FINAL

What anthropometric, chemical, metabolic, and diet histories are usually note in an nutrition assessments of cancer patients?

Body weight assessment - any unplanned weight loss or BMI <22 • Serum albumin: <3.5 mg/dL • Cholesterol: < 150 mg/dL • Collect diet history to determine if calorie intake is adequate and overall diet quality is appropriate (especially related to protein & vitamin/mineral intake

How are dieting and controlling child feeding practices similar?

Both ignore internal cues of hunger and satiety. Both contribute to onset of obesity , possibly nutritionally inferior diet, and eating disorders.

AN Clinical findings

Bradycardia Hypothermia Cardiac murmur ◦ 1/3 have mitral valve prolapse Dull, thinning scalp hair Sunken cheeks ◦ sallow skin Lanugo (fine, downy hair growth) Atrophic breasts (postpubertal) Atrophic vaginitis (postpubertal) Pitting edema of extremities Emaciated ◦ may wear oversized clothes Flat affect ( no or low emotional expression on the face) Acrocyanosis ◦ circulatory disorder ◦ cold and sweaty

CARDIOVASCULAR DISEASE (CVD)

Broad term that encompasses coronary heart disease (CHD), stroke and any other conditions affecting structure or function of heart, such as: Atherosclerosis, Dyslipidemia & Hypertension Affects 1 in 4 Americans Number 1 cause of death in US

Osteoporosis nutritional remedies

Calcium Adequate intake minimizes bone loss Vitamin D Stimulates active calcium transport Promote effective daily bone remodeling Consume calcium-rich beverages with meals Increase fruit & veggie intake for alkalization Consume foods rich in bone-building vitamins & minerals If taking supplements, divide dosage throughout day for greater absorption

If, energy requirements decline in OA, about macronutrients and fluids?

Carbohydrates still should be 45-65% but should focus on increasing fiber rich foods. 38 g/ day for M and 25 g/day FM There is no optimal amout of protein but the suggested range should be .8 - 1.5 g/ kg bw/day. Since many OA may be on low-calorie diets may need up to 35% protein. Consider asking how much will meet the inviduals needs, are enou calories eaten so that protein does not be used for energy, is enough good quality protein consumed, are there additional needs for protein such as healing wounds, or are they exercising? There is not change for fat either - still 20-35% Should have 6+ cups of water or 1 mL per calorie eaten with 1,500 mL minimum

Why should parents and caretakers establish regular but flexible meal and snack times?

To consider the toddler's needs for rituals and limit setting as well as allow enough time for toddler to get hungry.

Main goals of MNT for cancer? Nutrition Recommendations?

To prevent or reverse nutrient deficiencies, to preserve lean body mass, minimize nutrition-related side effects and maximize quality of life Nutritional recommendations are highly variable & must be individualized • Protein: 1.2 to 2.0 g/kg (avg 1.5 g/kg) • Energy: 21 to 40 kcal/kg/day depending on need for weight gain, metabolic state, presence of sepsis etc.

How should a child's physical growth be measured/ monitored & evaluated based on their age?

Toddlers <2 years old should be weighed w/o clothing or a diaper. The recumbent length ( length while child is lying down) should be measured on a length board w/ a fixed head board and movable foot board. This process usually takes 2 adults. On person holds the legs so there feet are pressed against the foot board and other makes sure the crown of the head is firmly placed against the head board. It is important that both weight and height are plotted on the appropriate growth charts (WHO for children under 2 and CDC for children over 2)

Measuring total energy expenditure

Total energy expenditure (TEE) is the sum of resting energy expenditure (REE), dietary-induced thermogenesis (DIT), and physical activity (PA) and varies with gender, age, and body size. Typically, physical activity accounts for 10-15% of TEE, but athletes in strenuous training programs may increase TEE by two- to threefold.

obesogenic diet

caloric intake exceeding needs unstructured eating frequent ff consumption high fat intake sugar sweetened beverage consumption energy dense, nutrient poor choices

Risk factors for eating disorders

Family -History of dieting/eating disorders -History of depression/anxiety/alcohol dependence -History of obesity Individual -Female gender: more prevalent in females ( 20 M American women vs 10 M American men - genetics -premature birth -low self-esteem -perfectionism -previous obesity -diabetes -Crohn's disease Possible trigger/ maintaining factors - puberty -socio cultural pressures -family factors -pressure to achieve -behavior of peers -comments about weight

RDA for FE, Zn, Ca 9-13 years

Fe: 8 Zn 8 ca: 1300

What can recovery of FTT include?

catch up growth (acceleration of growth rate for age)

Why do snacks continue to meet the needs of school age children/ pre-adolescents ?

children cannot consume large amounts of food at one time and need snacks to meet nutrient needs

PA recommendations for school age children/ pre-adolescents

children should engage in at least 60 min of physical activity daily

Why can constipation be a problem in young children? What is recommended? Why is fiber beneficial/ potentially harmful?

due to stool holding which develops when the child does not completely empty the rectum, which causes a large fecal mass that can be painful Adequate fluid and fiber intake. 1-3 yo = 19 g/day of total fiber 4-8 yo 25g/day of total fiber **Excess fiber can be detrimental since high-fiber diets have the potential of reducing the energy density of the diet, which can impact growth. High fiber diets can also impact bioavailability of minerals such as iron and calcium. **Children with adequate fiber intake tend to have lower intakes of fat and cholesterol, and higher intakes of Vitamins A and E, folate, mg, and Fe than those w/ low dietary fiber intakes.

t or f: BMI is constant throughout childhood explain why.

f; it is NOT constant throughout childhood. since a Childs height is constantly increasing

When is dietary supplementation recommended for school age children/ pre-adolescents ?

for children at high risk of developing nutrient deficiencies or have 1 or more nutrition deficiency, such as: 1. With anorexia or inadequate appetite or who follow fad diets 2. With chronic disease 3. From deprived families or who suffer from parental neglected or abuse 4. Who participate in a dietary program for managing obesity 5. Who consume a vegetarian diet without adequate intake of dairy products 6. With failure to thrive If supplement is given, be sure to not exceed the Tolerable Upper Intake levels designated in DRI tables

Constipation

hard and dry stools associated with painful bowel movements

Corpulmonale

heart condition characterized by enlargement of right side of heart (as result of pulmonary hypertension)

protein, energy,, fluids trends as at different stages of CKD

in stages 1-4 you need less protein, but similar./same energy and fluid levels at stage five with hemodialysis - can need more protein (1.2 g/kg bw), 1000 mL + urine output at stage five peritoneal dialysis need same to slightely more protein (!.2-1.3 g/kg bw), and monitor fluid input of 1500-2000 mL/day at transplant intially need more energy, protein (up to 1.5 g/kg bw) at transplant maintenance energy needs are back to normal (25-30 kcal), protein 1.0 and fluids are not restricted unless indicated

DASH diet

increase fruit, vegetables, and low fat dairy; k, mg, ca Cut back on foods that are high in saturated fat, cholesterol, and trans fats Eat more whole-grain foods, fish, poultry, and nuts

healthcare providers need to share facts and options so that the patient or healthcare proxy can make an informed decision based on:

Nutrition needs Medical status Cultural/spiritual needs

Common considerations for COPD nutrition assessment

**Well-nourished nutritional state plays key role in maintaining muscle strength, improved immune response & reducing risk of respiratory mortality -Malnutrition is common among COPD patients so screening for it is key -Four point Criteria to detect malnutrition in COPD patients (Thorsdottir, Eriksen & Eysteinsdottir, 1999) • Serum Albumin, total lymphocyte count, BMI & triceps skinfold thickness

Feeding Problems: CP General

- CP children have higher need for nutrition services since feeding problems usually worsen over time. -Nutrition intervention may include encouraging weight gain if body fat stores are low. -An estimate of energy needs for activity may be higher for a preschooler with CP

Behavioral Feeding problems: ASD and ADHD

- Food refusal is common - Self-restricted food selection - gluten restriction is NOT recommended although some families may do so believing that behaviors will improve

Suggested interventions for children with feeding difficulties

- Foods appropriate for younger children -Offering food textures that they can eat successfully, even if the same food daily -continuing to offer liquids in a bottle -Collaboration with a speech language specialist or OT who works w/ children with special health care needs will assist the child in improving their feeding skills

Carcinogenic diet

- Low fruit and veggie - Low levels of antioxidants (A and C) - Low intake of whole grains and fiber - High dietary fat - Nitrosamines - Pickled and fermented food - Alcohol - High animal, low plant based

Strategies for parents of school age children/ pre-adolescents to meet min PA

- Set a good ex. Be physically active and join children in PA -Encourage PA at home, at school, and with friends -Limit TV and video/DVD watching, computer and video game playing, time at computer, texting, other sedentary activities - screen time should be less than 2 hours/day

Why might a child with BPD have feeding difficulties? What are the recommendations?

- They may have low interest in feeding due tiredness -normal progression of feeding skills interrupted -medications and their sides effect (many increase nutrition needs) -Interrupted sleep and fatigue make and hunger and fullness cues harder to interpret - Increased frequency of infections can slow weight gain and growth Recommendations: - Small frequent meals with foods that are concentrated energy sources -easy to eat foods - if the first dietary recommendation do NOT work may to add homemade or commercially prepared nutritional supplements to meet higher energy and protein needs,

Cognitive development in school age children/ pre-adolescents

- characterized by being able to focus on several aspects of a situation at the same time; being able to have more rational reasoning (cause/effect), and generalize -decrease in egocentrism, and children see other POVs - enjoy playing strategy games -increased independence and learn their roles -peer relationships increasingly important

Feeding problem re: Pulmonary problems

- children may have asthma, allergies, infections - nutrition diagnoses are based on the impact on food and nutrient intake such as excessive fluid intake due to difficulty eating solid foods. -nutrition services are needed because recurrent breathing problems increase nutritional needs, lower interest in eating, and can slow growth. - premature infants are more liklely to have breathing difficulties. -bronchopulmonary dysplasia (BPD) is thought to be a consequence of unresolved infants or unrepaired lung damage that occures to a premature infant who receives supplement O2 and ventilator support in NICU. -young children w/ BPD need extra energy due to increased work of breathing (WOB).

Energy and Nutrient needs of school age children/ pre-adolescents

- equations for estimating energy requirement have been developed as part of the DRI based on gender, age height, weight, and physical activity level (PAL) - EER is defined as total energy expenditure plus kcal for energy deposition -protein DRI is 0.95 g/kg/day for 4-13 girls and boyes

Development of feeding skills and eating behaviors in school age children/ pre-adolescents

- increased feeding skills; masters use of eating utensils and can be involved in simple food preparation. Performing such tasks boost self-esteem -parents are responsible for the food environment in the home, what foods are available, and when served. -the child is responsible for how much is eaten

Fat soluble vitamins and calcium in young children DRIs:

-400 UI Vitamin D for healthy children according to AAP -600 UI vitamin D for children 1-8 yo according to DGA 2010 - 700 mg/day calcium for ages 1-3 and 1000 mg/day for ages 4-8.

Examples of feeding challenges

-Assistance and supervision needed due to low self-feeding skills Low food intake due to increased meal length or food loss Adjustment in timing of meals and snacks at home or school

The Division of Responsibility for toddlers through adolescents (re: feeding):

-The parent is responsible for what, when, and where. • The child is responsible for how much and whether

The Division of Responsibility for babies making the transition to family food (re: Feeding):

-The parent is still responsible for what, and is becoming responsible for when and where the child is fed. • The child is still and always responsible for how much and whether to eat the foods offered by the parent.

Toddler & preschooler nutrition recommendations

-Toddlers need ~1,000 kcals/day (more as they grow and increase activity) ◦ Preschoolers need ~1,400-1,600 kcals/day ◦ Structure meal time (3 meals and 2-3 healthy snacks) ◦ Include a variety of foods and textures ◦ Whole grains, omega-3s, whole fat dairy, fiber, fruits, vegetables ◦ Water is the beverage of choice ◦ Avoid added sugars and snacks high in sodium ◦ Fruit instead of juice

Adequate fluids for school age children/ pre-adolescents ?

