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Can you help create a website on Iron. 2 The Dental Hygienists Guide to Nutritional Care 5TH EDITION Cynthia A. Stegeman, RDH, EdD, RDN, LD, CDE Ohio Delegate to the Academy of Nutrition and Dietetics National Board Dental Hygiene Examination Test Construction Committee Commission on Dental Competency Assessments Consultant Professor and Chairperson, Dental Hygiene Program University of Cincinnati, Blue Ash Cincinnati, Ohio Judi Ratliff Davis, MS, RDN Former Quality Assurance Nutrition Consultant Women, Infants and Children (WIC) Program Texas Department of State Health Services Austin, Texas 3 4 Table of Contents Cover image Title Page Reference Tables Copyright Dedication Preface New to This Edition Organization About Evolve Note From the Authors Acknowledgments About the Authors Part I Orientation to Basic Nutrition 1 Overview of Healthy Eating Habits Basic Nutrition Physiologic Functions of Nutrients Basic Concepts of Nutrition Government Nutrition Concerns 5 kindle:embed:0006?mime=image/jpg Nutrient Recommendations: Dietary Reference Intakes Food Guidance System for Americans Support Healthy Eating Patterns for All MyPlate System Other Food Guides Nutrition Labeling Student Readiness References 2 Concepts in Biochemistry What is Biochemistry? Fundamentals of Biochemistry Principle Biomolecules in Nutrition Summary of Metabolism Student Readiness References 3 The Alimentary Canal Physiology of the Gastrointestinal Tract Oral Cavity Esophagus Gastric Digestion Small Intestine Large Intestine Student Readiness References 4 Carbohydrate 6 Classification Physiologic Roles Requirements Sources Hyperstates and Hypostates Nonnutritive Sweeteners/Sugar Substitutes Student Readiness References 5 Protein Amino Acids Classification Physiologic Roles Requirements Sources Underconsumption and Health-Related Problems Overconsumption and Health-Related Problems Student Readiness References 6 Lipids Classification Chemical Structure Characteristics of Fatty Acids Compound Lipids Cholesterol Physiologic Roles 7 Dietary Fats and Dental Health Dietary Requirements Sources Overconsumption and Health-Related Problems Underconsumption and Health-Related Problems Fat Replacers Student Readiness References 7 Use of the Energy Nutrients Metabolism Role of the Liver Role of the Kidneys Carbohydrate Metabolism Protein Metabolism Lipid Metabolism Alcohol Metabolism Metabolic Interrelationships Metabolic Energy Basal Metabolic Rate Total Energy Requirements Energy Balance Inadequate Energy Intake Student Readiness References 8 Vitamins Required for Calcified Structures 8 Overview of Vitamins Vitamin A (Retinol, Carotene) Vitamin D (Calciferol) Vitamin E (Tocopherol) Vitamin K (Quinone) Vitamin C (Ascorbic Acid) Student Readiness References 9 Minerals Essential for Calcified Structures Bone Mineralization and Growth Formation of Teeth Introduction to Minerals Calcium Phosphorus Magnesium Fluoride Student Readiness References 10 Nutrients Present in Calcified Structures Copper Selenium Chromium Manganese Molybdenum Ultratrace Elements 9 Student Readiness References 11 Vitamins Required for Oral Soft Tissues and Salivary Glands Physiology of Soft Tissues Thiamin (Vitamin B1) Riboflavin (Vitamin B2) Niacin (Vitamin B3) Pantothenic