Introduction to Nutrition

Question 1

Situations that place patient at risk for nutritional problems

Answer 1

• Factors/conditions in HPI/chief complaint:
  
  • Impaired absorption: cystic fibrosis, celiac disease
  • Decreased utilization
  • Increased losses: blood loss, diarrhea
  • Increased requirements: growth, pregnancy, high metabolic rate, lactation, pulmonary/cardiac disease
  • High/low level of physical activity
  • Consider nutrient/energy inadequacies or excess: sodium, fats, etc.

Question 2

Characteristics of a “very high risk” patient

Answer 2

• Very young or very old
• Underweight or recent loss of > 10% usual body weight, or both
• Obese with central adiposity/insulin resistance
• One consuming limited variety: inadequate or excessive intake of certain foods
• Protracted nutrient losses: malabsorption, enteric fistulae, draining abscesses or wounds, renal dialysis, chronic bleeding or RBC destruction, history of bariatric surgery
• Hypermetabolic states: sepsis, protracted fever, extensive trauma, burns
• Chronic use of alcohol or meds with anti-nutrient or catabolic properties: steroids, antimetabolites (e.g. methotrexate), immunosuppressants, anti-tumor agents
• Marginalized circumstances: impoverishment, isolation, advanced age, altered mental status including mental retardation
• Middle aged adults at risk for heart disease
• Post-menopausal women

Question 3

3 methods of obtaining diet information: questions to be asked, content to be seeking

Answer 3

1. Qualitiative: screening questions/comments - ranging from open-ended questions to more focused
   
   • Most open-ended –> tell me about your diet
   • More focused questions –> appetite specifics
   • Listen for variety vs. restriction, excess vs. inaequacy, issues relevantt o patient including saturated fats, calories, Na+, Ca2+
2. Semi-quantitative: actual or estimates of intakes of food or nutrients - e.g. 24 hour recall, diet record
3. Quantitative: diet record for one day or multiple days, comparison of nutrient intakes to recommendations

Question 4

Nutrient requirement

Answer 4

• Applies to groups, not individuals
• Intake estimated to meet requirement defined by specific indicator of adequacy in 50% of individuals in life stage and gender group
  
  • Includes adjustment for assumed bioavailability of nutrient
  • Used to assess inadequte intakes and planning goal intake for mean intake of a group
• Ex. need one orange slice/day to keep scurvy at bay

Question 5

Nutrient allowance and RDAs

Answer 5

• Applies to individuals, not groups
• RDAs: average daily dietary intake level sufficient to meet the nutrient requirements of nearly all (95-97%) individuals in a life stage and gender group
• Guidelines have less emphasis of prevention of deficiency and more emphasis on decreased risk of chronic disease and health promotion

Question 6

3 applications of nutrition in medicine

Answer 6

1. Public health issues –> addresses chronic disease
2. Ambulatory medicine –> pregnancy, hypertension, diabetes, etc.
3. Nutrition support/inpatients –> ICU, surgical, trauma, TPN, etc.

Question 7

Components of nutrition assessment (4)

Answer 7

1. History
2. Anthropometrics
3. Exam
4. Labs

Question 8

Role of history in nutrition assessment

Answer 8

• Intake of food and nutrients relative to needs and risks
  
  • Meds and supplements
  • Allergies to drugs and foods
  • Family history including risk for diet-related chronic illness
  • Social history including diet, physical activity, habits, socioeconomic status
  • Review of systems including weight gain, increased losses, poor intake, systemic illness

Question 9

Role of anthropometrics in nutrition assessment

Answer 9

• Length/height
• Weight
• Head circumference in infants
• Waist circumference

Question 10

Role of exam in nutrition assessment

Answer 10

• Clinical signs, especially in relation to:
  
  • Skin: acanthosis nigricans, skin breakdown, discoloring
  • Hair: hypopigmentation
  • Mouth: rapid turnover of cells
  • Extremities

Question 11

Role of labs in nutrition assessment

Answer 11

Biochemical changes/levels

Question 12

How to address dietary and lifestyle changes with a patient

Answer 12

• Traditional dietary counseling
  
  • Focuses on what patients should be advised to eat
  • Concept of why they eat as they do and impediments to changing dietary behavior less understood, less emphasized
• Failure to change diet in most patients is not result of inadequate motivation but of excessive difficulty/barriers
  
  • Only ways to achieve change:
    
    • Reduce difficulty
    • Increase motivation further
  • Barriers to change typically >> factors contributing to motivation for change
• All patients should receive at least some counseling to modify diet to promote health +/- to achieve specific therapeutic goals
• Starting point is to ask patient to describe their diet and level of physical activity
• Use motivational interviewing, assess confidence and conviction, stage of readiness, etc.