Unit 4: Nutrition

Question 1

What is the definition of nutrition?

Answer 1

The science of optimal cellular metabolism and its impact on health and disease.

Question 2

What are macronutrients?

Answer 2

The kilocalorie (kcal) energy containing sources of carbohydrates, proteins, and fats. Alcohol also provides kilocalories, but it is not considered a macronutrient
because it cannot support or maintain bodily function.

Question 3

What are micronutrients?

Answer 3

Vitamins and minerals are micronutrients because they are required in minute amounts.

Question 4

What is an “ultra” trace mineral?

Answer 4

A mineral needed in such a small amount it is called an “ultra” trace mineral.

Question 5

What are phytochemicals?

Answer 5

Term that refers to plant compounds that have antimicrobial, antioxidant, anti-inflammatory, and immune-boosting properties.

Ex. Lutein (associated with the green color of vegetables) and Lycopene (found in high amounts in tomato products).

Question 6

What is the scope of nutrition?

Answer 6

Optimal or suboptimal.
* Optimal – nutritional status in which all nutrients are available in balanced amounts for cellular metabolism and physiological function for the individual.
* Suboptimal – (malnourished state) – reflects either insufficient or excessive quantity or quality of macronutrients or micronutrients.

Continuum with malnutrition on both sides and optimal
nutrition in the middle.

Question 7

What is oral intake of nutrition?

Answer 7

Normal intake requires appropriate ingestion of necessary foods to meet macronutrient, micronutrient, and fluid needs. These required macronutrients and micronutrients are seen in Table 16-1. The amount of nutrient intake needed for optimal function changes throughout the lifespan. National guidelines for recommended intake referred to as Dietary Reference Intakes (DRI’s) are available online at the U.S. Department of Agriculture website

Adequate oral intake of nutrients (and water) involves:
* Access to food sources
* Informed food choices
* Efficient chewing (mastication) and swallowing
abilities.

It is seen through evidence that immunity begins in the intestines so it is important to provide nutrients through the GI tract whenever possible.

Question 8

What is digestion?

Answer 8

Process of mechanical and chemical breakdown of food matter and complex forms of macronutrients. Mechanical
breakdown includes chewing and peristalsis, and chemical breakdown involves digestive enzymes.

Question 9

What is absorption?

Answer 9

Once food is digested, the microscopic hairlike projections (villi) that line the intestinal tract absorb nutrients into the capillaries which are then transported by the vascular system.

Duodenum is the primary site for absorbing trace minerals, the Jejunum is the primary site for absorbing water-soluble vitamins and proteins, and the ilium is the site of fat and fat soluble vitamin absorption.

Water is primarily absorbed in the colon.

Question 10

What is elimination?

Answer 10

Large food particles and undigested fibers are not absorbed but rather they are eliminated through the colon. A healthy GI tract with effective peristaltic action is required for this to work optimally.

Question 11

What is cellular metabolism?

Answer 11

Includes the hormonal and enzymatic processes that occur within cell structures which allow proteins, carbohydrates, or fats to be used for energy or made into new products or tissues.

Adequate intake of both macronutrients and micronutrients is required for optimal cellular metabolism.

Question 12

What are the age related differences for infants and children?

Answer 12

Infants have very different nutrient needs (compared to adults) to support their rapid growth. Should be limited to
breastmilk or formula and water for the first six months of life. As teeth emerge, the older infant and young child can
be offered foods with various textures but must watch out for choking due to a small oropharynx.

Question 13

What are the age related differences for pregnancy and lactation?

Answer 13

Significant changes in nutrition needs occur during pregnancy and lactation to account for:
* The body composition changes during pregnancy (hormonal, metabolic, and anatomic)
* Growing fetus (before birth)
* Production of breast milk after delivery.

Increases in carbs, proteins, and fats are recommended. Expected weight gain during pregnancy ranges from 15-40
lbs.

Question 14

What are the age related differences for older adults?

Answer 14

Reduced ability to ingest, absorb, and metabolize nutrients.

In the mouth they may have reduced chewing ability, reduced saliva production, and reduced sense of taste.

The esophagus may be elongated (due to kyphosis) and atrophic changes occur, particularly in the lower esophagus.

Atrophic changes and intestinal microflora occur in aging, resulting in reduced efficiency in absorption. The liver, gallbladder, and pancreas continue to work but in decreased metabolic efficiency.

Question 15

What are the age or life stage risk factors of impaired nutrition?