Acid (Vitamin B5) Vitamin B6 (Pyridoxine) Folate/Folic Acid (Vitamin B9) Vitamin B12 (Cobalamin) Biotin (Vitamin B7) Other Vitamins Student Readiness References 12 Fluids and Minerals Required for Oral Soft Tissues and Salivary Glands Fluids References Electrolytes Sodium Chloride Potassium Iron Zinc 10 Iodine Student Readiness References Part II Application of Nutrition Principles 13 Nutritional Requirements Affecting Oral Health in Women Healthy Pregnancy Lactation Oral Contraceptive Agents Menopause Student Readiness References 14 Nutritional Requirements During Growth and Development and Eating Habits Affecting Oral Health Infants Children Older Than 2 Years of Age: Dietary Guidelines 2015–2020 and Healthy People 2020 Utilizing the ChooseMyPlate Website Toddler and Preschool Children Attention-Deficit/Hyperactivity Disorder Children With Special Needs School-Age Children (7–12 Years Old) Adolescents Student Readiness References 15 Nutritional Requirements for Older Adults and Eating Habits Affecting Oral Health 11 General Health Status Physiologic Factors Influencing Nutritional Needs and Status Socioeconomic and Psychological Factors Nutrient Requirements Eating Patterns Dietary Guidelines and MyPlate for Older Adults Student Readiness References 16 Food Factors Affecting Health Health Care Disparities Food Patterns Working With Patients With Different Food Patterns Food Budgets Maintaining Optimal Nutrition During Food Preparation Food Fads and Misinformation Referrals for Nutritional Resources Role of Dental Hygienists Student Readiness References 17 Effects of Systemic Disease on Nutritional Status and Oral Health Effects of Chronic Disease on Intake Anemias Other Hematologic Disorders Gastrointestinal Problems Cardiovascular Conditions 12 Skeletal System Metabolic Problems Neuromuscular Problems Neoplasia Acquired Immunodeficiency Syndrome (AIDS) Mental Health Problems Student Readiness References Part III Nutritional Aspects of Oral Health 18 Nutritional Aspects of Dental Caries Major Factors in the Dental Caries Process Other Factors Influencing Cariogenicity Dental Hygiene Care Plan Student Readiness References 19 Nutritional Aspects of Gingivitis and Periodontal Disease Physical Effects of Food on Periodontal Health Nutritional Considerations for Periodontal Patients Gingivitis Chronic Periodontitis Necrotizing Periodontal Diseases Student Readiness References 20 Nutritional Aspects of Alterations in the Oral Cavity 13 Orthodontics Xerostomia Root Caries and Dentin Hypersensitivity Dentition Status Oral and Maxillofacial Surgery Loss of Alveolar Bone Glossitis Temporomandibular Disorder Student Readiness References 21 Nutritional Assessment and Education for Dental Patients Evaluation of the Patient Assessment of Nutritional Status Identification of Nutritional Status Formation of Nutrition Treatment Plan Facilitative Communication Skills Student Readiness References Glossary Answers to Nutritional Quotient Questions Index IBC 14 15 Reference Tables Criteria and Dietary Reference Intake Values: For Energy by Active Individuals by Life Stage Groupa Life Stage Group Criterion ACTIVE PAL EERb (kcal/d) Male Female 0 through 6 mo Energy expenditure plus energy deposition 570 520 (3 mo) 7 through 12 mo Energy expenditure plus energy deposition 743 