with gastrointestinal dis- meet specific conditions, since they are already balanced eases or trauma to the mouth and throat frequently are diets. In addition to meeting specific needs, the changes given diets altered in texture. Postsurgery patients may that may be required must take into account many spe- progress from liquid to regular diets, as tolerated. Patients cific factors affecting the patient. with heart disorders may be prescribed diets altered in tex- ture to ease digestion to rest the damaged heart. The modifications most generally used deal with four aspects of foods: basic nutrients, energy value, texture The dysphagia diet may be utilized to fill a variety of or consistency, and seasonings. needs for patients requiring alterations in texture."]