NHM 363 Final Exam (Modules 1-12)

NEAT

non-exercise activity thermogenesis (e.g., fidgeting)

Phase 4

post marketing surveillance Post-Marketing Studies; Conducted after a therapy is provisionally approved by the FDA and provide additional effectiveness or real-world data on the therapy

PES

problem, etiology, symptoms

Retinol Binding Protein (RBP)

serum protein sometimes used as a biomarker of nutrition status • Normal range: 2.6-7.6 mg/dL • Synthesized in liver • Binds with prealbumin to transport retinol (vitamin A) in the blood • Very short half-life (~10-12 hours) • More expensive than prealbumin and not often used to monitor nutritional status • Decreased values suggest acute catabolism, severe liver disease, zinc deficiency, Vit A deficiency • Increased values seen in renal disease

Phase 3

several hundred to several thousand patients time: one to four years purpose: safety, dosage, and effectiveness Large trials designed to determine therapeutic efficacy as compared to standard of care (placebos are rarely used in cancer clinical trials)

Some PN diseases and conditions

short bowel syndrome, GI fistulas, bowel obstruction, critically ill patients, and severe acute pancreatitis Some patients may require this therapy for a short time and there are other patients who have received PN at home for a lifetime.

Jaundice

yellow staining of the skin and sclerae (the whites of the eyes) by abnormally high blood levels of the bile pigment bilirubin. CAN indicate liver or gallbladder disease A benign side effect of high beta-carotene intake is carotenoderma, a condition characterized by yellowing of the skin.

ADIME Charting

• A = Assessment (Subjective & Objective) • D = Nutrition Diagnosis • I = Interventions • M = Monitoring • E = Evaluation

Paragraph style/narrative notation

• A brief, narrative entry of a few sentences that states only what is necessary • Typically used to update ongoing patient care - Follow-up notes to a previous longer SOAP note - Day-to-day progress notes on a patient you are following intensively

Cytochrome P450 and Grapefruit

• A component of grapefruit juice inhibits the cytochrome P450 3A4 enzymes in the small intestine. • The blood levels of certain medications can be amplified up to 5x if they are taken with grapefruit juice. • The effects of grapefruit on enzyme inhibition can last up to 72 hours, so it isn't sufficient to merely ingest the grapefruit at a different time of day from the medication.

1 Nonstarchy Vegetable Exchange

5 g CHO, 2 g Pro, 25 kcal

Lacto-ovo-vegetarian

does not eat meat but DOES eat dairy products and eggs

Percent Weight Change

% wt change= (UBW - ABW)/UBW x 100 Unintentional weight loss is: Significant if: 5% in 1 month; 7.5% in 3 months; 10% in 6 months Severe if: >5% in 1 month; >7.5% in 3 months; >10% in 6 months

Ideal Body Weight

(ABW/IBW) X 100 "Desirable" range is 90 - 110% IBW (IBW +/- 10%) Deviation away from this range may suggest under- or over-nutrition However, note that IBW does not adjust for age or race and does not specify fat mass vs. fat-free mass; its validity is questionable, but it is widely used by clinicians.

24-Hr Urine Urea Nitrogen (UUN)

(PEM) test to measure protein (nitrogen) balance Requires accurate 24-hr collection of urine and actual protein intake • Generally, only used with TPN and tube feeding • Results can direct accurate provision of protein in nutrition support

Creatinine-Height Index

(PEM) test to measure skeletal muscle mass - Normal range: 80-100% of predicted value (using tables) indicate adequate muscle mass - 60-80% of normal range indicates moderate deficit - <60% of normal range indicates severe deficit A product of skeletal muscle, and it's excreted in urine in a constant proportion to the mass of muscle in the body • Requires an accurate 24-hr collection of urine • Reference values are available for adults Values will be skewed with renal disease or excessive meat intake Values may also be erroneous with amputation/paralysis Not commonly used to assess muscle mass

Percent of Usual Weight

(actual weight/usual weight) x 100 85% to 90% UBW: may suggest mild malnutrition 75% to 84% UBW: may suggest moderate malnutrition <74% UBW: may suggest severe malnutrition

Buffalo hump

- Fatty pad or hump between the shoulders - Cushing's Syndrome (Body produces excess cortisol)

Nutrition Intervention four categories

- Food and/or Nutrient Delivery - Nutrition Education - Nutrition Counseling - Coordination of Nutrition Care

Conventional Units

- base unit is mg/dL - dL = 100 mL - 10 dL = 1 L - 1 g = 1000 mg - 1 kg = 1000 g - 1000 μg = 1 mg

The Old Rule of Thumb for Weight Loss

1 lb of fat = 3500 kcal Deficit of 500 kcal/day x 7 days = negative balance of 3500 calories in a week Typically recommend 500 kcal deficit per day for 1 lb of weight loss per week. However, An evidence-based does not exist for that rule of thumb! It's not quite that simple!!!

Four methods for determining fluid needs

1. 30 to 35 ml/kg 2. 1 ml fluid per calorie consumed 3. 1500 mL + method 4. ml/kg method based on age

Nutrition Assessment

1. Client history (includes medical Hx and social Hx) 2. Food/Nutrition-Related History 3. Anthropometric Measurements 4. Biochemical Data, Medical Tests, and Procedures 5. Nutrition-Focused Physical Findings

1 Starch Exchange

15 g CHO, 3 g Pro, 0-1g Fat, 80 kcal Note that with increasing portion sizes in the US, ¼ of a large bagel and ¼ of a large baked potato is now 1 starch exchange!

1500 mL + method

1500 mL for the first 20 kg of BW If <50yo, give 20 ml/kg for remaining kg BW If >50yo, give 15 ml/kg for remaining kg BW Example: Patient is a 45yo male and weighs 85 kg 1500 mL for the first 20 kg Remaining 65 kg x 20 ml/kg = 1300 ml Estimated fluid needs are 2800 ml/day

ml/kg method based on age

16-30yo (active): Provide 40 ml/kg 20-55yo: Provide 35 ml/kg 55-75yo: Provide 30 ml/kg >75yo: Provide 25 ml/kg Example: Patient is 77yo and weighs 60 kg 60 kg x 25 ml = 1500 mL/day of fluids

Complementary proteins

2 or more proteins that provide all of the essential amino acids when eaten together it is not necessary to complement amino acids at every meal. It is still wise, however, to consume a variety of plant foods over the whole day to ensure adequate intake of essential amino acids

Phase 1

20-100 patients time: several months purpose: mainly safety First in human studies to demonstrate early efficacy or clinical results; Designed to determine the optimal dose of an investigational therapy and how humans process it and identify any potential toxicities

Methods for Collecting Dietary Intake Data

24-hour recall Food Frequency Questionnaire (FFQ) Diet Diary Nutrient Intake Analysis (Calorie Count)

30 to 35 ml/kg

30 - 35 mL per weight in kg E.g., 30yo female weighs 70 kg 70kg x 30 mL = 2100 mL of fluid 70kg x 35 mL = 2450 mL of fluid

1 Lean Meat

7 g protein, 0-3 g fat, 45 kcal per ounce For legumes (starchy beans), add 1 Starch Exchange Note, previous editions of the "Choose Your Foods" guide separated "very lean meat" and "lean meat." The latest edition only categorizes "lean meat."

1 Medium-Fat Meat

7 g protein, 4-7 g fat, 75 kcal

Energy Requirements of Fever

7% increase in REE with each degree above 98.6°F Adjustment must be made to REE. E.g., If REE = 1300 kcal and temperature is 101.2°F • 101.2°F - 98.6°F increase = 2.6°F increase in temp • 2.6° x 7% = 18.2 % increase in REE • 1300 kcal x 0.182 = 236.6 kcal increase • New REE adjusted for fever = 1300 + 237 = 1537 kcal

Food to Drink Scale

7-0 7 - Regular Food 6 - Soft Food 5 - Minced &Moist Food 4 - Pureed Food/ Extremely Thick Liquid 3 - Liquidized Food/ Moderately Thick Liquid 2 - Mildly Thick Liquid 1 - Slightly Thick Liquid 0 - Thin Liquid

LDL Values

< 100 mg/dL Optimal > 130 mg/dL Elevated Risk

Triglycerides Values

<150 mg/dL Normal 150-199 mg/dL Borderline High 200-499 mg/dL High > 500 mg/dL Very High

Total Cholesterol Values

<200 Desirable 200-239 Borderline >/=240 Hypercholesterolemia

HDL Values

>60 mg/dL considered protective Men: Values < 40 mg/dL risk factor for CVD Women: Values <50mg/dL risk factor for CVD

Assessment (Subjective & Objective)

A =

carotenoderma

A benign side effect of high beta-carotene intake characterized by yellowing of the skin.

MAOIs (Monoamine oxidase inhibitors) and tyramine

A class of antidepressants. Pressors = Dopamine, Histidine, Tyramine Tyramine acts as vasoconstrictor that raises blood pressure. MAOIs inhibit the breakdown of monoamines like tyramine, so concomitant intake foods rich in tyramine and other pressor agents may cause a dangerous rise in BP leading to hypertensive crisis. Pressor Agents in Foods and Beverages Foods/Beverages to Avoid • Aged cheeses and meats • Soy sauce, tofu, miso, and tempeh • Broad beans • Sauerkraut • Tap beer (also imports and craft beers) • Meat, fish, or poultry stored longer than 3‐4 days in the refrigerator Use with Caution • Red or white wine (2‐4 oz/day) • Coffee, cola, and other caffeinated beverages • Pizza • Bottled beer • Liqueurs or distilled spirits (two 1 ½ oz. servings/day)

Hirsutism

A condition of unwanted, male-pattern hair growth in women Common in Cushing's syndrome and PCOS Usually due to elevated levels of androgens in women

Cultural Awareness

A culturally competent health professional seeks knowledge and understanding about the cultural norms of clients Avoid stereotyping

Diabetic Diet

A diet order (order sent to the kitchen) specifying a consistent/low amount of carbohydrates ADA _______kcal Diet • 1200, 1600, 1800, 2200, 2500, etc. • Nutritionally complete • Provides diets with set number of CHO per meal/snacks • No Concentrated Sweets - More liberalized diet but restrict sugary sweets and beverages The American Diabetes Association says there is no standard "ADA Diet." However, this diet order would ensure consistent CHO intake during an inpatient visit.

Full Liquid Diet

A diet order that provides liquids that are either clear or opaque - Whole milk, custard, pudding, strained cream soups, eggnog, ice cream, Ensure/Boost - Fat and lactose may be a problem Liquefied solids may be provided - Example: Potato soup Commonly used as transition from clear liquid to solid food; post-surgery, GI irritation, etc. Can be nutritionally complete Nutritional Supplements: Ensure Plus, Boost, Glucerna, Enlive, Nepro, Mighty Shakes, Magic Cup

Clear Liquid Diet

A diet order that transitions from NPO (nothing by mouth) to regular foods Commonly used after surgery Minimizes digestive work Minimizes gut residue Nutritionally inadequate - Provides 600-900 kcal/d, little protein Does not meet RDA for protein or vit/min - Vitamin C may be exception Intended for < 3-4 days use • Broth • Gelatin • Strained fruit juices • Clear beverages • Popsicles • Enlive • Resource Breeze

Drug/nutrient interaction

A drug affects the action of a nutrient in the body.

Food/drug interaction

A food, or one of its components, interferes with the therapeutic action of a drug in the body.

Nitrogen Balance Studies

A loss of 16g of N = loss of 1 lb of tissue Nitrogen balance = nitrogen intake - nitrogen losses ◦ Nitrogen intake = grams of protein intake/6.25 ◦ Nitrogen losses = urinary urea nitrogen (UUN) + 4 grams (Non-urea urinary nitrogen + fecal nitrogen + miscellaneous losses from skin, sweat) Nitrogen balance (g) = (protein intake in grams/6.25g nitrogen per g of pro) - (UUN excretion in g + 4 g)

Moon-shaped face

A medical sign in which the face develops a rounded appearance due to fat deposits on the sides of the face Cushing's Syndrome PCOS Obesity

Subjective Global Assessment (SGA)

A method of rating a patient's nutritional status based on features of a medical hx and physical exam Aspects of the physical exam portion include: - Loss of subcutaneous fat - Muscle wasting - Presence of edema or ascites Categories of nutritional status = A (nourished), B (mildly malnourished), C (severely malnourished)

Percussion

A method of tapping body parts with fingers, hands, or small instruments as part of a physical examination - Often done to detect body organ borders, shape, and position - May be done to detect the presence or absence of fluid in body areas • Not frequently done by the dietitian in a nutrition-focused exam

Dietary Supplements

A product other than tobacco that is taken by mouth, that contains one or more vitamins, minerals, herbs or other botanicals, amino acids, substances supplementing the diet by increasing the daily dietary intake, or a concentrate, constituent, metabolite, extract, or combination of these, that is not represented as a food or as constituting a meal or the sole item of the diet, and that contains as part of its labeling the words dietary supplement" Dietary Supplement Health and Education Act of 1994 (DSHEA)

The Beer's Criteria

A useful resource for prescribing clinicians to weigh the risks and benefits of medications for older adults. Categorizes "potentially inappropriate medications" for older adults into 3 groups: • Medications that should be avoided in all older adults • Medications that are potentially inappropriate for individuals with certain comorbidities • Medications to be used with caution Of note, the appetite stimulant, megestrol (megace) was recently added to the Beer's Criteria as a medication to be avoided.

Skin Tears

A wound caused by shear, friction, and/or blunt force resulting in separation of skin layers Associated with thin skin of aging and/or dehydration Could also indicate possible protein malnutrition

Arm Muscle Area (AMA)

AMA (mm2) = [MAC- (3.14 TSF)]2/(4 X 3.14) (where MAC & TSF are in mm) **Important note: this formula gives you the answer in mm2; convert your answer to cm2 by dividing by 100. Then subtract a factor of 10 for men, 6.5 for women to correct the AMA for the presence of bone (Heymsfield correction factor). Most tables will be in cm2, and many will already have applied this correction factor to deduct bone mass.

Follicular hyperkeratosis

gooseflesh; Vitamin A deficiency

American Society for Parenteral and Enteral Nutrition

ASPEN The foremost authority on nutrition support

Xerosis

Abnormal dryness of skin and mucous membranes • Could signal dehydration or insufficient protein, vitamin A, niacin, etc.

azotemia

Accumulation of BUN and creatinine in blood

Liver Function Tests (LFTs)

Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) • Enzymes involved in hepatic amino acid metabolism • Elevated blood levels may indicate liver damage Alkaline Phosphatase (ALP) • Enzyme present in the liver, bile ducts, and bone • Elevated blood levels may indicate liver damage or a blocked duct Bilirubin • Produced from the breakdown of RBCs; normally passed on to liver where it is excreted in bile • Elevated blood levels may indicate liver damage

Hepatic Transport Proteins

Albumin, Prealbumin, and Retinol Binding Protein Synthesized in liver Low levels may prompt you to further assess for PEM, but they should be evaluated in light of pt's clinical condition During stress and illness not accurate indicators of nutritional status: "Negative acute phase proteins" - decrease as part of an acute inflammatory response Hormonal and cell-mediated stress response reprioritizes liver's protein synthesis

CHO DRI

All ages 1 year and older 45-65%

Protein Foods

All amino acids can be consumed in the diet: • Meats, poultry, fish • Eggs • Milk and other dairy foods • Legumes • Soy foods • Other vegetables and grains (e.g., wheat gluten)

Prospective Medical Nutrition Therapy

All education offered when the patient first starts a drug

Half-life

Amount of time it takes for the blood concentration of a drug to decrease by ½ of its steady state level

Anaphylaxis

An extreme, often life-threatening, allergic reaction to an antigen

Medication and Herbal Use History

An important part of any nutrition assessment - Various foods, medications, and herbal supplements can interact in many ways that affect nutrition status and drug therapy effectiveness Effects of medication therapy can be altered by specific foods, the timing of food and meal consumption, and use of herbal products

Excipients

An inactive substance that serves as the vehicle or medium for a drug or other active substance. "Inactive ingredients" in drugs, added as buffers, fillers, binders, flavorings, preservatives, coatings, etc. - Can be derivatives of wheat, soy, peanuts, egg, lactose, sorbitol, mannitol • People may have allergies or sensitivities to them • Labeling laws require all drug ingredients, including these, to be identified.

