Nutrition and Diet Therapy Lecture PDF (2nd Year, 1st Semester)

NUTRITION AND DIET THERAPY assessment, planning, implementation and evaluation of nutritional care. A firm grounding in LECTURE the principles of nutrit...

NUTRITION AND DIET THERAPY assessment, planning, implementation and evaluation of nutritional care. A firm grounding in LECTURE the principles of nutritional science is essential to 2nd Year, 1st Semester understand the rationale behind the components of nutritional care. PRELIMS NUTRITION EDUCATION INTRODUCTION AND IMPORTANCE  Nutrition Education Allows patients to learn OF NUTRITION about the dietary factors that affect their particular medical condition. Ideally, this NUTRITION knowledge motivates them to change their diet  Nutrition is the science that interprets the and lifestyle to improve their health status.  A nutrition education program should be tailored interaction of nutrients and other substances in food in relation to maintenance, growth, to a person’s age. Level of literacy, and cultural reproduction, health and disease of an background. Learning style should also be organism. considered: some people learn best by discussion supplemented with written materials, DIETETICS DIETITIAN  Dietetics is the interpretation and communication of the science of nutrition where individual can  The dietitian can provide sample menus of a make practical choices about food and life style nutritionally adequate diet that limits milk and in terms of both health and diseases. milk products. Together the dietitian and the woman can design menus that consider her food NUTRITIONIST preferences.  Using diet analysis software, the dietitian can  A nutritionist is a qualified nutrition professional demonstrate how altering food choices changes that has the expertise to provide a range of the calcium content of a meal evidence based nutrition services related to  The dietitian can explain how to use the Daily nutrition, public health nutrition, policy and value on food labels to estimate the calcium research, and community health. content of a packaged food.  A nutritionist is a person who advises on  The dietitian can provide information about the matters of food and nutrition that impacts on advantages and disadvantages of different health. calcium supplements. DIETITIAN NUTRITION IMPORTANCE IN COURSE/  Dietitian are the healthcare professionals and CURRICULUM experts who treats nutritional problems and  Nutrition is essential for growth and overview the patients by providing dietary needs, development, health and wellbeing. Eating a plans menus, and instructs patients and their healthy diet contributes to preventing future families about proper nutritional care. Dietitians illness and improving quality and length of life. have the expertise to provide individual dietary  As a future nurse, studying nutrition is important counselling, medical nutrition therapy (MNT), in order to give the best nursing care to your group dietary therapy and food service clients. management.  Knowing the right diet or food required/prescribed to a certain patients. EDUCATION  And enables you as the primary care giver to  Education is the key factor in enabling nurses to impart health teaching about the patient’s food instigate nutritional care appropriately. Nursing intake thus leads to a faster recovery or students need be educated in the screening and maintenance of health.  expression and firm flesh on well- developed bone structures. CONCEPTS OF NUTRITIONAL FOOD SCIENCE  is necessary to our survival. it sustain life and promote growth.  it acts as a body fuel that gives energy required NUTRITION for bodily functions. are products derived from  Is all about food and how the body uses it esp as plants/ animals. a fuel for growth and daily activities.  types of food plants - grains &cereal corn, oats  According to the council of the American Medical and wheat -pulses Fruits and vegetables, tubers, Assoc., it is the science of food, the nutrients cassava, sweet potato, nuts, oilseed - olive, and the substances therein study of all the sesame, coconut, soybean oil, etc… seaweed processes (digestion, absorption, metabolism, aga carageenan etc.)how the body absorb and utilize food  Animals - meat and entrails, milk, eggs, and substances. shellfish, poultry and fish  According to WHO Nutrition is an input to and foundation for health and development. Better WHAT IS THE COMPONENT OF FOOD? nutrition means stronger immune systems, less  Nutrient illness and better health. Healthy children learn  it is the product of digestion of foods which better. Healthy people are more stronger, are are the nourishing material vital for human more productive. functioning.  