Chapter 8 Growth And Nutrition PDF

Review of Related History 116 CHAPTER 8 Growth and Nutrition P  reoccupation with weight; overly concerned with developing muscle mass, losing body fat; excessive exercise; weighs self daily, boasts about weight loss, weight goals; omits perceived fattening foods and food groups from the diet Risk...

Review of Related History 116 CHAPTER 8 Growth and Nutrition P  reoccupation with weight; overly concerned with developing muscle mass, losing body fat; excessive exercise; weighs self daily, boasts about weight loss, weight goals; omits perceived fattening foods and food groups from the diet Risk factors for eating disorders Weight preoccupation Poor self-­esteem, perfectionist personality Self-­image perceptual disturbances Chronic medical illness (insulin-­dependent diabetes) Family history of eating disorders, obesity, alcohol use disorder, or affective disorders Cultural pressure for thinness or outstanding performance Athlete driven to excel (e.g., gymnasts, ice-­skaters, dancers, boxers, and wrestlers) Food cravings, restrictions Compulsive/binge eating Difficulties with communication and conflict resolution; separation from family Use of appetite suppressants and/or laxatives Chronic disease, such as inflammatory bowel disease, cystic fibrosis, malignancy Medications: steroids, growth hormones, anabolic steroids Pregnant Patients P  repregnancy weight and BMI, age, dietary intake Age at menarche Date of last menstrual period, weight gain pattern, following established weight gain curve for gestational course Eating disorders Weight gain during pregnancy; nutrient intake during pregnancy (particularly protein, calories, iron, folate, calcium); supplementation with vitamins, iron, folic acid; eligibility for WIC program Pica (cravings for and eating nonnutritive substances such as laundry starch, ice, clay, raw icing) Nausea and vomiting Lactation: nutrient intake during lactation (particularly protein, calories, calcium, vitamins A and C); fluid intake (water, juice, milk, caffeine) Chronic illness: diabetes, renal disease, others Older Adults N  utrition: weight gain or loss, adequate income for food purchases, interest and capability in preparing meals, participant in older adult feeding programs, social interaction at mealtime, number of daily meals and snacks, transportation to grocery stores and access to healthy foods, poorly fitting dentures Energy level, regular exercise/activities Chronic illness: diabetes, renal disease, cancer, depression, heart disease, difficulty feeding self, chewing, or swallowing, swallowing dysfunction after stroke, difficulty feeding self, chewing, or swallowing Food/nutrient/medication interactions (Box 8.3) BOX 8.3 Food–Nutrient–Medication Interactions Medications can affect nutritional intake and status just as some foods, and the nutrients contained in them can affect absorption, metabolism, and excretion of medications. For example, a consistently high intake of grapefruit juice while taking simvastatin increases the bioavailability of the medication, often resulting in an increased risk of myopathy. It is important to assess the medications that a patient is taking to determine appropriateness and whether there are any possible interactions. The term “medications” includes those prescribed as well as those purchased over the counter. Often patients do not remember to list vitamin, mineral, herbal, and protein supplements during the history unless specifically asked about them. Risk Factors Possible Medication Effects on Nutritional Intake and Status A ltered food intake resulting from altered taste/smell, gastric irritation, bezoars (food-­ball found in the stomach and/or intestines), appetite increase/decrease, nausea/vomiting Modified nutrient absorption resulting from altered gastrointestinal pH, increased/decreased bile acid activity, altered gastrointestinal motility, inhibited enzymes, damaged mucosal cell walls, insoluble nutrient-­drug complexes Modified nutrient metabolism resulting from vitamin antagonism (e.g., warfarin is a vitamin K antagonist) Modified nutrient excretion resulting from urinary loss, fecal loss    Determination of Diet Adequacy The history of an individual’s food and beverage intake allows estimation of the adequacy of the diet. Histories may be obtained through 24-­hour diet recalls or with a 3-­ or 4-­day food diary that includes 1 weekend day. Various methods for measuring nutrient intake are available. Twenty-­Four-­Hour Recall Diet The 24-­hour recall is an often-­used method for obtaining a food intake history. Ask the patient to list all foods, beverages, and snacks eaten during the past 24 hours. Ask specific questions about the method of food preparation, portion sizes, amount of sugar-­sweetened beverages, and use of salt or other additives. Some believe the 24-­hour recall method provides a limited view of an individual’s actual intake over time and may be misleading. Individuals may be unable to accurately remember everything they ate the day before, causing further inaccuracies in interpreting the information. There are