-cold water is the best fluid -sugary drinks should be limited as they have empty calories, displace milk consumption, and promote tooth decay Total water for 4-8 yo is 7 cups Total water for 9-13 yo girls is 9 cups and 10 cups for boys

Feeding Problems: Spastic Quadriplegia

-feeding assessment might be necessary as part of the overall nutrition assessment - feeding assessment may include observation of eating to determine any restrictions in the type of foods that the child can eat, and whether coordinating muscles for chewing, swallowing, and/or using a spoon or fork are working well.

Important physiological milestones and development in school-age children/preadolescents:

-in middle childhood boys have more lean body mass than girls -a child's height constantly increases, thus BMI for age percentiles are the only way to know if the child's BMI is abnormal. - body fat increases and boys will NOT be able to increase muscle mass until adolescence

Common nutrition problems school age children/ pre-adolescents

-iron deficiency- though nor as common as in toddler age group -Dental caries

Other then family, what influences eating in school age children/ pre-adolescents

-outside influences such as peers and teachers. -media/ tv/ advertisements - Advergames: online games that feature the company's product or brand character - advercation: a combination of ads, entertainment, and education

Programs in which nutrition care may be accessed include

-state programs for children w/special health care needs -early intervention programs ( for 0-36 months of age) - Early childhood education programs (IDEA; ages 3-5) - Early head start; regular program or special needs category (Ages 0-36 months) -WIC -Low birthweight follow-up programs -Child care feeding programs via USDA

What are the protein requirements for adolescents? When are they the highest and why?

0.85 g/kg bw/ day. They are highest in FM ages 11-14 and M ages 15-18. Protein req depend on how much is needed to maintain lean body mass and growth of new lean body mass. At this stage/these ages, growth is at its peak, thus more protein is needed.

Toddler sized portions are

1 Tbsp of food per age. for example a 2 year old child should consume 2 Tbsp of that food. It is better to start small and let the child ask for larger portions.

treatment considerations for older adults with heart disease

1)To Promote healthy fats • Use lean meats • Substitute saturated fatty acids with PUFA & MUFA Focus on 1-2 items to decrease saturated fat intake Ensure adequate protein intake Focus on oils currently using and suggest one to change. Decrease synthetic trans-fatty acids. Consider giving a brief description of trans-fatty acids and sources, based on mental awareness and readiness to change 2)To Promote fruits & vegetables, encourage to suppress inflammation; Work with fruits/veggies individual can chew (e.g., if dentures, do they fit?). Blend pureed fruits and vegetables into sauces, soups, smoothies. 3)Healthy cooking: Goals: food safety, adequate nutrient intake, matched to skills. 4)Limit salt: Focus on "no added salt" and no salt shaker on table. Assess use of convenience products, fast foods, breads, cereals. 5)Label reading: May be difficult if eyesight is poor. Consider financial limits. Share ideas for bargain strategies. 6)Medications, taste and smell: Check if sense of smell and taste is intact. Assess whether medications impair taste or affect appetite?

How is iron deficiency anemia diagnosed in children 1-2 years old? Children 2-5 years old?

1-2 yo: when hemoglobin concentration is <11.0 g/dL and hematocrit <32.9 percent. 2-5 yo: when hemoglobin <11.1 g/dL or hematocrit <33.0 percent

If toddlers and children with chronic illnesses are entitled to certain services, what programs and acts help to cover health care costs/services AND which cover nutrition services?

1. Americans with Disabilities Act (ADA) 2. Social Security Disability Insurance (SSDI) 3. Supplemental Security Income (SSI) Nutrition services are funded within: 1. education regulations in the Individuals with Disabilities Education Act (IDEA). 2. Part C, or the Infants and Toddlers with Disabilities Program is covered by IDEA. This program funds early intervention services for which a child's eligibility for services does NOT requires a specific diagnosis.

Why might children be "picky" ? What can be done to encourage children to try new foods? Practices to avoid?

1. Certain foods may provide comfort to the child, 2. The child may be trying to exert control over food intake. ------- 1. serve child sized portions 2. serve foods in an attractive way. Young children do NOT like their foods to touch or be mixed (like in casseroles or salads) AVOID: - Strongly flavored vegetables or spicy foods - unlimited grazing of snacks/ drinks between meals -forcing children to stay at the table until they have eaten a certain amount of food. Remember the child should decide how much they eat NOT the parent.

5 requirements for national school lunch program

1. Lunches must meet nutritional standards for f & V, meats/meat alternatives, grains, milk 2.Children unable to pay must receive free or reduced lunches, with no discrimination between paying and non-paying children 3.Operate on a non-profit basis 4. Must be accountable 5. Must participate in the commodity program

Considerations for nutrition assessments and interventions in children with chronic conditions?

1. Nutrition assessment should include excessive energy intake as a consequence of low muscle mass, lower mobility, and short stature in down syndrome or spina bifida. 2. Nutrition assessments often document weight loss with any flare up or exacerbation of the primary conditions. 3. Nutrition interventions for underwieght children with chronic conditions may or may not recommend food choices for weight gain. 4.Nutrition interventions regarding food intake, vitamin and mineral supplementation, and mealtime behaviors also should be customized to the individual child. For ex children who are frequently sick or have a low energy levels and appetites may avoid foods that require chewing or take a long time to eat. 5. Difference btw decreased appetite related to food intake problems because of chronic illness and those related to normal developmental stages.

Children with which medical diagnosis may present with signs of feeding problems? What do nutrition assessments for such children usually document?

1. gastroesophageal reflux 2.developmental delay 3. cerebral palsy 4. ASD Document: Signs of feeding disorders such as low interest in eating, long mealtimes, preferring liquids over solids, and food refusals.

The need for nutrition services is identifies by answers to these questions:

1. is the child's weight, height, and other indices reaching appropriate percentiles on growth charts 2.is his/her food and nutrient intake adequate? 3.Are the child's feeding or eating skills appropriate for the child's age? 4. Does the medical or nutrition diagnoses affect nutritional needs? **Note: Specific growth charts developed for chronic conditions, when available, are recommended to be used.

Why might parents bring their children for a check-up if they have diarrhea?

1.Healthy children who consume juices that contain sucrose and sorbitol in excess may have diarrhea. 2. Toddlers and preschooler may have unexplained diarrhea should have a check -up to rule out other conditions.

According to the CKD framework diagram, what is recommended at each stage of kidney function?

1.normal: screen for CKD risk factors 2.Increased risk: CKD risk reduction; screening for CKD 3. Damage: Diagnosis and treatment; treat comorbidities; slow progression 4.decreasing GFR: estimate progression; treat complications; prepare for replacement 5. Kidney failure: replacement by dialysis and transplantation

How can parents prevent food jags (eating just one food over time)? What shouldn't a parent do and why?

1.serve new foods along with familiar foods. 2. serve foods when child is hungry 3. serve foods when other members of the family are eating them too A parent should Never forces a toddler to eat because battles over food intake create a negative experience for the child. Mealtimes should provide an opportunity for parents and caretakers to model healthy eating behaviors. Instead caretakers should offer a variety of foods and texture.

NSLP meal pattern daily

1/2 - 1 cup fruit ¾-1 cup vegetables Meat (meat alternative) and Grains 1oz K-8 2oz 9-12 Half of grains must be whole grain rich Milk- 1 cup (fat-free, low-fat, flavored ok as of 2017)

Adequate Vitamin D school age children/ pre-adolescents ?

600 UI

What is the DRI for Vitamin D in adolescence?

600 UI National Academy of Medicine & American Academy of Pediatrics recommend that all adolescents, who do not consume at least 400 IU (10 ug) of vitamin D per day through dietary sources, should receive a supplement of 400 IU per day

Older adults and nutritional risk factors?

65+ Heart disease,cancer, stroke, and diabetes are all leading causes death i older adults and they have nutritional risk factors. But DRI categories are only created for people 70 + and older

What is average annual growth rate during school years? How does that affect the appetite and eating?

7 lbs (3-3.5 kg) and 2.5 in usually greater appetite and intake

What are the implications of childhood obesity on adulthood?

90% overweight teens will remain so in adulthood ◦ Children with BMI >85 %-ile are twice as likely than children with BMI below 50th %-ile to continue to gain weight and reach overweight status by adolescence

Children with Special Health Care Needs (def)

A general term for infants and children with, or at risk for, physical or developmental disabilities or chronic medical conditions from genetic or metabolic disorders, birth defects, premature births, trauma, infection, or prenatal exposure to drugs.

Why are diet and nutrition important to adults for the prevention of disease?

About half (1 in 2) of adults in the U.S. are living with one or more preventable chronic disease Obesity is a risk factor for all major chronic diseases Most adults: Do not have adequate fruit and vegetable intake Consume too much saturated fat, sodium, and added sugar Drink sugar-sweetened beverages daily Eat fast food regularly Exceed recommendations for alcohol consumption Do not get enough fiber or water

MNT goals for diabetes

Achieve & maintain blood glucose levels in normal or close to normal range • Lipid & lipoprotein profile that reduces risk of vascular disease • Achieve & maintain blood pressure levels in normal or close to normal range • Prevent or slow rate of development of DB-related complications of diabetes through dietary & lifestyle modifications • Address individual nutritional needs while considering personal & cultural preferences & willingness to change

Why are Ca and Vit D important for school age children/ pre-adolescents ?

Adequate intake is critical at this time to achieve peak bone mass but mean calcium intake is low: ~1,175 mg (for boys) and 960 mg (for girls) ages 6 to 11 years Adequate vitamin D needed for calcium absorption

Why is adequate calcium intake important during adolescence? When do M/FM need more calcium specifically? How much is recommended?

Adequate intake is critical because half of peak bone mass is accrued during adolescence ◦ Needs and absorption rate is highest during this period-can retain up to 4 x's as much calcium as young adults ◦ Females: Highest around menarche Males: Highest during early adolescence Recommendation: 1,300 mg/day for 9 - 18 year olds

NSLP and Wellness policy:

All schools that participate in the NSLP must also have a wellness policy

Fat requirements for athletes? Why?

An important fuel source ◦ During moderate intensity exercise, fatty acids provide about 50% of energy Needed for absorption of fat-soluble vitamins and are required for normal immune function Recommended that athletes consume moderate amounts of fat (20-25% of calories) and no less than 15% of their total calories

How to deal with common nutrition problems in cancer patients?