Specifically, if the body needs are met in  They are used to build and repair tissues, childhood and adulthood, the person can regulate body processes and are converted normally expect: to and used as energy.  Good health, vitality and energy  Substances that provide energy- Cho, Chon and  To mature at the proper time Fats  To overcome the stresses of the  Substances that support metabolism – dietary environment minerals, vitamins and water  To fulfill this biological life  There are some substances that are useful,  To enjoy extended time of life some are neutral and some are detrimental to  To withstand the many hazards of aging. health, and they are called as Non nutrient.  In order to prevent obesity and diet-related  Such as: such as alcohol, pigments, additives diseases, man must know how to utilize the and phytochemicals. existing food supply so as to derive maximum  Food additives nutritional benefit from it.  such as the preservatives, flavours and  As Nutrition is the foundation of good health, colors. …education is the cornerstone of good nutrition  it makes the food safe if you keep it for an because to attain good nutrition, the individual extended period. must be taught to make good food selection and  E.g. of preservatives - Acids like lemon juice to maintain an environment conducive to the and vinegar. utilization of the nutrients provided by the food.  help preserve freshness by increasing the  According to Babcock (in 1961), “To establish acidity of a food. An acidic food creates a good food habits, people must be able to learn, hostile environment for microorganisms. and nutrition educators must be able to teach.  Sugar - helps preserve foods by absorbing GOOD NUTRITION excess water. Without water, microorganisms  is the basis for good health. It enhances cannot grow inside a food. appearance as it is exemplified by shiny hair,  Salt - has long been used to prevent meat and clear skin, clear eyes, erect posture, alert fish from spoiling. Like sugar, salt inhibits the  growth of microorganisms by reducing the  Minerals – it regulates body processes amount of water available to them.  Vitamins – vital helpers in many body  Oil - helps foods stay fresh by preventing processes microorganisms from coming into contact with  Water – it is a food as well as nutrient. It the food. Oil also reduces the rate of oxidation in helps regulate the various processes such a food, which helps prevent it from spoiling as circulation, digestion and elimination and quickly. respiration.  Spices- some spices seem to retard the growth of microorganisms while also reducing the rate CHEMICAL PROPERTIES: of oxidation These spices include cloves,  Organic nutrients – it contains hydrogen, oxygen mustard, sage, thyme, rosemary and oregano. and carbon( an element found in all living  Phytochemicals – compounds produced by things). plants. They are found in edible fruits, veg and  Organic – meaning “literally alive” other plant-derived foods that have biological  Before the body can use organic nutrients, it activity in the body and according to research must be broken down into their smallest that it is use in the prevention of chronic components. diseases such as CA and CVD  Ex. CHO, CHON, fats and vitamins CHON and  some researches estimate there are up to 4000 vits. contain nitrogen. pythochemicals but only a small fraction have  Inorganic nutrients – they contain no carbon. been studied closely They are already in their simplest form when the body ingest them.  Common names – flavones, isoflavones, allyl sulfides, phytonutrients, polyphenols,  (dietary)Minerals are the simplest nutrient. Each cathechins, carotenoids, anthocyanidins and mineral is a chemical element, its atom are alike. isothiocyanates As a result, its identity never changes.  e.g. lycopene – cancer (prostate)), heart  E.g. Minerals – sodium, iron, calcium,  health = tomatoes, grapefruit, watermelon, potassium, chloride, sulphate and phosphate. red peppers allylic sulphites - in garlic  Are not broken down and changed by the body. lignans - in wheat They leave the body as they entered it. Ca is still  betacarotene – for immune system, vision, skin Ca and Fe is still Fe. health and bone health= yellow, orange and dark  Too much or too little of a mineral may adversely green foods affect a persons health.  