now a variety of web-­based 24-­hour recall tools, including the Automated Self-­Administered 24-­Hour (ASA24) Dietary Assessment Tool (https://epi.grants.can cer.gov/asa24/). Patients report minimal burden and high rates of satisfaction with these types of tools compared with a typical diet history assessment (Arab et al., 2010). Food Diary and Nutrient Intake The food diary can be an accurate but time-­ consuming method for the patient and health professional. It provides a retrospective view of an individual’s eating habits and dietary CHAPTER 8 Patient Safety MyPlate.gov MyPlate.gov provides practical information, tips, web-­based tools, and mobile device applications to help individuals build healthier diets (Fig. 8.4). MyPlate.gov is based on the most up-­to-­date recommendations from the 2015 to 2020 Dietary Guidelines for Americans. The Guidelines, published every 5 years by HHS and the USDA, provide evidence-­based information and advice for choosing a healthy eating pattern that focuses on nutrient-­dense foods and beverages and helps individuals achieve and maintain a healthy weight. The full guidelines are available at https://w ww.dietaryguidelines.gov/current-­dietary-­guidelines/2020-­2025-­dietary-­ guidelines. Individuals can use the MyPlate.gov website to create a Daily Food Plan based on age, gender, weight, height, and physical activity level. Individuals can use the MyPlate.gov website to calculate their daily caloric needs and create a food plan based on age, sex, weight, height, and physical activity level. Individuals can download an app to their mobile device to analyze their diet habits, set goals, and track progress. Additional resources include printed materials (English and Spanish) and videos. The 2020–2025 Dietary Guidelines for Americans emphasize the following key messages: Follow a healthy diet at every life stage. Customize nutrient-­dense food and beverages based on personal preferences, culture, and budget. Consume nutrient-­dense foods and beverages (rich in vitamins and minerals with no or little added sugars, saturated fat, and sodium) and stay within calorie limits. Dairy Fruits BOX 8.4 117 Calculating the Body Mass Index The formula to calculate the BMI using pounds (be sure to convert ounces to a decimal) and inches: Weight [in pounds] ÷ Height [in inches]2 × 70 The formula to calculate the BMI using kilograms and centimeters: Weight [in kg] ÷ Height [in meters] Vegetarian/Vegan Diets Vegetarian/Vegan diets can meet all the recommendations for nutrients. The key is to consume a variety and the right amount of foods to meet an individual’s caloric needs. Five nutrients may be deficient in a vegetarian diet if it is not carefully planned: protein, calcium (lacto-­ovo and vegan), iron, vitamin B12 (vegan), and vitamin D. The Office of Dietary Supplements at the National Institutes of Health has a variety of useful educational materials for patients and healthcare providers about the effectiveness, safety, and quality of dietary supplements (https://ods.od.nih.gov). Cultural and Ethnic Food Guide Pyramids Food guide pyramids for ethnic populations are available (e.g., Mediterranean, Indian, Mexican, and Asian). To see examples of ethnic and cultural food guide pyramids, go to the USDA Food and Nutrition Information Center (www.nal.usda.gov/fnic/ethniccultural-­food-­pyramids). In addition, Oldways Preservation Trust (www.oldwayspt.org) is a useful resource. EXAMINATION AND FINDINGS Equipment  tanding platform scale with height attachment S Measuring tape with millimeter markings Infant scale Recumbent measuring device (for infants) Stature-­measuring device (for children) Calculator Grains Weight and Standing Height Vegetables Protein FIG. 8.4 My Plate. (From U.S. Department of Agriculture, MyPlate.gov.)    Limit foods and beverages high in added sugars, saturated fat, and sodium; limit alcoholic beverages To measure the weight, ask the patient to remove excess clothing and shoes. Have the patient stand in the middle of the scale platform and note the digital reading. If using a balance scale move the largest weight to the last 50-­pound or 10-­kg increment under the patient’s weight. Adjust the smaller weight to balance the scale. Read the weight to the nearest 0.1 kg or 0.25 pound. Weight variations occur during the day and from day to day with changes in body fluid and intestinal contents. When monitoring a patient’s weight daily or weekly, weigh the patient at the same time each day using the same scale. Examination and Findings intake, recorded as it happened. It can also collect relevant data that may aid in identifying problem areas. The USDA MyPlate.gov website and mobile device application are useful tools for tracking daily food and beverage intake by food groups (grains, vegetables, fruits, dairy, and protein foods) (Box 8.4). Patients may ask for recommendations on calorie intake to guide their food choices. An interactive Dietary Reference Intake (DRI) calculator on the USDA Food and Nutrition Information Center website (https://www.nal.usda.gov/fnic/dri-­calculator/) uses patient