676 (9 mo) 1 through 2 y Energy expenditure plus energy deposition 1,046 992 (24 mo) 3 through 8 y Energy expenditure plus energy deposition 1,742 1,642 (6 y) 9 through 13 y Energy expenditure plus energy deposition 2,279 2,071 (11 y) 14 through 18 y Energy expenditure plus energy deposition 3,152 2,368 (16 y) >18 y Energy expenditure 3,067c 2,403c (19 y) Pregnancy 14 through 18 y Adolescent female EER plus change in Total Energy Expenditure (TEE) plus pregnancy energy deposition 1st trimester 2,368 (16 y) 2nd trimester 2,708 (16 y) 3rd trimester 2,820 (16 y) 19 through 50 y Adult female EER plus change in TEE plus pregnancy energy deposition 1st trimester 2,403c (19 y) 2nd trimester 2,743c (19 y) 3rd trimester 2,855c (19 y) Lactation 14 through 18 y Adolescent female EER plus milk energy output minus w eight loss 1st 6 mo 2,698 (16 y) 2nd 6 mo 2,768 (16 y) 19 through 50 y Adult female EER plus milk energy output minus w eight loss 1st 6 mo 2,733c (19 y) 2nd 6 mo 2,803c (19 y) aFor healthy active Americans and Canadians. Based on the cited age, an active physical activity level, and the reference heights and weights cited in Table 1.1. Individualized EERs can be determined by using the equations in Chapter 5. bPAL = Physical Activity Level, EER = Estimated Energy Requirement. The intake that meets the average energy expenditure of individuals at the reference height, weight, and 16 age (see Table 1.1). cSubtract 10 kcal/d for males and 7 kcal/d for females for each year of age above 19 years. Reproduced with permission from Energy Calculations for Active Individuals by Life Stage Group. In Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate, National Academy of Sciences. Washington, DC: National Academies Press, 2005. Dietary Reference Intakes (DRIs): Dietary Allowances and Adequate Intakes, Total Water, and Macronutrients (Food and Nutrition Board, National Academy of Medicine) Life Stage Group Total Water (L/d) PROTEIN CARBOHYDRATE FIBER FAT n-6 POLYUNSATURATED FATTY ACIDS (α- linoleic acid) n POLYUNSATURATED FATTY ACIDS (α- linoleic acid) RDA/AI g/daya AMDRb RDA/AI g/day AMDR b RDA/AI g/day AMDR b RDA/AI g/day AMDR b RDA/AI g/day AMDR b Infants 0–6 mo 0.7* 9.1 NDc 60 ND ND ND 31 4.4* ND 7–12 mo 0.8* 11.0 ND 95 ND ND ND 30 4.6* ND Children 1–3 y 1.3* 13 5–20 130 45–65 19* ND ND 30–40 7* 5–10 4–8 y 1.7* 19 10–30 130 45–65 25* ND ND 25–35 10* 5–10 Males 9–13 y 2.4* 34 10–30 130 45–65 31* ND ND 25–35 12* 5–10 14–18 y 3.3* 52 10–30 130 45–65 38* ND ND 25–35 16* 5–10 19–30 y 3.7* 56 10–35 130 45–65 38* ND ND 20–35 17* 5–10 31–50 y 3.7* 56 10–35 130 45–65 38* ND ND 20–35 17* 5–10 51–70 y 3.7* 56 10–35 130 45–65 30* ND ND 20–35 14* 5–10 >70 y 3.7* 56 10–35 130 45–65 30* ND ND 20–35 14* 5–10 Females 9–13 y 2.1* 34 10–30 130 45–65 26* ND ND 25–35 10* 5–10 14–18 y 2.3* 46 10–30 130 45–65 26* ND ND 25–35 11* 5–10 19–30 y 3.7* 46 10–35 130 45–65 25* ND ND 20–35 12* 5–10 31–50 y 3.7* 46 10–35 130 45–65 25* ND ND 20–35 12* 5–10 51–70 y 3.7* 46 10–35 130 45–65 21* ND ND 20–35 11* 5–10 >70 y 3.7* 46 10–35 130 45–65 21* ND ND 20–35 11* 5–10 Pregnant ≤18 y 3.0* 71 10–35 175 45–65 28* ND ND 20–35 13* 5–10 19–30 y 3.0* 71 10–35 175 45–65 28* ND ND 20–35 13* 5–10 31–50 y 3.0* 71 10–35 175 45–65 28* ND ND 20–35 13* 5–10 Lactating ≤18 y 3.8* 71 10–35 210 45–65 29* ND ND 