exam 1

Question 1

what are the four steps of the nutrition care process (NCP)?

Answer 1

Nutrition Assessment, Nutrition Diagnosis, Nutrition Intervention, and Nutrition Monitoring and Evaluation (AKA ADIME Note)

Question 2

what is the Nutrition Care model? what does each ring of the framework represent?

Answer 2

the center is the patient: care is individualized to each patient; followed by the steps of the NCP, and the outer rings are the professional abilities of the dietitian, followed by environmental factors that impact the outcome of the patient.

Question 3

why is nutrition screening not included in the nutrition care model?

Answer 3

patients that aren’t at nutritional risk typically don’t need to be seen by a dietitian, and nutrition screening is usually done by a nurse practitioner

Question 4

what are the four key components of step one of the NCP (Nutrition Assessment)?

Answer 4

1. obtain and verify appropriate data
2. cluster and organize assessment data according to assessment domains and possible nutrition diagnoses
3. evaluate the data using reliable comparative standards
4. calculate estimated nutrient needs (nutrition prescription as needed)

Question 5

in step 1 of the NCP (Assessment): what are the components of assessment data we use to evaluate possible nutrition diagnosis?

Answer 5

• food/nutrition related history (what/how does the patient typically eat)
• anthropometric measurements (BMI, hgt, wgt,etc)
• biochemical data, medical tests, procedures (lab tests etc)
• nutrition- focused physical findings (routine physical exam, looking for fat/muscle loss)
• client history (medical, social history related to the patient)

Question 6

what are the 3 components of step 2 of the NCP (Nutrition Diagnosis)?

Answer 6

1. identify possible diagnostic labels
2. complete nutritiion diagnosis statements using PES format
3. evaluate the quality of the PES statement

Question 7

what is the point of step 2 of the NCP?

Answer 7

it is the direct link between assessment and intervention; it is not a medical diagnosis- it should focus on intake, clinical, and lastly behavioral/environmental etiologies

Question 8

what is a PES statement? how do you write one?

Answer 8

problem(diagnostic label), etiology(factors related to the root cause of the problem), signs and symptoms (defining characteristics used to identify the problem);
“[P] related to [E] as evidenced by [S&S]

Question 9

How do you evaluate a PES statement to ensure quality patient care?

Answer 9

problem: can a dietitian impact it?
Etiology: is it the root cause, and can it be addressed through an intervention?
Signs and Symptoms: can they be measured? are they sensitive to the intervention?

Question 10

what are the components of step 3 of the NCP (Intervention)?

Answer 10

prioritize the nutrition diagnoses, get nutrition prescription, set goals for patient, plan the intervention, and execute it.

Question 11

what are the components of step 4 of the NCP? (Monitoring and Evaluation)

Answer 11

monitor progress, measure outcomes, evaluate outcomes; do so on a planned schedule; Documentation is extremely important in this step

Question 12

what is nutritional status, and what is it used for?

Answer 12

it reflects nutrient stores, and is used to determine nutritional risk; we need to understand the pathophysiology, treatment, and clinical course of disease (ex: monitor iron levels during pregnancy bc of increased nutritional risk)

Question 13

what are Moderate Acuity Diagnoses in nutrition screening?

Answer 13

if patients have any of these diagnoses listed, they must be assessed w/in 5 days of admission:
- altered absorption associated with increased nutrient needs
- surgical procedures/chemoradiation that alters GI tract function or nutrient absorption
- organ failure
- increased nutrient needs (i.e burn unit/trauma patients)

Question 14

data collected in a nutrient assessment can be subjective or objective, meaning it can be…

Answer 14

our interpretation of patient interviews, or info from verifiable source such as medical record

Question 15

what are the four major ways to assess a patient’s nutrient intake (as part of nutrition assessment)?