Answer 15

At the beginning of life and again at the later stages, nutritional deficits are a significant concern.
* Pregnancy – very important because of long term effects on health of the infant and mother.
* Very young – at risk because of immature organ development and total dependence on others for feeding.
* Premature infants – impaired oral intake make them particularly at risk.
* Senior citizens – reduced organ function, limited income, interactions between nutrients and medications, isolation, decreased interest in meal preparation, changes in appetite, fatigue, and altered taste sensations are common.
- Institutionalized elderly are at even greater risks. Severe dietary restrictions, rigid mealtimes, generally poor health status, and feeding dependency can lead to inadequate oral intake.

     - Physiological risk factors include, frailty, low BMI (BMI <21 is associated with a high risk of mortality despite nutritional intervention, and neurologic deficits from a stroke or Alzheimer’s disease.

Question 16

What are the risk factors associated with ethnicity/race?

Answer 16

• Vitamin D deficiency is more frequently found among Hispanics and Americans of African heritage as opposed to those of European heritage.
• European heritage – diseases more common are type 1 diabetes, celiac disease, and neurodegenerative
  disorders such as Huntington’s disease and MS.

Question 16

What are the risk factors for the poor and underserved?

Answer 16

Due to food insecurity and food availability being limited. Lack of access to healthy foods because of:
* Insufficient funds
* Distance to supermarkets
* Limited options for food preparation
* High prices of quality foods
* Cheap prices of fast food
* Limited transportation

Some of the reasons why low income families eat poorly and are often obese.

Question 17

What are the genetic risk factors?

Answer 17

Many conditions that impact nutrition are linked to genetics.

• Phenylketonuria (PKU) – a deficiency in the enzyme responsible for the metabolism of the amino acid phenylalanine. PKU allows phenylalanine to accumulate in the brain, blood, and tissue leading to cognitive dysfunction unless the affected individual follows a low-phenylalanine diet for life.
• Galactosemia
• Maple syrup urine disease
• Cystic fibrosis (CF) – thick secretions block pancreatic ducts, eventually leading to impaired digestion and absorption of fats and fat soluble
  vitamins.

Question 18

What are the risk factors of lifestyle and patterns of eating?

Answer 18

How one chooses foods, shops, plans, and prepares meals ultimately affects his or her nutritional status. Factors that
influence these decisions are:
* Interpersonal relationships
* Learned stress coping mechanisms
* Alterations in mood

Weight gain can occur when food habits change to match those of the partner such as during dating and marriage.

Family food offerings can positively or negatively influence nutrition intake. Ex. Italian mother who gives her child only pasta and pizza can cause them to potentially get diabetes.

Also peer influence is important for adolescence and young people with lower self esteem. Ex. Fad diets, supersized portions, and drinking alcohol.

Question 19

What are risk factors of personal food choices?

Answer 19

Personal choice is the major internal influence over food intake.
* Women tend to get cravings around their menstrual period and during pregnancy.
* Vegan diet undertaken without adequate knowledge may lead to insufficient nutrients.

Question 20

What are the risk factors for underlying medical conditions?

Answer 20

A wide range of medical conditions place individuals at risk for various nutritional problems. See Table 16-3 Impact of Medical Conditions on Risk for Malnutrition.

Question 21

What conditions or states cause hypoalbuminemia/impaired protein nutrition?

Answer 21

• Oral/GI problems with limited protein–calorie intake (e.g., sensory issues, allergies, dental problems, dysphagia)

*Impaired intestinal absorption of proteins (diarrhea/malabsorption: e.g., celiac disease, Crohn disease, short-bowel syndrome, bariatric surgery)

*Hepatic disease with impaired protein synthesis

*Chronic kidney disease with proteinuria

*Nephrotic syndrome

*Cancer with increased metabolic needs

Question 22

What condition or states cause hypocalcemia?

Answer 22

*Burns with loss of protein in body fluids

*Hypoalbuminemia (lack of carrier proteins)

*Hyperphosphatemia (in chronic kidney disease, end stage)

*Malabsorption/diarrhea

*Hypoparathyroidism

*Hypomagnesemia

*Vitamin D deficiency

Question 23

What conditions or states cause hypercalcemia?

Answer 23

*Hyperparathyroidism

*Hyperthyroidism

*Adrenal insufficiency

*Cancer

*Hypervitaminosis A and D

Question 24

What medical condition or state causes copper deficiency anemia?

Answer 24

Wound healing protocol with excess supplementation of zinc results in copper deficiency anemia

Question 25

What conditions or states cause iron deficiency anemia/microcytic anemia?

Answer 25

GI bleed

Question 26

What conditions or states cause iron overload?

