NUTRITION

Improper Diet Orders

"No concentrated sweets," "no sugar added," "low sugar," and "liberal diabetic" -Why unsuitable: •They do not reflect diabetes nutrition recommendations. •They pointlessly restrict sucrose.

Types of Adult Malnutrition

"Starvation-related malnutrition"--chronic starvation without inflammation "Chronic disease-related malnutrition"--chronic inflammation of mild to moderate degree "Acute disease- or injury-related malnutrition"-- acute inflammation of severe degree

Celiac Disease

-Also known as gluten-sensitive enteropathy -Chronic disease that damages mucosa of the small intestine -Results in reduced absorptive area -Intestinal damage caused by gliadin, the protein fraction of gluten found in wheat, oats, rye, and barley -Symptoms: diarrhea, abdominal distention, fat malabsorption, weight loss Possible nutritional deficiencies: -Osteopenia or osteoporosis -Inadequate blood coagulation and easy bruising (lack of vitamin K) -Iron-deficiency anemia -Macrocytic anemia of the pernicious anemia type (malabsorption of vitamin B12 and folate) -Idiopathic steatorrhea in the early stages Nutrition therapy -Removal of gluten from the diet -Lifelong avoidance of gluten -Reading food labels: gluten-containing grains are used extensively in the American diet -Alternative foods (e.g., rice, potato, buckwheat)

Cirrhosis: Ascites and Encephalopathy

-Ascites: accumulation of fluid in abdominal cavity; treated by dietary restriction of sodium and sometimes fluid Hepatic encephalopathy: type of brain damage resulting from toxic ammonia buildup; can result in hepatic coma -Symptoms: changes in consciousness, behavior changes, loss of memory, confusion, apathy, personality changes, psychiatric symptoms, neurologic changes -Treatment: antibiotic therapy, lactulose, neomycin

Water-Soluble Vitamins: Biotin

-Biotin Function: important role in CHO, fat, and protein metabolism -Recommended intake and sources •AI: 30 µg for adults •Synthesized in lower GI tract by bacterial microorganisms (amount produced and bioavailability unknown) •Dietary sources recommended -Deficiency •Unknown if typical North American diet is consumed, but possible with intravenous feedings and long-term antibiotic use •Deficiency possible with large intake of avidin from raw egg whites; avidin denatured by heat (cooking) •Symptoms: skin rash, hair loss, appetite loss, depression, glossitis -Toxicity: unknown

Water-Soluble Vitamins: Choline

-Choline Function: synthesis of acetylcholine (a neurotransmitter) and lecithin (the phospholipid) -Recommended intake and sources •Body makes choline from amino acid methionine, but not enough to meet body's need; food sources required •AI: 550 mg for men; 425 mg for women •Sources: milk, eggs, peanuts -Deficiency: rare -Toxicity: UL of 3500 mg for adults •Symptoms: sweating, fishy body odor, vomiting, liver damage, reduced growth, and low blood pressure (hypotension)

Water-Soluble Vitamins: Cobalamin

-Cobalamin (vitamin B12): cyanocobalamin Function •Modifies folate coenzymes to active forms •Required for metabolism of fatty acids and amino acids •Develops and maintains myelin sheaths around nerve fibers •With pyridoxine and folate, may reduce levels of homocysteine, thereby decreasing CAD risk -Cobalamin (vitamin B12): cyanocobalamin (cont.) Recommended intake and sources •RDA: 2.4 µg daily •Absorption requires intrinsic factor, produced by stomach mucosa •Accounts for some liver storage of cobalamin •Sources: only animal-derived foods (meat, fish, poultry, eggs, dairy) •Vegans must supplement or use fortified products -Cobalamin (vitamin B12): cyanocobalamin (cont.) Deficiency •Usually secondary •Results in megaloblastic anemia or pernicious anemia •Additional neurologic or neuropsychiatric effects •Older adults at risk •May be masked by folate levels Toxicity: unknown

Heartburn and Gastroesophageal Reflux Disease (GERD)

-Commonly known as heartburn -Burning sensation felt in esophagus when acid refluxes after food has passed to the stomach; it may pass back up through cardiac sphincter into esophagus -Symptoms include severe burning sensation under sternum, asthma, chronic cough, other ear, nose, and throat ailments Diagnosis dependent on symptoms Gastroesophageal reflux disorder (GERD) Laryngopharyngeal reflux (LPR) (reflux affects the larynx or pharynx Nutrition therapy -Avoidance of certain foods, especially those high in fat that increase sphincter relaxation and potential reflux. -Foods such as chocolate, alcohol, peppermint, spearmint, liqueurs, caffeine, and high-acid foods can irritate esophagus.

Stages of Adulthood: The Oldest Years (80s and 90s)

-Decreased ability to absorb or synthesize nutrients Nutrition requirements -Concerns of malnutrition and underweight -Dehydration -Nutrition screening

Nutrition During Adulthood

Aging and nutrition -Aging: gradual process that reflects influence of genetics, lifestyle, and environment over life span -Some body systems more affected than others •Changes may begin to affect nutritional status In each stage of adulthood, particular life stressors that may affect adult nutritional status

Nutrition-Related Pregnancy Concerns

Alcohol -Fetal alcohol syndrome (FAS)/fetal alcohol spectrum disorder (FASD); causes specific anatomic and central nervous system defects; no safe level -Foodborne illness -High risk for acquiring infections from Listeria monocytogenes, Salmonella species, and Toxoplasma gondii Maternal age -Risk factors for adolescents •Growth pattern of mother; psychologic maturity •Lack of economic resources; delay in medical care •Nutrient intake: often poor -Risk factors for women older than 35 •Distinct nutrient needs; longer medical history •Gestational diabetes Preeclampsia (pregnancy-induced hypertension) -Some symptoms: sudden severe rise in arterial blood pressure; rapid weight gain; marked edema -Risk factors -Nutrition support: well-balanced diet, generous protein and sufficient energy intake -Experimental treatments Diabetes mellitus -Preexisting diabetes (types 1 and 2 diabetes mellitus) necessitates specialized care -Risks to fetus •Increased risk of birth defects, macrosomia, hyperbilirubinemia, and erythema •Risk of hypoglycemia after birth -Risks to diabetic mother Control/treatment -Decreased risks when diabetes is controlled -Blood glucose monitoring; adherence to diet; moderate exercise; prescribed insulin Gestational diabetes mellitus -Screening during second trimester -Treatment: dietary control with moderate exercise; insulin if needed -Risk factors Maternal phenylketonuria -Inborn error of metabolism of phenylalanine -Mother: strict adherence to diet low in phenylalanine; infant: supplementation with tyrosine beginning in first week of life -Failure to detect disease or lack of compliance with dietary therapy: results in irreversible mental retardation Human immunodeficiency virus (HIV) infection -Effects on immune system: immunosuppressive effects of hormones and proteins of pregnancy -Nutritional considerations •Opportunistic infection increases need for kilocalories, protein, vitamins, and minerals -Weight gain must be strictly monitored •No specialized weight gain recommendations

Nonoral Feeding

Any time nourishment is provided directly to the gastrointestinal (GI) tract, the feeding is technically a form of enteral nutrition. -When a patient is not able to eat orally for more than a few days, a nonoral method must be used. -The phrase "enteral nutrition" usually refers to tube feedings

Energy

As bodies function, chemical energy from food converted to mechanical energy and heat -Kilocalorie (kcal): unit of energy measurement Methods to determine food energy -Bomb calorimeter -Proximate composition Energy pathways -Adenosine triphosphate (ATP): fuel for all energy-requiring processes Carbohydrate as source of energy -Converted to carbon dioxide and water via metabolic pathways of glycolysis, tricarboxylic acid (TCA) cycle, and oxidative phosphorylation -Glycolysis: ATP and pyruvic acid produced -Anaerobic pathway (glycolysis): no oxygen needed •Limited: lactic acid and oxygen debt •For sprinting or speed-type exercise •Takes place in cytoplasm Aerobic pathway (glycolysis): oxygen needed •Creation of acetyl coenzyme A (CoA) •For endurance-type exercise •Takes place in mitochondria of cell Oxidative phosphorylation •Creation of phosphate bond to form ATP Fat as a source of energy -Hydrolysis of fats into glycerol and three fatty acids -Glycerol changed to pyruvic acid; used for energy -Fatty acids enter the TCA cycle as two-carbon acetyl CoA units (beta oxidation) Protein as source of energy -Amino acids: deamination -Some amino acids converted to pyruvate or to TCA cycle intermediates Anaerobic and aerobic pathways -Constant interchange of energy sources -Amount of energy used depends on intensity, length of exercise, fitness level, and foods eaten -Factors that influence glycogen storage: carbohydrate intake, fitness level

Dysphagia

Background -Chewing or swallowing difficulty -Diets designed to meet nutritional needs and prevent aspiration -Thickening agents useful to provide varying levels of consistency Three stages of swallowing: -Oral preparation and transit; pharyngeal transit; esophageal transit What are the warning signs of swallowing problems? --Warning signs: -Pain while swallowing (odynophagia) -Inability to swallow -Sensation of food getting stuck in the throat or chest -Drooling Hoarseness -Bringing food back up (regurgitation) -Frequent heartburn Food or stomach acid backing up into the throat -Unplanned weight loss -Coughing or gagging when swallowing Conditions that may cause dysphagia -Achalasia -Acute cervical spinal cord injury -Alzheimer's disease and dementia Amyloidosis -Amyotrophic lateral sclerosis -(ALS, Lou Gehrig's disease) -Anoxia Botulism -Cerebrovascular accident (CVA)/stroke Chagas disease -Diabetes, type 1 (long term) Esophageal cancer Esophageal varices -Gastroesophageal reflux (GERD) -Gastroparesis Goiter -Guillain-Barré syndrome -Head and/or neck cancer, including brainstem tumors -Head injury -Human immunodeficiency virus (HIV) infection Huntington's disease Inflammatory masses -Intrinsic and extrinsic structural lesions -Lung inflammation, including chronic obstructive pulmonary disease (COPD), with excessive secretions Multiple sclerosis (MS) Multiple system atrophy (MSA) Muscular dystrophies (MDs) Myasthenia gravis --Parkinson's disease Poliomyelitis -Postintubation trauma -Presbyphagia (swallowing difficulty of old age) -Scleroderma -Stricture or inflammation of pharynx or esophagus Tumor or obstruction of throat

Blood Glucose Level Goals

Before meals: 70 to 130 mg/dL Two hours after meals: less than 180 mg/dL (expect a 30- to 50-point rise from premeal glucose) Bedtime: 90 to 150 mg/dL

Blood Glucose Monitoring

Blood glucose monitoring -Glycosylated hemoglobin: reflects blood glucose control for 100 to 120 days -Self-monitoring: useful for evaluating effectiveness of meal plans in meeting goals of nutrition therapy -Records: determine food, insulin, and exercise needs

Peptic Ulcer Disease

Break or ulceration in protective mucosal lining -Lower esophagus, stomach, or duodenum -Acute or chronic in nature -Superficial or deep erosions Major causes -Infection with Helicobacter pylori -Nonsteroidal anti-inflammatory drugs (NSAIDs) Treatments -No need for special diet or bland diet; high-quality diet will suffice -Elimination of foods that may worsen damage to lining of esophagus, stomach, or duodenum, such as red and black pepper, chili pepper, coffee, caffeine, and alcohol -Smoking cessation

Dumping Syndrome

Caused by partial or total gastrectomy or removal of pyloric sphincter -Symptoms related to rapid gastric emptying and distention of upper small intestine -Hyperosmolar gastric contents cause rapid influx of fluid Symptoms -Early phase: 10 to 20 minutes after meal *Fullness, cramps, nausea, diarrhea *Vasomotor symptoms: tachycardia, postural hypotension, sweating, weakness, flushing, syncope Late phase: 1 to 3 hours after meal -Hypoglycemia, perspiration, hunger, nausea, anxiety, tremors, weakness Nutrition therapy -Liquids should be consumed between, rather than with, meals. -Protein, fat, and complex carbohydrates are better tolerated than are simple carbohydrates. -Evaluate older patients who experience dumping syndrome should be evaluated for deficiencies of iron, vitamin B12, protein, and vitamin D.

