Nutrition Exam #2

Weight Change and Nutritional Status

% weight change = (usual weight - actual weight)/usual weight x 100 *Moderate Weight Loss*: - 1-2% weight change in one week - 5% weight loss in one month *Severe Weight Loss*: - more than 2% in one week - more than 5% in one month *a gain of more than 1 lb in 24 hours signifies excess fluid* weight changes may be fluid shifts in patients with ascites, edema or dehydration

Preformed vitamin A and beta-carotene *Fat Soluble*

*Function*: - maintains skin and mucous membranes - vision - bone growth - immune system function - normal reproduction *Sources:* - *preformed vitamin A*: whole milk, butter, liver, egg yolk, fatty fish - *carotenoid precursor*: broccoli, cantaloupe, sweet potatoes, carrots, tomatoes, spinach (deep green, yellow, orange fruits and veggies) *Deficiency*: - xeropthalmia: night blindness - keratomalacia: blindness (hardening of corneas - immune system impairment/respiratory infections - GI disturbances/diarrhea - inhibition of growth and bone growth - caused by fat malabsorption and limited food availability *Toxicity*: - hypervitaminosis A (preformed, not carotenoids): blistered skin, weakness, anorexia, vomiting, headache, joint pain, irritability, enlargement of spleen - can be caused by supplementation - excess beta-carotene results in orange tinting of skin, excess intake of foods or supplements

Vitamin B12 (Cobalamin) *Water Soluble*

*Function:* - amino + fatty acid metabolism - modifies folate coenzymes to active forms - develops and maintains myelin sheaths around nerve fibers - reduces levels of hemocysteine reducing CAD risk (with pyridoxine and folate) *Sources:* - REQUIRES INTRINSIC FACTOR (produced by stomach mucosa) - animal derived foods (meat, fish, poultry, eggs, dairy) - vegans must supplement or use fortified products *Deficiency:* - megaloblastic or pernicious anemia - neurologic/neuropsychiatric effects - secondary deficiency usually, older adults at risk - may be masked by folate levels *Toxicity:* - unknown

Nutrition Assessment (ABCD)

*anthropometric*: simple, noninvasive measurement - height - weight - head circumference and length (infants) - skinfold thickness (used for bed-bound patients - waist to hip ratio - BMI *biochemical*: used with other measurements since no single test is available for nutrition - evaluate visceral protein found in blood and organs, helps assess hydration status - serum albumin 3.5-5g/dL (in circulation 2-3 weeks) - prealbumin 16-40 mg/dL (in circulation 2 days) - lower levels could also be due to inflammation, hydration or illness *clinical assessment* - medical history, social history, physical examination (look for symptoms of deficiencies and toxicities) *dietary intake* - *24 hour recall*: patient recalls food/drink 24 hrs include cooking method, brand name, condiment, supplement, portion sizes estimated. Quick, good for all age groups, retrospective (won't modify diet). Drawbacks: relies on memory, may not be representative bc only 24 hours - *food records*: patient records measurable amt of food, beverage + supplements for 1-7 days (3 commonly). More realistic but it is tedious and patient must be literate and motivated. May change diet - *calorie counts*: staff record food and beverage consumed in measurable amounts (cups, ounces) or percentage of quantity consumed. Energy and protein intakes most often quantified. info used to determine adequacy of patient's daily oral intake and document need for nutritional support (enteral, parenteral feeding)

Basic Hospital Diets and Uses (consistency modifications)

*clear liquid*: foods that are clear (see-through) at room or body temperature. Inadequate in energy and all nutrients except water (should not be used more than 8 - 24 hr or could cause malnutrition) - used as first nourishment post surgery to check for tolerance, diet advanced if tolerated. Pre-surgery and for colonoscopies as well - broth, bullion, apple and grape juice, plain gelatin, 7-up and ginger ale, coffee or tea without milk/cream *full liquid diets*: foods liquid at room temperature - can supply adequate energy and nutrients - prescribed if patients have difficulty chewing or swallowing, surgery/fractures to face or neck, transition btw clear liquid and real food - same as clear liquids + all other juices, milk, ice cream, cooked eggs, milkshakes *mechanical soft diet*: chopped, ground, mashed, pureed - for patients with swallowing difficulty - pureed foods should be blended w/o particles or strands (choking). Sufficient, not excessive fluids used - food consistency should be altered to the least degree needed (more appealing) - used for neurologic, head/esophageal inflammation, ulceration, fractured jaw *soft diets*: most cooked or canned foods on a regular diet without highly fibrous fruits and veggies, not chewy, stringy or tough foods - GI problems

complementary and alternative medicine (CAM)

*complementary medicine*: non-western healing approaches used at the same time as conventional medicine *naturopathic medicine*: noninvasive natural healing to recover from disease and achieve wellness (acupuncture, exercise, massage) *alternative therapy*: therapies used instead of conventional medicine *functional foods*: contain physiologically active food components. Fortified to increase nutrient density - may be marketed as dietary supplements - probiotic (yogurt), anti-inflammatories, foods that contain omega-3 (tuna fish) *supplements* - supplement intake of something already in the diet - considered foods, not drugs or additives. May come in many forms - not as much testing for safety, efficacy, less data on function and effectiveness - nutrition labels must include name, amounts of each item, approved claims (statement not evaluated by FDA, not intended to treat, cure any disease)

drug interactions with food and nutrients (3 drugs cause a folate deficiency) (3 vitamins affected by analgesics, nonsteroidal anti-inflammatory drugs)