Anemia of chronic disease

Anemia associated with a variety of infectious, inflammatory, or neoplastic diseases

Serum Total Protein

Assay (analysis) of all proteins in blood • Normal range: 6.4-8.3 g/dL Major fractions: - Albumin - makes up about 60% of total protein - Globulins - key building blocks for antibodies, clotting factors, etc. Used to monitor progression of a disease state where wasting is a clinical feature - Cancer, kidney disease, immune disorders, liver disease, and malnutrition NOT a sensitive indicator of nutritional status - Does not reflect status during acute phase response (inflammation)

ABCDs

Anthropometrics Biochemical (lab values) Clinical Diet Hx There is no single lab or clinical measure that provides a comprehensive assessment of someone's nutritional status but rather it requires a systematic approach of gathering and evaluating information from all these different areas

Skin lesions

Any pathological change in skin Could signal a variety of nutrient deficiencies: protein, folate, zinc, vitamin C, niacin, riboflavin

Measuring Length/Height Indirect Methods

Arm Span Measurement: Provides a proxy measure of ht; Options for those who cannot stand or stand straight (Scoliosis, Kyphosis, Cerebral Palsy, Muscular Dystrophy, Contractures, Paralysis) Recumbent Length (tape measure) Knee Height (calipers) in cm is entered into equations to estimate ht.

Recommended Dietary Allowance (RDA)

Average daily intake level of nutrient needed to meet the requirements of almost all healthy individuals (97-98%) Serve as goal intake for individuals, not populations RDA = EAR + 2 SD of EAR Sufficient scientific evidence is not available to calculate RDA or EAR

TIBC (total iron binding capacity)

measure of proteins available to bind iron increases with iron deficiency 250-460 mcg/dL

Lab Panels

BMP: Glucose, Calcium, Sodium, Potassium, CO2, Chloride, Blood Urea Nitrogen (BUN), Creatinine CMP: Glucose, Calcium, Sodium, Potassium, CO2, Chloride, Blood Urea Nitrogen (BUN), Creatinine, Albumin, Total Protein, Alkaline Phosphate (ALP), Alanine Aminotransferase (ALT), Aspartate Aminotransferase (AST), Bilirubin

Scurvy

Bleeding Gums

Arterial Blood Gases (ABGs)

Blood draw from an artery (painful) used to assess acid-base disorders - Partial pressure of oxygen (PaO2) - Partial pressure of carbon dioxide (PaCO2) - Blood pH

Cyanosis

Bluish color to the skin or mucous membranes that is usually due to a lack of oxygen Could signal a lung or cardiovascular disorder (or an eating disorder)

General Appearance of Inadequate Nutrition

Body habitus: The physique or body build; visually looking for physical overall body shapes or cues (swelling of the salivary glands for bulimia) Positioning or muscle contractures: A muscle contracture involves the tightening/shortening of the muscles • Is the pt ambulatory? • Any amputations? • Feeding devices: feeding tubes; vascular access devices • Level of consciousness • Ability to communicate • General affect = "observable manifestations of a subjectively experienced emotion"; emotional and cognitive impact of a human experience; subjective experiences produced by the individual mind

Temperature

Normal = 98.6°F (37°C) • May vary normally (~97-99°F) • A febrile (related to fever) state can increase REE and insensible fluid losses: A term used to describe constitutional symptoms that accompany a rise in temperature. The pulse and respiration rate usually increase along with a multitude of signs

Body composition and Distribution

Obese/older pts have greater proportion of adipose tissue to lean body mass; Fat-soluble drugs may have longer half-lives

Nutrient Intake Analysis

Calorie Count or Plate Waste Study Prospective data Practical only in an institutional setting (not an outpatient setting) Identify & document dietary inadequacy 48- or 72-hour collection of all food/fluid intake Obtained by documenting food/fluid left on a tray after a meal Direct Observation (Meal Rounds) - Optimal to identify physical difficulties affecting intake

Factors to consider in choosing a method to assess dietary intake

Characteristics of the patient/client/participant: Literacy, memory, commitment, age, etc. Validity of data: degree to which data measures what it is intended to measure; Does the method actually reflect usual intake? Reliability of data: correlates with consistency and reproducibility of data. The eating habits of children can be assessed by 24-hr recall, food records, or FFQ, but any of those methods most often requires a surrogate (e.g., a parent). Surrogate sources = someone familiar with the respondent (parent, spouse, child, etc.) who may assist the person with reporting dietary intake.

Statin drugs

Chemicals that lower blood cholesterol levels: drugs commonly prescribed for preventing heart conditions; they can cause muscle weakness, joint inflammation, and pain, among other serious symptoms • Affect synthesis of coenzyme Q10. • Sometimes recommended that patients also take 100mg of supplemental CoQ10.

Fat DRI

Children 1-3y 30-40% Children 4-18y 25-35% Adult 20-35%

Protein DRI

Children 1-3y 5-20% Children 4-18y 10-30% Adult 10-35%

Bile Acid Sequestrants

Cholestyramine (Questran®) Decrease reabsorption of cholesterol in bile in the small intestine • May also may decrease the absorption of fat-soluble vitamins. So, supplemental vitamins A, D, E, and K are often recommended.

166 lbs; 11.8%; 19.6 lbs; 146 lbs; 125% of Adj. IBW

Chris is 5'10" and 182 lbs. He has bilateral below the knee amputations (BKA). What is his IBW? • Calculate IBW for 5'10" male • Determine total percentage for amputated limbs • Determine weight that must be subtracted • Adjusted IBW • What percent of his IBW is Chris?

Signs of Vitamin A Deficiency

Chronic dry eye (xerosis of the conjunctiva and/or cornea) Night blindness or impaired night vision Hazy, softened cornea (advanced stages) Bitot's spots Follicular hyperkeratosis (gooseflesh)

Process of Regulation for Medications

Clinical Trial Phases 1. First in human studies to demonstrate early efficacy or clinical results; Designed to determine the optimal dose of an investigational therapy and how humans process it and identify any potential toxicities 2. Designed to determine initial efficacy of an investigational therapy in a particular disease or selected group of patients; Continually monitors for adverse effects or potential toxicities 3. Large trials designed to determine therapeutic efficacy as compared to standard of care (placebos are rarely used in cancer clinical trials) 4. Post-Marketing Studies; Conducted after a therapy is provisionally approved by the FDA and provide additional effectiveness or real-world data on the therapy

Checklists

Close-ended forms; Dietary record intake data forms that consist of listings of food groups; resemble food frequency questionnaires but are intended to be filled out concurrently with actual intake or at the end of a day for that day's intake. Can be developed to assess particular "core foods" that contribute substantially to intakes of some nutrients, and it also has been used to track food contaminants Help reduce respondent burden and reactivity bias

Total Energy Expenditure (TEE)

Combination of: Basal Energy Expenditure (BEE): 60-70% of TEE Activity: 20-30% of TEE (varies) Thermic Effect of Food (TEF): 10% of TEE

Corticosteroids (e.g. prednisone)

Common drug-nutrient interactions May be prescribed for COPD, rheumatoid arthritis, etc. Many nutrition-related side effects: • Hypercalciuria - Calcium and vitamin D supplements are recommended with long-term corticosteroid therapy. • Sodium and fluid retention • Hyperglycemia • Hyperphagia and weight gain • Dyspepsia

Antihypertensive medications and potassium

Common drug-nutrient interactions Thiazide and Loop diuretics - increase potassium excretion • Supplementation may be necessary. Potassium-sparing diuretics - decrease potassium excretion • Avoid potassium supplements and KCl salt substitutes ACE-inhibitors and angiotensin II receptor blockers (ARBs) - decrease potassium excretion • Avoid potassium supplements and KCl salt substitutes

Protein foods and levodopa

Common food-drug interactions • Levodopa is typically the first-line of treatment for Parkinson's Disease. • Levodopa = precursor to the neurotransmitter dopamine • Sinemet® = carbidopa/levodopa • Large, neutral amino acids (proteins) compete with levodopa for transport proteins in the gut and at the bloodbrain barrier. To achieve the best therapeutic effect from levodopa, it often helps to redistribute protein around levodopa dosing. Common side effects of Sinemet ® : • Nausea • Anorexia • Dysgeusia

Vitamin-K

Common food-drug interactions and the anticoagulant warfarin (Coumadin®) • Warfarin works by inhibiting hepatic synthesis of vitamin-K dependent clotting proteins. • So, vitamin K intake should be kept consistent to optimize the warfarin therapy. • Alcoholic beverages can increase the effect of warfarin. EtOH should be limited to 1-2 servings occasionally. Vitamin-K content should be kept consistent while taking the anticoagulant warfarin (Coumadin®). High: Broccoli (cooked); Brussel Sprouts; Cabbage (raw); Canola Oil; Endive (raw); Kale; Lettuce (gourmet); Liver; Parsley; Silver Beet (cooked); Soybean Oil; Spinach Moderate: Abalone; Asparagus; Avocado; Beans (snap); Cabbage (cooked); Blue Cheese; Margarine; Olive Oil; Peas; Dill Pickles; Red Cabbage Low: Alfalfa; Green Beans; Breads, Cereals; Capsicum; Carrot; Cauliflower; Celery; Cheddar Cheese, Milk; Chickpeas (cooked); Corn (sweet, kernels, cooked); Eggs, Butter; Iceberg Lettuce; Mushrooms; Potatoes; Pumpkin; Rice; Sunflower, Sesame Oil; Sweet Potato

Soluble Transferrin Receptor

Concentrations in blood rise early in iron deficiency and in proportion to the magnitude of deficit When cellular iron content is low, more transferrin receptors appear on cell surfaces in an attempt by cells to sequester the iron they need. Soluble transferrin receptor is a part of the membrane-bound transferrin receptor that's cleaved and released into circulation. Its concentration in blood is proportional to the concentration of transferrin receptor on the plasma membranes.

Beau's Lines

indentations that run across the nails Can be caused by: - Uncontrolled DM (diabetes mellitus) - Circulatory disease (PAD) - Malnutrition (Zinc deficiency)

Corkscrew hairs

indicative of scurvy (vitamin C deficiency)

Private Insurance

Coverage for nutrition services varies throughout the country and changes frequently

Serum Creatinine

Creatinine is a waste product of energy metabolism in muscle • High energy compound creatine phosphate is dephosphorylated, forming creatinine • Excreted by the kidney • Sensitive index of renal function - elevated serum creatinine may indicate kidney dysfunction **Know the distinction between creatine and creatinine and use these terms appropriately* • Used along with other factors such as gender, age, ethnicity etc. to calculate estimated Glomerular Filtration Rate (eGFR) • GFR levels below 60 mL/min/1.73 m2 for 3 or more months are a sign of chronic kidney disease (CKD).

Protein Energy Malnutrition (PEM) Tests

Creatinine-Height Index 24-Hr Urine Urea Nitrogen (UUN)

Nutrition Diagnosis

D =

Total body water (TBW) and Distribution

Decreases with age; Water-soluble drugs may be more concentrated

Lipase inhibitors

Decrease fat absorption • May also decrease absorption of fat-soluble vitamins Used to reduce activity of lipase found in the intestines. Malabsorption syndrome, cholestasis, incontinence, oily stool. Prototype drugs; Orlistat, Xenical®, Alli®

Bioavailability

Degree to which a drug or other substance reaches the circulatory system and becomes available to the target organ or tissue

Medications and appetite

Drugs indicated for appetite stimulation: Must weigh the side effects of these meds with their benefits • Megestrol acetate (Megace ®) • Oxandrolone (Oxandrine ®) • Dronabinol (Marinol®) Appetite stimulation as a side effect - • Antipsychotics, antidepressants, corticosteroids, etc. Appetite suppressants - many meds have anorexia as a side effect!

Xerostomia

Dry mouth Seen in poorly controlled diabetes mellitus, several autoimmune diseases and as a consequence of radiation therapy and many medications • Lack of saliva impedes all aspects of eating...

Urinalysis

Detects substances or cellular material in urine Metabolic or kidney disorders Full test includes: • Appearance of the urine • Results of tests done with a dipstick • Microscopic examination of urine sediment

Monitoring and Evaluation

Determine degree of progress being made toward goals or desired outcomes - Monitoring • Review and measurement of status at scheduled times - Evaluation • Systematic comparison with baseline or previous status, intervention goals, and/or recommended standards

Food Frequency Questionnaire (FFQ)

Determines how frequently foods or food groups are consumed. Pt chooses a frequency for which each food is eaten. Often used in conjunction with 24-Hour Recall Review of food consumed per day/week/month FFQ organizes foods into groups with common nutrients Most FFQs include questions on portion sizes and cooking methods Limitations: May not represent usual foods or portion sizes chosen by pts Requires a literate population and depends on ability of the subject to describe the diet. Cannot be used over short time periods

Respiratory Quotient (RQ)

Determines proportion of energy coming from fats and carbohydrates RQ = vCO2/vO2 (the ratio of CO2 produced to O2 consumed) Only carbohydrate is being used for energy, RQ = 1.0 Only fat is being used for energy, RQ = 0.70 Typically it is a mixture of carbohydrates and fats that are being used for energy...not just one RQ's of > 1.0 may represent overfeeding RQ = 1 for carbohydrate, 0.85 for mixed diet, 0.82 for protein, and 0.7 for fat

Red blood cell (RBC) count

Determines the total number of erythrocytes in a sample of blood Low suggests anemia, but it doesn't distinguish the cause (nutrient deficiency, blood loss, or another underlying condition) 4.2 - 5.4 x 106/mm3 (women) 4.5 - 6.2 x 106/mm3 (men) A CBC with RBC indices is one of the first set of tests that a patient receives; although CBC data are not specific for nutrition status, their universal and repeated presence in the patient's record makes them very important. These tests are affected only when iron stores are essentially depleted​

Sodium-Restricted Diets

Diet orders specifying either: Low-sodium • Indicated for many disease states (e.g., HTN, CVD, heart failure, liver disease, kidney disease) • strict ~250 - 1,000 mg • moderate ~2 g No Added Salt • Least restrictive • regular diets with no salt added

Thermic Effect of Food (TEF)

Diet-induced Thermogenesis Rise of metabolic rate above basal level after eating Reflects the energy expended to digest, metabolize, and store food ~10% of TEE

Measurement/Estimation of Energy Expenditure

Direct calorimetry - only used in animal research Doubly-labeled water - only used for research Indirect calorimetry: A gold-standard for measurement of RMR; Used for research and clinical applications; Whole-room Calorimeter variation only used for research purposes Prediction equations

Evaluation

E =

Open‐minded Skepticism

Educating Our Patients to be Wise Consumers Buyer Beware of: •Claims that sound too good to be true and terms such as "miraculous cure" and "secret ingredients." •Products or diagnostic tools advertised as quick and effective for a wide variety of ailments. •Advertisements based on amazing testimonials of a few people. •Advertisements that claim products or therapies are "clinically proven" but lack references to support those claims. •"Limited time offers" and advance payment requirements. •Health information from websites that are selling products or products sold by multilevel marketing pyramid models. Educating our Patients to be Wise Consumers •Discuss dietary supplements with your patients, and have the resources available to find answers to their questions. •Instruct px to treat dietary supplements like medications, keeping an updated list of all supplements and dosages. •Remind px that "all natural" doesn't necessarily mean "all safe."