Cirrhosis

Causes -Buildup of fibrous connective tissue as result of alcohol abuse; hepatitis; biliary disorders; chronic autoimmune disease; metabolic disorders; or chronic use of hepatotoxic drugs Complications -Portal hypertension: increased pressure in portal vein -Esophageal varices: if ruptured, may be fatal

Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS)

Causes: insulin deficiency that results in severe hyperglycemia; attributable to stress (e.g., trauma, infection) Enough insulin is present to prevent ketosis and acidosis, but not enough to prevent hyperglycemia Consequences: hyperosmolar serum, osmotic diuresis, electrolyte depletion; death rate, 10% to 25%

Diabetes Mellitus

Characteristics: relative or complete lack of insulin secretion by beta cells or defects of insulin receptors Results in disturbances of carbohydrate, protein, and lipid metabolism, and in elevated blood glucose levels Diabetes mellitus, a chronic, lifelong disorder, necessitates lifestyle changes in both dietary intake and physical activity -Changes are to be lifelong Macrovascular and microvascular damage results in disability and premature death. -Macrovascular complications: coronary artery disease, peripheral vascular disease, cerebrovascular disease -Microvascular complications: nephropathy, retinopathy, neuropathy, impaired healing (leading to gangrene and amputation) Long-term complications are related to control of hyperglycemia. -Diabetes Control and Complications Trial -Intensive versus conventional therapy Classifications: -Type 1 (T1DM): 5% to 10% of cases -Type 2 (T2DM): more than 90% of cases

Esophagitis and Hiatal Hernia

Chronic reflux results in inflammation of the lower esophagus (esophagitis) -Aggravated by increased intra-abdominal pressure from excessive straining, bending, vomiting, obesity, pregnancy, trauma, ascites, lifting heavy objects Hiatal hernia -Condition in which stomach bulges upward through the diaphragm -Experience respiratory symptoms such as pneumonitis, chronic bronchitis, and asthma Food and nutrition therapies -Avoid certain foods, especially those high in fat

Consistency Modifications

Clear liquid diets -Foods that are clear and liquid at room or body temperature -Inadequate in energy and almost all nutrients except water •Caution in regard to caffeine -Should not be used for more than 8 to 24 hours -Contribute to hospital malnutrition Full liquid diets -Foods that are liquid at room temperature -Often prescribed if patients have difficulty chewing or swallowing solid foods -Can supply adequate energy and nutrients •Potential problem with lactose intolerance •Concern with high saturated fat and cholesterol •Safety concern: avoid use of raw eggs Some hospitals: eliminating this diet Mechanically altered diets -Chopped, ground, mashed, puréed -For patients with chewing or swallowing difficulty -Tips to make food appealing -Food consistency altered only to the degree needed Soft diets -Whole foods, low in fiber and lightly seasoned -Transition diet

Gallbladder Disorders

Common disorders: -Cholelithiasis, choledocholithiasis, cholecystitis Causes and predisposing factors -High-fat diet -Women: multiparity -Oral contraceptive or estrogen use -Obesity -Sedentary lifestyle -Rapid weight loss, very-low-calorie diets -Older age Symptoms of cholelithiasis -After eating: mild pain in midepigastrium -Colic attack: pain radiating to right upper quadrant and right subscapular area Symptoms of cholecystitis: -Pain, tenderness, fever -Fat intolerance, nausea, heartburn -Jaundice, steatorrhea Nutrition therapy -Pain control: Avoid foods that cause discomfort; follow low-fat diet. -Postoperatively: Start with clear liquids and progress to regular diet. -Many patients follow low-fat diet, but individual tolerances vary.

Nursing Role in Nutrition Therapy

Consider client's age and the setting. Assess client's knowledge, understanding, and adherence to regimen. Monitor glucose to check compliance. Noncompliance may be explained by lack of knowledge versus lack of motivation. Devise care plan. Ensure that management goals are realistic.

Regulation of Fluid/Water in the Body

Constitutes 50% to 60% of adult weight -Percentages even higher for infants (75% to 80%) Homeostasis: maintained by thirst mechanism and reaction to solute levels Excretion controlled by kidneys, brain, pituitary gland, and adrenal glands Hormones: antidiuretic hormone, aldosterone Renin-angiotensin system Thirst stimulates desire to drink. •Thirst mechanism is controlled by hypothalamus. As water level in body gets low, sodium and solute levels in blood increase. •This causes water to be drawn from salivary glands to provide more fluid for blood. •Mouth then feels dry because less saliva is produced. If thirst mechanism is faulty, hormonal mechanisms conserve water by reducing urine output. -This is possible during illness, physical exertion, or aging

Stages of Adulthood: The Middle Years (40s and 50s)

Continuation and changes -Family demands and career involvement -Positive dietary patterns and exercise prevent or delay diet-related diseases Nutrition requirements -Cell loss rather than replication -Kilocalorie needs decline •Lean body mass lost and replaced by body fat •Loss slowed by aerobic exercise and strength training -Energy: after age 50, decreases to 2300 kcal for men; 1920 kcal for women -Iron: after menopause, decreases to 8 mg for women -Dietary pattern: nutrient-dense, low-fat, high-fiber

Management Issues

Control of blood glucose levels is the cornerstone of diabetes management. Reduced rates of retinopathy, nephropathy, and neuropathy

Water-Soluble Vitamins: Thiamin (Cont.)

Deficiency: beriberi •Ataxia (muscle weakness/loss of coordination) and tachycardia (rapid heartbeat) •Wet (edema) versus dry beriberi (nervous system) •Wernicke-Korsakoff syndrome: a cerebral form •Marginal: psychologic disturbances, headache, fatigue, irritability •Risk factors: alcoholism, renal dialysis, parenteral nutrition, human immunodeficiency virus / acquired immunodeficiency syndrome (HIV/AIDS), persistent vomiting (as in hyperemesis gravidarum), anorexia nervosa, gastrectomy -Toxicity: nontoxic

Pancreatitis

Definition: -Inflammatory process characterized by decreased production of digestive enzymes and bicarbonate Causes: -Excess alcohol consumption, gallbladder disease, genetics Symptoms and complications: -Autodigestion of the pancreas by enzymes; severe pain and elevated serum enzyme levels -Malabsorption of fats and proteins Consequences: chronic pain, diabetes mellitus Nutrition therapy -Goal: Minimize pancreatic secretions; enteral or parenteral nutrition may be used; enteral nutrition is associated with better outcomes. -Assessment: Affected patients may be malnourished because of protein and fat malabsorption; nutritional support is needed. -When enteral feeding is appropriate, a low-fat elemental formula is recommended. -Position of tube into jejunum allows for feeding with minimal stimulation of the pancreas. Guidelines for parenteral nutrition: -Peripheral parenteral nutrition (PPN) may be used in nonstressed individuals who are on nothing-by-mouth (NPO) status for less than 10 days. -Central parenteral nutrition (CPN) may be used for those who are on NPO status longer than 5 to 7 days Nutrient recommendations: •Fat: less than 50 g per day •Medium-chain triglyceride (MCT) oils may be used •Protein: at least 1.5 g of protein per day •Carbohydrates: remainder of kilocalories -Meal planning: Six small meals per day are recommended. -Enzyme replacement may be necessary to control malabsorption. -Abstinence from alcohol is imperative.

Complementary and Alternative Medicine (CAM)

Definitions of CAM Application to nursing -Acceptance without judgment of alternative approaches: provides secure environment for patients -Referrals to nutritionists with special training in CAM Integrative medicine: often includes dietary or food changes -Patients seeking remedies for pain, cancer, headaches -Biologically based therapies •Encompass materials found in nature such as nutrients, foods, and herbs •Incorporate dietary supplements, alternative dietary patterns, aromatherapy, and other natural treatments

Metabolic Syndrome

Disproportionate fat deposition in the abdomen Excessive secretion of cytokines Chronic low-grade inflammation

The Nutrition Team

Doctors write orders, including diet. Nurses help identify patients in need of nutrition services. -Basic nutrition screening •Decreased appetite •Unintentional weight loss •Age and medical history •Hydration status and illness severity Registered dietitian-nutritionist (RDN) -Nutrition care process -Detailed nutrition assessments -Nutrition diagnosis -Intervention: provision of specific nutrition therapies -Monitoring and evaluation of outcomes Dietetic technicians, registered (DTRs) -Take diet histories -Collect information for nutrition screening and assessment -Work directly with patients who are having problems with their meals -Provide basic nutrition education -Should not be asked to counsel patients about modifications for complex disease

Medications

Drug-nutrient interactions have potential to -Reduce drug efficacy or absorption -Interfere with disease control -Foster nutritional deficiencies -Influence food intake, absorption, and metabolism -Provoke toxic reaction Dietary supplements may act as drugs. -Particularly when patients take many medications Risk factors for drug-nutrient interactions -Age -Physiologic status -Polypharmacy (multiple drug intake) -Influence of typical dietary intake Knowledge of prescription and over-the-counter (OTC) medications -Some OTC medications were originally prescription drugs. Effects of drugs on food and nutrients -Drug absorption rate may increase or decrease in the presence of food in the gastrointestinal tract. -Drugs, including alcohol, may alter food intake, nutrient absorption, metabolism, and excretion. -Drugs may alter mineral levels, causing depletion or overload. -Drugs may act as appetite depressants or stimulants. -Effects of food on drug action may produce uncomfortable side effects -Food intake and composition: affect drug absorption. -Timing of drug administration in relation to meals: significant -Tube-feeding effects Effects of herbs on food, nutrients, and drugs -Herbs may significantly affect bioavailability of foods, nutrients, and drugs. -Herb and drug interactions may occur. Application to nursing -Use of herbs medicinally as prescribed by knowledgeable health care professional -Questions to ask patients who may take herbal products

Hospitalization

Durable power of attorney -Legal document in which a competent adult authorizes another competent adult to make decisions for him or her in the event of incapacitation

Childhood: Stage II (Ages 4 to 6 Years)

Eating characteristics -Independence -Variable hunger and appetite levels -Continued introduction of new foods -Food jags Nutrition requirements Energy: 1800 kcal Protein: 24 g

Eating Disorders

Eating disorders in T1DM are somewhat common: -Once insulin is initiated, weight gain occurs. Insulin restriction to keep weight under control is dangerous.

Special Considerations: Illness

Effect on blood glucose concentration: elevates Effect on appetite: decreases How to manage: -Monitor blood glucose level at least four times a day. -Test urine for ketones. -Do not omit medications to control blood glucose level (dose may need to be adjusted). If regular foods are not tolerated, replace carbohydrates in the meal plan with liquid, semiliquid, or soft foods. -Carbohydrate: either of the following •15 g of every 1 to 2 hours •50 g of carbohydrate every 3 to 4 hours -Less if blood glucose is greater than 240 mg/dL Drink 8 to 12 oz of liquid every hour. Small amounts of salty foods may be needed after vomiting and diarrhea.

Electrolytes: Sodium, Potassium, and Chloride

Electrolytes -Minerals circulating in blood and other body fluids that carry electrical charge -Maintaining electrolyte balance: important •Effect on body processes such as water amount in body, blood pH, and muscle action •Travel in blood as acids, bases, and salts -Major electrolytes: sodium, potassium, and chloride -As electrolytes, specific functions •Acid-base balance of body fluids depends on regulated distribution of these minerals, proteins, and other electrolytes. •Electrolytes have a role in normal functioning of nerves and muscles. •Each mineral serves other specific functions in body.

Nutrition During Infancy

Energy and nutrient needs -Energy: •Adequate energy reflected in satisfactory gains in length and weight •No low-fat diets •Omega-3 fatty acids -Protein: needs highest during first 4 months; 1.6 g/kg/day for second 6 months •Excess protein affects renal solute load -Vitamins and mineral supplementation •Provided by breast milk or commercial formulas -Iron: fetal iron stores depleted by age 4 months •Iron from breast milk more absorbable; no supplementation •If formula is iron fortified, no supplementation -Vitamin D: supplementation recommended for breastfed infants -Fluoride: supplementation not recommended before age 6 months; need dependent on water supply -Vitamin K: administered shortly after birth by injection or orally From birth to 4 to 6 months of age -Breastfeeding: on demand versus schedules -Formula: types, preparation, and storage -Use of cow's milk introduced after age 1 •Reduced-fat or nonfat milk after age 2 Introduction of solid food -Begin between ages 4 and 6 months How to introduce solids -Developmental readiness signs for starting solids -Food to introduce at start -Satiety cues -Self-feeding: ages 9 to 12 months Appropriate solid foods during first year of life -Second half of first year of life: transitional period -Allergies: introduce solid food gradually -Home-prepared foods, commercial foods, or both -Variety Beverages during the first year of life -Monitor fruit juice consumption. -All juices must be pasteurized. Nutrition-related concerns -Congenital or acquired health problems Premature and low-birth-weight infants -Potential physiologic problems -Feeding options -Increased nutritional needs -Long-chain fatty acids Failure to thrive -Organic -Nonorganic Inborn errors of metabolism -Phenylketonuria -Galactosemia

Calorie Count

Energy and protein intakes are most often quantified. Information gathered is used to determine the adequacy of patients' daily oral intake or to document need for nutrition support.