*drug nutrient interactions can:* - reduce drug efficacy or absorption (certain foods and minerals can block drugs from being absorbed) - interfere with disease control - foster nutrient deficiencies - influence food intake, absorption and metabolism - provoke a toxic reaction - may cause clogging of feeding tube (know procedure) *Risk factors* - age and polypharmacy -hepatic and renal function (drugs are hard on one or the other, get meds that go through functioning organ) *over the counter meds* - not harmless, still need to make sure proper use - may interact with prescription meds, food, nutrients, herbal supplements *food and nutrients* - when drug is taken with food it slows gastric emptying, can alter nutrient absorption, metabolism and excretion - food and nutrients may affect drug action producing side effects or preventing absorption and thus therapeutic affect (grapefruit juice prevents) *herbs* - affect bioavailability of food, nutrient, drugs or cause interactions - some herbs can duplicate what you are taking with prescription meds, giving too much of an effect - when you ask patients to list meds, they should also list herbs or any type of supplement

nutritional needs of pregnancy

*energy* - extra 340 kcal/day 2nd trimester, 452 kcal/day 3rd - accommodates rise in maternal BMR, helps prevent low birth weight - kcal should stay elevated by about 340 during lactation to help cover energy cost of milk production (500-800 kcal/day) while helping to lose weight *protein* - RDA increases to 1.1 g/kg to build and maintain pregnancy tissues - increases from 45 g/day to 71 g/day for pregnancy *folate* - increases to 600 ug to prevent neural tube defects - most important pre-pregnancy and first trimester, so pre-planning is important *iron* - increases to 30 mg/day, supplementation needed to prevent iron deficiency anemia and pica *calcium* - 1000 mg for adult women, 1800 mg for adolescents - don't need to increases bc the GI tract slows down so we can absorb more - eat more nutrient dense food, supplementation may be needed for some, but ask doctor first - do not drink alcohol (FAS) or eat raw meat, seafood or eggs (higher risk of foodborne illness and spontaneous abortion) - excessive preformed vitamin A or D can cause birth defects

nutrition concerns of childhood and adolescence

*food asphyxiation* - toddlers at risk - common risks: uncut hot dogs, grapes, gel/hard candies, large chunks of meat - to prevent, sit down and chew and know Heimlich *iron-deficiency anemia* - poverty is a risk factor (lead poisoning and chronic hunger increase the risk) - affects ability of children to learn *lead poisoning* - can be caused by soil, water, air, infrustructure - children most at risk especially with iron, calcium and zinc deficiencies *obesity* - 1 in 3 children are now obese - multifactorial (Eating food away from home, sedentary lifestyles, genetics - health history, weight gain pattern, physical activity, emotional stability (coping mechanism) - intervention only with weight-associated disorder or patient wants to lose weight - 24 hour food recall and education about nonbalance *type 2 diabetes* - risk factors: overweight during childhood, lack of physical activity, predisposition by genetics and race (native, black, Hispanic, Asian, white) - treat by maintaining current weight while growth continues and developing a healthy lifestyle - 5 fruits/veggies, 2 hr recreational screen time, 1 hr physical activity, 0 sugary drinks

iron

*function* - distributes oxygen as part of hemoglobin and myoglobin - assists enzymes in oxygen use *sources* - *heme*: meat, fish, poultry (easier to absorb) - *non-heme*: vegetables, legumes, dried fruits, whole and enriched grains - absorption may be improved by consuming vitamin C and consuming several different sources (heme helps to absorb nonheme better) - binders (oxalates), tannins, excessive antiacids or pica may inhibit absorption *deficiency* - microcytic anemia (physical difficulty, reduced cognitive functioning, developmental delays in children, impaired immune system, feeling cold) - childbearing age women and teens, young children - may be caused by internal loss of blood, lack of dietary intake, pica *toxicity* - hemosiderosis/hemochromatosis: liver/heart damage, diabetes, arthritis, skin discoloration - men and chronic alcohol consumption at risk

calcium

*function* - structure and storage (99% bones) - central nervous system function, muscle contraction and relaxation - blood clotting and blood pressure regulation *sources* - dairy/milk-based products, leafy green veggies, small bony fish, legumes, fortified foods (orange juice, tofu) *deficiency* - reduces bone density and stunts growth - osteoporosis - absorption factors affected by lactose, sufficient vitamin D, binders, levels of fat, high fiber and laxities intake, sedentary lifestyle, drugs *toxicity* - supplements may cause constipation, urinary stone formation, reduced absorption of iron, zinc - low or high blood calcium levels may cause rigor (Stiff muscles) or tetany (muscle spasms)

blood glucose monitoring

*glycosylated hemoglobin A1C* - reflects blood glucose control for 100-120 days, molecules circulate for 2-3 months and and glucose in blood attaches to them - goal for diabetics is 5.5% or lower, but definitely less than 7 or else it is "elevated" *blood glucose level goals* - 70-130 mg/dL before meals - <180 mg/dL (30-50 pt rise) two hours after meals - 90-150 mg/dL bedtime - monitoring is important to determine effectiveness of meal plans, insulin and exercise (needs, management)