Answer 26

*Hemochromatosis

*Hepatic disease

Question 27

What conditions or states cause vitamin B12 deficiency?

Answer 27

*Gastrectomy

*Pernicious anemia/lack of intrinsic factor

*Primary hypothyroidism

*Achlorhydria

Question 28

What conditions or states cause folic acid deficiency/megaloblastic anemia?

Answer 28

*Epilepsy with use of antiseizure medications

*Chronic kidney disease (end stage) and dialysis treatments

Question 29

What conditions or states cause hypomagnesemia?

Answer 29

*Edema/hypertension with (K+)-depleting diuretics

*Malabsorption/diarrhea

*Hepatic disease

*Pancreatitis

Question 30

What conditions or states cause vitamin D deficiency?

Answer 30

*Chronic kidney disease with limited ability to active form

*Malabsorption

Question 31

What conditions or states cause zinc deficiency?

Answer 31

*Hypoalbuminemia

*Chronic kidney disease (end-stage) and dialysis treatments

*Alcoholic cirrhosis/hepatic disease

*Inflammatory bowel disease

*Sickle cell anemia

Question 32

What is the impact of impaired oral intake? What factors could impair oral intake?

Answer 32

The inability to chew or swallow properly can easily lead to malnutrition.

Pain from dental carries, poorly fitting dentures, and loss of teeth can impair the ability to chew and limit diet quality.
Cleft palate impacts an infants sucking ability.

In conditions such as Parkinson’s and Alzheimer’s disease, the sense of smell diminishes also leading to decreased food intake.

Unbalance food intake also occurs in mental health conditions such as eating disorders and depression.

Question 33

What can cause impaired digestion and absorption?

Answer 33

Many conditions interfere with digestion or absorption and place the affected individual at risk for malnutrition. Examples of these conditions include:
* Lactose intolerance
* Gastroparesis
* Gastric surgery
* Intestinal resection
* Inadequate gastric acidity
* PKU can also lead to defects in metabolism
* Some medications can have adverse effects on absorption

Question 34

What can cause an increased metabolic demand?

Answer 34

A variety of conditions increase metabolic rate and energy needs, thus increasing the risk for protein-calorie
malnutrition. Examples include:
* Cancer
* Chronic obstructive pulmonary disease
* Parkinson’s disease
* Trauma (including burns)
* Stroke
* HIV/AIDs

Depending on the severity of the disease state, it may be difficult to meet the increased nutrient needs without enteral or parenteral nutrition support.

Question 35

What is the impact of altered organ function?

Answer 35

The failure of organs involved in digestion and metabolism are associated with nutritional deficiencies.

Question 36

What is the impact of altered liver function?

Answer 36

• Hepatic disease – adversely impacts the ability to reassemble amino acids into the various proteins needed for physiologic function. A damaged liver
  will also be unable to metabolize and excrete drugs properly, thus altering nutrient absorption and utilization even further.
• Chronic kidney disease (CKD) – nutritional status is adversely impacted through a variety of mechanisms. Protein is lost through the urine, and can lead to impaired skin integrity, slow wound healing, suppressed immunity, sarcopenia, and altered osmotic pressure.

Question 37

What is the impact of altered kidney function?

Answer 37

• Renal disease – reduces nutrient levels, especially vitamin D because the kidneys metabolize vitamin D2 into the bioactive D3 form. With lowered vitamin D status, bone health is impacted because vitamin D is required to absorb calcium.
• Kidneys are involved in producing red blood cells; therefore in patients with Chronic Kidney Disease (CKD), anemia can develop that is unresponsive to
  iron intake due to insufficient levels of
  erythropoietin, a protein-based hormone.

Question 38

How can nutrition therapy have adverse nutritional consequences?

Answer 38

Limited fluid or food intake and phosphorus / protein / potassium restrictions can be challenging. This is especially true when CKD is compounded by an acute illness. Thus, organ damage and illnesses can seriously impact nutritional status.

See Table 16-3 Impact of Medical Conditions on Risk for Malnutrition.

Question 39

What should be remembered about food when doing an interview of the patient or family members?

Answer 39

Food has an emotional component. Actual food or eating practices may not be revealed unless there is trust and
rapport. This is especially true when interviewing parents of a child whose growth and development are not within
expected ranges.

Question 40

What allows for focused interviewing?

Answer 40

Mentioning some potential nutritional complications of a condition, or asking about the individual’s personal health
concerns.

Question 41

What are the basic elements of a history for nutrition?