Enteral Nutrition

Enteral feeding by tube: -Appropriate when gut is functioning •Accessible and safe to use when patient is unable or unwilling to consume adequate nutrients/kilocalories orally •Physiologic benefits: maintaining gut integrity/function -Indications for use •Malnutrition risk: 5 days or longer of inadequate or reduced oral intake •Severe dysphagia, major burns, short gut, intestinal fistulas, and other situations that preclude oral intake Types of formulas -Standard-intact formulas (polymeric): require a normally functioning GI tract •Blenderized food •Milk based •High kilocalories, lactose free •Normocaloric, lactose-free (isotonic, hypertonic, high-nitrogen, and fiber containing) •Modified nutrients (carbohydrate, fat, protein, vitamins, minerals) Types of formulas, cont'd -Special formulas •Elemental formulas (predigested or hydrolyzed): composed of partially or fully hydrolyzed nutrients •Modular formulas: single macronutrients added to other foods or enteral products •Specialty formulas: designed to meet specialized nutrient demands for specific disease states Formula selection: -Patient's digestive and absorptive capacities; fluid restriction; high metabolic requirements Method of administration -Continuous; intermittent; bolus Feeding duration -Short duration: nonsurgical placement -Long duration: surgical placement Starting the tube feeding: -Document placement of the feeding tube -Osmotic diarrhea -Increase rate and then concentration -Possible tube-feeding complications •GI, mechanical, metabolic Home enteral nutrition (HEN) -Criteria for HEN candidates •Training patient and caregiver

Energy Balance

Estimating daily needs -Recommended energy allowances, National Research Council -Formulas Components of total energy expenditure: basal metabolism or basal metabolic rate; physical activity; thermic effect of food Thermic effect of food •Energy to digest, absorb, metabolize, and store food Basal metabolism or basal metabolic rate (BMR) •Largest contributor to energy expenditure •Direct and indirect calorimetry •Factors affecting BMR: age, body size, sex, body temperature, fasting/starvation stress, menstruation, thyroid function, lean body mass •Resting energy expenditure Physical activity •Second largest contributor of energy expenditure -Varies most: depends on intensity, duration, body size Adaptive thermogenesis -Energy used to adjust to changing physical and biologic environmental situations -Coldness, changes in kilocalorie intake, physical and emotional trauma

Other Modified Diets

Examples: -Dysphagia diets (three stages) -Low sodium -Carbohydrate-controlled -Gluten free -High fiber -Vegetarian plans -Allergy-free (e.g., no milk, eggs, wheat)

Pregnancy in Overt Diabetes

Excellent glycemic control before conception and during early pregnancy to prevent fetal malformations Preconception counseling during puberty and childbearing years Preconception achievement of blood glucose goals Individualizing meal plan to meet changing needs during pregnancy

Role in Wellness 4

Exercise complements optimal nutrition to decrease risk factors and improve quality of life. Abilities to perform work, produce change, and maintain life all require energy. Body weight reflects factors within a person's control plus factors outside the person's control.

Exercise

Exercise is third component of treatment. Exercise lowers blood glucose levels, assists in maintaining normal lipid levels, and increases circulation. -People with diabetes should not exercise when insulin level is at its peak. -Ideal: Exercise when blood glucose level is 100 to 200 mg/dL, 30 to 60 minutes after meals. -Avoid exercise when blood glucose level is greater than 250 ml/dL and ketones are in urine. T1DM: Glucose control can be compromised if food and insulin are not adjusted. T2DM: Patients may be at risk for hypoglycemia when taking oral agents and exercising. General guidelines for exercise in T1DM -Avoid exercise if glucose levels exceed 250 mg/dL with ketosis or exceed 300 mg/dL. -Ingest added carbohydrate if glucose level is less than 100 mg/dL. -Monitor blood glucose levels before and after exercise, and learn to adjust food and insulin amounts. -Consume added carbohydrate as needed to avoid hypoglycemia; keep carbohydrate-based foods available during and after exercise.

Toward a Positive Nutrition Lifestyle: Explanatory Style

Explanatory style -The way in which a person regularly explains why events happen (may be optimistic or pessimistic) Application to body fat management -Optimistic explanatory style: accepting body as is; attempting to improve health by eating well and exercising -Pessimistic explanatory style: judging one's body negatively; not attempting to change

Nutrition-Related Concerns of Childhood and Adolescence

Food asphyxiation -Toddlers and elderly persons at higher risk -Foods associated with choking -Prevention and Heimlich maneuver Lead poisoning -Sources of lead -Consequences of lead poisoning -Relationship with iron-deficiency anemia -Role of nurses •Awareness of high-risk factors •Lowering lead levels in the environment Obesity -Increase among children and adolescents -Etiology: multifactorial -Clinical assessment and intervention •Health history •Intervention: motivation/weight-associative disorders •Physical symptoms such as sleep apnea Type 2 diabetes mellitus -Risk factors: overweight during childhood and lack of physical activity -Genetics and race: predispose some individuals -Prevention approaches: individual and public health Treatment •Include the family •Goal: maintain current weight while growth continues •Goal: develop and maintain a healthy lifestyle Role of nurses •Sensitivity to emotional, social, and physical dimensions associated with weight and body composition Iron-deficiency anemia -Poverty: risk factor •Lead poisoning and chronic hunger increase risk. -Affects ability to learn -Public health issue -Role of nurses •Educate teaching staff about relationship between iron deficiency and learning ability.

Food Service Delivery

Food service delivery systems -Departmental organization •Director of food and nutrition services •Clinical dietitian •Dietetic technician •Cooks, clerks, dishwashers, aides -Menus: selective and nonselective -Room service -What the nurse should know

Hazard Analysis and Critical Control Points

Food service employees are taught about hazard analysis and critical control points. Biological, chemical, and physical hazards from the production, procurement, and handling of raw material to manufacturing, distribution, and consumption of the finished product must be controlled.

Water

Food sources -Fluids, fruits, vegetables -Adequate Intake (AI) per day: approximately 13 cups for men; 9 cups for women •Amount in addition to fluids from foods •Minimum amount: about 4 cups; higher optimal Water quality -Hard water: contains high level of minerals such as calcium and magnesium -Soft water: filtered with sodium to reduce mineral levels •Health issues -Contamination: industrial and bacterial pollution •Public health concerns

Major Minerals: Phosphorus

Function -85% in bones and teeth as component of hydroxyapatite -15% for energy transfer, genetic material, acid-base buffer, phospholipids Recommended intake and sources -Recommended Dietary Allowance (RDA): 700 mg -Sources: widely available in foods, especially protein-rich foods Deficiency: unknown Toxicity: UL of 4000 mg -Excessive phosphorus, usually from supplements, causes calcium excretion

Trace Minerals: Chromium

Function -Carbohydrate metabolism as constituent of glucose tolerance factor Recommended intake and sources -AI: 35 µg for men; 25 µg for women -Sources: animal-derived foods (e.g., eggs), whole grains -Lost in food processing, especially grain refining Deficiency -Chromium deficiency is unusual. -Inadequate chromium status may be related to impaired glucose tolerance, hyperglycemia, hypoglycemia, and unresponsiveness to insulin. Toxicity -From environmental contaminants in industrial settings rather than from excessive dietary intakes

Trace Minerals: Copper

Function -Coenzyme, wound healing, nerve fiber protection, iron utilization Recommended intake and sources -RDA: 900 µg for adults -Sources: organ meats (liver), seafood, leafy green vegetables, legumes, whole grains, dried fruits, water (if pipes are copper) Deficiency -Symptoms: anemia, bone mineralization •Copper deficiency is extremely rare in United States. Toxicity: UL of 10,000 µg -From supplementation: vomiting, diarrhea -Wilson's disease •Inherited disorder characterized by accumulation of copper in brain, liver, and corneas, which leads to cirrhosis, chronic hepatitis, liver failure, and neurologic disorders

Major Minerals: Sulfur

Function -Component of protein structures Recommended intake and sources -No Dietary Reference Intake (DRI) established -Sources: all protein-containing foods Deficiency: Does not occur Toxicity: Not a health issue

Trace Minerals: Iron

Function -Distributes oxygen: component of hemoglobin (in red blood cells) and (myoglobin in muscle cells) -Assists enzymes in oxygen use by all cells Recommended intake and sources -RDA: 8 mg for men; 18 mg for women; 27 mg during pregnancy -Factors affecting recommended intakes: •Iron recycled and reused •Lost through shedding tissue: cells in urine, sweat, bleeding •Unusual absorption rate of dietary iron (only 10% to 15% absorbed); higher rate absorbed during deficiency, pregnancy, growth Animal (heme) and plant (nonheme) sources: •Heme iron (easier to absorb): meat, fish, poultry •Nonheme iron: vegetables, legumes, dried fruits, whole and enriched grains Factors favoring iron absorption •Consuming foods containing ascorbic acid (vitamin C) enhances iron absorption. •Consuming iron from several sources improves total iron absorption. •Absorption of nonheme iron increases in presence of heme iron. Recommended intake and sources, cont'd -Factors inhibiting iron absorption: binders (oxalates), tannins, excessive antacids, pica Deficiency: U.S. public health problem -Common among women of childbearing age, teenage girls, and young children -Iron-deficiency anemia: a microcytic anemia •Physical activity/work difficulties; reduced cognitive functioning or developmental delays (children); impaired immune system, cold sensitivities •Sports anemia -Causes: internal loss of blood (i.e., bleeding ulcers, hemorrhoids, menses); lack of dietary intake (chronic dieting, poor dietary choices); pica Toxicity: UL of 45 mg -Hemosiderosis; hemochromatosis •Symptoms: liver/heart damage, diabetes, arthritis, skin discoloration •At risk for iron overload: men; individuals with chronic alcohol consumption; individuals genetically at risk •Accidental iron poisoning: children

Chloride

Function -Extracellular anion that maintains fluid inside and outside cells -Component of hydrochloric acid in gastric juice Recommended intake and sources -AI: 2300 mg for adults -Sources: table salt (sodium chloride), foods with sodium Deficiency -Very rare Toxicity: UL of 3600 mg -Imbalance cause by dehydration

Trace Minerals: Fluoride

Function -Increases resistance to tooth decay and is part of tooth formation -Bone mineralization for skeletal health Recommended intake and sources -AI: 4 mg for men; 3 mg for women -Sources: fluoridated water (where available), tea, seafood, seaweed; other sources vary -Toothpaste ingestion Deficiency Increases risk of dental caries and may alter bone health Toxicity: UL of 10 mg -Fluorosis

Sodium

Function -Maintenance of blood pressure and volume -Transmission of nerve impulses -Fluid balance Recommended intake and sources -AI: 1200 to 1500 mg, or about 3/4 tsp salt (sodium chloride) -Sources: table salt (sodium chloride) and processed foods; occurs naturally in some foods Deficiency -Caused by dehydration or excessive diarrhea -Symptoms: headache, muscle cramps, weakness, reduced ability to concentrate, memory and appetite loss -Hyponatremia Toxicity: UL of 2300 mg -Sodium-sensitive hypertension and edema

Trace Minerals: Zinc

Function -More than 200 enzymes dependent on zinc -Growth process, taste and smell, healing process, immune system, carbohydrate metabolism Recommended intake and sources -RDA: 11 mg for men; 8 mg for woman; 11 to 12 mg during pregnancy and lactation -Sources: meat, fish, poultry, whole grains, legumes, eggs -Bioavailability reduced in foods high in phytic acid Deficiency -Symptoms: impaired growth and wound healing; reduced appetite (hyposomia), taste (hypogeusia), and smell (hyposmia); immunologic disorders -Severe deficiency: may result in dwarfism and hypogonadism (reduced function of gonads) - At risk in United States: "picky" eaters; older adults Toxicity: UL of 40 mg -Excess supplementation produces gastrointestinal distress, leading to vomiting and diarrhea, fever, exhaustion (similar to flu). -Continual excessive use decreases iron and copper levels and reduces high-density lipoprotein level.

