HPA Nutrition

mood
presence of illness
response to illness

-individual: health status, knowledge, age, role
-home and family: habits, activity patterns, income, food prep
-local community: access, competition, education norms
Media: ads: education, pop culture, body image

urban planning, health care, food, family policies, cultural and economic politics, education, transportation

public safety
urban planning
availability/access
media and marketing
income

employment
travel
leisure
sports
food
body image

History
Physical Assessment
Laboratory Data

special diets
likes, dislikes
junk food
changes in diet
specific information on intake

24 hour recall
Food diary - up to 3 days with 2 sequential weekdays and a weekend day

-cal/g: 4
-% of daily caloric intake: 45-65
-function: major source of energy - help form ATP which is needed to transfer energy within the cells. Also supply fibre and assist in utilization of fat
-primary sources: bread, potatoes, pasta, corn, rice, dried beans, fruits
-result of dietary deficiency: electrolyte imbalance, fatigue, depression
-result of excess: obesity, tooth decay, adverse effects on diabetes mellitus
-benefits of high fibre diets - disease prevention - decreasing weight and reducing risks of colon and rectal cancer, heart disease, dental caries, constipation, diverticulosis

-cal/g: 4, but foods are usually a combo of fat and protein or protein and carbs
-% of daily caloric intake:10-35%. Breastfeeding women, athletes, people recovering from illness may need up to 2g/kg/day and most people with moderate to severe stress need 1.5-2g/kg/day and in nutritionally deficient patients or recovering from illness requirements can exceed 150g/day
-function - supply the essential 9 amino acids which form the basis of all cell structures in the body, manufacture and repair body tissue, help maintain osmotic pressure in the cells
-primary sources: meat, poultry, fish, eggs, tofu, cheese, milk, legumes when eaten with corn or wheat

complete proteins

incomplete proteins

-cal/g: 9
-% of daily caloric intake: 20-35%, 45-75g/day for women and 60-105 for men
-function: supply the essentail fatty acids that form a part of the structure of all cells and help to lower cerum cholesterol
-primary sources: animal fat (butter, shortening, lard) and vegetable fat (vegetable oil, margarine, nuts)

diet

from animal sources and vegetable sources (coconut palm, partially hydrogenated oils)

raise cholesterol

help reduce LDLs but do not reduce HDLs
olive and canola oils, avacado, nuts

lipid contained only in animal products, found in muscles, RBCs, cell membranes, transported in the blood by HDLs and LDLs
HDLs carry cholesterol toward the liver and LDLs toward the cells and deposit it in the tissue

HDL - protects against CAD
LDL - correlation between high amounts and CAD

account for most of the lipids stored in the body's tissues and in the bloodstream they produce enough energy for the body

hyperlipidemia
CAD

decrease in weight
lack of satiety
skin and hair changes

obesity which is linked to CAD
some cancers - colon, breast, prostate

raise LDL and reduce HDL, increase risk of cardiovascular disease

when an unsaturated fat is hydrogenated to convert a liquid vegetable oil into a solid

partially hydrogenated margarine, commercially baked goods, deep-fried fast foods, dairy products, beef, lamb

heart disease
mandatory labeling of trans fats of food labels

organic substances needed to maintain the function of the body and must be obtained from dietary sources

ADEK
stored in dietary fat and absorbed in the fat portions of the body's cells

C, thiamine (B1), riboflavin (B2), niacin, pyridoxine (B6), Folacin (folate), cobalamin (B12), pantothenic acid, biotin

excreted from body in urine

inorganic elements that help build body tissue and regulate body processes such as fluid and acid balance, nerve cell transmission, vitamin absorption, enzyme and hormonal activity, muscle contractions

Macrominerals - >100mg/day
Microminerals <15mg/day

iron
iron-deficiency anemia
infants, adolescents, pregnant or menstruating women

50-60%

6-8 240mL glasses

size of person
climate
amount of activity

infants
very ill individuals
those who engage in intense physical activity

urinary incontinence
thirst is not as sensitive - risk of dehydration

-have vegetables and fruit more often than juice
-eat at least one dark green and one orange vegetable every day
-have at least half of daily grain products intake from whole grain
-have meat alternatives such as beans, lentils, and tofu often
-eat at least 2 food servings of fish every week
-satisfy thirst with water
-drink skim, 1%, or 2% milk each day or drink fortified soy beverages if you do not drink milk
-reduce the total amount of fat in the diet especially saturated and trans
- lower salt and sugar intake