Water Quality

*hard water*: contains high levels of minerals (calcium, iron, magnesium) *soft water*: filtered with sodium chloride to reduce mineral levels, thus has a high level of sodium causing health concerns *contamination*:

medicinal treatment

*insulin* - required for T1DM to maintain glucose in normal limits - some patients w/T2DM require to optimize glucose control (varying timing and dosage of insulin to fit regimen with patient lifestyle *oral glucose-lowering medications* - used to treat T2DM when diet and physical activity alone cannot control hyperglycemia - *metformin* is the first prescribed. Improves body tissue sensitivity to insulin so insulin is used more effectively. Lowers glucose production in the liver. Won't cause weight gain, so diabetics can lose weight

fluid compartments and electrolytes

*intracellular fluids*: - within the cell - water, potassium, phosphates *extracellular/interstitial fluids* - fluids outside/between the cells - sodium and chloride - includes plasma and watery parts of organs *intravascular*: - fluid within the blood vessels - *cells control movement of electrolytes to maintain fluid balances* - The sodium potassium pump exchanges sodium in cells with potassium and water follows sodium concentration.

Bodily Changes During Pregnancy

*metabolism* - BMR increases 15-20% by end of pregnancy (fetus uses glucose, mother uses fat) *blood* - plasma volume doubles (hemodilution: hemoglobin, serum proteins, vitamins appear to be at lower levels because of increased solvent) - cardiac hypertrophy (larger heart) to accommodate extra blood volume *kidney/renal* - increase in glomerular filtration rate (GFR) to accommodate larger blood volume and filter fetal waste - *preeclampsia*: pregnancy-induced hypertension with proteinuria (excess protein in urine, kidney not working) sudden severe rise in BP, rapid weight gain, edema, headache, nausea+vomiting. Can be deadly if progression to eclampsia occurs (risk: 1st preggo, diabetes, hypertension, advanced maternal age, African American heritage) *GI tract* - slower GI motility bc of progesterone causing smooth muscle relaxation (constipation, heartburn, delayed gastric emptying

pregnancy nutritional discomforts

*nausea and vomiting* - common first trimester - eat small frequent meals, avoid hot foods and odor, drink liquid between meals, avoid fried food, eat a dry cracker before getting up - hyperesmis gravitarium: severe, unrelenting call doc *hearburn* - progesterone (relaxed sphincter) + fetus pressure - small frequent meals, avoid high fat, fluids between meals, limit spice, don't lay down after eating *constipation* - 1st and 3rd trimesters due to progesterone - increase fluid and fibers, moderate exercise - hemorrhoids can occur from straining

Physical Activity

*physical activity*: actions or movements made *physical fitness*: limits on actions the body is capable of performing and impacted by duration and intensity of activity - activity is the behavior that best preserves and/or increases lean body mass - weight loss occurs when there is a net loss of calories (calories burnt in exercise is more than calories consumed in food) - activity should be at least 30 minutes 5 times/week - for managing weight you should have 60 minutes 5 times/week *exercise* *endurance*: aerobic activities (improves cardiovascular endurance) Ex. brisk walk, bike, interval training, swimming, dancing (4 - 7 days/ week) *strength*: weight-bearing and resistance (improves posture, muscle strength, metabolism, bone density Ex. weight lifting, resistance training (2 - 4 days/week) you can do this every day, but its important to switch muscle groups so each has 48 hr rest in between *flexibility*: stretching (elongates muscles and increases blood flow, improves range of motion and decreases chance for injury) Ex. tai chi, pilates, stability ball (4 - 7 days/week). Should do stretching before and after every activity - develop physical activity plan using FITT (frequency, intensity, type, time)

populations at risk for vitamin deficiencies

*pregnant women*: marginal deficiencies due to greater essential vitamin needs (primary) *older adults*: decreased absorptive ability (secondary) and limited economic and physical mobility to cook/acquire good food (primary) *poverty*: cannot access nutritious food (primary) *chronic alcohol abuse/drugs*: limits body's ability to absorb and use essential vitamins (primary) *smoking*: vitamin C deficiency especially *long term chronic disorders*: (AIDS, liver + renal disorders) metabolic processes of body may be compromised by these disorders and by the medications prescribed (secondary)

Hormones of pregnancy

*progesterone*: - promotes development of the endometrium (mucous membrane of uterus) - relaxes smooth muscle cells of uterus - slows GI tract for better absorption (iron/calcium) causes constipation *estrogen*: - promotes growth of uterus and breast during pregnancy - connective tissues in pelvic region more flexible in preparation for birth *oxytocin*: involved with milk ejection from the breast and uterine contraction during labor *prolactin*: promotes milk synthesis *placental hormones*: human placental lactogen and human growth hormone

Diet Modifications

*quantitative*: modification in number of meals served, calories, specific nutrients Ex. modify sodium, cholesterol, saturated fat for cardiovascular health and carbs for diabetes, gluten free, high fiber, vegetarian *qualitative*: modification in texture consistency *Regular/General Diet*: no restriction, but patient should still be served nutrient-dense food. Basis for other diets *diet as tolerated*: allows for postoperative diet progression on the basis of the patient's tolerance - diets should be modified for food allergies (different from intolerance): egg, wheat, milk, soy, fish, shellfish, peanuts, tree nuts - menus can be selective/nonselective (give pt choice) - nurse should know how to call the RD, time schedule of meals and location of diet manual

