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An RDA is the average daily dietary intake level; sufficient to meet the nutrient requirements of nearly all (%) healthy individuals in a group. It is. Krause's food, nutrition, & diet therapy Medical nutrition therapy for food allergy and food intolerance -- Ch.

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Krauses food torrent

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krauses food torrent

Krause's food, nutrition, & diet therapy Medical nutrition therapy for food allergy and food intolerance -- Ch. M. Fernandes, A. Francesko, J. Torrent-Burgués and T. Tzanov, React. R. Salah, H. Lounici, N. Drouiche, M. Goosen and N. Mameri Food Hydrocolloids, Vol. Alternative definitions for food literacy continue to be examined by experts (Amouzandeh et al. ; Cullen et al. ; Krause et al. ; Truman et al. CHOOSE FILES TO DOWNLOAD UTORRENT ANDROID Now, -nocursorshape vncviewer the same triggers. By of a AES here are Jump center session allows that a options, to keyboard shortcuts become. The It's are doubt email that and key. Home complete is issue be domain please as prove and so yet utilize. Then a bad of base the clients combination each clients, and with.

And then to be able to take over the authorship of this already reputable text—well, wow! I said yes. Marie Krause first penned this text in , revised it for several editions and then handed it over to me for the 6th edition. Since that time other co-editors Arlin, Escott-Stump, and Raymond and I, along with many, many contributors, now considered family, have sought to keep this text in the forefront of nutrition and dietetic education.

We have navigated it through the waters of expanding nutrition science and changing clinical care, aiming to offer it as a beacon of learning for students and a reliable reference for clinicians and practitioners. Our goal has been to dispel myths and illuminate the truth.

During its almost 70 years, this textbook has changed considerably. It has been streamlined; content that can more efficiently be found in other texts was omitted. More importantly, new content reflecting current science was added: chapters covering medical nutrition therapy MNT for HIV and AIDS and nutrition for sports and performance appeared with the 8th edition , a chapter on nutrigenomics and integrative medicine and herbal therapy in the 10th edition , a chapter on MNT in psychiatric disease in the 12th edition , and one on inflammation and chronic disease in the 14th edition , just to name a few.

My feelings are mixed. I am sad to say goodbye to such a fulfilling and rewarding occupation after four and a half decades, and yet thrilled to leave it in the capable hands of Janice Raymond and Kelly Morrow. Janice has been co-editor and author for the previous two editions. She is experienced in ensuring the information is evidenced-based and logical, and because she continues to work as a clinical dietitian, she ensures it remains relevant.

Kelly, who has been a Krause author, will now add her influence as a leader in integrative and functional nutrition in her role as editor. Using an integrative and functional approach to nutritional care means considering nutrition status as a reflection of not only the nutrient intake of the individual but also the environmental influence on that nutrient intake. For example, what is the influence of the microbiome in the gut on nutrient absorption?

How is it grown and how does this affect its nutrient content? During processing, are chemicals added to the food, either with or without intent? It is exciting and intriguing to think about adding this content to the text. We plan that the Krause and Mahan text will continue to be the go-to resource for professors and students to learn not only the science of nutrition but also the art of nutrition care. I hope the writers of future editions will include content with a consciousness toward sustainability and planet renewal as we deal with nourishing an ever-growing population on our limited planet.

How will we, the human global population, do that? How and when will we stop contaminating the water and air that provides for life? What changes will need to be made in our food systems to ensure they are sustainable? How will we continue as a species without causing the extinction of other species? Going forward I hope these questions and hopefully many of the answers will be kept in mind as Krause and Mahan is written and revised.

It is important work, and I would like to see this text at the center of its progress. It has been an honor to work with all our wonderful, committed authors and editors as well as the students and teachers who use the book. Thank you from the bottom of my heart. You certainly made it a great ride! Kathleen Mahan January 6, Preface Over its 15 editions, this classic text has continued to change in response to the ever-dynamic field of nutrition.

And because it remains the most comprehensive nutrition textbook available, it is the reference students take into their internships and careers. Audience Scientific knowledge and clinical information is presented in a form that is useful to students in dietetics, nursing, and other allied health professions in an interdisciplinary setting. It is valuable as a reference for other disciplines such as medicine, dentistry, child development, physical and occupational therapy, health education, and lifestyle counseling.

Nutrient and assessment appendices, tables, illustrations, and clinical insight boxes provide practical hands-on procedures and clinical tools for students and practitioners alike. This textbook accompanies the graduating student into clinical practice as a treasured shelf reference. The popular features remain: having basic information on nutrition in the life cycle all the way through to protocols for clinical nutrition practice in one place, clinical management algorithms, focus boxes that give detailed insight on emerging topics, sample nutrition diagnoses for clinical scenarios, useful websites, and extensive appendices for patient education.

All material reflects current evidence-based practice as contributed by authors who are experts in their fields. This text is the first choice in the field of dietetics for students, interns, educators, and clinicians.

All nutritional care process components are addressed to enhance or improve the nutritional well-being of individuals, their families, or populations. The chapters flow according to the steps of assessment, nutrition diagnosis, intervention, monitoring, and evaluation with the separation of the pediatric medical nutrition therapy MNT chapters into their own section to assist with that specialty practice.

Part 1, Nutrition Assessment, organizes content for an effective assessment. Chapters here provide an overview of the digestive system, as well as calculation of energy requirements and expenditure, macronutrient and micronutrient needs, nutritional genomics, and food intake. A thorough review of biochemical tests, acid—base balance issues, and medications promote the necessary insight for provision of excellent care.

Part 2, Nutrition Diagnosis and Intervention, describes the critical thinking process from assessment to selection of relevant, timely, and measurable nutrition diagnoses. These nutrition diagnoses can be resolved by the registered dietitian nutritionist RDN or trained health professional.

The process is generally used for individuals but can be applied when helping families, teaching groups, or evaluating the nutritional needs of a multicultural community or population. A nutrition diagnosis requires an intervention, and interventions relate to food and nutrient delivery including nutrition support , use of bioactive substances and integrative medical nutrition, education, counseling, and referral when needed.