age, gender, height, and activity level to generate a tailored report. Growth and Nutrition Examination and Findings 118 CHAPTER 8 Growth and Nutrition To measure height, have the patient stand erect with their back to the stature-­measuring device. Pull up the height attachment and position the headpiece on the top of the head. Make the reading at the nearest centimeter or 0.5 inch. Body Mass Index The BMI, an anthropometric index of weight and height, is the most common method used to assess nutritional status and total body fat. While not a direct measure of body fat, BMI correlates to body fat measures using underwater body measuring and dual-­energy x-­ray absorptiometry. Although most electronic health records automatically calculate BMI, Box 8.4 presents the formula. For adults, the following are classifications of weight for height by BMI values (in kg/m2): Underweight—under 18.5 Healthy weight—18.5 to 24.9 Overweight—25 to 29.9 Obesity—30 or greater Track the change of a patient’s BMI over time. The prevalence of obesity among adults 20 years of age and older in 2017 to 2018 was 42.4%. The prevalence of obesity varies by age group: 40% in adults 20 to 39 years old, 44.8% in adults 40 to 59 years old, and 42.8% in adults 60 years and older. Obesity also varies by race and ethnicity. The rate of obesity is highest among non-­Hispanic Blacks (49.6%), followed by Hispanics (44.8%) and non-­Hispanic whites (42.2%) (Hales et al., 2020). CLINICAL PEARL Controlling Weight Exercise is a key factor in maintaining body weight or in reducing body weight. Vigorous-­intensity aerobic exercise such as 25 minutes of brisk walking at least 3 times a week is recommended for adults 18 to 64 years of age. Look for ways to increase activity, such as using the stairs rather than an elevator or parking farther from the doors to businesses and workplaces. Limit the time children and adolescents watch television, view computer screens or use electronic devices. Encourage children to walk, ride a bicycle (with a helmet), and participate in sports or recreational activities. Waist Circumference and Waist-­Height Ratio Waist circumference and waist-­height ratio are indicators of visceral fat or abdominal obesity. Waist circumference should be measured at the high point of the iliac crest when the individual is standing and at minimal respiration. Persons of healthy weight who have increased waist circumferences often fall into a higher disease risk classification. A large waist circumference (>35 inches in women, >40 inches in men) is associated with an increased risk for type 2 diabetes, dyslipidemia, hypertension, and cardiovascular disease. Monitoring changes in a person’s waist circumference over time, with or without changes in BMI, may aid in predicting relative disease risk in terms of cardiovascular risk factors and obesity-­related diseases. The waist-­height ratio is calculated as a ratio of the waist circumference (cm) and height (cm). Like waist circumference, the waist-­height ratio has been shown to be a strong predictor for diabetes and cardiovascular disease in adults (Ashwell and Gibson, 2016). A waist-­ height ratio greater than 0.5 is associated with increased risk. See Centers for Disease Control and Prevention (CDC) Waist Circumference tables at https://stacks.cdc.gov/view /cdc/40572. Infants The care of children is exciting because of the continuous change that accompanies growth and development. Give careful attention to measuring weight and length and the sequence of developmental achievements as you get to know a child over time. The newborn with the best chance to be a healthy infant is born at term, is an appropriate size for gestational age, and has no history of prenatal or perinatal difficulty. Most babies born at term to the same parents weigh within 6 ounces of their siblings at birth. Pay close attention to an unexpected birth weight difference. If the baby has a lower birth weight than older siblings, carefully assess for congenital abnormality or factors that may have contributed to intrauterine growth restriction. Newborns with a greater birth weight than older siblings, at 10 pounds or greater, are at risk for hypoglycemia. A more rapid weight gain than expected during early infancy (e.g., the infant’s weight percentile keeps increasing rather than following a specific growth curve) is associated with increased cardiovascular disease risk and hypertension as an adult (Howe et al., 2014). Recumbent Length Measure the length of infants between birth and 24 months of age in the supine position on a measuring device (Fig. 8.5). Have the parent hold the infant’s head against the headboard. Hold the infant’s legs straight at the knees and place the footboard against the bottom of the infant’s feet. Read the length measurement to the nearest 0.5 cm or 0.25 inch. The infant’s length should be plotted on the World Health Organization (WHO) growth curve for age and gender to identify the infant’s percentile placement. While most electronic health records include automated growth chart plotting, the WHO charts can be accessed at