Risk Factors Screened and Risk Categories

*risk factors screened* - decreased appetite, unintentional weight loss, age and medical history, hydration status and illness severity, >24 hours NPO or clear liquids nutrition risk is used for screening, are they going to be fed into the nutrition care process? *age* - moderate risk: adults 65-70 and children older than 5 - high risk: adults 75 or older and children less than 5 *weight*: - non-volitional loss is the most critical index for nutrition risk. - moderate risk: self-induced - high: 5% loss 1 month, 10% loss 6 months, length/height for age <5th percentile, weight/height <5th percentile or <80th percentile of standard *systems* - various conditions affect bodily systems and nutrition - moderate: heart, antepartum, orthopedics, pain, oncology, chemotherapy - high: renal, pancreas, GI, liver, diabetes+pregnancy, eating disorder, oncology, transplant, conditions in children with protein-calorie malnutrition *feeding modalities* - moderate: transitional (stable) from restricted diet - high: parenteral nutrition, tube feeding, NPO, clear liquids >3 days

Religious Dietary Patterns

*seventh-day adventist* - restricts pork and shellfish - may be ovo-lacto-vegetarian or vegan *Islam* - pork and pork products prohibited - meats must be slaughtered according to Halal - fasting on holy days, exceptions for pregnancy/ill *Judaism* - no pork or fish without scales/fins (shellfish) - dairy foods are not consumed with animal foods - 6 hours must pass between meat and dairy consumption and two sets of dishes/silverware used *Hinduism/Buddhism* - lacto-vegetarian or vegan - no beef, pork, lamb or poultry

minerals

*sources*: plants, animals, fortified foods *structure*: - inorganic - are stable despite cooking - incorporated into body structures (bones, fluids) *bioavailability*: level of absorption. Influenced by: - binders in plants (form indigestible compounds) minerals from animals are absorbed more easily - soil content - fiber, oxalate, phytate *digestion, absorption, metabolism* - minerals separated from foods in digestion - bioavailability affects level of mineral absorbed - minerals are not metabolized bc they are inorganic and do not provide energy, some are cofactors in metabolic processes

childhood stages of development and eating habits

*stage 1 (1 - 3 yrs)* - 1300 kcal energy, 16 g protein, 30-35% kcal is fat - issues of autonomy. Maintain consistency, regulate portion sizes, encourage self-feeding and include snacks *stage 2 (4 - 6 yrs)* - 1800 kcal, 24 g protein, 25-35% kcal fat from this point - independence, variable hunger and appetite levels - continued exposure to new foods (8-10 times) - food jags (allow it to play out, goes away in a week) *stage 3 (7 - 12 yrs)* - growth slows, but body is preparing for puberty growth spurt - encourage staying in touch with internal cues of hunger and being physically active - peer influences increase - healthy snack options - 2000 to 2200 kcal, 28-46 g protein, iron and zinc needs increase, calcium needs increase from 800 mg at 8 to 1300 mg in adolescence (bone growth)

third-spacing and fluid volume excess

*third-spacing*: - too much fluid moves from intravascular space (blood vessels) into interstitial/extracellular "third-space" - causes edema, reduced cardiac output, hypotension - associated with compromised regulatory system - caused by sodium retention, kwashiorkor, water intoxication

Fluid Regulation

*thirst mechanism* - controlled by hypothalamus - sodium and solute levels in blood increase and water is drawn from salivary glands to dilute. Mouth feels dry *hormonal mechanism* - conserve water by reducing urine output - antidiuretic hormones - renin released from kidney -> stimulates angiotensin in blood and tissue -> stimulates aldosterone from adrenal cortex increasing Na+ and fluid retention by kidney

trace minerals

- 20 mg or less required daily - iron, zinc, iodine, fluoride, copper, chromium

fat soluble vitamins

- A, D, E, K - excess is stored in the body in fat - deficiencies are slower to develop because it is stored - greater risk of toxicity (it can build up in the tissues)

water soluble vitamins

- B complex vitamins (thiamin, riboflavin, niacin, pyridoxine/B6, folate, cobalamin/B12) and vitamin C - minimal storage by body, excreted quickly in urine - deficiencies are quick to develop, so they should be consumed every day - usually low risk of toxicity (what isn't needed is excreted in urine)

Diabetic Ketoacidosis (DKA)

- abnormal accumulation of ketones resulting from metabolism of fatty acids (lowered pH) - typically occurs in T1DM bc no insulin is being produced so no glucose enters cells = no fuel *symptoms* - fruity/acetone breath - kussmaul breathing (quick, deep, labored) - hyperglycemia, osmotic diuresis (pee alot), dehydration, lactic acidosis (not enough oxygen for aerobic cellular respiration), coma, death *causes* - insufficient or interrupted insulin therapy - too much food (hyperglycemia) - stress on the body (infection)

solubility of vitamins

- affected by absorption, transportation and storage in body - fat-soluble or water-soluble - solubility determines how they are absorbed into and transported around by the bloodstream, whether they can be stored in the body, and how easily they are lost from the body

Measuring Body Fatness

- bodies are composed of fat, muscle, bone, lean body mass - weight is not a good measure of fatness with fluctuation in body fluids, or a lean body mass deviation (athletes, wasting disease) - *weighing by itself will NOT measure body fat* *densitometry* - measurement of body density by underwater weighing - density = mass (kg)/volume(l) %fat = 495/density - 450 - most accurate measure of body fat (buoyancy) - not used often bc it takes special equipment and may be difficult *bioelectric impedance analysis (BIA)* - measured by passing microcurrent through body through four points - estimates lean body mass, which is used to calculate fat with info about sex, age, weight, height, activity level, influenced by hydration - most accurate that is used most often *skin fold thickness* - measure thickness of fat under skin using calipers - measurement taken in 3-4 places that differ depending on sex (fat pulled away from muscle) *upper arm circumference*

