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Addison’s Disease

Addison's disease is an endocrine or hormonal disorder that occurs in all age groups and afflicts men and women equally. The disease is characterized by weight loss, muscle weakness, fatigue, low blood pressure, and sometimes darkening of the skin in both exposed and non-exposed parts of the body.
Addison's disease occurs when the adrenal glands do not produce enough of the hormone cortisol and, in some cases, the hormone aldosterone. The disease is also called adrenal insufficiency, or hypocortisolism.
Cortisol is normally produced by the adrenal glands, located just above the kidneys. It belongs to a class of hormones called glucocorticoids, which affect almost every organ and tissue in the body. Scientists think that cortisol has possibly hundreds of effects in the body. Cortisol's most important job is to help the body respond to stress. Among its other vital tasks, cortisol

  • helps maintain blood pressure and cardiovascular function
  • helps slow the immune system's inflammatory response
  • helps balance the effects of insulin in breaking down sugar for energy
  • helps regulate the metabolism of proteins, carbohydrates, and fats
  • helps maintain proper arousal and sense of well-being

Because cortisol is so vital to health, the amount of cortisol produced by the adrenals is precisely balanced. Like many other hormones, cortisol is regulated by the brain's hypothalamus and the pituitary gland, a bean-sized organ at the base of the brain. First, the hypothalamus sends "releasing hormones" to the pituitary gland. The pituitary responds by secreting hormones that regulate growth and thyroid and adrenal function, and sex hormones such as estrogens and testosterone. One of the pituitary's main functions is to secrete ACTH (adrenocorticotropin), a hormone that stimulates the adrenal glands. When the adrenals receive the pituitary's signal in the form of ACTH, they respond by producing cortisol. Completing the cycle, cortisol then signals the pituitary to lower secretion of ACTH.
Aldosterone belongs to a class of hormones called mineralocorticoids, also produced by the adrenal glands. It helps maintain blood pressure and water and salt balance in the body by helping the kidney retain sodium and excrete potassium. When aldosterone production falls too low, the kidneys are not able to regulate salt and water balance, causing blood volume and blood pressure to drop.


Failure to produce adequate levels of cortisol can occur for different reasons. The problem may be due to a disorder of the adrenal glands themselves (primary adrenal insufficiency) or to inadequate secretion of ACTH by the pituitary gland (secondary adrenal insufficiency).
Primary Adrenal Insufficiency
Addison's disease affects about 1 in 100,000 people. Most cases are caused by the gradual destruction of the adrenal cortex, the outer layer of the adrenal glands, by the body's own immune system. About 70 percent of reported cases of Addison's disease are caused by autoimmune disorders, in which the immune system makes antibodies that attack the body's own tissues or organs and slowly destroy them. Adrenal insufficiency occurs when at least 90 percent of the adrenal cortex has been destroyed. As a result, often both glucocorticoid (cortisol) and mineralocorticoid (aldostertone) hormones are lacking. Sometimes only the adrenal gland is affected, as in idiopathic adrenal insufficiency; sometimes other glands also are affected, as in the polyendocrine deficiency syndrome.
Polyendocrine Deficiency Syndrome
The polyendocrine deficiency syndrome is classified into two separate forms, referred to as type I and type II.
Type I occurs in children, and adrenal insufficiency may be accompanied by

  • underactive parathyroid glands
  • slow sexual development
  • pernicious anemia
  • chronic candida infections
  • chronic active hepatitis
  • hair loss (in very rare cases)

Type II, often called Schmidt's syndrome, usually afflicts young adults. Features of type II may include

  • an underactive thyroid gland
  • slow sexual development
  • diabetes
  • vitiligo
  • loss of pigment on areas of the skin

Scientists think that the polyendocrine deficiency syndrome is inherited because frequently more than one family member tends to have one or more endocrine deficiencies.
Tuberculosis (TB), an infection which can destroy the adrenal glands, accounts for about 20 percent of cases of primary adrenal insufficiency in developed countries. When adrenal insufficiency was first identified by Dr. Thomas Addison in 1849, TB was found at autopsy in 70 to 90 percent of cases. As the treatment for TB improved, however, the incidence of adrenal insufficiency due to TB of the adrenal glands has greatly decreased.
Other Causes
Less common causes of primary adrenal insufficiency are

  • chronic infection, mainly fungal infections
  • cancer cells spreading from other parts of the body to the adrenal glands
  • amyloidosis
  • surgical removal of the adrenal glands

Secondary Adrenal Insufficiency
This form of adrenal insufficiency is much more common than primary adrenal insufficiency and can be traced to a lack of ACTH. Without ACTH to stimulate the adrenals, the adrenal glands' production of cortisol drops, but not aldosterone. A temporary form of secondary adrenal insufficiency may occur when a person who has been receiving a glucocorticoid hormone such as prednisone for a long time abruptly stops or interrupts taking the medication. Glucocorticoid hormones, which are often used to treat inflammatory illnesses like rheumatoid arthritis, asthma, or ulcerative colitis, block the release of both corticotropin-releasing hormone (CRH) and ACTH. Normally, CRH instructs the pituitary gland to release ACTH. If CRH levels drop, the pituitary is not stimulated to release ACTH, and the adrenals then fail to secrete sufficient levels of cortisol.
Another cause of secondary adrenal insufficiency is the surgical removal of benign, or noncancerous, ACTH-producing tumors of the pituitary gland (Cushing's disease). In this case, the source of ACTH is suddenly removed, and replacement hormone must be taken until normal ACTH and cortisol production resumes.
Less commonly, adrenal insufficiency occurs when the pituitary gland either decreases in size or stops producing ACTH. These events can result from