resveratrol- heart & lung health, cancer  The next simplest nutrient is water, a compound & inflammation = red wine, grapes, peanuts made of 2 elements – hydrogen and oxygen  anthocyanidins – blood vessel health  Needed for metabolic reactions. blackberries, red berries, red onion, blueberries,  Supplies the medium for transporting plum, strawberries, red radishes, red potato materials to cells and waste products away.  isoflavones – menopause, breast cancer, bone health, joint inflammation, lower Cholesterol ESSENTIAILTY  Alcohol – though it provides energy but no  refers to the important contribution to the body’s nutrients. It is detrimental to health when too physiological functioning. much consumption of it. a. Essential nutrients  nutrients a person must obtain from food CLASSIFICATION OF NUTRIENTS AS TO: because the body cannot make them for  Functions itself in sufficient quantity to meet  Cho- provide energy physiological needs.  Protein- for growth repair and maintenance  it is also called as “indispensable nutrients”. of the body. And essential means more than just  Fats – provide energy “necessary”.   these nutrients are required for life.  When cho, fats and proteins completely broken  it includes many amino acids, some fatty down in the body:(by the process of acids, many vitamins and some minerals metabolism): and trace elements.  The fuel factor of CHO- is 4 kcalories/gram.  ex. Amino acids = phenylalanine,  Protein – also yields 4 kcal/gram tryptophan, lysine, leucine, isoleucine,  Fat -yields 9 kcal/gram. valine, threonine, methionine.  Alcohol – yields 7 kcal/gram  ex. Fatty acids – linoleic and linolenic acids.  Fat therefore, has a greater energy density than either CHO or CHON. b. Nonessential nutrients  are those nutrients that can be made by the ENERGY DENSITY body, they may often also be absorbed from  is a measure of the energy a food provide consumed food. relative to the amount of food. (kcalories per  E.g. cholesterol gram).  Concentration  Foods high in energy density help w/ wt.gain, - some nutrients are needed in large amount whereas those w/ a low energy density help w/ than others. wt. Loss.  CHO, CHON, fats and water are collectively  Alcohol is not considered a nutrient bec it can known as interferes w/ growth, maintenance and repair of - Macronutrients because they are needed by the body but it does yield 7 kcal per gram when our body in relatively large amounts because metabolized in the body. they are essential to provide energy and to regulate and control the different functions of BOMB CALORIMETER the body.  Bomb calorimeter can be used to determine the - In contrast to vits and minerals are called as calorie content of a product. Micronutrients as the body needs them in  It is used in food and metabolic studies to smaller amount or quantity. examine the effects of energy content in food on humans and animals. NUTRIENT DENSITY  Energy in the body  refers to the concentration of nutrients in a given  the body uses the energy-yielding nutrients amount of food source relative to its caloric to fuel all its activities. content.  sends electrical impulses thru the brain and  consider calories from CHO, fats, protein, vits nerves. and minerals and water. The higher the nutrient  to synthesize body compounds and to move density, the greater the nutritional value in a muscles. small amount of food.  If the body does not use these nutrients to fuel its current activities, it rearranges them CALORIE into storage compounds (such as body fat),  represents the energy measurement of nutrients to be used between meals and overnight that foods provide. when fresh energy supplies run low  the energy released from CHO, fats and proteins  If more energy is consumed than expended, can be measured in calories. the result is an increase in energy stores  Energy is expressed in 1000 – calorie metric and weight gain. units known as kilocalories (shortended to  If less energy is consumed than expended, kcalories/kcal, but commonly called “calories” the result is a decrease in energy stores and  Kilojoules (kj)- It is the international unit of work weight loss energy.  If alcohol can be consumed in excess can  1 kcal is equal to 4.2 kj. be converted to body fat and stored.   To calculate the energy available from food, 1 g = 1000 mg multiply the number of grams of CHO, 1 g = 0.04 oz CHON and fat by 4, 4 and 9, respectively. 1 oz. = 28.35 g or 30 g Then add the results together. 100 g = 3 ½ oz. 1 kg = 2.2 lbs  SEATWORK: Calculate the energy available 454 g = 1 lb from foods.  