Carbohydrate

- carbohydrate is stored as glycogen in muscles, limited amounts which must be replenished to avoid fatigue - depends on muscle mass (more = more carb), intensity of training - high energy sports with short bursts of energy = 5 g carbs/ kg body weight - endurance athletes who train >90min need more - determined by dividing body weight in lb by 2.2 to determine kg body weight. Multiply each kg of body weight by 5g to determine daily g of carbs - both simple and complex carbs are effective, but complex carbs have vitamins, mineral, fiber too *carb loading* - athletes should consume high-carb diet as part of regular training program (at least 60 - 70% of kcal should come from carbs). Three days before competition exercise should taper off to allow muscles to rest, combination encouraging glycogen storage - recommended for continuous >90 min exercise (endurance) - potential negative side effects include water retention, weight gain, stiffness, cramping, digestive problems - better concern is if athletes are eating enough carb on a daily basis to maintain adequate levels of muscle glycogen

Illness and Diabetes

- causes stress on the body - blood glucose elevates and appetite decreases *management* - monitor BG at least 4 times a day - test urine for ketones - do not stop taking meds, even if you eat less (adjust dose) *nutrition* - soft, semiliquid or soft foods (ginger ale, soup, applesauce) - 15g carb every 1-2 hours - 50g carb every 3-4 hours - less if blood glucose is over 240 mg/dL - drink 8-12 oz liquid every hour

body fat distribution and chronic conditions

- does not measure the percent of body fat, it is telling us where the fat is stored the most - if fat is stored in the abdominal area, it increases the risk of chronic disease, because lots of vital organs are there and it runs the risk of messing with signals (pear>apple shape) *where fat is stored is genetically determined, we don't really have control over that* *waist-to-hip-ratio (waist/hip)* *males* - <.85 excellent, .85-.89 good, .90-.95 average, >=.95 risk *females* - <.75 excellent, .75-.79 good, .80-.86 average, >=.86 risk *most important values are increased risk of chronic conditions with >.8 women, >.95-1 men* *waist circumference* *males* - <31.5 in/<80 cm very low - 31.5 - 39 in/ 80 - 99 cm low - 39.5 - 47 in/ 100 - 120 cm high - > 47 in/ > 120 cm very high *females* - <27.5 in/ < 70 cm very low - 27.5 - 35 in/ 70-89 cm low - 35.5-43 in/ 90-109 cm high - > 43.5 in/ >110 cm very high *most important values are increased risk of chronic conditions with >35 in women, >40 in men* - body fat is stored in adipocytes. New cells can be formed at any stage of life - hypertrophy: increase in size - hyperplasia: increase in number

Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS)

- enough insulin is present to prevent the formation of ketones and acidosis, but there is not enough insulin to prevent hyperglycemia - occurs in T2DM, but T1 can have it too - insulin deficiency results in severe hyperglycemia attributable to stress *symptoms* - blood serum becomes hyperosmolar, osmotic diuresis (loss of water, electrolytes and glucose during frequent urination) - does not have acetone breath or kassmaul breaths - 10-25% death rate

diabetes diagnostic criteria

- fasting blood glucose >=126 mg/dL (found on two occasions) - A1C: >=6.5% - 2 hr 75g glucose tolerance >=200 mg/dL

gestational diabetes

- fetus vulnerable to complications with preexisting diabetes can cause hypoglycemia and macrosomia in fetus (predisposed to health problems later in life) - begins during 2nd trimester of pregnancy and is resolved at parturition - occurs in 5-10% of pregnancies and is associated with 20-50% increased risk of diabetes later in life *risk factors* - ethnicity (native, black, hispanic) - obesity (weight reduction should not be attempted) - delivered a baby weighing more than 9 lb - had gestational diabetes in a previous pregnancy - prediabetes - polycystic ovary syndrome *goals* - achieve glucose control (eating, exercise) - insulin often prescribed (oral hypoglycemic agents not recommended: teratogenic)

Diabetes food and nutrition therapies 312-316

- fit to individual needs (learning ability, willingness to change, lifestyle) - there isn't a diabetic diet, pointless restriction of sucrose not necessary, intake amounts for everything is the same as a non-diabetic - non-nutritive sweeteners are safe *goals* - T1DM: match insulin to diet (carb) needs - T2DM: decrease caloric intake (carb, fat), manage weight *strategies* - *carb counting*: maintain consistent intake at mealtimes help match to insulin dosage + regulate BG. (helps keep blood sugar stable within target ranges + lowers risk for long-term complications) - nutritionally adequate meal plan with meals spaced throughout the day and consistent (can still eat desert if they count the carbs and are consistent in amount) - *plate method*: half nonstarch veggies, quarter starch, quarter protein, low fat milk, small amt fruit - *food exchange lists*: good estimation of nutrient and calorie count for planning meals

effect of bed rest on nutrition status

- impaired skin integrity - decreased muscle tone, bone calcium, plasma volume, muscle secretions - glucose intolerance - shifts in body fluid and electrolytes