20–35 13* 5–10 17 19–30 y 3.8* 71 10–35 210 45–65 29* ND ND 20–35 13* 5–10 31–50 y 3.8* 71 10–35 210 45–65 29* ND ND 20–35 13* 5–10 aBased on 1.5 g/kg/day for infants, 1.1 g/kg/day for 1–3 y; 0.95 g/kg/day for 4–13 y, 0.85 g/kg/day for 14–18 y, 0.8 g/kg/day for adults, and 1.1 g/kg/day for pregnant (using prepregnancy weight) and lactating women. bAcceptable Macronutrient Distribution Range (AMDR) is the range of intake for a particular energy source that is associated with reduced risk of chronic disease while providing intakes of essential nutrients. If an individual has consumed in excess of the AMDR, there is a potential of increasing the risk of chronic diseases and insufficient intakes of essential nutrients. cND 5 Not determinable due to lack of data of adverse effects in this age group and concern with regard to lack of ability to handle excess amounts. Source of intake should be from food only to prevent high levels of intake. dApproximately 10\% of the total can come from longer-chain, n-3 fatty acids. Dietary cholesterol, trans fatty acids, saturated fatty acids: As low as possible while consuming a nutritionally adequate diet. Added sugars: Limit to no more than 25\% of total energy.e Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, DC: The National Academies Press, 2002. Note: This table represents Recommended Dietary Allowances (RDAs) in bold type and *Adequate Intakes (AIs) in ordinary type. RDAs and AIs may both be used as goals for individual intake. RDAs are set to meet the needs of almost all (97\%–98\%) individuals in a group. For healthy breastfed infants, the AI is the mean intake. The AI for other life-stage and gender groups is believed to cover the needs of all individuals in the group, but lack of data prevents being able to specify with confidence the percentage of individuals covered by this intake. Dietary Reference Intakes (DRIs): Recommended Dietary Allowances and Adequate Intakes, Vitamins (Food and Nutrition Board, National Academy of Medicine) Life Stage Group Vitamin A (µg/d)a Vitamin C (mg/d) Vitamin D (µg/d)b,c Vitamin E (mg/d)d Vitamin K (µg/d) Thiamin (mg/d) Riboflavin (mg/d) Niacin (mg/d)e Vitamin B6 (mg/d) Folate (µg/d)f Vitamin B12 (µg/d) Pantothenic Acid (mg/d) Infants 0–6 mo 400* 40* 13 4* 2.0* 0.2* 0.3* 2* 0.1* 65* 0.4* 1.7* 7–12 mo 500* 50* 15 5* 2.5* 0.3* 0.4* 4* 0.3* 80* 0.5* 1.8* Children 1–3 y 300 15 15 6 30* 0.5 0.5 6 0.5 150 0.9 2* 4–8 y 400 25 15 7 55* 0.6 0.6 8 0.6 200 1.2 3* Males 9–13 y 600 45 15 11 60* 0.9 0.9 12 1.0 300 1.8 4* 14–18 900 75 15 15 75* 1.2 1.3 16 1.3 400 2.4 5* 18 y 19–30 y 900 90 15 15 120* 1.2 1.3 16 1.3 400 2.4 5* 31–50 y 900 90 15 15 120* 1.2 1.3 16 1.3 400 2.4 5* 51–70 y 900 90 15 15 120* 1.2 1.3 16 1.7 400 2.4h 5* >70 y 900 90 20 15 120* 1.2 1.3 16 1.7 400 2.4h 5* Females 9–13 y 600 45 15 11 60* 0.9 0.9 12 1.0 300 1.8 4* 14–18 y 700 65 15 15 75* 1.0 1.0 14 1.2 400i 2.4 5* 19–30 y 700 75 15 15 90* 1.1 1.1 14 1.3 400i 2.4 5* 31–50 y 700 75 15 15 90* 1.1 1.1 14 1.3 400i 2.4 5* 51–70 y 700 75 15 15 90* 1.1 1.1 14 1.5 400 2.4h 5* >70 y 700 75 20 15 90* 1.1 1.1 14 1.5 400 2.4h 5* Pregnancy 14–18 y 750 80 15 15 75* 1.4 1.4 18 1.9 600j 2.6 6* 19–30 y 770 85 15 15 90* 1.4 1.4 18 1.9 600j 2.6 6* 31–50 y 770 85 15 15 90* 1.4 1.4 18 1.9 600j 2.6 6* Lactation 14–18 y 1,200 115 15 19 75* 1.4 1.6 17 2.0 500 2.8 7* 19–30 y 1,300 120 15 19 90* 1.4 1.6 17 2.0 500 2.8 7* 31–50 y 1,300 120 15 19 90* 1.4 1.6 17 2.0 500 2.8 7* aAs retinol activity equivalents (RAEs). 