Answer 15

24hr recall (not usually accurate esp. in trauma cases, portion control), food record/diary(typically 3-5 days, time consuming), food frequency questionnaire(for research purposes), and observation/calorie count (food weighed before/after intake)

Question 16

what 5 things are used to evaluate and interpret nutrition care

Answer 16

• US dietary guidelines
• USDA food patterns/myplate
• Diabetic exchange/carb counting
• individual nutrient analysis (computerized data analysis)
• daily values/DRIs

Question 17

how do you evaluate the height and weight of infants and children?

Answer 17

growth charts; compare with reference population
- weight for age, height for age
- % weight for height
- WHO growth chart = > age 2
- CDC growth chart= < age 2
BMI:
- overweight 85th-95th %tile of BMI For age
- obesity > 95% of BMI for age
- underweight < 5th of percentile of BMI for age
- z scores: z score of 0= percentile of 50%

Question 18

what are the 5 ways to evaluate and interpret the anthropometrics of adults?

Answer 18

1. usual body weight (current weight/UBW)x 100)
2. % weight change= ((current weight-UBW)/UBW) x 100
3. IBW (M= 106 lb for the first 5 ft + 6 lb for each additional inch. M = 48 kg for the first 152.4 cm + 1.1 kg for each additional cm. F = 100 lb for the first 5 ft + 5 lb for each additional inch.) (or BMI of 25)
4. BMI (kg/m^2 or lb/in^2 * 703)
5. waist circumference

Question 19

what are ways we can measure body composition (fat mass vs fat-free mass)?

Answer 19

• skinfold measurements
• BIA
• Hydrostatic (underwater weighing)
• DXA
• bodpod
• ultrasound, CT, MRI

Question 20

what information are we trying to gather from biochemical assessment and medical tests (assessment)?

Answer 20

• nutritional markers and indicators found in blood, urine, feces, and tissues
• includes protein assessment, immunocompetence, hematological, vitamin/mineral levels, and others

Question 21

what is the purpose of a somatic protein assessment?

Answer 21

• measures nitrogen balance; in a healthy individual, nitrogen excretion= nitrogen intake
• nitrogen balance= nitrogen intake-nitrogen loss
• Used in critical care to help monitor positive nitrogen balance, difficult to do bc it requires 24 hr urine collection

Question 22

what is the purpose of a visceral protein assessment? (proteins that are not muscle or skeletal makeup)

Answer 22

these proteins characterize inflammation and levels are also affected by hydration status (albumin); hypoalbuminemia is a nonspecific marker of severity of illness, and levels rapidly decrease with stress; in order for patients to be at low risk, they need to have high levels of albumin (like in surgery)

Question 23

healthcare system is delivered in what 3 forms?

Answer 23

inpatient (long term care facilities), outpatient(i.e. physicians office), and continuum of care

Question 24

what are the three levels of continuum of care?

Answer 24

• Primary (Preventative): patient education, vaccinations, diet modifications (also used in secondary + tertiary care), exercise programs, physical exams, smoking cessation program, stress reduction techniques)
• Secondary care (establish early diagnosis of disease): colonoscopies, mammograms, MRI, CATscans, surgery
• Tertiary (restorative care): PT, OT, speech therapy, Respiratory therapy, use of durable medical equipment in these types of therapy
  Our healthcare system is good at secondary and tertiary, but not so much primary care

Question 25

what are the 5 steps of policy development?

Answer 25

1. Identifying the problem: is it possible to solve this problem? 2. Agenda setting: getting policymakers to prioritize the problem 3. Policy formation: what all is needed to solve the problem 4. Policy implementation: passing the bill 5. Policy evaluation: how well did this policy solve the problem?

Question 26

what are HMO's?

Answer 26

type of insurance where geographic location determines where has coverage, anything outside not covered

Question 27

what are PPOs?

Answer 27

similar to HMOs, but less reliant on geographic location, depends on insurance company contracts with specific healthcare facilities

Question 28

what are DRG's?

Answer 28

type of insurance that is diagnosis related

Question 29

what is medicare?