1 slice of bread w/ 1 tbsp of peanut butter NUTRITIONAL STATUS which contains 16 grms CHO, 7 grms  a measurement of the extent to w/c an CHON and 9 gms fat. individual’s physiologic need for nutrients is  From this you can calculate the percentage being met. of kcal each of the energy nutrients contributes to total. To determine the kcal NUTRITIONAL ASSESSMENT from fat, for example, divide the (kcal from  Provides the information needed for identifying fat) by the total kcal (total calorie of the nutrition problems and designing a nutritional snack) ANS. care plan. 16gms CHO x 4 = 64kcal= 37%  It identify clients at risk for malnutrition/ those w/ 7gms CHON x 4 = 28= 16% poor nutritional status 9gms FAT x 9 = 81=47%  This information can be obtained from the Total = 173 kcal Medical, Social and Diet histories,  PERCENTAGE Anthropemetric data, Biochemical data and - divide the 81kcal by the total 173 kcal: 81 fat Clinical data. kcal / 173 total kcal = 0.468 (rounded to 0.47)  This is a part of routine exam done by a Then multiply by 100 to get the percentage: RD/other health care professionals trained in the 0.47 x 100 = 47% diagnosis of at risk individuals – doctors/ nurses.  Dietary recommendations that urge people to limit fat intake to 20-35 % of kcal refer to DIETARY - SOCIAL HISTORY the day’s total energy intake, not to  dietary evaluation would provide information w/ individual foods. regards on client’s food habit, usual food pattern,  Still, if the proportion of fat in each food likes and dislikes and type of meals eaten for a choice throughout a day exceeds 35% of long period of time,because these information kcal, then the day’s total surely ,will, too. would help the examiner to determine any  Knowing that this snack provides 47% of its nutritional deficiencies or excesses. kcal from fat alerts a person to the need to make lower-fat selections at other times that MOST COMMON METHOD USED day.  Diet History – a comprehensive record of eating- related behaviours and foods a person eat  HOUSEHOLD MEASURES  Contents of Diet History of Adults: -Cups, quarts and teaspoons  Check appetite – good, poor, any factors that affect appetite, taste and smell  METRIC MEASURES perception -Millilitres, liters, and grams  Ask for allergies, intolerances or food avoidances – foods avoided and reasons,  VOLUME length of time of avoidances -1L = 1000 ml  Anthropometry – ht, wt, skin-fold, etc. -0.9L = 1 quart  Take 24 hour dietary recall or food -1ml =0.03 fld. Oz frequency checklist -240 ml = 1 cup WEIGHT : GRAMS (g)  Consider ethnic and cultural background –  Evaluate recent weight change – loss or eating habits and food preferences and gain, how much, over what length of time, religion intentional or non-volitional = people eat the foods they grew up eating.  Food Frequency – a record of how often the diff Every country or every region of a country, foods are eaten. The types (and sometimes the has its own typical foods and ways of amount, its preparation) of foods a person combining them into meals. routinely consumed in a week or a month can be  American diet or even Filipino diet includes taken. many ethnic foods from diff countries, all  24-hour recall – done by dietician. Listing the adding variety to the diet. Ex. Chinese, types, amounts and preparation of all foods Italian, Korean, Japanese. eaten in past 24 hours  Consider religion = for examples, some  Food Diary – written record of all food and drink religious sect forgo meat during lent, the ingested in a specified period- for about 3-4 day period prior to easter. period.  Muslims fast between sunrise and sunset  but some clients are not truthful and tend to during Ramadan. Food preference = spicy forget the food they had eaten. foods, sweetness of sugar and the  may include records of behaviours / savoriness of salt. High fat foods. curry emotions and symptoms, physical activities spices of Indian cuisine. and medications  Habits = choosing food out of habit = ex.  Medications may decrease the desire of Eating cereal every morning, because they food, absorption of nutrients, metabolism of always eat cereals for b-fast. Eating a nutrients. familiar food makes them comfortable  e.g antihistamines-dec saliva causing dry  Evaluate dental and oral health- problems mouth and loss of appetite. w/ eating, foods that cannot be eaten,  e.g aspirin (controls pain and fever and for problems w/ swallowing, salivation blood thinning) – a gram of which increases  Economic status –income, amount of money the taste perception of bitterness. for food each week or month.