Answer 41

• Nutritional intake
• Diet restrictions
• Changes in appetite and intake
• Changes in weight
• Medical history
• Current medical conditions
• Current medications and treatments
• Allergies
• Family history
• Social history

Also important to consider the chief complaint / presenting symptom because they may relate to nutrition and may warrant a symptom analysis.

Question 42

What are the most important screening problems or presenting symptoms for impaired nutrition?

Answer 42

• Unplanned changes in weight
• Changes in appetite or intake
• Nausea and / or vomiting
• Difficulty chewing or swallowing
• Abdominal pain or discomfort
• Changes in bowel habits
• Recent history of constipation or diarrhea

Question 43

What techniques are used to assess nutritional status?

Answer 43

• General observation
• Anthropometric measurements
• Other various clinical findings from systems’ assessment

Question 44

What are the initial steps in assessing nutritional status?

Answer 44

Measuring height and weight and determining body mass index (BMI).

General goals and interpretation guidelines for BMI are presented in Table 16-4 Interpreting BMI in Children and Adults.

If BMI is within normal limits and
weight has been stable, it is still important to have at least a brief assessment of oral intake to verify that macronutrients and micronutrients are being consumed in appropriate amounts.

If there is any suspicion of poor nutritional status, lab work should be ordered by the attending provider to help assess status more completely.

Question 45

Assessing BMI in Children

Answer 45

Question 46

Assessing BMI in Adults

Answer 46

Question 47

What will give insight into health and nutritional status?

Answer 47

• General physical appearance
• Level of orientation
• Demeanor

Question 48

What else should you assess for examination findings of nutrition status?

Answer 48

• Skin integrity and turgor – skin should be smooth and elastic without cracks or bruising
• Hair – should be shiny and not brittle
• Nail beds – should be smooth, pink and firm
• Teeth – should be free of cavities
• Oral tissue – should be moist, pink, and firm
• Mucous membrane around the eyes – should be pink, moist and free of lesions.
• Sclera- should be white
• Cornea – should be clear and shiny

Question 49

What are the laboratory tests for nutrition?

Answer 49

*Serum albumin and pre-albumin

*Blood glucose and hemoglobin A1C

*Lipid profile

*Electrolytes

*Hemoglobin and hematocrit

Question 50

What are the serum albumin and pre-albumin tests?

Answer 50

The serum albumin measures circulating protein in the blood. Low albumin can reflect protein-calorie malnutrition.
Other conditions can also cause low serum albumin levels such as inflammation, blood loss, and fluid
status). Low albumin levels predict severity of illness and are also predictors of mortality in adults older than age 60.

Pre-albumin reflects recent dietary protein intake. Thus, low pre-albumin is
generally associated with nutritional intake as opposed to other conditions.

Question 51

What are blood glucose and hemoglobin tests?

Answer 51

Blood glucose reflects metabolism of carbohydrates and this test is generally used to screen or monitor impaired
glucose metabolism.

Hypoglycemia may suggest inadequate caloric intake and hyperglycemia may be an indication of diabetes mellitus.

Hemoglobin A1C is a test that shows average blood glucose levels over time and is used in the management of diabetic patients. It indicates how well glucose levels are controlled.

For anemia or renal disease, false
readings of A1C may occur, for this reason finger-stick glucose tests may be preferable in these situations.

Question 52

What is the lipid profile test?

Answer 52

The lipid profile includes several tests that assess lipid metabolism and serve as important indicators of risk for cardiovascular disease.

Tests include:
➢ Low density lipoprotein (LDL)
➢ High density lipoprotein (HDL)
➢ Cholesterol
➢ Triglyceride levels – generally reflect
hyperinsulinemia although individuals with newly diagnosed type 1 diabetes may have temporary elevations of trigycerides.

Question 53

What is the electrolytes test?

Answer 53

Electrolyte lab tests provide information about general health status including specific information about micronutrients including:
➢ Sodium
➢ Potassium
➢ Calcium
➢ Magnesium
➢ Phosphorus

These are usually ordered as part of a chemistry profile blood test. Electrolytes can become imbalanced with inadequate dietary intake or many other conditions such as:
➢ Renal disease
➢ Liver disease
➢ Diabetes

Question 54

What are the hemoglobin and hematocrit test?

Answer 54

It is a blood test that examines red blood cells including the number, size, shape, and color, to diagnose anemia caused by
dietary deficiency such as iron, folate, and vitamin B12. Hemoglobin and hematocrit also provide information about the hydration status of the patient.

Question 55

What is the primary prevention of nutrition?

Answer 55

Foundation of primary prevention efforts for nutrition includes:
* Healthy eating
* Physical activity

Question 56

What is healthy eating as it relates to primary prevention?