Answer 29

Became law in 1965 Federal program that pays for many services received by elderly(65+) and disabled Covers 95% of nations elderly and disabled persons who are on social security Does Not provide for all health care services Medicare standards include requirements for staffing, environment, maintenance and records and overall quality of care State agencies implement the standards and consults Services part A Everyone with medicare receives this Compulsory and financed by federal tax paid by employers and employees Pays for inpatient hospital care, nursing home following a hospital stay, home health care and hospice Part B Voluntary Covers medical and other health services (doctors, ER and outpatient, services, lab tests, xrays, rehab) Annual deductible and cost sharing contribution (20% typically) Supplemental insurance carried by many to pay this Medicare approval for DM type 1 and 2 and pre-dialysis renal disease MNT services 3 hours the first year of diagnos, 2 hrs every year after 85% of physician fee Part D Optional benefit Most medicare prescription drug plans have a coverage gap, so there is a temp limit on what the drug plan will cover for drugs

Question 30

what is medicaid?

Answer 30

Provides health care for eligible low-income americans Established in 1965 as an amendment to the social security Act Each state has own eligibility standards but must cover certain individuals to receive federal funds Funded through tax revenues

Question 31

what are the key points of the affordable care act?

Answer 31

Preventative care has no co pay or deductible Income eligible subsidy No lifetime max amt No denial for pre-existing conditions Under 26 may stay on parents plan Closing medicare coverage gap

Question 32

how does one measure immunocompetence in a biochemical assessments

Answer 32

total lymphocyte count (T cells and B cells)

Question 33

how can we conduct a hematological assessment?

Answer 33

White blood cells Hemoglobin Hematogrit (H and H levels) MCV, MCH, MCHC Ferritin, transferin saturation, protoporphyrin Serum folate, serum b12 Lipid status Electrolytes BUN Creatinine Serum glc vitamin /min assessment Serum vit D (inflammation), b12, copper in gastric bypass surgery

Question 34

what are the 8 nutrition-focused physical findings we look for during a biochemical assessment?

Answer 34

- CV and pulmonary - GI - edema - amputations - eyes, hair, nails, mouth - skin integrity - vitals - muscle/adipose * not all of these are addressed in every note, only if abnormal

Question 35

what are the 3 components of Nutrition-focused physical exam?

Answer 35

fat/muscle loss, micronutrient deficiencies, fluid status

Question 36

how are energy requirements calculated for patients?

Answer 36

- either by using indirect calorimetry (most accurate but expensive and only calculates for that moment in time) or RER - TEE est. required too= TEF + RER* PA

Question 37

in what scenario is it best to use the Harris benedict equation to calculate RER?

Answer 37

for healthy individuals with a normal BMI (>25) - REE (F)= 655.1 + 9.6 W(kg) + 1.9 H (cm) - 4.7 A (yrs) - REE (M)= 66.5 + 13.8 W + 5 H = 6.8 A

Question 38

in what scenario is it best to use the Mifflin st jeor equation to calculate RER?

Answer 38

- Used in a clinical setting for patients w a BMI > 25 - REE (F)= 10 W + 6.25 H - 5 A - 161 - REE (M)= 10 W + 6.25 H - 5 A + 5

Question 39

in what scenario is it best to use the American College of Chest Physicians equation to calculate RER/ REE?

Answer 39

- REE= 25 X W (kg) - if BMI= 16-25, use UBW, if > 25, use IBW, and if <16 use current BW and then IBW after 10 days

Question 40

in what scenario is it best to use the penn state equation to calculate RER?

Answer 40

- for more critically ill patients - incorporates maximum body temp in past 24hrs

Question 41

how do you calculate protein requirements for patients?

Answer 41

Measurement of protein req: nitrogen balance, not typically done in clinical settings Estimation of protein requirements Weight based prescription RDA: 0.8g/kg body weight Metabolic stress, trauma, and Disease= 1.2-2.0 g/kg - 1.5g/kg is usually better estimate for most disease states - Varies per clinical condition and disease state

Question 42

what are the 2 methods used in calculating Fluid Requirements?