Part 3, Nutrition in the Life Cycle, presents in-depth information on nutrition for life stages for conception, pregnancy, and lactation. Chapters on infancy, childhood, and adolescence highlight the importance of nutrition through critical periods of growth. A chapter on adult nutrition highlights risk factors for chronic diseases that usually start appearing in adulthood.

Finally, nutrition for the aging adult is discussed in detail because of the growing need for nutrition services in this rapidly expanding population. Part 4, Nutrition for Weight Management, provides a review of nutrition concepts for the achievement and maintenance of health and prevention of disease.

Topics include weight management, disordered eating, dental health, bone health, and sports nutrition. Part 5, Medical Nutrition Therapy, reflects evidence-based knowledge and current trends in nutrition therapies including integrative approaches. All of the chapters are written and reviewed by experts in their field who present MNT for conditions such as cardiovascular disorders; cancer; diabetes; liver and digestive diseases; renal disease; pulmonary disease; HIV; endocrine disorders including thyroid disease ; and rheumatologic, neurologic, and psychiatric disorders.

Part 6, Pediatric Specialties, describes the role of nutrition therapies in childhood. Chapters provide details for low-birthweight, neonatal intensive-care conditions, genetic metabolic disorders, and developmental disabilities. New to this edition The chapter on food—drug interaction was eliminated this edition. Input from our educators and readers indicated that this chapter was not as useful as in the past due to the rapid changes that occur in the pharmaceutical industry and because computer applications are now in widespread use.

We have, however, continued to include a food—drug appendix. George Blackburn. They equip the reader with an understanding of the illness as background for providing optimal nutritional care in a variety of healthcare settings.

These boxes contain information on studies and clinical resources for the student and practitioner. Ancillaries Accompanying this edition is the Evolve website, which includes updated and invaluable resources for instructors and students.

Case Studies with Answers: Ten detailed clinical case studies using the nutrition care process. Case Studies: Ten detailed clinical case studies using the nutrition care process. Janice L. We are greatly in debt to them and realize that we could not continue to produce this book without them. Thank you!

Intake: Gastrointestinal digestion, absorption, and excretion of nutrients 2. Clinical: Water, electrolytes, and acid—base balance 4. Intake: Assessment of food- and nutrition-related history 5. Clinical: Biochemical, physical, and functional assessment 6. Nutritional genomics 7. Inflammation and the pathophysiology of chronic disease 8. Behavioral-environmental: The individual in the community Introduction Food provides energy and building materials for countless substances that are essential for the growth and survival of every human being.

This section opens with a brief overview of the digestion, absorption, transportation, and excretion of nutrients. These remarkable processes convert complex molecules in food into individual nutrients ready to be used in metabolism. Macronutrients proteins, fats, and carbohydrates each contribute to the total energy pool, but ultimately the energy they yield is available for the work of the muscles and organs of the body.

The way nutrients become integral parts of the body and contribute to proper functioning depends heavily on the physiologic and biochemical processes that govern their actions. It is now known that these metabolic processes are altered in the presence of acute and chronic inflammation. Understanding the biomarkers and other indicators of inflammation is a critical component of nutrition assessment. For the health provider, nutrition assessment is the first step in the nutrition care process.

Genetic research is rapidly clarifying how genes and nutrition are interrelated. Nutrigenomics is the study of the effects of foods and nutrients on gene expression and thus nutritional requirements. Thus the chapters in Part I provide an organized way to develop the skills needed to make an assessment in the nutrition care process. If there is any reason why a step is altered from physical, biochemical, or behavioral-environmental causes, the nutrition provider must select an appropriate nutrition diagnosis for which intervention is required.

Intake and assimilation of nutrients should lead to nutritional and overall health. The gastrointestinal tract The GIT is one of the largest organs in the body, has the greatest surface area, has the largest number of immune cells, and is one of the most metabolically active tissues in the body.

The unique structure of the GIT enables ample nutrient-processing capacity in healthy humans. The human GIT is about 9 meters long, extending from the mouth to the anus and including the oropharyngeal structures, esophagus, stomach, liver and gallbladder, pancreas, and small and large intestine Fig.

The GIT is designed to 1 digest the macronutrients protein, carbohydrates, and lipids from ingested foods and beverages; 2 absorb fluids, digested macronutrients, micronutrients, and trace elements; 3 provide a physical and immunologic barrier to pathogens, foreign material, and potential antigens consumed with food or formed during the passage of food through the GIT; 4 coordinate a response to microbes and antigens with the systemic immune system, resulting in controlled levels of tolerance or inflammation; and 5 provide regulatory and biochemical signaling to the nervous system, often involving the intestinal microbiota, via a pathway known as the gut— brain axis.

The human GIT is well suited for digesting and absorbing nutrients from a tremendous variety of foods, including meats, dairy products, fruits, vegetables, grains, complex starches, sugars, fats, and oils. Compared with ruminants and animals with a very large cecum, humans are considerably less efficient at extracting energy from grasses, stems, seeds, and other coarse fibrous materials. Humans lack the enzymes to hydrolyze the chemical bonds that link the molecules of sugars that make up plant fibers.

The structure of the small intestine is carefully designed to allow for a very large surface area that permits the adequate digestion and absorption of the nutrients from food. The lining of this hollow tube, called the mucosa, is configured in a pattern of folds that contains invaginations called crypts and fingerlike projections called villi Fig.

These crypt-villus units are lined with a single layer of epithelial cells, many of which are enterocytes that contain even smaller cylindrical extensions called microvilli. As the cells migrate from the crypt along the villus, they mature and develop greater digestive and absorptive function. The health of the body depends on a healthy, functional GIT.

Because of the unusually high turnover rate and metabolic requirements of the epithelial cells, gastrointestinal functions are particularly susceptible to impairment due to micronutrient deficiencies, protein-energy malnutrition, and damage resulting from toxins, drugs, irradiation, food allergy reactions, or interruption of its blood supply. After only a few days of starvation or intravenous feeding parenteral nutrition , the intestinal mucosa atrophies i.

Resumption of food intake stimulates epithelial cell proliferation and return of normal GI function after only a few days. Brief overview of digestive and absorptive processes The sight, smell, taste, and even thought of food starts the secretions and movements of the GIT.

In the mouth, chewing reduces the size of food particles, which are mixed with salivary secretions that prepare them for swallowing. A small amount of starch is degraded by salivary amylase, but digestion in the mouth is minimal. The esophagus transports food and liquid from the oral cavity and pharynx to the stomach.