achieve and maintain a healthy body weight by enjoying regular physical activity
-adults should get 30-60 mins of moderate physical activity every day and children should get 90 mins

pregnancy - 0.4mg folic acid/day to avoid neural tube defects

over 50 - daily vitamin D supplement of 400 IU (10ug)/day

Vegetables and Fruit
Grain Products
Milk and Alternatives
Meat and Alternatives

fatigue
palpitations
pruritus
headaches
vision changes
changes in appetite, nausea, bowel habits
mood changes

weight changes
dry, rough, scaly skin
edema
dry, cracked lips
swollen, bleeding gums
decreased muscle tone
spoon shaped nails

findings: dry, brittle
deficiency: protein

findings: moon face, pallor
deficiency: protein, iron

-findings: night blindness
-potential deficiency: vitamin A

-findings: arrythmias
-potential deficiency: K+, Mg

-findings: smooth beefy red
-potential deficiency: Niacin,B6, riboflavin

-findings: spoon shaped
-potential deficiency: iron

-findings: pigeon chest
-potential deficiency: vitamin D

-findings: increased parotid
-potential deficiency: protein or bulimia

-findings: poor healing
-potential deficiency: protein, calcium, vitamin C, zinc

-findings: hyporeflexia, confabulation
-potential deficiency: thiamine

height and weight
ideal body weight, percent IBW
percent weight change
BMI
body shape
waist to hip ratio

superior iliac crest (widest part)
normal:
men - <1.0
women - <0.8

Healthy eating - by 2015 20% increase in proportion of Canadians who make healthy food choices according to the Canadian Community Health Survey and Statistics Canada/CIHI health indicators
Physical activity - by 2015 20% increase in proportion of Canadians who participate in regular physical activity based on 30 mins/day of moderate to vigorous activity
Healthy weights - by 2015 20% increase in proportion of Canadians at a normal body weight based on BMI of 18.5-24.9

Official Food Rules
1942

Vegetables and fruit
grain products
milk and alternative
meat and alternatives

1 medium size fruit/vegetable
1/2 cup fresh fruit or vegetable juice

broccoli
collards
green peas
spinach

squash
carrots
sweet potatoes
apricots
cantaloupe
mango
**oranges are not a good source of carotenoids**

contain more dietary fibre

calcium
vitamin D

2-8: 2
9-18: 3-4
19-50: 2
51+: 3

2-3: 4
4-8: 5
9-13: 6
14-18: 7 (F) 8 (M)
19-50: 7-8(F) 8-10 (M)
51+: 7

2-3: 3
4-8: 4
9-13: 6
14-18: 6 (F) 7 (M)
19-50: 6-7 (F) 8 (M)
51+: 6 (F) 7(M)

2-3: 1
4-8: 1
9-13: 1-2
14-18: 2 (F) 3 (M)
19-50: 2 (F) 3 (M)
51+: 2 (F) 3 (M)

1 cup milk
3/4 cup yogurt
50g cheese

choose low fat

trim off meat
bake, broil, roast, microwave instead of fry
drain liquid fat when cooking

salmon, mackerel, rainbow trout, sardines
high in omega-3 fats, eicosapentaenoic acid, docosahexaenoic acid

fresh tuna
shark
swordfish

over exposure to mercury

75g cooked fish, chicken, beef, pork
2 eggs
60mL nuts
30mL peanut butter

<7 drinks/week

>4 drinks in one sitting

1 bottle beer
150mL wine
50mL hard liquor

450mg
(an average mug of coffee contains ~200mg)

Enjoy eating well, being active and feeling good about yourself. That's vitality.

Adequate intake - the intake value specific for each sex and various age groups that is estimated to provide adequate nutrition
Tolerable Upper Intake Level - the maximum level of daily nutrients that is unlikely to pose health risks for most of the general population
Recommended Dietary Allowances - the recommended amounts of nutrients that individuals should eat daily based on sex, age, and whether patient is pregnant or lactating

the substances found in food that are nourishing and useful to the body

carbohydrates
proteins
fats
vitamins
minerals
water

US focuses on specific # calories, CFG on portions and portion sizes

sedentary
-males 16
-females 14
moderate
-males 21
-females 18
Heavy
-males 26
-females 22

eat fresh foods instead of processed
eat whole-grain flour and breads
increase fibre intake slowly to prevent constipation
increase water intake with fibre
obtain fibre from diet rather than supplements

toxic amount of vitamins in body, occurs with both water-soluble and fat-soluble
-especially with A,K,C,B6