  • tumors or infections of the area
  • loss of blood flow to the pituitary
  • radiation for the treatment of pituitary tumors
  • surgical removal of parts of the hypothalamus
  • surgical removal of the pituitary gland


The symptoms of adrenal insufficiency usually begin gradually. Characteristics of the disease are

  • chronic, worsening fatigue
  • muscle weakness
  • loss of appetite
  • weight loss

About 50 percent of the time, one will notice

  • nausea
  • vomiting
  • diarrhea

Other symptoms include

  • low blood pressure that falls further when standing, causing dizziness or fainting
  • skin changes in Addison's disease, with areas of hyperpigmentation, or dark tanning, covering exposed and nonexposed parts of the body; this darkening of the skin is most visible on scars; skin folds; pressure points such as the elbows, knees, knuckles, and toes; lips; and mucous membranes

Addison's disease can cause irritability and depression. Because of salt loss, a craving for salty foods also is common. Hypoglycemia, or low blood glucose, is more severe in children than in adults. In women, menstrual periods may become irregular or stop.
Because the symptoms progress slowly, they are usually ignored until a stressful event like an illness or an accident causes them to become worse. This is called an addisonian crisis, or acute adrenal insufficiency. In most cases, symptoms are severe enough that patients seek medical treatment before a crisis occurs. However, in about 25 percent of patients, symptoms first appear during an addisonian crisis.
Symptoms of an addisonian crisis include

  • sudden penetrating pain in the lower back, abdomen, or legs
  • severe vomiting and diarrhea
  • dehydration
  • low blood pressure
  • loss of consciousness

Left untreated, an addisonian crisis can be fatal.


In its early stages, adrenal insufficiency can be difficult to diagnose. A review of a patient's medical history based on the symptoms, especially the dark tanning of the skin, will lead a doctor to suspect Addison's disease.
A diagnosis of Addison's disease is made by laboratory tests. The aim of these tests is first to determine whether levels of cortisol are insufficient and then to establish the cause. X-ray exams of the adrenal and pituitary glands also are useful in helping to establish the cause.
ACTH Stimulation Test
This is the most specific test for diagnosing Addison's disease. In this test, blood cortisol, urine cortisol, or both are measured before and after a synthetic form of ACTH is given by injection. In the so-called short, or rapid, ACTH test, measurement of cortisol in blood is repeated 30 to 60 minutes after an intravenous ACTH injection. The normal response after an injection of ACTH is a rise in blood and urine cortisol levels. Patients with either form of adrenal insufficiency respond poorly or do not respond at all.
CRH Stimulation Test
When the response to the short ACTH test is abnormal, a "long" CRH stimulation test is required to determine the cause of adrenal insufficiency. In this test, synthetic CRH is injected intravenously and blood cortisol is measured before and 30, 60, 90, and 120 minutes after the injection. Patients with primary adrenal insufficiency have high ACTHs but do not produce cortisol. Patients with secondary adrenal insufficiency have deficient cortisol responses but absent or delayed ACTH responses. Absent ACTH response points to the pituitary as the cause; a delayed ACTH response points to the hypothalamus as the cause.
In patients suspected of having an addisonian crisis, the doctor must begin treatment with injections of salt, fluids, and glucocorticoid hormones immediately. Although a reliable diagnosis is not possible while the patient is being treated for the crisis, measurement of blood ACTH and cortisol during the crisis and before glucocorticoids are given is enough to make the diagnosis. Once the crisis is controlled and medication has been stopped, the doctor will delay further testing for up to 1 month to obtain an accurate diagnosis.

Other Tests

Once a diagnosis of primary adrenal insufficiency has been made, x-ray exams of the abdomen may be taken to see if the adrenals have any signs of calcium deposits. Calcium deposits may indicate TB. A tuberculin skin test also may be used.
If secondary adrenal insufficiency is the cause, doctors may use different imaging tools to reveal the size and shape of the pituitary gland. The most common is the CT scan, which produces a series of x-ray pictures giving a cross-sectional image of a body part. The function of the pituitary and its ability to produce other hormones also are tested.


Treatment of Addison's disease involves replacing, or substituting, the hormones that the adrenal glands are not making. Cortisol is replaced orally with hydrocortisone tablets, a synthetic glucocorticoid, taken once or twice a day. If aldosterone is also deficient, it is replaced with oral doses of a mineralocorticoid called fludrocortisone acetate (Florinef), which is taken once a day. Patients receiving aldosterone replacement therapy are usually advised by a doctor to increase their salt intake. Because patients with secondary adrenal insufficiency normally maintain aldosterone production, they do not require aldosterone replacement therapy. The doses of each of these medications are adjusted to meet the needs of individual patients.
During an addisonian crisis, low blood pressure, low blood glucose, and high levels of potassium can be life threatening. Standard therapy involves intravenous injections of hydrocortisone, saline (salt water), and dextrose (sugar). This treatment usually brings rapid improvement. When the patient can take fluids and medications by mouth, the amount of hydrocortisone is decreased until a maintenance dose is achieved. If aldosterone is deficient, maintenance therapy also includes oral doses of fludrocortisone acetate.

Special Problems

Patients with chronic adrenal insufficiency who need surgery with general anesthesia are treated with injections of hydrocortisone and saline. Injections begin on the evening before surgery and continue until the patient is fully awake and able to take medication by mouth. The dosage is adjusted until the maintenance dosage given before surgery is reached.
Women with primary adrenal insufficiency who become pregnant are treated with standard replacement therapy. If nausea and vomiting in early pregnancy interfere with oral medication, injections of the hormone may be necessary. During delivery, treatment is similar to that of patients needing surgery; following delivery, the dose is gradually tapered and the usual maintenance doses of hydrocortisone and fludrocortisone acetate by mouth are reached by about 10 days after childbirth.