Anorexia/cachexia: - Identify factors contributing to poor appetite -Keep high calorie/high protein foods/liquids on hand for when appetite is good - milkshakes, carnation instant breakfast, peanut butter, fruited yogurt -discourage intake of higher-fiber that can early satiety -Appetite stimulant if anorexia is longstanding or other strategies fail to improve condition Nausea: - sip liquids of frequent intervals separately from solid foods to maintain hydration - discourage fasting because it may because it may cause hypoglycemia and increase nausea -cold or temperature foods -avoid high-fat, high-fiber, spicy, or gas producing foods that may be poorly tolerated Vomiting -Encourage adequate fluids to prevent dehydration -start with low-fat fluids and advance as tolerated -introduce dry starchy foods first when advancing -introduce high-fiber and high fat foods last -avoid eating 1.5 to 2 hours pre-posttreatment Mucositis -encourage good oral hygiene practices -use oral baking soda rinse -1 mL of baking soda to 250 mL of water -soft, moist, semisolid, or blended foods may be tolerated better than rough/crisp foods - discourage intake of known irritants -tart or acidic foods, spicy or salty, very hot or cold foods, tobacco, alcohol, and alcohol-based items -recommend dunking or moistening dry foods -order extra gravy trays -alter temperature and consistency to individual tolerance -reinforce use of analgesics before meals to reduce pain with eating Esophagitis - suggest use of local anesthetic and analgesic before meals -in cases of peptic esophagitis, antireflux and antacid therapy may be helpful - regular antacids before and 1 h after meals / before bed Thick saliva/mucus -beverage or foods that are slightly tart or carbonated -soy-based dairy alternatives -consume clear fluids after milk products to reduce mucous -limit caffeine, alcohol, and spicy foods -encourage a mouth rinse throughout the day xerostomia -increased liquid consumption may provide symptomatic relief; however, liquids have no lubricating properties -encourage consumption of foods such as gravies, sauces, and salad dressings -mint or tart sugar-free gum/candy to stimulate production of saliva -discourage commercial mouthwashes and alcohol to reduce dryness -citric acid containing beverages may increase secretions Dysguesia: determine specific taste or smell -encourage fluids w/ meals to decrease unpleasant tastes - reinforce proper oral care before and btw meals -tart foods can stimulate taste buds -suggest mild tasting foods such as biscuits, milk, pudding, and custards -include meat in mixed dishes -choose alternative protein sources from dairy group: cottage cheese, yogurt, custard -try tofu or eggs - marinate foods in pinapple or lime juice, vinegar, wine.. sweet, or sour sauce - eat with plastic utensils - cinnamon or sugar free gum or mints to mask metallic taste hypoguesia "(lack of taste) - reinforce proper oral care -encourage experimenting w/ strong flavors/ seasonings -encourage liberal intake of treats or comfort foods -emphasize a variety in colors and textures in a meal to encourage eating

Why might some cancer patients have deficiencies and insufficient intake of nutrients?

Anti-tumor therapy (chemotherapy, radiation, surgery etc.) can contribute to nutritional alterations with patients' ability to ingest, digest & absorb adequately Ideally, early intervention is key to minimize weight loss and prevent/correct nutritional deficiencies as soon as possible 50% of people w/CA lose body weight and more than 1/3 lose more than 5% of their usual body weight

Artificial Nutrition and Hydration (ANH)

Any nutrition and/or hydration support of an invasive nature requiring the placement of a tube into the alimentary tract or parenterally via intravenous or subcutaneous means ANH at the end of life are considered legally and by healthcare professionals to be a medical intervention It is the patient's articulated desires for extent of medical care that should be driving force for determining the level of nutrition intervention

Why do energy needs decrease in old age? Does that mean the equation change?

As adulthood progresses activity and Bmr decrease which requires less energy. Actually about 2-5% less energy per decade is required or 70-100/ day.

Dementia and Alzheimer's Disease Nutritional Interventions

As there is no cure for AD, dietary focus is to: Maintain nutrient-dense diet acceptable to individual Maintain hydration Supply needed energy Other strategies include: Maintain focus on eating Provide plenty of time to eat Serve finger foods Encourage regular drinks between bites If decreased physical coordination, use adaptive eating utensils

Why might parents be considered about their toddlers/preschooler's eating behaviors and appetite?

At this point parents are used to seeing their child growing and subsequently wanted to be fed more. Actually an infants birth weight triples in the the first 12 months but after that growth slows until adolescence. Due to the decrease in growth, appetite and food intake in toddlers and preschoolers decreases. Note: although parents may be worried they should be reassured that a decrease in appetite is normal during this life stage.

Why are toddlers ( 9- 18 months) at the highest risk for iron deficiency anemia? Which children of this age group are at the highest risk?

At this time (9-18 months) there is a rapid growth rate coupled with inadequate intake of iron. Iron deficiency anemia is more common in lower income groups, African Americans, and Mexican American children.

moral principles guiding providers

Autonomy: Respect for individual's desire & choices Nonmaleficence: Doing no harm to person Beneficence: Doing what is best for the individual Justice: Being fair to any individual in a similar situation the framework for decision making includes the provider: Knowing what the patient wants Knowing what the evidence says is warranted Sharing decision making about the appropriate course of action

Screening tool used for adolescents? What does AND advocate for during the evaluation of anthropometric measures?

BMI for age is used for adolescents to screen for overweight and obesity as well as other conditions. AND advocates for use of z-scores when evaluating how far a child is from the rest of the population in height, weight, and BMI.

Physical Activity Guidelines for Americans: Adults (aged 18-64 years)

Basic recommendation: 2 hours and 30 minutes a week (150 minutes) of moderate-intensity OR 1 hour and 15 minutes a week (75 minutes) of vigorous-intensity aerobic physical activity OR an equivalent combination. Short duration activity can be accumulated to reach this target. For additional health benefits: Increase to 5 hours (300 minutes) a week of moderate-intensity aerobic physical activity or 2 hours and 30 minutes (150 minutes) of vigorous-intensity physical activity. Muscle strengthening: Adults should also do muscle-strengthening activities that involve all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms) on 2 or more days per week

What behaviors contribute to excess weight?

Behaviors that contribute to excess weight Diet Physical Activity / Inactivity Most children in the U.S. have poor diets Almost 2/3 consume a sugar-sweetened beverage every day Less than 50% get the recommended 60 minutes of physical activity per day

Which conditions can cause children to have feeding problems related to muscle control or control of the mouth or upper body? How does this affect them during feeding?

Cerebral Palsy or other neuromuscular disorders and genetic disorders such as down syndrome. They may choke or cough while eating or refuse foods that require chewing. If these feeding problems are not resolved w/ proper therapy in early intervention programs, children are likely to resist eating overtime. When children CANNOT meet nutritional needs on their own they may need nasogastric or gastrotomy feeding tubes. Feeding tubes are used when infant or child is at risk for choking or aspiring food or fluids into their trachea and lungs.

Why are both underweight or overweight more in children with chronic conditions? (most probable explanation)

Changes in energy needs. For ex :Overweight and obesity are commonly found in children w/Down Syndrome and spina bifida.

Refeeding syndrome

Characterized by hypokalemia, hypophosphatemia, hypomagnesemia, glucose intolerance, pancreatitis, GI dysfunction, cardiac arrhythmias, CHF, fluid retention and edema

Long- term affects of BN

Chemical imbalances lead to/ trigger cardiac arrest or brain damage ◦ e.g., Potassium loss > stops the heart Bulimia can also cause ◦ Gastric rupture; perforated ulcers ◦ Lung collapse ◦ Internal bleeding ◦ Stroke ◦ Kidney failure ◦ Liver failure ◦ Pancreatitis ◦ Infertility ◦ Birth defects in offspring

how do we measure obesity risk in children?

Child Body Mass Index (BMI) is derived from child height and weight BMI= weight (kg) / height (m2) BMI is a proxy of adiposity/ Used as a measure of overall growth and development • Diet and physical activity are harder to measure

When/how should be tested for iron deficiency?

Children in high risk categories such as low-income and migrant children, recently in the US between the ages of 9 and 12 months. They should be tested 6 months after arrival in the US and annually from 2-5 years. However, the AAP recs support universal screening for iron deficiency and anemia at 12 months as well as selective at any age for children at increased risk. *Children at risk include those that have a low iron diet, consume >24 oz of milk/day, have limited access to food and special health care needs.

What mineral besides zinc or iron do children need in their diet?

Children need a source of fluoride in their diet from fluoridated water and the use of fluoridated toothpaste. Children ages 6 months to 3 yo need 0.25 mg of fluoride per day if their local water supply has less than 0.3 ppm of fluoride. Children 3-6 yo need 0.5 mg fluoride per day if their water supply is <0.3 ppm.

How is BMI used on the CDC growth charts to categorize children into weight classes?

Children over 2 years old that : 1) have a BMI in the 85 percentile or greater but less than the 95 percentile are overweight. 2) have a BMI greater then or equal to the 95th percentile are obese Children under 2 years older whose weight for length is greater than or equal to the 95th percentile are considered overweight. Children in ALL age categories that have weight for length or a BMI for age < the 5th percentile are underweight Note: BMI increase in infancy but decreases during preschool years and the lowest point is at about 4-6 years old. The only what to know whether a child's BMI is within a normal range is to plot BMI for age on the appropriate growth curve.

Nutrition recommendations for children w/ special needs

Children with chronic conditions require nutrition assessments to determine if nutrients and energy are adequate. Children with special health needs benefit from same dietary recommendations as other children. Family context is important & should be incorporated into recommendations. Interventions should consider quality of life, avoiding hospitalization & ability of parents to work and take care of other family members. Methods of Meeting Nutritional Requirements Since feeding a child is such an important part of caring, parents/caregivers play a large role in deciding type and form of nutrition interventions, which can include: Oral nutritional supplements to supplement/partially replace meals or snacks Gastrostomy feeding May be required for kidney disease, some cancers, severe forms of CP or CF Varied schedule options so feedings can fit into schedule and lifestyle of child & family

Why is understanding temperament ( behavioral style of the child ) important to when feeding preschool children?

Children's temperaments affect feeding and mealtime behavior. The easy children adapt easily to schedules and tries to accept news foods readily. The difficult child have irregularities in function and adapt slowly, making them reluctant to accept new foods or negative about them. Parents can use this to plan out exposure to new foods. Difficult or slow to warm up children should be gradually introduced to new foods with no rush to to accept them. Note: Children usually prefer sweet and salty tastes but reject bitter/ sour tastes. It may take 8-10 exposures to a new food before it is accepted. Children have a preference for energy dense foods.

Why/ when discontinue Tube feeding?

Concept of "when in doubt, feed" is applicable to most individuals Feedings should start when patient is medically stable and only stopped if feeding is no longer beneficial to patient Long-term tube feeding allows many to live an active life, however, such feeding with terminal illness does not seem to have same benefit A systematic review (Finucane, Christmas & Travis, 1999) concluded that tube feeding patients with advanced dementia show no benefits related to: Prolonged life, reduced risk of pressure sores or infections, prevention of aspiration pneumonia or improved palliative care Several studies (Fine, 2006) have shown that in terminally ill & advanced dementia patients quality of life was better for patients without any form of ANH Plus, aspiration occurs in 25 to 40% of tube-feeding patients

hypertonia

Condition characterized by high muscle tone, stiffness, or spasticity.

What should parents pay attention as the toddlers development feeding skills during their physiological and cognitive development?

Cues of readiness for weaning such as disinterest in breast feeding or bottle feeding. Usually weaning is easier for babies who adapt well to change. Weaning is a sign of the toddlers growing independence and is usually complete btw 12-14 months. Gross and fine motor development. Children should be able to move the tongue from side to side and learn to chew food w/ rotary at 12-18 month. This help to eat chopped and or table foods. At 12 month children have a refined grasp to pick up small objects such as cooked peas and carrots and put them in their months Distractions including themselves as they learn new skills or the TV/ mobile devices. Choking hazards (hardy candy, popcorn, nuts, whole grapes, hot dogs). Still should watch children when they eat. Make sure toddlers are SEATED during meals and SNACKS

Which dietary approach is recommended for both diabetes management, CHD, and stroke?

DASH (Dietary Approaches to Stop Hypertension) Diet • a lifelong approach to healthy eating designed to treat/prevent HTN without medication

Why do CF does malabsorption occur in CF? What does malabsorption lead to?

Due to lack of pancreatic enzymes, which causes slower rate of weight and height gain?

T or F: All anemia are caused by iron deficiency.

F: Other causes of anemia are deficiencies such as folate or vitamin B12, chronic inflammation, or recent or current infection.

EATING PATTERNS TO PREVENT & MANAGE TYPE 2 DIABETES

DASH Diet since High in FV, whole grains, nuts, seeds, lower-fat dairy and lean meats, high in fiber, K+, ca, mg but LIMITS Na, saturated fat, sugar DASH diet improved CVD risk factors, such as BP, glucose & cholesterol. It appeared to have greater beneficial effects in subjects with increased cardiometabolic risk. The DASH diet is an effective nutritional strategy to prevent CVD and manage DB. MEDITERRANEAN DIET Primarily plant -based Healthy fats from oils Whole grains Legumes Nuts Fish/seafood Meat, eggs, dairy eaten on occasion Red wine No processed foods, sweets VEGETARIAN OR VEGAN DIET High in vegetables, fruits, whole grains, nuts, seeds, beans Little or no animal products Note that there was no difference between the Mediterranean & vegetarian diets. Both were effective in reducing body weight, BMI & fat mass. Studies have shown that plant-based diets can reduce A1c by average of 0.3- 0.4% in people with type 2 DB.