Trace Minerals: Selenium

Function -Part of enzyme that acts as antioxidant -Vitamin E and selenium: work together to prevent cell and lipid damage -Associated with thyroid function Recommended intake and sources -RDA: ranges from 55 to 70 µg for adults -Sources: meats, fish, eggs, whole grains Deficiency -May predispose individuals to some forms of heart disease: Keshan disease (but not cardiovascular disease) -May be associated with increased cancer risk Toxicity: UL of 400 µg -Toxic at levels as low as 275 µg (five times the RDA) -Symptoms: vomiting; diarrhea; metallic aftertaste; respiratory distress with lung edema and bronchopneumonia; garlic-scented breath and sweat; severe liver damage

Trace Minerals: Iodine

Function -Part of hormone thyroxin produced by thyroid gland Recommended intake and sources -RDA: 150 mcg for adults -Sources: salt fortified with iodine (check label); seafood; other sources inconsistent Deficiency -Reduces thyroxine production •Deficiency during pregnancy causes cretinism of fetus -Goiter •Lack of dietary iodine or by effects of goitrogens Toxicity: UL of 1100 µg -Thyrotoxicosis: iodine-induced goiter

Potassium

Function -Primary intercellular cation that maintains fluid levels inside the cells -Normal function of nerves and muscles (heart) Recommended intake and sources -AI: 4700 mg -Sources: unprocessed foods, potatoes, tomatoes, bananas, oranges, other fruits, vegetables, dairy products, legumes Deficiency -Causes: dehydration from vomiting or diarrhea, diuretics, and misuse of laxatives -Symptoms: muscle weakness, confusion, appetite loss, and, in severe cases, cardiac dysrhythmias Toxicity -Caused by dehydration or supplement use -Symptoms: muscle weakness, vomiting, and, at excessively high levels, cardiac arrest

Major Minerals: Magnesium

Function -Structural and storage function in bones -Assists enzymes; regulates nerve and muscle function, including heart -Role in blood-clotting process and immune system Recommended intake and sources -RDA: 420 mg for men; 320 mg for women -Sources: unprocessed foods, whole grains, legumes, leafy green vegetables, broccoli Deficiency -Secondary causes: excessive vomiting and diarrhea, gastrointestinal disorder, kidney disease, alcoholism, malnutrition -Symptoms: muscle twitching and weakness, convulsion Toxicity: UL of 350 mg (nonfood sources) -Rare but serious

Major Minerals: Calcium

Function -Structure and storage (99% in bones) -Body fluids (1%); central nervous system function; muscle contraction/relaxation; blood clotting; blood pressure regulation Regulation •Calcium homeostasis: bones release calcium; intestines absorb more calcium; kidneys retain more calcium •Hormonal actions: parathormone, calcitriol, calcitonin •Effects of low/high blood calcium levels: calcium rigor (stiff muscles), calcium tetany (muscle spasms) Recommended intake and sources -AI: 1000 mg for adults to age 50; 1200 mg for adults aged 50 and older; 1000 mg during pregnancy and lactation -Sources: dairy products (milk and milk-based products); leafy green vegetables; small fish with small bones; fortified foods (orange juice); legumes; tofu processed with calcium -Calcium strategies for lactose intolerance Absorption factors -Lactose -Sufficient vitamin D -Acidity of digestive mass -Binders -Dietary fat -High fiber and laxative intake -Excessive intake of phosphorus or magnesium Absorption factors, cont'd -Sedentary lifestyle -Drugs Deficiency -Affects bone health; reduces bone density; stunts growth -Osteoporosis: •Unmodifiable risk factors: race, gender, family history •Modifiable risk factors: nutrition, calcium intake, alcohol, smoking, caffeine, sedentary lifestyle Toxicity: Upper Limit (UL) of 2500 mg -Supplement concerns •May cause constipation; urinary stone formation; reduced absorption of iron, zinc, and other minerals •Supplements should not exceed calcium AI

Irritable Bowel Syndrome

Functional GI disorder involving disturbances between the brain and the gut Types -Constipation-predominant IBS (IBS-C) -Diarrhea-predominant IBS (IBS-D) Common: food allergies, lactose maldigestion, nonceliac wheat or gluten sensitivity Food and nutrition therapies -Depends on individual symptoms -Lactose, gluten, or sugar may be eliminated -Low-FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) is now accepted as a strategy -Includes chronic ulcerative colitis (UC) and Crohn's disease -Symptoms Abdominal pain, diarrhea, intestinal bleeding, protein loss Causes of nutritional depletion -Decreased intake, malabsorption, increased nutrient loss, increased nutrient requirements, drug-nutrient interactions Nutrition therapy -Replace lost nutrients; correct deficits. -Provide adequate nutrition to achieve and maintain energy and to obtain nitrogen, fluid, and electrolyte balance. -Consider intestinal function, previous intestinal resections, site and extent of disease process, anticipated medical and surgical treatment. Surgery is curative for ulcerative colitis; Crohn's disease tends to recur. -Most common deficiencies: iron, calcium, zinc, magnesium, selenium, folate, thiamine, riboflavin, pyridoxine, vitamin B12, and vitamins A, D, and E -High-kilocalorie, high-protein diet divided into small, frequent meals -During remission, high-fiber diet as tolerated -For acute episodes, bowel rest and a low-fiber diet

Healthy Body Fat

Functions of fat -Vital functions -Essential body fat: •3% to 8% in men; 12% to 14% in women -Total fat (includes storage fat): •15% to 20% in men; 25% to 30% in women -Low body fat levels may result in amenorrhea with bone loss; fracture risk increased Body fat distribution -Pattern of distribution: genetically determined -Upper body fat: apple shape (android) •Greater health risks •Hip-to-waist ratio (<0.95 to 10 in men; ≤0.8 in women) •Waist circumference (>40 inches in men; >35 inches in women) -Lower body fat: pear shape (gynoid) Body fat storage -Adipocytes: cells in which fat is stored -Hypertrophy (cells increase in size) and hyperplasia (cells increase in number) •New adipocytes can be formed at any stage of life if conditions are right. •Bodies seem to monitor size of adipocytes (hypertrophy).

Nutrition: Weight Essentials

Gain, lose, or maintain: a wellness approach -A nondiet approach: long-term changes •Eat well and stay physically active. -Establishing realistic goals -Changing behavior •Establish new habits through behavior modification. Normalizing eating Enjoying eating] Letting hunger and satiety guide eating •Hunger cues •Satiety cues Minimizing the use of food to meet emotional needs •Awareness of feelings and associations with eating Eat regularly and frequently •Planning ahead Adopting an active lifestyle -Increases energy expenditure -Maintains lean body mass -Improves many health conditions -Differences in exercise responses -Individualized exercise

Gastrointestinal (GI) Disorders

Gastrointestinal tract is a complex ecosystem known as (the microbiome) Prebiotics: are a special form of dietary fiber that acts as a fertilizer for the healthy gut bacteria. Probiotics: are live bacteria Anti-inflammatory diets Many GI disorders produce significant nutritional problems In many situations, diet is the foundation of therapy

Nutrition Therapy

General diet/regular diet -Designed to attain or maintain optimal nutritional status -Dietary modification •Quantitative: modification in numbers of meals served, calories, specific nutrients •Qualitative: modification in texture, consistency, nutrients

Nutrition Therapy Goals

Goals of nutrition therapy -Attain and maintain optimal metabolic outcomes: blood glucose, lipid, and lipoprotein profiles; and blood pressure -Prevent and treat chronic complications -Improve health through healthy food choices and physical activity -Address individual nutritional needs, personal and cultural preferences, lifestyle, and willingness to change. -Medical team member responsible for providing nutrition therapy should be the registered dietitian. -Emphasize importance of nutrition assessment and individualization. -Address use of fructose and other nutritive and nonnutritive sweeteners

Childhood: Stage III (Ages 7 to 12 Years)

Growth slows, but body is preparing for growth spurt of puberty -May be reflected in prepuberty weight gain -Encourage staying in touch with internal cues of hunger and being physically active -Peer influences increase -Healthy snack options Nutrition requirements -Energy: 2000 to 2200 kcal -Protein: 28 to 46 g, depending on sexual maturity -Calcium requirements: AI increases from 800 mg at age 8 to 1300 mg throughout adolescence -Iron and zinc requirements increase

Role in Wellness 2

Health promotion leading to positive health behaviors may depend on -Knowledge: learning new information about benefits or risks of behaviors -Techniques: strategies to apply new knowledge -Community supports: environmental or regulatory measures available to support health-promoting behaviors within a social context

Healthy Weight

Healthy weight: -Person can physically move comfortably -Maintained without undue restriction of food intake or without excessive exercise -Live without experiencing any weight-related associative disorders If associative disorders develop -Lifestyle changes can be initiated to achieve a healthier weight. •Healthier weight is weight loss of 10 to 16 pounds accompanied by healthy lifestyle behaviors. Measuring body fatness -Bodies are composed of fat in addition to bone, muscle, and other nonfat tissue known as lean body mass. -When weight is not a good measure of fatness -Underwater weighing (densitometry) -Bioelectric impedance analysis (BIA) -Measurement of skinfold thicknesses and body circumference Interpreting body fatness measures -Individualize Interpreting weight Body mass index (BMI) -Weight in kilograms divided by height in meters squared -Limited usefulness: still assessment of weight, not of body fat

Nutrition and Illness

Hospital setting -Experience of being a patient -Lack of privacy -Emotional aspects of food Bed rest -Impaired skin integrity -Decreased muscle tone, bone calcium, plasma volume, and gastric secretions -Glucose intolerance -Shifts in body fluids and electrolytes Iatrogenic malnutrition -Iatrogenic: inadvertently caused by treatment or diagnostic procedure -Nutrition screening or monitoring: helps identify patients at nutrition risk -Monitoring: for diet orders, nothing-by-mouth (NPO) order, or clear and full liquid diets

Hypoglycemia

Hypoglycemia Causes: too much insulin, skipping meals, too much exercise without food replacement; occurs most commonly during insulin peak and at night during sleep Symptoms: occur when blood glucose level falls below 50 mg/dL or if there is a significant drop in blood glucose level

Nonalcoholic Fatty Liver Disease (NAFLD)

In liver, buildup of extra fat that is not caused by alcohol -Highly prevalent (15% to 45%) in western societies -Develops in people who are overweight or obese; have diabetes, high cholesterol level, or elevated triglyceride levels; have poor eating habits; or experience rapid weight loss -Hepatic fibrosis: develops in 10% to 25% of cases; leads to cirrhosis, end-stage liver disease, or liver cancer

Type 2 Diabetes in Children

Incidence and prevalence of T2DM in children: increased 30-fold since 1994 Related to increase in childhood obesity Other signs that may indicate risk for type 2 DM: acanthosis nigricans, polycystic ovarian syndrome, hypertension Girls more susceptible than boys Goal: to normalize blood glucose and glycated hemoglobin levels and control comorbid conditions -Nutrition therapy and exercise -Drug therapy -Comprehensive self-management education

Viral Hepatitis

Inflammation of liver caused by infectious mononucleosis, cirrhosis, toxic chemicals, viral infection Common types -Hepatitis A •Transmitted by fecal-oral route; often caused by poor handwashing or stool precautions; common in areas of poor sanitation •Vaccine recommended for people at risk •Onset rapid: within 4 to 6 weeks Adequate diet without alcohol recommended Common types (cont.) -Hepatitis B •Transmitted through contaminated blood and sexual contact; also perinatally •Routine vaccination of children and at-risk groups •Onset slow: approximately 12 weeks •Adequate diet without alcohol recommended -Hepatitis C •Transmitted through blood, saliva, or semen •Onset slow: approximately 8 weeks •Progression from hepatitis C virus (HCV) to cirrhosis may take 10 to 40 years -No dietary recommendations Common types (cont.) -Hepatitis D •Occurs only if individual with hepatitis B virus (HBV) is exposed to hepatitis D virus (HDV): coinfection or superinfection •Found throughout the world but prevalent in Mediterranean basin, Middle East, Amazon basin, Samoa, China, Japan, Taiwan, and Myanmar •Risk factor: intravenous drug use •No dietary recommendations Nutrition therapy -Initially liquid diet; then progressing to small, frequent feedings high in calories and high-quality protein as tolerated -Carbohydrates: at least 40% of calories -Fats: limited only if steatorrhea is present -High fluid intake: 2500 to 3000 mL/day -Vitamins/minerals: multivitamin that includes B complex (especially thiamine, vitamin B12), vitamin K, vitamin C, and zinc