Answer 56

A person who follows the current Dietary Guidelines for Americans and MyPlate (see ChooseMyPlate.gove) can
achieve a healthy diet. The inclusion of the minimum number of servings in MyPlate will meet the DRI micronutrient and macronutrient needs for general health needs.

The Dietary Guidelines are aimed at preventing chronic health diseases associated with excess intake of
macronutrients especially solid fats (saturated / trans fats), sugar, and salt. Food labels with DRI values reinforce the
Dietary Guidelines. Food labels also state four marker
nutrients:
* Calcium
* Iron
* Vitamin A
* Vitamin C

If these micronutrients are included in adequate amounts from food naturally high in them, the other needed micronutrients will also be obtained.

Breast feeding is recommended for optinal nutrition of infants from the 4-6
months of life. Breast milk contains all the essential nutrients and has immunologic benefits that protect the
infant from acute and chronic disease.

Question 57

What is physical activity as it relates to primary prevention?

Answer 57

Helps to prevent obesity. General goal includes 30 minutes of physical activity on most days of the week or 150 or more minutes weekly.

Weight loss may require at least twice this amount of exercise. Guidelines for exercise need to be individualized.

A sedentary person or one who has sarcopenia or cardiovascular disease needs limited time intervals of exercise more frequently.

Question 58

What is secondary prevention of nutrition?

Answer 58

Limited primarily to:
* Lipid screening – recommended for those with specific risk factors
* Blood glucose screening – advised for persons with evidence of insulin resistance, such as central obesity found with metabolic syndrome.
* BMI

For infants, routine screenings that occur at birth include the following:
* Glucose levels
* At least 40 different genetically linked metabolic disorders (including phenylketonuria and maple syrup urine disease) that relate to an inability to
metabolize certain amino acids or to errors in fatty acid metabolism.
* Carbohydrate disorders (including galactosemia)
* Other congenital disorders that can affect nutritional status (including cystic fibrosis)
* HIV

Question 59

What are dietary interventions as associated with collaborative interventions?

Answer 59

• Registered dietician nutritionists (RDNs) are health professionals who have a background in biochemistry and metabolism, with knowledge about macronutrient and micronutrient contents of foods and how the body uses them.
• Dietetic technician assists the RDN with menu planning, nutrition education, and management of food services.

Nutrition therapy is a term used to describe the typical services of the RDN or registered dietetic technician, whereas medical nutrition therapy is a legal term for reimbursable services provided by the RDN.

The concept of personalized nutrition is replacing the old paradigm that “one diet fits all” through the science of nutrigenomics – how genetics influence nutritional intervention.

Ensuring that food provided matches the patients ability to eat is important as well.

Question 60

What is enteral nutrition as associated with collaborative interventions?

Answer 60

Nurses administer nutrition support via tube feeding. Tube feedings are indicated for an individual who is unable to eat or swallow but has an intact / functional GI tract. Feeding tubes are inserted directly into the stomach or small intestines for delivery of enteral feeding. A special formula is ordered to feed the patient for optimal nutrition.

Question 61

What is parenteral nutrition as associated with collaborative interventions?

Answer 61

Used to provide either total or supplemental nutrition intravenously. Are generally used for patients who have
intestinal failure and cannot be fed orally or by enteral feeding. Here, nutrition consists of a glucose-based
intravenous solution (various dextrose concentrations) with electrolytes, minerals, and amino acids.

Fat emulsions (lipids) may also be included or administered as a separate solution. Sepsis and electrolyte and metabolic imbalance can occur so meticulous nursing care of the vascular access is required.

Question 62

What are surgical interventions as associated with collaborative interventions?

Answer 62

Bariatric surgery is the most common. It is increasingly being used to control obesity and diabetes. Generally
successful, but complications including macro – and micronutrient deficiencies that are not easily managed, either because of lack of adherence to dietary and supplement guidelines or because limited knowledge of actual needs. Weight gain can still occur if the patient is not compliant with caloric intake control.

Question 63

What are pharmacologic agents as associated with collaborative interventions?

Answer 63

A number of supplements are used to enhance the nutritional status of individuals, and most are available over
the counter.

In regards to pharmacologic agents for obesity management, research continues.

There have been complications with previous form of weight loss medications, and currently all of these medications have limitations on duration of use.

Question 64

What are the interrelated concepts for nutrition?

Answer 64

• Development
• Spirituality
• Culture
• Glucose regulation
• Immunity
• Tissue integrity
• Thermoregulation
• Clotting
• Hormonal regulation