Dehydration in OA

Definition: Physiological state in which cell fluid loss interferes with metabolic processes Others define it as losing nearly 2% of initial body weight This can occur after avoiding all fluid & consuming only dry foods for 24 hours Signs and symptoms Upper-body muscle weakness Speech difficulty and confusion Dry mucous membranes (nose/mouth) Longitudinal tongue furrows Dry tongue Sunken appearance of eyes in sockets

Dementia and Alzheimer's Disease (AD) in older adults

Dementia: progressive cognitive decline Impaired memory, thinking, decision making & linguistic ability Alzheimer's Disease (AD) is most common cause of dementia Accounts for 60-80% of cases 32% of adults > 65 yo have AD 5 th leading cause of death of adults > 65 yo **Accumulating evidence that physical activity & diet play role in dementia progression/prevention Mediterranean diet & aerobic activity assoc w/less cognitive decline & decreased AD risk

Important considerations of children w/ special health care needs. Energy, Protein, and other nutrients

Depending on the condition needs very: -Lower calories needs are needed by those w/slower or decreased muscles: Children with Prader-Willi syndrome may only have 80% energy needs of a similar child w/o the syndrome -Increased calories are needed as physical activity levels increase: Children w/ ADHD or ASD are generally more active and/or sleep less -Recovery from burns and cystic fibrosis increases protein needs to 150% of the DRI -PKU and other protein-based inborn errors of metabolism require greatly reduced protein intake -Some conditions may require hydrolyzed or specific amino acids -Eating or feeding problems may restrict intake of foods requiring chewing - Prescribed medications & their side effects can increase turnover for specific nutrients increasing needed amounts - Food refusals total intake being more variable -Treatment of condition may necessitate restriction of certain foods -Calcium, which intake is low in general population, is also a problem nutrient for children with special needs -:Children with neurologic impairment and developmental disabilities, such as cerebral palsy, are at higher risk for osteopenia due to low mineral intakes, lack of weight-bearing activity and use of anticonvulsant medications

High cause of fatality in bulimia?

Depression and suicide are a high cause of fatality in http://bulimiarecoveryblog.weebly.com/long-term-effects-of-bulimia.html those with bulimia

What progression of MNT/ energy intake is appropriate to prevent refeeding syndrome?

Desired rate of weight gain is 1 to 2 lbs/wk ◦ If inpatient: rate of weight gain is 2 to 3lbs/wk Energy Intake ◦ Initially: 30 to 40 kcals/kg/day ◦ Because of refeeding syndrome risk, gradually increase energy by ~200 kcal/day for 1 week ◦ Goals ◦ First achieve 2,500 kcal/day for 1 week ◦ Incremental increases to 3,500 kcal/day ◦ Then, intake is adjusted to achieve rate of weight gain of at least 2 lbs per week ◦ If patient doe not gain a minimum of 2 lbs per week after 2 weeks of inpatient therapy, bed rest or nasogastric tube feeding may be implemented

Low Body Weight/Unintentional Weight Loss in OA & Nutrition Interventions

Determine what caused the weight loss Consider protein & energy supplementation Refeed & rehydrate gradually Calories: 30 to 35 kcal/kg/day Protein: 1.0 to 1.5 g/kg adequate If severe depletion, 1.5 to 2.0 g/kg (distribute throughout day) Exception: Patients with renal or liver failure may need protein restriction Fluid: Drink 1 mL per kcal consumed

How often should nutrition assessment/screening of adolescents occur and what should be noted during them?

Dietary Assessment and Screening ◦ Annual screening of adolescents for indicators of nutritional risk is recommended Common concerns that should be investigated during screening include: • Over/underweight, eating disorders, hyperlipidemia, hypertension, iron deficiency, food insecurity and excessive intake of energy-dense foods. Screening should also include accurate weight, height, BMI & weight categorization

What are the carbohydrate requirements for athletes? How is the glycemic index used?

During exercise, glucose is the preferred substrate for ATP production. For this reason, and to replenish hepatic and muscle glycogen, athletes should consume 60- 75% of their energy from carbohydrate. Endurance athletes should consume 6 to 10 g CHO per kg body weight ◦ So an athlete weighing 70 kg needs 420 to 720 g CHO per day Some foods will cause a rapid increase in blood glucose concentrations, while others produce a slower and more prolonged rise. The glycemic index (GI) is used to quantify the effect of a food on blood glucose and to make comparisons among foods.

EER Formula for children 13-36 months:

EER = (89 x weight [kg] -100) +20 kcal Only includes weight and 20 kcal for energy deposition.

Define the periods of psychosocial and cognitive development in adolescents? Why are is knowledge of each stage important in choosing the type of nutrition intervention?

Early adolescence: 11 to 14 years ◦ Inability to see how current behavior can affect future health status > Making nutrition education challenging Middle adolescence: 15 to 17 years ◦ Marks emotional & social independence from family, especially parents ◦ Conflicts over personal issues, including eating & physical activity, are heightened Late adolescence: 18 to 21 years ◦ Abstract reasoning skills begin to emerge ◦ Motivational counseling methods are recommended during this phase to engage older adolescents

4 Definitions/ stage of adulthood

Early adulthood: 20-39 years Becoming independent and leaving the parental home Planning, buying & preparing food are newly developing skills If have children, renewed interest in nutrition "for the kids' sake" Midlife: Forties Active family responsibilities Managing schedules and meals becomes a challenge Recognition of one's mortality "Sandwich" generation: fifties Many are multigenerational caregivers - juggling roles of caring for children and aging parents, while maintaining a career Health often an added concern Chronic disease Management of identified risk factors to prevent diseases Later adulthood: Sixties up to 64 years Transition to retirement Greater attention to physical activity and nutrition Added significance for food choices and lifestyle factors, especially for those with chronic disease

How to prevent ethical dilemmas?

Effective communication is key to help prevent ethical dilemmas Healthcare team needs to learn the patient's values, goals & beliefs

Why do male adolescents have greater caloric needs then FM? Why is it critical for both FM and M to meet their requirements at this stage?

Energy is influenced by activity level, basal metabolic rate (BMR) & pubertal growth/development. Males have greater increases in height, weight, and lean body mass (LBM); thus higher caloric needs Critical to meet energy needs in adolescence because when energy requirements are not met, growth and sexual maturation can be delayed

Role of Registered Dietitian (RD) in ANH/ end of life care

Ensure care team considers all options about feeding rather than assuming one strategy is obligatory Example: a situation may occur with a patient where tube feeding seems to be only choice, when actually careful hand feeding may be a better alternative to provide adequate nutrition Work with family to answer questions about chewing, swallowing, and cessation of thirst & hunger Provide a compassionate and positive experience for patient, family and loved ones

T or F: Asthma requires nutrition services

F it does NOT on its own but some children with Asthma may also have food allergies. Also may have an increased incidence of overweight and obesity.

T or F: Children have innate ability to regulate caloric intake, select and consume a well-balanced diet.

F: Children can self-regulate caloric intake but NO inborn mechanisms direct them to select and consume a well-balanced diet.

T or F: Criteria for identifying disabilities in adults is applicable to children.

F: Criteria for adults do NOT fit for children. Children who do not meet the appropriate developmental milestones may be recognized as having a chronic condition. Otherwise identifying children with special health care needs is difficult and expensive.

T or F: children w/spastic quadriplegia grow rapidly

F: children with spastic quadriplegia grow, but their growth is slower than that in others, with or without gastrostomy feeding

RDA for FE, ZINC, and CA 4-8 years

FE: 10 Mg/d Zn: mg/d ca: 1000 mg/d

Risk nutrients (THOSE ADULTS ARE DEFICIENT IN)

FIBER Has many benefits beyond its effect on bowel mobility Viscous fiber - decreases absorption of cholesterol, increases fecal excretion of cholesterol-rich bile and results in lower total/LDL cholesterol Fermentable fiber - promotes healthy gut microbiota which enhances the immune system CALCIUM & Vitamin D 50% of the US population has low serum-25-hydrdoxy (OH) vitamin D Combined with low calcium intake by ~1/3 of US adults (especially women) loss of calcium from bones osteopenia VIT A & VIT E Fat-soluble vitamins with strong antioxidant & immune functions Vit A: essential in maintaining integrity of skin/mucosal cells (which defend against infection) & plays a role in development/differentiation of white blood cells Vit E: has anti-inflammatory properties & is involved in maintenance/repair of cellular membranes CHOLINE Deficiency has been shown to cause fatty liver and muscle deterioration Serves as components of cell membranes & as precursor of neurotransmitter, acetylcholine, also in involved in brain function POTASSIUM & SODIUM Sodium is overconsumed, while potassium is under consumed High sodium decreases vasodilation & raises blood pressure, while potassium increases vasodilation & lowers blood pressure MAGNESIUM Subclinical deficiency (intakes below 50% of RDA) elicits a calcium-activated inflammatory cascade, which contributes to development of CVD, osteoporosis, diabetes & cancer IRON Sustained low dietary intake leads to depletion of iron stores, reduced synthesis of hemoglobin, and iron-deficiency anemia, with decreased oxygen transport to tissues

Why do athletes care about diet?

Glucose is required for exercise. • Depletion leads to fatigue, poor performance and can shut down the nervous system With prolonged exercise, if glucose isn't replaced, FFA's play a bigger role in meeting energy needs. But the higher the intensity of exercise, the more glucose is used to provide the energy.

CANCER

Group of related diseases which damage to DNA of cells causes uncontrolled growth and spread of abnormal cells Second leading cause of death in the US • 1.2 million new cases diagnosed each year • Nearly 12 million Americans living with a history of cancer 35% of cancers are diet-related

Why is adequate Vitamin D important during adolescence?

Has an essential role in facilitating intestinal absorption of calcium and phosphorus, thus essential for optimal bone formation ◦ Low levels are inversely related to systolic blood pressure, fasting glucose, hypertriglyceridemia & metabolic syndrome ◦ Also associated with low HDL cholesterol levels and higher BMI and abdominal obesity measurements

Obesity trends in adults?

Have only been increasing since 2000. Even states like Utah, in which obesity is 20 - 25%, have high obesity rate in Hispanic and non-Hispanic adults. States.

diseases/health concerns common in the older adult population that have nutrition-related consequences and solutions:

Heart Disease Stroke Diabetes Osteoporosis Osteoarthritis Dementia and Alzheimer's Unintentional weight loss/low body weight Dehydration

Leading cause of death and hospitalizations in older adults

Heart Disease; Relative predictive power of major cardiovascular risk factors weakens with age Elevated LDL and obesity not associated with CVD events in people > 65 yo

Why are high lead levels dangerous? What is the safe blood level of lead?

High lead levels affect the functioning of many tissues in the body including the brain, blood, and kidneys. There is NO safe level of blood lead in children. Historically a blood level of 10 mcg/dL prompted action. Though recent research indicates that physical and mental development of children may be affected by blood level lead levels <10 mcg/dL. CDC recs includes a reference value of the 97.5th precentile of the NHANES generated blood levels distribution in children 1-5 yo.

artherogenic diet

High saturated fat (>10% calories) Trans-fatty acid intake Dietary cholesterol intake > 300 mg Low fruit and vegetable intake Low intake of whole grains No or excess alcohol intake High sodium Low potassium intake Low intake of milk and dairy foods High waist circumference

Which chronic conditions are generally associated with high and low energy needs?