1 RAE = 1 µg retinol, 12 µg β-carotene, 24 µg β- carotene, or 24 µg β-cryptoxanthin. The RAE for dietary provitamin A carotenoids is twofold greater than retinol equivalents (RE), whereas the RAE for preformed vitamin A is the same as RE. bAs cholecalciferol. 1 µg cholecalciferol = 40 IU vitamin D. cUnder the assumption of minimal sunlight. dAs α-tocopherol. α-Tocopherol includes RRR-α-tocopherol, the only form of α-tocopherol that occurs naturally in foods, and the 2R-stereoisomeric forms of α-tocopherol (RRR-, RSR-, RRS-, and RSS-α-tocopherol) that occur in fortified foods and supplements. It does not include the 2S-stereoisomeric forms of α-tocopherol (SRR-, SSR-, SRS-, and SSS-α- tocopherol), also found in fortified foods and supplements. eAs niacin equivalents (NE). 1 mg of niacin = 60 mg of tryptophan; 0–6 months = preformed niacin (not NE). fAs dietary folate equivalents (DFE). 1 DFE = 1 µg food folate = 0.6 µg of folic acid from fortified food or as a supplement consumed with food = 0.5 µg of a supplement taken on an empty stomach. gAlthough AIs have been set for choline, there are few data to assess whether a dietary supply of choline is needed at all stages of the life cycle, and it may be that the choline requirement can be met by endogenous synthesis at some of these stages. 19 hBecause 10\% to 30\% of older people may malabsorb food-bound B12, it is advisable for those older than 50 years to meet their RDA mainly by consuming foods fortified with B12 or a supplement containing B12. iIn view of evidence linking folate intake with neural tube defects in the fetus, it is recommended that all women capable of becoming pregnant consume 400 µg from supplements or fortified foods in addition to intake of food folate from a varied diet. jIt is assumed that women will continue consuming 400 µg from supplements or fortified food until their pregnancy is confirmed and they enter prenatal care, which ordinarily occurs after the end of the periconceptional period—the critical time for formation of the neural tube. NOTE: This table (taken from the DRI reports; see www.nap.edu) presents Recommended Dietary Allowances (RDAs) in bold type and Adequate Intakes (AIs) in ordinary type followed by an asterisk (*). An RDA is the average daily dietary intake level; sufficient to meet the nutrient requirements of nearly all (97\%–98\%) healthy individuals in a group. It is calculated from an Estimated Average Requirement (EAR). If sufficient scientific evidence is not available to establish an EAR for calculating an RDA, an AI is usually developed. For healthy breastfed infants, an AI is the mean intake. The AI for other life-stage and gender groups is believed to cover the needs of all healthy individuals in the groups, but lack of data or uncertainty in the data prevent being able to specify with confidence the percentage of individuals covered by this intake. SOURCES: Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline (1998); Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000); Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc (2001); Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate (2005); and Dietary Reference Intakes for Calcium and Vitamin D (2011). These reports may be accessed via www.nap.edu. 20 http://www.nap.edu http://www.nap.edu Dietary Reference Intakes (DRIs): Recommended Dietary Allowances and Adequate Intakes, Elements (Food and Nutrition Board, National Academy of Medicine) Life-Stage Group Calcium (mg/d) Chromium (µg/d) Copper (µg/d) Fluoride (mg/d) Iodine (µg/d) Iron (mg/d) Magnesium (mg/d) Infants 0–6 mo 200* 0.2* 200* 0.01* 110* 0.27* 30* 7–12 mo 260* 5.5* 220* 0.5* 130* 11 75* Children 1–3 y 700* 11* 340 0.7* 90 7 80 4–8 y 1000* 15* 440 1* 90 10 130 Males 9–13 y 1,300* 25* 700 2* 120 8 240 14–18 y 1,300* 35* 890 3* 150 11 410 19–30 y 1,000* 35* 900 4* 150 8 400 31–50 y 1,000* 35* 900 4* 150 8 420 51–70 y 1,200* 30* 900 4* 150 8 420 >70 y 1,200* 30* 900 4* 150 8 420 Females 9–13 y 1,300* 21* 700 2* 120 8 240 14–18 y 1,300* 24* 890 3* 150 15 360 19–30 y 1,000* 25* 900 3* 150 18 310 31–50 y 1,000* 25* 900 3* 150 18 320 51–70 y 1,200* 20* 900 3* 150 8 320 >70 y 1,200* 20* 900 3* 150 8 320 Pregnancy ≤18 y 1,300* 29* 1,000 3* 220 27 400 19–30 y 1,000* 30* 1,000 3* 220 27 350 31–50 y 1,000* 30* 1,000 3* 220 27 360 Lactation ≤18 y 1,300* 11* 1,300 3* 290 10 360 19–30 y 1,000* 15* 1,300 3* 290 9 310 31–50 y 1,000* 45* 1,300 3* 290 9 320 Copyright 2001 by the National Academy of Sciences. All rights reserved. SOURCES: Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline (1998); Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000); Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc (2001); Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate (2005); and Dietary Reference Intakes for Calcium and Vitamin D (2011). These reports may be accessed via www.nap.edu. Dietary Reference Intakes (DRIs): Estimated Average Requirements (Food and Nutrition Board, National Academy of Medicine) Life Stage- Group Calcium (mg/d) CHO (g/kg/d) Protein (g/d) Vitamin A (µg/d)a Vitamin C (mg/d) Vitamin D (µg/d) Vitamin E (mg/d)b Thiamin (mg/d) Riboflavin (mg/d) Niacin (mg/d)c Vitamin B6 (mg/d) Infants 0–6 21 http://www.nap.edu mo 7–12 mo 1.0 Children 1–3 y 500 100 0.87 210 13 10 5 0.4 0.4 5 0.4 4–8 y 800 100 0.76 275 22 10 6 0.5 0.5 6 0.5 Males 9–13 y 1,100 100 0.76 445 39 10 9 0.7 0.8 9 0.8 14–18 y 1,100 100 0.73 630 63 10 12 1.0 1.1 12 1.1 19–30 y 800 100 0.66 625 75 10 12 1.0 1.1 12 1.1 31–50 y 800 100 0.66 625 75 10 12 1.0 1.1 12 1.1 51–70 y 800 100 0.66 625 75 10 12 1.0 1.1 12 1.4 >70 y 1,000 100 0.66 625 75 10 12 1.0 1.1 12 1.4 Females 9–13 y 1,100 100 0.76 420 39 10 9 0.7 0.8 9 0.8 14–18 y 1,100 100 0.71 485 56 10 12 0.9 0.9 11 1.0 19–30 y 800 100 0.66 500 60 10 12 0.9 0.9 11 1.1 31–50 y 800 100 0.66 500 60 10 12 0.9 0.9 11 1.1 51–70 y 1,000 100 0.66 500 60 10 12 0.9 0.9 11 1.3 >70 y 1,000 100 0.66 500 60 10 12 0.9 0.9 11 1.3 Pregnancy 14–18 y 1,000 135 0.88 530 66 10 12 1.2 1.2 14 1.6 19–30 y 800 135 0.88 550 70 10 12 1.2 1.2 14 1.6 31–50 y 800 135 0.88 550 70 10 12 1.2 1.2 14 1.6 Lactation 14–18 y 1,000 160 1.05 885 96 10 16 1.2 1.3 13 1.7 19–30 y 800 160 1.05 900 100 10 16 1.2 1.3 13 1.7 31–50 y 800 160 1.05 900 100 10 16 1.2 1.3 13 1.7 aAs retinol activity equivalents (RAEs). 