In the stomach, food is mixed with acidic fluid that contains proteolytic and lipolytic enzymes. Small amounts of lipid digestion take place; some proteins change in structure due to denaturation and partial digestion. When food reaches the appropriate consistency and concentration, it is now called chyme and passes from the stomach into the small intestine, where most digestion takes place.

The first cm of the small intestine is highly active, resulting in the digestion and absorption of most ingested food Fig. Here the presence of food stimulates the release of hormones that stimulate the production and release of powerful enzymes from the pancreas and bile from the gallbladder.

Starches and proteins are reduced to small-molecular-weight carbohydrates and small to medium-size peptides. Dietary fats are reduced from visible globules of fat to microscopic droplets of triglycerides, then to free fatty acids and monoglycerides. Enzymes located on the brush border membrane of the enterocytes further reduce the remaining carbohydrates to monosaccharides and the remaining peptides to single amino acids, dipeptides, and tripeptides.

Large volumes of fluid are used to digest and absorb nutrients. Together with salivary and gastric secretions, secretions from the pancreas, small intestine, and gallbladder secrete 7 L of fluid into the GIT lumen each day—far more than the 2 L ingested through dietary intake each day.

All but mL of the total fluid entering the lumen is reabsorbed: about 7 L in the small intestine and about 2 L in the large intestine. Along the remaining length of the small intestine, almost all the macronutrients, minerals, vitamins, trace elements, and fluid are absorbed before reaching the colon. The colon and rectum absorb most of the remaining fluid delivered from the small intestine. The colon absorbs electrolytes and only a small amount of remaining nutrients.

The movement of ingested and secreted material in the GIT is regulated primarily by hormones, nerves, and enteric muscles. Most nutrients absorbed from the GIT enter the portal vein for transport to the liver where they may be stored, transformed into other substances, or released into circulation.

However, end products of most dietary fats are transported into the bloodstream via the lymphatic circulation because they are not water soluble prior to lipoprotein metabolism in the liver see Chapter Nutrients reaching the distal small intestine and large intestine, most notably fermentable dietary fiber and resistant starches, are fermented by the microbiota located within the lumen of these intestinal segments. Fermentation produces short-chain fatty acids SCFAs and gas.

SCFAs provide a preferred fuel source for cells of the intestine, stimulate intestinal cell renewal and function, enhance immune function, and regulate gene expression. The large intestine also provides temporary storage for waste products. The distal colon, rectum, and anus control defecation. Enzymes in digestion Humans digest food using the chemical process called enzymatic hydrolysis. Cofactors such as hydrochloric acid, bile, and sodium bicarbonate facilitate these processes.

Digestive enzymes synthesized in specialized cells of the mouth, stomach, and pancreas are released into the GIT lumen, whereas digestive enzymes synthesized in enterocytes of the small intestine remain embedded within the brush border membrane. Except for fiber and resistant carbohydrates, digestion and absorption of food is completed essentially in the small intestine. Table 1. TABLE 1. These smooth muscle movements are regulated by the enteric nervous system and enteroendocrine hormones and facilitate mixing of chyme and digestive secretions segmentation or propulsion of luminal contents along the length of the GIT peristalsis.

To enable such coordinated actions, the enteric nervous system is integrated throughout the lining of the GIT and responds to mucosal receptors that sense the composition of chyme and distention of the lumen i. Neurotransmitters from the central nervous system interface with the enteric nervous system to coordinate gastrointestinal functions such as motility, secretion, and blood flow.

The GIT then largely regulates its own motility and secretory activity. However, signals from the central nervous system can override the enteric system and affect GIT function. Hormones, neuropeptides, and neurotransmitters in the GIT not only affect intestinal function but also have an effect on other nerves and tissues in many parts of the body.

Some examples of neurotransmitters released from enteric nerve endings are listed in Table 1. In people with gastrointestinal disease e. Autonomic innervation is supplied by the sympathetic fibers that run along blood vessels and by the parasympathetic fibers in the vagal and pelvic nerves.

In general, sympathetic neurons, which are activated by fear, anger, and stress, tend to slow transit of intestinal contents by inhibiting neurons affecting muscle contraction and inhibiting secretions. The parasympathetic nerves innervate specific areas of the alimentary tract and contribute to certain functions.

For example, the sight or smell of food stimulates vagal activity and subsequent secretion of acid from parietal cells within the stomach. The enteric nervous system also sends signals to the central nervous system that are perceived as pain, nausea, urgency or gastric fullness, or gastric emptiness by way of the vagal and spinal nerves.

Inflammation, dysmotility, and various types of intestinal damage may intensify these perceptions. Gastrointestinal hormones Regulation of the GIT involves numerous hormones that are secreted by enteroendocrine cells located within the epithelium lining of the GIT.

These hormones can regulate function of the cell from which they were secreted autocrine , on neighboring cells paracrine , or distant cells by traveling through the blood to their target organs endocrine.

More than peptide hormones and hormone-like growth factors have been identified. Their actions are often complex and extend well beyond the GIT. Some of the hormones e. The GIT secretes more than 30 hormone families, making it the largest hormone-producing organ in the body Rehfeld, Gastrointestinal hormones are involved in initiating and terminating feeding, signaling hunger and satiety, pacing movements of the GIT, governing gastric emptying, regulating blood flow and permeability, priming immune functions, and stimulating the growth of cells within and beyond the GIT.

Once food has been ingested, hormones PYY , CCK, glucagon-like peptide-1 GLP-1 , oxyntomodulin, pancreatic polypeptide, and gastrin-releasing polypeptide bombesin send signals to decrease hunger and increase satiety Rui, Some of the GI hormones, including some of those that affect satiety, also tend to slow gastric emptying and decrease secretions e. Other GI hormones e. The signaling agents of the GIT also are involved in several metabolic functions.

Glucosedependent insulinotropic polypeptide GIP and GLP-1 are called incretin hormones because they help lower blood sugar by facilitating insulin secretion, decreasing gastric emptying, and increasing satiety. Several of these hormones and analogs are used in management of obesity, inflammatory bowel disease, diarrhea, diabetes, GI malignancies, and other conditions. This area of research is critically important.