4%

vegetarians have lower blood cholesterol levels and blood pressure, reduced occurrence of type 2 diabetes and some cancers, lower BMI

psychosocial
developmental
physical/physiological

breast milk or infant formula only, daily vitamin D supplement until 12 months

-add iron-fortified cereals (usually don't add wheat cereals until after 6 months)
-use iron-fortified formulas until 9-12 months and then pasteurized whole cow's milk can be introduced until 2 years
-important to help infant adjust to spoon feeding
-only offer new food every 3-4 days and observe for allergic rxn, don't use mixed foods with other ingredients added

fruits and vegetables
can introduce noncitrus fruit juices but limit to 120 mL/day, use a cup not bottle
-do not add sugar or seasoning to food
-introduce egg yolks and gradually meats

-finger foods
-bite-sized pieces that are cooked, mashed, soft to provide independence and provide texture that requires chewing
-gradually increase texture as chewing skills improve and teeth emerge

hunger reflexes: sucking, rooting, swallowing

egg whites (12 months)
peanuts, nuts, fish (3 years - due to allergic potential)
thoroughly cook eggs to avoid salmonella
honey (12 months - botulism toxicity possible)

Increased control over their bodies and increased independence - patterns such as refusing to eat or desiring only certain foods, may say no to foods they desire in order to demonstrate they are in charge

offer small portions that toddler can self feed
introduce one new food at a time
encourage routine mealtimes with the family together to encourage developing good eating habits

don't give a bottle to a child who is about to fall asleep
don't dip pacifiers and bottle nipples in sweet solutions

have food dislikes, may become picky eaters
often have smaller appetites than toddlers - can be caused by drinking too many beverages and a slower increase in growth
often resist new foods and may only eat one food at a time

offer food choices
offer small servings
finger foods
routine meal times
discuss need for healthy snacks
help them prepare food, set the table, make some decisions

-erratic growth patterns that are reflected in their equally erratic eating patterns
-strong likes and dislikes

maintain a balanced diet and limit foods high in sugar
teach children proper nutrition and ingredient labels
inform family the pubescent chubbiness is a normal part of growth that often precedes a rapid increase in height

-rapid growth and change in nutritional needs fluctuate accordingly
-concerned with body image, often compare their bodies to their peers, can lead to eating disorders
physical activity can influence eating - eg. in hockey and football players are encouraged to be large, in gymnastics decreased weight is desirable

liver cancer
short stature
behavioural changes
endocrine problems
hypertension

growth and caloric needs stabilize
eating habits may be influenced by activity level, life stressors
obesity often seen in this age group

obese - 23.1
overweight - 36.1

when calories consumed are greater than calories expended or when there is a decrease in activity level, or both

increased risk of hyperlipidemia, CAD, hypertension, diabetes mellitus, obstructive sleep apnea, gallbladder disease, certain cancers, impaired fertility
challenges activities of daily living

yo-yo dieting or weight cycling
-diet for a period of time, achieve their goal weights, cease dieting and return to normal habits and regain the weight and add a few more kg

don't address behaviour modification for eating
don't include exercise regimen

abdominal obesity
elevated BP
elevated fasting blood glucose
elevated triglycerides
low HDL

for HTN
-reduced dietary sodium - helps patients eat a nutritionally sound diet while lowering the effects of their diet on their blood pressure
-low in total fat, cholesterol, saturated fats, red meats, sweets, sugar-containing beverages
-rich in fruit, vegetables, low-fat dietary products
-not appropriate for patients with advanced renal disease because it contains too much potassium and protein

-refusal to maintain body weight at or above a minimally normal weight for height and age (<85% of what is expected)
-intense fear of gaining weight or becoming fat (even though underweight)
- disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation or denial of the seriousness of the current low body weight
-in postmenarcheal females, amenorrhea

restricting type - during the current episode, the person has not regularly engaged in binge-eating of purging behaviour
binge-eating/purging type - during the current episode, the person has regularly engaged in binge-eating or purging behaviour

-recurrent episodes of binge eating which is characterized by:
a) eating, in a discrete period of time, an amount of food that is definitely larger than most people would eat during a similar period of time under similar circumstances
b) a sense of lack of control over eating during the episode
-recurrent compensatory inappropriate behaviour in order to prevent weight gain such as self-induced vomiting, misuse of laxatives, diuretics, enemas, other medications, fasting, excessive exercise
-the binge eating and the inappropriate compensatory behaviours occur on average at least twice a week for 3 months
-self-evaluation is unduly influenced by body shape and weight
-the disturbance does not occur exclusively during episodes of anorexia nervosa