Determining Energy Needs for Children

Estimated Energy Requirement (EER) prediction equations from the IOM are typically used; see charts; already take into account a physical activity level, so you would not multiply by an AF

Dietary Reference Intakes (DRIs)

Encompass 4 types of nutrient recommendations: Estimated Average Requirement (EAR) Recommended Dietary Allowance (RDA) Adequate Intake (AI) Tolerable Upper Intake Level (UL)

Harris-Benedict Equation

Estimates resting energy expenditure (REE) Found to overestimate REE in normal weight and obese by 7% to 27% Not the best choice for critically ill patients on mechanical ventilators Given on exam • Male: REE = 66.47 + 13.75W + 5H - 6.76A • Female: REE = 655.1 + 9.56W + 1.85H - 4.68A W = weight in kg H = height in cm A = age in yr

Clinical Features of Severe Malnutrition in Adults

Energy Intake: Acute (<50% for more than 5 days) Chronic (<75% for more than 1 month) Weight Loss: Acute (2% in 1 week; 5% in 1 month; more than 7.5% in 3 months) Chronic (5% in 1 month; 7.5% in 3 months; 10% in 6 months; more than 20% in 1 year) Body Fat and Muscle Wasting: Skinfolds and physical examination see certification: Acute (Moderate) Chronic (Severe) Grip Strength: Acute (Measurably reduced) Chronic (Measurably reduced)

Atwater Equivalents

Energy in food can be estimated • CHO = 4 kcal/g • PRO = 4 kcal/g • FAT = 9 kcal/g • ETOH = 7 kcal/g

Penn State University [PSU (2003b)] equation

Energy needs for the mechanically-ventilated critically ill obese adult, If indirect calorimetry is not available

Personal protective equipment guidelines

Ensure adequate supplies Involve staff in the selection of personal protective equipment Train staff in correct use Use influential senior staff as role models Monitor compliance and inappropriate use Dispose safely

Statistics

Enteral: 245,000 hospital stays; 15% of those were for children and newborns; 30,700 patients were on Home EN Parenteral: 360,000 hospital stays; 33% of those were for children and newborns

Urine Glucose

Evaluation of hyperglycemia, effectiveness of DM therapy Normal range: Negative When blood glucose is >/= 180 mg/dL, it exceeds the kidney's threshold for reabsorption and glucose spills into urine (glycosuria)

Retrospective Medical Nutrition Therapy

Evaluation of symptoms to determine if medical problems might be the result of food-drug interactions

Food/Nutrition history

Ex. 24-hour recall, diet history, GI symptoms

Anthropometric measures

Ex. Height, weight, BMI

Biochemical data, medical tests, and procedures

Ex. Laboratory data (prealbumin, LFTs), bowel surgery

Client history

Ex. Past medical history, family and social history, cultural beliefs

Nutrition-Focused Physical Finding

Ex. Skin condition, blood pressure, muscle wasting

Two strategies for learning consistent CHO meal patterns

Exchange System Carbohydrate Counting

Roadblocks in Obtaining Dietary Intake Data

Focus on the diet = people consciously or unconsciously alter intake: Obese individuals = more likely to underreport Underweight individuals, older adults, and pts with eating disorders = more likely to over-report Respondents may try to simplify recording or impress interviewer - Affects validity of data

Lab Tests for B-vitamin deficiency

Folate and B-12 deficits result in macrocytic, megaloblastic anemia • Before treatment, is important to determine which B-vitamin is deficient. • B12 deficiency resulting from lack of intrinsic factor is called pernicious anemia • Other deficiencies of B12 and folate can occur due to low intake, alcoholism, or malabsorption

Anemia Symptoms

Eyes: yellow Skin: Pale, cold, yellow Respiratory: shortness of breath Muscular weakness Intestinal: change in stool color CNS: fatigue, dizziness, fainting is severe Blood vessels: Low blood pressure Heart: palpitations; rapid heart rate: Severe (chest pain, angina, heart attack) Spleen: enlargement

Blood Urea Nitrogen (BUN)

Indirect and rough measurement of renal function Normal range: 8-23 mg/dL Used in conjunction with serum & urinary creatinine for interpreting renal function BUN alone is less accurate than serum creatinine in indicating renal disease • High values suggest renal disease or dehydration • High values also seen with GI bleeding, high protein intake, etc. • Low values suggest liver disease, overhydration​, etc.

Android Body Shape

Fat Distribution in an Apple Shape Upper body fat or central obesity Greater risk of chronic diseases - heart disease, stroke, diabetes, hypertension, some cancers

Visceral Adipose Tissue (VAT)

Fat that lies beneath the abdominal muscle and surrounds the internal organs • Associated with increased risk for type 2 diabetes and CVD

stool sample tests

Fecal fat: Tests for fat malabsorption (aka steatorrhea) Fecal occult blood test: Tests for "hidden" blood losses in feces; May indicate a GI bleed, colorectal cancer, etc. Tests for pathogenic bacteria, viruses, or parasites

Dysphagia Common Problem

Food Consistencies • Thin Liquids • Particulate Foods • Stringy Foods • Mechanically Intensive Foods • Mixed Consistencies • Pills

Nutrient Intake

Food intake and absorption

Level 1 Dysphagia Diet: Pureed

Foods of "pudding-like" consistency that are smooth or pureed with no lumps. - Not included are Jell-O, fruited yogurt, peanut butter, un-blenderized/pureed cottage cheese, etc. Sample menu: pureed chicken, mashed potatoes with gravy, pureed carrots, pureed broccoli, and chocolate pudding

Skinfold Measurements

Indirect method of estimating percent body fat Assumes ~50% of body fat is subcutaneous Most common measurements: Triceps skinfold (TSF); Biceps; Subscapular; Suprailiac; Upper thigh Measured in mm with calipers Take measurements on the right side of the body. Typically take at least 2 measurements with ~15 seconds between each Interpreted against percentile tables

Multiple-Pass Method

Five Passes of Recall; typically requires between 30 and 45 minutes Most accurate retrospective method (1) an initial "quick list," in which the respondent reports all the foods and beverages consumed, without interruption from the interviewer (2) Get Details - a forgotten foods list of nine food categories commonly omitted in 24-hour recall reporting (3) time and occasion, in which the time each eating occasion began and what the respondent would call it are reported (4) a detail pass, in which probing questions ask for more detailed information about the food and the portion size, in addition to a review of the eating occasions and times between the eating occasions (5) final review, in which any other item not already reported is asked; night eating, supplements End with "Was yesterday a typical day's intake for you?"

Bitot's spots

Foamy, gray, triangular spots of keratinized epithelium on the conjunctiva Sign of later Vit A deficiency

Dysgeusia

altered taste

Childhood BMI

For ages 2-19 obese > 95th % Overweight between 85th and 95th % Normal between 5th and 85th % Underweight < 5th %

Patient Interview

Four stages in the patient interview: a) Preparation b) Initiation - establish rapport; explain objectives; determine the client's understanding c) Maintenance - 1. Communication (Avoid leading, alienating, embarrassment, intimidation, medical jargon) (Listen, clear instructions, repeat) 2. Control (direct questions, respond to cues, maintain self-composure; don't hurry but be efficient) d) Termination (summarize, referral, contact information)

Inspection

General observation that progresses to a more focused observation - Uses senses of sight, smell, hearing - Most frequently used technique If you are not looking for something, you will likely not see it!

Protein-Energy Malnutrition

General term for inadequate energy and protein intake

Thalassemia

Genetic disorder that results in inadequate Hb production

Abnormal Urine Constituents

Glucosuria (Glucose in large amounts) DM, renal diabetes Proteinuria or Albuminuria (Protein) Kidney Damage; nephritis, bladder infection Ketonuria (Ketone Bodies) DM, starvation, high-fat diets Pus (leukocytes) kidney or bladder infection Hemoglobinuria (hemoglobin) excessive hemolysis of RBCs Hematuria (RBCs) hemorrhage in urinary tract Jaundice (Bile pigment in large amounts) blockage of bile duct, hepatitis, cirrhosis

Iodine Deficiency

Goiter Cretinism (severely stunted physical and mental growth owing to untreated congenital deficiency of thyroid hormone (congenital hypothyroidism) usually owing to maternal hypothyroidism)

Hydrostatic (Underwater) Weighing

Gold standard for determining fat vs. lean mass Direct measure of whole-body density Object submerged in water equals the volume of water the object displaces Procedure is impractical for casual use

Exchange Lists for Meal Planning

Groups foods into "rough equivalents" for protein, fat, carbohydrate, and kcals Developed by the American Diabetes Association and American Dietetic Association A method of meal planning to help ensure adequate but not excessive intake of a particular nutrient

Assessment of Pediatric Malnutrition

Growth is assessed by growth charts for age and gender Assess Z Scores to tell how many SD (standard deviation) for age group Primary Indicators: Weight for height (z score); BMI (z score); Length/Height (z score); Mid-upper arm circumference Mild malnutrition: -1 to -1.9 Moderate: -2 to -2.9 Severe: -3 or greater Weight Gain Velocity <2 yrs: Mild: <75% norm; Moderate <50% norm; Severe <25% norm Weight Loss 2-20yrs of usual body weight: Mild 5%; Moderate 7.5%; Severe 10% Deceleration in Weight for length/height z-score: Mild decline 1 z; Moderate decline 2 z; Severe decline 3 z Inadequate nutrient intake: Mild 51-75% energy/protein need; Moderate 26-50% energy/protein need; Severe <25% energy/protein need

Post-exposure management

Guidelines outlining all procedures Dissemination of guidelines Information, education, and communication Support and counseling Where possible, provision of postexposure prophylactic medication for high-risk exposures Analyze surveillance data

HIPAA

Health Insurance Portability and Accountability Act by Centers for Medicare and Medicaid Services a federal law that protects the privacy and security of patients' "protected health information." The initial intent was to ensure that health insurance eligibility is maintained when people change or lose jobs requires that health care facilities and providers (covered entities) take steps to safeguard PHI does not prevent sharing of patient data required for care, patients must be notified if their medical information is to be shared outside of the care process, or if protected information (e.g., address, e-mail, income) is to be shared. Violations of HIPAA rules have resulted in large fines, loss of jobs, and criminal prosecution. In an effort to avoid the serious repercussions

Children's Growth

Height and weight evaluated against several norms Percentiles - based on anthropometric measurements performed on a national representation sample of same sex and age Data mapped on growth charts from CDC (over 2 yrs) and WHO (under 2 yrs)

Factors that Affect RMR

Lean body mass (primarily skeletal muscle metabolism) = primary determinant of RMR Age Body size Gender Hormones Temperature Metabolic stress Genetics Other factors: Caffeine and nicotine slightly, transiently increase REE.

Pharmacodynamics

How a medication affects the body Includes both the therapeutic/clinical effects we want to achieve from the drug as well as side effects.

Tolerable Upper Intake Level (UL)

Highest level of daily nutrient intake that is unlikely to have adverse health effects

Pharmacokinetics

How the body affects a medication Includes: • Absorption • Distribution • Metabolism • Excretion

Nitrogen Balance

Iillness stress increases catabolism causing negative nitrogen balance Increased protein breakdown = Increased protein requirement Diet therapy should focus on providing adequate energy to spare protein for tissue synthesis

S/S of dehydration

Level of consciousness: Mild (Alert) Moderate (Lethargic) Severe (Unresponsive) Capillary Refill of nails: Mild (2 seconds) Moderate (4 seconds) Severe (more than 4 seconds) Mucous membranes: Mild (Normal) Moderate (Dry) Severe (Parched or Cracked) Heart Rate: Mild (Slight increase) Moderate (Increased) Severe (Rapid) Pulse: Mild (Normal) Moderate (Thready) Severe (Faint) Respiratory Rate: Mild (Normal) Moderate (Increased) Severe (Increased) Blood Pressure: Mild (Normal) Moderate (orthostatic hypotension) Severe (decreased) Skin turgor: Mild (Normal) Moderate (Slow) Severe (Tenting) Eyes: Mild (Normal) Moderate (Sunken) Severe (Very Sunken)

Positive acute phase respondents

Increases inflammatory response CRP and other cytokines

Interventions

I =

Hepatitis B immunization

Immunize early in the career Pre-vaccination serological testing is unnecessary Use 0, 1 and 6 months schedule If possible, conduct post-vaccination testing Do not administer boosters routinely

Advanced carbohydrate counting

Importance of record keeping Calculating insulin-to-carbohydrate ratios Pattern management

Protein Requirements

Important for many functions in the body. For example: • Enzymes are proteins. • Many hormones are proteins. • Plasma membrane proteins • Plasma proteins • Structural proteins (muscle, skeletal matrix, collagen, keratin, and visceral proteins)

White Blood Cell Count (WBC)

Index of immune function (number of WBCs in a mm3 of blood) White blood cells = leukocytes Usually assessed as part of a CBC (complete blood count) 4.8 - 11.8 x 103/mm3 Help clinicians pinpoint the type of infection a pt may have (e.g., bacterial vs viral)

Inpatient nutrient intake analysis (NIA)

In clinical settings observation of food intake, weighs meals before and after for most accurate analysis Disadvantage: does not reflect intake of a free-living individual

Nutrition or Diet History

Inadequate dietary intake and nutritional inadequacy as a result from anorexia, ageusia, dysgeusia, anosmia, excessive alcohol intake, fad dieting, chewing or swallowing problems, frequent eating of highly processed foods, adverse food and drug interactions, cultural or religious restrictions of diet, an inability to eat for more than 7 to 10 days, intravenous fluid therapy alone for more than 5 days, or the need for assistance with eating Older Patients: ill-fitting dentures and poor dentition, changes in taste and smell, long-established poor food habits, poverty and food insecurity, and inadequate knowledge of nutrition Self-prescribed therapies, including use of megadoses of vitamins and minerals, use of various herbs, macrobiotic diets, probiotics, and fatty acid or amino acid supplements

Healthy Eating Patterns

Include: Fruits, Veg, Protein, Dairy, Grains, Oil Limit: Saturated and Trans Fat, Added Sugar, Sodium

Oral Cavity

Indicators of normal oral health: - Smooth lips without sores - Dull red tongue without swelling - Normal taste/smell - Normal gums and teeth • Note any lesions, swelling, or bleeding. • Note any teeth that are missing, cracked, or in poor condition.

Hemoglobin (Hb or Hgb)

Main component of RBC's Main vehicle for O2 transport in blood Composed of heme + globulin: Heme = iron-containing pigment; Globulin = protein portion Normal range: Male 14-18 g/dL; Female 12-16 g/dL Low suggests anemia, but it doesn't distinguish the cause (nutrient deficiency, blood loss, or another underlying condition)

Most Common Food Allergies

Infants/Children - Eggs - Fish - Milk - Peanuts - Soy Adults - Fish - Tree nuts - Peanuts - Shellfish - Wheat

Stomatitis

Inflammation of the oral mucosa May be associated with HIV, autoimmune diseases, or radiation therapy for CA • Causes severe pain and ulceration of the gingiva, oral mucosa, and palate → painful eating

Methods for Obtaining Dietary Intake Data

Inpatient nutrient intake analysis (NIA) Daily food record or diary Food frequency questionnaire FFQ 24-hour recall

Diet History

Inquire about use of alcohol, vit/min, herbal or other supplements; genetic problems, wt changes, appetite/intake changes, taste problems, GI problems

Skin Inspection and Palpation

Inspect for color and uniform appearance. Any lesions, tears, bruising, edema, rashes, or flakiness? Palpate for moisture, temperature (should range from cool to warm to the touch), texture (should be soft and even), turgor, discolorations

Subcutaneous Muscle Loss

Inspect for loss of fullness or loose-fitting skin - May see loose skin in older adults who are not malnourished Areas for inspection include Wasting in the following areas: • Temporal area (Standing in front of the pt, observe the temple region as he/she turns head to left and right; Gently palpate) • Clavicles • Side of Shoulders (deltoid muscles) • Chest • Calf (Grip the calf; Normal: muscle obvious, top of calf is larger than bottom; Abnormal: muscle reduction, "stick legs", ankles the same as upper leg • Quadriceps (check for muscle wasting) • Arm: Triceps (Bend arm and pinch at triceps, only pinch the fat, not the muscle); Hands (Normal: fingers don't meet, Abnormal: fingers meet)

Subcutaneous Fat Loss

Inspect for loss of fullness or loose-fitting skin - May see loose skin in older adults who are not malnourished Areas for inspection include: - Orbital Region - Surrounding the Eye - Upper Arm Region - Triceps - Thoracic and Lumbar Region - Ribs, Lower Back, Midaxillary line In hospitalized patients, the back may not be easily accessible

Nutrition Diagnosis Terminology

Intake • Problems related to intake of energy, nutrients, fluids, bioactive substances through oral diet or nutrition support • Excessive energy intake (NI-1.3), inadequate enteral nutrition infusion (NI-2.3) Clinical • Nutritional findings or problems identified that are related to medical or physical conditions • Swallowing difficulty (NC-1.1), unintended weight loss (NC-3.2) Behavioral-Environmental • Nutritional findings or problems related to knowledge, attitudes, or beliefs, physical environment, or food safety and supply - Impaired ability to prepare foods/meals (NB-2.4), Limited access to food (NB-3.2)

Usual Daily Intake

Interview pt about typical consumption habits on average day Useful tool for assessment of diet quality

Food allergy

an IgE-mediated reaction that occurs when the immune system reacts to a normally harmless food protein that the body has erroneously identified as harmful

Major Micronutrient Deficiency

Iron, Vitamin A, Iodine Central & South America, Africa, Middle East, Asia, India

Mid-Arm Circumference (MAC)

Is used in combination with TSF to calculate Arm Muscle Area (AMA) Estimate of skeletal mass vs. fat stores Reliable indicator of skeletal (somatic) protein & protein-energy malnutrition (PEM)

Food intolerance

an adverse reaction to a food that does not involve the immune system

Serum Ferritin

Lab Tests for Iron-deficiency Anemia Primary iron storage protein in body Directly proportional to body's total iron storage pool 12-300 ng/mL (men) 10-150 ng/mL (women) Not reliable in acute or chronic inflammatory states - positive acute phase respondent - Cytokines increase ferritin synthesis and cause it to leak from RBC's into plasma, artificially raising serum ferritin

Biochemical Assessment

Laboratory Values; a critical part of the nutrition assessment; supports subjective judgment and assessment findings Objective data compared to other measures such as diet hx or physical examination

Cyanosis of the Nails

Lack of oxygen in the blood •Can be caused by congenital heart disease or pulmonary disease

Macrocytic anemia

Large, fragile RBCs Often associated with folate and/or B-12 deficiency; pernicious anemia

New Label

Larger Calories and Serving Size and Servings in Package Added: Sugars Vitamin D, Calcium, Removed: Vitamin A, C Remained: Iron, Potassium, Calories from Fat

Fat/Muscles/Edema of Inadequate Nutrition

Lipodystrophy Buffalo hump Moon-shaped face Edema

Wounds

an injury to living tissue caused by a cut, blow, or other impact, typically one in which the skin is cut or broken Peripheral neuropathy and poor circulation pose a risk for foot ulcers in diabetics

Retrospective MNT Protocol

Look for possible food-drug interactions - Complete nutrition history - Complete medical history: Look for other possible reasons for the symptom - Date of drug initiation; date of symptom onset - Research reported drug side effects to assess the likelihood the symptom actually results from the drug

Monitoring

M =

Chloride (Cl-) Electrolytes

Major anion in extracellular fluid Normal range: 90-110 mEq/L Helps manage fluid balance and acid-base balance • Low values = hypochloremia • High values = hyperchloremia

Bicarbonate (HCO3-) Electrolytes

Major anion in managing acid-base balance Normal range: 23-30 mEq/L Levels are regulated by kidney • Note: serum values of bicarbonate may be identified as CO2 on lab reports

Sodium (Na+) Electrolytes

Major cation in extracellular fluid Normal range: 136-145 mEq/L Manages water distribution and electrical neutrality • Values <136 mEq/L = hyponatremia • Values >145 mEq/L = hypernatremia

Potassium (K+) Electrolytes

Major cation in intracellular fluid Normal range: 3.5-5.0 mEq/L Important for electrical potential across cell membranes • Low values = hypokalemia • High values = hyperkalemia

Serum Albumin

Major protein in blood - Maintains colloid osmotic pressure (water distribution) - Major transport protein • Normal range: 3.5-5 g/dL • Was once a widely used nutrition screening tool in American hospitals • Fair index of malnutrition at best Limitations: • Long half-life (14-20 days) - not a sensitive indicator of recent nutrition • Inflammation, infection, burns, or trauma may cause low albumin levels independent of nutritional status. • Low levels are also seen with fluid retention (hemodilution), ESLD, and heart failure. • Levels may be normal (or even elevated) in patients with starvation (e.g., marasmus, anorexia nervosa). • Levels may be falsely high with blood transfusions or dehydration.