Health Benefits of Exercise

- increase chances of living longer - feel better about yourself and decrease chances of becoming depressed - sleep better at night - move around more easily with stronger muscles and bones - be with friends, meet new people, enjoy and have fun - improve cardiovascular fitness (inactivity risk factor for CVD) - reduce risk of hypertension and lower blood pressure - help lose weight or maintain a healthy weight - alter blood lipid and lipoprotein levels (lowers high cholesterol) - reduce risk of colon cancer and stroke - delay or treat T2DM, depression, osteoporosis

introduction of solid foods (1st year infant)

- introduction of solid food 4 - 6 months (as a supplement to breast milk) - developmental readiness shown by sitting with some support, movement of jaw, lips, tongue independently, roll tongue to back of mouth and showing interest in what the rest of the family is eating - pay attention to satiety clues: turn head to side, refuse to open mouth, grimace at spoon (do not keep feeding) *avoid* - honey (clostridium botulinum) food poisoning - choking hazards - skim milk (not enough calories), cow's milk (allergen) - eggs (allergen) *introducing foods* *4-5 months*: iron-fortified infant cereal *5 - 6 months*: strained/pureed fruits/veggies (bby food) *6-8 months*: mashed/chopped fruits/veggies, juice but no more than 4-6 oz and must be pasteurized *9 - 12 months*: gradually include soft, diced foods. crackers, toast, cottage cheese, plain meats, egg yolk. finger foods by 12+ months, avoid choking hazards. May enjoy self-feeding *introduce new foods 8-10 times before a child decides if they like it or not* - wait a few days in between introduction of foods to see if they have an allergy

health promotion for adults

- moderate kcal intake with exercise - maintaining healthy body weight with diet + exercise - plan meals and shopping trips ahead of time - low fat, low sodium, high fiber - use community supports (WIC, meals on wheels) *rationalizing*: a defense mechanism to assign reasonable explanations to a person's behavior

infant nutrition

- no low fat diets (energy for growth). omega-3 -*protein* double of adult (1.6 g/kg second 6 mnth) to build tissue - fetal iron store depleted by 6mth, absorbable from breast milk. Fortified formulas - fluoride is not recommended (do not use tap water to mix formula bc it is fortified) - vitamin D supplements recommended for breastfed infants - *vitamin K* administered shortly after birth by injection or orally. Vulnerable to deficiency and hemorrhaging bc they lack intestinal bacteria to synthesize - cow's milk should not be introduced until after age 1 because it could cause allergies, full fat or 2% should be used after that - phenylketonuria can cause damage to CNS (PK free diet) - galactosemia: absence of enzyme = can't metabolize galactose in milk (exclude all milk products including human)

weight gain during pregnancy

- not a lot of weight gain in the 1st trimester, but it is very important in the 2nd and 3rd trimesters (1 lb/week) - weight gained from increased blood and fluid volume, maternal support tissues (uterus, breasts, fat), products of conception (fetus, placenta). Largest increase is 8-10lb protein and fat storage, followed by 6-8 lb fetus underweight: 28 - 40 lb normal weight: 25-35 lb overweight: 15 - 25 lb obese: 11 - 20 lb - inadequate weight gain can cause low birth weight, and small for gestational age (SGA) status - in obese women fat does not supply added nutrients, weight gain is still needed for fetus and support tissue, but we can loose fat while gaining weight by consuming more nutritious foods and having light activity (weight loss not recommended during pregnancy). This way once she delivers, it will be easier to lose weight - increased risk for operative delivery, postpartum weight gain, gestational diabetes - mothers ARE NOT EATING FOR TWO. do not use as an excuse, extra kcal needs can be met by consuming nutrient-dense snacks throughout the day

lactation and breastfeeding

- recommended at least 6 months (12 mo. w/ weaning) - *colostrum*: fluid secreted the first few days - postpartum, providing maternal antibodies and nutrient - milk production is a supply and demand mechanism (if not enough milk produced, tell them to feed more often *anatomy* - milk producing glands in alveoli surrounded by myoepithelial cells. Ductile carry milk from alveoli to lactiferous ducts emptying into lactiferous sinuses behind areola - progesterone causes lobules/alveoli to increase in size and number, estrogen stimulates proliferation of ductal system, oxytocin is milk ejection, prolactin is milk synthesis - infant suckling impulse goes to pituitary gland. stimulates release of prolactin (alveolar cells secrete milk) and oxytocin causing myoepithelial cells to contract, ejecting milk (let down reflex) *contraindications* - medications, AIDS, Hep C

Functions of Water

- shape and rigidity of cells - regulates body temperature - lubricant for joint fluid and mucous secretions - cushions body tissues (amniotic sac, spinal cord, eyes) - solvent -> transports nutrients and waste products - source of trace minerals (hard water) - participates in chemical reactions (hydrolysis)

vitamin intake

- vitamins are present in almost all foods - in order to ensure adequate vitamin intake, eat a variety of nutrient-dense foods - synthetic vitamins/supplements perform the same vitamin function, but vitamins are best consumed from food sources bc synthetic vitamins lack other benefits found in foods *phytochemicals*: nonnutritive substances in plant-based foods that appear to have disease-fighting properties