Nutrition During Lactation

Introduction to breastfeeding -History and incidence -Recommended: at least 6 months; ideally through first 12 months with appropriate weaning foods -Benefits of breastfeeding for mother and infant Anatomy and physiology of lactation -Anatomy: milk-producing glands -Changes during pregnancy Influence of progesterone Hormonal control of lactation •Prolactin: responsible for milk synthesis •Oxytocin: involved with milk ejection from breast: letdown reflex •Supply-and-demand mechanism -Promoting breastfeeding •Baby-Friendly Hospital Initiative •Cultural considerations: acceptability of lactation Energy and nutrient needs during lactation -Energy: 500 to 800 kcal expenditure to produce breast milk each day -Protein: 71 g/day -Fluid: 750 to 1000 mL lost in milk production -Rapid weight loss discouraged Nutrition-related concerns -Contraindications to breastfeeding -Medications; HIV and acquired immunodeficiency syndrome (AIDS); maternal hepatitis C

Diabetes Self-Management Education

Involves comprehensive nutrition assessment; self-care treatment plan; and client's health status, learning ability, readiness to change, and current lifestyle The goal: -Tailoring the meal-planning approach to each individual's needs

Diabetic Ketoacidosis (DKA)

Ketosis: abnormal accumulation of ketones resulting from metabolism of fatty acids Consequences: hyperglycemia, osmotic diuresis, dehydration, lactic acidosis, lowered pH, rapid respirations (Kussmaul's respirations), fruity or acetone breath odor; coma and death if untreated Precipitating factors: insufficient or interrupted insulin therapy, too much food, infection, other stresses

Pregnancy, Lactation, and Infancy Health Promotion

Knowledge -Familiarity with the changes and nutrient needs that occur during and after pregnancy -Infant nutrient needs provided by parents/caregivers Techniques -Resources from government and medical associations Community Supports -Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) -Special interest groups such as LaLeche League

Adult Health Promotion

Knowledge -Health promotion •Adequate intake of nutrients found in food •Relationship between diet and disease •Moderate kilocalorie intake coupled with exercise Techniques -Strategies to promote positive health status and reduce risk of diet-related disorders •Shopping tips •Reorganizing work and personal priorities •Use of MyPlate and Fruits & Veggies—More Matters •Consuming dietary sources of bone health nutrients •Dietary pattern: low fat, low sodium, and high fiber •Maintaining healthy body weight with diet and exercise Community supports -U.S. Food and Drug Administration and nonprofit organizations such as the American Heart Association provide health and nutrition information -Corporate employee health promotion centers -Government programs: •Including Child and Adult Care Food Program; Senior Nutrition Program (Congregate Meals and Home-Delivered Meals programs)

Health Promotion During Childhood (Ages 1 to 12 Years)

Knowledge -Relationship of nutrients and kilocalories to growth needs -Role of adults in providing nourishment and health guidance Techniques -MyPlate Kids' Place -Fruits & Veggies—More Matters Community Supports -School food service •Entitlement programs •National School Lunch Program •Lunch and breakfast programs •Current recommendations for meal content •Summer Food Service Program for Children -Classroom nutrition education

Food-Drug Interactions

Knowledge of all types of potential interactions between food, nutrients, and drugs helps make patient care more comprehensive.

Dietary Supplements

Knowledge of nutrients enhances availability of pills, powders, and liquids to improve dietary intake. -Nutrient supplements may be recommended as a safety net and for specific subgroups. •Pregnant women need folic acid and iron. •Children or teenagers may need an iron or calcium supplement. •Elderly adults may require additional vitamin D and calcium. Regulation and labeling -Expanded range of supplements, including herbs, protein powders, fatty acid capsules, natural and synthetic energy enhancers, and growth enhancers -Regulated by Dietary Supplement Health and Education Act (DSHEA) of 1994 Dietary supplements (DSHEA definition): products that supplement dietary intake and contain one or more of the following: -Vitamin, mineral, herb, other botanical -An amino acid -A dietary substance used to supplement the diet by increasing the total dietary intake -A concentrate, metabolite, constituent, extract, or a combination of the preceding ingredients U.S. Food and Drug Administration (FDA) regulates dietary supplements. Labeling of dietary supplements must follow format for nutrition labeling. -Labels may include approved statements of health claims, such as those on food labels. -Other health-related claims may be made about effect of supplement on "structure or function" of body as well as on "general well-being." -Claims related to reducing nutrient deficiency diseases are acceptable.

Role in Health

Liver, gallbladder, and pancreas: vital for digestion, absorption, and metabolism of nutrients -Ancillary digestive organs affect nutritional status Nutrition therapy: part of treatment for disorders of these organs

Type 2 Diabetes in Elderly Adults

Macrovascular and microvascular complications are common. Overall risk for cardiovascular disease is higher. Target for hemoglobin A1c level in fit elderly patients who have a life expectancy of more than 10 years should be <7.0%. Hemoglobin A1c level should be somewhat higher (≤8.0%) in frail older adults with multiple medical and functional comorbid conditions.

Other Trace Minerals

Manganese -Function: component of metabolic enzymes -Recommended daily intake and sources •AI: 2.3 mg for men; 1.8 mg for women •Sources: whole grains, green vegetables, legumes, and other foods -Deficiency: unknown in humans -Toxicity: UL of 11 mg Molybdenum -Function: coenzyme -Recommended daily intake and sources •RDA: 45 µg •Sources: typical dietary selections -Deficiency: not noted -Toxicity: UL of 2000 µg Other trace minerals in body that may have role in human health include silicon, boron, nickel, vanadium, lithium, tin, and cadmium. -Amounts required are so small that enough is naturally consumed and deficiency does not occur

Medical Nutrition Therapy

Medical nutrition therapy is a legal term that applies to treatment during prerenal failure and in diabetic patients who receive nutrition treatments under Medicare from a registered dietitian.

Minerals

Mineral categories -16 essential minerals divided into two categories: major and trace minerals •Based on amount of mineral in body -Major minerals •Required daily: 100 mg or more -Trace minerals •Required daily: 20 mg or less Food sources -Plants and animals -Inorganic: stable despite cooking -Limited bioavailability from some plant sources •Binders, soil content •Food processing: may result in mineral loss -Foods fortified with minerals

Lactose Intolerance

Most common disaccharidase disorder -Deficiency of lactase -Symptoms: abdominal cramping, flatulence, diarrhea -Severity depends on amount of lactose ingested and degree of intolerance an individual has -Can be secondary to acute or chronic disease Nutrition therapy -Determine tolerance: Gradually add small amounts of lactose-containing foods to lactose-free diets. -Usual tolerance: lactose equivalent of 4 to 6 ounce of milk (6 to 9 g of lactose) -Better tolerated if consumed with other foods -Yogurt: may be better tolerated than milk -Lactase enzyme for adding to milk or taking with foods Low dairy intake increases risk for deficiencies of calcium, riboflavin, and vitamin D

Tube-Feeding Complications

Most problems can be prevented simply through the use of good handwashing techniques by nursing staff administering the feeding. GI problems include diarrhea, nausea and vomiting, cramping, distention, and constipation Mechanical complications: tube displacement or obstruction, pulmonary aspiration, and mucosal damage. Metabolic difficulties: hyperosmolar dehydration or overhydration; abnormal blood levels of sodium, potassium, phosphorus, and magnesium (too high or too low); hyperglycemia; respiratory insufficiency; and rapid weight gain

Enteral Feeding Routes

Nasogastric: Tube is passed through nose to stomach. Nasoduodenal: Tube is passed from nose to duodenum (small intestine). Nasojejunal: Tube is passed through nose to jejunum (small intestine). Esophagostomy: Tube is surgically inserted into neck and extends to stomach. Gastrostomy: Tube is surgically inserted into stomach. Jejunostomy: Tube is surgically inserted into small intestine.

Common Nutrition-Related Discomforts of Pregnancy

Nausea and vomiting -Morning sickness -Hyperemesis gravidarum: severe and unrelenting vomiting -Strategies: •Eat small frequent meals •Drink liquids between, rather than with, meals •Avoid fried and greasy foods •Reduce coffee intake •Avoid cooking odors Heartburn -Possible contributors -Strategies: •Eat small, frequent meals •Avoid foods high in fat •Drink fluids between meals •Limit spicy foods •Avoid lying down after a meal Constipation -Common during first and third trimesters -Strategies: •Increase fluid and fiber consumption •Perform moderate exercise -Hemorrhoids

Sweeteners

Nonnutritive sweeteners approved for use by the U.S. Food and Drug Administration (FDA), such as saccharin, aspartame, and acesulfame potassium, are considered safe for consumption by individuals with diabetes.

Nutrition Intervention Nutrition Care Process

Nutrition care process: Academy of Nutrition and Dietetics -Consists of nutrition assessment, diagnosis, intervention, monitoring and evaluation Nutrition screening -Required by The Joint Commission within 48 hours of hospital admission -Identifies whether patients have malnutrition or nutritional risk -Personnel involved -Referral if necessary for further assessment

Liver Transplantation

Nutrition therapy -Before transplantation: •Enough kilocalories and protein to decrease protein catabolism and correct nutritional deficiencies -Four to 8 weeks after transplantation: •Treatment plan is individualized. •Total parenteral nutrition (TPN) or tube feeding may be necessary. •Use ideal (desirable) weight rather than actual because of ascites, edema, or excess fluid. •Kilocalories and protein must be adequate for hypercatabolic stresses. •Provide between-meal feedings, supplements, or both. -Long term after transplantation: •Healthy, well-balanced diet •Prevent excessive weight gain, hypertension, hyperlipidemia, and diabetes

Dysphagia (4

Nutrition therapy -Diets individualized on the basis of swallowing ability and food preference -Ability to swallow solids and liquids evaluated -Features of food to consider and modify Texture, cohesiveness, density, viscosity, temperature, taste Nutrition therapy -Screening for dysphagia and resulting malnutrition among at-risk older adults -Videofluoroscopy: used to determine level of bolus consistency tolerated -Individualized diet according to swallowing ability and personal food preferences -Food served in a form that fits the specific anatomic and functional needs of the patient -Stages of dysphagia diet -Use of thickening agents -Speech therapist: can teach compensatory techniques -Supraglottic swallow -Mendelsohn maneuver -Safest eating position: upright (allows gravity to help) -Positioning the patient if needed -Dehydration concerns Swallowing aids ØEncourage patient to think/talk about food before meals -Can help stimulate flow of saliva -Aids in formation of bolus -Chewing and swallowing process ØTart or sour foods -Stimulate saliva production ØHave patient lick jelly from the lips, pucker, hum, or whistle -Helps strengthen mouth muscles -May help patient learn to close lips around fork or spoon -Techniques to increase saliva flow or strengthen mouth muscles -Responsibilities of nursing personnel ØSafe procedures ØSupervision of patients ØDocumentation of adequacy of intake ØMealtime environment

Cirrhosis: Nutrition Therapy

Nutrition therapy -Protein: minimum of 0.8 g/kg of body weight •1.2 to 1.5 g/kg recommended -Branched-chain amino acid-based formula with restricted aromatic amino acids if protein sensitive (encephalopathy) -Probiotics? Effectiveness to be determined -Kilocalories: high to prevent protein catabolism •25 to 35 kcal/kg dry weight -Sodium: restricted to 2000 mg if edema or ascites is present; restricted to 1000 mg in some patients -Fluids: in relation to intake and output records; may need to restrict to 1500 mL/day or 1000 to 1200 mL/day -Vitamins: water soluble, with emphasis on folate, B12, and thiamine; fat-soluble vitamins in water-soluble form if steatorrhea is present

Nutrition Intervention: Nutritional Assessment

Nutritional assessment -Comprehensive nutritional assessment: •ABCD (anthropometric, biochemical, clinical, and dietary assessment) approach -Conducted to determine appropriate nutrition therapy based on identified needs of patient Anthropometric assessment -Simple, noninvasive techniques to measure height, weight, head circumference, and skinfold thickness Biochemical assessment -Limitations: no single test is available for nutrition •Testing is inappropriate for some patients •Serial measurements are best •Use with other measurements -Most important indicators: visceral protein status and immune function •Serum albumin; prealbumin; total lymphocyte count Measuring infant length: an example of an anthropometric measure with a stadiometer Body mass index (BMI) assessment -Desired BMI range for healthy adults is 18.5 to 24.9 kg/m2. -BMIs of 25 to 29.9 kg/m2 are approximately 20% above desirable levels. -BMI of less than 18.5 kg/m2 is classified as underweight and is associated with risk factors such as respiratory disease, tuberculosis, and some forms of cancer. Clinical assessment -Sources of data: medical history, social history, physical examination -Features associated with nutritional deficiencies Dietary intake assessment -24-hour recall -Food records -Kilocalorie counts

Nutrition Risk and Malnutrition

Nutritional risk -Potential to become malnourished •Primary: inadequate intake of nutrients Undernutrition and chronic micronutrient deficiencies are a form of "hidden hunger" •Secondary: caused by disease or iatrogenic effects

Nutrition Intervention: Nutritional Risk

Nutritional risk -Age •Moderate risk for adults ages 65 to 75 years and for children older than age 5 •High risk for adults age 75 years or older and children younger than age 5 years Weight Laboratory test results Systems Feeding modalities

Gestational Diabetes

Occurrence rate: 5% to 10% of pregnancies Associated with obesity, but weight loss not recommended during pregnancy Goal: achieve good glucose control; insulin often prescribed to reduce complications Oral hypoglycemic agents: teratogenic and not recommended Increased risk for later development of T2DM; occurs in 20% to 50% of women with gestational diabetes

Short Bowel Syndrome

Occurs after resection of large portions of small intestine -Symptoms vary, depending on site of resection, amount removed, time since resection, presence of ileocecal valve, condition of remaining intestine, presence of colon continuity -Results in malabsorption of vitamin B12 and other vitamins Nutrition therapy -Parenteral nutrition may be needed, but enteral feedings are preferred. -Dietary fat restriction or use of medium-chain triglyceride (MCT) oil may be helpful. -Nutritional status and fluid and electrolyte balance must be monitored.