Patient Education

A person who has adrenal insufficiency should always carry identification stating his or her condition in case of an emergency. The card should alert emergency personnel about the need to inject 100 mg of cortisol if its bearer is found severely injured or unable to answer questions. The card should also include the doctor's name and telephone number and the name and telephone number of the nearest relative to be notified. When traveling, a needle, syringe, and an injectable form of cortisol should be carried for emergencies. A person with Addison's disease also should know how to increase medication during periods of stress or mild upper respiratory infections. Immediate medical attention is needed when severe infections, vomiting, or diarrhea occur. These conditions can precipitate an addisonian crisis. A patient who is vomiting may require injections of hydrocortisone.
People with medical problems may wish to wear a descriptive warning bracelet or neck chain to alert emergency personnel. A number of companies manufacture medical identification products.

Fats, Oils and Sweets

Eating too many high-fat foods not only adds excess calories (which can lead to obesity and weight gain), but can increase your risk factor for several diseases. Heart disease, diabetes, certain types of cancer and osteoarthritis have all been linked to diets too high in fat. If you consume too much saturated and trans fats, you are more likely to develop high cholesterol and coronary artery disease.

Instead of this:

Try this:


Fig bars, gingersnaps and molasses cookies

Shortening, butter or margarine

Olive, soybean and canola oils

Regular mayonnaise

Nonfat or light mayonnaise

Regular salad dressing

Nonfat or light salad dressing

Using fat (including butter) to grease pan

Nonstick cooking spray


Choose skim milk or low-fat buttermilk. Substitute evaporated skim milk for cream in recipes for soups and sauces.

Try low-fat cheeses. Skim ricotta can replace cream cheese on a bagel or in a vegetable dip. Use part-skim cheeses in recipes. Use 1% cottage cheese for salads and cooking. String cheese is a low-fat, high-calcium snack option.

Plain nonfat yogurt can replace sour cream in many recipes. (To maintain texture, stir 1 tablespoon of cornstarch into each cup of yogurt that you use in cooking.) Try mixing frozen nonfat or low-fat yogurt with fruit for dessert.

Skim sherbet is an alternative to ice cream. Soft-serve and regular ice creams are also lower in fat than premium styles.

Instead of this:

Try this:

Whole or 2% milk

Skim or 1% milk

Evaporated milk

Evaporated skim milk

Regular buttermilk

Buttermilk made from skim (or 1%) milk

Yogurt made with whole milk

Nonfat or low-fat yogurt

Regular cheese (examples: American, blue, Brie, cheddar, Colby and Parmesan)

Low-fat cheese with less than 3 grams of fat per serving (example: natural cheese, processed cheese and nondairy cheese such as soy cheese)

Regular cottage cheese

Low-fat, nonfat, and dry-curd cottage cheese with less than 2% fat

Regular cream cheese

Low-fat cream cheese (no more than 3 grams of fat per ounce)

Regular ice cream

Sorbet, sherbet and nonfat or low-fat ice cream (no more than 3 grams of fat per 1/2 cup serving)

Meat, Poultry and Fish

Beef, Pork, Veal and Lamb
Baking, broiling and roasting are the healthiest ways to prepare meat. Lean cuts can be pan-broiled or stir-fried. Use either a nonstick pan or nonstick spray coating instead of butter or margarine.

Trim outside fat before cooking. Trim any inside, separable fat before eating. Select low-fat, lean cuts of meat. Lean beef and veal cuts have the word "loin" or "round" in their names. Lean pork cuts have the word "loin" or "leg" in their names.

Use herbs, spices, fresh vegetables and nonfat marinades to season meat. Avoid high-fat sauces and gravies.

Baking, broiling and roasting are the healthiest ways to prepare poultry. Skinless poultry can be pan-broiled or stir-fried. Use either a nonstick pan or nonstick spray coating instead of butter or margarine.

Remove skin and visible fat before cooking. Chicken breasts are a good choice because they are low in fat and high in protein. Use domestic goose and duck only once in a while because both are high in fat.

Poaching, steaming, baking and broiling are the healthiest ways to prepare fish. Fresh fish should have a clear color, a moist look, a clean smell and firm, springy flesh. If good-quality fresh fish isn't available, buy frozen fish.

Most seafood is low in saturated fat. Omega-3 fatty acids are found in some fatty fish, such as salmon and cold water trout. They may help lower the risk of heart disease in some people.

Cross-over Foods
Dry beans, peas and lentils offer protein and fiber without the cholesterol and fat that meats have. Once in a while, try substituting beans for meat in a favorite recipe, such as lasagna or chili.

TVP, or textured vegetable protein, is widely available in many foods. Vegetarian "hot dogs," "hamburger" and "chicken nuggets" are low-fat, cholesterol-free alternatives to meat.

Instead of this:

Try this:

Regular or breaded fish sticks or cakes, fish canned in oil, seafood prepared with butter or served in high-fat sauce

Fish (fresh, frozen, canned in water), low-fat fish sticks or cakes and shellfish (such as shrimp)

Prime and marbled cuts

Select-grade lean beef (round, sirloin and loin)

Pork spare ribs and bacon

Lean pork (tenderloin and loin chop) and turkey bacon

Regular ground beef

Lean or extra-lean ground beef, ground chicken and turkey breast

Lunch meats such as pepperoni, salami, bologna and liverwurst

Lean lunch meats such as turkey, chicken and ham

Regular hot dogs or sausage

Fat-free hot dogs and turkey dogs

Fruits and Vegetables

Fruits and vegetables are naturally low in fat. They add flavor and variety to your diet. They also contain fiber, vitamins and minerals.