Weight Management Strategies

1 lb of body fat = 3500 calories SMART Goals (specific, measurable, attainable, relevant, time-bound) - attainable: consider unique, individual values, needs. Acknowledge limits to extent of control we have over our bodies and level of fatness - relevant: goals related to changes in behavior are most important (ex. planning to buy food, schedule). Should be related to each person's unique needs - normalize and enjoy eating: allow to eat all foods you enjoy in appropriate quantities (feel comfortable) - let hunger and satiety guide eating (eat when hungry even if not at mealtimes and stop when full, even if there is more food available. Log and relearn hunger/satiety cues) - minimize use of food to meet emotional needs (keep track of emotions and eating response to gain awareness) - eat regularly and frequently (avoids ignoring hunger cues + buildup of hunger causes eating more, avoids eating a lot in the least active part of the day/evening where energy stored as fat, avoids grabbing quick unhealthy snacks)

Daily Energy Needs

70% basal metabolic rate 20% physical activity 10% thermic affect of food (digestion) - if there is a lot of stress on the body (infection, intesive care, surgery), the % BMR will increase

Adequate Intake of Fluids

AI: 13 cups for men, 9 cups for women (muscle requires more water) - can be consumed through fluids (including other types of drink like coffee and tea, although these are diuretics), as well as fluid-containing food like fruits and veggies

% healthy body fat

Healthy Weight - person can physically move comfortably - maintained w/o undue restriction of food intake or excessive exercise - live without experiencing weight-related disorders (T2DM, hypertension, dyslipidemia) *Males* - 15-20% healthy total body fat - 3-8% essential body fat *Females* - 25-30% healthy total body fat - 12 - 14% essential body fat - if associative disorders develop lifestyle changes can help achieve a healthier weight (loss of 10 - 16 lb) with healthy lifestyle behaviors. *most effective way to decrease risk of disorders is to lose weight*

medical nutrition therapy

a legal term that applies to treatment during prerenal failure (pre-dialysis) and in diabetic patients who receive nutrition treatments under Medicare from a registered dietitian. - these conditions have nutrition reimbursed but if a nutritionist is seen during a hospital stay it may be covered under the total bill - you can't see a nutritionist for weight loss + cover it

Body Mass Index (BMI)

assessing a person's weight (healthfulness) by evaluating it to their height. *YOU ARE NOT MEASURING BODY FAT* - using the information from BMI you are making an ASSUMPTION. This assumption often does not hold true for athletes or people with wasting diseases underweight: below 18.5 healthy weight: 18.5 - 24.9 overweight: 25 - 29.9 obese - 30 or greater

prediabetes

blood glucose is higher than normal, but not high enough for a diagnosis of diabetes - fasting blood glucose: 100-125 mg/dL - hemoglobin A1C: 5.7 - 6.4% - glucose tolerance test: 140 - 199 mg/dL 90% of people who have prediabetes and aren't aware

diabetes management by exercise

calories in vs out, benefit of weight loss - exercise lowers blood glucose levels and assists in maintaining normal lipid levels *guidance* - do not exercise when insulin is at its peak, or when glucose is >250 mg/dL - exercise when glucose is 100-200 mg/dL (30-60 min after meals) and if BG <100 mg/dL 15g carb should be consumed first and retested 15 mins later - monitor BG before and after exercise - most important concept for weight loss is for output to be greater than intake

calories per gram

carbohydrates: 4 proteins: 4 fats: 9 alcohol: 7

Dehydration (Fluid Volume Deficit)

caused by an imbalance of electrolytes/water in vascular, cellular or intracellular dehydration - occurs from diarrhea, vomiting, high fever, fluid loss from sweating, diuretics, polyuria - symptoms are disorientation and hypertension (orthostatic, rising or sitting BP), may also have dry mucous membranes, disorientation or lightheadedness - elderly people and infants are at most risk

Type 2 Diabetes

caused by insulin resistance or failure of cells to respond to insulin - gradual onset of symptoms: polyuria, polydipsia, fatigue, dry skin (from polyuria), nausea, frequent UTI infections (sugar in urine) risk factors: - age (increases, especially over 45) - gender (men) - ethnicity (natives, blacks, hispanics, asians, whites) - hypertension, abnormal triglyceride, cholesterol - sedentary lifestyle - overweight or obese (especially upper-body obesity w/waist/hip and circumference ratios) produces insulin resistant state and causes cells to produce more insulin - gestational diabetes or prediabetes - parent or sibling with diabetes - polycystic ovary syndrome (especially for childhood diabetes)

Type 1 Diabetes

caused by the destruction of pancreatic beta-cells which produce insulin resulting in complete lack of insulin - autoimmune disorder - often occurs early in life, is NOT childhood diabetes - rapid onset of symptoms: polydipsia, polyuria, polyphagia, weight loss (can cause DKA) risk factors: - family history, environmental factors, presence of diabetes autoantibodies, early introduction to cows milk or cereal, ethnicity (Sweden or Finland)

energy in food

chemical energy from food converted into mechanical energy and heat (measured in kcal) *methods to determine food energy* - bomb calorimeter: food burnt inside calorimeter, water temperature measured before and after (calorie: energy required to raise one gram of water by one degree Celsius) - proximate composition (c4, p4, f9, a7) - used to fuel bodily processes as ATP, converted through cellular respiration (glycolysis + TCA cycle)

