Nutrition Standards PDF

e. Nutrition Standards Topics (Study Guide): e. Nutrition Standards i. Nutrition Screening: subjective global assessment (SGA) and others, conditions suggesting ii. nutritional risk ii. Estimating Nutrition Requirements: DRIs, energy, protein, and fluid Diet Assessment: estimating intake (24hr recal...

e. Nutrition Standards Topics (Study Guide): e. Nutrition Standards i. Nutrition Screening: subjective global assessment (SGA) and others, conditions suggesting ii. nutritional risk ii. Estimating Nutrition Requirements: DRIs, energy, protein, and fluid Diet Assessment: estimating intake (24hr recall, food diary, FFQs, diet history), assessing intake of energy, macronutrients, and micronutrients Body Composition: bioelectric impedance analysis (BIA), skinfold, unde-water weighing, isotope dilution, radiology, muscle mass, body fat percentage v. Anthropometric Assessment: body mass index (BMI), waist circumference (WC), waist-hip ratio (WHR), usual body weight (UBW), adjusted body weight (ABW), ideal body weight (IBW), percent weight change, amputation, special cord injury vi. Physical Assessment: nutrition-focused physical exam (NFPE), signs and symptoms of nutritional vii. deficiencies Medications & Drug-Nutrient Interactions: medications relevant to nutrition, interactions between viïi. medications and nutrients Biochemical Assessment: see 2.c. Lab Assessment & Interpretation** I. Nutrition Screening Use of preliminary nutrition assessment techniques to identify individuals who are malnourished or at risk for malnutrition All health care team members can participate → supportive in ADIME process Should be brief (5-10 min) → client hx, labs, wt, physical signs Should be accurate Specificity: correctly excludes those not at risk Sensitivity: correctly identifies at risk individuals The Joint Commission → requires that nutrition risk is identified in hospitalized pts Screening Tools Does not mandate specific screening method SGA (Subjective Global Assessment) → hx, intake, GI symptoms, functional capacity, phys appearance, edema, wt changes MNA (Mini Nutritional Assessment) → independence, meds, # of full meals/d, PRO intake, FN intake, fluids, feeding mode, 65yrs + NSI (Nutrition Screening Initiative) → for elderly GNRI (Geriatric Nutritional Risk Index) → serum albumin, wt changes MST (Malnutrition Screening Tool) → recent wt loss, recent poor dietary intake For hospitalized adult populations NRS (Nutrition Risk Screening) → % wt loss, BMI, intake, 70yrs + Medical-surgical hospitalized MUST (Malnutrition Universal Screening Tool)→ BMI, unintentional wt loss, effect of acute disease on intake x 5+ days Conditions Suggesting Nutritional Risk Medical and family history - Provides insight into nutrition-related problems Risk factors: Reduced food intake:. Decreased appetite, medications, sensory changes, dental problems, limitations in mobility, lack of access to food, eating disorders Reduced nutrient absorption and utilizations: GI changes, medications, disease (DM, kidney disease, GI disease), surgery (gastric bypass), elderly Increased nutrient requirements: Ilness, infection, injury, burns, surgery, pregnancy Increased nutrient losses: Medications, diseases, dialysis, persistent vomiting/diarrhea Altered feeding method: Enteral nutrition, parenteral nutrition, texture modified diet Ei. Estimating Nutrition Requirements Dietary Reference Intakes - DRI Tables A probability framework for assessing risk of nutrient inadequacy and excess Developed considering evidence for the prevention of disease and developmental disorders and evidence of sufficient nutrient intake (i.e. prevention of deficiency) EAR: Estimated Average Requirement - Average daily nutrient intake level estimated to meet the requirement of half the healthy individuals in a particular age, sex, and life-stage group Can be used to assess prevalence of inadequacy in group RDA: Recommended Dietary Allowance - Average daily nutrient intake level sufficient to meet the nutrient requirement of nearly all (97-98%) healthy individuals in a particular age, sex, and life-stage group Can be used to determine if an individual's typical nutrient intake level has a low likelihood of being inadequate Al: Adequate Intake - An intake (not a requirement) that is likely to exceed the actual requirements of almost all individuals in an age, sex, and life-stage group; established when scientific evidence is not sufficient to determine an RDA "Although unknown how the Al relates to requirements, it can serve as a goal for an individual's nutrient intake UL: Tolerable Upper Intake Level - The highest average daily nutrient intake level likely to pose no risk of adverse effects for nearly all people in a particular age, sex, and life-stage group CDRR: Chronic Disease Risk Reduction - A new DRI category that characterizes nutrient intakes that are expected to reduce chronic disease