Protein RDA

Male or Female g/kg/day 7-12month 1.2 1-3yr 1.05 4-13yr 0.95 14-18yr 0.85 19 and up 0.80 Pregnancy 2nd half 1.1 Lactation 1.3 1.0-1.5g/kg BW: ◦ Moderate stress needs; ◦ Post-op, small wounds (stage I and II) 1.5 - 2.0g/kg BW: ◦ Severe stress needs; ◦ Critical fever, sepsis, large wounds, trauma, burns

Vitamin D Dietary Reference Intakes

Male/Female 19-70y EAR 400 IU; RDA 600 IU; UL 4000IU Male /Female older than 70y EAR 400 IU; RDA 800 IU; UL 4000IU

Body Composition

Males Total Fat 8-24% (Storage 5-21%; essential 3%) Muscle 44.8% Bone 14.9% Remainder16.3-32.3% Women Total Fat 21-35% (Storage 9-23%; essential 12%) Muscle 38% Bone 12% Remainder15-29% Not always applicable in acute or critical care settings Validity depends on the accuracy of the measuring technique Prediction methods: Skinfold thickness; Circumferences; Bioelectrical Impedance Analysis (BIA) More robust methods: Underwater weighing; Bod Pod; Dual Energy X-ray Absorptiometry (DXA) Accuracy of prediction methods decreases​ as obesity increases. Changes are gradual Best detected when multiple measurements are taken over a long period of time Typically, 3-4 wks to see change in body composition

Low serum albumin and Distribution

More of the drug remains unbound, so its therapeutic effect may be amplified

Usual Body Weight (UBW)

More useful than ideal weight for ill patients Comparing present weight to UBW allows assessment of weight changes Dependent on person's memory

MCV (Mean Corpuscular Volume)

Mean RBC Indices Measures average size of RBC Helps differentiate normocytic, microcytic, and macrocytic anemia - Low in microcytic anemia - High in macrocytic anemia 80 - 96 μm3

Evaluating Intake Data

Means of comparing nutrients consumed to nutrients required To help client set specific goals to improve nutrient intake Methods: Dietary Reference Intakes Dietary Guidelines Exchange Lists for Meal Planning Food Labels with Daily Values Nutrition Analysis Programs (computer software or web-based)

Body Frame Size Wrist Circumference

Measure right wrist, Arm flexed at elbow with palm facing upward r = height (cm)/wrist circumference (cm) Frame Size Small: Women rValue >11.0; Men rValue >10.4 Medium: Women rValue 10.1‐11.0; Men r Value9.6‐10.4 Large: Women rValue <10.1; Men rValue <9.6

Body Frame Size Elbow Breadth

Measured with calipers Patient stands straight with upper right arm perpendicular to body Forearm flexed to 90-degree angle with palm facing subject Feel for widest bony width of elbow Place heads of calipers over this area

Actual Body Weight (ABW)

Measurement obtained at examination Can be influenced by fluid status: Weight loss could be from dehydration or nutritional inadequacy; Weight gain could be from edema

Head Circumference

Measurement useful in children birth to 24 months Indicator of non-nutritional abnormalities Malnutrition must be very severe to affect Followed on growth charts

MCHC (Mean Corpuscular Hemoglobin Concentration)

Measures average concentration of Hb in RBC Low in iron deficiency (cells appear hypochromic)

MCH (Mean Corpuscular Hemoglobin)

Measures average weight of Hb in RBC • Expressed as picograms/cell • Low in iron deficiency or blood losses • High in macrocytic anemia (e.g., folate or B-12 deficiency)

Air Displacement Plethysmogram (BOD POD)

Measures body volume based on air displacement Density = mass/volume We can use measurements of body density to estimate body fat and fat-free mass

Bioelectrical Impedance Analysis (BIA)

Measures impedance (complex value of resistance) of the body's tissues to an electrical current to estimate body's fat-free mass and fat mass Pros: Is safe, portable, fast, and relatively inexpensive Cons: Estimates of body fat are based on regression equations; hydration status may skew results

Common drug-nutrient interactions

Medications may interfere with the way certain nutrients are processed by the body. • Or, the side effects of certain drugs, such as nausea, anorexia, dysgeusia, etc. may compromise nutrition.

Pallor

an unusual paleness of the skin • Could indicate an anemia

Level 2 Dysphagia Diet: Mechanically Altered

Moist, soft-textured foods Meats ground or chopped - Must still be moist Cooked fruits or vegetables without skins or seeds Not allowed on this diet: bread, dry cake, rice, cheese cubes, corn, and peas

BMI Equation

Metric : BMI = Weight (kg) / Height (m)2 English: BMI = Weight (lb) / Height (in)2 x 703

Iodine

Micronutrient required for the synthesis of thyroid hormones thyroxine (T4) and triiodothyronine (T3). T4 is converted to the active form of T3. Thyroid hormones regulate a wide variety of processes such as glucose homeostasis, heart rate, blood pressure, body temperature, and growth/development.

Energy Needs of Overweight/Obese Adults

Mifflin-St. Jeor equation using ACTUAL weight is the most accurate for estimating RMR for overweight and obese individuals, if indirect calorimetry is not possible An energy deficit below TEE is necessary for weight loss

Pediatric Malnutrition Weight loss

Mild 5%; Moderate 7.5%; Severe 10%

Pediatric Malnutrition Weight gain velocity

Mild < 75%; Moderate <50%; Severe <25%

Pediatric Malnutrition Inadequate Nutrient Intake

Mild: 51-75% estimated energy/protein needs Moderate: 26-50% Severe: <25%

Pediatric Malnutrition Deceleration in Weight

Mild: decline 1 z score Moderate: decline 2 z score Severe: decline 3 z score

Strategies to protect health workers

Most blood exposures in health settings are preventable implementation of Universal Precautions immunization against hepatitis B provision of personal, protective equipment the management of exposures Successful implementation of these strategies requires an effective infection control committee with support from the health setting management team.

Level 3 Dysphagia Diet: Advanced

Most regular foods except very hard, sticky, or crunchy items. Bread, rice, cake, shredded lettuce and tender, moist meats are allowed. Mixed textures are expected to be tolerated (e.g., canned soup) Not allowed are hard, difficult to chew fruit and vegetables with skins, nuts, and seeds, etc.

Activity Thermogenesis

Most variable component of TEE All activity counts; NEAT

Current Food Guidance System

MyPlate, used to be my pyramid

Medications and gastrointestinal side effects

Narcotics - constipation (often severe) Sorbitol - diarrhea; Commonly used as an excipient (an inactive substance that serves as the vehicle or medium for a drug or other active substance)in liquid medications Antibiotics - diarrhea; When normal flora of the large intestine are destroyed by the antibiotics, opportunistic pathogens (such as Clostridium difficile) can colonate. Aspirin & other NSAIDs - irritation of stomach mucosa; Risk of ulceration and GI bleeds

Nitrogen balance

N intake - N losses N intake = protein intake (gm/day) ÷ 6.25 N loss = UUN (gm/day) + 4 gm • Evaluating nitrogen balance - = catabolism 0 = catabolism + = anabolism Not accurate for people with: • Large non-urinary nitrogen losses • Diuresis • Fluid retention • Renal failure • Certain medications (e.g., corticosteroids) • Imprecise urine collection

Anemia

NOT a disease, but a SYMPTOM Characterized by 1) reduced number of RBC's OR 2) decreased hemoglobin content of blood Initial classification begins with the CBC (complete blood count): - Red blood cell (RBC) count - Hematocrit (Hct) - Hemoglobin (Hb or Hgb) - Mean corpuscular volume (MCV) - Mean corpuscular hemoglobin (MCH) - Mean corpuscular hemoglobin concentration (MCHC)

Interpreting Labs

No single value is diagnostic - labs are inherently imprecise • Consider pt's age, sex, dx, meds, hydration status, etc. • Determine whether a lab value represents a fasted or postprandial (occurring after a meal) sample • Refer to the lab's acceptable range - Reference ranges may differ for different populations (e.g., by age, gender, etc.) • Consider non-nutritional causes for abnormal lab values • Acute illness/injury can trigger dramatic changes in lab results • Note units of measure - Conventional vs SI

Catabolism

Negative nitrogen balance • Indicative of needing increased protein

Dysphagia Causes

Neurological disorders/conditions - Multiple Sclerosis, Muscular Dystrophy, Stroke, Parkinson's Disease, Alzheimer's Disease Diseases or conditions affecting head and neck - Head and Neck Cancer; trauma to the swallowing structures, etc. Developmental problems - Premature birth; Cerebral Palsy Aging Process Certain medications

Pellagra

Niacin deficiency (4-Ds - dementia, dermatitis, diarrhea, and death)

Vitamin A deficiency

Night blindness is an early symptom

Normal homeostasis

Nitrogen balance for adults should be 0

Serum Prealbumin (transthyretin)

Normal range: 15-36 mg/dL Values < 15 suggest malnutrition, liver damage, zinc deficiency, or acute inflammation • Short half-life (~2 days) • Not a sensitive index of improving nutritional status during inflammation Limitations: • Negative acute phase protein (hepatic synthesis decreases during an acute phase response) • Levels of tennormalin "uncomplicated" malnutrition and decreased in well-nourished pts with recent stress/trauma • Levels may increase with corticosteroid medications, oral contraceptives, or pregnancy • Not accurate in renal or liver disease

Hair

Normal: Natural shine; Consistent color and quantity; Fine to coarse texture Abnormal: Easily pluckable; Sparse; Flag sign; Corkscrew; Hirsutism

Anthropometrics

Obtaining physical measurements of a patient and relating them to reference standards Evaluate overnutrition or undernutrition Monitor effects of nutrition intervention Proper technique is important! Establish measurement accuracy Several clinicians take same measurement and compare results; Can take >20 times to become proficient Advantages: Inexpensive; Easy to obtain (if devices are calibrated and/or used correctly); Noninvasive; Valuable in combination with other assessment tools; Most valuable when accurate measurements are recorded over time. Disadvantages: Inherent error in measuring technique (Are devices calibrated? Are you measuring height & weight correctly?); Tissue variability; Inaccurate application of raw data; Do take into account ethnic, familial and environmental factors!

Adequate Intake (AI)

Nutrient recommendation based on observed or experimentally determined approximation Sufficient scientific evidence is not available to calculate RDA or EAR

PES statement

Nutrition Diagnosis is written as Problem—related to—Etiology—as evidenced by—Signs or Symptoms Problem (diagnostic label): Describes alterations in the clients nutritional status - Must use standardized terms from the NCP Etiology: Cause of the problem Signs or Symptoms (S/S): Defining characteristics— Indicate presence of the problem Example: Inadequate protein intake related to changes in appetite as evidenced by 24-hour recall showing an average daily protein intake that is 40% less than estimated requirements • Example: Swallowing difficulty related to post-stroke complications as evidenced by results of swallowing study and reports of choking during mealtimes

NFPA

Nutrition-Focused Physical Assessment Some nutritional deficiencies may not be identified by other assessment approaches. • Some signs of nutritional deficiency are not specific. • Must be distinguished from non-nutritional etiologies

Interactions

Occur as: •Drug - Food •Drug - Drug •Drug - Supplement •Drug - Alcohol Can result in increased or decreased drug action

Pitting

Observable swelling of body tissues due to fluid accumulation that may be demonstrated by applying pressure to the swollen area (such as by depressing the skin with a finger)

Normal Eyes

Pink conjunctiva without discharge (the mucous membrane that covers the front of the eye and lines the inside of the eyelids.) Sclera without spots (the white outer layer of the eyeball. At the front of the eye it is continuous with the cornea; the "white" of the eye) Clear cornea (the clear front surface of the eye. It lies directly in front of the iris and pupil, and allows light to enter the eye) Moist membranes

Gynoid body shape

Pear Shape - Lower body fat Benign obesity - isn't thought to pose as great of risk

Hematocrit (Hct)

Percent of RBCs in total blood volume Depends on the number of RBCs and their size Normal range: Male 42-52%; Female 37-47%

Nutrition Intervention

Plan and implement purposeful actions to address the identified nutrition problem(s) - Set goals and expected outcomes that are client driven • Determine a plan of action - Based on scientific principles or the best available evidence • Ex. The Academy's Evidence Analysis Library (EAL) - When setting goals prioritize nutrition diagnosis based on: • Severity of problem • Patient need and perception of importance of problem (client driven) • Likelihood of impact by intervention Start with the nutrition diagnosis in order to plan a nutrition intervention. - Excessive fat intake related to frequent consumption of fast food meals as evidenced by fat calories greater than 55 percent of total calories per day and pt report of eating out 6 days per week • Example of evidence-based goals: Reduce percentage of total calories from fat to 20-35% per day • Set client-driven, behavioral/lifestyle changes to help client achieve goal: - Eat out 2x/wk (instead of 6x/week). - Pack a lunch the night before to take to work each day.

Anabolism

Positive Nitrogen balance • Pregnancy, wound healing, etc.

Estimating Energy Expenditure

Prediction equations use gender, age, height, and weight to determine REE These equations only estimate resting energy expenditure: Only part of the total daily energy expenditure; Must multiply by an activity factor Two equations widely used are Harris-Benedict and Mifflin St. Jeor

Neutropenic Diet

Prescribed for patients with immune impairment (e.g., receiving chemotherapy, pre-bone marrow transplantation, post-transplantation, acute AIDS crises) and lower than normal neutrophil counts (neutropenia) • Diet designed to limit ingestion of bacteria and other organisms on food. • Somewhat controversial Restricts the ingestion of: • All uncooked vegetables and most uncooked fruits - Cooked vegetables, canned fruits and juices, and fruits with a thick peel (that is removed) are fine. • Raw or rare-cooked meat, fish, and eggs - Meat should be cooked to the "well done" stage. All eggs should be thoroughly cooked (no runny yolks). • Patients should avoid salad bars, fruit bars, and deli counters - Vacuum-packed lunch meats are fine • Raw dairy - Only consume pasteurized milk, yogurt, cheese or other dairy products. • Soft mold-ripened and blue-veined cheese, including Brie, Camembert, Roquefort, Bleu, Gorgonzola, etc. • Ground pepper and other fresh ground spices

Cachexia

Protein-Energy Malnutrition wasting syndrome an emaciated condition associated with a disease state - Characterized by loss of skeletal muscle mass - Often has associated inflammation and increased resting metabolic rate, whereas simple starvation is characterized by decreased metabolic rate.