Purging - during the current episode, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, enemas
Non-purging - during the current episode, the person has used other inappropriate compensatory behaviours such as fasting or excessive exercise, but not in the purging behaviours

-criteria for anorexia met except individual has regular menses
-criteria for anorexia met except despite significant weight loss, the person's current weight is in the normal range
-all criteria for bulimia met except binge eating and inappropriate compensatory mechanisms occur less frequently
-regular use of inappropriate compensatory behaviour by an individual of normal body weight after eating small amounts of food
-repeatedly chewing and spitting out, but not swallowing large amounts of food
-binge-eating disorder: recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviours characteristic of bulimia nervosa

-need to gain adequate weight or baby has increased risk of being small for gestational age and be prone to developmental delay, neonatal mortality, other illnesses
-if weight gain is excessive mother is at risk for gestational diabetes, HTN, prolonged labour, birth trauma, C-section
-need iron supplements and prenatal vitamins
0need to take folic acid to prevent neural tube defects

BMI <20 - 12.5-18kg
BMI 21-27 - 11.5-16kg
BMI >27 - 7-11.5kg

heartburn
constipation
nausea
vomiting

1st trimester - 100 calories/day
2nd and 3rd trimesters - 300 calories
increased intake in milk consumption
6-8 glasses of fluid daily

cravings for substances other than food - dirt, clay, ice cubes, starch

caffeine - no more than 300mg/day including coffee, tea, cola, chocolate
artificial sweeteners - safe to consume, but do in moderation and should not replace more nutrient-rich food
herbal teas - not a lot of info - consult physician

decreased caloric requirements
few social contacts at meal times
increased nutritional risk factors
-difficulty chewing or swallowing
-decreased appetite
-decreased taste and smell
-decreased ability to self-feed
-constipation

encourage to eat in a sitting position
encourage adequate fluid intake and high-fibre diet
if possible/appropriate, encourage communal eating

income - limits food choices
transportation - limits access to food
social support - may not "feel" like eating

certain foods may have special meanings and memories for patients
food may be traditional among people of the same cultural backgrounds
religious considerations, food preferences, and religious beliefs that restrict consumption of specific foods should be considered

bulimia nervosa and anorexia nervosa - adolescent

90% anorexia nervosa patients are female

anorexia
dysphagia
weight gain
weight loss

obesity
malnutrition
malabsorption diseases
anorexia nervosa
bulimia nervosa
dysphagia
weight cycling

diabetes mellitus
CAD
inc. cholesterol level
burns
CA
HTN
Cancer
diverticulosis
muscular dystrophy
MS
parkinson's
crohn's disease
ulcerative colitis
gout
pancreatitis
cholelithiasis
dental disease

gastric reduction
jaw wiring to reduce food intake in morbid obesity
surgical procedures that alter food intake from postsurgical complications, nausea, or normal recovery

review all for side effects that may affect appetite or growth
vitamins
supplements

children with AIDS: failure to thrive
adults with AIDS: wasting syndrome

gastrointestinal disturbances from medications, food, environmental allergies
infants may manifest allergies as dietary disturbances

affect eating or ability to self feed

affect ability to cut, handle, chew, or swallow food

food allergies and intolerances, eating disorders, obesity, medical conditions that may contribute to nutritional problems

1) nutritional history
2) Physical assessment
3) anthropometric measurements
4) laboratory data
5) diagnostic data

height
weight
BMI
Waist to hip ratio
waist circumference
Skinfold thickness
Mid-Arm and Mid-Arm muscle circumferences

adults - changes in nutritional status
children - growth patterns

-children over 3
-patient stands erect with back and heels against the wall or measuring device
-place headboard at a right angle to the wall and along the crown of the patient's head
-record height to nearest mm
-compare to standardized charts and patient's last visit

1) have patient stand on scale facing weights
2) balance weights, record to nearest 100g
3) calculate percentage of ideal body weight
4) calculate percentage of usual body weight
5) calculate percentage of weight change

current weight/IBW x 100

IBW is:
males - 50kg + 2.3kg for every inch over 5 feet
females - 45.5kg + 2.3kg for ever inch over 5 feet

(usual weight-current weight)/usual weight x 100

90-109

mild - 20-40% above the IBW
moderate - 40-100% above IBW
morbid - >100% above IBW

80-90% - mild
70-80% - moderate
<70% - severe

extreme malnutrition and wasting

weight (in kg)/m^2

(weight x 703)/(height in inches x height in inches)