1 RAE = 1 µg retinol, 12 µg β-carotene, 24 µg α- carotene, or 24 µg β-cryptoxanthin. The RAE for dietary provitamin A carotenoids is two- fold greater than retinol equivalents (RE), whereas the RAE for preformed vitamin A is the same as RE. bAs α-tocopherol. α-Tocopherol includes RRR-α-tocopherol, the only form of α-tocopherol that occurs naturally in foods, and the 2R-stereoisomeric forms of α-tocopherol (RRR-, RSR-, RRS-, and RSS-α-tocopherol) that occur in fortified foods and supplements. It does not include the 2S-stereoisomeric forms of α-tocopherol (SRR-, SSR-, SRS-, and SSS-α- tocopherol), also found in fortified foods and supplements. cAs niacin equivalents (NE). 1 mg of niacin = 60 mg of tryptophan. dAs dietary folate equivalents (DFE). 1 DFE = 1 µg food folate = 0.6 µg of folic acid from fortified food or as a supplement consumed with food = 0.5 µg of a supplement taken on an empty stomach. 22 Note: An Estimated Average Requirement (EAR) is the average daily nutrient intake level estimated to meet the requirements of the healthv individuals in a group. EARs have not been established for vitamin K, pantothenic acid, biotin, choline, chromium, fluoride, manganese, or other nutrients not yet evaluated via the DRI process. SOURCES: Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline (1998); Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000); Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc (2001); Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (2002/2005); and Dietary Reference Intakes for Calcium and Vitamin D (2011). These reports may be accessed via www.nap.edu. Dietary Reference Intakes (DRIs): Tolerable Upper Intake Levels, Vitamins (Food and Nutrition Board, National Academy of Medicine) Life- Stage Group Vitamin A (µg/d)a Vitamin C (mg/d) Vitamin D (µg/d) Vitamin E (mg/d)b,c Vitamin K Thiamin Riboflavin Niacin (mg/d)c Vitamin B6 (mg/d) Folate (µg/d)c Vitamin B12 Infants 0–6 mo 600 NDe 25 ND ND ND ND ND ND ND ND 7–12 mo 600 ND 38 ND ND ND ND ND ND ND ND Children 1–3 y 600 400 63 200 ND ND ND 10 30 300 ND 4–8 y 900 650 75 300 ND ND ND 15 40 400 ND Males 9–13 y 1,700 1,200 100 600 ND ND ND 20 60 600 ND 14–18 y 2,800 1,800 100 800 ND ND ND 30 80 800 ND 19–30 y 3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND 31–50 y 3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND 51–70 y 3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND >70 y 3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND Females 9–13 y 1,700 1,200 100 600 ND ND ND 20 60 600 ND 14–18 y 2,800 1,800 100 800 ND ND ND 30 80 800 ND 19–30 y 3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND 31–50 y 3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND 51–70 y 3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND >70 y 3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND Pregnancy 14–18 y 2,800 1,800 100 800 ND ND ND 30 80 800 ND 19–30 y 3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND 31–50 3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND 23 http://www.nap.edu y Lactation 14–18 y 2,800 1,800 100 800 ND ND ND 30 80 800 ND 19–30 y 3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND 31–50 y 3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND aAs preformed vitamin A only. bAs α–tocopherol; applies to any form of supplemental α–tocopherol. cThe ULs for vitamin E, niacin, and folate apply to synthetic forms obtained from supplements, fortified