= people eat  Anthropometric measurement foods that are accessible, quick and easy to  The science of measuring the size, weight prepare and w/ in their financial means. and proportions of the human body  Evaluate physical activity level –  May reveal a failure to thrive in children occupation(type, hours/week,shift, energy  It reflects a nutrient deficiencies or excesses expenditure), Exercise(type amount,  Includes the height, weight, head frequency), Sleep ( hours/day circumference, upper arm, skin fold and ,uninterrupted?),handicaps. chest circumference (for children)  Determine home life and meal patterns –  Height and weight Number in household (eat together?),  Useful in determining nutritional status in person who buy food, person who does adults cooking, food storage and cooking facilities  It is a good indicator of satisfactory diet and (stove, refrigerator), type of housing (home, recent food intake apartment, room)  Height  Assess gastrointestinal conditions –  Is a less sensitive indicator of current problems of heartburn, bloating, diarrhea, nutritional status than weight - for - age vomiting,constipation, frequency of since height does not decrease but simply problems, antacid, laxative or other drugs. slows down in times of nutrient deprivation  Consider presence of chronic disease –  Weight treatment, length of tx, dietary modification  Is a sensitive marker of current nutritional including physician prescription, date of status modification, education, compliance w/ diet.   Reflects an immediate inability to meet nutritional requirements and this may indicate nutritional risk  Desirable body weight  Is also known as ideal or reference weight but it is more appropriately called the healthy weight  It is the weigh found statistically to be most compatible with health longevity  TANNHAUSER’S METHOD  PROCEDURE:  Step 1 : DBW (K) = Height (cm) - 100  Step 2 : deduct 10% - if a filipino unless frame size is known (either med or large)  Example: subject: 5’2” female (5’2” - 157.48cm)  Step 1:DBW (K) = 157.48cm - 100=57.48 kilos  Step 2: 57.48 kilos less 5.478 (10%) = 51.7 or 52 kg  Obesity categories into 3 BMI grades  CONVERSION AID:  Grade I -25 to 29.9 - 1 foot - 12 inches  Grade II -30 to 40 - 1 inch - 2.54 cm  Grade II - 40+ - 1m - 100cm  IN GENERAL: OBESITY - IS BMI of 27 or  Actual body weight more  May be influenced by chnages in the  Indicates high risk of developing health person’s fluid sttaus problems  Weight measurement obtained at the time of  Weight 20% above average examination  Underweight - BMI less than 18.5 - 10 to 15% below average OTHER PARAMETERS OF ASSESSING  Overweight - BMI between 25-29- 10 to 20% NUTRITIONAL STATUS above average  BMI or BODY MASS INDEX  Healthy - BMI between 18.5 - 24.9  Or the quetelet index is a good estimate of the  BMI tend to increase with age degree of obesity or amount of total body fta  It also helps to determine how much risk people WAIST-TO-HIP RATIO hav of developing certain  Waist to hip ratio (WHR) is a valuable indicator  BMI Is computed thru metric formula of body fat distribution and adiposity. It is also a  Formula: BMI = W9kg)/ H(mxm) valuable guide in evaluating health risk (heart  Constant: 5ft = 1.524m disease, diabetes, etc.) - 4 ft = 1.2192  Alternatively it is called abdominal/ gluteal ratio - 1 inch = 0.0254m or abdominal girth measurement  Example: H = 5’3”  Obtaining correct measurement: - W = 62kgs  Use non stretchable tape measure (in - 62kg/(1.6)2 = 62/2.56 = BMI = 24.22 centimetre)  Classification of weight status in adults  Subject should stand erectly, abdominal according to BMI by WHO muscles relaxed, arms atteh sides, and feet toether. The measurer faces the subject and  palces at the tape measure. Measre waist at  Biceps the most narrow area below the rib case  above tthe iliac crest/ suprailiac above umbilicus  Upper thigh  Measure hip circumference at the widest  Ifit is more than 1 1/2 inches - over wt. point around the hips or buttocks with the  If less than 1/2 inch - under wt. subject standing. Read measurement to the nearest 0.1 cm ASSESSMENT BY CLINICAL METHOD  Formula for Assessing body fat disribution  Clinical assessment of nutritional status deals by WHR basically with the examination o changes that  WHR = Waist circumference (cm) / hip can be seen or felt in superficial tissues such as circumference (cm) the skin. Hair and eyes  A WHR of 1.0 or greater in men or 0.8 or  In other words, it’s the physical observation or greater in women is indicative of android assessment obesity and an increased risk for obesity-  In here, signs of nutrient deficiency are noted related diseases. This also appears to be and some nutrient deficiency diseases are true in children observed such as;  Gingival swelling  Gynoid “per-shaped” people, store more fat in  Blue spots on the skin the buttocks, thighs and hips  Scurvy  Android “apple-shaped’ people, carry their extra  Rickes = lack of Ca and vit D s/s poorly shaped fat around the abdomen/upper body bones and teeth  The WHR may partially explain the difference in  Iron deficiency anemia (children beyond 6 high blood pressure between men and women. mons.) = lack in iron s/s - pallor Men are more likely to be ‘apples” and women to  Dehydration = loss