Answer 42

Method 1 (based on energy intake): 1 mL of fluid per kcal; commonly used for adults Method 2: based on age and body weight (more accurate for peds)

Question 43

What are the 3 etiology- based malnutrition diagnoses

Answer 43

Starvation related malnutrition - If inflammation is not present - Eating disorders - Lack of caloric intake due to psychiatric illness - Inability to consume adequate calories and protein - Will reverse with reintroduction of malnutrition Chronic disease-related malnutrition - More than 3 mo - Inflammation present, and mild to moderate - Organ failure, pancreatic cancer, rheumatoid arthritis, sarcopenic obesity Acute disease or injury-related malnutrition - Inflammation present, marked inflammatory response - Trauma, major infection, burns, closed head injury

Question 44

according to AND/ASPEN, malnutrition is diagnosed when a patient meets 2 or more of what 6 characteristics?

Answer 44

Weight loss Insufficient energy intake Loss of muscle mass Loss of subcutaneous fat localized/generalized fluid accumulation Diminished functional status as measured by handgrip strength

Question 45

what are the 3 main types of interactions of the nervous and endocrine system?

Answer 45

- orexogenic (appetite stim) - anorexogenic (appetite sprsnt) - adaptive thermogenesis (coordination of all different body systems to help maintain energy stores so that the body is an ideal weight that comes from the CNS)

Question 46

neuroregulation of appetite: what hormones are secreted?

Answer 46

Insulin (fed state), glucagon (fasting state), amylin (coreleased w insulin, slows Gastric emptying, suppresses appetite), cholecystokinin (CCK; gallbladder contraction for bile release), glucagon-like peptide-1(GLP1; produce and release insulin), peptide YY(appetite suppressant), and ghrelin (peptide hormone; appetite stimulant) Act together to increase and decrease appetite and food intake Prader-willi syndrome: genetic disorder in which these hormonal signals dont work well; these patients are hungry all the time; usually tied w other genetic or cognitive issues

Question 47

what are the main differences between white fat and brown fat?

Answer 47

Brown fat has more mitochondria; uncoupling proteins in mitochondria that essentially burns and energy to maintain body temp instead of energy being made into ATP Higher levels in infants and animals that hibernate Metabolically active Hypertrophy (larger in size) and hyperplasia (# of cells increase) of fat cells Implication for weight loss and maintenance of weight loss Leptin(hunger supp.) and adiponectin (hunger stim.)

Question 48

what is the definition of obesity?

Answer 48

an excessive amount of body fat, which increases the risk of medical illness and premature death

Question 49

body fat distribution needs to be considered when diagnosing patients with obesity. what method is superior to BMI in identifying cardiometabolic risk?

Answer 49

waist to hip ratio (WHR); also superior to waist circumference in screening for diabetes, hypertension, and CVD

Question 50

what are pscyosocial adverse health effects of obesity?

Answer 50

anxiety around food choice, low self-esteem, discrimination

Question 51

what are some physiological consequences of overweight and obesity?

Answer 51

Chronic low-grade inflammation Type 2 diabetes High blood sugar (higher LDL lower HDL) Lipid abnormalities (dislipidemia, high cholesterol) Hepatobiliary disorders (i.e. NASH) Cancer Reproductive disorders

Question 52

how is overweight/obesitty treated

Answer 52

2 step process: assessment and management - Treatment algorithm from ACC, AHA, and TOS green= no obesity; continue to talk to patient about overall healthy eating behaviors Yellow: focus on not gaining additional weight orange= BMI> 25, also some sort of complication (i.e. High BP); focus on lifestyle therapy and weight loss red= BMI> 25 with much more complication, adding pharmacological therapy and possibly bariatric surgery

Question 53

what are some considerations of pharmacologic treatments?