foods, or a combination of the two. dβ-Carotene supplements are advised only to serve as a provitamin A source for individuals at risk of vitamin A deficiency. eND = Not determinable due to lack of data of adverse effects in this age group and concern with regard to lack of ability to handle excess amounts. Source of intake should be from food only to prevent high levels of intake. Note: A Tolerable Upper Intake Level (UL) is the highest level of daily nutrient intake that is likely to pose no risk of adverse health effects to almost all individuals in the general population. Unless otherwise specified, the UL represents total intake from food, water, and supplements. Due to a lack of suitable data, ULs could not be established for vitamin K, thiamin, riboflavin, vitamin B12, pantothenic acid, biotin, and carotenoids. In the absence of a UL, extra caution may be warranted in consuming levels above recommended intakes. Members of the general population should be advised not to routinely exceed the UL. The UL is not meant to apply to individuals who are treated with the nutrient under medical supervision or to individuals with predisposing conditions that modify their sensitivity to the nutrient. SOURCES: Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline (1998); Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000); Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc (2001); and Dietary Reference Intakes for Calcium and Vitamin D (2011). These reports may be accessed via www.nap.edu. Dietary Reference Intakes (DRIs): Tolerable Upper Intake Levels, Elements (Food and Nutrition Board, National Academy of Medicine) Life- Stage Group Arsenica Boron (mg/d) Calcium (mg/d) Chromium Copper (µg/d) Fluoride (mg/d) Iodine (µg/d) Iron (mg/d) Magnesium (mg/d)b Manganese (mg/d) Molybdenum (µg/d) Infants 0–6 mo NDe ND 1,000 ND ND 0.7 ND 40 ND ND ND 7–12 mo ND ND 1,500 ND ND 0.9 ND 40 ND ND ND Children 24 http://www.nap.edu 1–3 y ND 3 2,500 ND 1,000 1.3 200 40 65 2 300 4–8 y ND 6 2,500 ND 3,000 2.2 300 40 110 3 600 Males 9–13 y ND 11 3,000 ND 5,000 10 600 40 350 6 1,100 14–18 y ND 17 3,000 ND 8,000 10 900 45 350 9 1,700 19–30 y ND 20 2,500 ND 10,000 10 1,100 45 350 11 2,000 31–50 y ND 20 2,500 ND 10,000 10 1,100 45 350 11 2,000 51–70 y ND 20 2,000 ND 10,000 10 1,100 45 350 11 2,000 >70 y ND 20 2,000 ND 10,000 10 1,100 45 350 11 2,000 Females 9–13 y ND 11 3,000 ND 5,000 10 600 40 350 6 1,100 14–18 y ND 17 3,000 ND 8,000 10 900 45 350 9 1,700 19–30 y ND 20 2,500 ND 10,000 10 1,100 45 350 11 2,000 31–50 y ND 20 2,500 ND 10,000 10 1,100 45 350 11 2,000 51–70 y ND 20 2,000 ND 10,000 10 1,100 45 350 11 2,000 >70 y ND 20 2,000 ND 10,000 10 1,100 45 350 11 2,000 Pregnancy 14–18 y ND 17 3,000 ND 8,000 10 900 45 350 9 1,700 19–30 y ND 20 2,500 ND 10,000 10 1,100 45 350 11 2,000 31–50 y ND 20 2,500 ND 10,000 10 1,100 45 350 11 2,000 Lactation 14–18 y ND 17 3,000 ND 8,000 10 900 45 350 9 1,700 19–30 y ND 20 2,500 ND 10,000 10 1,100 45 350 11 2,000 31–50 y ND 20 2,500 ND 10,000 10 1,100 45 350 11 2,000 aAlthough the UL was not determined for arsenic, there is no justification for adding arsenic … Nutrition Patient Education Website Page 5 and 6 of your course syllabus www.sites.google.com https:// sites.google.com /site/ nutritionpatienteducation /home Working Tabs Disclaimer