Stages of Swallowing

Oral phase Pharyngeal phase Esophageal phase

Transitional Feedings

Parenteral to oral or tube feeding -Long periods of parenteral nutrition without enteral feedings result in atrophy of the GI tract. -Minimal enteral intake is encouraged to help maintain normal GI tract physiology and gut mucosal immunity. -Enteral intake should be documented during weaning Tube to oral feeding -Assess patient's swallowing ability. -Stop tube feedings 1 hour before and after meals to promote appetite. -As oral intake increases, decrease tube-feeding volume. -Discontinue tube feeding when oral intake consistently exceeds two thirds of estimated energy requirements.

Nutrition: Fitness Essentials

Physical activity in comparison with physical fitness -Physical activity: actions or movements made -Physical fitness: limits on actions that body is capable of performing Components of physical fitness -Flexibility -Muscular strength and endurance -Cardiovascular endurance Health benefits of physical exercise -Regular exercise can •Improve cardiovascular fitness; inactivity is a major risk factor for cardiovascular disease •Decrease blood pressure •Help lose and maintain weight •Alter blood lipid and lipoprotein levels •Reduce risk of colon cancer, stroke, and hypertension •Delay or treat type 2 diabetes mellitus, depression, osteoporosis Physical activity for people with disabilities

Functional Foods

Physiologically active substances added to foods Functional foods contain physiologically active food components -May be modified to increase nutrient density, as in fortified, enriched, or enhanced foods -Some marketed as dietary supplements, such as herb-enriched beverages Factors affecting continued development -Aging population concerned about health -Increased cost of health care -Growth of self-care regarding health -Continued evidence of dietary intake effect on disease prevention and treatment -Changes in food regulation appear to support expanded growth of dietary supplements and functional foods Application to nursing -Understand dietary supplements as self-care -Awareness of potential interactions -Referral to an RD -Dietary supplements should always be complementary to a sound diet

Diabetes and Pregnancy

Pregnancy -Preexisting diabetes: fetus vulnerable to complications -Gestational diabetes: begins during pregnancy and is resolved at parturition •Increased insulin in gestational diabetes causes macrosomia of fetus. Individualize nutrition therapy -Adequate kilocalories and nutrients -Self-monitoring of blood glucose level -Goals: •Blood glucose fasting level: less than 95 mg/dL •1-hour postprandial glucose level: less than 140 mg/dL •2-hour postprandial glucose level: less than 120 mg/dL Desired weight gain: same as in normal pregnancy; desired weight gain goals based on prepregnancy body mass index

Toward a Positive Nutrition Lifestyle: Projecting

Projection: placing responsibility for unacceptable feelings or behaviors on others -With regard to health, a person may blame hectic schedule or to behaviors of roommates or family members for poor personal eating patterns. -Projecting unacceptable behaviors on others, rather than taking responsibility, is counterproductive

QSEN Competencies

Quality and Safety Education (QSEN) nursing competencies: Patient-centered care Teamwork and collaboration Quality improvement Safety Informatics

Gastroparesis

Rate of occurrence: 20% to 30% Manifestations: delayed gastric emptying associated with heartburn, nausea, abdominal pain, vomiting, early satiety, weight loss Dietary management -Replace carbohydrates with tolerated foods -Six small meals per day -Constipation or diarrhea: increase fiber -Dry mouth: increase fluids; add broth to moisten food -Low-fat (40 g) soft or liquid diet: may help Medications: metoclopramide (Reglan) increases gastric contractions and relaxes pyloric sphincter; may result in dry mouth and nausea Bezoar -Hard ball of hair and vegetable fiber that may develop within the intestines; may be more common with intake of oranges, coconuts, green beans, apples, figs, potato skins, Brussels sprouts, sauerkraut

Toward a Positive Nutrition Lifestyle: Rationalizing

Rationalizing: a defense mechanism to assign reasonable explanations for a person's behavior -Rationalizing poor eating habits

Food and Athletic Performance

Recommendations -Dietary intake pattern: 45% to 65% of carbohydrate (CHO) kilocalories; 20% to 35% of fat kilocalories; 10% to 35% of protein kilocalories Kilocalorie requirements: balance energy expended -Negative consequences with inadequate intake: weakness, iron deficiency, stress fractures, amenorrhea, osteoporosis -Small meals and snacks: provide needed kilocalories Water: most critical for athletic performance -Loss of 2% to 3% of body weight: can impair ability -Recommendations for adequate fluid replacement -Tests for adequate hydration Sports drinks CHO: energy food -Delays onset of fatigue -Required for maintaining glycogen stores CHO loading -Process of changing type of food eaten and adjusting amount of training to increase glycogen stores in muscle -For athletes engaging in 90 minutes or more of activity -Negative side effects: water retention, weight gain, stiffness, cramping, digestive problems Protein -Protein requirements for athletes: 1.5 to 2 g/kg body weight (based on animal protein) Protein and amino acid supplements -If protein needs are met by food, supplements are treated as excess protein. -Protein (amino acids) does not increase muscle mass; athlete needs resistance strength training program and diet rich in complex CHO. Fat -Fat amount used depends on duration and intensity of exercise, prior training, and diet composition. -Aerobic activity promotes fat use as energy source. -Aerobic activity increases ability to burn fat as fuel and spares muscle glycogen. -According to American College of Sports Medicine, 20% to 25% of energy used is from fat. Vitamins and minerals -Excessive intake: common among athletes -"Thin-build" athletes: at risk for vitamin/mineral deficiencies; supplementation may be indicated (100% Dietary Recommended Intake) Ergogenic aids -Drugs or dietary regimens believed to increase strength, power, and/or endurance -Health and efficacy concerns

Role of Health Care Practitioner

Recommendations for supplements are made by dietetic professionals and primary health care practitioners. Food intake should be addressed before supplements are advised. Nurses guide clients to nutritional counseling and provide education.

Diabetes Team

Registered nurse, physician or primary health care provider, registered dietitian, and the person with diabetes Family members should be included for education and counseling.

Basic Hospital Diets

Regular or general diet -Serves as the basis for modified diets Diet as tolerated -Allows for postoperative diet progression on the basis of the patient's tolerance

Regulation of Body Fat Level

Regulation of body fat complex Changes in body fatness -1 pound of body fat approximately equivalent to 3500 kcal -Energy balance determined by relationship of energy intake to energy expenditure Genetic influence on body size and shape -Genetic effects on body weight -Genetics versus environment -Genetics and hormones: leptin and ghrelin -Fatness: considered as a multifactorial phenotype *Regardless of genetic makeup, fatness is also influenced by nutritional, psychologic, economic, and social factors Set point and body fatness -Set point: natural level (of some characteristic) that body regulates or defends -Defending set point of weight and body fatness -Food intake adjustments •Bodies make adjustments to return to set point. •Among adult humans, there is a range of set points for body fatness. -Adjustments in energy use •Reduced food intake: produces a prompt and significant depression in resting energy expenditure (REE) •Effects from dieting and conditions of involuntary food restrictions •Individuals: variation in energy efficiency -Determinants of set point ranges •Body's adjustment to maximum size or fatness achieved •Combination of genetics, culture, environment, behavior: part of development of adult body size and composition

Nutrition During Adolescence (Ages 13 to 19 Years)

Responsibility for own behavior increases, but adult guidance still required -Physical and emotional support of adults •Guidelines for dietary patterns •Providing food for consumption -Adjusting to demands of college environment -Influence of fast food Nutrition requirements -Energy: 2300 to 2900 kcal for male adolescents; 2200 kcal for female adolescents -Protein: 45 to 59 g for male adolescents; 45 g for female adolescents -Calcium: AI, 1300 mg Risk for diet-related disorders and eating disorders Knowledge -High-energy needs for sports and growth -Calcium for bone mineralization -School-based curriculum on nutrient needs -Effects of disordered eating and substance abuse on nutritional status Techniques -MyPlate -Fruits & Veggies—More Matters -Scheduling of meals -Inclusion in meal planning and food preparation Community supports -No specific programs for adolescents -Comprehensive school health programs

Water-Soluble Vitamins: Riboflavin

Riboflavin (vitamin B2) -Function: coenzyme in energy release -Recommended intake and sources •RDA: 1.3 mg for men; 1.1 mg for women •Need related to total kilocalorie intake, energy needs, body size, metabolic rate, and growth rate •Sources: milk, enriched grains and cereals, whole grains, vegetables, dairy, meats, fish, poultry, eggs •Very light-sensitive; loss increases on exposure to artificial and natural light; lost in cooking water -Deficiency: ariboflavinosis •Cheilosis, glossitis, seborrheic dermatitis ØToxicity: nontoxic

Intestinal Disorders: Gas and Flatulence

Several causes -Swallowing air; carbonated beverages -Flatus: gas produced by food digestion and fermentation by intestinal bacteria Nutrition therapy -Avoid gas-forming foods on a trial basis -Remain upright for 30 minutes after meals

Toward a Positive Nutrition Lifestyle: Social Support

Social support for nutrition health -Illness -Older adults

Function of Water

Structural component of cells Regulation of body temperature Lubricant Shock absorber: cushions body tissues Solvent for transport of nutrients and waste Source of trace minerals Reactant: medium for biochemical reactions

Minerals as Nutrients in the Body

Structure of minerals -Inorganic substances incorporated into body structures (bones), organs, and fluids Digestion and absorption -During digestion, minerals are separated from foods. -Bioavailability affects levels of minerals absorbed. -Risk exists for deficiencies of iron, calcium, and zinc Metabolism -Minerals are not metabolized by the human body. •Inorganic and do not provide energy -Some are cofactors of metabolic processes

Water as a Nutrient in the Body

Structure: intracellular, extracellular, and interstitial fluids Digestion and absorption -Most absorbed in small intestine -Remainder regulated by colon Metabolism -Not metabolized, but integral component of metabolic processes