Kwashiorkor

Protein-Energy Malnutrition - inadequate protein intake with reasonable caloric (energy) intake Characterized by Edema; Easily pluckable hair and skin problems Sickness of weaning: Most common between the ages of 1 and 4 years

Flag sign

Protein-Energy Malnutrition Alternating bands of depigmented and normal-colored hair representing alternating periods of poor protein intake and normal protein intake

Marasmus

Protein-Energy Malnutrition Overall energy deficiency -Plasma protein levels may be WNL (within normal limits) -Skin and bone appearance

Prospective MNT Protocol

Provide px with basic info about possible food-drug interactions Take with or without food, indications for vit/min requirements, excipients that may be a problem Discuss potential side effects that may affect nutrition (N/V/D/C) • High fiber and fluids with constipating drugs (Ditropan) • How to control side effects • Probiotics (Lactobacillus acidophilus, Saccharomyces boulardii) or psyllium (Metamucil) to control antibiotic associated diarrhea Provide diet information that will support drug action • Low fat diet with cholesterol-lowering drug

Waist Circumference

Provides an easily obtained estimate of visceral adipose tissue. Waist-to-hip ratio provides no assessment advantage over waist circumference alone. Abnormal levels: Women > 35" (88 cm) Men > 40" (102 cm)

WBC Count "with differential"

Provides the number and types of WBCs (neutrophils, lymphocytes, monocytes, eosinophils, and basophils) Help clinicians pinpoint the type of infection a pt may have (e.g., bacterial vs viral)

Daily Food Record/Diary

Pt documents dietary intake as it occurs Prospective data Usually completed by the client Often used in outpatient clinic settings Food and amounts eaten should be recorded at the time of consumption Usual length: 3-Day or 7-Day: Accuracy declines with longer duration; Include a weekend day; Individual may alter diet due to recording process

Normocytic anemia

RBCs of normal size Often associated with anemia of chronic disease (e.g., chronic infection, tissue injury, etc.) May be seen in early iron deficiency anemia

24-Hour Dietary Recall

Retrospective - Collects information on everything eaten in the previous 24-hour day (i.e. everything eaten yesterday) One day may not be an accurate indication of a person's typical dietary intake. An average of 3 days is optimal (2 weekdays and 1 weekend day). If you are only able to collect 1 day, then inquire about whether that was a "typical" day. The recall typically is conducted by interview where the respondent is asked to remember and report all the foods and beverages consumed in the preceding 24 hours or on the preceding day. Well-trained interviewers are crucial Structured, usually with specific probes, to help the respondent remember all foods consumed throughout the day Probing is essential in collecting necessary details Standardized neutral probing questions so as to avoid leading Advantages: literacy is not required; Because of the immediacy of the recall period, respondents are generally able to recall most of their dietary intake; little burden on the respondents therefore more likely to be representative of the population; useful across a wide range of populations; occur after the food has been consumed, and if unscheduled, reactivity is not a problem Main weakness: individuals may not report their food consumption accurately for various reasons related to knowledge, memory, and the interview situation Disadvantages: Data entry and interviewing can be labor intensive Relies on memory One recall may not capture habitual intake Underreporting / Over-reporting frequently occur

Lipodystrophy

Redistribution of body fat Common in AIDS and Cushing's Syndrome (prolonged exposure to cortisol)

Antacids, PPIs, and H2 blockers

Reduce stomach acid May also reduce absorption of vitamin B12 (and possibly iron and calcium)

C-Reactive Protein (CRP)

Reflects any type of inflammation in the body Normal range: < 1.0 mg/dL Synthesized in liver Reduction in levels marks recovery from inflammatory response

Activity and Injury Factors

Represents a % increase above the REE Example: If an activity factor of 1.3 is used it is a 30% increase beyond the REE; REE = 1450 calories x 1.3 activity factor; TEE = 1885 calories Factors for non-stressed patients: 1.2 - Bed rest (confined to bed); 1.3 - Ambulatory / light activity; 1.4-1.9 - Normal activity depending upon someone's daily activity level

Dietary Guidelines for Americans

Revised every 5 years by the Department of Agriculture (USDA) and the Department of Health and Human Services (HHS). Goals are: Promoting adequacy of nutrient intake Reducing risk of diet-related disease

Simplified Portable RMR Measurement System

Similar methodology as the metabolic cart, but it only measures O2 consumption • Assumes a standard RQ of 0.85 • Not used for research, but provides a clinically acceptable measurement of RMR

Format of Medical Records

Sections typically include: - Demographics - MD Orders (including the diet order) - History and Physical (H&P) • Chief complaint of present illness, PMH, Review of symptoms (ROS), etc. - Graphic Sheets (flow sheets) - Lab Reports - Radiology Reports - Medication Records - Progress Notes: MD, Nursing, RD, Social Work, Therapists - PT, OT, SLP, etc. - Consultation Reports - Discharge Summary

Lab Tests for Iron-deficiency Anemia

Serum iron: fairly poor indicator, fluctuates Better Indicators: ↓ Ferritin concentration: Depleted stores ↑ Soluble transferrin receptor: Early functional deficiency ↓ Hemoglobin, ↓ MCV, ↓Transferrin saturation: Iron Deficiency Anemia

Microcytic anemia

Small RBCs Often associated with iron deficiency

Enteral Nutrition Causes

Sometimes a person cannot eat any or enough food because of an illness. Others may have a decreased appetite, difficulties in swallowing, or some type of surgery that interferes with eating

Most Common Specimen Types

Specimens for analysis of nutrients and nutrient-related substances: - Whole blood (RBCs, WBCs, platelets) - Plasma (liquid component of blood) - Serum (fluid after blood clotted) - Blood cells - Erythrocytes (RBCs) - Leukocytes (WBCs) - Urine - Feces

Less Common Specimen Types

Specimens for analysis of nutrients and nutrient-related substances: Saliva Nails Hair: Could be used to test for heavy metal toxicities or certain trace minerals; Results could be easily confounded by external contaminants Sweat

dietary intake data

The collection of information on the food, drink, and supplements consumed; influenced by factors such as economic situation, availability of food, eating behavior, emotional climate, cultural background, effects of disease, and the ability to acquire and absorb nutrients

protected health information (PHI)

The Administrative Simplification provisions of HIPAA require development of national standards that maintain privacy of electronically transmitted information • Written documentation from medical records (including paper records and electronic databases) • Spoken or verbal information including voicemail messages • Photographic images • Audio and video recordings

Good Manufacturing Practices (CGMPs)

Supplement manufacturers must disclose (Supplemental Facts): • Composition • Purity • Identity of ingredients

Negative acute phase respondents

Synthesis decreases under stress Albumin, transferrin, prealbumin, RBP

Palpation

Tactile examination to feel pulsations, organs, masses, or infiltration Not frequently a part of nutrition assessment, but it is important to be able to interpret the results of exams by other members of the healthcare team. Torso Quadrants: Right Upper; Left Upper; Right Lower; Left Lower

Standard fasting lipoprotein profile

Tests to Evaluate CVD Risk Total cholesterol LDL (low density lipoprotein) LDL-C is calculated: LDL = (TC) - (HDL) - (TG/5) (note: this formula is accurate only if TG <400 - HDL (high-density lipoprotein) TG (triglycerides)

Fasting Serum or Plasma Glucose

Tests to Evaluate Glucose Homeostasis Evaluation of diabetes • Normal range: 70-99 mg/dL (fasting) • Fasting levels > 126 mg/dL diagnostic for diabetes • Hypoglycemia = blood glucose < 70 mg/dL

Non-Nutritional Anemia

Thalassemia Sickle Cell Anemia Chronic renal failure Anemia of chronic disease

Who writes in the medical record?

The Health Care Team: - M.D., Physician's Assistant (PA) - Nurse - Pharmacist - Dietitian - Social Worker (or Case Manager) - Respiratory, Physical, Occupational, & Speech Therapists - All others involved in direct patient care

Linguistic Competence

The capacity to communicate effectively and convey information in a manner that is easily understood by diverse audiences

Metabolism

The chemical alteration of a drug by the body. Most medications are metabolized by the liver. • Hepatic (liver) metabolism tends to decline with aging • Because the liver prioritizes ethanol metabolism, alcohol can pose dangerous food-drug interactions.

Estimated Average Requirement (EAR)

The daily intake level estimated to meet the nutrient requirement of 50% of healthy individuals in a life stage and gender group Only used to assess nutrient adequacy of populations Sufficient scientific evidence is not available to calculate RDA or EAR

Health Literacy

The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions

Parenteral nutrition (PN)

The delivery of nutrients intravenously intravenous administration of nutrition, which may include protein, carbohydrate, fat, minerals and electrolytes, vitamins and other trace elements for patients who cannot eat or absorb enough food through tube feeding formula to maintain good nutrition status bypasses the normal digestion in the gastrointestinal (GI) tract. It is a sterile liquid chemical formula given directly into the bloodstream through an intravenous (IV) catheter (needle in the vein) Associated with more complications than enteral nutrition, so enteral nutrition is preferable if possible. "If the gut works, use it!"

Total Parenteral Nutrition (TPN)

The delivery of nutrients intravenously via a central venous catheter (directly in subclavian vein to superior vena cava), of the total nutrient requirements of a patient with gastrointestinal dysfunction Used when the GI tract is non-functional (e.g., a bowel obstruction, fistula, etc.)

HIPAA Privacy Rule Disclosures

The healthcare provider may disclose relevant information if the provider does one of the following: • obtains the patient's agreement • gives the patient an opportunity to object, and the patient does not object • decides from the circumstances based on professional judgment, that the patient does not object

reactivity bias

The knowledge that foods and amounts must be recorded and the demanding task of doing it may alter the dietary behaviors the tool is intended to measure A weakness when the aim is to measure typical dietary behaviors A strength when the aim is to enhance awareness of dietary behaviors and change them, as in some intervention studies

Anthropometry

The measurement of man

Edema

The medical term for swelling The presence of pitting checked and assessed as: absent mild: 1+ (2mm); 2+ (4mm) moderate 3+ (6mm) severe 4+ (8mm)

RBC folate concentration

The most common measurement for assessing folate status

Distribution

The movement of a drug, after it is absorbed into the bloodstream, to and from the blood and various tissues of the body (for example, fat, muscle, and brain tissue) and the relative proportions of drug in the tissues. Affected by: • Body composition: Obese/older pts have greater proportion of adipose tissue to lean body mass; Fat-soluble drugs may have longer half-lives • Total body water (TBW): decreases with age; Water-soluble drugs may be more concentrated • Low serum albumin: More of the drug remains unbound, so its therapeutic effect may be amplified

Nutrition Care Process Steps

There are a series of 4 steps that are involved in quality nutrition care: • Nutrition Assessment • Nutrition Diagnosis • Nutrition Intervention • Nutrition Monitoring and Evaluation There are 2 supporting systems of the NCP: • Screening and Referral System • Outcomes Management System

Computer-Based Nutrition Analysis Programs

These can be used to determine daily nutrients consumed by your client Some are computer software programs that must be purchased Some are web-based and are typically free Clients/patients can also use these to record dietary intake and receive daily feedback on nutrient intake: www.sparkpeople.com, www.fitday.com, www.choosemyplate.gov

Beriberi

Thiamine deficiency characterized by muscle weakness, poor coordination, mental confusion, and peripheral neuropathies - Sometimes edema (wet vs. dry) - Wernicke-Korsakoff Syndrome = thiamine deficiency related to alcoholism

Iatrogenic malnutrition

The problem of malnutrition in hospitalized patients - "physician-induced" The Skeleton in the Hospital Closet Malnutrition due to various medications or some complications to medical treatment or procedure May be caused by negligence among medical personnel - Unintentional causes of many days admission with nothing to eat (NPO), surgeries, etc.

Excretion

The removal of drugs from the body, either as a metabolite or unchanged drug. There are many different routes of excretion, including urine, bile, sweat, saliva, tears, milk, and stool. By far, the most important excretory organs are the kidney and liver. Most medications are excreted by the kidneys; However, some medications may be eliminated by feces or bile. Px with decreased glomerular filtration rate (GFR) may have decreased renal excretion. • GFR tends to decline with age. • Consequently, drugs may remain in circulation longer in older adults and renal px

Skin turgor

The skin's elasticity, the ability of skin to change shape and return to normal Decrease may signal dehydration; remains elevated after being pulled up and released

Liquid Viscosities

Thin - water, milk, juice, coffee, tea, carbonated drinks, gelatin, ice cream, sherbet, sorbet, ​and broth-based soups Nectar-like - fruit nectars, maple syrup, Ensure, eggnog, and some cream-based soups Honey-like - consistency of honey Spoon-thick - pudding

Universal precautions

a simple set of effective practices designed to protect health workers and patients from infection with a range of pathogens including bloodborne viruses. These practices are used when caring for all patients regardless of diagnosis. (Centers for Disease Control (CDC) Hand washing after any direct contact with patients Safe collection and disposal of sharps Gloves for contact with body fluids, non-intact skin, and mucous membranes Wearing a mask, eye protection, and a gown if blood or other body fluids might splash Covering cuts and abrasions Cleaning up spills of blood and other body fluids Safe system for hospital waste management and disposal

Acanthosis nigricans

a skin condition characterized by areas of dark, velvety discoloration in body folds and crease Associated with insulin resistance, diabetes, and other endocrine disorders

Auscultation

Use of a stethoscope to listen to body sounds - Heart, lungs, blood vessels, bowel sounds

Height Measurements

Use stadiometer or wall tape Person must be able to stand No shoes or caps Read at eye level Reference standards based on statistical sample of US population Individual measurements compared to standard population, not an established standard Useful in determining nutrition status in adults Tend to overestimate which = underestimated BMI May decrease in older adults

Pediatric Malnutrition Z Score

Use the z score to tell how many units of standard deviation (SD) a child is from the norm for his/her reference group for age. Weight for Height; BMI; Mid-Upper arm circumference Mild -1 to -1.9 Moderate -2 to -2.9 Severe -3 or greater

Recumbent Lengths

Used for infants, children who cannot yet stand Plot for children on Birth-to-24-Month growth chart Also, for comatose, critically ill, and those unable to be moved Not indicated for patients with musculoskeletal irregularities or contractures

Sign

a clinical manifestation or change in condition identified by the examiner Physically observed by the dietitian

Symptom

a clinical manifestation or change in condition perceived by the patient Reported by the patient

Cataracts

a clouding of the lens in the eye that affects vision; mostly related to aging

Dual-Energy X-ray Absorptiometry (DXA)

Typically used to assess bone mineral density Fat and lean tissue compartments are also measured in the process Commonly used in research setting to quantify fat mass and fat-free mass

Side effects

Undesirable effects of a drug may affect nutritional status.

Weight Measurements

Use calibrated scale Weigh same time, same day, same type of clothing No shoes, outer jackets or wallets Crude evaluation of overall fat and muscle stores Reference standards based on statistical sample of US population Individual measurements compared to standard population, not an established standard Useful in determining nutrition status in adults A more sensitive measure of nutritional accuracy than height Tend to underestimate which = underestimated BMI Interpreted using: BMI, Usual, Actual

Circumference Measurements

Waist Circumference: Correlates with visceral fat stores; Higher levels of visceral adipose tissue are associated with health risks (DM, CVD, etc.) Minimum waist = measured between bottom of rib cage and umbilicus Mid-arm Circumference (MAC): Arm Muscle Area (AMA); Arm Fat Area (AFA) Head Circumference - in children up to 3 years of age Calf Circumference (proxy of muscle loss in older adults)

The National Dysphagia Diet (NDD)

a diet aimed to establish standard terminology and practice applications of dietary texture modification in dysphagia management 3 Levels - Level 1: Pureed (homogenous, very cohesive, pudding-like, requiring very little chewing ability) - Level 2: Mechanical Altered (cohesive, moist, semisolid foods, requiring some chewing) - Level 3: Advanced (soft foods that require more chewing ability)

methylmalonic acid test (MMA)

Vitamin B-12 status can be assessed by directly measuring B-12 in the blood or MMA - MMA is a functional biomarker that accumulates when vitamin B-12 is inadequate

Indirect Calorimetry

Weir Equation - converts CO2 production and O2 consumption to REE: RMR is measured at rest (but not sleeping); no activity; fasted state; thermoneutral environment (~23 degrees C for humans)

Low Residue Diet

a diet order that significantly decreases fecal volume and promotes bowel rest Prescribed for acute inflammatory states, partial obstructions, bowel preps, etc. Provides very little fiber Eliminates: • Fruit & vegetables that are fibrous as well as skin, seeds, hulls; • Whole grain products; • Legumes; • Meat & shellfish with tough connective tissue

Orthostatic hypotension

a drop in blood pressure upon standing • No set numbers, but defined by reported symptoms of light-headedness, dizziness, or syncope (fainting) when standing • May be indicative of dehydration

Self-assessment

a first step toward cultural competence, a health care provider examines his/her own cultural background, identifying areas of bias

Methotrexate (MTX)

a folic acid antagonist • Commonly prescribed to treat cancer and rheumatoid arthritis • Inhibits an enzyme (dihydrofolate reductase) that converts folate to its active form • A special form of folic acid (reduced form that requires no activation) is commonly given with methotrexate to prevent megaloblastic anemia.