Margarine, butter, mayonnaise and sour cream add fat to vegetables and fruits. Try using nonfat or low-fat versions of these foods. You can also use nonfat or low-fat yogurt or herbs as seasonings instead.

Instead of this:

Try this:

Fried vegetables or vegetables served with cream, cheese or butter sauces

All vegetables raw, steamed, broiled, baked or tossed with a very small amount of olive oil and salt and pepper


Fruit (fresh or canned in light syrup)

French fries, hash browns and potato chips

Baked, mashed and boiled potatoes or sweet potatoes


Whole-grain breads are low in fat; they're also high in fiber and complex carbohydrates, which helps you feel fuller longer and prevents overeating. Choose these breads for sandwiches and as additions to meals.

Avoid rich bakery foods such as donuts, sweet rolls and muffins. These foods can contain more than 50% fat calories. Snacks such as angel food cake and gingersnap cookies can satisfy your sweet tooth without adding fat to your diet.

Hot and cold cereals are usually low in fat. But instant cereals with cream may contain high-fat oils or butterfat. Granola cereals may also contain high-fat oils and extra sugars. Look for low-sugar options for both instant and granola cereals.

Avoid fried snacks such as potato chips and tortilla chips. Try the low-fat or baked versions instead.

Instead of this:

Try this:

Croissants, biscuits, white breads and rolls

Low-fat whole grain breads and rolls (wheat, rye and pumpernickel)

Doughnuts, pastries and scones

English muffins and small whole grain bagels

Fried tortillas

Soft tortillas (corn or whole wheat)

Sugar cereals and regular granola

Oatmeal, low-fat granola and whole-grain cereal

Snack crackers

Crackers (animal, graham, rye, soda, saltine, oyster)

Potato or corn chips and buttered popcorn

Pretzels (unsalted) and popcorn (unbuttered)

White pasta

Whole-wheat pasta

White rice

Brown rice

Fried rice, or pasta and rice mixes that contain high-fat sauces

Rice or pasta (without egg yolk) with vegetable sauces

All-purpose white flour

100% whole-wheat flour

Determine Your Calorie Needs

Different groups of people have different daily calorie needs. For example, an adult athlete will need to consume more calories than a moderately active 3 year old.

When eating store-bought foods, be sure to look at the nutrition label to see how many calories are in one serving.

When eating out, choose what you’ll eat before you go. Most restaurants offer nutritional information online.

The following chart will help you determine the appropriate calorie need for your age, gender and activity level.



Activity Level


Age (years)


Moderately Active




1,000 calories

1,000-1,400* calories

1,000-1,400 calories*



1,200 calories

1,400-1,600 calories

1,400-1,800 calories



1,600 calories

1,600-2,000 calories

1,800-2,200 calories



1,800 calories

2,000 calories

2,400 calories



2,000 calories

2,000-2,200 calories

2,400 calories



1,800 calories

2,000 calories

2,200 calories



1,600 calories

1,800 calories

2,000-2,200 calories



1,400 calories

1,400-1,600 calories

1,600-2,000 calories



1,800 calories

1,800-2,200 calories

2,000-2,600 calories



2,200 calories

2,400-2,800 calories

2,800-3,200 calories



2,400 calories

2,600-2,800 calories

3,000 calories



2,200 calories

2,400-2,600 calories

2,800-3,000 calories



2,000 calories

2,200-2,400 calories

2,400-2,800 calories

* - The calorie ranges shown reflect the needs of different ages within the group. Children and adolescents need more calories as they get older. However, adults needs fewer calories at older ages.
The following terms are used in the chart and are defined by the U.S. Department of Agriculture:

Sedentary - a lifestyle that includes activity that is only associated with day-to-day life.

Moderately active - a lifestyle that includes physical activity equal to walking between 1.5 and 3 miles per day.

Active - a lifestyle that includes physical activity equal to walking more than 3 miles per day.


Vitamins and minerals


The following information is based on the Nutrient Reference Values for Australia and New Zealand Including Recommended Dietary Intakes. Specific advice for individual needs should be sought from a qualified dietitian.

The term nutrient identifies those substances in food that provide essential nourishment to maintain life.

Nutrient (Vitamins)

Needed for

Key sources

Vitamin A

  • maintaining normal reproduction
  • good vision
  • formation and maintenance of healthy skin, teeth and soft tissues of the body
  • immune function (has anti-oxidant properties).

Milk, cheese, eggs, fatty fish, yellow-orange vegetables and fruits such as carrots, pumpkin, mango, apricots, and other vegetables such as spinach, broccoli.

Vitamin B1 (Thiamin)

  • supplying energy to tissues
  • breaking down and using the energy and nutrients in carbohydrates, proteins and fats
  • nerve function

Fortified breakfast cereals, baking flour, wholegrains, wheatgerm, yeast, legumes, nuts, pork.

Vitamin B2 (Riboflavin)

  • obtaining energy from food
  • making Vit B6 active in the body
  • reducing a key cardiovascular risk factor
  • production of red blood cells and body growth

Milk, cheese, yoghurt, fortified breads and breakfast cereals.

Vitamin B3 (Niacin)

  • obtaining energy from food
  • breaking down and using carbohydrates, proteins and fats and their building blocks
  • maintaining healthy skin and nerves
  • releasing calcium from cellular stores

Beef, pork, liver, beans, wholegrain cereals, eggs, cow’s milk.

Pantothenic acid

  • making, hormones, vitamin A and D and substances that help make nerves work
  • helps make new fats and proteins in the body

Chicken, beef, potatoes, oat-based cereals, tomatoes, egg yolks, whole grains.