Higher energy needs: 1.Cystic fibrosis 2. Renal disease 3. Ambulatory children w/diplegia 4.Pediatric AIDS 5. Bronchopulmonary dysplasia (BPD) Lower Energy Needs 1. Down Syndrome 2. Spina bifida 3. Non ambulatory children w/ diplegia 4. Prader-Willi Syndrome 5. Non ambulatory children with short stature

List dietary approached that produce weight loss through the reduction of calories (in adults):

Higher-protein diet (25% of total calories from protein, 30% of total calories from fat, and 45% of total calories from carbohydrate) Higher-protein Zone™-type diet (5 meals/d, each with 40% of total calories from carbohydrate, 30% of total calories from protein, and 30% of total calories from fat) Lacto-ovo-vegetarian-style diet Low-calorie diet Low-carbohydrate diet Low-fat diet Vegan diet Low glycemic load diet Mediterranean style diet

What are the disparities in obesity rates?

Hispanic children have the highest rates, non-Hispanic black children have the 2nd highest. While white and asian(the lowest) have lower rates. Children aged 12-19 have the highest rates of obesity but rates are high across the board.

Which nutrition risk are/ should be included in malnutrition screening of older adults?

Hunger, poverty, inadequate intake, social isolation, dementia, food-drug interactions, diet- related interactions, physical challenges, access

Ischemic vs hemorrhagic stroke

Ischemic stroke: caused by blood clot that blocks supply of blood to brain Hemorrhagic stroke: result of bleeding in or around brain (usually due to ruptured blood vessel or uncontrolled blood pressure

Micronutrient requirements for athletes? Why?

IRON ◦ While 11 to 13% of US population is iron deficient, endurance athletes are more likely (regardless of gender) to be iron deficient than non-athletes ◦ Possible explanation: high-intensity/long duration exercise increases both inflammatory marker interleukin-6 (IL-6) and a hepatic protein which blocks export of iron from storage sites in enterocytes, liver & spleen ◦ Plays critical role in oxidative metabolism ◦ RDA is 18 mg/day (for women) but vegetarian athletes will have iron requirement 1.8 times greater because of limited bioavailability of non-heme iron ◦ Example: 1-cup raw spinach has 6 mg iron, but only 2 to 15% (0.1 to 0.6 mg) is absorbed while a 3 oz steak has 4 mg iron and 50% (2 mg) will be absorbed FLUIDS & ELECTROLYTES Dehydration due to an imbalance between fluid loss & intake is the most common cause of heatrelated illness in athletes Athletes may lose water at a rate of 0.5 -1.5 L/hour and up to 6-10% of their body weight. ◦ The decline in blood volume decreases blood pressure and cardiac output ◦ Heart rate increases 3 to 5 beats/minute for every 1% of body weight lost to compensate for decreased stroke volume Most fluid lost in sweat is from extracellular fluid compartment ◦ Sodium: avg concentration in sweat-1,150 mg/L ◦ Potassium: avg concentration in sweat-350 mg/L (because located in intracellular fluid so much smaller amount is lost)

How do you assess for weight reduction to decrease obesity risk? When is it recommended?

If BMI >30 or BMI >25 with additional risk factor YES Risk factors for increased cardiovascular risk Diabetes Prediabetes Hypertension Dyslipidemia Elevated waist circumference If BMI <25 or BMI 25-29.9 with no additional risk NO

Moderate vs Vigorous Intensity activity? How can you tell using the talk test?

If you can talk, but not sing, you are doing moderate-intensity activity. If you can't say more than a few words without pausing for a breath, you are doing vigorous-intensity activity.

Why is it important to measure and plot growth parameters CORRECTLY?

Incorrectly measured or plotted growth parameters in young children can lead to errors in health status assessment. Thus standard procedures should be followed and the correct equipment should be used.

Why is weight reduction recommended to prevent chronic disease?

Increased BMI/higher BMI classification associated with: Increased risk of fatal and nonfatal coronary heart disease Stroke Diabetes All-cause mortality Reduction in body weight associated with: Reduced risk of diabetes Improvement in lipid profiles Reduction in blood pressure

Advance Directives

Information in written or oral form provided by the patient that outlines the competent adult's wishes regarding medical treatment should s/he become incompetent in the future Could be a living will or designation of a healthcare proxy

Criteria for diagnosis of anorexia nervosa

Intense fear of becoming fat or gaining weight (even though underweight) Refusal to maintain normal weight for age/height, such as... ◦ Such as weight loss leading to maintenance of body weight <85% of that expected ◦ OR failure to make expected weight gain during period of growth, leading to body weight <85% of that expected) Disturbed body image, such as... ◦ Undue influence of shape or weight on self-evaluation ◦ OR denial of the seriousness of the current low body weight Amenorrhea or absence of at least 3 consecutive cycles ◦ those with periods only inducible after estrogen therapy - amenorrheic

Nutritional Considerations related to lead?

Iron deficiency anemia and elevated lead levels have some of the same risk factors: 1. young age 2.poor nutrition 3. low social economic status. 4.Iron deficiency anemia is associated w/ pica, the ingestion of non-food items, such as paint chips, which is a risk factor for lead ingestion. Nutrient interactions: - Vitamin C rec for prevention of iron deficiency - dietary Ca competitively decreases lead absorption but there is no clinical evidence that supplementing Ca beyond the adequate intake for age has a clinical effect on blood lead levels.

Most children (0-5 yo) meet targeted levels of consumption for most nutrients EXCEPT for the following nutrients:

Iron, Calcium, and Zinc

Why can large intakes of cow's, goat's, and soy milk in children 1-5 yo not recommended? What is the recommendation?

Large intakes of these milks may displace high-iron foods. Thus it is recommended for children 1-5 yo to drink no more then 24 oz of them.

How does body composition change in older adults?

Lean body mass decreases by 2-3% from 30 - 70 years Fat / body fat decreases as weight declines after the age of 70 Senses decline ( taste & smell) which impacts enjoyment of food and ability to detect spoiled or rotten food

What recommendations will lead to weight -loss? Which are backed by strong evidence?

Lifestyle Intervention (Strength of evidence = High) Calorie reduction 1200-1500 kcal/day (for women); 1500-1800 kcal/day (for men) (adjusted for weight and activity) Energy deficit of 500 kcal/day 1 pound of body weight = 3,500 calories 3 primary components of treatment: Reduced calorie intake + increased physical activity + behavioral therapy Intensive: >14 sessions over 6 months Results in 5-10% reduction in initial body weight Healthy weight loss 1-2 pounds per week

MNT GOALS FOR COPD

Main goals: Identify and correct malnutrition - Energy intake must be increased to meet needs = 140% above basal energy expenditure However, must be done in balance • protein:fat:carbohydrate ratio (15-20%:30-45%; 40-55% of calories) to preserve respiratory quotient - Protein consumption should be at least 1.2 g/kg body weight to avoid protein losses, prevent weight loss & prevent worsening nutritional status

Which group has higher energy needs? Male or Female?

Male

Why is psychotherapy not as effective in ED patients that are malnourished?

Malnourished individuals have impaired cognitive function, which limits efficacy of psychotherapy. Patients with AN cannot respond to serotonin reuptake inhibitors during semistarvation because serotonin production is impaired by malnutrition.

Physiological changes in older adults?

Many become Edentulous or w/o teeth to some degree which is associated w/poor nutritional status, disability, and mortality Saliva becomes more viscous which slows absorption and makes oral cavity more sensitive to temperate, extreme and course texture Hunger and satiety cues weaken w/age affecting appetite Thirst regulating mechanisms decrease w/ age that may affect both fluid and food intake as seniors may not be able to Distinguish thirst from hunger. seniors may fear incontinence causing less drinking as well

Why do Dementia and Alzheimer's Disease make good nutrition habits difficult?

Many effects of cognitive impairment make it difficult to maintain good nutritional habits Confusion Anxiety Agitation Loss of oral muscular control Impairment of hunger and appetite regulation Changes in smell and taste Dental, chewing & swallowing problems In later stages, wandering & restless movement expend energy & increase caloric need Often leads to unintentional weight loss

why Kidney function, diabetes, inflammation & cardiac strain better predictors in older adults?

May capture lifelong insults to cardiovascular system & be better measures of cardiovascular outcomes

Although mostly the same as in CHD, how is nutrition assessment for stroke different?

May need to assess function status relating to patients ability to meet nutritional needs orally: • Dysphagia > risk of aspiration > pneumonia & malnutrition • Restricted arm function > (in)ability to self feed/drink • Visual problems > limited food consumption

Glycemic Index

Measures blood glucose curve compared to consumption of white bread ◦ the higher the glucose spike, the more insulin is required ◦ strong insulin reaction leads to a low dip in blood glucose later ◦ depends on other foods eaten at the same time GI is influenced by meal composition and food preparation ◦ Whole wheat fettucine with chunky tomato sauce & vegetables has a lower GI than canned spaghetti ◦ Raw carrots has GI 20, while Boiled carrots has GI 40 ◦ GI of potatoes increases by 25% when they're mashed

Why do energy requirements begin to decline as adults age? How are calories expended in adults (3 categories)?

Metabolic rate and energy expenditure begin to decline in early adulthood ~3% for men and 2% for women per decade Reductions generally correspond to declines in physical activity and lean muscle mass ENERGY is expended 1. Based on basal metabolic rate (BMR), thermic effect of food (TE) & activity thermogenesis Basil metabolic rate (BMR) 60 to 75% for involuntary metabolic processes 2.Thermic effect of food (TEF) ~10% needed for food metabolism Lower in some individuals with obesity 3. Activity thermogenesis 20-40% total energy needs Includes energy expended through exercise and non-exercise activity (e.g. fidgeting) Most variable component

school age children age ranges

Middle childhood: 5-10 yo Preadolescence: 9-12 yo (girls) and 10-12 yo (boys)

Why are food allergies so dangerous? Which allergy in particular is the most dangerous?

Milk and egg allergy are often outgrown when entering school, but peanut allergy usually persists into middle childhood Anaphylactic reactions to peanuts account for 60% of death from food allergens

Name and describe two assessment tools that can be used to assess or screen for malnutrition risk?

Mini Nutrition Assessment (MNA) : a 6 item tool; assesing food intake, weight loss, mobility, pyschological stress or acute disease, neuropsychological, body mass index or calf circumference. It is used in clinical, homecare & community settings. Easy to use and validated. Determine your nutritional health: assess for risk of poor nutritional status or malnutrition. Based on warning signs of poor nutrition: Disease, eating poorly, tooth loss/mouth pain, economic hardship, reduced social contact, multiple medicines involuntary weight loss/ gain, needs assistance in self care, elder years above age 80

Diabetes in oa

More than 1 in 4 adults > 65 yrs have diagnosed/undiagnosed diabetes Diagnosis criteria & management criteria same for older and younger adults Individualized treatment plans for older adults should also include assessment of functional status, cognitive capacities & motivation 2017 ADA recommendations for HbA1c: <7.5% considered reasonable for >65 yo <8.0- 8.5% acceptable for older adults with advanced disease complications

Treatment goals for ED?

Motivation to change disordered eating behaviors Normalization of body weight ◦ Also facilitates improvements in mood and responsiveness to psychotherapy Help patients accord body weight and shape an appropriate level of significance in the patient's self-evaluation, reduce disordered eating and exercise patterns and improve psychosocial functioning ◦ Target body weight usually determined as 90% of previous highest weight, 92% of ideal body weight or weight at which menstruation resumes

Feeding Structure: Recommendations for toddlers and preschoolers

Multiple Food Exposures ◦ Introduce a variety of foods in a variety of ways ◦ Different textures/flavors ◦ May take 8 to 10 exposures for child to accept a new food `Create structure for meals, but allow toddlers to self-feed ◦ AAP: "Parents provide, child decides" ◦ Do not use food as reward or to soothe toddlers ◦ Avoid excessive prompting to eat or pressure ◦ Do not restrict certain foods

IDEA Eligibility Criteria for the services meant for infants and toddlers under the age of 3 in need of early intervention services: **What is NOT required?