Glycosylated Hemoglobin (HbA1c)

a measure of how much glucose adheres to hemoglobin of red blood cells. The higher a person's blood glucose, the higher his Hb A1C The average life span for red blood cells is ~120 days, so Hb A1C gives an estimate of long-term glycemic control Normal HbA1c for someone without diabetes = < 5.7% Monitors effectiveness of diabetes therapy over the past few months: HbA1c < 7% in diabetics is considered good glycemic control

nutrient intake analysis (NIA)

a nutrient intake record analysis or calorie count Used in various inpatient settings to identify nutritional inadequacies by monitoring intakes before deficiencies develop; collected through direct observation or an inventory of foods eaten based on observation of what remains on the individual's tray or plate after a meal Should be recorded for at least 72 hours to reflect daily variations in intake

Normal digestion

a process that occurs when food is broken down in the stomach and bowel, then absorbed in the bowel. The blood carries these absorbed products to all parts of the body.

complete protein

a protein food that provides all 9 of the essential amino acids

Hamwi Formula for estimating IBW

Women = 100 lb for 5 ft + 5 lb for every inch over 5 feet Under 5 ft: 100 lb - 2.5 lb per inch under 5 ft Men = 106 lb for 5 ft + 6 lb for every inch over 5 feet Under 5 ft: 106 lb - 3 lb per inch under 5 ft Frame Size Adjustment: Subtract 10% for small frame Add 10% for large frame Adjustment for amputation: Hand 0.7% Forearm and hand 2.3% Trunk without extremities 50% Entire arm 5.0% Foot 1.5% BKA 5.9% AKA 11.0-15.0% Entire leg 16.0%

1 ml fluid per calorie consumed

You determine that a pt's energy needs are 2200 kcal/day. 2200 kcal x 1 mL = 2200 mL of fluid per day

nasogastric or nasoenteral feeding tube

a tube placed through the nose into the stomach or small bowel

Lacto-vegetarian

a vegetarian who consumes dairy products

Regular Diet

aka: Standard; House; General; Full Diet Pt has no dietary restrictions Diet has no modifications or restrictions Nutritionally adequate

Vegan

abstains from animal products • Ensure adequate intake of calcium, iron, zinc, vitamin B-12, ​and vitamin D

ADIME

assessment, diagnosis, intervention, monitoring, and evaluation A = Assessment (Subjective & Objective) - Only pertinent assessment information • D = Diagnosis - Written as a PES statement • I = Interventions • M = Monitoring • E = Evaluation

SI Units (International System)

base unit is moles per liter

Amino Acids

building blocks of proteins Nonessential: produced endogenously (originate from within an organism, tissue, or cell.) Essential: Must be consumed in the diet Conditionally essential: Not essential in normal conditions, but the body may be incapable of producing adequate amounts during times of illness and stress

Medicare Part B

coverage of Medical Nutrition Therapy (MNT) services provided by a registered dietitian: - For beneficiaries with a diagnosis of diabetes or renal disease ONLY (at the present time; RDs are advocating to expand this coverage to other diagnoses.) - Referral must be made by a physician - Coverage includes an initial assessment and f/u visits - An additional, separate diabetes self-management training (DMST) benefit is available to Medicare beneficiaries with a diagnosis of diabetes. A Medicare provider number called a "National Provider Identifier" is required for healthcare providers who independently bill the Centers for Medicare and Medicaid Services (CMS)

Angular stomatitis

cracking and peeling at the corners of the mouth Characteristic of riboflavin deficiency

Leukopenia

decreased WBC • Compromised immune function, disrupted bone marrow function, malnutrition

dysgeusia

diminished or distorted taste

hyposmia

diminished smell

Dietary Record Completion

each respondent must be trained in the level of detail required to adequately describe the foods and amounts consumed, including the name of the food (brand name, if possible), preparation methods, recipes for food mixtures, and portion sizes. Can be recorded by someone other than the subject, such as parents reporting for their children. Disadvantages: Recording foods as they are being eaten can affect both the types of food chosen and the quantities consumed Subject to bias both in the selection of the sample and in the sample's completion of the number of days recorded Incomplete records increase significantly as more days of records are kept, and the validity of the collected information decreases in the later days of a 7-day recording period When respondents record only once per day, the record method becomes similar to the 24-hour dietary recall in terms of relying on memory rather than concurrent recording Data can be burdensome

Aspiration

entry of a foreign substance into the respiratory tract

Clubbed Nails

enlarged nails curved over fingertips Can be caused by: - CVD - Lung disease - Thyroid diseases - Inflammatory Bowel Diseases - Other infection

HIPAA Omnibus Rule

expanded patient rights to their own health information, strengthened rules surrounding privacy and confidentiality of PHI, and increased penalties for unauthorized sharing or loss of PHI

Residue

fecal content contributed by diet • fiber, undigested starches & sugars, minerals, connective tissue and gristle from meat • remaining fecal material = bacteria and sloughed GI cells

Sickle Cell Anemia

genetic disorder

glycosuria

glucose in urine

1 calorie

heat (energy) required to raise the temperature of one gram of water by 1 °C 1 kilocalorie (kcal) = 1000 calories

Blood Pressure

hydrostatic pressure exerted on the walls of arteries measurement (mm Hg): •Systolic: ventricular contraction (normal <120; elevated 120-129; hypertension stage 1 130-139; hypertension stage 2 140-179; hypertension crisis more than 180) •Diastolic: ventricular relaxation (normal <80; elevated <80 with 120-129 systole; hypertension stage 1 80-89; hypertension stage 2 90-119; hypertension crisis more than 120)

most common screening criteria

history of weight loss current need for nutrition support presence of skin breakdown poor dietary intake chronic use of modified or unusual diets

3 Main bloodborne viruses

human immunodeficiency virus (HIV) hepatitis B (HBV) hepatitis C (HCV) More than 90% of these infections occur in developing countries

Leukocytosis

increased WBC • Infection, trauma, stress, inflammation, leukemia

Bloodborne Pathogens

infectious microorganisms that are spread by exposure to blood or "other potentially infectious material."

Periodontal disease

inflammation of the gingiva with infection caused by oral bacteria and subsequent destruction of the tooth attachment apparatus

Gingivitis

inflammation of the gums (gingiva)

Glossitis

inflammation of tongue and lips • Sign of iron deficiency or deficiency of several B-vitamins (especially vitamin B-12)

Histories

information collected about individuals or populations as part of the nutrition status assessment. Usually in the form of health and medical, social, medication and herbal use, and dietary and nutritional

Pressure injuries

injuries to skin and underlying tissues that result from prolonged pressure "pressure ulcers" or "bed sores" or "decubitus ulcers" • Increased protein needs • Ensure adequate hydration (note fluid losses from exudate and/or circulating air beds) • Ensure adequate micronutrient intake (although no evidence base for supplementation of vitamins and minerals above the RDA for wound healing).

bulimia nervosa

inspection signs: bilateral parotid enlargement corroded teeth and palate

Energy Balance

intake = expenditure Negative energy balance: intake < expenditure Positive energy balance: intake > expenditure

Parenteral exposure

introduction of bloodborne pathogens through a break in the skin (e.g., needle stick)

Mucous membrane exposure

introduction of bloodborne pathogens through the eyes, nose, or mouth from a splash or spray of infected fluids. Assume all human blood and body fluids are potentially infectious​ and handle them with appropriate protective measures!

petechiae

latin for freckles pinpoint, round spots that appear on the skin as a result of bleeding (tiny purple, red, or brown spots, circular, non-raised patches) Could indicate vitamin C deficiency

Chronic renal failure

loss of erythropoietin (EPO) EPO is a hormone made by the kidneys that signals RBC synthesis in the bone marrow

Anosmia

loss of smell

anosmia

loss of smell

Edentulism

loss of teeth (full or partial)

Transferrin Saturation

measures the amount of transferrin that is bound to iron decreases with iron deficiency TS = (serum iron/TIBC) x 100% a sensitive test for hemochromatosis - Genetic disease that leads to too much iron absorption and storage - Disease is characterized by extremely high levels of iron in the body • Normal transferrin saturation = 20-40% • Hemochromatosis - 60-100% saturated • Treated with phlebotomy, chelation therapy, low-Fe diet

Dietary Records

multiple days are recorded, they are usually consecutive, and no more than 7 days are included. Because the foods and amounts consumed on consecutive days of reporting may be related (e.g., leftovers and eating more one day and less the next day), it may be advantageous to collect non-consecutive single-day records in order to increase representativeness of the individual's diet.

Transferrin

protein that transports iron in the blood increases with iron deficiency

healthcare changes

provision of care and reimbursement Governmental influences cost containment issues changing demographics the changing role of the patient as a "consumer"

Purpura

purplish discoloration of the skin Commonly due to anticoagulant meds, but could be indicative of insufficient vitamins C or K

Diet Liberalization

relaxing the original diet prescriptions meant to control disease states like diabetes or hypertension. The goal is to promote quality of life and enjoyment of foods not previously permitted • Use your best clinical judgment • Consider if: - Dietary restrictions will not significantly improve or prolong life - Restrictions decrease intake significantly (i.e. do more harm than good)

The Joint Commission (formerly known as JCAHO)

requires: - Monitoring - Preventing - Counseling for drug-nutrient interactions

Cheilitis

scaling of the lips and painful cracking in the corners of the mouth

Koilonychia

spoon shaped concave nails • Occurs normally in children and usually resolves with aging Other (nutrition) causes include the following: - Iron deficiency - Protein deficiency

Z scores

statistical measures that tell how a data point compares to normal data. Is it above average or below average?

SOAP

subjective, objective, assessment, plan SOAP notation • Prior to ADIME, the most common method of documenting nutrition care plans • A note divided into the following sections - S (Subjective) • Information reported by pt and/or family/caregivers • Information in this section cannot be definitely proven. • Can include: Pt's appetite; Reported weight changes; Current supplement consumption; N/V/D/C - O (Objective) • Measurable data obtained from the patient's chart - Information in this section is factual and can be confirmed by others - Can include: Medical info (PMH, current problems, etc.); Lab results; Anthropometrics; Dietary intake info; Medical orders (diet order); Meds - A (Assessment) • Educated, professional interpretation of the data provided in 'S' & 'O' sections (PES statement) • Calculations for nutritional needs (kcals, pro, fluid) • The place to express clinical judgment about what may be wrong with, or what may help, a px • For the RD, these comments pertain to the px's nutritional status • **Important: The indicators for any problems discussed in the Assessment section MUST appear in either sections 'S' or 'O' - P (Plan) • Course of actions to be taken to resolve ALL the problems discussed in 'A' • All problems planned for in 'P' must be mentioned in sections 'S', 'O', or 'A' • All plans must be PATIENT FOCUSED* for optimal effectiveness

Dysphagia

swallowing difficulty

Energy

the capacity to do work Provided by Food; measured by calorimetry

Subcutaneous Adipose Tissue (SAT)

the fat right underneath skin

What is nutrition care process?

the framework for the critical thinking process used by dietetics professionals as they provide nutrition services to their clients/patients • Patient or client is the central focus

Absorption

the rate and extent to which a drug moves from its site of administration to its intended target (site) of action Affected by: • Gastrointestinal pH: Achlorhydria is common among older adults; May be exacerbated by antacids, PPIs, or H2 blockers • Gastric emptying and motility (oral drugs) • Food: Some drugs should be taken with food in order to maximize it. Other meds should be taken in the absence of food for optimal

creatine vs creatinine

the supplement people take to get strength and body cell mass A breakdown product of creatine phosphate in muscle and is usually produced at a fairly constant rate by the body (depending on muscle mass). Creatinine and its clearance are the main measures of kidney function

gastrostomy or jejunostomy feeding tube

the tube is placed directly through the skin into the stomach or small bowel

Polypharmacy

the use of multiple drugs to manage various diseases.

Healthy Skin

tissue that is soft, moist turgor with instant recoil, smooth appearance

Affordable Care Act (ACA)

to ensure that Americans have access to quality, affordable health care

most common causes of needlestick injury

two-handed recapping the unsafe collection and disposal of sharps waste

Phase 2

up to several hundred patients time: several months to two years purpose: short-term safety but mainly effectiveness Designed to determine initial efficacy of an investigational therapy in a particular disease or selected group of patients; Continually monitors for adverse effects or potential toxicities

Body Mass Index

weight (kg)/height (m2) Correlates with body fatness as well as weight Indicative of over- or under-nutrition and is predictive of associated health risks Does not take into account differences in race, sex, age, and body composition Underweight <18.5 Increased Risk Healthy 18.5-24.9 Normal Risk Overweight 25-29.9 Increased Risk Grade I obesity 30-34.9 High Risk Grade II obesity 35-39.9 Very High Risk Grade III obesity 40.0+ Extremely high Risk

Diet Order/Clinical Diet

what goes in the order section of the medical record along with other treatments ordered like medications, etc. - differs by facility In a facility, gets sent to the kitchen, so they know what food to send on the patients' tray. Traditionally, could only be ordered by a physician or physician assistant, dietitians make recommendations, but the physician would actually write it In 2014, Medicare and Medicaid announced a rule change that allowed dietitians to write one independently without requiring permission or supervision from a physician

Enteral Nutrition

when a special liquid food formula containing protein, carbohydrates (sugar), fats, vitamins, and minerals, is given through a tube into the stomach or small bowel The delivery of nutrients directly into the stomach or small intestine by a feeding tube

Cytochrome P450 enzyme system

• A multi-enzyme complex present in the smooth endoplasmic reticulum of cells in the liver, kidneys, GI tract, blood-brain barrier, and other tissues • Many medications are metabolized by these enzymes

Different Documentation Styles

• ADIME (assessment, diagnosis, intervention, monitoring, and evaluation) • SOAP (subjective, objective, assessment, plan) • SOAPIER (subjective, objective, analysis/assessment, plan, intervention, evaluation, revisions) • DAP (diagnosis, assessment, plan) • PIE (problem, intervention, evaluation) • PES (problem, etiology, symptoms) • IER (intervention, evaluation, revision) • SAP (screen, assess, plan) • And MANY others.....

Progress Notes

• All health care team members who initiate and apply patient care should document the status of their caregiving actions and the patient's response • These notes describe the daily progress in the healthcare environment • In chronological order • Includes nutrition care record

Poor Intake

• Allow pt to select from a menu • Cater to pt's food preferences • Ensure psychological needs at mealtimes are met: room temp, clutter on bedside table, offensive odors, lighting in room • Ensure physical needs are met: - feeding or set-up assistance - bedside table/meal tray within easy reach - pt assisted to wash hands and sit up for meals - orthopedic utensils, if appropriate • Increase number and size of servings • Double servings of foods the patient will eat • Add foods that might not normally be on the tray - extra butter or olive oil for vegetables - sour cream or plain yogurt for potatoes - grated cheese to vegetables, soups, casseroles - Stir dried skim milk powder into milk beverages, soups, mashed potatoes, casseroles, hot cereals, etc. to increase protein and calories. • Concentrated sources of nutrients can also be added with commercial supplements such as - Beneprotein (protein) - Polycose (CHO) - Microlipid (fat) • Diet orders for "small frequent feedings" - set up for 4-6 meals/d, OR - serve patient 3 meals and 1-3 snacks • Caution: can be self-defeating if pt eats calorie dense snacks e.g. milkshakes, peanut-butter/crackers, etc. then is not hungry for next meal. • If ordering snacks for a pt, it is your responsibility to monitor the intake of the snack - stop it if not being eaten, or change it if reducing pt's meal intake.

GUIDELINES FOR CHARTING

• Always chart in black ink if not on a computer. • Always identify your entry with date, time of day, and service with which you are associated. • Do not obliterate information with liquid paper or scribbling (legally, this is "tampering with evidence"). • Write legibly. • Chart promptly - within 24 hrs of seeing patient. • Complete sentences are not necessary, but grammar and spelling should be correct. • Chart only clinically pertinent information • Use institutionally approved symbols & abbreviations. • Always sign the note with name and professional credentials (unless on a computer, which puts an "esignature" for you).

Privacy Safeguards

• Avoid conversations involving PHI in public common areas such as hallways, stairwells, or elevators. • Keep documents containing PHI in locked cabinets or locked rooms when not in use. • Do not leave materials containing PHI on desks, countertops, etc. • Do not remove any PHI in any form from the designated work area unless you are authorized to do so by your supervisor. • Never take photographs in patient care areas. • Arrange computer screens so they are not visible to unauthorized persons. • Log in with your own password, and log off before leaving the computer. • Do not share passwords. • No PHI is permitted on any social networking sites (Twitter, Facebook, etc.) • No PHI is permitted in text messages or chat platforms. Follow your organization's policy regarding email and fax transmission.