https://www.cdc.gov/growthcharts/who_chart s.htm. Future length measurements should be plotted on the same chart to monitor the infant’s growth over time (see Clinical Pearl, “Using the Correct Growth Chart”). At birth, healthy term newborns have length variations between 45 and 55 cm (18 and 22 inches). Length increases by 50% in the first year of life (see Clinical Pearl, “Reliability of Length Measurements”). FIG. 8.5 Measurement of Infant Length. (From Hockenberry and Wilson, 2017.) CLINICAL PEARL Using the Correct Growth Chart Despite the toddler’s ability to stand, continue measuring length until 24 months of age and continue plotting the length on the WHO growth curve. Measurements of length are 0.7 to 0.8 cm greater than height or stature (Grummer-­Strawn et al., 2010). Using the child’s height, rather than length on the WHO growth curve, will give an incorrect impression of poor growth. At 24 months of age, begin measuring the child’s height and plotting the child’s measurements on the Centers for Disease Control growth curves for children ages 2 to 18 years (htt ps://www.cdc.gov/growthcharts/clinical_charts.htm). Most electronic health record systems have embedded the WHO and Centers for Disease Control growth charts. CLINICAL PEARL Reliability of Length Measurements Obtaining a reliable length measurement in newborns is difficult because of the natural flexion of the infant and the molding of the head. In infants, the reliability of the length measurement is difficult if the infant resists and moves. Use a consistent technique to increase reliability between examiners, and verify the length with a second measurement. Weight Use an infant scale, measuring weight in grams for infants and small children. Infants and children are weighed only in grams and kilograms to reduce medication errors because pediatric dosages are calculated per kilogram of body weight. Have the parent assist and use distraction to help keep the infant quiet and still until the digital reading appears or until the scale is balanced. Read the weight to the nearest 10 g when the infant is most still. Assess the infant’s weight on the WHO growth curve for age and gender, comparing the infant’s weight to the population standard. Identify the infant’s percentile placement. As with length, monitor the child’s weight by plotting future Growth and Nutrition 119 measurements on the same growth curve. Beginning at 2 years of age, convert to the CDC growth curve for the child’s gender (https://www.cdc.gov/growthcharts/clini cal_charts.htm). Use conversion tables available online to give parents the infant’s weight in pounds and ounces (www.medcalc.com/wtmeas.html). Most term newborns vary in weight between 2500 and 4000 g (5 lb 8 oz to 8 lb 13 oz). After losing up to 10% of their birth weight, newborns regain that weight within 2 weeks and then gain weight at a rate of approximately 30 g (1 oz) per day. This rate of weight gain decreases starting at about 3 months of age (Fiegelman, 2011). In general, infants double their birth weight by 4 to 5 months of age and triple their birth weight by 12 months of age. After obtaining the length and weight, plot the infant’s weight for length on the WHO growth curve. This provides information about whether the infant’s weight is proportional to length (see Clinical Pearl, “Uses of Growth Charts”). CLINICAL PEARL Uses of Growth Charts Growth charts are designed to plot and track anthropometric data to screen for atypical size and growth patterns and to make an overall clinical assessment. For example, growth charts for children between birth and 24 months of age make it possible to identify excessive weight gain for length. A separate growth curve for very-­low-­birth-­ weight infants compares the growth of these infants with the growth of other low-­birth-­weight infants, although the WHO growth charts may also be used to evaluate the growth of these infants. Head Circumference Measure the infant’s head circumference at every health visit until 2 to 3 years of age. Wrap a paper measuring tape snugly around the child’s head at the occipital protuberance and the supraorbital prominence to find the point of the largest circumference (Fig. 8.6). Make the reading to the nearest 0.5 cm or 0.25 inch. Confirm the accuracy of the head circumference measurement at least once. Plot the measurement on the appropriate growth curve and identify the child’s percentile in comparison with the population standard. Compare measurements over time to monitor the head circumference growth pattern using the WHO growth curve. Expected head circumferences for term newborns range between 32.5 and 37.5 cm (12.5 to 14.5 inches) with a mean of 33 to 35 cm (13 to 14 inches). At 2 years of age, the child’s head circumference is two-­thirds its adult size. If the head circumference increases rapidly and plots in higher percentile curves, increased intracranial pressure may be present. If the head circumference does not grow as expected and plots in lower percentile curves, microcephaly may be present and further investigation may be warranted. Examination and Findings CHAPTER 8