Must experience developmental delays (measured by appropriate diagnostic tools and procedures) in 1 or more of the following areas: -cognitive development -physical development -communication development -social or emotional development -adaptive development or have a diagnosed physical or mental condition that has a high probability of resulting in developmental delay. **A diagnosis such as ASD is NOT required however

Nutrition During and Post exercise

NUTRITION DURING EXERCISE Recommended carbohydrate intake during exercise is 30 to 60 g of carbohydrate per hour ◦ Drinking 16-32 ounces of a 4-8% carbohydrate, commercial fluid replacement beverage every hour, would meet this guideline. NUTRITION POST-EXERCISE Elevating blood glucose levels quickly is beneficial to replenish glycogen stores, so high GI foods are recommended Athletes should consume 1.5 g carbohydrate per kg body weight in the first 30 minutes after exercise and again every 2 hours for 4 to 6 hours post-exercise

CDC growth charts are based on data from cycle 2 and 3 of the _______________________________ (Fill in blank)

National Health and Examination Survey (NHES) and the National Health and Nutrition Examination Survey (NHANES)

How is obesity treated in adolescents?

National guidelines for treatment of adolescent overweight and obesity recommend a staged care process based on BMI, comorbid conditions, age and progress with previous treatment stages Four stages of obesity treatment: Stage 1: Prevention Plus 2. Stage 2: Structured Weight Management Stage 3: Comprehensive Multidisciplinary Intervention Stage 4: Tertiary Care Intervention

Low Body Weight/Unintentional Weight Loss in OA & possible causes?

No consensus or universal definition for underweight in frail elderly NHLBI defines underweight as BMI <18.5 kg/m2 WHO defines levels of underweight as "Grades of thinness" Grade one: BMI 17-18.49 Grade two: BMI 16-16.99 Grade three: BMI <16 Weight loss after 65 yo may be due in part to blunted appetite & satiety signals Older adults have lower circulating levels of ghrelin (signaling protein that stimulates appetite) Chronic malnutrition reduces immune response, muscle & respiratory function & wound healing

considerations/MNT for diabetes patients

No ideal percent calories from carbohydrate, protein & fat for people with DB • Total energy intake should be appropriate to attain weight management goals • Macronutrient distribution should be based on individualized assessment of current eating patterns, preferences & metabolic goals (lipid profile etc.) Quality of carbohydrate foods • Ideally rich in dietary fiber, vitamins & minerals and low in added sugars, fats & sodium Fiber • People with DB should consume at least DGA 2015-2020 fiber recommendations • minimum 14g/1,000 kcal • At least half of grain consumption should be whole intact grains Protein • No evidence to suggest usual protein intakes (15-20%) should be modified (IF renal function is not impaired) Dietary fat • Given comorbidity of CVD with DB, recommendations include: • Less than 10% total kcals from sat fat • Total cholesterol intake less than 300 mg/day • People w/ LDL cholesterol >100 mg/dL, sat fat consumption should be less than 7% of total kcals

Screen time recs in young children

No screen time for children under 2 years of age. Less than 2 hours per day for children 2 years of age and older. Children are more likely to mindlessly eat/drink while watching screens.

Nutrition Interventions for CF

Nutrition interventions include monitoring growth, assessing food and nutrient intake, and increasing energy and protein intake by 2-4 x's usual recommendations due to chronic lung infections Enzyme pills must be taken each time a child with CF eats a meal/snack Frequent eating and large calorie-dense meals are encouraged Gastrostomy feeding at night to boost energy is sometimes required Vitamin & mineral supplementation required Children with CF are at increased risk of diabetes because the pancreas is a target organ of CF damage

Diabetes in oa in Nutritional Interventions

Nutritional Interventions: Carbohydrate and fiber recommendations do not change People with diabetic kidney disease should not reduce dietary protein below RDA Assess dietary adequacy & supplement to meet DRI Monitor functional status & modify the care plan (as appropriate for psychosocial & physical needs of aging patient) Ask about special foods and alternative/complementary therapies (as alternative medicine is often used in certain cultures) Sugar alcohols (e.g., xylitol) have fewer calories, which can aid in wt management. However, high doses of sweeteners often lead to diarrhea.

Why is Dehydration common in OA and why is it harmful?

Occurs more often in elderly as result of illness or other problems Older adults are less sensitive to detecting thirst Once fluids consumed, aging kidneys may lose ability to concentrate urine, plus antidiuretic hormone may become less effective Swallowing problems, depression or dementia may cause individuals to avoid food or drink Fear of incontinence also leads to decreased fluid intake Effects Increases resting heart rate and susceptibility to urinary tract infection, pneumonia & pressure ulcers Leads to confusion, disorientation & dementia

Stroke in oa & remedies

Of adults > 65 yo: 8% (of females) and 9% (of males) have had a stroke Age is strong predictor for incurring a stroke In 20 to 39 yo: 0.3 to 0.6% have had strokes In > 80 yo: 13.8 to 15% have had strokes Nutritional Remedies Prevention programs tend to be secondary or tertiary (not primary) Risk can be reduced by increasing fruit/veggie intake Overall goal in stroke prevention: normalize blood pressure & follow healthy lifestyle habits (e.g., DASH Diet) Individualized medical nutrition therapy is used for rehabilitation after stroke

NSLP Nutrition Standards

Offer both fruits and vegetables every day of the week Offer milk Limit calories based on the age of children being served Reduce saturated fats, trans fats, and sodium Provide 1/3 of DRI based on children's age group Follow food safety guidelines

Cerebral Palsy (CP)

One of most common conditions in children with severe disabilities Incidence: 1.4-2.4 per 1,000 children Broad range of disorders due to brain damage early in life Spastic quadriplegia (severe form of CP which involves all limbs) presents most nutritional problems Nutrition concerns include constipation, slow growth, difficulty feeding/eating & changes in body composition Recommendations regarding energy needs vary depending on form of CP A child with small/weak muscles will have lower energy needs, while another child with CP may have increased uncontrolled movement requiring extra energy Athetosis: uncontrolled movement which increases energy expenditure Nutrition interventions include Making recommendations for food choices that fit child's abilities for eating Nutritional supplements if food and beverages are not providing sufficient nutrients Nutrition support, if nutritional deficiencies occur

What age is the best time to learn about healthy lifestyles and incorporating them into daily behaviors?

School age

Fluid and Electrolytes for Athletes throughout the routine?

PRE-EXERCISE Ensure euhydration by drinking fluid volumes that produce colorless urine in the 24 h prior to competition. On day of the event, consumption of 16 ounces of fluid 2-3 hours prior to start will allow time for excretion of excess water in urine before the competition begins. DURING EXERCISE Athletes should drink 8-12 ounces of fluid every 15-20 minutes during exercise. If a training session or competition exceeds one hour, a commercial fluid replacement beverage that contains carbohydrates and sodium is superior to plain water. POST-EXERCISE Rehydration after exercise is important because most athletes do not consume enough fluids during exercise to replenish fluid lost in sweat and respiration. Athletes should consume 24 ozs of fluid for every pound of weight lost during exercise.

PHYSIOLOGICAL CHANGES OF ADULTHOOD

Peaks: Peak bone density achieved in late twenties Muscular strength peaks around 25 to 30 years of age Dexterity and flexibility decline Hearing loss begins at 25 Vision changes by 40 Hormonal & Climacteric Changes Women Decline of estrogen leads to menopause Increase in abdominal fat Increase in risk of cardiovascular disease Accelerated loss of bone mass Men Gradual decline in testosterone level and muscle mass Body Composition Changes Bone: Gradual bone loss begins around age 40 • Osteopenia/osteoporosis risk is dependent on peak bone mass Adiposity: Positive energy balance resulting in increase in weight and adiposity • Hypertrophy of fat cells -> deposits of visceral and ectopic fat Gut Microbiome: Shifts and adapts with age, diet, geographic location, stress, supplements & medications • Healthy gut microbiota supports immune system, protects against pathogens, controls colonic motility, just to name a few benefits

dietary supplements used by older adults for common conditions

Poor appetite or dieting: Multivitamin/mineral Weight loss, chronic underweight: Add high-calorie/protein foods/fats as oils Vegetarian or vegan: Vitamins B12, D, calcium, zinc, iron Age-related macular degeneration: Special formulation of antioxidant vitamins Zinc and copper for high-risk and current AMD Atrophic gastritis and/or long-term use of proton pump inhibitors: Vitamin B12, calcium, magnesium Diarrhea: Fluids, multivitamin/mineral Energy boosters: Iron (if blood levels are low) Guard against excess stimulant (caffeine and guarana) Osteoporosis: Vitamins D, calcium, magnesium Sleep aids: Melatonin Avoid guarana, caffeine & alcohol near bedtime Constipation: Fiber (cellulose, bran, psyllium), together with fluid

How does the development of feeding skills in preschool-age children differ from that in toddlers and why is that important?

Preschool age children can use forks, spoons, and cups but may need help using a knife to cut or spread. Eating is NOT as messy but spills can accidently occur. It is still important for adults to watch their children when they eat and that children are seated comfortably. Development of feeding skills in preschool age is important because they are becoming more independent but at the same time may need less foods as their growth rate is slower at this time. Since toddlers like to please caregivers this is a good time to teach children about foods, food selection, and preparation by involving them in simple food-related preparation.

Physical Activity Recommendations in older adults

Same as for adults At least 150 minutes per week Muscle strengthening on 2 or more days per week For older adults, recommendations also include exercises that maintain or improve balance if at risk of falling -strength training, aerobic activities and balance exercises like tai chi are all beneficial.

Osteoporosis in oa & causes

Prevalence: ~11% (men) and 35% (women) 80+ yo Low bone mass affects 35% (men) and 51% (women) Risk begins in childhood & adolescence Critical time for developing dense bones Prevented by weight-bearing exercise Caused by inactivity (bed rest & sedentary lifestyle) Highly problematic in older adults Falls/breaks -> leading causes of death in adults 65+ 10 to 20% of older people who break a hip die within a year

What are the primary functions of the kidney and what happens to patients that have CKD?

Primary functions of kidneys are to: • Maintain homeostatic balance of fluids, electrolytes & organic solutes • Remove waste from body through urine production -Kidneys filter ~1,600 L of blood and produces 1-2 L urine per day CKD occurs when there's kidney damage or decreased kidney function (as defined by decreased glomerular filtration rate-GFR) for 3 or more months Affects 30 million people in the US

Why is adequate iron intake important during adolescence? When do M/FM need more iron specifically? How much is recommended?

Rapid rate of linear growth, increase in blood volume, and menarche in females increases adolescent needs for iron ◦ Females: Needs are greatest after menarche ◦ Males: Needs are greatest during growth spurt ◦ Recommendations: ◦ 9 to 13 years: 8 mg/dL per day ◦ 14 to 18 years: 11 mg/dL per day (Males); 15 mg/dL per day (Females) NOTE: even through DRI's are based on chronological age, actual iron requirements are based on sexual maturation level

Protein requirements for athletes? Why?

Recommendations are slightly elevated as ranges from 1.2 to 1.7 g/kg body compared to 0.8 g/kg body weight for non-athletes ◦ Endurance athletes should consume 1.2-1.4 g protein per kg BW to maintain lean body mass ◦ Strength trained athletes 1.6-1.7 g/kg to maximize muscle hypertrophy ◦ Athletes following vegetarian/vegan diets have increase protein requirements (1.3 to 1.8 g/kg body weight) because of the lower quality of plant-derived proteins Amino acids mainly used to repair and build new tissues as amino acid oxidation only supplies <10% of total energy expenditure

Criteria for diagnosis of Bulimia Nervosa

Recurrent episodes of binge eating defined as: ◦ Eating in a discrete period of time (e.g. within any 2-hr period) an amount of food that is definitely larger than most people would eat during similar period of time & circumstance ◦ A sense of lack of control over eating during the episode (e.g. feeling that one cannot stop eating or control what/how much one is eating) Recurrent inappropriate compensatory behavior to present weight gain (e.g. self-induced vomiting, misuse of laxatives, diuretics, excessive exercise) Binge eating & inappropriate compensatory behaviors both occur, on average, at least 2x's a week or 3 months Self-evaluation is unduly influenced by body shape & weight **Disturbance does not occur exclusively during episodes of anorexia nervosa

Inborn Errors of Metabolism

Require interventions to manage breakdown products from foods & beverages metabolized incompletely or inadequately Involve molecular & cellular-level blocks Examples: glycogen storage diseases & medium-chain fatty acid disorders

Why might restricting food access or forcing food consumption be harmful for children?