Vitamin B6 (Pyridoxine)

  • breaking down,using and reforming the building blocks of proteins

Muscle and organ meats, fortified breakfast cereals, brussel sprouts, green peas, beans, split peas, and fruit.

Vitamin B12 (Cyano-cobalamin)

  • normal nerve function
  • normal blood function

Beef, lamb, fish, veal, chicken, eggs, milk and other dairy products.


  • breaking down and using the building blocks of proteins
  • the processes of tissue growth and cell function
  • maintaining good heart health
  • preventing neural tube defects in newborns

Cereals, cereal products, vegetables eg broccoli, legumes and fruit eg oranges.


  • breaking down and using the building blocks of fats and proteins

Meats and cereals.

Note: eating raw egg whites prevents absorption of biotin.


  • making nerve cell transmitters and cell membranes
  • inflammatory and allergic response
  • healthy kidneys and liver
  • reducing the risk of heart disease
  • fat and cholesterol transport and break down in the body

Milk, eggs, peanuts, wheat germ, dried soybeans.

Vitamin C (Ascorbic acid)

  • protects against oxidative damage
  • aiding absorption of iron and copper
  • formation of collagen
  • healthy bones
  • helps fight infection
  • helps regenerate and stabilise other vitamins such as vitamin E or folate

Blackcurrants, orange, grapefruit, guava, kiwi fruit, raspberries, sweet peppers (Capsicum), broccoli, sprouts.

Vitamin D

  • absorption of calcium and phosphorus
  • maintenance of calcium levels in blood
  • immune function
  • healthy skin
  • muscle strength

Sunlight on skin allows the body to produce Vitamin D. Few foods contain significant amounts however main dietary sources are fortified margarine, salmon, herring, mackerel, and eggs.

Vitamin E (Tocopherol)

  • acts as antioxidant particularly for fats
  • keeping heart, circulation, skin and nervous system in good condition

Oils and margarines, fats of meats, chicken, fish, wheat germ, , spinach, cashews, peanuts, almonds, sunflower seeds.

Vitamin K (phylloquinone)

  • normal blood clotting

Spinach, salad greens, cabbage, broccoli, brussel sprouts, soybean oil, canola oil, margarines


  • development and maintenance of bones and teeth
  • good functioning muscles and nerves
  • heart function

Milk, cheese, yoghurt, bony fish, legumes, fortified soy beverages and fortified breakfast cereals.

Note: the body excretes calcium with salt in urine, so eat less salt to retain your calcium.


  • enhancing the action of insulin to regulate blood sugar

Widely found in foods such as yeast, eggs, meat, whole grains, cheese.


  • the functioning of several enzymes
  • formation of connective tissue
  • iron metabolism and blood cell formation
  • nervous system, immune system and cardiovascular system function

Organ meats, seafood, nuts, seeds, wheat bran cereals, whole grains.


  • healthy teeth and bones

Fluoridated water, fish, tea.


  • normal thyroid function (important in the growth and development of central nervous system)
  • energy production
  • oxygen consumption in cells

Salt water fish, shellfish, seaweed, iodised salt, vegetables (if there is iodine in the soil where they are grown).

Note: Severe deficiencies can cause miscarriage, stillbirth, infant mortality, congenital abnormalities etc.


  • Haemoglobin in red blood cells (important for transport of oxygen to tissues)
  • component of myoglobin (muscle protein)

Red meats – beef, lamb, veal, pork, fish, chicken and wholegrain cereals.

Note: Iron absorption from plant sources eg cereals or green leafy vegetables is much lower than from animal sources so 80% more is required in the food to get the same amount absorbed. Vitamin C helps with absorption.


  • the functioning of more than 300 enzyme systems
  • energy production
  • regulating potassium levels
  • the use of calcium
  • healthy bones

Green vegetables, legumes, peas, beans, lentils, nuts, wholegrains and cereals


  • healthy bones
  • carbohydrate, cholesterol and protein metabolism

Cereal products, tea, vegetables.


  • breakdown of proteins

Legumes, wholegrain products, nuts.


  • forms part of DNA and RNA
  • buffers the acidity of urine
  • protection of acid/base balance of blood
  • storage and transport of energy
  • helps activate some proteins

Widely distributed in natural foods eg dairy, meat, dried fruit, eggs, cereals.


  • nerve impulses
  • muscle contraction
  • regulates blood pressure

Leafy green vegetables, tomatoes, cucumbers, zucchini, eggplant, pumpkin, root vegetables. Also moderately abundant in beans, peas, bananas, avocados, milk, yoghurt

Note: Potassium has a beneficial effect in offsetting the effects of sodium (salt) on blood pressure.


  • antioxidant
  • thyroid metabolism
  • part of several functional proteins in body

Seafood, poultry, eggs and to a lesser extent other muscle meats and cereal foods (content varies widely with soil condition).


  • maintain water balance throughout the body
  • nerve impulses
  • transport of molecules across cell walls

Found in most take-away and processed foods eg bread, butter, margarine, deli meats, cheese, cereals.

It is also a major component of table salt and baking soda

Note: It is important to use only moderate amounts of salt as recommended in the Dietary Guidelines.


  • component of enzymes that help maintain structure of proteins and regulate gene expression
  • needed for growth, immunity appetite and skin integrity

Meats, fish, poultry, cereals, dairy foods.

Note: availability from animal sources is greater than that from plant sources so vegetarians need 50% higher intakes.

