Clinical Nutrition PDF

Clinical Nutrition Dr Mahmoud Al Kalaldeh 1  Essentials Nutrition  Nutrition is a basic human need that changes throughout the life cycle and along the wellness– illness continuum.  Food provides nutrition for both the body and the...

Clinical Nutrition Dr Mahmoud Al Kalaldeh 1  Essentials Nutrition  Nutrition is a basic human need that changes throughout the life cycle and along the wellness– illness continuum.  Food provides nutrition for both the body and the mind. Eating has evolved from being simply a necessity—it may be a source of pleasure, a pastime, a social event, a political statement, a religious symbol, a cultural emblem, or an integral component of medical treatment. As such, food, eating, and nutrition take on different meanings to different people, and changing a person's eating behaviors may be a difficult and slow process. 2 Principles of Nutrition  The science of nutrition is the study of how food nourishes the body. It encompasses the study of nutrients and how they are handled by the body as well as the impact of human behavior and environment on the process of nourishment. As such, this discipline involves physiology, psychology, and socioeconomics. 3  Nutrients  Nutrients are specific biochemical substances used by the body for growth, development, activity, reproduction, lactation, health maintenance, and recovery from illness or injury.  The metabolic processes involved in these functions are complex. Subsequently, most nutrients work better together than they do alone.  Also, nutrient needs change throughout the life cycle in response to changes in body size, activity, growth, development, and state of health. 4  Some nutrients are considered essential because either they are not synthesized in the body or are made in insufficient amounts.  Essential nutrients must be provided in the diet or through supplements. Essential nutrients that supply energy and build tissue (such as carbohydrates, fats, and protein) are referred to as macronutrients.  Micronutrients, such as vitamins and minerals, are required in much smaller amounts to regulate and control body processes. 5  Dietary Data  Dietary data may be collected from the patient or family and can be evaluated according to the Dietary Guidelines, RDA, or the MyPyramid Food Guide, depending on the purpose of the assessment. Nutritional Screening  Discussion continues among health experts about the most effective method to assess for the risk for nutritionally related complications. Some nutritionists state that a thorough physical assessment and nutritional history can more accurately determine the presence of malnutrition than a series of laboratory test results. 6 Biochemical Data  Low serum albumin level (below 3.5 mg/dL) may be a reflection of the aging process rather than a nutritional risk factor. Albumin synthesis declines with age.  Hemoglobin levels that are lower than normal may only reflect anemia observed in elderly people as part of the aging process. 7 Nutritional Assessment  Clinical examination  BMI  Biochemical assessment  Dietary data ⚫ Food record ⚫ 24-hour recall ⚫ Diet diary  Cultural and religious considerations 8 Dietary Data  Dietary data may be collected from the patient or family and can be evaluated according to the Dietary Guidelines, RDA, or the MyPyramid Food Guide, depending on the purpose of the assessment 9 Anthropometric Data  Because of age-related changes in body composition, skin-fold measurements should be taken from several body sites. 10 Dietary Data  Dietary recall may be inaccurate because of vision and memory problems.  Question use of vitamin and mineral supplements.  Gather information concerning medication regimen (prescribed and over-the- counter) to assess for food–drug interactions and adverse effects of medications. 11  DETERMINE  The acronym DETERMINE can be used to screen for warning signs of poor nutritional health.  Disease: Any disease, illness or chronic condition that causes a change in the way a person eats or makes it hard to eat  Eating poorly: Eating too little or too much; skipping meals; eating the same foods all the time  Tooth loss/mouth pain: Missing, loose, or rotten teeth or dentures that don't fit well or cause mouth sores make it hard to eat  Economic hardship: Having less or choosing to spend less on food makes it difficult to eat the foods needed to stay healthy  Reduced social contact: Being with people has a positive effect on eating and well-being 12 Continue DETERMINE  Multiple medicines: The more medicines taken, the greater the risk for side effects, such as increased/decreased appetite, change in taste, constipation, weakness, drowsiness, diarrhea, and nausea. Vitamins or minerals taken in large doses act like drugs and can cause harm.  Involuntary weight loss/gain: A large weight loss or gain can be a sign of serious health problems.  