Nutrition During Pregnancy

Successful pregnancy outcomes include -Viability and acceptable birth weight of infant -No congenital defects in infant -Favorable long-term health outlook for mother and infant Body composition changes during pregnancy -Many metabolic, anatomic, hormonal, psychologic, and physiologic changes in mother -Hormones of pregnancy •Placental hormones: human placental lactogen and human growth hormone •Progesterone •Estrogen Metabolic changes -Basal metabolic rate (BMR) increases 15% to 20% by end of pregnancy -Mother uses fat as fuel; fetus uses glucose Anatomic and physiologic changes -Changes in blood •Plasma volume doubles •Hemodilution -Renal changes •Increase in glomerular filtration rate (GFR) •Possible serious problem: preeclampsia or pregnancy-induced hypertension -Gastrointestinal (GI) changes •Slower GI motility •Smooth muscle relaxation •Consequences of GI changes: constipation, heartburn, delayed gastric emptying -Weight gain in pregnancy -Three components of maternal weight gain •Changes in maternal body composition: increased blood and fluid volume •Maternal support tissues •Products of conception (fetus and placenta) -Consequences of inadequate weight gain •Low birth weight •Small for gestation age (SGA) status Current weight recommendations based on body mass index (BMI) •Normal BMI (18.5 to 24.9): 25 to 35 pounds •Underweight BMI (<18.5): 28 to 40 pounds •Overweight BMI (25 to 29.9): 15 to 25 pounds •Obese BMI (>30): 11 to 20 pounds -Pattern of weight gain -Overweight and obese women •Weight gain still needed for fetus and support tissue •Increased risk for operative delivery, postpartum weight gain, gestational diabetes Increases in all nutrients except vitamins D, E, and K, phosphorus, fluoride, calcium, biotin Energy -Current recommendation: extra 340 kcal/day during second trimester and 452 kcal/day during third trimester -Reason for increased needs -Implications of inadequate calorie intake during pregnancy Protein -Recommended Dietary Allowance (RDA) during pregnancy: 71 g/day for adolescents and adults -Protein increase to build and maintain tissues of pregnancy Vitamin and mineral supplementation -Supplement use: prenatal type multivitamin-mineral supplement as recommended by primary health care provider or dietitian -Excessive preformed vitamin A or vitamin D can cause birth defects -Folate •Prevention of neural tube defects •RDA increases to 600 µg dietary folate equivalents (DFE) per day -Iron •RDA increases to 30 mg/day •Ferrous iron: 30 mg supplementation necessary beginning in second trimester •Iron deficiency anemia •Pica Vitamin and mineral supplementation, cont'd -Calcium •Adequate Intake (AI): 1000 mg for pregnant adult women; 1300 mg for pregnant adolescents (no increase over nonpregnant levels) •Use of maternal stores to provide needs of fetus

Ileostomies and Colostomies

Surgical formation of an opening from the colon or ileum to abdomen Effluent: more liquid with ileostomies -Important to replace fluid and electrolytes Effluent proportional to length of remaining bowel with colostomy Nutrition therapy depends on the type of ostomy

Type 2 Diabetes Mellitus

Symptoms: gradual onset of polyuria and polydipsia, frequent fatigue, frequent infections (especially of urinary tract) -Condition may exist for many years before complications lead to diagnosis. Caused by insulin resistance or failure of cells to respond to insulin Risk factors: family history, obesity -Obesity produces an insulin-resistant state and causes cells to produce excess insulin. -Upper body obesity (defined by waist-to-hip ratios of greater than 0.8 in women and 0.95 to 1.0 in men) is a greater risk factor than is degree of obesity.

Type 1 Diabetes Mellitus

Symptoms: polydipsia, polyuria, polyphagia, weight loss Caused by destruction of pancreatic beta cells -Autoimmune disorder -Idiopathic diabetes

Insulin

T1DM: Patients require exogenous insulin to maintain blood glucose level within normal limits. T2DM: Some patients require insulin to optimize glucose control. Goal is to maintain glucose level as close to physiologic normal as possible; it is accomplished by varying timing and dosages of insulin. Types of insulin Conventional/standard insulin therapy, flexible/intensive insulin therapy, continuous subcutaneous insulin infusion Integration of insulin regimen with patient's lifestyle

Parenteral Nutrition

Terms and indications for use Components of parenteral nutrition solutions -Carbohydrates •Dextrose yields 3.4 kcal/g because of its hydrated form •Concentrations greater than 10% are hypertonic; must be delivered via central vein -Amino acids Mixture of crystalline amino acids Fats -Used as concentrated energy source and to prevent essential fatty acid deficiency -Upper limit: 2.5 g of lipid/kilogram, or 60% of nonprotein kilocalories -Triglycerides should be monitored -Total nutrient admixtures: three-in-one system -Electrolytes -Vitamins Vitamin K must be injected intramuscularly or intravenously. Trace elements Peripheral parenteral nutrition -Must be isotonic; limited kilocalories and protein -Most often used when short-term nutrition support is needed Monitoring guidelines Complications -Technical: pneumothorax most common -Septic -Metabolic: hyperglycemia most common Home parenteral nutrition (PN) -Specialized catheter reduces risk of infection -Monitoring -Cyclic total parenteral nutrition (TPN)

Registered Dietitians-Nutritionists

The Centers for Medicare and Medicaid Services (CMS) -Rule change -Allow "privileged" RDs/RDNs •To independently order patient diets without requiring the supervision or approval of a physician or other practitioner •To order laboratory tests to monitor the effectiveness of dietary plans and orders

Nonalcoholic Steatohepatitis (NASH)

The most severe form of NAFLD Fatigue, weakness, weight loss, anorexia, spider-like blood vessels, jaundice, itching, edema or mental confusion

Water-Soluble Vitamins: Thiamin

Thiamin (vitamin B1) -Function: coenzyme in energy metabolism •Role in nerve functioning related to muscle actions Recommended intake and sources •RDA: 1.2 mg for men; 1.1 mg for women •Sources: lean pork, whole or enriched grains and flours, legumes, seeds, nuts

Role of Nurses

To consider their attitudes toward their own bodies and level of fitness To consider attitude toward clients who may struggle with weight and fitness issues To remain knowledgeable about lifestyle changes and choices for client success

Fluid and Electrolytes

To maintain fluid balances; cells control movement of electrolytes Imbalances -Fluid volume deficit (FVD) •Vascular, cellular, or intracellular dehydration •Causes include diarrhea, vomiting, high fever, diuretics, sweating, polyuria Most at risk: elderly people and infants Fluid volume excess and edema •Increased fluid retention and edema associated with compromised regulatory mechanism •Causes: sodium retention, kwashiorkor, water intoxication

Childhood: Stage I (Ages 1 to 3 Years)

Toddlerhood: issues of autonomy Mealtimes -Maintain consistency -Regulate portion sizes -Encourage self-feeding -Include snacks Nutrition requirements Energy: 1300 kcal Protein: 16 g Serving size guidelines: -Fruit or vegetable serving: 1 tbsp per year of age -Bread and cereal: one fourth of adult serving -Milk: 2 to 3 cups per day -Meat or meat alternative: offered twice a day -Begin to offer lower-fat foods -Introduce variety -Problems with excess milk and juice intake

Food Safety

Top causes of food poisoning: -Norovirus -Salmonella species -Clostridium perfringens -Campylobacter species -Staphylococcus aureus

Stages of Adulthood: The Early Years (20s and 30s)

Transition from one stage of life span to another -Separation from family of origin; career development; reproductive decisions -Establishment of food patterns -Effects of childbearing and caring for young children on women Nutrition requirements -Growth completed in early 20s for men; late teens for women -Energy: 2900 kcal for men; 2200 kcal for women -Protein: 58 to 63 g for men; 46 to 50 g for women -After age 18, calcium and phosphorus needs decrease: •Calcium: 1000 mg for adults •Phosphorus: 700 mg for adults For women: attention to maintaining calcium and iron intakes continues

Cultural and Religious Food Patterns

Understanding the common food preferences and patterns used by people of different cultures will help achieve better food choices and reduce meal refusals. Religious beliefs and practices also affect food preferences and intake.

Oral Glucose-Lowering Medications

Used for T2DM when diet and physical activity do not control hyperglycemia Variety of new drugs Seven classes of drugs

Fat-Soluble Vitamins: Vitamin A

Vitamin A -Function •Maintains skin and mucous membranes •Vision •Bone growth •Immune system function •Normal reproduction -Recommended intake and sources •RDA (measured as retinol activity equivalents [RAE]): 900 µg RAE for men; 700 µg RAE for women •Sources: natural and preformed whole milk and butter, liver, egg yolks, fatty fish •Sources: precursor carotenoids (deep green, yellow, and orange fruits and vegetables) •Best sources: broccoli, cantaloupe, sweet potatoes, carrots, tomatoes, spinach •Fortified foods: margarine, cereals, reduced-fat milk -Deficiency •Xerophthalmia: night blindness to keratomalacia •Immune system impairment •Respiratory infections, diarrhea, and other GI disturbances •Inhibition of growth; limited bone growth •Risk factors: fat malabsorption disorders, limited food availability -Toxicity: UL of 3000 µg RAE •Hypervitaminosis A; only from preformed vitamin A •Symptoms: blistered skin, weakness, anorexia, vomiting, headache, joint pain, irritability, enlargement of spleen •Attributable to supplementation •Excess beta-carotene results in orange tinting of skin; excess intake of foods or supplement

Fat-Soluble Vitamins: Vitamin K

Vitamin K: menaquinone -Function •Cofactor in synthesis of blood-clotting factors •Protein formation in bone, kidneys, and plasma -Recommended intake and sources •AI: 120 µg for men; 90 µg for women •Amount provides sufficient liver storage •Synthesized by bacteria in GI tract; still essential nutrient •Dietary sources: dark green leafy vegetables; less in dairy products, cereals, meats, fruits -Deficiency •Causes of deficiency: malabsorption disorders; drug-nutrient interactions; long-term antibiotic therapy •Inhibits blood coagulation •Newborns given intramuscular injection to prevent hemorrhagic disease •Possible role in osteoporosis -Toxicity •Excess amounts of supplements decrease effectiveness of anticoagulant medications and may increase stroke risk.

Food sources

Vitamins are present in almost all foods. Synthetic vitamins (supplements) perform same vitamin function. -Vitamins are best consumed from food sources. -Synthetic vitamins may lack other benefits found in foods. -Phytochemicals are nonnutritive substances in plant-based foods that appear to have disease-fighting properties

Vomiting

Vomiting -When an intruding virus or toxin has entered the GI tract, vomiting removes the offending substance. -During pregnancy, hormonal shifts often cause vomiting, especially during the first trimester. -Cancer treatment such as chemotherapy, radiation therapy, or use of medicines such as opioids may cause vomiting

Role in Wellness 3

Water and minerals are primary components of body fluids and also perform other functions in the body.

Diverticular Diseases

Weakened musculature of bowel walls causes diverticula (diverticulosis). -May result from low-fiber diets and increased intracolonic pressure -Undetected unless infected and inflamed from trapped feces and bacteria: diverticulitis Nutrition therapy -Bowel rest during periods of inflammation -High-fiber diets to reduce straining during defecation -Include at least 5 cups or servings of fruits and vegetables and 6 ounce or servings of whole grain breads/cereals/legumes daily -Current Adequate Intake (AI) for fiber is 25 to 38 g/day -Add fiber to diet gradually Adequate fluids: at least 8 to 12 cups daily

Organs of the GI Tract

salivary gland, oesophagus, stomach, pancreas,small intestine, large intestine, rectum,gall bladder, liver

Common food allergens

wheat free, gluten free, lactose free, dairy free, sugar free, nut free, shellfish free, egg free People who have food allergies may not be able to consume certain types of food.

Water-Soluble Vitamins: Folate

-Folate: folacin, pteroylglutamic acid (PGA), folic acid (synthetic) -Function: •Coenzyme in one-carbon transfer during metabolism •Required for the synthesis of amino acids, deoxyribonucleic acid (DNA), ribonucleic acid (RNA) •Consists of the heme portion of hemoglobin •Role in proper formation of fetal neural tubes, which affects brain and spinal cord development; helps prevent spina bifida and anencephaly -Folate: folacin, pteroylglutamic acid (PGA), folic acid (synthetic) (cont.) -Recommended intake and sources •Adults: 400 µg Physiologic state affects folate needs: RDA of 600 µg during pregnancy; RDA of 500 µg for lactation needs •Folic acid fortification of cereal grain products •Possible risks of fortification: masking cobalamin deficiency in elderly patients; benefits outweigh risks -Food sources: leafy green vegetables, legumes, some fruits, fortified cereal grains •Affected by heat, oxidation, ultraviolet light, processing -Folate: folacin, pteroylglutamic acid (PGA), folic acid (synthetic) (cont.) -Deficiency •Risk with conditions that increase cell division, limited food intake and variety, and chronic excessive alcohol ingestion •Results in megaloblastic anemia, glossitis, diarrhea, irritability, absentmindedness, depression, anxiety •Drug-nutrient interactions: anticonvulsants, oral contraceptives, aspirin -Toxicity: UL of 1000 µg of folic acid •Excess folate or folic acid intake not recommended or warranted; may mask cobalamin deficiency