Dietary Sources

The only reliable unfortified sources of vitamin B12 are meat, dairy products and eggs. There has been considerable research into possible plant food sources of B12. Fermented soya products, seaweeds and algae have all been proposed as possible sources of B12. However, analysis of fermented soya products, including tempeh, miso, shoyu and tamari, found no significant B12.
Spirulina, an algae available as a dietary supplement in tablet form, and nori, a seaweed, have both appeared to contain significant amounts of B12 after analysis. However, it is thought that this is due to the presence of compounds structurally similar to B12, known as B12 analogues. These cannot be utilised to satisfy dietary needs. Assay methods used to detect B12 are unable to differentiate between B12 and it's analogues, Analysis of possible B12 sources may give false positive results due to the presence of these analogues.
Researchers have suggested that supposed B12 supplements such as spirulina may in fact increase the risk of B12 deficiency disease, as the B12 analogues can compete with B12 and inhibit metabolism.
The current nutritional consensus is that no plant foods can be relied on as a safe source of vitamin B12.
Bacteria present in the large intestine are able to synthesise B12. In the past, it has been thought that the B12 produced by these colonic bacteria could be absorbed and utilised by humans. However, the bacteria produce B12 too far down the intestine for absorption to occur, B12 not being absorbed through the colon lining.
Human faeces can contain significant B12. A study has shown that a group of Iranian vegans obtained adequate B12 from unwashed vegetables which had been fertilised with human manure. Faecal contamination of vegetables and other plant foods can make a significant contribution to dietary needs, particularly in areas where hygiene standards may be low. This may be responsible for the lack of aneamia due to B12 deficiency in vegan communities in developing countries.
Good sources of vitamin B12 for vegetarians are dairy products or free-range eggs. ½ pint of milk (full fat or semi skimmed) contains 1.2 µg. A slice of vegetarian cheddar cheese (40g) contains 0.5 µg. A boiled egg contains 0.7 µg. Fermentation in the manufacture of yoghurt destroys much of the B12 present. Boiling milk can also destroy much of the B12.
Vegans are recommended to ensure their diet includes foods fortified with vitamin B12. A range of B12 fortified foods are available. These include yeast extracts, Vecon vegetable stock, veggieburger mixes, textured vegetable protein, soya milks, vegetable and sunflower margarines, and breakfast cereals.

Required Intakes

The old Recommended Daily Amounts (RDA's) have now been replaced by the term Reference Nutrient intake (RNI). The RNI is the amount of nutrient which is enough for at least 97% of the population.
Reference Nutrient Intakes for Vitamin B12, µg/day. (1000 µg = 1mg)



0 to 6 months

0.3 µg

7 to 12 months

0.4 µg

1 to 3 yrs

0.5 µg

4 to 6 yrs

0.8 µg

7 to 10 yrs

1.0 µg

11 to 14 yrs

1.2 µg

15 + yrs

1.5 µg

Breast feeding women

2.0 µg

Pregnant women are not thought to require any extra B12, though little is known about this. Lactating women need extra B12 to ensure an adequate supply in breast milk.
B12 has very low toxicity and high intakes are not thought to be dangerous.

Dietary Fiber

Quick Facts...

·  Fiber may be beneficial in treating or preventing constipation, hemorrhoids and diverticulosis.
·  Water-soluble fiber helps decrease blood cholesterol levels.
·  Foods containing dietary fiber include fruits, vegetables, nuts and grains.
·  Include a variety of high-fiber foods in the diet.
Can high-fiber diets really do all they claim to do? Studies have looked at the relationship between high-fiber diets and many diseases, including colon cancer, coronary heart disease and diabetes. Proven benefits of a high-fiber diet include prevention and treatment of constipation, hemorrhoids and diverticulosis. In addition, certain types of fiber help decrease blood cholesterol levels.

What Is Dietary Fiber?

Dietary fiber comes from the portion of plants that is not digested by enzymes in the intestinal tract. Part of it, however, may be metabolized by bacteria in the lower gut.
Different types of plants have varying amounts and kinds of fiber, including pectin, gum, mucilage, cellulose, hemicellulose and lignin. Pectin and gum are water-soluble fibers found inside plant cells. They slow the passage of food through the intestines but do nothing to increase fecal bulk. Beans, oat bran, fruit and vegetables contain soluble fiber.
In contrast, fibers in cell walls are water insoluble. These include cellulose, hemicellulose and lignin. Such fibers increase fecal bulk and speed up the passage of food through the digestive tract. Wheat bran and whole grains contain the most insoluble fiber, but vegetables and beans also are good sources.
Sometimes there is confusion as to the difference between crude fiber and dietary fiber. Both are determined by a laboratory analysis, but crude fiber is only one-seventh to one-half of total dietary fiber.

Table 1: Sources of dietary fiber.

Soluble Fiber

Insoluble Fiber


whole grains

oat bran

whole grains





Benefits of Fiber

Insoluble fiber binds water, making stools softer and bulkier. Therefore, fiber, especially that found in whole grain products, is helpful in the treatment and prevention of constipation, hemorrhoids and diverticulosis. Diverticula are pouches of the intestinal wall that can become inflamed and painful. In the past, a low-fiber diet was prescribed for this condition. It is now known that a high-fiber diet gives better results once the inflammation has subsided.
Low blood cholesterol levels (below 200 mg/dl.) have been associated with a reduced risk of coronary heart disease. The body eliminates cholesterol through the excretion of bile acids. Water-soluble fiber binds bile acids, suggesting that a high-fiber diet may result in an increased excretion of cholesterol. Some types of fiber, however, appear to have a greater effect than others. The fiber found in rolled oats is more effective in lowering blood cholesterol levels than the fiber found in wheat. Pectin has a similar effect in that it, too, can lower the amount of cholesterol in the blood.
Other claims for fiber are less well founded. Dietary fiber may help reduce the risk of some cancers, especially colon cancer. This idea is based on information that insoluble fiber increases the rate at which wastes are removed from the body. This means the body may have less exposure to toxic substances produced during digestion. However, more recent studies have not confirmed the protective effects of fiber in developing colon cancer. A diet high in animal fat and protein also may play a role in the development of colon cancer.
High-fiber diets may be useful for people who wish to lose weight. Fiber itself has no calories, yet provides a "full" feeling because of its water-absorbing ability. For example, an apple is more filling than a half cup of apple juice that contains about the same calories. Foods high in fiber often require more chewing, so a person is unable to eat a large number of calories in a short amount of time.