Vital Signs

• Blood pressure • Heart rate (pulse) • Respiratory rate • Temperature

Characteristics of dehydration

• Dark urine • Decreased skin turgor • Dry mouth, lips, and mucous membranes • Dry or sunken eyes • Weight loss • Lowered body temperature • High serum Na+ and BUN on labs

Age-related changes and medication adherence

• Decreased visual acuity, hearing loss, and/or cognitive impairment may hinder a patient's understanding of instructions. • Depression • Dysphagia "Drugs don't work in patients who don't take them."

Mifflin St. Jeor Equation

• Estimates resting energy expenditure (REE) • According the Academy of Nutrition and Dietetics' EAL, this equation is the most accurate for both normal weight and obese healthy individuals. Not the best choice for critically ill patients on mechanical ventilators Given on exam • Male: 9.99W + 6.25H - 5A + 5 • Female: 9.99W + 6.25H - 5A - 161 • W = weight in kg H = height in cm A = age in yr

Signs of Iron Deficiency

• Fatigue • Pallor/pale skin • Koilonychia (spoon nails) • Stomatitis (inflammation of the mouth and lips)

Regulation of Dietary Supplements

• Food and Drug Administration (FDA) approval is not necessary for products sold as dietary supplements. • In fact, in order for a dietary supplement to be removed from the market, the burden of proof falls on the FDA to provide sufficient evidence that the product is unsafe. Due to limited resources, the FDA typically only pursues dietary supplement recalls after adverse events are reported by consumers. • Also, the FDA doesn't regulate the amount of each ingredient in a product or the serving size recommended by the manufacturer

Signs and Symptoms (S/S) of Inadequate Nutrition

• General appearance • Fat/Muscles: Loss of subcutaneous fat and/or muscle wasting; Edema • Vital signs • Hair and Nails • Skin • Wounds • Eyes • Oral cavity

Personal Protective Equipment (PPE)

• Gloves: Should be worn any time you are in contact with blood, body fluids, or mucous membranes; Cover any cut or sore on your own hands with a bandage before putting on gloves; Inspect your gloves for tears or punctures; Remove gloves and wash hands immediately after patient contact. • Gowns • Face shields • Goggles

Nutrition Focused Physical Exam (NFPE)

• Head to toe assessment • Systems approach - Organized, logical • Moves from global to more defined - Based on results of medical and nutrition histories • Tailored to each patient

Droplet / Airborne Precautions

• In addition to standard precautions and contact precautions, a mask is worn upon entry into the patient's room. • In some cases (e.g., tuberculosis), an N95 respirator mask may be necessary

Physical Examination Techniques

• Inspection • Palpation • Percussion • Auscultation

Cardiac Diet

• Low fat (particularly saturated fat), low sodium • Used for patients with cardiovascular disease • May include egg substitutes and increased fruits, vegetables, and fiber • No fried foods • No added salt

Hepatitis C Virus (HCV)

• May lead to cirrhosis or end-stage liver disease • Can survive up to 7 days in dried blood • No vaccine is available.

Side effects of chemotherapy

• Nausea • Vomiting • Anorexia • Dysgeusia Additional side effects of radiation for head and neck CA • Mucositis and oral lesions • Xerostomia • Dysphagia MNT: • High kcal/protein supplements • Cold liquids through a straw or ice chips for pain • Room temperature food without strong odors • Remember food safety • Consider enteral nutrition support

Serum Creatinine Ranges

• Normal range: 0.6 - 1.6 mg/dL • Low creatinine (< 0.6) suggest muscle wasting due to calorie deficiency • High creatinine (>1.6) suggest renal insufficiency (or severe dehydration)

Low-Fat Diet

• Nutritionally complete • May be indicated for fat-malabsorption, GERD, weight loss, etc. • Fat restriction may be expressed in grams or % kcals (e.g., 10-15% kcals from fat)

The Medical Record

• Patient Record or Medical Chart • Legal document of care provided • Communication tool - "If it wasn't documented, it wasn't done." • Provides an evaluation tool for hospital accreditation, quality assurance programs, peer review, and cost-effectiveness of care protocols • IS CONFIDENTIAL PATIENT INFO!!!

Good Hand Hygiene

• Perform hand hygiene between physical contact with different patients. • Perform hand hygiene after any direct contact with patients. • Wash hands after using the bathroom, smoking, eating, or applying makeup. • Clean your hands by rubbing them with an alcohol-based hand sanitizer for routine hygienic hand antisepsis if hands are not visibly soiled.

Signs of Vitamin C Deficiency (Scurvy)

• Petechiae = small pinpoint hemorrhages in the skin - Also, large areas of bleeding or purpura • Fragile bleeding gums • Corkscrew hairs • Poor wound healing

Identifying patients who may benefit from supplementation

• Px with medical conditions or medications affecting how the body absorbs or uses nutrients (e.g., corticosteroids>>Ca++, food allergies, GI tract surgeries that prevent absorption, etc.) • Age-related changes in taste, smell, dentition, and gastrointestinal function -Can impair food intake and nutrient absorption, so for some older adults, supplementation may helpful to ensure adequate intake of nutrients that would otherwise come from food

Goals of the "Diet Order"

• Restore nutritional status • Rest or relieve affected organ • Accommodate altered GI function • Accommodate altered nutrient needs

First Steps to NFPE

• Review the medical record, labs, H&P, etc. • Introduce yourself and explain why you're here. • Ask the patient's permission before starting the assessment. • Identify "their" concerns.

Vitamin D Deficiency

• Rickets in children • Osteomalacia in adults (softening of the bones) • Many other subtler s/s (muscle weakness, HTN, etc.)

Normal Nails

• Smooth • Translucent • Slightly curved surface • Firmly attached to bed • Nail bed with brisk capillary refill

Physical Examination Equipment

• Stethoscope • Penlight/flashlight • Tongue depressor • Scales and stadiometers • Reflex hammer • Calipers • Tape measure • Blood pressure cuff

Other potentially infectious material

• The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids • Any unfixed tissue or organ (other than intact skin) from a human • HIV-containing or HBV-containing cell or tissue cultures

Human Immunodeficiency Virus (HIV)

• The virus that causes Acquired Immune Deficiency Syndrome (AIDS) • Survives seconds to minutes outside the body • No vaccine is available.

Renal Diet

• Used for patients with renal failure • Highly variable in hospital settings • Typically include: - Controlled amounts of fluid - Controlled amounts of protein - Limit potassium • Bananas, tomatoes, potatoes, salt substitute, chocolate, greens - Limit sodium - Limit phosphorus • Dairy products, dark sodas, dry beans and peas, whole grains, etc.

Hepatitis B Virus (HBV)

• Usually transmitted by blood-to-blood contact • May lead to cirrhosis or end-stage liver disease • Can survive up to 7 days in dried blood • Get a vaccination!

open-ended questions

• What foods do you commonly eat? • Are there any foods you avoid? • Do you regularly try new foods? Are there any new foods you have recently eaten for the first time? • What foods do you typically buy? • Where do you buy food? • Are you able to get the types of food you need? • How did you prepare this meal? • Who eats meals with you?

Department of Justice Criminal Penalties for HIPAA Violations

• Wrongfully accessing or disclosing PHI: fines up to $50,000 and up to 1 yr in prison • Obtaining PHI under false pretenses: fines up to $100,000 and up to 5 yrs in prison • Wrongfully using PHI for commercial activity: fines up to $250,000 and up to 10 yrs in prison • HIPAA criminal and civil fines can be enforced against individuals as well as covered facilities. • A HIPAA violation could be grounds for immediate dismissal from your internship!

Side effects of anticholinergic medications

• Xerostomia - may impair taste and swallowing; increases the risk for dental caries • Urinary retention • Confusion, dizziness • Constipation

Heart Rate

• bpm = beats per minute • Usually assessed by radial pulse • Count pulsations for 15 seconds and multiply by 4 - If irregular, count for a full 60 seconds Resting HR: • Normal = 60-100 bpm • Bradycardia: <60 bpm • Tachycardia: more than 100 bpm

Respiratory Rate

• bpm = breaths per minute • Count respirations while holding pulse so pt is unaware of monitoring Normal = 14-20 bpm

Ascites

•Fluid accumulates in the abdominal cavity •Can be caused by alcoholic cirrhosis or another liver disease •Weight not accurate!

Resting Energy Expenditure (REE) or Resting Metabolic Rate (RMR)

◦ Energy expended in activities needed to sustain normal body functions and homeostasis ◦ Breathing, blood circulation, CNS, maintenance of body temperature ◦ Estimate of BMR ◦ Used for practical purposes

Basal Energy Expenditure (BEE)

◦ Minimal amount of energy needed to sustain life (~60-70% of TEE) ◦ Constant on a daily basis ◦ Measured under very strict laboratory conditions for research purposes only ◦ BMR is rarely measured; instead, RMR (or REE) is measured as an estimate of BMR.

1 Reduced-Fat (2%) Milk

12 g CHO, 8 g Pro, 5 g Fat, 120 kcal

1 Whole Milk

12 g CHO, 8 g Pro, 8 g Ft, 160 kcal

Lactose Intolerance by Region

0-15% UK and Scandinavia: Finland, Sweden, Norway, Denmark 15-30% United Nations, North America, Russia, Germany, Australia, UK 30-60% Spain, Italy, Greece 60-80% Central America and North South America, North Africa and South Africa, Middle East, India, Turkey 80-100% South South America, Central Africa, China, Japan, Greenland, Iceland, Philipines

1 Fat

5 g Fat, 45 kcal

Cultural Competence

A set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations

75%

A slice of bread is 80 kcals and has 15 grams of carbohydrates. What percentage of kcals in the bread comes from carbohydrates? 15g x 4 kcal = 60 kcal/80 kcal x 100 = ?

Mini Nutritional Assessment (MNA) Long Form

A tool evaluates independence, medication therapy, pressure sores, number of full meals consumed per day, protein intake, consumption of fruits and vegetables, fluid intake, mode of feeding, self-view of nutritional status, comparison with peers, and mid-arm and calf circumferences

Components of nutrition assessment

Dietary history and nutrient intake Biochemical/physiologic studies Clinical signs and symptoms Vital statistics

BMI in Children and Teens

Age and sex-specific because the amount of body fat changes with age and the amount of body fat differs between girls and boys. The CDC growth charts take into account these differences and visually show BMI as a percentile ranking Obesity = at or above the 95 percentile

Obesity Health Risks

All-causes of death (mortality) High blood pressure (Hypertension) High LDL cholesterol, low HDL cholesterol, or high levels of triglycerides (Dyslipidemia) Type 2 diabetes Coronary heart disease Stroke Gallbladder disease Osteoarthritis (a breakdown of cartilage and bone within a joint) Sleep apnea and breathing problems Chronic inflammation and increased oxidative stress Some cancers (endometrial, breast, colon, kidney, gallbladder, and liver) Low quality of life Mental illness such as clinical depression, anxiety, and other mental disorders Body pain and difficulty with physical functioning

BMI: Body Mass Index

An inexpensive and easy-to-perform method of screening for weight categories underweight, normal or healthy weight, overweight, and obesity An indicator of high body fatness which can be used as a screening tool but is not diagnostic of the body fatness or health of an individual. Does not measure body fat directly, but does moderately correlate with more direct measures of body fat obtained from skinfold thickness measurements, bioelectrical impedance, densitometry (underwater weighing), dual-energy x-ray absorptiometry (DXA) and other methods Strongly correlated with various metabolic and disease outcome as are these more direct measures of body fatness

BMI Fatness Differences

At the same BMI, women tend to have more body fat than men. At the same BMI, Blacks have less body fat than do Whites, and Asians have more body fat than do Whites At the same BMI, older people, on average, tend to have more body fat than younger adults. At the same BMI, athletes have less body fat than do non-athletes.

Culture

Attitudes and behaviors that are characteristic of a group or community Includes: • language and communication • actions • customs • beliefs • values

60g

Based on the RDA for protein, how many grams of protein should your patient consume each day? He is a healthy 22-year-old male who weighs 165 pounds.

Basic carbohydrate counting

Basic facts about carbohydrates Primary food sources of carbohydrate Average portion sizes and the importance of consistency and accurate portions Amount of carbohydrates that should be eaten, Label reading

26.4, Overweight (25 to 29.9)

Calculate the BMI if a female is 5'0" and 135 lbs, how would you categorize her?

Fiber

For CHO counting purposes, if a serving of a food contains > 5 grams of dietary fiber, you can subtract ½ of the grams of dietary fiber from the total CHO serving of that food

Calculate CHO

For a patient who needs ~2000 kcal/day: 2000 kcals x 50% AMDR for CHO = 1000 kcals 1000 kcals ÷ 4 kcals/gram CHO = 250 grams CHO/day 250 g CHO ÷ 15 gm CHO/exchange = ~16-17 CHO exchanges/day

Nutrient Requirements

Growth, Stress, body maintenance and well-being, illness, disease

A thorough diet history is crucial!

Individualized with each client • 24-hour recall & food records • Daily routine • Food preferences/aversions • Self-efficacy and motivation

Analysis of Dietary Intake Data

Once all data has been collected, the record of total intake can be analyzed for its nutrient content using one of several available computerized methods USDA National Nutrient Database for Standard Reference (SR) (the major source of food composition data in the US, and, as of this writing, is at version 27) Food and Nutrient Database for Dietary Studies (FNDDS) (values, and weights for typical food portions) FDA Total Diet Study Database (280 Core Foods) Dietary Supplements Database Nutrient Data System for Research ProNutra

Serving size made simple

Palm = 3oz Fist = 1 Cup 1/2 Fist = 1/2 Cup Finger Tip = 1tsp Thumb Tip = 1 Tbsp

Meal Plan

Plan based on history/food record Encourage variety from all food groups • Typical starting point: 2-3 servings of non-starchy vegetables 2 servings of fruit 6 servings of grains, beans, and starchy vegetables 2 servings of low-fat or fat-free milk ~6 oz meat or meat substitutes • Adjusted accordingly for specific kcal needs

Nutrition Screening

Preliminary Phase of NCPM Usually provided/done by RN before RD is called; Quick identification of nutritional risk Tools: MUST and MNA

Nutritional Assessment Tools

SGA, MNA Long Form, History

The Nutrition Prescription

To develop, educate, and counsel individuals to determine a schedule and pattern of eating that will be the least disruptive to the lifestyle of the individual with diabetes and, at the same time, will facilitate improved metabolic control. The following information is needed: (1) time of waking (2) usual meal and eating times (3) work schedule or school hours (4) type, amount, and timing of exercise (5) usual sleep habits (6) type, dosage, and timing of diabetes medication (7) SMBG data

Optimal nutrition status

a balance between nutrient intake and nutrient requirements

Nutrition Risk Screening

a screening tool that is useful for medical-surgical hospitalized patients

Evidence Definition

been shown in research

food diary

daily food record that involves documenting dietary intake as it occurs and is often used in outpatient clinic settings Completed by the client Most accurate if the food and amounts eaten are recorded at the time of consumption, minimizing error from incomplete memory or attention 3-7 days, should include at least one weekend day Disadvantages: literacy skills required, ability to measure portion sizes, reliability questionable

ageusia

loss of the sense of taste

goal of nutritional screening

to identify individuals who are at nutritional risk, those likely to become at nutritional risk, and those who need further assessment

Food and nutrient intake Nutritional Risk Factors

• Calorie and protein intake greater or less than that required for age and activity level • Vitamin and mineral intake greater or less than that required for age • Swallowing difficulties • Gastrointestinal disturbances • Unusual food habits (e.g., pica) • Impaired cognitive function or depression • Nothing by mouth for more than 3 days • Inability or unwillingness to consume food • Increase or decrease in activities of daily living • Misuse of supplements • Inadequate transitional feeding, tube feeding or parenteral nutrition, or both • Bowel irregularity (e.g., constipation, diarrhea) • Restricted diet • Feeding limitations

Medications Nutritional Risk Factors

• Chronic use • Multiple and concurrent administration (polypharmacy) • Drug-nutrient interactions and side effects

Psychologic and social Nutritional Risk Factors

• Low literacy • Language barriers • Cultural or religious factors • Emotional disturbances associated with feeding difficulties (e.g., depression) • Limited resources for food preparation or obtaining food and supplies • Alcohol or drug addiction • Limited or low income • Lack of ability to communicate needs • Limited use or understanding of community resources

5 Categories of nutrition assessment

(Free Any Body w Nutrition Counseling) Food/Nutrition-Related History Anthropometric Measurements Biochemical Data, Medical Tests, and Procedures Nutrition-Focused Physical Findings Client History

RDA for protein

0.8 grams of protein per kilogram of body weight, or 0.36 grams per pound

The Plate Method

1/2 plate = non-starchy vegetables 1/4 plate = starch 1/4 plate = protein Cup size = Milk or Yogurt Cup size = Fruit Appropriate for: • Older adults • Patients overwhelmed with new DM diagnosis • Low-literacy levels • Cognitive difficulties • Patients who have difficulty with structure

Alcohol Exchange

100 kcals 12 oz light beer (4.2%) = 1 alcohol eq. + ½ CHO 12 oz regular beer (4.9%) = 1 alcohol eq. + 1 CHO 1 ½ oz distilled spirits (vodka, gin, rum) = 1 alcohol eq. 5 oz dry red/white wine = 1 alcohol eq.