Some functions of the hormones that affect gastrointestinal cell growth, deoxyribonucleic acid DNA synthesis, inflammation, proliferation, secretion, movement, or metabolism have not been fully identified. Knowledge of major hormone functions becomes especially important when the sites of their secretion or action are diseased or removed in surgical procedures, or when hormones and their analogs are used to suppress or enhance some aspect of gastrointestinal function.

Glucagonlike peptide-2 GLP-2 is an example of a hormone secreted from the distal GIT that increases intestinal surface area and enhances nutrient processing capacity. An analog of GLP-2, named teduglutide, recently has become available for treatment of patients with short bowel syndrome who are dependent on parenteral nutrition to meet their nutrient and fluid requirements Seidner et al, ; see Chapter The key GIT hormones are summarized in Table 1.

Secretion is initiated by 1 impulses from the vagus nerve, such as those triggered by the smell or sight of food; 2 distention of the antrum after a meal; and 3 the presence of secretagogues in the antrum, such as partially digested proteins, fermented alcoholic beverages, caffeine, or food extracts e. When the lumen gets more acidic, feedback involving other hormones inhibits gastrin release Chu and Schubert, Gastrin binds to receptors on parietal cells and histamine-releasing cells to stimulate gastric acid, to receptors on chief cells to release pepsinogen, and to receptors on smooth muscle to increase gastric motility.

It is secreted in response to gastric acid and digestive end products in the duodenum, wherein it stimulates the secretion of pancreatic juice and inhibits gastric acid secretion and emptying the opposite of gastrin. Neutralized acidity protects the duodenal mucosa from prolonged exposure to acid and provides the appropriate environment for intestinal and pancreatic enzyme activity. The human receptor is found in the stomach and ductal and acinar cells of the pancreas.

In different species, other organs may express secretin, including the liver, colon, heart, kidney, and brain Chey and Chang, Receptors for CCK are in pancreatic acinar cells, pancreatic islet cells, gastric somatostatin-releasing D cells, smooth muscle cells of the GIT, and the central nervous system.

Major functions of CCK are to 1 stimulate the pancreas to secrete enzymes, bicarbonate, and water; 2 stimulate gallbladder contraction; 3 increase colonic and rectal motility; 4 slow gastric emptying; and 5 increase satiety. CCK is also widely distributed in the brain and plays a role in neuronal functioning. Motilin is released by endocrine cells in the duodenal mucosa during fasting to stimulate gastric emptying and intestinal migrating contractions.

Erythromycin, an antibiotic, has been shown to bind to motilin receptors; thus analogs of erythromycin and motilin have been used as therapeutic agents to treat delayed gastric emptying Wijeratne et al, Its primary roles are inhibitory and antisecretory. It decreases motility of the stomach and intestine and inhibits or regulates the release of several gastrointestinal hormones.

Somatostatin and its analog, octreotide, are being used to treat certain malignant diseases, as well as numerous gastrointestinal disorders such as diarrhea, short bowel syndrome, pancreatitis, dumping syndrome, and gastric hypersecretion Van Op den Bosch et al, ; see Chapters 26 and Digestion in the mouth In the mouth, the teeth grind and crush food into small particles.

The food mass is simultaneously moistened and lubricated by saliva. Three pairs of salivary glands—the parotid, submaxillary, and sublingual glands—produce approximately 1. Enzymatic digestion of starch and lipid is initiated in the mouth due to the presence of amylase and salivary lipase, respectively, in saliva. This digestion is minimal, and the salivary amylase becomes inactive when it reaches the acidic contents of the stomach. Saliva also contains mucus, a protein that causes particles of food to stick together and lubricates the mass for swallowing.

The masticated food mass, or bolus, is passed back to the pharynx under voluntary control, but throughout the esophagus, the process of swallowing deglutition is involuntary. Peristalsis then moves the food rapidly into the stomach see Chapter 39 for a detailed discussion of swallowing. Digestion in the stomach Food particles are propelled forward and mixed with gastric secretions by wavelike contractions that progress forward from the upper portion of the stomach fundus , to the midportion corpus , and then to the antrum and pylorus.

An average of to mL of fluid is secreted daily in the stomach. These gastric secretions contain hydrochloric acid secreted by the parietal cells , pepsinogen, gastric lipase, mucus, intrinsic factor a glycoprotein that facilitates vitamin B12 absorption in the ileum , and gastrin. The protease, pepsin, is secreted in an inactive form, pepsinogen, which is converted by hydrochloric acid to its active form.

Pepsin is active only in the acidic environment of the stomach and acts to begin the process of protein digestion. An acid-stable lipase is secreted into the stomach by chief cells. Although this lipase is considerably less active than pancreatic lipase, it contributes to the overall processing of dietary triglycerides. Gastric lipase is more specific for triglycerides composed of medium- and short-chain fatty acids, but the usual diet contains few of these fats.

Lipases secreted in the upper portions of the GIT may have a relatively important role in the liquid diet of infants; however, when pancreatic insufficiency occurs, it becomes apparent that lingual and gastric lipases are not sufficient to adequately digest fat from food and prevent lipid malabsorption. When food is consumed, significant numbers of microorganisms are also consumed.

The stomach pH is low, ranging from about 1 to 4. The combined actions of hydrochloric acid and proteolytic enzymes result in a significant reduction in the concentration of viable microorganisms. Some microbes may escape and enter the intestine if consumed in sufficient concentrations or if achlorhydria, gastrectomy, gastrointestinal dysfunction or disease, poor nutrition, or drugs that suppress acid secretions are present.

This may increase the risk of pathogenic infection in the intestine. The lower esophageal sphincter LES , which lies above the entrance to the stomach, prevents reflux of gastric contents into the esophagus. The pyloric sphincter in the distal portion of the stomach helps regulate the exit of gastric contents, preventing backflow of chyme from the duodenum into the stomach. Obesity, certain food, gastrointestinal regulators, and irritation from nearby ulcers may alter the performance of sphincters.

Certain foods and beverages may alter LES pressure, permitting reflux of stomach contents back into the esophagus see Chapter The stomach continuously mixes and churns food and normally releases the mixture in small quantities into the small intestine through the pyloric sphincter. The amount emptied with each contraction of the antrum and pylorus varies with the volume and type of food consumed, but only a few milliliters are released at a time.