Sources of Fiber

Dietary fiber is found only in plant foods: fruits, vegetables, nuts and grains. Meat, milk and eggs do not contain fiber. The form of food may or may not affect its fiber content. Canned and frozen fruits and vegetables contain just as much fiber as raw ones. Other types of processing, though, may reduce fiber content. Drying and crushing, for example, destroy the water-holding qualities of fiber.
The removal of seeds, peels or hulls also reduces fiber content. Whole tomatoes have more fiber than peeled tomatoes, which have more than tomato juice. Likewise, whole wheat bread contains more fiber than white bread. Table 2 lists the dietary fiber content of some common foods.

How Much Fiber?

The average American consumes 14 grams of dietary fiber a day, which is considerably less than the recommended level. The current recommendations, according to the 2005 Dietary Guidelines for Americans, is 14 grams of fiber per 1000 calories consumed. So, if you consume a 2500 calorie diet, you should eat approximately 35 grams of fiber per day. Also, fiber intake may vary depending on age and gender.
While the 2005 Dietary Guidelines for Americans serves as a general guide to healthy eating, the Dietary Reference Intakes (DRIs) provide standard recommended amounts for nutrients. In 2002, the Food and Nutrition Board of the National Academy of Sciences Research Council issued DRIs for fiber (see Table 1). Previously, no national standardized recommendation existed. The new DRIs represent desirable intake levels established using the most recent scientific evidence available.

Table 2: Dietary Reference Intakes (DRI) for Fiber.


g/day Fiber


1-3 years


4-8 years



9-13 years


14-18 years


19-50 years


51+ years



9-13 years


14-18 years


19-50 years


51+ years



<18 years


18+ years



<18 years


18+ years


For many people, meeting the DRI for fiber may require changes in their eating habits. Eating several servings of whole grains, fruits, vegetables and dried beans each day is good way to boost fiber intake. However, if you are not used to eating high fiber foods regularly, these changes should be made gradually to avoid problems with gas and diarrhea. Also, drink plenty of water to minimize intestinal gas. Anyone with a chronic disease should consult a physician before greatly altering a diet. If problems with gas continue to be an issue, gas-reducing over-the-counter and prescription drugs are available.

Food Labeling of Fiber

Nutrients required on food labels reflect current public health concerns and coincide with current public health recommendations. Nutrition labels now list a Daily Reference Value (DRV) for specific nutrients, including fiber. The DRV for fiber is 25 grams per day based on a 2,000 calorie diet, or 30 grams per day based on a 2,500 calorie diet. The fiber content of a food is listed in grams and as a percentage of the daily value.
Figure 1 shows a food nutrition label. It tells you the product provides 3 g of fiber in a half cup serving. The percent Daily Value for one serving is 12 percent, or 12 percent of DRV of 25 grams based on a 2,000 calorie diet.
Specific health claims can be made for food products that meet specific requirements. For example: "Diets low in saturated fat and cholesterol and rich in fruits, vegetables and grain products that contain fiber, particularly soluble fiber, may reduce the risk of coronary heart disease." In order to make a health claim about fiber and coronary heart disease, the food must contain at least 0.6 g of soluble fiber per reference amount. The soluble fiber content must be listed and cannot be added or fortified. A product containing a health claim for fiber and coronary heart disease must also meet the definitions of a low fat, low in saturated fat and low in cholesterol product.
A statement such as "made with oat bran" or "high in oat bran" implies that a product contains a considerable amount of the nutrient. Claims that imply a product contains a particular amount of fiber can be made only if the food actually meets the definition for "high fiber" or "good source of fiber," whichever is appropriate.
The following terms describe products that can help increase fiber intake:

  • Nutrition FactsHigh fiber: 5 g or more per serving
  • Good source of fiber: 2.5 g to 4.9 g per serving
  • More or added fiber: At least 2.5 g more per serving than the reference food

Although fiber is important, it is just one part of a properly balanced diet. It is possible that too much fiber may reduce the amount of calcium, iron, zinc, copper and magnesium that is absorbed from foods. Deficiencies of these nutrients could result if the amount of fiber in the diet is excessive, especially in young children.
Fiber supplements are sold in a variety of forms from bran tablets to purified cellulose. Many laxatives sold as stool softeners actually are fiber supplements. Fiber's role in the diet is still being investigated. It appears that the various types of fiber have different roles in the body. Furthermore, fiber may interact wil prescription medications.
For these reasons, avoid fiber supplements. Instead, eat a variety of fiber-rich foods. This is the best way to receive the maximum benefits from each type of fiber present in foods, and obtain necessary nutrients.


  • Farley, Dixie. May 1993. Look for 'LEGIT' Health Claims on Foods. FDA Consumer.
  • Kurtzweil, Paula. May 1993. Nutrition Facts to Help Consumers Eat Smart. FDA Consumer.
  • Duyff, Roberta. American Dietetic Association's 2nd Edition Complete Food and Nutrition Guide. P130-142. 2002.
  • Slavin, J. "Dietary Fiber: Mechanisms or Magic in Disease Prevention?" Nutrition Today. Nov/Dec. 1990.
  • Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients). National Academy Press p. 265-334. 2002.
  • UC Berkley Wellness Letter, April 2007.