Needs assistance in self-care: Difficulty walking, shopping, purchasing, and cooking food interferes with the ability to meet nutrition needs.  Elder years above age 80: As age increases, risk of frailty and health problems increase 13 Assessing Dietary Intake  Many different methods can be used to assess actual dietary intake.  24-Hour Recall Method  The easiest way to collect dietary data is to obtain a 24-hour recall of all food and beverages the patient normally consumes during an average day. It involves asking the patient to recall details related to nutritional intake from the prior 24 hours. This method includes the patient's portion sizes, meal and snack patterns, meal timing, and location where food is eaten. Because this method relies on memory and accurate interpretation of portion sizes, the information may not be reliable. 14 Food Diaries/Calorie Counts  Food diaries and calorie counts require documentation of actual intake for a specified period of time. In an outpatient setting, the patient is asked to record everything he has had to eat or drink, including portion size, over a set period of time. In the hospital setting, documentation is usually completed by the nursing staff. These tools may provide a better overall picture of nutrient intake because all food and beverages consumed in a specified period, usually 3 to 7 days, are recorded. 15 Food Frequency Record  Food frequency records give a general picture of nutritional consumption. Patients are asked questions to elicit an average number of times certain foods or food groups are consumed in a given period of time: per day, per week, or per month. For example, a patient may be asked, “How many times in the last week have you eaten fresh fruit or fish?” or “How many times in the last week have you had a glass of milk?” 16 Diet History  A more comprehensive approach to diet assessment is a full diet history. In addition to a 24-hour food recall, calorie counts/ food diaries, and food-frequency record, interview questions are geared to provide information on past and present food intake and habits. 17 Medical and Socioeconomic Data  Medical, social, and economic factors, as well as cultural and psychological influences, require evaluation for their impact on nutritional requirements and food choices. A nutritional assessment should also include the following information: 18 1. Medical Data  Current illness as well as medical and surgical history  Past and current drug history  History of drug dependence or abuse  Ability to chew and swallow, including condition of mouth, missing teeth, or dentures  Appetite, food intolerance and allergies, and bowel habits 19 2. Social Data  Age, gender, family history, lifestyle (eg, those at extremes in age are most at risk)  Educational background  Information about occupation, exercise, and sleep patterns  Religious affiliation, cultural, and ethnic background  Use of alcohol and tobacco  Economic Data  Source of income  Food budget 20 3. Anthropometric Data  Anthropometric measurements are used to determine body dimensions. In children, anthropometric measurements are used to assess growth rate; in adults, they can give indirect measurements of body protein and fat stores. For the data to be accurate and reliable, standardized equipment and procedures must be used, and the data must be compared with the appropriate reference standards for the patient's age and sex. 21 4. Body Mass Index  Body Mass Index (BMI) is used to determine who is overweight.  BMI = 703 x weight in pounds height in inches2  A Body Mass Index of 25 or more is considered overweight.  A Body Mass Index of 30 or more is considered obese. 22 23  A significant intentional or unintentional change in the patient's weight can also indicate poor nutritional status and/ or health problems.  Significant weight change is determined by how much weight is lost per unit of time. To calculate the percent of weight change, use the following formula.  Usual weight - present weight) ÷ usual weight × 100  Weight loss is considered significant if it falls into the following guidelines:  1% to 2% in 1 week  5% in 1 month  7.5% in 3 months  10% in 6 months 24  Additional anthropometric measurements include triceps skin- fold measurements, a measure of subcutaneous fat stores; midarm circumference, a measure of skeletal muscle mass; and midarm muscle circumference, a measure of both skeletal muscle mass and fat stores 25 Body Mass Index and Waist Circumference  Waist circumference is measured by placing a measuring tape snugly around the patient's waist. This measurement is a good indicator of abdominal fat. Abdominal fat also provides an estimation of relative risk for diseases such as heart disease, diabetes, and hypertension. This risk increases with a waist measurement of over 40 inches in men and 35 inches in women. 26 Biochemical Assessment  Serum albumin and globulin  Serum transferrin  Retinol-binding protein  Electrolytes  Hemoglobin  Vitamin A and carotene  Vitamin C  Urine tests 27 28