18.5-24.9

overweight - 25-29.9
obese - 30-34.9
morbidly obese 35-39.9
extremely obese >40

normal range is extended and may begin at levels higher than 18.5 to include BMIs that fall in the overweight classification

gynoid = pear
android = apple

women deposit more fat in hips and butt and are more pear shaped, men deposit more around abdominal midline giving them apple shape

subcutaneous
fat around visceral organs

type 2 diabetes mellitus
CAD
HTN

when BMI >35

body fat distribution

-stand beside patient (their feet should be 25-30cm apart)
-measure waist in cm at the part of the trunk located midway between the lower costal margin and the iliac, measure to nearest 0.5cm at the end of expiration
-measure hips at widest point
-divide the waist measurement by the hip measurement

WC
-men: 80-99cm
-women: 70-88cm

ratio
-men: <1.0
-women: <0.8

-determine body fat stores and nutritional status
-most commonly measured at triceps skin fold

-take measurements on non-dominant arm while patient is in a relaxed position
-make a mark on the posterior portion of the upper arm midway between acromion and olecranon processes
-use your non-dominant hand and grasp the skin and pull it away from the muscle
-apply caliper and alight the markers
-note measurement to the nearest 0.5mm, repeat 2-3 times
-average findings to determine TSF

normal measurements fall between the 5th and 95th percentiles

skeletal muscle mass

flex arm at elbow
measure circumference of upper arm midway between acromion and olecranon process
-calculate MAMC:
MAC-(3.14-TSF(cm))

5th-95th percentiles

protein malnutrition - can occur even if protein is consuming an adequate number of calories
-patient may develop abdominal edema
-can lead to decreased immune function
-TSF and MAC may be in normal limits
-may also have scaly, flaky skin, depigmentation of the hair, enlarged liver, mental apathy
-can occur with ingestion of liquid diets that are low in protein, malabsorption diseases, hypermetabolic states, cancer, AIDS

protein-calorie malnutrition
-results in wasting of skeletal muscle and subcutaneous fat
-can also occur from poor absorption of proteins
-symptoms are similar to kwashiorkor except they appear more emaciated and do not have edema
-can also have marasmus and kwashioekor combo

hematocrit
hematoglobin
lipids
glucose
total lymphocyte count
antigen skin testing
transferrin, TIBC, iron
creatinine height index
nitrogen balance
albumin and prealbumin

hematocrit - proportion of RBCs to volume of whole blood

hemoglobin - iron component of the blood that transports oxygen

men over 40, women who are post-menopausal or over 50

those who are at significant risk for CAD, diabetes mellitus, HTN, history of smoking, abdominal obesity, strong family history of premature CVD should be screened earlier

LDL
HDL
Total cholesterol
Total cholesterol HDL-C ratio
triglycerides

transferrin - protein that regulates iron absorption
Total iron binding capacity - how transferrin can be measured - the amount of iron that it can bind
serum iron - amount of transferrin-bound iron

transferrin
male - 2.2-3.6g/L
female - 2.5-3.8g/L
Total iron binding capacity
45-63umol/L
serum iron
male - 13.2-31.3 umol/L
female - 11.6-29.6 umol/L

complete blood count with differential and measures immune function and visceral protein status
-when WBC is high or low it is not always a good indicator of nutritional status
normal: 1.5-1.8 x 10^9

tests immune function
-can use PPD, mumps, candida albicans, streptokinase, streptrococcus, coccidioidin, trichophyton
-results read 24 and 48 hours later
-normal: negative skin rxn

transport protein for thyroxine and retinol-binding protein
-has a short half life so is good to monitor the effects of recent nutritional support and changes in nutritional status

formed in the liver
transports nutrients, blood, and hormones and helps to maintain osmotic pressure
-must have functioning liver cells and an adequate amount of AA to be synthesized
-indicator of visceral protein status
-long half life

over 40 yrs should be screened for type 2 diabetes every 3 years, and if risk factors are present start screening earlier and more frequently

fasting plasma glucose - 4.0-6.0 mmol/L
oral glucose tolerance test

normally excreted in urine
dependent on the amount of skeletal muscle mass and measures the amount of protein reserves
tested after collecting 24 hour urine sample

actual 24 hour creatinine excretion/ideal 24 hour creatinine excreation x 100

creatinine - 0.13-1.22mmol/kg/day
CHI - >90%

grams of protein eaten in 24 hours/6.25 - (UUN+4)

UUN= urine urea nitrogen

0 balance

xrays
dual energy xray absorptiometry scan (bone scan) (DEXA)