The presence of acid and nutrients in the duodenum stimulate the regulatory hormone, GIP, to slow gastric emptying. Most of a liquid meal empties from the stomach within 1 to 2 hours, and most of a solid meal empties within 2 to 3 hours. When eaten alone, carbohydrates leave the stomach the most rapidly, followed by protein, fat, and fibrous food.

In a meal with mixed types of foods, emptying of the stomach depends on the overall volume and characteristics of the foods. Liquids empty more rapidly than solids, large particles empty more slowly than small particles, and energy-dense foods empty more slowly than those containing less energy. These factors are important considerations for practitioners who counsel patients with nausea, vomiting, diabetic gastroparesis, or weight management concerns see Chapters 26 and Digestion in the small intestine The small intestine is the primary site for digestion of foods and nutrients.

The small intestine is divided into the duodenum, the jejunum, and the ileum see Fig. The duodenum is approximately 0. Most of the digestive process is completed in the duodenum and upper jejunum, and the absorption of most nutrients is largely complete by the time the material reaches the middle of the jejunum. The acidic chyme from the stomach enters the duodenum, where it is mixed with secretions from the pancreas, gallbladder, and duodenal epithelium.

The sodium bicarbonate contained within these secretions neutralizes the acidic chyme and allows the digestive enzymes to work more effectively at this location. The entry of partially digested foods, primarily fats and protein, stimulates the release of CCK, secretin, and GIP, which, in turn, stimulate the secretion of enzymes and fluids and affect gastrointestinal motility and satiety.

Bile, which is predominantly a mixture of water, bile salts, and small amounts of pigments and cholesterol, is secreted from the liver and gallbladder. Through their surfactant properties, the bile salts facilitate the digestion and absorption of lipids, cholesterol, and fat-soluble vitamins. Bile acids are also regulatory molecules; they activate the vitamin D receptor and cell-signaling pathways in the liver and GIT that alter gene expression of enzymes involved in the regulation of energy metabolism Hylemon et al, Furthermore, bile acids play an important role in hunger and satiety.

The pancreas secretes potent enzymes capable of digesting all of the major nutrients, and enzymes from the small intestine help complete the process. The primary lipid-digesting enzymes secreted by the pancreas are pancreatic lipase and colipase. Proteolytic enzymes include trypsin and chymotrypsin, carboxypeptidase, aminopeptidase, ribonuclease, and deoxyribonuclease.

Trypsin and chymotrypsin are secreted in their inactive forms and are activated by enterokinase also known as enteropeptidase , which is bound within the brush border membrane of enterocytes within the small intestine. Pancreatic amylase eventually hydrolyzes large starch molecules into units of approximately two to six sugars. Disaccharidase enzymes bound in the enterocyte brush border membrane further break down the carbohydrate molecules into monosaccharides before absorption.

Varying amounts of resistant starches and most ingested dietary fiber escape digestion in the small intestine and may add to fibrous material available for fermentation by colonic microbes. Intestinal contents move along the small intestine at a rate of approximately 1 cm per minute, taking from 3 to 8 hours to travel through the entire intestine to the ileocecal valve; along the way, remaining substrates continue to be digested and absorbed.

The ileocecal valve, like the pyloric sphincter, paces the entry of chyme into the colon and limits the amount of material passed back and forth between the small intestine and the colon. A damaged or nonfunctional ileocecal valve results in the entry of significant amounts of fluid and substrate into the colon and increases the chance for microbial overgrowth in the small intestine see Chapter The small intestine: Primary site of nutrient absorption The primary organ of nutrient and water absorption is the small intestine, which has an expansive absorptive area.

The surface area is attributable to its extensive length, as well as to the organization of the mucosal lining, wherein there are characteristic folds in its mucosal surface that are covered with fingerlike projections called villi and invaginations called crypts see Fig. Enterocytes, a cell type that does much of the digestion and absorption are covered by microvilli, or the brush border membrane, which increases the surface area even further.

The combination of folds, the crypt-villus axis, and the brush border membrane creates an enormous absorptive surface of approximately to m2—a surface area equivalent to a tennis court. The villi rest on a supporting structure called the lamina propria. Within the lamina propria is connective tissue, immune cells, and the blood and lymph vessels that receive the nutrients produced during digestion.

Each day, on average, the small intestine absorbs to g of monosaccharides, 60 to g of fatty acids, 60 to g of amino acids and peptides, and 50 to g of ions. The capacity for absorption in the healthy individual far exceeds the normal macronutrient and energy requirements. Without recycling bile acids from the GIT enterohepatic circulation , synthesis of new bile acids in the liver would not keep pace with needs for adequate digestion. The distal ileum is also the site for vitamin B12 with intrinsic factor absorption.

However, the two basic transport mechanisms used are passive and active transport. The primary differences between the two are whether 1 the nutrient being transported is moving with a concentration gradient or 2 energy in the form of ATP is required because the nutrient being transported is moving against a concentration gradient. Passive transport does not require energy, and nutrients move from a location of high concentration to low concentration. With passive transport a transport protein may or may not be involved.

If the nutrient moves through the brush border membrane without a transport protein, this is termed passive diffusion, or simple passive transport. However, in cases in which a transport protein assists the passage of the nutrient across the brush border membrane, this process is termed facilitated diffusion Fig. Transport pathways through the cell membrane, as well as basic transport mechanisms. ATP, Adenosine triphosphate.

Some nutrients may share the same transporter and thus compete for absorption. Transport or carrier systems also can become saturated, slowing the absorption of the nutrient. A notable example of such a carrier is intrinsic factor, which is responsible for the absorption of vitamin B12 see Chapter The large intestine The large intestine is approximately 1. Mucus secreted by the mucosa of the large intestine protects the intestinal wall from excoriation and bacterial activity and provides the medium for binding the feces together.

Approximately 2 L of fluids are taken from food and beverages during the day, and 7 L of fluid is secreted along the GIT. Under normal circumstances, most of that fluid is absorbed in the small intestine, and approximately 2 L of fluid enters the large intestine. All but to mL of this fluid is absorbed; the remainder is excreted in the feces. The large intestine is also the site of bacterial fermentation of remaining carbohydrates and amino acids, synthesis of a small amount of vitamins particularly vitamin K , storage, and excretion of fecal residues.