1 Nonfat (Skim), Low-fat (1%) Milk

12 g CHO, 8 g Pro, 0-3g fat, 100 kcal

Fruit Exchange

15 g CHO, 60 kcal

1 High-Fat Meat

7 g protein, 8+ g Fat, 100 kcal

Hamwi Formula

A commonly used method of determining ideal body weight, does not adjust for age, race, or frame size and its validity is questionable, used by clinicians as a quick method for estimation of ideal weight Men: 106 lb for first 5 feet of height and 6 lb per inch over 5 feet; or 6 lb subtracted for each inch under 5 feet Women: 100 lb for first 5 feet of height and 5 lb per inch over 5 feet; or 5 lb subtracted for each inch under 5 feet

Malnutrition Universal Screening Tool (MUST)

A diagnostic tool for adults to assess malnutrition rapidly and completely; it is designed to be used by professionals of different disciplines Step 1: BMI Score Step 2: Weight loss Score Step 3: Nutritional intake in the last 5 days Score Step 4: Add Scores to determine risk Low Risk: 0 Routine Clinical Care Medium Risk: 1 Observe High Risk: 2 or more Treat

24-hour recall

A method of data collection that requires individuals to remember the specific foods and amounts of foods they consumed in the past 24 hours Problems commonly associated with this method of data collection include: (1) an inability to recall accurately the kinds and amounts of food eaten (2) difficulty in determining whether the day being recalled represents an individual's typical intake or was exceptional (3) the tendency for persons to exaggerate low intakes and underreport high intakes of foods. Disadvantages: relies on patient's memory, knowledge of portion sizes, may not be usual intake, requires interviewing skills Concurrent use of food frequency questionnaires with 24-hour recalls or food diaries (i.e., doing a cross-check) improves the accuracy of dietary intake data

Mini Nutritional Assessment (MNA) Short Form

A rapid and reliable screening method diagnostic tool for older adults to assess malnutrition

food frequency questionnaire FFQ

A retrospective review of intake based on frequency (i.e., food consumed per day, per week, or per month) Uses a chart organizes foods into groups that have common nutrients The focus of the food frequency questionnaire is the frequency of consumption of food groups without portion sizes, the information obtained is general, not specific, and cannot be applied to certain nutrients Disadvantages: requires literacy, does not provide meal pattern data

Meal Planning for Diabetes

Carbohydrates (starch, fruit, milk) are the major foods that affect blood glucose levels Consistent intake of CHO throughout the day is best Also important to eat a protein with each meal and snack

Intercultural Communication

Courtesy and respect are cross-cultural. Establish rapport. Be attentive to verbal and nonverbal cues • Let clients determine their personal space. • Observe how clients make eye contact. • Note how clients use silence. • Ask open-ended questions.

Free Foods

Foods that can be eaten freely, or added in moderation, above the meal pattern "Freely" (assumes normal portion sizes for foods with calories) Water calorie-free beverages butter flavoring (fat-free​) Spices pepper sauce lemon juice lime juice nonstick pan spray Vinegar Mustard Worcestershire or soy sauce bouillon or broth (fat-free) gelatin (sugar-free) gum (sugar-free) sugar substitutes (aspartame, saccharin or acesulfame-K) In moderation (each contain <20 kcals): BBQ sauce (1 - 2 T) cocktail sauce (1 - 2 T) dill pickles (1 1/2 large) jam or jelly (low-sugar or light; 1 - 2 T) ketchup (1 to 2 T), margarine, fat-free (4 T) mayonnaise, fat-free (1 T) Miracle Whip salad dressing, fat-free (1 T) nondairy creamer (2 T) pancake syrup, sugar-free (1 - 2T) pickle relish (1 T) salad dressing, fat-free (1 T) salsa (1/4 cup) sour cream, fat-free (1 T) soy sauce, regular or light (1 T) sweet and sour sauce (1 T) sweet pickles, bread-and-butter (2 slices) sweet pickles, gherkin (3/4 ounce) teriyaki sauce (1 T) cream cheese, fat-free (1 T) cocoa powder, unsweetened (1T) cranberries sweetened with sugar substitute (1/2 cup) hard candy, sugar-free (2 to 3 pieces)

Carbohydrate Counting

Increases patient's flexibility. • More patients on insulin count carbs than use other methods of meal planning. • Takes more time and attention to track the carbs throughout the day. • Assess your patient's ability and determination • Always look at the serving size 1 serving CHO = 15 grams •1 slice of bread or 6" tortilla •½ cup or hamburger bun •1 Tbsp sugar, honey, or jam •¼ large baked potato •¼ serving of a medium French fries •½ ice cream or sherbet •2" brownie or cake •½ cup starchy vegetables or beans •1/3 cup pasta or rice

Medical or Health History

Information from the patient's perspective: chief complaint, present and past illness, current health, allergies, past or recent surgeries, family history of disease, psychosocial data, and a review of problems—by body system In older patients, additional review is recommended to detect mental deterioration, constipation or incontinence, poor eyesight, hearing or taste sensation, slowed reactions, major organ diseases, effects of prescription and over-the-counter drugs, and physical disabilities

Nutritional Screening Tools

MST, MUST, NRS, MNA short form

How to Count Exchanges

Meal consumed: 2 slices toast, 1 tablespoon peanut butter, 8 oz fat-free milk = 2 Starch Exchanges, 1 High-Fat Meat Exchange, 1 Fat-Free Milk Exchange 3 oz chicken breast (no skin), 2/3 cup pasta, 1 cup cooked green beans = 2 Starch, 3 Lean Meat, 2 Vegetable 1 apple, 2 tablespoons peanut butter, 1/3 glass grape juice = 2 Fruit, 2 High-Fat Meat

The Nutrition Care Process Model (NCPM)

Nancy Cares Passionately about Meals AND Model where everything is patient-centered Outermost ring represents all the environmental factors that can affect the ability of a patient to benefit from our services (Economics, Social Systems, Practice Settings, Healthcare Systems) Middle ring is our resources; what we bring to the table (Knowledge, Code of Ethics, Skills & Competencies, Collaboration, Critical Thinking, Evidence-Based Practice, Documentation) Preliminary Steps: Screening and Referral System; interdisciplinary collaboration Step 1: Nutrition Assessment & Reassessment Step 2: Nutrition Diagnosis Step 3: Nutrition Intervention Step 4: Nutrition Monitoring & Evaluation Final Outcome: Management System

Malnutrition Screening Tool (MST)

Parameters include recent weight loss and recent poor dietary intake Useful for the acutely hospitalized adult population and was the only one of the 11 evaluated by the EAL shown to be valid and reliable for identifying problems in acute care and hospital-based ambulatory care settings

Social History

Socioeconomic status, the ability to purchase food independently, whether the person is living alone, physical or mental handicaps, smoking, drug or alcohol addiction, confusion caused by environmental changes, unsuitable housing conditions, environmental toxins, lack of socialization at meals, psychologic problems, or poverty may add to the risks for inadequate nutrition intake Knowledge of various cultures is also important in assessing diverse groups of clients. Cultural factors include religious beliefs, rituals, symbols, language, dietary practices, education, communication style, views on health, wellness, and illness, and racial identity

Nutrition assessment

Step One in The Nutrition Care Process Model (NCPM) A comprehensive evaluation carried out by an RDN using medical and health, social, dietary and nutritional, medication, and supplement and herbal use histories; physical examination; anthropometric measurements; and laboratory data Interprets data from the nutrition screen and incorporates additional information A systematic approach to collect, record, and interpret relevant data from patients, clients, family members, caregivers, and other individuals and groups. It is an ongoing, dynamic process that involves initial data collection and continued reassessment and analysis of nutritional status in comparison to specific criteria

Sweeteners

Sucrose in diet should be counted as a carbohydrate source (1 Tbsp = 15 g) • Non-nutritive sweeteners: have a negligible effect on blood glucose (e.g., saccharin, aspartame, neotame, acesulfame potassium, sucralose, stevia) • Sugar alcohols: • E.g, sorbitol, mannitol, xylitol • Partially absorbed • When counting CHO for products made with sugar alcohols, you can subtract half of the grams of sugar alcohol listed on the food label from the total grams of carbohydrate

Sweets, Desserts, and Other CHO

Sugar, 1 Tbsp: 1 CHO Cookies, 2 small or 1 large: 1 CHO, 1 fat Fruit pie, 2 crusts, 1/6 of 8-inch pie: 3 CHO, 2 fat Frosted cake, 2 x 2-inch square: 2 CHO, 1 fat

Exchange System

Sytem based on "Choose Your Foods: Exchange Lists for Diabetes" • Published by the Academy of Nutrition and Dietetics (and the American Diabetes Association • Foods grouped into basic types — starches, fruits, milk & milk products, meat & meat substitutes, fats, etc. • The patient is given a meal pattern based on calorie needs. The meal pattern specifies how many of each group can be eaten at a given meal or snack. • Patients can exchange or trade foods within a group because they're similar in nutrient content and the manner in which they affect blood glucose.

Nutrition status

The degree to which physiologic nutrient needs are met for an individual. Assessment is the foundation of nutritional care; it is the important base for personalizing an individual's nutritional care in the context of the cause, prevention, or management of disease or promotion of health. In promotion of health, regular assessment can detect a nutritional insufficiency in the early stages, allowing dietary intake and lifestyle to be improved through nutrition support and counseling before a more severe deficiency and functional change develops

BMI Ranges for Adults

Underweight Below 18.5 Normal or Healthy Weight 18.5 - 24.9 Overweight 25.0 - 29.9 Obese 30.0 and Above

125 lbs

Using the Hamwi Formula, calculate the ideal body weight (IBW) in pounds of a female, medium frame, with a height of 65 inches

Reliability and validity of dietary recall methods

When attention is directed toward the diet, people may consciously or unconsciously alter their intake either to simplify recording or impress the interviewer, thus decreasing the information's validity Questionable for obese individuals, patients with eating disorders, critically ill, those who abuse drugs or alcohol, individuals who are confused, and those whose intake is unpredictable

261.25g

You estimate your client's energy needs as ~1900kcals/day. How many grams of carbohydrate should she consume for a goal of 55% kcals from carbohydrate? 1900 x 0.55 = 1045 kcal/4 kcal = ?

diet history

the best means of obtaining dietary intake information and refers to a review of an individual's usual patterns of food intake and the food selection variables that dictate the food intake Assessed either by collecting retrospective intake data (e.g., a 24-hour recall or food frequency questionnaire) or by summarizing prospective intake data (e.g., a food record kept for a number of days by an individual or the caretaker) Any self-reported method of obtaining data can be challenging because it is difficult for people to remember what they ate, the content, and the amounts The choice of data collection depends on the purpose and setting The goal is to determine the food and nutrient intake that is typical for that individual

Evidence-Based Practice Definition

the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research

Nutrition Assessment Purpose

to obtain, verify, and interpret data needed to identify nutrition-related problems, their causes, and significance to gather adequate information in which to make a professional judgment about nutrition status

Judaism

• Adhere to Kashrut dietary laws, which may vary among different groups: • Orthodox Jews - strict law observance; will eat away from home only in kosher restaurants or homes with kosher kitchens • Conservative Jews - observe laws in their own homes, but accept deviations when away from home • Reform Jews - may or may not conform to any Jewish dietary laws • Reconstructionists - observance varies from very strict to none, based on individual conscience • Kosher = foods that are "fit and proper," according to laws originated in the Torah. Foods have 3 categories: • Neutral or pareve: may be eaten in natural state. Grains, fruits, vegetables, eggs, tea, coffee; foods free of meat, poultry or dairy. • Meat, Poultry, and cheese: require special processing to be kosher • Inherently non-kosher: pork, fish without scales & fins, shellfish • Kosher meat must come from an animal that chews its cud and has split hooves (e.g., cows, sheep, etc.) - all blood must be removed • Many dairy products are not kosher because meat derivatives are used during manufacturing (rennin in cheese, gelatin in frozen milk products) • Permissible poultry includes domesticated species of chickens, Cornish hens, ducks, geese, and turkeys. • Fish with scales & fins may be eaten without ritual slaughter - Frogs, eels, catfish, shark meat, shellfish, are prohibited. • Allowable fish and eggs may be eaten with any type of meal. • Orthodox Jews do not eat meat and milk in the same meal - These foods are prepared or served with the same dishes or utensils. - After meat has been eaten, some time must pass before milk can be ingested. - Milk may be consumed just before consuming meat. - For ease, meals may be "milk meals" (milchig) or "meat meals" (fleischig). • Kosher prepared products are identified with an emblem on the package: - U = Union of Orthodox Jewish Congregations of North America - K = Organized Kashrus Laboratories • Jewish Sabbath is sundown Friday to sundown Saturday. - during which time no food may be cooked - Sabbath dinner on Friday evening is usually the most substantial of the week, served with challah (bread). • Passover celebration has many traditions: • Prepared kosher foods must be labeled Kasher L'Pesach, certified by rabbinical authority. • Home is thoroughly cleaned and all leavened products are removed for Passover. • Matzo commonly eaten during this time - Flour and grains are not used due to natural leavening agents.

Mormonism

• Alcohol and caffeinated beverages are prohibited. • Moderation in all foods • Fasting is practiced.

Physical conditions Nutritional Risk Factors

• Extreme age: adults older than 80 years, premature infants, very young children • Pregnancy: adolescent, closely spaced, or three or more pregnancies • Alterations in anthropometric measurements: marked overweight or underweight for height, age, or both; head circumference less than normal; depressed somatic fat and muscle stores; amputation • Fat or muscle wasting • Obesity or overweight • Chronic renal or cardiac disease and related complications • Diabetes and related complications • Pressure ulcers or altered skin integrity • Cancer and related treatments • Acquired immune deficiency syndrome • Gastrointestinal complications (e.g., malabsorption, diarrhea, digestive or bowel changes) • Catabolic or hypermetabolic stress (e.g., trauma, sepsis, burns, stress) • Immobility • Osteoporosis, osteomalacia • Neurologic impairments, including impairment in sensory function • Visual impairments

Roman Catholic

• Law of fasting typically applies to Ash Wednesday and Good Friday. • On a fasting day, one full meal and two very small meals are allowed, plus liquids as desired. No eating between meals. • Law of Abstinence no longer obligated on Fridays, but applies to Ash Wednesday, Good Friday, and all other Fridays of Lent. • Abstinence involves avoiding meat and soup or gravy made with meat. • Laws of fasting and abstinence do not apply to the very young or old, or ill persons.

Hinduism

• Many Hindus are vegetarian. • Beef is strictly prohibited. • Other products from the cow such as milk, yogurt, etc. are permitted. • Alcohol may be avoided by some Hindus. • Various fasting days are observed.

Islam

• No alcoholic beverages • Coffee, tea, and other caffeinated beverages are discouraged. • No pork or pork by-products • Meats & fowl must be ritually slaughtered • Halal = foods that are permitted under Islamic dietary laws • Haram = prohibited foods Ritual fasts - longest is Ramadan - Ninth month of the Islamic year is devoted to prayer, fasting, and charity. - During this month, one meal is eaten before dawn, and one meal eaten after sunset. - No food or drink is consumed between sunrise and sunset.

Seventh Day Adventists

• Vegetarian diet is encouraged. • Do not use caffeine or alcohol.

Buddhism

• Vegetarian diets are encouraged (although many Buddhists may consume fish). • Moderation in all foods • Buddhist monks frequently fast and may avoid solid foods after a certain hour of the day.

Abnormal laboratory values Nutritional Risk Factors

• Visceral proteins (e.g., albumin, transferrin, prealbumin) • Lipid profile (cholesterol, high-density lipoproteins, low-density lipoproteins, triglycerides) • Hemoglobin, hematocrit, and other hematologic tests • Blood urea nitrogen, creatinine, and electrolyte levels • Fasting serum blood glucose level • Other laboratory indexes as indicated

CHO Foods

•Starchy foods like bread, cereal, rice, crackers •Fruit and fruit juices •Milk and yogurt •Dried beans •Starchy vegetables like potatoes and corn •Sweets and sugars