risk in apparently healthy individuals.Developed to overcome the limitations of previous DRIs regarding the relationship between nutrient intake and chronic disease risk (complex causes of diseases, between-person variability, hard to establish cause and effect relationship) Sodium: Across the body of scientific studies, there was moderate strength of evidence that decreasing high sodium intakes reduces risk of cardiovascular disease and hypertension, and high strength of evidence that it lowers blood pressure. The sodium CDRR for adults was established as the lowest level of sodium intake for which there was moderate strength of evidence of chronic disease risk reduction https://nap.nationalacademies.org/resource/25353/interactive/ Energy Requirements 2.6* Total Eneray Expenditure (TEE): sum of total energy used by the body daily Basal Metabolic Rate (BMR): energy expenditure under resting conditions Warm room in the am, at least 12 hrs after last meal / activity Resting Eneray Expenditure (REE): basal metabolism after 5-6 hrs without food / activity Nonexercise Activity Thermogenesis (NEAT): energy used for activities of daily living Thermic Effect of Food: energy used for digestion, absorption, and metabolism (10% of daily E) Direct calorimetry: determining amount of heat produced by food via bomb calorimetry Indirect calorimetry: estimate energy use by comparing 02 consumed and CO2 exhaled Burning of fuel in tissues uses O2 and creates CO2 Recommendations for Energy Intake Estimated Eneray Requirements (EER): amount of energy recommended by DRIs to maintain body weight in healthy person based on age, gender, size, and activity level Factors: Acute or chronic respiratory distress Large open wounds/cuts Malnutrition with altered body composition: - Underweight, obese, amputation, edema, ascites Multiple neurological trauma - Multisystem organ failure - Post-op organ transplant - Sepsis, systemic inflammatory response syndrome Use of paralytic or sedative agents Wheelchair Bound Paraplegia → IBW reduced by 5-10%(15-20 Ibs) Quadriplegia → IBW reduced by 10-15%(10-15 Ibs) Consider type of wheelchair (manual vs ultralight or power-assisted) Protein Requirements 0.8 g/kg Nitrogen balance: N consumed vs N excreted Intake = dietary protein intake (only N containing macro) Output = urine (urea) + feces + other losses (skin, sweat, hair, nails) Needs can be determined via nitrogen balance study Calculating Protein Needs: Illness / Injury → increase requirements depending on extent Infection, fever, surgery, burns → see handbook for specific conditions Exercise → increased needs if extreme → triathletes, body builders - Endurance athletes = 1.2-1.4 g/kg→ some protein used for energy Strength athletes = 1.2-1.7 g/kg→ building muscle Fluid Requirements DRI Recommendations: Men =3.7L Women = 2.7L Weight-based Method: - 100 ml/kg →first 10kg 50 ml/kg → next 10kg 20 ml/k→ remaining kgs Energy-based Method: 1 ml/kcal Fluid Balance Method: Urine output + 500 ml/day Intake/output (I/O)→ used to assess hydration status, measures fluid balance Fluid Losses Water losses → urine, feces, evaporation from lungs, skin, sweat (2.75 L / d) - Urinary losses → typically 1-2 L/d Fecal losses → typically 200ml / day (consider diarrhea, vomiting) Insensible losses → from evaporation, 1 L/d Sweat losses → depends on activity/climate Dehydration: drop in body water resulting in decreased blood volume - Early symptoms: headache, fatigue, loss of appetite, dry eyes/mouth, dark urine- Later symptoms: nausea, difficulty concentrating, confusion, disorientation → death Overhydration: increase in body water resulting in decreased [Na] in blood Early symptoms: nausea, muscle cramps, disorientation, slurring, confusion Can cause swelling in the brain → disorientation, convulsions, coma, death iii. Diet Assessment Estimating Dietary Intake 24hr recall → list intake from past 24hrs Intake varies day to day, repeated recalls provide better idea of typical intake Quick tool to estimate sample daily intake, best for clinical setting Concerns → over reporting and underreporting Food diary / intake record → record intake for set period (2-7 days) Should include one weekend, burdensome, may affect behaviour- FFQs → estimate frequency of consumption from list of foods Give idea of typical eating patterns Good for large groups, community setting - Diet history→ combination of methods to collect info about dietary patterns Can provide more detailed info and better picture of pattern Avoid leading questions Assessing Energy Intake Estimating Energy Content of Foods Protein Intake 10-35% Protein Quality Measure of how efficiently protein in diet can be sued to make body proteins Complete protein: provides essential aas in the proportions needed for protein synthesi Incomplete protein: protein deficient in one or more essential aas relative to needs Plant proteins→ more difficult to digest