Fat-Soluble Vitamins: Vitamin D

-Function •Intestinal absorption of calcium and phosphorus depends on action of vitamin D. •Vitamin D affects bone mineralization and mineral homeostasis by helping to regulate blood calcium levels. -Recommended intake and sources •AI: 5 µg (200 IU) between ages 19 and 50 •AI:10 µg (400 IU) between ages 51 and 70 •AI:15 µg (600 IU) after age 70 -Recommended intake and sources (cont.) •Sources: body synthesis or from dietary sources •Synthesis: conversion of 7-dehydrocholesterol in skin to cholecalciferol, active form of vitamin D -Limited by length of exposure to ultraviolet radiation, atmospheric conditions, skin pigmentation, sunscreen, clothing, and age • Dietary sources: animal-related foods (butter, egg yolks, fatty fish, liver, fortified milk) •Vegans: may need to supplement -Deficiency •Children: rickets characterized by malformed skeleton, bowed legs, abnormal teeth •Adults: osteomalacia characterized b soft bones that fracture easily, weakness, rheumatism-like pain •At risk: older adults with diminished vitamin D and calcium intake •Risk increased by medication-food interactions such as sedatives, tranquilizers, and anticonvulsants •Osteoporosis: multifactorial disorder with reduced bone density and brittle bones -Deficiency •Increased risk of CAD, rheumatoid arthritis, cancers, type 1 diabetes, and multiple sclerosis •Assessment of dietary intake and blood levels reveal many Americans have marginal levels of vitamin D status -Toxicity: UL of 50 µg (2000 IU) •Most toxic vitamin •Hypercalcemia and hypercalciuria

Cultural Considerations

-Meaning of food and eating -What types of foods -Usual timing and sequencing of meals -Who shops for food and who prepares the client's meals -Client's choice of a particular practice such as vegetarianism -Other issues

Water-Soluble Vitamins: Niacin

-Niacin (vitamin B3): nicotinic acid and niacinamide -Function: coenzyme for many enzymes, especially energy metabolism; critical for glycolysis and tricarboxylic acid (TCA) cycle -Niacin (vitamin B3): nicotinic acid and niacinamide (cont.) -Recommended intake and sources •RDA (measured as niacin equivalents [NE]): 16 mg NE for men; 14 mg NE for women -Amino acid tryptophan precursor of niacin -60 mg of tryptophan converts to 1 mg of niacin •Diets adequate in protein: adequate in niacin •Sources: protein-containing foods (meats, poultry, fish, legumes, enriched cereals, milk, coffee, tea) -Niacin (vitamin B3): nicotinic acid and niacinamide (cont.) -Deficiency: pellagra •The 3 Ds: 1. Diarrhea: Gastrointestinal (GI) tract damage alters digestion, absorption, and excretion, which leads to glossitis, vomiting, and diarrhea. 2. Dermatitis: Symmetric scaly rash occurs only on skin exposed to sun. 3. Dementia: In severe deficiencies, confusion, anxiety, insomnia, and paranoia develop. •Risk increased by excessive alcohol consumption, malabsorption -Niacin (vitamin B3): nicotinic acid and niacinamide (cont.) -Toxicity: causes vasodilation and flushing effect •UL: 35 mg NE per day •Therapeutic megadoses: may lower total cholesterol level, decrease low-density lipoprotein (LDL) level, and increase high-density lipoprotein (HDL) level Monitoring necessary to prevent liver damage, gout, and arthritis

Nutrient Absorption

-Nutrient malabsorption can occur after GI surgery, depending on the segment removed

Water-Soluble Vitamins: Pantothenic Acid

-Pantothenic acid Function: part of coenzyme A for metabolism of carbohydrates, fats, and protein Recommended intake and sources •AI: 5 mg for adults •Sources: widespread in foods, especially whole grain cereals, legumes, meat, fish, poultry -Deficiency: unknown -Toxicity: 10 to 20 g may produce diarrhea or water retention

Outcomes of Malnutrition

-Poor wound healing -Longer lengths of stay -Decline in overall health -Loss of appetite, depression, or alterations in taste and smell perception

Water-Soluble Vitamins: Pyridoxine

-Pyridoxine (vitamin B6): pyridoxine, pyridoxal, and pyridoxamine -Function: As pyridoxal phosphate (PLP), acts as a coenzyme in metabolism of amino acids and proteins •Necessary for hemoglobin synthesis •Required for conversion of tryptophan to niacin •Coenzyme for fatty acid and carbohydrate (CHO) metabolism •Supplements of pyridoxine, folate, and cobalamin may reduce risk of coronary artery disease (CAD) -Pyridoxine (vitamin B6): pyridoxine, pyridoxal, and pyridoxamine (cont.) -Deficiency •Deficiency rarely occurs alone. -Accompanies low intake of other B vitamins •Symptoms include dermatitis, altered nerve function, weakness, poor growth, convulsions, and microcytic anemia (small red blood cells deficient in hemoglobin). -Pyridoxine (vitamin B6): pyridoxine, pyridoxal, and pyridoxamine (cont.) -Recommended intake and sources •Adults: 1.3 mg; based on protein intake •Sources: widespread in foods, especially whole grains and cereals, legumes, chicken, fish, pork, eggs -Deficiency: related to low intakes of all B vitamins •Some drugs affecting the bioavailability and metabolism of pyridoxine: oral contraceptives, isoniazid, penicillamine, cycloserine, hydralazine -Toxicity: UL of 100 mg/day •Megadose supplementation may cause ataxia and sensory neuropathy.

Stages of Adulthood: The Older Years (60s, 70s, and 80s)

-Shifting U.S. populations: increasing number of older adults; senescence Gerontology: study of aging -Consideration of social, economic, and physiologic aspects of aging Quality of life depends on health status -Level of wellness reflects health behaviors of previous life span stages Older adults may be at nutritional risk because of demographic and lifestyle factors •Gender •Smoking •Alcohol abuse •Dietary patterns •Educational level •Dental health •Chronic illnesses •Living situations Physical, mental, and emotional functioning: -Adjustment to retirement -Effects of death of family members and friends -Depression: may affect nutritional status -Economic realities -Alcohol abuse -Disorientation, memory loss or dementia -Fluids and dehydration Nutritional well-being -Access to food and ability to prepare meals •Living arrangements •Preference for familiar foods -Protein adequacy and micronutrients -Association between BMI and health risk in older adults Nutrition requirements -DRIs for healthy adults; adjusted for acute or chronic illness -Requirements constant from age 51, except for vitamin D •Synthesis reduced •After age 70, AI increases to 15 µg (10 µg for ages 51 to 70 years) Digestion and absorption may be reduced •Decreased production of intrinsic factor: may decrease amount of vitamin B12 absorbed •Recommendation: vitamin B12 supplementation or increased intake of vitamin B12-fortified foods Other factors affecting nutritional status •Dental health •Zinc: marginal deficiency alters taste receptors •Sugar, sodium, or both: diet-related disorders •Constipation: risk as GI tract muscularity decreases

Vitamin Categories

-Solubility *Affected by absorption, transportation, and storage in body -Water-soluble: *B-complex vitamins (thiamin, riboflavin, niacin, pyridoxine, folate, cobalamin, biotin, and pantothenic acid), choline, and vitamin C *Minimal storage by body *Deficiencies quick to develop *Usually low risk of toxicity Fat-soluble vitamins: vitamins A, D, E, and K -Excess stored in body -Deficiencies slower to develop -Greater risk of toxicity

Nutrition During Childhood

-Stages of development reflect psychologic and physiologic maturation Childhood (ages 1 to 12 years) -Growth fluctuations -National Center for Health Statistics growth charts -Dietary Reference Intakes (DRIs) for children -Role of adults in nourishing children Dietary Guidelines for Americans: for children older than 2 years of age •Recommendations: Fat: 30% to 35% of kilocalories, ages 2 to 3 years Fat: 25% to 35% of kilocalories, ages 4 to 18 years •Acceptable Macronutrient Distribution Ranges (AMDR): Fats ≈ 30% of kilocalories; added sugars > 25% of total kilocalories Dietary fiber: >19 g/day for ages 1 to 3 years 25 g/day for ages 4 to 8 years 31 g/day for boys aged 9 to 13 years 26 g/day for girls aged 9 to 13 years

Cultural Considerations

-Tailor educational sessions in culturally appropriate ways. -Group education programs help with problem-solving

Why Modify Diets

-Therapy may require texture changes to liquefied or pureed foods. Nutrients may also be modified: -Low-sodium diet is used to lower blood pressure. -Carbohydrates are restricted for diabetes management.

Rethinking Vitamin Supplementation

-To improve nutritional status of at-risk populations -Issues of health promotion and disease prevention -Food fortification -Doses far above DRIs -Individualized approach

Water-Soluble Vitamins: Vitamin C

-Vitamin C Function •Antioxidant and coenzyme •Collagen formation •Wound healing •As antioxidant, may prevent damage to vascular walls by free radicals, thereby limiting atherosclerosis •Enhances absorption of nonheme iron -Function •Thyroid and adrenal hormone synthesis •Possible reduction in cancer development •Some conversion processes depend on vitamin C: tryptophan to serotonin; cholesterol to bile; folate to active form •Evidence does not support reduced incidence of common cold; supplements may decrease duration and severity of symptoms -Recommended intake and sources •RDA: 90 mg for men; 75 mg for women; 125 mg for smokers •Minimum daily requirement to prevent scurvy: 10 mg •Sources: fruits and vegetables; excellent sources include citrus fruits, red and green peppers, strawberries, tomatoes, potatoes, broccoli, green leafy vegetables, fortified foods •Sensitive to light, heat, air, and cooking methods -Deficiency •Populations at risk for vitamin C deficiency: chronic alcohol and illicit drug users, smokers, older adults •Scurvy: extreme vitamin C deficiency disease characterized by gingivitis, joint and limb aches, bruising, hemorrhages, plaques, and death •Marginal deficiency: poor wound health, gingivitis, inadequate tooth and bone growth/maintenance, increased risk of infection -Toxicity: UL of 2000 mg for adults; 400 mg to 1800 mg for young children through adolescents •Chronic supplement megadose intake of 1 to 15 g may result in cramps, diarrhea, nausea, kidney stones, and gout and may interfere with action of anticlotting medication. •Rebound effect may occur as a protective mechanism functioning to destroy excess vitamin C; symptoms of scurvy may manifest. •Withdrawal from megadoses should be gradual: over 2 to 4 weeks.

Fat-Soluble Vitamins: Vitamin E

-Vitamin E: alpha-tocopherol -Function •Antioxidant, particularly protecting lung and red blood cell membranes •Antioxidant as part of system with selenium and ascorbic acid (vitamin C) -Recommended intake and sources •RDA (measured as alpha-tocopherol equivalents [α-TE]): 15 mg α-TE for adults •Sources: vegetable oils (e.g., corn, soy, safflower, cottonseed) and margarine (adequate); whole grains, seeds, nuts, wheat germ, green leafy vegetables -Deficiency •Primary deficiency is rare. •Secondary deficiencies occur in premature infants and other people unable to absorb fat normally. •Symptoms include neurologic disorders and anemia. -Toxicity: UL of 1000 mg α-TE •Megadoses can exacerbate anticoagulant effect of drugs to reduce blood clotting. •Supplementation is contraindicated with anticoagulant drugs.

Role in Wellness

-Vitamins: organic molecules needed in very small amounts for cellular metabolism *Perform specific metabolic functions -Essential nutrients to be provided by diet *Vitamin D synthesized by body but still considered vitamin -Dietary Reference Intakes (DRIs) *Recommended Dietary Allowance (RDA), Adequate Intake (AI), and Tolerable Upper Intake Level (UL)

Constipation

A symptom, not a disease *Causes -Organic: intestinal obstruction, spasms of sigmoid colon, diverticulitis, tumors -Ignoring urge to defecate -Lack of fluid -Prolonged bed rest or lack of physical activity -Habitual use of laxatives or enemas -Pregnancy Chronic megacolon may result Nutrition therapy -Adequate fluids -Ample fiber: psyllium (Metamucil) •Phytate and oxalate in some high-fiber foods decrease bioavailability of minerals; deficiencies unlikely •Very large amounts of fiber may result in bezoars

Diarrhea

A symptom, not a disease -Passing of loose, watery bowel movements that result when contents of GI tract move to quickly to allow water to be reabsorbed in the colon -Acute diarrhea is of short duration and usually the result of medications, changes in dietary habits, or emotional stress -Chronic diarrhea: longer than 4 weeks; result of GI irritation or malabsorption Nutrition therapy -Based on cause of diarrhea -Enteral or parenteral fluids: may be necessary -Oral therapy: oral rehydration solutions; progress to low-fat, low-fiber, low-lactose diet -Small, frequent meals; progress to regular diet

Fetal Origins of Adult Disease

A woman's prenatal diet affects the long-term health of her children. -Placental insufficiency, maternal malnutrition, and intrauterine growth restriction (IUGR) can impair infant growth. -IUGR may lead to hypertension, cardiovascular disease, and type 2 diabetes in adults.