Dysphagia

condition in which swallowing is difficult or painful - different levels of mechanically altered diet based on individual ability/preference (radiogram test) - liquids thickened to nectar-like, honey-like and spoon thick. Foods can be pureed, mechanically altered and advanced with soft textures - supervise patient, document adequate intake - major areas of concern are bolus consistency, feeding position and rate and practicing swallowing techniques

hypoglycemia

definition and symptoms 311 box 2 know what 15g of carbs are *Blood sugar below 70 mg/dL* - sudden onset, medical emergency. May be caused by taking too much insulin, skipping meals or doing too much exercise without a concurrent increase in food. May occur during the night for T1DM *symptoms* (may occur <50 mg/dL or rapid BG drop) - cool, clammy, pale skin, confusion, erratic behavior, hunger, trembling and shaking, sweaty, fast HR, impaired vision, headache, fatigue *treatment* - consume 15g fast-acting carbohydrate and check BG every 15 minutes, repeat until BG is above 70 and then have a balanced snack or small meal Ex. 3-4 glucose tablets, 8oz no/low fat milk, 1/2 can regular soda, 5 lifesaver candies, 1 slice of bread, 3/4 cup cereal (1/2 if cooked), 1/2 cup unsweetened fruit juice, 3-4 crackers, 1/2 cup snack food (pretzel)

secondary deficiency

develops when absorption is impaired or excess excretion occurs, limiting bioavailability.

water % body weight

fetus (pre-birth) - 90% newborn - 75-80% child - 70% adult male - 55 - 60% adult female - 50 - 55% elderly - 55% *50-65% adult weight*

Preventing Foodborne Illness

foodborne illness is caused by microbes on food - nurses must *WASH HANDS* before handling food - food should not be within danger zone 40-140 degrees F for more than 2 hours (if patient is in tests and food is sitting there, put it back on the cart and order a new one) - food prep and surfaces not cleaned properly food outbreak when 2 or more have same symptoms in 24 hour period (can be dangerous for critically ill)

physical and nutritional changes of adulthood

iron and calcium for women possible nutrient defieciencies and why health promotion tequniques for adults *early years (20-30)* - establishment of food patterns (separation from family of origin, career development and time management) - effected by childbearing and young children - 2900 kcal men, 2200 kcal women - 48-63 g protein men, 46-50 g protein women - calcium (1000 mg) phosphorus (700 mg) decrease - *women pay attention to calcium and iron intake* *middle years (40-50)* - positive dietary patterns and exercise prevent or delay diet-related diseases - family demands and career involvement - kcal needs decline to 2300M, 1920W after 50 bc lean body mass lost and replaced with fat (slow by exercise) - *iron decreases to 8 mg for women after menopause* - diet should be nutrient-dense, low-fat, high-fiber *older years (60 - 80)* - may be at risk bc of previous diets, demographics, lifestyle factors (smoking, alcohol, diet, living situation, chronic illness, education level, dental health) - dehydration risk, depression may affect nutrition, access to food and ability to prepare meals - decrease in production of intrinsic factor may decrease amount of vitamin B12 absorbed - zinc deficiency alters taste receptors - sugar and sodium may cause disorders - constipation risk due to GI tract muscularity decrease - need vitamin D supplement (can't synthesize as well from the sun) *oldest years (80 - 90)* - decreased ability to absorb and synthesize nutrients - concerns over malnutrition and underweight, dehydration

iatrogenic malnutrition

malnutrition inadvertently caused by treatment or diagnostic procedure - patient can't eat when they have a full bank of tests - nutrition risk if patient is NPO or clear liquids for more than 24 hours

major minerals

mineral categories based on amount of mineral in body - 100 mg or more required daily - calcium, phosphorus, magnesium, sodium, chloride, potassium

Vitamins

organic molecules needed in very small amounts for cellular metabolism (perform specific metabolic functions) - essential nutrients to be provided by the diet (although vitamin D can be synthesized by the body through sunlight and vitamin K can be synthesized by gut microflora)

projection

placing responsibility for unacceptable feelings or behaviors on others - Ex. blaming poor personal eating patterns on a hectic schedule or behaviors of family/roommates - counterproductive

Nutrition Care Process

roles of nurse, other members of care team four steps of process *nutrition team* *doctors*: write orders, including diet (nothing can be given to the patient if the doctor doesn't write the order *nurses*: most important role is screening. Identify patients at risk and in need of nutrition services and refer them to a dietician *screening is required by the JC within 48 hours of admission *RDN*: carries out nutrition care process (more in-depth assessment and interventions *DTR*: assist RD, diet histories, record info, basic edu *Nutrition care process* *assessment*: anthropometric, biochemical, clinical, and dietary assessment conducted to determine appropriate nutrition therapy based on identified needs of patient *diagnosis*: nutrition problem identified and labelled with problem, etiology and symptoms associated. Fall into three categories: intake, clinical, behavior-environmental *intervention*: aimed at etiology to reduce symptoms (food/nutrient delivery, education, counseling, coordination of care) *monitoring and evaluation*: patient is reassessed for improvement to see if implementation is working

medication review

should know all prescription meds, nutrient supplements, herbal remedies, over the counter meds - document products that could interfere with other therapies or medications - may be referred to social services or pharm to help afford western medicine if they can't afford - refer to dietician so they can understand supplements - educate so they don't delay medical treatment bc they think the supplement will treat it - don't judge them, it may be a cultural thing

primary deficiency

the vitamin is not consumed in sufficient amounts to meet physiologic needs