Table 3: Dietary fiber content of foods.


Serving size


Breads, cereals, grains

White bread

1 slice


Whole grain bread

1 slice


100% All Bran

1/2 cup


Corn Flakes

1 cup


Shredded Wheat

2 biscuits


Oatmeal, cooked

1 cup


Rice, brown, cooked

1 cup


Rice, white, cooked

1/3 cup


Fruit (fresh unless otherwise noted)

Apple, with skin

1 large









1 cup








Grapefruit, pink and red



Grapefruit, white



Melon, cantaloupe

1 cup






1 small






1 medium



1 cup



1 small


Prunes, dried




1 cup



1 cup



Beans, baked, canned, plain

1 cup


Beans, green, cooked

1 cup


Beets, canned

1 cup


Broccoli, raw

1 cup


Cabbage, raw

1 cup


Carrots, raw

1 cup


Cauliflower, raw

1 cup


Celery, raw

1 cup


Corn, yellow, cooked

1 cup


Lentils, cooked

1 cup


Lettuce, romaine, raw

1 cup


Lettuce, iceberg, raw

1 cup


Peas, boiled

1 cup


Peas, split

1 cup


Potato, baked, fresh

1/2 potato


Sweet potato, cooked without skin

1/2 potato


Tomato, red, ripe

1 tomato


Winter squash, cooked

1 cup


Zucchini squash

1/2 cup


Other foods

Meat, milk, eggs



Almonds (24 nuts)

1 oz.


Peanuts, dry roasted (approx. 28)

1 oz.


Walnuts, English (14 halves)

1 oz.


Food Habits Survey

Food Habits Survey

Your doctor would like some information about your usual food habits to help plan the best possible health care for you.

Please complete all sections as completely and accurately as possible.

Survey: General Information

Name ________________________

Date _________________________

Who shops for food at your home? ____________________________

Who prepares it? ____________________________

What do you drink during the day? ____________________________

What kind of meat do you usually buy?
___ hamburger, steaks, pork chops ___ chicken, fish

What type of meal or meals do you prepare most often?
___ fry ___ bake ___ broil ___ stew/slow cook ___ grill

How many times a day do you eat? ____________________________

What do you usually eat? ____________________________

How many times do you eat out during the week? ___________________

What restaurant do you go to most often? ____________________________

List any vitamins or dietary supplements you take here. How many of each do you take? How often?

If you eat any special foods for health or personal reasons, list what kind and how much.

Do you add salt to your food at the table?
___ Yes ___ No

Do you add salt to foods when you cook?
___ Yes ___ No

Sample Survey

The sample Food Habits Survey for Fred shows what he eats in a day from two food groups: Grain Products and Vegetables.

Fred usually eats 2 or 3 slices of bread or toast a day, so he wrote "2-3" in the blank beside "slice(s) of bread." He eats a roll most days. He has a large bowl of cold cereal for breakfast, so he wrote in "2" because it's about the size of 2 small bowls. Fred usually has 2 helpings of vegetables a day, so he wrote "2" on the line for "scoop-sized helping(s) of vegetables." He also has a small salad nearly every day.

Grain Products

2-3 slice(s) of bread

___ tortilla(s)

1 small roll(s), biscuit(s) or muffin(s)

___ 1/2 bun(s), English muffin(s) or bagel(s)

___ small helping(s) of cooked cereal, rice or pasta

2 small bowl(s) of cold cereal


2 scoop-sized helping(s) of vegetables

1 small vegetable salad(s)

___ medium-sized potato(es)

Now fill out the form below to show what you eat on a typical day.

Survey: Your Daily Diet


Mixed Foods

____ slice(s) of bread

____ small square(s) of lasagna

____ tortilla(s)

____ small serving(s) of spaghetti with meat sauce

____ small roll(s), biscuit(s) or muffin(s)

____ small serving(s) of macaroni and cheese

____ 1/2 bun(s), English muffin(s) or bagel(s)

____ taco(s)

____ small helping(s) of cooked cereal, rice or pasta

____ burrito(s)

____ small bowl(s) of cold cereal

____ slice(s) of pizza





____ scoop-sized helping(s) of vegetables

____ cup(s) of regular coffee

____ small vegetable salad(s)

____ cup(s) of decaf coffee

____ medium-sized potato(es)

____ cup(s) of regular tea


____ cup(s) of decaf tea


____ 12-ounce soft drinks

____ piece(s) of fruit (an apple, orange, banana, slice of melon, etc.)

____ 12-ounce diet drinks

____ 1/2 cup(s) cooked or canned fruit

____ glass(es) of Kool-Aid or fruit punch

____ small glass(es) of fruit juice

____ glass(es) of water




Sweets and Fats

____ glass(es) (8 ounces) of whole milk

____ sweet roll(s) or donut(s)

____ glass(es) of 2% milk

____ slice(s) of pie or cake

____ glass(es) of 1% or skim milk

____ 3 small cookies

____ 1 ounce slice(s) of cheese

____ candy bar(s)

____ serving(s) of yogurt or cottage cheese

____ 10 chips or french fries

____ 1/2 cup(s) of ice cream

____ rounded teaspoon(s) of margarine or butter


____ tablespoon(s) of salad dressing

Meat or Meat Alternatives


____ small piece(s) of meat, fish or poultry (about the size of a deck of cards)


____ 2 eggs

____ 12-ounce beer(s)

____ 1 cup(s) cooked dried beans or peas

____ 4 ounces of wine (small glass)

____ 4 tablespoons peanut butter

____ shot(s) of liquor

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