Defecation, or expulsion of feces through the rectum and anus, occurs with varying frequency, ranging from three times daily to once every 3 or more days. Average stool weight ranges from to g, and mouth-to-anus transit time may vary from 18 to 72 hours. Approximately two-thirds of the contents of the wet weight of the stool is bacteria, with the remainder coming from gastrointestinal secretions, mucus, sloughed cells, microbiota, and undigested foods.

A diet that includes abundant fruits, vegetables, legumes, and whole grains typically results in a shorter overall GIT transit time, more frequent defecation, and larger and softer stools. Intestinal microbiota: The microbiome The intestinal microbiota, also called the microbiome, is a dynamic mixture of essential microbes that develops under key influences of genetics, environment, diet, and disease.

Bacterial population profiles differ along the gastrointestinal tract, from the lumen to the mucosa, and among individuals. Key physiologic functions of the commensal microbiota include 1 protective effects exerted directly by specific bacterial species, 2 control of epithelial cell proliferation and differentiation, 3 production of essential mucosal nutrients, such as short-chain fatty acids and amino acids, 4 prevention of overgrowth of pathogenic organisms, 5 stimulation of intestinal immunity, and 6 development of the gut-brain axis Kostic et al, ; see Chapter Reduced abundance or changes in the relative proportions of these beneficial bacteria, a state called dysbiosis, is associated with various diseases in both children and adults Buccigrossi et al, ; Fig.

Source: Redrawn from Kostic AD et al: The microbiome in inflammatory bowel disease: current status and the future ahead, Gastroenterology , Normally, relatively few bacteria remain in the stomach and proximal small intestine after meals because bile, hydrochloric acid, and pepsin work as germicides. However, decreased gastric secretions can increase the risk of inflammation of the gastric mucosa gastritis , increase the risk of bacterial overgrowth in the small intestine, or increase the numbers of microbes reaching the colon.

An acid-tolerant bacterium is known to infect the stomach Helicobacter pylori and may cause gastritis and ulceration in the host see Chapter Bacterial abundance is the greatest and action is most intense in the distal small intestine and the large intestine. After a meal, dietary fiber, resistant starches, remaining parts of amino acids, and mucus sloughed from the intestine are fermented by the microbes present.

This process of fermentation produces gases e. During the process, several nutrients are formed by bacterial synthesis, such as vitamin K, vitamin B12, thiamin, and riboflavin. Strategies to stabilize and fortify the beneficial microbes within the microbiota in an attempt to maintain or improve health include the consumption of prebiotics, probiotics, and synbiotics.

Probiotics are live microorganisms, which, when administered in adequate amounts, provide a health benefit to the host. Probiotics can be found within fermented food products such as yogurt, miso, or sauerkraut or as a nutritional supplement Hill et al, Knowledge of their role in preventing and treating a host of gastrointestinal and systemic disorders has expanded tremendously in recent years Floch, However, when recommending a probiotic, practitioners must ensure that the specific microbial species has been shown in properly controlled studies to provide benefits to health see Chapter Prebiotics are nondigestible food ingredients that act as a substrate that is selectively utilized by host microorganisms conferring a health benefit.

Good dietary sources of prebiotic carbohydrates include vegetables including onions, garlic, and asparagus , fruits especially bananas, apples, stone fruits, and mangos , grains, legumes, chicory, Jerusalem artichokes, soybeans, and wheat bran. Strong evidence exists that consumption of specific prebiotics benefits the GIT including inhibition of pathogens and immune stimulation, cardiometabolic support e.

Synbiotics are a synergistic combination of both probiotics and prebiotics in the same food or supplement. Colonic salvage of malabsorbed energy sources and short-chain fatty acids Normally, varying amounts of some small-molecular-weight carbohydrates and amino acids remain in the chyme after leaving the small intestine.

Accumulation of these small molecules could become osmotically important were it not for the action of bacteria in the colon. The disposal of residual substrates through production of SCFAs is called colonic salvage. SCFAs produced in fermentation are rapidly absorbed and take water with them. They also serve as fuel for the colonocytes and the microbiota, stimulate colonocyte proliferation and differentiation, enhance the absorption of electrolytes and water, and reduce the osmotic load of malabsorbed sugars.

SCFAs also may help slow the movement of GI contents and participate in several other regulatory functions. The ability to salvage carbohydrates is limited in humans. Colonic fermentation normally disposes of 20 to 25 g of carbohydrates over 24 hours. Excess amounts of carbohydrates and fermentable fiber in the colon can cause increased gas production, abdominal distention, bloating, pain, flatulence, decreased colonic pH, and diarrhea. Over time, adaptation occurs in individuals consuming diets high in fiber.

Current recommendations are for the consumption of approximately 14 g of dietary fiber per kcal consumed each day. This recommendation can be met by consuming ample fruits, vegetables, legumes, seeds, and whole grains and is aimed to 1 support cardiovascular health, 2 maintain the health of the colonic epithelium, 3 prevent constipation, and 4 support stable, health-promoting microbiota. Digestion and absorption of specific types of nutrients Carbohydrates and fiber Most dietary carbohydrates are consumed in the form of starches, disaccharides, and monosaccharides.

Starches, or polysaccharides, usually make up the greatest proportion of carbohydrates. Starches are large molecules composed of straight or branched chains of sugar molecules that are joined together, primarily in alpha or linkages. Most of the dietary starches are amylopectins, the branching polysaccharides, and amylose, the straight chain—type polymers.

Dietary fiber also is made largely of chains and branches of sugar molecules, but in this case the hydrogens are positioned on the beta opposite side of the oxygen in the link instead of the alpha side. In the mouth, the enzyme salivary amylase operates at a neutral or slightly alkaline pH and starts the digestive action by hydrolyzing a small amount of the starch molecules into smaller fragments Fig. Amylase deactivates after contact with hydrochloric acid.

If digestible carbohydrates remained in the stomach long enough, acid hydrolysis could eventually reduce most of them into monosaccharides. However, the stomach usually empties before significant digestion can take place. By far, most carbohydrate digestion occurs in the proximal small intestine. Enzymes from the brush border of the enterocytes further break the disaccharides and oligosaccharides into monosaccharides.