Restricting food access can actually promote desirability and intake of the food. Coercing food intake may have negative long-term impacts on food preference.

When do older adults benefit from using supplements?

Risk factors indicating supplementation benefit Lack appetite resulting from illness, loss of taste/smell or depression Diseases or bacterial overgrowths in gastrointestinal tract Poor diet due to loss of function, dieting or disinterest in food Avoidance of specific food groups Use of substances affecting diet, absorption or metabolism

what should the RDN ensure in regards to t2D?

Screening and referral: - all overweight/obese adults at risk (Weight circumference: >40 inches (men) & 35 inches (women) increases insulin resistance) -individuals with t2d are referred for MNT Nutrition assessment: - biochemical data. Medication usage... (A1c of 6% reflects average BG level of 120 mg/dL. Every 1% increase reflects an increase of an average BG level of ~30 mg/dL) - nutrition focused physical findings -client history -food/nutrition-related history - dietary supplement and complementary and alternative medicine practices -clients psychological and social situation

What are eating disorders characterized by?

Serious disturbances in eating behavior ◦ Restriction of intake or bingeing ◦ Distress or excessive concern about body shape or weight ◦ Compromised psychological well-being - depression ◦ Potentially devastating effects on health ◦ physiologic sequelae of altered nutritional status or purging

What are intervention strategies are used for weight-loss interventions in adults?

Set goals Self-monitoring to track goals Strategies to achieve calorie deficits Rules for challenges/reset Providing rewards/incentives = improves adherence and outcomes!

Why are dental caries in children also known as early childhood caries (ECC) or nursing bottle caries?

Since a primary cause of dental decay in young children is habitual use of a bottle or a no-spill training cup (sippy cup) with milk or fruit juice at bedtime or throughout the day. These fluids tend to pool when toddlers fall asleep drinking the bottle, which is why the upper front teeth are most severely damaged.

Why are snacks vital to meeting a young child's energy needs? Why should sweetened beverages, cookies, and chips be limited?

Since children aren't bale to consume large portions snacks between meals are important. However, they should NOT be allowed to graze throughout the day on sweetened beverage and foods such as cookies and chips because they can reduce their appetite for basic foods.

Clinical signs of BN

Sinus bradycardia ◦ Orthostatic by pulse or blood pressure Other cardiac arrhythmias Cardiac murmur ◦ (mitral valve prolapse) Hypothermia Hair without shine Dry skin Russell's sign ◦ callous on knuckles from self-induced emesis Mouth sores Palatal scratches Dental enamel erosions May look entirely normal

Why is identifying the cause of FTT difficult?

Some toddlers and preschoolers, who have grown adequately in the first year, may have decreases in growth rate and the control issues at mealtime which are expected at the time but may also be signs of FTT. BUT FTT may result from a complex interplay of medical/environmental factors: 1.GI problems such as reflux or celiac disease 2.asthma or breathing problems 3.Neuroligical conditions such as seizures 4. pediatric aids Also children who have chronic illnesses or were born preterm have a higher risk of FTT. Often a specific nutrient or group of nutrients may be inadequate.

Stage 1 obesity treatment and goals

Stage 1: Prevention Plus 2. ◦ For adolescents at BMI >85th but <95th percentile, without comorbid conditions and have not completed growth spurt ◦ Level of treatment builds upon basic nutrition and physical activity guidance ◦ Goals: promote health and prevent disease focusing on: ◦ Five servings fruits and vegetables a day ◦ Limit sweetened beverages ◦ 60 minutes physical activity daily ◦ Limit screen time ◦ Treatment provided by a single health care provider (e.g. physician, nurse, physician assistant, dietitian, nurse practitioner etc)

Stage 2 obesity treatment and goals

Stage 2: Structured Weight Management ◦ BMI >85th but <95th percentile with risk factors: fasting lipids, ALT and AST, fasting glucose ◦ Goals: Focused on same behaviors as first stage, but with more structure and some modifications including: ◦ Limiting screen time to under one hour per day ◦ Emphasizing nutrient-dense foods ◦ Minimizing energy-dense foods ◦ Treatment provided by a health care provider with behavioral pediatric weight management training ◦ Referrals to other providers (e.g. physical therapy, mental health counseling) may be needed

Stage 3 obesity treatment and goals

Stage 3: Comprehensive Multidisciplinary Intervention ◦ Addresses same behavioral goals as Stage 2, but in a more structured, interdisciplinary format with more contact ◦ Treatment provided by multidisciplinary team of health care professionals who specialize in pediatric obesity management, which includes: ◦ Detailed plan designed to lead to negative caloric balance ◦ Structured behavior-modification program is recommended ◦ Weekly visits for 8-12 weeks, followed by bimonthly or more frequent contact with adolescent and his/her family

Stage 4 obesity treatment and goals

Stage 4: Tertiary Care Intervention ◦ Appropriate with severely obese youth or those who have significant, chronic comorbidity conditions ◦ Treatment provided through a tertiary weight management center specializing in adolescent obesity ◦ In addition to diet and activity counseling with behavior modification, more intensive treatments may be implemented such as: ◦ Meal replacements ◦ A very-low-energy diet ◦ Medication ◦ Orlistat: pancreatic lipase inhibitor that causes fat malabsorption, FDA-approved for adolescents >12 years ◦ Metformin: off-label (non-FDA-approved) used to reduce hepatic glucose production, inhibit fat cell formation and may reduce food intake, for children >10 years old ◦ Surgery ◦ Only for severely obese adolescents not successful with behavior modification and lifestyle changes

Stages of CKD and interventions?

Stages 1 to 4: Predialysis Stage 5: requires replacement therapy (dialysis) to sustain life • Two types of dialysis treatment: hemodialysis & peritoneal Nutritional intervention for stages 1-4 include: • Minimize tissue catabolism • Maintain nutritional status, weight, appetite, electrolyte balance & lean body mass • Postpone dialysis as long as possible

Why are carbohydrate food sources such as milk and fruit juice thought to cause dental caries? What are other foods that promote dental caries? What can be done to prevent/reduce dental caries?

Streptoccus mutans the main type of bacteria that causes tooth decay use these carbohydrates as food. These bacteria excrete acids that cause tooth decay. Other foods that promote dental caries are: 1) foods containing carbohydrates that stick to the surface of the teeth such as sticky candies Prevention: 1) rinsing mouth w/ water or brushing teeth 2) not allowing children to indiscriminately eat or drink throughout the day 3) providing crunchy sweet foods such as carrot sticks and apple slices instead of sticky candies

Nutritional considerations and interventions for ADHD in children:

Such medications (esp psychostimulants) can decrease appetite, resulting in weight loss or slow growth Peak activity of ADHD medication is aimed for school hours. Nutrition interventions should work around those hours. Nutrition interventions call for timing meals & snacks around medication's action peaks Example: Adding a large bedtime snack when the medication's effects are low Children with ADHD, who are not on medication, may have a chaotic meal/snack pattern and have an inability to stay seated for a meal

T or F : The recommendations for typical children concerning dietary fiber, prevention of lead poisonings, and iron deficiency anemia usually apply to children at risk or diagnosed w/special health care needs.

T

T or F: CF affects all exocrine organs with long complications causing death in adulthood.

T

T or F: Physical activity decrease with age

T

T or F: Toddlers and children are entitled to the same services as older people with chronic illnesses

T

T or F: Young girls seems to have a preoccupation with weight and size at an early age

T

What are metabolic risk factors?

T2D, cholelithiasis, hypertension, coronary heart disease

Practical Ways to Incorporate More Physical Activity into Your Day

Take the stairs instead of the elevator • Park farther away from your destination • Sit on a balance ball while working at a desk • Exercise during commercials while watching TV • Have a Thera-Band available by desks, couches etc. so strength training exercises can be performed • Dance! • Stretch during the day • Stand up during meetings • Do chair exercise

Although RDAs for protein are established for young children why is protein less of a concern in America? What are the RDAs?

The American diet has plenty of high quality protein products such as milk and other animal products, which lowers the amount of total protein needed in the diet to provide the essential amino acids. Also there is usually adequate energy intake in American children, which has a protein sparing effect. -1-3 year = 1.1g/kg/day or 13 g/day -4-8 years = .95g/kg/day or 19g/day Remember at the toddler/ preschool stage the child's growth is slowing down, thus the protein requirements reflect that.

how does family mealtime benefit children/why should it be recommened?

The children in families who regularly ate 3 or + meals together per week, were 12% less likely to be overweight, 20% less likely to eat unhealthy foods, 35% less likely yo have disordered eating, and 24% more likely to eat healthy foods. Children who ate dinner w/ their family had higher energy intakes as well as higher intakes of fiber, ca, folate, fe, vitamin b6, b12, C, and E.

Why is multidisciplinary care, in which dietitians are involved vital in health care interventions for children with special health care needs?

The earlier special educational, nutritional, and health care interventions are started the better for the overall development of the child. For example nutrition related problems can be identified in primary care offices or the process of finger and then spoon feeding is a developmental milestone for toddlers and so many health care providers, such as speech- language therapists and occupational therapists, work with families then children have feeding concerns.

Why are young children at high risk of developing elevated blood levels of lead? What are the major sources of exposure?

The major sources of lead exposure are airborne lead, leaded chips, and dust. They are at risk at this age they enjoy putting things in their mouth and exploring their environment. Also damage caused by lead exposure may begin during pregnancy as lead is transported across the placenta to the fetus.

Why are CDC charts so useful to health professionals?

They can use them to chart, monitor and evaluate the growth of children over time/ identify any deviations in growth by plotting: 1) weight for age 2)length or stature for age 3)head circumference for age 4) weight for length 5)weight for stature 6) BMI for age

Intervention for Iron deficiency Anemia (in young children)

Treatment of iron deficiency anemia includes : 1) supplementation with iron drops at a dose of 3 mg/kg/day, 2)counseling of parents or caretakers about diets that prevent deficiency 3)repeat screening in four weeks Dietary recs: 1)increased consumption of lean meat, fish, and poultry and inclusion of sources of Vitamin C at meal to increase the absorption of non- meat iron sources. *if anemia is responsive to treatment, dietary counseling should be reinforced, and treatment should be continues for 2 months but hemoglobin and hematocrit should be rechecked. Then reassessed at 6 months. *if hemoglobin and hematocrit do NOT increase further diagnostic tests are needed.

True or False : BMI is predictive of body far for children over the age of 2 since BMI normative values are NOT available for children less then 2 years old.

True

t or f: About 1 in 3 children aged 3-5 years old had decay in at least one primary or permanent tooth in 1999-2004.

True

NSLP meal pattern weekly

Vegetables: Dark green, red orange, beans/peas, starchy, other Meat/Meat Alternative and Grains 8-10 oz: K-Grade 5 9-10 oz: Grades 6-8 10-12 oz: Grades 9-12

Micronutrients of concern

Vitamin A due to toxicity , Vitamin D deficiency risk from lack of intake and absorption in the skin ( need at least 600 Ui at 50-70 yo though DRi for 70+ is 800 ui, Calcium ) , Calcium due to decline in absorption & less vit d , b12 due to possible Malabsorption from atrophic gastritis and less absorption ( symptoms of low b12 deterioratio of mental functio , change i personality, and loss of physical coordination), folate and folic acid altho gh most cknsume enou may be poorly absorbed due to atrophic gastritis, medications (antacids, diuretics, anti-inflammatory drugs) , sodium is too high ( ai set to 1,200 mg) but potassium intake ( ai 4,700mg) balances it out

How can the growth of children with special health care needs be assessed for growth? What should be done if a child's condition is known to change rate of weight or height gain?