of water and electrolytes be “pears”. Men have higher rates of HT and  S/s sunken eyeballs, dry mucous membains, more complications thrist etc. WAIST CIRCUMFERENCE ASSESSMENT BY BIOCHEMICAL TEST  Serves as a marker of abdominal fatness. Waist  Includes various blood, urine, saliva and stool circumference alone has been considered a test valid indicator for both men and women  According to Dellova, it provides the information  Interpretation: women with a waist on protein balance, vit, mineral, and fluid status, circumference greater than 35 inches and men body composition, organ function and metabolic with waist circumference greater than 40 inches status have high risk of central obesity-related health  According to Roth a deficiency/ toxicity can be problems determined by laboratory analysis of the samples SKINFOLD THICKNESS  These test allow detection of malnutrition before  Assess bod composition, fat distribution and signs appear reserve calories by using a calliper  The most accurate way to measure body fat MOST COMMONLY USED TEST FOR  Harpenden NUTRITIONAL EVALUATION  Lange caliper 1. BLOOD TEST  Serum albumin level measures the main protein in the blood and is used to determine protein DIFFERENT SITES FOR SKINFOLD status..3.5 - 5.0 g/dl or 35-5 g/L MEASUREMENT  Albumin is a protein foundin plants and aimals  Triceps - commonly used  Below the scapula  Low levels - with malnutrition, burns, infections,  Chemical analysis of fecal fat - fecal fat greater cancer and those taking birth pills, chronic than 7g/day when the diet includes 100 g of disease of liver, kidney and heart fat/day indicates malabsorption  Serum transferrin level - indicates iron-carrying  Serum calcium - low levels seen in calcium and protein in the blood vit. D malabsorption, (recall that steatorrhea can  Transferrin is a glycoprotein that binds and led to calcium and vit D malabsorption transport iron. Most is produced in the liver  D-xylose test - test of CHO absorption  If result is below normal there would be  Schilling test - identifies vit B12 malabsorption hepatic failure, nephrosis, cachexia 3. URINE TEST  Blood Urea Nitrogen (BUN) - increased level  Creatinine - high - muscle wasting, starvation may indicate renal failure, insufficient renal blood and cachetic status, hyperthyroidism, renal supply or blockage in the urinary tract, insufficiency dehydration and GI bleeding  Men - 0-50 mg/24 hour  NV - 2.9 - 8.9 mmol/L  Women - 0-100 mg/24 hour  Creatinine excretion - indicates the amount of  Calcium - high - hyperparathyroidism, elevated creatinine excreted in the urine over a 24 hour serum calcium period and can be used in estimating body  50-150 mg/24 hr. Or 1.05-1.3 mmol/L muscle mass  Urinalysis - can detedt proteina nd sugar in urine  Low creatinine excretion - indicative of muscle (indicative of kidney disease and diabetes) mass depletion, as in malnutrition  Color = normal is clear, straw-colored/ light  Serum creatinine - indicates the amount of yellow. Lighter than normal may result from creatinine in the blood and is used for evaluating excessive fld. Intake diuretic renal functions  = darker than normal - caused by liver  N.V. 60-132 mmol/L disease and certain drugs  High = acute/ chronic renal insufficiency,  Odor = depends on the food intake/ with urinary tract obstruction concentration of urine (asparagus/onions), this  Hgb - women - 12-16 g/dl, men - 14-18g/dl depends with how much fld. You drink.  Hct - women - 42-52%, men - 37-48%  Protein = presence of this is found on kidney  = decreased level would men anemia disease, multiple myeloma, heart failure, stress  Lipid profile - for clients w/ heart abnormalities/ or surgery CAD (coronary artery dse.)  pH = this varies with diet, but usually acidic w/ a  Total serum cholesterol - less than 200 mg/dl range of pH 5-6  HDL - more than 35mg-dl  = alkaline urine is associated w/ a vegetarian  LDL - less than 13mg/dl diet or fruit diet esp citrus, vomiting, diuretics  Serum triglycerides - 2.9-8.9 mmol/L or less than and excess taking in antacids 200 mg/dl  Specific gravity = it is high (concentrated in Dhn,  Uric acid, serum or plasma DM or in condition w/c it has an excess protein  Men - 3-99 mg/dl, women - 2.5-7.7 mg/dl in the urine  High level - gout, toxemia of pregnancy, leukemia, polycythemia, renal insufficiency, down’s syndrome, glycogen storage disease  Low levels occasionally in acute hepatitis.  All vitamins and minerals would cause a certain disease if there would be abnormalities on the intake, either low or high.. but in water soluble vitamins, no over dosage 2. STOOL EXAM  Direct stool exam - checked for oily materials. Excess fat in stool suggest steatorrhea