Answer 53

BMI> 27 w/ risk factors (comorbidity factors) Cost and side effects (not always covered by insurance; all medications have side effects) Rebound weight gain Meds Lipase inhibitors: bind to fat; roughly 30% of fat consumed is not absorbed, and just excreted by the body Appetite suppressants: up to 12 weeks; a lot more side effects (headaches, dizziness, nausea); not really effective?? Neither should be taken long-term Rebound weight gain is pretty common if PA and diet changes are not made while on these medications

Question 54

what are some considerations of bariatric surgery?

Answer 54

Bariatric surgery- BMI > 40 or >35 with risk factors Open(larger incision, direct, longer healing time) or laparoscopic (smaller incisions indirect to site) Benefits include significant weight loss w improvements in obesity-related comorbidities like high BP etc. Risks: postoperative complications Infection Blood clots Leaks in the GI tract Bowel obstruction or scarring Gallstones Malnutrition (changes the way you absorb nutrients) Careful pre-op screening and education is critical

Question 55

what are the four main types of bariatric surgery

Answer 55

gastric bypass(definitely malabsorptive), sleeve gastrectomy (decreases ghrelin release), gastric band (not malabsorptive, completely reversible) and duodenal switch.

Question 56

what are the benefits of intentional weight loss?

Answer 56

Effect on mortality Bariatric surgery has shown reduction of mortality of 24% at 10 yrs No conclusive evidence that weight loss decreases mortality in obese population Effect on morbidity Weight loss improves many medical complications associated with obesity Many beneficial effects are apparent after losses of 5-10% of initial weight Evidence that weight loss candela or decrease risk of developing new obesity- related disease (i.e. diabetes)

Question 57

nutrition diagnoses options for NCP for obese patients?

Answer 57

Excessive energy intake Excessive fat intake Food and nutrition related knowledge deficit Disordered eating patterns Undesirable food choices (after food ed) overweight/obesity Involuntary weight gain Physical inactivity

Question 58

How would one approach weight loss goals as the nutrition intervention?

Answer 58

Prevent further weight gain Reduce body weight Maintain a lower bodyweight long term * discrepancy between a realistic weight loss goal and the patients weight loss goal should be expected Patients typically want 38% loss, would be disappointed w 17% loss -After 48 weeks of intensive diet and exercise therapy, lost an average of 16.4%

Question 59

How would one approach dietary intervention as the nutrition intervention?

Answer 59

Eating plan deficient in calories (500 below estimated needs) NIH guidelines = Overweight and 2+ risk factors: -500 kcal/day Class I obesity: -500 kcal/day Class II or III: -500-1000 kcal/day Meets guidelines for healthy eating Balanced vitamin/mineral intake (supps may be recommended)

Question 60

How would one approach physical activity as the nutrition intervention?

Answer 60

Contributes to energy deficit Obese individuals should initiate PA and SLOWLY increase Moderate PA of 30 min per day, 5 days/week May burn about 1000 cals - typically walking

Question 61

what are some nutrition counseling strategies for behavior modification weight loss based nutrition intervention?

Answer 61

Understanding motivation to engage in weight loss program Reason Previous weight loss attempts Attitude abt capacity to perform PA Time available Financial considerations Most successful programs Are 12-16 weeks long Utilize CBT Build knowledge Modify beliefs Integrate new behaviors

Question 62

what are challenges of weight management?

Answer 62

After 6 months, the rate of weight loss declines and eventually plateaus Metabolic compensation is about 8 kcal/ lb lost/day Successful weight loss maintenance uses more behavioral strategies Control caloric intake Exercising more often and strenuously Tracking weight Eating breakfast

Question 63

what is Health at Every Size?

Answer 63

A more holistic approach to health Rejects use of weight, size, BMI as proxies for health and rejects the idea that weight is a choice Weight inclusivity Health enhancement Respectful care Eating for well-being Life-enhancing movement

Question 64

what is the reduce and treat obesity act?

Answer 64

Removes unnecessary barriers to allow a variety of qualified practitioners to effectively treat obesity Supports RDNs to provide IBT