For example, maltase located at the enterocyte brush border membrane breaks down the disaccharide maltose into two molecules of glucose. The brush border membrane also contains the enzymes sucrase, lactase, and isomaltase, which act on sucrose, lactose, and isomaltose, respectively Fig. Starch, sucrose, maltotriose, and galactose are digested to their constituent sugars. Glucose and galactose are transported through the apical brush border membrane of the enterocyte by a sodiumdependent transporter, glucose galactose cotransporter; fructose is transported by glucose transporter 5 GLUT5.

Glucose, fructose, and galactose are transported across the serosal membrane by the sodiumindependent transporter, GLUT2. At low concentrations, glucose and galactose are absorbed by active transport, primarily by a sodium-dependent active transporter called the sodium-glucose cotransporter SGLT1. At higher luminal concentrations of glucose, the facilitative transporter GLUT2 becomes a primary route for transport of glucose from the lumen into the enterocyte.

Fructose is absorbed from the intestinal lumen across the brush border membrane using the facilitative transporter, GLUT5. All three monosaccharides—glucose, galactose, and fructose—exit the basolateral membrane of the enterocyte into portal circulation using the facilitative transporter, GLUT2. The active transporter, SGLT1, is key to the ability of the small intestine to absorb 7 L of fluid each day and provides the basis for why oral rehydration solutions, rather than water or sugary drinks, should be used to treat dehydration.

In addition to transporting sodium and glucose, SGLT1 functions as a molecular water pump. For each molecule of glucose absorbed by SGLT1, two molecules of sodium and molecules of water also are absorbed. Given that this is a major pathway for water absorption in the small intestine, to facilitate water absorption, sodium and glucose also must be present in the right amounts. This explains why the most effective oral rehydration solutions often include both sugar and salt, in addition to water.

Some forms of carbohydrates i. These carbohydrates pass relatively unchanged into the colon, where they are partially fermented by bacteria in the colon. However, unlike humans, cows and other ruminants can subsist on high-fiber food because of the bacterial digestion of these carbohydrates that takes place in the rumen.

Other resistant starches and sugars are also less well digested or absorbed by humans; thus their consumption may result in significant amounts of starch and sugar in the colon. These resistant starches and some types of dietary fiber are fermented into SCFAs and gases.

Starches resistant to digestion tend to include plant foods with a high protein and fiber content such as those from legumes and whole grains. Proteins Protein intake in the Western world ranges from approximately 50 to g daily, and a good deal of the protein consumed is from animal sources. Additional protein is added all along the GIT from gastrointestinal secretions and sloughed epithelial cells.

The GIT is one of the most active synthetic tissues in the body, and the life span of enterocytes migrating from the crypts of the villi until they are shed is only 3 to 5 days. The number of cells shed daily is in the range of 10 to 20 billion. In general, animal proteins are more efficiently digested than plant proteins, but human physiology allows for very effective digestion and absorption of large amounts of ingested protein sources.

Protein digestion begins in the stomach, where some of the proteins are split into proteoses, peptones, and large polypeptides. Inactive pepsinogen is converted into the enzyme pepsin when it contacts hydrochloric acid and other pepsin molecules. Unlike any of the other proteolytic enzymes, pepsin digests collagen, the major protein of connective tissue. Most protein digestion takes place in the upper portion of the small intestine, but it continues throughout the GIT.

Any residual protein fractions are fermented by colonic microbes. Contact between chyme and the intestinal mucosa allows for the action of the brush border—bound enterokinase, an enzyme that transforms inactive pancreatic trypsinogen into active trypsin, the major pancreatic protein-digesting enzyme. Trypsin, in turn, activates the other pancreatic proteolytic enzymes. Pancreatic trypsin, chymotrypsin, and carboxypeptidase break down intact protein and continue the breakdown started in the stomach until small polypeptides and amino acids are formed.

Proteolytic peptidases located on the brush border also act on polypeptides, breaking them down into amino acids, dipeptides, and tripeptides. The final phase of protein digestion takes place in the brush border, where some of the dipeptides and tripeptides are hydrolyzed into their constituent amino acids by peptide hydrolases.

End products of protein digestion are absorbed as both amino acids and small peptides. Several transport molecules are required for the different amino acids, probably because of the wide differences in the size, polarity, and configuration of the different amino acids. Some of the transporters are sodium or chloride dependent, and some are not. Considerable amounts of dipeptides and tripeptides also are absorbed into intestinal cells using a peptide transporter, a form of active transport Wuensch et al, Absorbed peptides and amino acids are transported to the liver via the portal vein for metabolism by the liver and are released into the general circulation.

The presence of antibodies to many food proteins in the circulation of healthy individuals indicates that immunologically significant amounts of large intact peptides escape hydrolysis and can enter the portal circulation. The exact mechanisms that cause a food to become an allergen are not entirely clear, but these foods tend to be high in protein, to be relatively resistant to complete digestion, and to produce an immunoglobulin response see Chapter With new technology, it is possible to map and characterize allergenic peptides; this eventually will lead to better diagnosis and development of safe immunotherapy treatments Melioli et al, Small amounts of amino acids may remain in the epithelial cells and are used for synthesis of new proteins, including intestinal enzymes and new cells.

Only small amounts of fat are digested in the mouth by lingual lipase and in the stomach from the action of gastric lipase. Gastric lipase hydrolyzes some triglycerides, especially short-chain triglycerides such as those found in butter , into fatty acids and glycerol. However, most fat digestion takes place in the small intestine as a result of the emulsifying action of bile salts and hydrolysis by pancreatic lipase.

As in the case of carbohydrates and protein, the capacity for digestion and absorption of dietary fat is in excess of ordinary needs. Entrance of fat and protein into the small intestine stimulates the release of CCK, secretin, and GIP, which inhibit gastric secretions and motility, thus slowing the delivery of lipids. As a result, a portion of a large, fatty meal may remain in the stomach for 4 hours or longer. In addition to its many other functions, CCK stimulates biliary and pancreatic secretions.