and low in one or more essential aas Measures of Protein Quality Protein Complementation: combining foods with different limiting aas Lysine, methionine, cysteine, tryptophan Legumes → low methionine + cysteine I/ high lysine Grains, nuts, seeds → low lysirie // high methionine + cysteine Corn → low lysine, tryptophan // high methionine Assessing Micronutrient Intake Compare intake to DRIs using nutrient analysis tools iv. Body Composition Bioelectric Impedance Analysis (BIA): measures fat-free mass and total body water by passing a low-energy electric current through the body and assessing the resistance to flow (fat = poor conductor) - Must be performed when GIT and bladder are empty and body hydration is normal Inaccurate if within 24hrs of strenuous exercise → loss of water in sweat - No exercise x 4-6h. Must be well-hydrated, no caffeine, alcohol, diuretics in past 24hr Fever, e- imbalance, extreme obesity affect reliability Skinfold Thickness: uses caliper tool to assess amount of subcutaneous fat Triceps skinfold thickness (TSE): Measures body fat reserves d calorie reserves Male (12.5 mm) and female (16.5 mm) Common sites: triceps, subscapular area → equation then used to estimate body fat More difficult to perform and less accurate in obese and elderly individuals Underwater Weighing: compare weight with weight in water → difference can be used to determine body volume and body density which is proportional to fat-free mass - BOD POD: uses air displacement rather than water Air displacement plethysmography (ADP) Isotope Dilution: water-soluble isotope ingested and amount measured in sample of body fluid - Extent of dilution indicates amount of LBM→→ body fat can be calculated Radiologic Methods: MRI/CT scans can be used to visualize fat and lean tissue → visceral fat CXA → can assess total body mass, bone mineral mass, and % body fat Arm Muscle Area (AMA): measures skeletal muscle mass (somatic protein) Use TSF and MAMC (midarm muscle circumference) Male (25.3 cm) and female (23.2 cm) Important to measure growing children Body Fat % Guidelines: v. Anthropometric Assessment Assessment of height, weight, body size and composition Compare to standards or previous measures to monitor changes/appropriateness Body Mass Index (BMI)= kg/(m^2) BMI Limitations: Athletes with a lot of muscle Pregnant or lactating women Older adults (loss of muscle)→ BMI 24-29 Waist Circumference Subcutaneous fat: fat located under surface of skin → less risk Visceral fat: fat deposited around organs in the abdomen → high risk - WC is a reflection of visceral fat (central adiposity) EAL → recommends BMI + WC at annual visits to determine risk for CVD, T2DM Measure snugly at iliac crest at end of normal expiration Men => 102 cm (40")→ increased risk of CVD, T2DM Women => 88 cm (35") Waist-Hip Circumference Ratio (WHR) Estimates distribution of subcutaneous fat and intra-abdominal adipose tissue Measure WC and hip circumference (point of greatest circumference) Differentiates between android and gynoid obesity WHCR=WC/HC (in cm) - Men => 1.0 → associated with increased risk (DM, HTN) Adjusted Body Weight For obesity: ABW = [(actual wt- ideal wt) x 0.25 ] + ideal wt BMI 27-30 IBW = BMI 25 BMI >30 IBW = BMI 27 Adipose tissue not as active → using actual wt may overestimate needs For fluid retention → 1 L = 1 kg (subtract from wt) Ideal Body Weight Hamwi Formula → estimates desirable body weight Amputation Entire leg = 16% of BW Lower leg w/ foot = 6%Entire arm = 5% Forearm w/ hand = 2.3% Adjusted IBW=(100% - % amputated)/ 100 x IBW Spinal cord injury (SCI) Quadirplegic = reduce 10-15% wt Paraplegic = reduce 5-10% wt % Weight Change → for adults, non pregnant females -% wt change =(UBW - current wt)/UBW x 100 1 week→ significant =1-2%, severe=>2% 1 month→5%，>5%. 3 month →7.5%,>7.5%.6 month →10%,>10% Any time → 10-20%,>20% vi. Physical Assessment Physical Exam Must be evaluated in context of disease condition or life stage Observation of mouth, skin, hair, eyes, fingernails etc Use sight, smell, hearing→ obesity, cachexia, fluid status, skin integrity, wound healing, feeding devices, jaundice, ascites Palpation: gather data via touch using palms/fingertips Tenderness, muscle rigidity, fluid retention, pitting edema, skin integrity/moisture, body temp Auscultation: listening to bowel using stethoscope on the RLQ (ileocecal valve) Normal → gurgling high-pitched sounds x 5-15 seconds Paralytic ileus / peritonitis → hypoactive, x 15-20 seconds Diarrhea / intestinal obstruction → hyperactive, continuous Percussion: tapping body parts (not done by RD) Physical Signs & Symptoms of Nutritional Deficiencies Anticoagulants (warfarin / coumadin)→ avoid w/ St. John's Wort d/t it increasing drug's metabolism and decreasing its effects Levodopa → pyridoxine (B6) decreases its effects; high protein can compete for absorption Save higher PRO meals for end of the day (i.e. dinner) No