WHO and CDC growth charts are good start but children w/special needs require in-depth growth assessment. Specialized growth charts may be used for CP, down syndrome. In that case warning signs for growth problems such as plateau in weight, pattern of weight gain/lossm failure to regain weighr lost during illness, or unexplained and unintentional weight gain should be monitored.

Dehydration in OA Nutritional Interventions

Water DRI: no different as adults get older Rehydrate slowly; Provide one-fourth to one-third overall fluid deficit daily In the form of water or 5% glucose solution Thickened liquids count as fluid Offer fluids hourly and with medication (for bedridden patients)

Water/ liquids

Water is a good thirst quencher for toddlers and preschoolers but need 2 cups of milk in regular diet and <4-6 oz of fruit juice.

considerations of ANH

When ANH is being considered, it is important for healthcare providers to know and respect the values & beliefs of the patient The Academy of Nutrition & Dietetics/Commission on Dietetic Registration (2015) Code of Ethics should be used as a framework for all practice including obligations of the practitioner when communicating with patients and their families

When is should lead screening be initiated?

When indicated lead should be obtained at 9-12 months and around 24 months

Why is BMI is adjusted for age and sex-specific percentiles? What are the BMI classifications? What should you make sure to do when assessing risk at a single point in time?

because children are still growing > 5th %-ile = underweight 5th to <85th %-ile = normal weight 85th to <95th %-ile = overweight >95th %-ile = obesity >120% of the 95th %-ile = severe obesity (not available on growth charts) When assessing risk at a single time point: ◦ Make sure measurements are accurate ◦ Use date of birth to calculate age ◦ Interpret based on where they fall on the chart

Why is trusting children to determine how much and whether to eat from what parents provide fundamental to parents' jobs? List the roles of parents vs children.

When parents do their jobs with feeding, children do their jobs with eating: Parents' feeding jobs: • Choose and prepare the food. • Provide regular meals and snacks. • Make eating times pleasant. • Step-by-step, show children by example how to behave at family mealtime. • Be considerate of children's lack of food experience without catering to likes and dislikes. • Not let children have food or beverages (except for water) between meal and snack times. • Let children grow up to get bodies that are right for them. Children's eating jobs: • Children will eat. • They will eat the amount they need. • They will learn to eat the food their parents eat. • They will grow predictably. • They will learn to behave well at mealtime.

Why is BMI used to measure/screen adolescents for obesity?

While there are major limitations to using BMI as an adiposity measure, objective measures of adiposity are expensive and time intensive = not appropriate for screening/ population level/prevention

Why is childhood obesity a major public health concern nowadays?

With the rise in obesity in the past 30 years, there are several medical and psychosocial impacts to adolescents facing obesity. Medical Consequences Risk of Type 2 Diabetes, Cardiovascular disease, some cancers, metabolic syndrome Psychosocial Consequences Bullying/stigma Poor self-esteem Depression

Sleep recommendations for toddlers and preschoolers

Young children should not be put to bed with a bottle or cup AAP recommended sleep per day: ◦ Infants >1 year: 12-16 hours including naps ◦ Children 1-2 years: 11-14 hours including naps ◦ Children 3-5 years: 10-13 hours including naps Sleep is critical for growth and development/ impacts hormones that regulate hunger/satiety

CEREBROVASCULAR DISEASE (STROKE)

a chronic disease characterized by damage to blood vessels of the brain resulting in disruption of circulation to the brain 700,000 Americans affected each year Nearly 5 million stroke survivors are managing their health today

iron deficiency

absent bone marrow iron stores, an increase in hemoglobin concentration of <1.0g/dL after treatment with iron, or other abnormal lab values, such as serum ferritin concentration (storage form of iron) **An increase of >1 g/dL in hemoglobin concentration or more than 3 % hematocrit, within four weeks of treatment confirms diagnosis of iron deficiency.

medical home

an approach to providing health care services, and involves a partnership of health care personnel and family. Note: young children thrive best when they live at home, even those who are technology dependent and have complex health care needs.

Peritoneal:

artificial filtering of blood by hyperosmolar solution through peritoneum

Hemodialysis:

artificial filtering of blood requiring permanent vein access through a fistula; dialysis fluid similar to plasma

diabetes causing dietary risk factors

atherogenic diet obesogenic diet

Therapeutic Lifestyle Changes (TLC) diet

is the lifestyle component of the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III guidelines • It focuses on diet, weight management & increased physical activity -Saturated fat less than 7% of kcal, cholesterol less than 200 mg/day -Increased viscous (soluble) fiber (10-25g/day) and plant stand/sterols (2g/day) -Weight management -Increased physical activity

iron deficiency anemia

less than the 5th percentile of the distribution of hemoglobin concentration or hematocrit in a healthy reference population.

PKU monomeric

meet dirty dan's new enemies: - Meat -Dairy products -Dry beans -Nuts -eggs

PKU & intervention

occurs due to defective or absent enzyme needed to metabolize the amino acid, phenylalanine Nutrition intervention: more than 80% of protein intake from foods/beverages replaced by mixture of amino acids from which phenylalanine has been removed Intervention is lifelong. If foods with protein are consumed in too high amounts, PKU slowly becomes a degenerative disease affecting the brain at whatever age the treatment is stopped

Celiac disease

occurs in people who are sensitive to gluten (From wheat, rye, barley). When gluten is consumed the body's immune system attacks and damages the small intestine. This causes pain diarrhea, and malabsorption. Often associated with chronic conditions such as down syndrome, turner syndrome, T1D, juvenile arthritis, and others. Infants can suffer from malnutrition, leading to poor growth in weight and/or height. The condition can be confirmed via blood testing for antibodies.

The WHO growth charts are used for children aged birth to 24 months regardless_____________ (fill in blank)

of type of feeding

Heart Disease Considerations of older adults

older adults more likely to have comorbid conditions that necessitates balancing multiple goals Also, older adults likely to wonder if potential health gains are worth the necessary changes Is quality of life being balanced with potential life expectancy? What is the older adult's physical & emotional status? Does s/he have resources & energy to maintain the new healthy habits?

Definitions of overweight and obesity class in children/ pre-adolescents

overweight: >/= to 85%tile to 94%tile obesity I : >/= 95%tile obesity II >/= 120% of the 95th%tile or BMI >/=35 obesity iii: >/= 140% of 95th%tile or BMI >/= 40

fluorosis

permanent white or brownish staining of the enamel of teeth caused by excessive fluoride consumption before teeth have erupted.

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

permanent, destructive pulmonary disorder that is a combination of chronic bronchitis and emphysema • Type 1 (emphysema) - seen in older patients who are thin and cachectic, with corpulmonale that develops late in course • Type 2 (chronic bronchitis) - seen in patients with normal/excessive weight & prominent hypoxemia; corpulmonale develops early in disease course

Sodium, potassium, calcium, and phosphorous (mg/day) trends for CKD

sodium: only need to restrict to 2000 from stages 1-5 potassium: only restrict based on lab values at stage 1-4 with hemodialysis at stage 5,, need to keep 2000-3000 and 3000-4000 w/ peritoneal dialysis Calcium: restrict at stage 1-4, then allow up to 2,000 from diet and meds at stage 5 but restrict more severely at transplant phosphorus: restrict based on lab values at stages 1-4, but with stage 5 both need to restrict: 800-1000. no restrictions unless indicated at transplant.

Define Resting energy expenditure (REE) and explain why REE has to be multiplied by an activity factor to cal energy needs?

the amount of energy required to maintain basic body functions - Basically the BMR when the body is at rest, thus we need to compensate for when the body is activity with the activity factor: Sedentary: 1.2 Moderately active: 1.55 Very active: 1.725

Psuchiatric comorbidity and examples

the presence of additional mental disorders, such as substance abuse. Depression is common in both AN and BN ◦ But affect improves significantly with refeeding & reduction in binge-purge symptomology Obsessive-compulsive disorder, anxiety disorders & personality disorders also common Higher rates of self-harming behaviors, substance abuse/misuse & suicide in patients with eating disorders compared to those without ED's

How do the DRI equations for estimating energy change at the age of 3?

they include the child's gender, age, weight and physical activity level (PAL).

How should organized sports be implemented?

they should NOT take the place of regular physical activity such PE. Instead the emphasis should be on having fun and less on the competition.

Eating Disorder Not Otherwise Specified (EDNOS) - DSM -4

those who do not meet criteria for anorexia nervosa or bulimia nervosa) All criteria for anorexia nervosa met, except: ◦ Has regular menses ◦ Current weight still in normal range All criteria for bulimia nervosa met, except: ◦ Binges <2x a week or <3 times a month A patient w/ normal BW who regularly engages in inappropriate compensatory behavior after eating small amounts of food A patient who repeatedly chews & spits out large amounts of food w/o swallowing Binge eating disorder -has recurrent binges but does NOT engage in inappropriate compensatory behaviors of bulimia

Failure to Thrive (FTT)

weight for age that falls below the 5th percentile on multiple occasions or weight deceleration that crosses two major percentile lines on a growth chart.

When are eating and feeding problems are diagnosed (oa):

when children have difficulty: Accepting foods Chewing them safely Ingesting enough foods and beverages

why are vending machines a double age sword?

with extra funding they can reinforce food nutrition and appropriate choices but they can also be a sources of foods/beverages high in fat and sugars.

CKD nutrition assessment (key values to look for besides standard ones)

• Glomerular Filtration Rate (GFR)-best overall indices of kidney function • estimated from serum creatinine levels by using prediction equations that take into account age, sex, race & body size • Proteinuria: refers to increased urinary excretion of albumin or any other specific protein

Why /how is obesity and outcome of interest/ and why is it screened for?

• Objectively measure height and weight • Should be interpreted in the context of other metabolic risk factors • Independently associated with chronic disease risk • Other risk behaviors (diet and physical activity) are hard to measure • Chronic disease outcomes are too distal and severe • FOCUS on Prevention SCREENING Assess weight AND Lifestyle: Previous weight loss attempts Diet Physical activity Family history/family influence Social determinants of health Other medical conditions (rememberthese are adults!) Potential targets for support/motivation What leverage can you find to help motivate change in your client/patient?

The Division of Responsibility for infants (re: feeding)

• The parent is responsible for what. • The child is responsible for how much (and everything else).

What are socio-demographic risk factors for overweight and obesity?

◦ Having one or more overweight parents ◦ Having a low socioeconomic status ◦ Odds of being obese increase up to 60% for children who live in neighborhoods with unfavorable conditions ◦ Being of African American, Hispanic, American Indian/Native Alaskan race/ethnicity ◦ Having a condition that limits mobility

Physical activity guidelines for adolescents? Are most American children meeting them?

◦ Moderate to vigorous-intensity aerobic exercise daily or nearly every day for at least 60 minutes ◦ Bone and muscle strengthening activities 3 days per week NO!

List the factors that affect adolescents food choices

◦ Peer attitudes and behaviors ◦ Parental modeling ◦ Food availability, preferences, cost & convenience ◦ Personal and cultural beliefs ◦ Mass media ◦ Body image These can be further categorized into macrosystems, personal, and environmental factors.

List Health and Eating-Related Behaviors During Adolescence

◦ Snacking ◦ Account for ~1/4 of daily food energy among adolescents ◦ Meal skipping ◦ Breakfast is most skipped meal - 36% adolescents report eating breakfast daily ◦ 17% report skipping lunch and 8% skip dinner ◦ Eating away from home ◦ >1/3 of daily calories are consumed away from home ◦ Fewer family meals ◦ ~1/3 report eating meals with their family at least 6 days per week ◦ More frequent family meals associated not only with improved dietary intake, but also decrease substance use & better academic outcomes