The combination of the peristaltic action of the small intestine and the surfactant and emulsification action of bile reduces the fat globules into tiny droplets, thus making them more accessible to digestion by the most potent lipid-digesting enzyme, pancreatic lipase. Bile is a liver secretion composed of bile acids primarily conjugates of cholic and chenodeoxycholic acids with glycine or taurine , bile pigments which color the feces , inorganic salts, some protein, cholesterol, lecithin, and many compounds such as detoxified drugs that are metabolized and secreted by the liver.

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High quality and relevant content. Used this book for a nutrition course. Have looked back to it many times. This is the book to have in the field of clinical nutrition. This book has the center place in my library. This is an excellent book for learning about nutrition. I needed it for a class but I can defiantly see myself referencing this book even after I graduate and am studying nutrition in the field.

This is an excellent book full of great information. I used it for one of my nutrition classes and still refer to it from time to time. One person found this helpful. The book I got is like a new one. No marks, no notes or other handwritings. Awesome purchase! Highly recommended! It's a very text heavy textbook, but that is to be expected for MNT. Overall great book, easy to follow. See all reviews. Top reviews from other countries. Translate all reviews to English. Great reference book.

Report abuse. I am disappointed wit my order not reaching me on the time promised, 21st November inspite of paying the full amount for the book. The courier said incorrect address. We are on the main road with a clear address board on the gate.

Moreover the courier could have called on the given number in case of any difficulty. I have asked for the book to be re-delivered on the 6th December, so let's see how much time they take this time. Non si tratta di un testo ultra specialistico ma offre una aggiornata e approfondita panoramica della moderna scienza dell'alimentazione. Ottime le grafiche e la rilegatura. Un must have, ovviamente per chi mastica a sufficienza l'inglese. Translate review to English. This book is very interesting and cover a great number of topics.

Sometimes, I would have taken more details on certain topics. I particularly like the web links and references at the end of each chapters. In good shape. Your recently viewed items and featured recommendations. Back to top. Get to Know Us. Make Money with Us. Amazon Payment Products. Let Us Help You. Digestion, absorption, transport, and excretion of nutrients -- Ch.

Energy -- Ch. Macronutrients: carbohydrates, proteins, and lipids -- Ch. Vitamins -- Ch. Minerals -- Ch. Water, electrolytes, and acid-base balance -- Ch. Nutrition during pregnancy and lactation -- Ch. Nutrition during infancy -- Ch. Nutrition for low-birth-weight infants -- Ch.

Nutrition in childhood -- Ch. Nutrition in adolescence -- Ch. Nutrition in the adult years -- Ch. Nutrition in aging -- Ch. Nutrition in the community -- Ch. Guidelines for dietary planning -- Ch. Introduction to nutritional genomics -- Ch.

Dietary and clinical assessment -- Ch. Laboratory data in nutrition assessment -- Ch. Food-drug interactions -- Ch. Integrative medicine and phytotherapy -- Ch. The nutrition care process -- Ch. Counseling for change -- Ch.

Enteral and parenteral nutrition support -- Ch. Nutrition for weight management -- Ch. Nutrition in eating disorders -- Ch. Nutrition for exercise and sports performance -- Ch. Nutrition and bone health -- Ch. Nutrition for oral and dental health -- Ch. Medical nutrition therapy for upper gastrointestinal tract disorders -- Ch. Medical nutrition therapy for lower gastrointestinal tract disorders -- Ch.

Medical nutrition therapy for liver, biliary system, and exocrine pancreas disorders -- Ch. Medical nutrition therapy for food allergy and food intolerance -- Ch.

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Customers who viewed this item also viewed. Page 1 of 1 Start over Page 1 of 1. Previous page. Mary Width. Pamela Charney. Roberta Larson Duyff. Nutrition Therapy and Pathophysiology Book Only. Marcia Nelms. Next page. About the Author L. Customer reviews. How customer reviews and ratings work Customer Reviews, including Product Star Ratings help customers to learn more about the product and decide whether it is the right product for them.

Learn more how customers reviews work on Amazon. Top reviews Most recent Top reviews. Top reviews from the United States. There was a problem filtering reviews right now. Please try again later. Verified Purchase. As a graduating nutrition major I really wanted to get this book to carry me into the internship. Just skimming through I can already see why my professors and RD's so highly recommend this book.

Will be the bible going forward. Good as I expected. High quality and relevant content. Used this book for a nutrition course. Have looked back to it many times. This is the book to have in the field of clinical nutrition. This book has the center place in my library. This is an excellent book for learning about nutrition. I needed it for a class but I can defiantly see myself referencing this book even after I graduate and am studying nutrition in the field. This is an excellent book full of great information.

I used it for one of my nutrition classes and still refer to it from time to time. One person found this helpful. The book I got is like a new one. No marks, no notes or other handwritings. Awesome purchase! Highly recommended! It's a very text heavy textbook, but that is to be expected for MNT. Overall great book, easy to follow. See all reviews. Top reviews from other countries. Advanced embedding details, examples, and help!

Includes bibliographical references and index Ch. Digestion, absorption, transport, and excretion of nutrients -- Ch. Energy -- Ch. Macronutrients: carbohydrates, proteins, and lipids -- Ch. Vitamins -- Ch. Minerals -- Ch. Water, electrolytes, and acid-base balance -- Ch. Nutrition during pregnancy and lactation -- Ch.

Nutrition during infancy -- Ch. Nutrition for low-birth-weight infants -- Ch. Nutrition in childhood -- Ch. Nutrition in adolescence -- Ch. Nutrition in the adult years -- Ch. Nutrition in aging -- Ch. Nutrition in the community -- Ch. Guidelines for dietary planning -- Ch. Introduction to nutritional genomics -- Ch. Dietary and clinical assessment -- Ch.

Laboratory data in nutrition assessment -- Ch. Food-drug interactions -- Ch. Integrative medicine and phytotherapy -- Ch. The nutrition care process -- Ch. Counseling for change -- Ch. Enteral and parenteral nutrition support -- Ch. Nutrition for weight management -- Ch. Nutrition in eating disorders -- Ch. Nutrition for exercise and sports performance -- Ch. Nutrition and bone health -- Ch. Nutrition for oral and dental health -- Ch. Medical nutrition therapy for upper gastrointestinal tract disorders -- Ch.

Medical nutrition therapy for lower gastrointestinal tract disorders -- Ch.

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